Ep. 217: Translational Neurology Beyond the Bench: Guidelines, Implementation, and Population Impact

00:00:00: Welcome to EANcast, your weekly source for education research and updates from the European Academy of Neurology.

00:00:15: Hello!

00:00:15: And welcome to this EANCast Weekly Neurology.

00:00:20: My name is Kerstin Stehn-Felixen.

00:00:22: I'm a professor of neurology at The Danish Dementia Research Center in Copenhagen Also the past co-chair of the guideline production group.

00:00:31: This EAN cast is on guidelines implementation and has been organized on behalf of the EEN Panel on Translational Neuroscience.

00:00:41: And I'm very pleased to be joined by a true expert in guideline implementation, Katarina Rukavina!

00:00:50: Katarina welcome!

00:00:52: Thank you Christian.

00:00:54: So the topic of today is guideline implementation and I want to start really in the clinic because you work as a clinical neurologist.

00:01:02: when You're not working as an Implementation resident then in there.

00:01:06: The European Academy of Neurology.

00:01:08: so can you take me into your clinical practice?

00:01:11: And how do you use guidelines in your everyday workers neurologists?

00:01:16: Yes, so guidelines are very important part of my clinical work because I think guidelines provide us with a really good opportunity to know very quickly what is the evidence-based best practice, how we can treat our patients in a best way.

00:01:38: This is true at the moment for me but also throughout my training and neurology Because often changed countries so i worked into different countries.

00:01:50: I always found a security in the EAN guidelines because these are European guidance and i knew that wherever i go, where ever work.

00:01:59: I can rely on the Guidelines That will show me what's best practice is.

00:02:04: so So I think in clinical practice Guidelines really an important part.

00:02:12: Yeah And I think you hit on very important aspect of EAN Guidelines made to be applicable across many different regions and the countries in Europe, not all of which are able to develop guidelines including my own country on all subjects.

00:02:29: So that's an important point.

00:02:31: I think also there really Guidelines or the bedrock off evidence-based medicine But of course they have to get into the clinic And that's why we're talking about implementation today.

00:02:42: so i want to start.

00:02:43: So you use guidelines, I use guidelines but what do we really know in general about how high the uptake is of guidelines?

00:02:50: In general and clinical practice and neurology.

00:02:54: Yes so that's a very important point because the production of guidelines And EAN and many European experts, key opinion leaders in neurology are investing a lot of resources.

00:03:11: A lot their time and expertise into production of the EAN guidelines.

00:03:17: However studies reporting in different areas of Neurology that actual uptake of the guidelines in clinical practice remains quite low And we have some data, for example in migraine treatment the adherence to guidelines can be as low as five percent.

00:03:39: Then in epilepsy there is a data that the guideline's adherence is around seventy percent so this is very-very low.

00:03:49: we have been interested into EAN Guidelines in particular, and I've recently served the EAN members about their adherence to EAN guidelines.

00:04:01: And i would like to thank on this participation for everybody who participated.

00:04:08: We have here seen that In general, the EAN members do appreciate EAN guidelines and in general believe that EAN guidance would bring benefits for their patients to improve health care they deliver.

00:04:24: However only one third of our members stated regularly use the Ean Guidelines as definitely there is a place space for improvement also here.

00:04:39: Yeah, that sounds quite low in some areas at least of neurology.

00:04:43: I'm wondering do you know anything about what factors might impact whether guidelines are being used or not?

00:04:50: Do we know from the survey perhaps?

00:04:54: So in general... We now know there's many factors working either for-or against a guideline update and implementation.

00:05:05: science is relatively new discipline but its goal is to understand those factors better and then consequently be able to tackle them.

00:05:17: And in general, these factors that determine whether guidelines will actually be used or not do at least partially depend on the guideline itself.

00:05:29: We have also seen it in our survey because as you already mentioned Christian, the EAN Guidelines are made tailored to work in all European countries, which is very challenging because the countries differ so much in terms of resources and different settings.

00:05:51: And that's why some members have stated... In some situations, the problem is that guidelines require resources that are not available in their setting or work.

00:06:05: So this is a very important point that we need to be aware of.

00:06:11: So it sounds like, as you said different factors play a role and that's perhaps not surprising.

00:06:18: I kind of want to start with.

00:06:19: those factors that you mentioned were related to how the guideline is designed.

00:06:25: could you speak a bit about that?

00:06:27: And also maybe when should task forces tasked with developing guidelines, start thinking about implementation.

00:06:37: Is that at the very beginning?

00:06:39: At the protocol level?

00:06:41: is it during or after the protocol has been written... Oh sorry!

00:06:46: The guideline perhaps even when should task forces be starting to think and what can they do to ensure better implementation?

00:06:57: That's a really important point.

00:06:58: Thank you Christian.

00:07:00: Actually the literature is suggesting that the implementation efforts need to start in parallel with a start of the guideline development.

00:07:11: So this traditional view, we will produce guidelines and once it's published then we'll take care about being used.

00:07:20: This isn't working well at all And this contributes very low adherence.

00:07:25: so really the implementation considerations need to be integrated in the guideline development already.

00:07:34: And at the EAN level, we are now introducing several strategies for improving this.

00:07:45: One of these factors is that it's important to include stakeholders into the guidelines and this is something really important.

00:07:56: So as per definitions, stakeholder is a person.

00:08:00: Any person who's either impacted by guidelines or can impact the guideline implementation and I think that group plays really very important role in this process of people living with disease being addressed in the guideline.

00:08:20: So it is really important to meaningfully involve patients or affected individuals from the start, from beginning of the guideline development.

00:08:31: Then what has been shown?

00:08:33: that it's important for guidelines be very clear and pragmatic about these recommendations so they can easily identify those recommendations.

00:08:44: Apologies I made a mistake!

00:08:46: It is important that the recommendations in the guidelines are easy to identify, and with this in mind we're now introducing a new so-called guideline highlights.

00:08:59: So from the newest guidance, the EAN Guidelines which start at the so called highlight section that will briefly describe for whom is this guideline, how was it developed and then outline all its recommendations.

00:09:16: And the recommendations would be classified into strong recommendations, weak or conditional recommendations because we want to help busy neurologists in a daily practice.

00:09:31: To be able quickly look at the guideline document and then get an overview of what does this guide recommend?

00:09:39: We are quite excited about these changes, so it will make it easier for us to follow our EAN guidelines.

00:09:47: That sounds very relevant!

00:09:48: To make guidelines more readable.

00:09:56: accessibility is really important.

00:09:58: So I think that's a wonderful initiative, so you already touched upon stakeholders and of course here patients are really patient representatives or key players.

00:10:10: what about other partners perhaps not directly involved in the development?

00:10:17: Yes, that's another very important question.

00:10:28: Thank you for raising this.

00:10:30: so in other another very very important group are the National Neurological Societies because national neurological societies are actually distributing and implementing EAN guidelines into real life clinical practice.

00:10:49: So these is a group of people we are working on to involve earlier in the guideline process.

00:10:57: So, I think it is important that the National Neurological Society is informed about the EAN guidelines that are in development as soon as the development starts so they're already aware of upcoming guidance and can prepare for their implementation.

00:11:17: We also plan work more with National Neurological Societies to have a presence of the EAN Guidelines, for example at national conferences because these are points where our members stated they would like to learn about the guidelines.

00:11:37: And this partnership between National Neurological Society is really important and needs further enhanced and strengthened.

00:11:50: That sounds like an important partnership, but also perhaps a bit difficult one as we of course have many things that we share and unite us here in Europe.

00:12:00: We also had the somewhat fragmented landscape when it comes to guidelines.

00:12:04: I know there are different rules regarding whether you're bound by law or how much national Societies are involved in developing guidelines.

00:12:17: Is that also the picture you've seen and the survey conducted?

00:12:22: Yes, as you say regulatory points differ between countries within Europe And this makes it really difficult for implementation of EAN Guidelines.

00:12:36: This actually makes impossible to have a cookie cutter approach To have same strategies for each country And we really need to, as already mentioned work together with national neurological societies.

00:12:50: To understand on each countries level what is the right strategy?

00:12:56: To increase use of the EAN guidelines.

00:13:00: EAN cannot influence regulation in different European countries so this not something that can be influenced But we need to be aware of it and understand this more in order not to achieve a competition with the nationally produced guidelines, but work together for collaboration to improve evidence-based practices across Europe.

00:13:29: I want one last question because any podcast that the present moment has to involve something on AI.

00:13:36: So I want to ask you, what's the role of AI in guideline implementation?

00:13:42: Because there is definitely something to be said about AI and development guidelines.

00:13:48: but what about implementation?

00:13:49: using agents that probe guidelines things like that?

00:13:53: do see it also for helping guideline implementation?

00:13:58: yes sure I think the use of AI in medicine is already there, everybody in medicine more or less uses AI.

00:14:10: And i see it really as a wonderful opportunity to increase this guideline adherence clinical practice.

00:14:18: because Actually, not in the future but from today on we need to think about creation of AI tools that would be guideline based and it will simply make guidelines very accessible to neurologists.

00:14:38: and make it really timely, very efficient to find the right recommendation.

00:14:44: And could bring guidelines closer to clinical practice.

00:14:48: so I think its a very nice opportunity that is opening now with this technology advance.

00:14:56: So we should keep our eyes open for future EAN agent on guidelines?

00:15:02: That's wonderful idea!

00:15:07: Kassadina, so we are running out of time now but I want to thank you for sharing your insights into guideline implementation.

00:15:15: i think it's really a very important step to get the clear advantages that guidelines bring to medicine two patients.

00:15:25: So We need more of That!

00:15:27: Thank You For Joining me and thank you all there in front Of The screens wherever you Are for joining us on this EANcast.

00:15:36: Thank you very much, Christian.

00:15:45: This has been EANcast Weekly Neurology!

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00:16:20: Thanks for listening!