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Improving the use of research evidence in guideline development: 14. Reporting guidelines.
No full textBACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 14th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on reporting guidelines and recommendations. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: There is little empirical evidence that addresses these questions. Our answers are based on logical arguments and standards put forward by other groups.What standard types of recommendations or reports should WHO use? WHO should develop standard formats for reporting recommendations to facilitate recognition and use by decision makers for whom the recommendations are intended, and to ensure that all the information needed to judge the quality of a guideline, determine its applicability and, if needed, adapt it, is reported. WHO should develop standard formats for full systematically developed guidelines that are sponsored by WHO, rapid assessments, and guidelines that are endorsed by WHO. All three formats should include the same information as full guidelines, indicating explicitly what the group preparing the guideline did not do, as well as the methods that were used. These formats should be used across clinical, public health and health systems recommendations. How should recommendations be formulated and reported? Reports should be structured, using headings that correspond to those suggested by the Conference on Guideline Standardization or similar headings. The quality of evidence and strength of recommendations should be reported explicitly using a standard approach. The way in which recommendations are formulated should be adapted to the specific characteristics of a specific guideline. Urgent attention should be given to developing a template that provides decision makers with the relevant global evidence that is needed to inform a decision and offers practical methods for incorporating the context specific evidence and judgements that are needed
Når det haster… Øyeblikkelig hjelp ved bevisstløshet - annerledes ved rus?
No full textNORSK SAMMENDRAG: På oppdrag fra Statens helsetilsyn har Nasjonalt kompetansesenter for prehospital akuttmedisin (NAKOS) gjennomført en undersøkelse av den akuttmedisinske kjeden fra henvendelse om funn av bevisstløs person er mottatt hos akuttmedisinsk kommunikasjonssentral (AMK) til oppdraget er avsluttet av ambulansetjenesten. \ud
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Rapporten består av to deler: Helsetilsynets tilsynsmessige vurdering av resultatene fra undersøkelsen og rapport fra NAKOS. \ud
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Resultater i NAKOS-rapporten viser at AMK har etablert gode rutiner og prosedyrer som skal brukes og som ansatte og ledere opplever at blir brukt ved melding om behov for øyeblikkelig hjelp. Likevel viser et utvalg journaler at AMK ved mange av hendelsene ikke har gjort det de sier at de gjør. Ved flere av henvendelsene om behov for øyeblikkelig hjelp har ikke AMK innhentet tilstrekkelig informasjon om pasientens vitale funksjoner til å ha et godt nok beslutningsgrunnlag for å vurdere forsvarlig respons. Resultatene indikerer også at det kan være behov for å bedre samarbeidsrutinene mellom AMK og politiet ved henvendelse om medisinsk nødhjelp. \ud
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Vår undersøkelse kan ikke gi svar på om rusrelaterte hendelser håndteres annerledes enn ved antagelse om andre årsaker til bevisstløshet, men vi har heller ikke holdepunkter for å hevde at dette faktisk skjer. \ud
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Det forutsettes at ansvarlige eiere og drivere etterser at rutiner gjennomgås og eventuelt forbedres og at det legges til rette for å utnytte eksisterende læringsmuligheter.SUMMARY IN ENGLISH: NAKOS (Norwegian Competence Centre for Emergency Medicine) carried out a study, on behalf of the Norwegian Board of Health, of the chain of events from when emergency service headquarters (AMK) are informed that an unconscious person has been found until the ambulance service has completed dealing with the event. \ud
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The aim of the study was to obtain information about routines, procedures and assessments made after emergency service headquarters have been informed about an event involving an unconscious person and to establish whether events involving alcohol or drugs are dealt with differently from other emergency events.\ud
The study was carried out over a three-month period during the autumn of 2005, and was based on an analysis of data from three sources:\ud
A questionnaire to staff in emergency service headquarters \ud
Interviews of leaders in a sample of emergency service headquarters \ud
Log recordings 1 and associated print-outs from AMIS 2 for a sample of events dealt with by the emergency services, and ambulance records for the same events. \ud
The report is in two parts: \ud
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I. Assessment by the Norwegian Board of Health of the results of the study, and the implications for supervision\ud
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II. The NAKOS report “Survey of Health Services for Substance Abusers. The chain of events from when the emergency service headquarters (AMK) is informed that an unconscious person has been found until the pre-hospital service has completed dealing with the event” (Wik, 2005). (This report is only available in Norwegian).\ud
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The results of the NAKOS report indicate that emergency service headquarters have established good routines and procedures. When asked in the questionnaire and interviews, both staff and managers replied that they put these into practice when an emergency event is reported. However, a sample of the records shows that emergency service headquarters did not always do as they said. For several emergency events, emergency service headquarters did not collect adequate information about the patient’s vital functions (level of consciousness, respiration and circulation) before making a decision about the appropriate response. The results also indicate that better routines for cooperation between emergency service headquarters and the police are needed in cases of emergency.\ud
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The NAKOS report also indicates that emergency service headquarters do not always use their experience to improve services. The findings show that the system for registering emergency calls and response is not designed in a way which facilitates correcting incorrect information. Consequently the system is not adequate as an instrument for learning and continuous improvement.\ud
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The study does not provide a conclusive answer to the question about whether or not events involving alcohol and drugs are dealt with differently from other events.\ud
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According to the assessment made by the Norwegian Board of Health, there is considerable potential for improving emergency services and learning from experience. Those responsible for running emergency service headquarters should examine current routines and practices and improve them as necessary. \ud
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1 Log recordings are recordings of all telephone calls and radio communication lines at the emergency service headquarters, including conversations between the emergency service operator and telephone calls to the emergency telephone number (113).\ud
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2 The database AMIS, which is an abbreviation for Acute Medicine Information System, is the emergency service headquarters’ system for registering events that the emergency services are informed about through telephone calls to the emergency telephone number (113)
The ratio of Matriptase/HAI-1 mRNA is higher in colorectal cancer adenomas and carcinomas than corresponding tissue from control individuals.
No full textBACKGROUND: It has recently been shown that overexpression of the serine protease, matriptase, in transgenic mice causes a dramatically increased frequency of carcinoma formation. Overexpression of HAI-1 and matriptase together changed the frequency of carcinoma formation to normal. This suggests that the ratio of matriptase to HAI-1 influences the malignant progression. The aim of this study has been to determine the ratio of matriptase to HAI-1 mRNA expression in affected and normal tissue from individuals with colorectal cancer adenomas and carcinomas as well as in healthy individuals, in order to determine at which stages a dysregulated ratio of matriptase/HAI-1 mRNA is present during carcinogenesis. METHODS: Using quantitative RT-PCR, we have determined the mRNA levels for matriptase and HAI-1 in colorectal cancer tissue (n = 9), severe dysplasia (n = 15), mild/moderate dysplasia (n = 21) and in normal tissue from the same individuals. In addition, corresponding tissue was examined from healthy volunteers (n = 10). Matriptase and HAI-1 mRNA levels were normalized to beta-actin. RESULTS: Matriptase mRNA level was lower in carcinomas compared to normal tissue from healthy individuals (p < 0.01). In accordance with this, the matriptase mRNA level was also lower in adenomas/carcinomas combined as compared to their adjacent normal tissue (p < 0.01). HAI-1 mRNA levels in both normal and affected tissue from individuals with severe dysplasia or carcinomas and in affected tissue with mild/moderate dysplasia were all significantly lower than mRNA levels observed in corresponding tissue from healthy control individuals. HAI-1 mRNA was lower in carcinomas as compared to normal tissue from healthy individuals (p < 0.001). HAI-1 mRNA levels were significantly lower in tissue displaying mild/moderate (p < 0.001) and severe (p < 0.01) dysplasia compared to normal tissue from the same patients. Both adenomas and carcinomas displayed a significantly different matriptase/HAI-1 mRNA ratio than corresponding normal tissue from healthy control individuals (p < 0.05). In addition statistically significant difference (p < 0.001) could be observed between mild/moderate and severe adenomas and their adjacent normal tissue. CONCLUSION: Our results show that dysregulation of the matriptase/HAI-1 mRNA ratio occurs early during carcinogenesis. Future studies are required to clarify whether the dysregulated matriptase/HAI-1 ratio was causing the malignant progression or is a consequence of the same
Improving the use of research evidence in guideline development: 9. Grading evidence and recommendations.
No full textBACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the ninth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on grading evidence and recommendations in guidelines. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct a full systematic review ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: Should WHO grade the quality of evidence and the strength of recommendations? Users of recommendations need to know how much confidence they can place in the underlying evidence and the recommendations. The degree of confidence depends on a number of factors and requires complex judgments. These judgments should be made explicitly in WHO recommendations. A systematic and explicit approach to making judgments about the quality of evidence and the strength of recommendations can help to prevent errors, facilitate critical appraisal of these judgments, and can help to improve communication of this information. What criteria should be used to grade evidence and recommendations? Both the quality of evidence and the strength of recommendations should be graded. The criteria used to grade the strength of recommendations should include the quality of the underlying evidence, but should not be limited to that. The approach to grading should be one that has wide international support and is suitable for a wide range of different types of recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which is currently suggested in the Guidelines for WHO Guidelines, is being used by an increasing number of other organizations internationally. It should be used more consistently by WHO. Further developments of this approach should ensure its wide applicability. Should WHO use the same grading system for all of its recommendations? Although there are arguments for and against using the same grading system across a wide range of different types of recommendations, WHO should use a uniform grading system to prevent confusion for developers and users of recommendations
”Et stykkevis og delt tjenestetilbud?” Oppsummering av landsomfattende tilsyn 2005 med kommunale helse- og sosiale tjenester til voksne over 18 år med langvarige og sammensatte behov for tjenester.
No full textNORSK SAMMENDRAG: Statens helsetilsyn gjennomførte i 2005 et landsomfattende tilsyn som undersøkte hvordan 60 norske kommuner gjennom systematisk styring sikrer at personer med sammensatte og langvarige behov for helse- og sosialtjenester får et helhetlig og koordinert tjenestetilbud i alle faser i et tjenesteforløp, og dermed sikrer at tjenestemottakerne får forsvarlige tjenester i samsvar med myndighetskravene. \ud
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Funn fra tilsynet viser at kommunene ikke har etablert robuste styringsstrukturer som sikrer at deltjenestene sammen og i samarbeid med tjenestemottakeren, gjør en forsvarlig utredning og dermed legger det grunnlaget som er nødvendig for å etablere et forsvarlig tilbud slik lovgivningen krever. Helsetilsynet ser det som alvorlig at kommunene ikke sikrer en tverrfaglig vurdering og utredning av tjenestemottakere som har sammensatte helsemessige og sosiale behov. Svikt i en eller flere deltjenester vil påvirke helheten i tjenestetilbudet og kan dermed ha betydning for om tjenestetilbudet er forsvarlig. Når utredningen av tjenestebehovet og planleggingen av tjenestetilbudet er fragmentert, og i noen tilfeller kan karakteriseres som uforsvarlig, er det rimelig å anta at heller ikke de konkrete tjenestene og tiltakene blir tilstrekkelig tilrettelagt og tilpasset; det er heller ikke grunn til å tro at oppfølgingen og evalueringen av tjenestebehov og tjenestetilbud er tilstrekkelig systematisk. Funn fra dette tilsynet støtter slike antagelser.SUMMARY IN ENGLISH: In 2005 the Norwegian Board of Health in the Counties carried out country-wide supervision in 60 Norwegian municipalities. The aim of supervision was to examine how municipalities, through systematic management, ensure that people with complex and long-term needs for health and social services receive comprehensive and coordinated care during all stages of their treatment and care, and thus ensure that clients receive adequate services that are in line with statutory requirements.\ud
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The results of supervision show that the municipalities have not established management structures that are robust enough to ensure that service sectors, together and in cooperation with clients, carry out an adequate investigation of clients’ needs. Such an investigation is necessary in order to plan service provision that fulfils the requirements laid down in the legislation. \ud
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In the opinion of the Norwegian Board of Health, it is a serious situation that municipalities do not ensure that a multidisciplinary assessment and investigation is carried out for clients who have complex health care and social needs. Deficiencies in one or several service sectors influence the comprehensiveness of the services that are offered and whether the services are in line with statutory requirements. When assessment of service needs is inadequate, and when planning of service provision is fragmentary and in some cases inadequate, then the services offered may not be adequately organized and adapted to meet the needs of individual clients. The results of supervision give reason to believe that follow-up and evaluation of service needs and service supply may not be not systematic
Improving the use of research evidence in guideline development: 15. Disseminating and implementing guidelines.
No full textBACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 15th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: In this review we address strategies for the implementation of recommendations in health care. METHODS: We examined overviews of systematic reviews of interventions to improve health care delivery and health care systems prepared by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We also conducted searches using PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: What should WHO do to disseminate and facilitate the uptake of recommendations? WHO should choose strategies to implement their guidelines from among those which have been evaluated positively in the published literature on implementation research Because the evidence base is weak and modest to moderate effects, at best, can be anticipated, WHO should promote rigorous evaluations of implementation strategies. What should be done at headquarters, by regional offices and in countries? Adaptation and implementation of WHO guidelines should be done locally, at the national or sub-national level. WHO headquarters and regional offices should support the development and evaluation of implementation strategies by local authorities
Fastlegenes vurdering av kvaliteten ved distriktspsykiatriske sentra. Utvikling av spørreskjema og innsamlingsopplegg.
No full textHelse- og omsorgsdepartementet har besluttet at ”tilfredshet hos samarbeidspartnere”skal være en ny kvalitetsindikator innen psykisk helsevern. På oppdrag fra Sosial- og helsedirektoratet har Nasjonalt kunnskapssenter for helsetjenesten påtatt seg å utvikle og gjennomføre et undersøkelsesopplegg som kan danne grunnlaget for denne kvalitetsindikatoren. Kunnskapssenteret har ansvaret for de nasjonale pasienterfaringsundersøkelsene (PasOpp), og ser ”tilfredshet hos samarbeidspartnere” som et nyttig supplement til pasienterfaringsundersøkelsene.\ud
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Kunnskapssenteret har i første omgang avgrenset prosjektet til å gjelde fastlegenes evaluering av de distriktspsykiatriske sentrene (DPSene). Prosjektet begrenses ytterligere til det psykiske helsevernet for voksne i Norge.\ud
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Hovedmålet med denne rapporten er å beskrive utvikling og validering av et måleinstrument og en innsamlingsmetode som kan anvendes for å måle fastlegenes evaluering av samarbeidet med og kvaliteten ved de distriktspsykiatriske sentrene. Hovedaktivitetene i prosessen er beskrevet i kap.1.2.\ud
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Måleinstrumentet og innsamlingsmetoden som skisseres i denne rapporten ble benyttet i en nasjonal kartlegging i januar – mars 2006
Improving the use of research evidence in guideline development: 12. Incorporating considerations of equity.
No full textBACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 12th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on incorporating considerations of equity in guidelines and recommendations. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: We found few directly relevant empirical methodological studies. These answers are based largely on logical arguments.When and how should inequities be addressed in systematic reviews that are used as background documents for recommendations? The following question should routinely be considered: Are there plausible reasons for anticipating differential relative effects across disadvantaged and advantaged populations? If there are plausible reasons for anticipating differential effects, additional evidence should be included in a review to inform judgments about the likelihood of differential effects.What questions about equity should routinely be addressed by those making recommendations on behalf of WHO? The following additional questions should routinely be considered: How likely is it that the results of available research are applicable to disadvantaged populations and settings? How likely are differences in baseline risk that would result in differential absolute effects across disadvantaged and advantaged populations? How likely is it that there are important differences in trade-offs between the expected benefits and harms across disadvantaged and advantaged populations? Are there different implications for disadvantaged and advantaged populations, or implications for addressing inequities? What context specific information is needed to inform adaptation and decision making in a specific setting with regard to impacts on equity? Those making recommendations on behalf of WHO should routinely consider and offer advice about the importance of the following types of context specific data that might be needed to inform adaptation and decision making in a specific setting: Effect modifiers for disadvantaged populations and for the likelihood of differential effects. Baseline risk in relationship to social and economic status. Utilization and access to care in relationship to social and economic status. Costs in relationship to social and economic status. Ethics and laws that may impact on strategies for addressing inequities. Availability of resources to address inequities. What implementation strategies are likely be needed to ensure that recommendations are implemented equitably? Organisational changes are likely to be important to address inequities. While it may only be possible to consider these in relationship to specific settings, consideration should be given to how best to provide support for identifying and addressing needs for organisational changes. In countries with pervasive inequities institutional, cultural and political changes may first be needed. Appropriate indicators of social and economic status should be used to monitor the effects of implementing recommendations on disadvantaged populations and on changes in social and economic status