Kaiser Permanente National Guideline Program (NGP): Implications of

Kaiser Permanente National Guideline Program (NGP): Implications of April 2009 IOM CPG Standards Netta Conyers-Haynes, Principal Consultant, Communications Craig Robbins, MD, MPH KP Colorado-Family Physician Medical Director-KP National Guideline Program Kaiser Permanente: Largest Non-Profit Health Care Program in the United States Permanente Medical Groups Kaiser Permanente Kaiser Foundation Hospitals Kaiser Foundation Health Plan Founded in 1945 8 regions in 9 states and District of Columbia 8.6 million members (as of 12/09) 15,129 physicians (as of 12/09) 164,098 employees (as of 12/09) KP Care Management Institute (CMI)

KP National Guideline Program (NGP) Kaiser Permanente Evidence Network 15 KP National Evidence-Based Guidelines Supported by full systematic reviews 3.5 staff FTEs dedicated to KP NGP work 1 Principal Consultant, 2 Evidence Analysts, 2 Project Managers 1.5 physician FTEs dedicated to KP NGP work 7 Physician EBM Methodologists External Vendor: Doctor Evidence Search & Data Extraction Technology platform Data repository, analysis & documentation KP National Guideline Program Portfolio Asthma-Adult Asthma-Child/ Adolescent ADHD Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening CAD Depression Diabetes Dyslipidemia (Integrated CVD Risk

Reduction) Heart Failure HIV/STI Screening & Prevention Hypertension Osteoporosis Prostate Cancer Screening IOM Clinical Practice Guideline Standards: Congruent Areas for KP Establishing transparency Management of conflict of interest GDG Composition: Multidisciplinary & balanced CPG-SR intersection Evidence foundations & strength of recommendations Articulation of recommendations Updating IOM Clinical Practice Guideline Standards: Problem Areas for KP GDG composition Patient & public involvement Strategies to increase effective participation of patient and consumer representatives External review No review outside KP No posting for public comment Kaiser Permanente National Guideline Program: Process & Methodology

New Clinical Issue Scheduled Update Clinical Questions (CQ) Key to Abbreviations: CQ Clinical Question SR Systematic Review GDT Guideline Development Team GQ Guideline Quality Committee NGD KP National Guideline Directors Overview Existing No Guideline? Yes CQ Match? No Yes Assess Guideline

No Acceptable? Yes Existing No SR by CQ? Evidence Search Abstract Article Review Inclusion/ Exclusion Data Extraction Critical Appraisal Qualitative/ Quantitative Synthesis Assess Evidence Quality Evidence Summary Rationale

Recommendations Yes Assess SR No Acceptable? Yes Yes New Relevant Studies? Assess Implementability of Recommendations GDT Approval Internal Review GQ NGD Approval National Guideline No Implementation Kaiser Permanente National Guideline Program: Process & Methodology

New Clinical Issue Scheduled Update Clinical Questions (CQ) Acceptable External Guideline ADAPTE/AGREE Existing Guideline? Yes CQ Match? Yes Assess Guideline Acceptable? Yes GDT Approval Internal Review GQ NGD Approval

National Guideline Implementation Kaiser Permanente National Guideline Program: Process & Methodology New Clinical Issue Scheduled Update Clinical Questions (CQ) No Acceptable External Guideline Acceptable External Systematic Review No New Relevant Studies Modified AMSTAR GRADE Existing No Guideline? Yes CQ Match? No Yes Assess Guideline

No Acceptable? Existing SR by CQ? Yes Assess SR Acceptable? Yes New Relevant Studies? Evidence Summary Assess Implementability of Recommendations GDT Approval Rationale Internal Review Recommendations GQ NGD Approval

National Guideline No Implementation Kaiser Permanente National Guideline Program: Process & Methodology New Clinical Issue Scheduled Update Clinical Questions (CQ) No Acceptable External Guideline No Acceptable External Systematic Review Internal Systematic Review GRADE Existing No Guideline? Yes CQ Match? No Yes Assess Guideline

No Acceptable? Existing No SR by CQ? Evidence Search Abstract Article Review Inclusion/ Exclusion Data Extraction Critical Appraisal Qualitative/ Quantitative Synthesis Assess Evidence Quality Evidence Summary Rationale

Recommendations Yes Assess SR No Acceptable? Assess Implementability of Recommendations GDT Approval Internal Review GQ NGD Approval National Guideline Implementation Kaiser Permanente National Guideline Program: Process & Methodology Guideline Implementation National Guideline

Regions (EHR, CDS, Operations) Patient Education Tools (KP.ORG, National Patient Instructions Clinician & Staff Education Tools (Clinical Library) Disease Management Accreditation (NCQA) Key to Abbreviations: EHR Electronic Health Record CDS Clinical Decision Support KP.ORG KP publicly-accessible Internet site NCQA National Committee for Quality Assurance CPG Challenges Infinite needs/finite resources Balancing rigor with efficiency Updating requirements Every 2 years? Dynamic updating, based on evidence & impact?

Patient/public involvement Rigor of external SRs/CPGs Implementation of CPGs at the point of care CPG Opportunities Improved SR & CPG rigor & transparency Common evidence-grading & recommendation strength framework SR & CPG developer collaboration Prioritize & coordinate topics Avoid duplication Target funding Collaboration with performance metric developers KP National Guideline Program Questions? My contact information: Craig Robbins, MD, MPH Email: [email protected] Phone: 303-614-1103 Address: 10065 E Harvard Ave, Suite 250 Denver, CO 80231