How we draw up the guidelines
Choosing guideline area
When we choose a guideline area within health and medical care one criterion is that the area shall cover a large group with a serious chronic illness that makes a considerable claim on society’s resources. Guidelines for social services are selected on the basis of similar criteria: a large patient or client group with a serious illness or major problems (e.g. alcohol abuse). There must also be a significant demand for guidance and direction on the part of decision-makers and the professions concerned.
Where dental care is concerned, which is a direct government mandate, we must draw up guidelines for the entire adult dental care sector. However, here too we choose those parts of adult dental care where there is the greatest need for guidance and support.
Once the National Board of Health and Welfare has decided to work on a new guideline we then tie in qualified experts in the areas concerned.
Delimit and examine
Our first task is to properly delimit the guideline work. This we do through defining the condition or problem where there is a requirement for guidance and then connect these to the remedial measures required. This we call the condition-intervention pair.
Subsequently, we engage a so-called fact group with scientifically well-qualified experts to conduct a methodical literature search based on the condition-intervention pair. The fact group shall, in the first place, make use of systematic surveys from SBU (Swedish Council on Health Technology Assessment) and The National Board of Health and Welfare. Subsequently, the fact group seeks other systematic surveys or separate studies in the relevant area.
Parallel to this work, experts in health economics prepare background data on the cost effectiveness of the condition-intervention pair. Where relevant studies are lacking, the experts frequently carry out their own model calculations, estimates or on occasions, only costings.
Ranking condition and intervention
A prioritizing group then ranks all condition-intervention pairs on a scale from one to ten, where one is best and ten is worst. This ranking shall function as a support for the decision-makers in health and medical care and social services when they come to allocate the resources. The idea is that highly ranked interventions shall receive a large share of the resources and low ranked interventions shall only receive a small share of the resources available.
The prioritizing group consists of experts with clear grounding in health and medical care, social services and dental care e.g. professors, senior physicians, medical officers and nurses with practical experience of the relevant areas.
The prioritizing group bases its ranking on how serious the condition is, the effect the remedial measures have as well as the cost-effectiveness of the particular measures. The strength of the scientific evidence in assessing the effect of the input and its cost-effectiveness is also of importance in the ranking. Ethical considerations also influence the ranking carried out by the prioritizing group.
In overall terms, it may be said that highly ranked condition-intervention pairs frequently deliver major benefits for the patient and high cost-effectiveness for society as a whole. On the other hand, condition-intervention pairs with a low ranking deliver limited or uncertain benefit for the patient or a very high cost in relation to the measure’s effect. A low ranking is also the consequence for those condition-intervention pairs where the scientific data is incomplete or insufficient and there are, at the same time, other alternatives based on sound scientific evidence.
National guidelines also include recommendations relating to measures that Medical Care and Social Services should not implement at all (Do Not Do) since the particular measures have no effect or may entail risks for the patient.
The recommendation R&D we assign to those inputs that medical care and social services should not carry out routinely since they are insufficiently evaluated and ongoing or future research may provide new knowledge.
Preliminary version of the guidelines
When the prioritising work is concluded, we compile a preliminary version of the guidelines as well as – on occasions – also shortened versions for different target groups, e.g. patients.
On the basis of the preliminary version, the decision-makers at municipal and county council (landsting) level can make an analysis of how the guidelines may affect their activities. The analyses are important to the National Board of Health and Welfare in the continued work up to the time that a final version is produced.
Final version of the guidelines
After we have collected the results of the decision-makers' impact analyses on the basis of the preliminary version, we publish a final version of the guidelines. In this final version are included the National Board of Health and Welfare’s priorities (1–10), Do Not Do and R&D.
Here are also to be found analyses of cost-effectiveness or costs on the basis of the recommendations provided by the National Board of Health and Welfare. The analyses provide information on the implications for Health and Medical Care or Social Services in following these recommendations.
The final version also includes indicators of a good standard of care. Read more about indicators under Measure and follow-up.
Measure and follow-up
In co-ordination with the work of drawing up the guidelines, a special group of experts works on so-called indicators of good care which can be used for following the development and improvement of health and medical care, social services and dental care services.
In connection with each individual guideline task, the National Board of Health and Welfare draws up a number of indicators which are central for the decision-makers and that are possible to measure.
One example of an indicator for cardiac care may be to follow up – in the different county councils (landsting) – whether patients stop smoking after a heart attack. The indicators reflect the quality of different activities and the results of the measurements may be used as background data for the development of health and medical care.
The National Board of Health and Welfare uses indicators for good care as a basis for following up how the guidelines are adhered to and how they affect practice. They are also used in the open comparisons carried out by the National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions (SALAR) in order to report and compare e.g. health and medical care services at the county council (landsting) level.