While Clinical Practice Guidelines (CPGs) have gained momentum to
inform evidence-based practices, less investment has been made to use CPGs
to support evidence-informed patient choice. The qualitative study by van
der Weijden et al. shows a consensual vision of the need for and benefice
of adapting CPGs into relevant patient versions to integrate patients'
preferences in clinical decision-making. While we agree with the...
While Clinical Practice Guidelines (CPGs) have gained momentum to
inform evidence-based practices, less investment has been made to use CPGs
to support evidence-informed patient choice. The qualitative study by van
der Weijden et al. shows a consensual vision of the need for and benefice
of adapting CPGs into relevant patient versions to integrate patients'
preferences in clinical decision-making. While we agree with the authors'
conclusions and the suggested so-called generic strategy in principle, we
would like to comment the proposed approach from the French perspective of
CPG development and shared decision-making (SDM). Doing so, we respond to
a major limitation stressed by Weijden et al. stemming from the fact that
the results reflect merely an anglo-saxon perspective.
Examination of non-adherence to practice guidelines of the French oncology
guidelines program "Standards, Options, Recommendations" (SOR) established
in 1993 by the National French Federation of Comprehensive Cancer
Centres,?1? revealed that diverging patient values and preferences may
hamper guideline adherence. This observation has led to two developments
we would like to share here: the development of patient versions of SOR
CPGs, and cancer patients' involvement in the development process of SOR
CPGs.
To improve patients' involvement in decision-making, participants
interviewed by the authors suggested translating CPG reports into lay
terminology useful to professionals and patients. Such an approach has
been implemented within the SOR program since 1999. It is based on an
interdisciplinary working group (clinicians, methodologists,
psychologists, linguist, anthropologist) and a triangulation of methods to
involve cancer patients, combining focus groups, semi-structured
interviews and postal surveys. We translated the SOR CPGs into patient
versions in more than twenty cancer sites. An innovative linguistic
approach was used to ensure that the information provided is adapted to
patients' health literacy. A list of generic questions that patients may
ask to health professionals was developed to support patient-centered
communication during the medical encounter and encourage SDM,?2?. As was
pointed out by Weijden et al., patient involvement in the development of
SOR patient versions let us to the awareness that SOR CPGs did not
adequately incorporate patient preferences, in particular the presentation
of treatment options, their benefits and risks. Consequently, we set up in
2003 a process to involve cancer patients in the development of these
guidelines,?3?. Our approach consisted in a cancer patient panel reviewing
the guideline draft and feeding back their comments and recommendations to
the guideline panel. Our approach allowed the patient group to formulate a
list of key recommendations from their perspective to be addressed in the
final guideline, and to point out situations most appropriate for SDM.
Patients stressed the importance of improved communication and information
to facilitate patient participation in the decision-making process.
Based on our experience, we hypothesize that CPGs can be adapted to
facilitate the integration of patients' preferences in clinical decision-
making. The French experience suggests that the consensual 'generic'
strategy proposed by the authors is applicable beyond the anglo-saxon
context of their study and provide a practical example of how the proposed
approaches could be translated within existing guideline programs. Recent
French institutional initiatives highlight a growing awareness of the need
to improve connection between CPGs, patient decision aids and SDM,?4-5?.
Developing and updating high quality CPGs and patient decision
support tools require substantial time, expertise and resources. We
support the author's view that it is preferable to adapt existing CPGs
rather than developing new patient decision support tools. Such approaches
may foster the integration of research evidence and individual preferences
in health care decisions, avoid duplication of effort and enhance
efficiency. Further research is needed to assess the impact on clinical
practice of such approaches.
Bibliography
1. Fervers B, Hardy J, Philip T. ? Standards, Options and
Recommendations ?. Clinical Practice Guidelines for cancer care from the
French National Federation of Cancer Centres (FNCLCC). Br J Cancer 2001;
84(Suppl2):1-92.
2. Fervers B, Leichtnam-Dugarin L, Carretier J, Delavigne V, Hoarau
H, Brusco S, Philip T. The SOR SAVOIR PATIENT project--an evidence-based
patient information and education project. Br J Cancer. 2003 Aug; 89 Suppl
1:S111-6.
3. Fervers B, Bataillard A, Carretier J, Kelson M. Involving cancer
patients in clinical practice guidelines (CPGs) development in a French
guidelines program: What are the key issues? Journal of Clinical Oncology,
2006 ASCO Annual Meeting Proceedings (Post-Meeting Edition).Vol 24, No 18S
(June 20 Supplement), 2006: 16029.
4. Haute Autorite de Sante (Health National Authority). Etat des
lieux. Patient et professionnels de sante : decider ensemble. Concept,
aides destinees aux patients et impact de la decision medicale partageee,
octobre 2013. http://www.has-
sante.fr/portail/upload/docs/application/pdf/2013-
10/12iex04_decision_medicale_partagee_mel_vd.pdf
5. Cnamts (National Health Insurance Fund). Ameliorer la qualite du
systeme de sante et maitriser les depenses : propositions de l'Assurance
maladie pour 2014. Rapport au ministre charge de la securite sociale et au
Parlement sur l'evolution des charges et des produits de l'Assurance
maladie au titre de 2014 (loi du 13 aout 2004), juillet 2013.
http://www.ameli.fr/fileadmin/user_upload/documents/cnamts_rapport_charges_produits_2014.pdf
With respect to the scientific article of Franklin et al. (BMJ Qual
Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two
further issues concerning the learning and reporting system in general as
well as defense strategies in order to prevent errors in administration of
intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive
when compared to other repor...
With respect to the scientific article of Franklin et al. (BMJ Qual
Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two
further issues concerning the learning and reporting system in general as
well as defense strategies in order to prevent errors in administration of
intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive
when compared to other reporting systems within European countries. NHS-
reports over a period of 11 years implicates that more than 2.000
incidents have to be sent per day by healthcare professionals to the
National Reporting and Learnings System (NRLS). According to published
data (1) for England and Wales more than 153.000 out of 1.45 million
incidents of the type "medication" were reported from Oct 2012 to Sep
2013. Severe harm or deaths were scored in 10.781 cases (0.7% per year).
Errors in administration of intrathecal chemotherapy have been reported in
38 times over a decade within NHS. Compared to the German Medicine (2)
(between 1995 to 2005 528 suspected adverse concerning vinca alkaloids) or
the European Medicine Agency (approximately 350 documented cases), the
number of reported events seems low within NHS. Nevertheless, reporting of
patient safety incidents is a subjective and voluntarily exercise and on a
very high level within NHS.
In many other European countries, homogenous reporting and learning
system are lacking so far. In Austria for example, a NLRS is implemented
and accessible for the public (3), whereas hospitals run various reporting
and learning systems without national coordination and evaluation. Within
four years of being online, in total 344 incidents were reported (4
reports per week) to the NLRS and thereof, 21% were scored implicating
therapeutic harm.
NHS is in a leading role concerning NRLS and the level of patient
safety culture with respect of reporting events as well as their open-
minded way in presenting statistics to the public is unique. Concerning
the data pool, NHS could support others in the development of guidelines
and patient safety practices in order to overcome the most prominent
hazards.
The authors presented a comprehensive list of defense strategies to
prevent vinca alkaloids errors. Furthermore, we suggest, in line with the
Evidence-Based Practice guideline (4), team trainings and in analogy to
the WHO-Surgical Safety Checklist a team-time-out before administration of
high-risk medication.
Author:
Name:Dr. Gerald Sendlhofer
Email:gerald.sendlhofer@medunigraz.at
Title/position:
1) Head
2) Scientific co-worker
Affiliations:
1) Department of Quality and Risk Management, University Hospital Graz, Graz, Styria, Austria
2) Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University Graz, Styria, Austria
(1) http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-
summaries/?entryid45=135253 (accessed 7 May 2014)
(2) http://www.akdae.de/Arzneimittelsicherheit/Bekanntgaben/Archiv/2005/791_20050603.html
(accessed 7 May 2014)
(3) https://www.cirsmedical.ch/austria/m_files/cirs.php?seitennr=cpFBeri
(accessed 7 May 2014)
(4) Schulmeister L. Preventing vincristine administration errors: does
evidence support minibag infusions? dOI: 10.1188/06.CJON.271-273
Stephanie et al has produced some very interesting observations about
the impact of electronic medical records on patient-doctor communication.
Recent investigations into the social care system in the light of child
abuse enquiries depicted that professionals spend far too much time on
making records rather than face to face meetings with families and
children. More trusts in the NHS are adapting paper light patient recor...
Stephanie et al has produced some very interesting observations about
the impact of electronic medical records on patient-doctor communication.
Recent investigations into the social care system in the light of child
abuse enquiries depicted that professionals spend far too much time on
making records rather than face to face meetings with families and
children. More trusts in the NHS are adapting paper light patient record
to improve efficiency and patient care. However, we conducted an audit in
a medium secure unit in Manchester to evaluate the efficiency of
electronic system and staff ability to access important clinical
documents. The results showed that time spent to find these documents was
significantly more on electronic record than the paper record which raises
questions about the efficiency of electronic patients record.
The editorial from Sheikh, Atun, and Bates is welcome in flagging up
a key issue in the context of England and the US. However, it is not a
new issue, and it is disappointing that they do not acknowledge prior and
concurrent work.
The need for, and challenges impeding, evaluation of health
information systems have been flagged up much earlier, e.g. Rigby 1999;
2001. Both the European Federation for Medical In...
The editorial from Sheikh, Atun, and Bates is welcome in flagging up
a key issue in the context of England and the US. However, it is not a
new issue, and it is disappointing that they do not acknowledge prior and
concurrent work.
The need for, and challenges impeding, evaluation of health
information systems have been flagged up much earlier, e.g. Rigby 1999;
2001. Both the European Federation for Medical Informatics (EFMI) and the
International Medical Informatics Association (IMIA) have groups which
have followed up this theme. Ammenwerth instigated a European workshop
which inspired a significant work programme (Ammenwerth et al, 2004), and
led to production of reporting standards adopted by the EQUATOR network
(Talmon et al, 2009)and guidelines (Nyk?nen et al, 2011) which have been
fully elaborated (Brender et al, 2013).
The specific dual challenges behind the editorial by Sheikh, Atun and
Bates are the penchant for politicians to decree policy outside their
technical knowledge in order to appear progressive, and the generic need
for evidence-based policy in health informatics. This latter too has
recently been addressed - generically by a dedicated edition of the IMIA
Year Book (S?rousi et al, 2013) which included a summary of the concerted
actions of a decade (Rigby et al, 2013); and in the context of developing
countries by WHO (2011) and through a joint WHO-IMIA Programme (IMIA,
2012).
Moving to evidence-based health informatics policy is vital for
effectiveness, efficiency, safety, and enhanced health care delivery and
outcomes. Such an approach faces challenges as it cuts across the
perceived autonomy of politicians, and the worrying scant regard for a
scientific evidence base of some sectors of the supplier industry, while
evaluation to produce the evidence continually faces impediments as
described. It is therefore vitally important that all innovators and
activists work collaboratively to progress the issues.
Michael Rigby
Rigby M (1999) Health Informatics as a Tool to Improve Quality in Non
-acute Care - New Opportunities and a Matching Need for a New Evaluation
Paradigm; International Journal of Medical Informatics, 56, 1999, 141-150.
Rigby M (2001.)Evaluation: 16 Powerful Reasons Why Not to Do It - And
6 Over-Riding Imperatives; in Patel V, Rogers R, Haux R (eds.): Medinfo
2001: Proceedings of the 10th. World Congress on Medical Informatics, IOS
Press, Amsterdam, 2001, 1198-1202.
Ammenwerth E et al (2004). Visions and strategies to improve
evaluation of health information systems: Reflections and lessons based on
the HIS-EVAL workshop in Innsbruck. International Journal of Medical
Informatics, 2004 Jun 30; 73(6):479-91.
Talmon J. et al (2009. STARE-HI - Statement on Reporting of
Evaluation Studies in Health Informatics; International Journal of Medical
Informatics; 78 2009, 1, 1-9.
Nyk?nen P. (2011). Guideline for good evaluation practice in health
informatics (GEP-HI); International Journal of Medical Informatics, 80,
815-827, 2011.
Brender J (2013). STARE-HI - Statement on Reporting of Evaluation
Studies in Health Informatics: explanation and elaboration. Applied
Clinical Informatics, 2013; 4: 331-358.
S?rousi B, Jaulent M-C, Lehmann CU (eds.) (2013). Evidence-based
Health Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46,
Schattauer, Stuttgart, 2013.
Rigby M. et al (2013). Evidence Based Health Informatics: 10 Years of
Efforts to Promote the Principle - Joint Contribution of IMIA WG EVAL and
EFMI WG EVAL; in S?rousi B, Jaulent M-C, Lehmann CU. Evidence-based Health
Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46,
Schattauer, Stuttgart, 2013.
WHO(2011)Call to Action on Global eHealth Evaluation - Consensus
Statement of the WHO Global eHealth Evaluation Meeting, Bellagio,
September 2011; available from http://www.healthunbound.org/content/call-
action-global-ehealth-evaluation
While Clinical Practice Guidelines (CPGs) have gained momentum to inform evidence-based practices, less investment has been made to use CPGs to support evidence-informed patient choice. The qualitative study by van der Weijden et al. shows a consensual vision of the need for and benefice of adapting CPGs into relevant patient versions to integrate patients' preferences in clinical decision-making. While we agree with the...
With respect to the scientific article of Franklin et al. (BMJ Qual Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two further issues concerning the learning and reporting system in general as well as defense strategies in order to prevent errors in administration of intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive when compared to other repor...
Stephanie et al has produced some very interesting observations about the impact of electronic medical records on patient-doctor communication. Recent investigations into the social care system in the light of child abuse enquiries depicted that professionals spend far too much time on making records rather than face to face meetings with families and children. More trusts in the NHS are adapting paper light patient recor...
The editorial from Sheikh, Atun, and Bates is welcome in flagging up a key issue in the context of England and the US. However, it is not a new issue, and it is disappointing that they do not acknowledge prior and concurrent work.
The need for, and challenges impeding, evaluation of health information systems have been flagged up much earlier, e.g. Rigby 1999; 2001. Both the European Federation for Medical In...
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