ESC Guidelines:Expanding Implementation Strategies in Europe

Nobody will argue against the usefulness of the European Society of Cardiology’s (ESC) guidelines. Firstly, it is acknowledged worldwide that ESC guidelines have a great scientific value. Secondly, following these recommendations saves patient lives, which is our ultimate goal. The ESC also has a unique structure, which provides the opportunity to produce good documents. Guidelines are now a core activity for the ESC, and the guidelines committee interacts with other available structures within the ESC. Guidelines are derived from the results of research and clinical trials, and they also generate education through the education committee. Finally, their efficacy is then scrutinised by the Euro Heart Survey.

The cornerstone of ESC guidelines is teamwork, as their generation involves the close cooperation of all the constituents of the ESC. They are edited under the umbrella of the board, which solicits the involvement of working groups, associations and national societies for the production and implementation of guidelines. Harmonising so many different views is a challenge, but it has many advantages since different backgrounds provide balanced views from experts who are not just sub-specialists. The final product takes advantage of this varied expertise to achieve the appropriate methodology, homogeneity and consistency in its message.

How is Guidelines Generated?

The ESC has produced more than thirty different documents since 2001, covering over 85% of the core syllabus, as well as providing updates on a regular basis. The Clinical Practice Guidelines (CPG) committee is responsible for the selection of topics, the coordination of the writing and review processes, and final approval before publication. It is composed of members from many different national societies as well as associations and working groups.

The CPG works very closely with taskforce members. Here again, the composition of taskforces should represent a good balance of different nations, working groups and sub-specialties. These members are chosen according to their expertise and representativeness. There, independence from industry is clearly stated in a declaration of conflicts of interest. The same should also be true for the reviewers.

Focus on Good Quality a Future Goal

Our first goal for the future is to continue this production of good quality documents.

The recipe for good documents is nicely summarised in a message delivered by Michal Tendera, the Past-President of the ESC, who says that in order to be implemented, guidelines must be universal, coherent and credible, and it is very important to avoid any bias. These guidelines must be easy to understand and applicable. Guidelines reflect the best knowledge we have from trials, etc, however, they should be less focused on describing results and more focused on practice options. Finally, we should always have in mind that guidelines help in the management of our patients but should be used as a supplement to and not instead of good clinical judgement.

Our second main goal is to improve implementation, as it is pointless to have a good product and not to use it! If we look at real life, there is a gap between guidelines and practice as shown by the Euro Heart Survey. Why do we not follow guidelines in practice? Generally speaking, cardiologists may remark on the proliferation of guidelines worldwide, as well as their being too complex, too long, irrelevant for our patients, impractical or even impossible to use.

Improving Implementation

There are several steps that could be followed to improve the implementation of guidelines. During the annual ESC congress the presence of guidelines could be improved by involving them in “Meet the Expert” sessions. Guidelines sessions could also form part of the programme at association meetings. We should also aim to hold guideline implementation courses. National societies are key players in the lifeblood of guidelines. Naturally, they participate in the elaboration of guidelines through the participation of their members in the working groups and associations, but they also have a pivotal role in their implementation. These steps for endorsement and implementation have been set up through several SOPs, which are accessible on the ESC website. The first step is the endorsement and translation of the guidelines by the national societies.

The national society may endorse and adapt guidelines, meaning that the document may be translated, annotated and implemented. Good translation is a key issue for publication. This mutual enrichment is the key to success and requires good communication.

Dissemination the Key to Awareness

Our challenge is to encourage dissemination to the widest possible professional readership. Guidelines are published in the family of journals of sub-specialties within the ESC, a key way to publish the full text given that the Euro Heart Journal only publishes the executive summary. In addition, the 35 national journals within the ESC represent a fantastic driving force for dissemination. A fast track procedure has now been adopted by several countries such as Spain, Greece, and Poland, a list that should keep growing. In this respect, we are very happy to see the initiatives taken under the umbrella of the new editors club.

National societies can also be useful in the implementation of guidelines through the organisation of meetings. During the national meetings, dedicated guidelines sessions organised in partnership with the ESC, highlights or more specific sessions would help as well as interactive sessions, or «Guidelines Versus Practice» sessions. The national society may also organise specific implementation meetings and courses with national experts and taskforce members, to go through the main points and engage in a constructive discussion.

Another important point in the implementation of guidelines is to improve the tools we have for their dissemination. In addition to the publication in the European Heart Journal, there is also a vast armamentarium of increasingly popular derivative products, such as pocket guidelines, compendiums of these pocket versions, PDA versions, and educational slide sets, etc. The internet is the preferred vector for the dissemination of guidelines. The number of hits to the site show just how successful it is. The PDA pocket guidelines are also very successful with more than 100,000 transfers. The site is being modified in order to make it user friendly, and links to the national sites are particularly important.

Dissemination is clearly crucial, however, it is also paramount to follow up the quality of this dissemination through audits. Here again we have tools available with the Euro Heart Survey. In the hospitals themselves we can develop feedback tools as well as give feedback on the adherence to guidelines. This feedback system will even transform simple data collection into dedicated studies with educational consequences. An example of this exists in Ludwigshafen and could be disseminated.

Finally, the links between guidelines and education are obvious. The guidelines may well serve as a platform for building the educational material used at a European level to obtain accreditation and revalidation. Clearly, we have a large armamentarium of methods to pass on the message.