Country update - Portugal and the IberoGPC

• Portugal

• The Ibero American Network for Clinical Practice Guidelines (Red/E Iberoamericana de Guias para la Calidad de La Asistencia Sanitaria/Rede de Diretrizes para a Qualidade Sanitária)

Portugal

Portugal is an Atlantic country with one continental and two autonomous island regions (Madeira and Açores). In 2007 the overall population was 10.6 million.

The Portuguese national health system is composed by 3 different sub-systems: a public National Health Service (NHS) with universal coverage (±80%), funded by the public budget (taxes); a group of sub-systems with social health insurance covering defined professions (±25%) and, finally, private insurance bought by individuals (±17%).

In 2007 there were 36844 doctors and 50634 nurses, with a ratio of 3,6 doctors and 5 nurses per 1000 people. There are 126,257 health professionals (23,125 doctors, 36,509 nurses, 4,840 pharmacists and 7,715 allied professionals) working for the NHS. Total health expenditure is around 9.8% of the national product and two thirds of the population find the NHS good or very good.

In Portugal there are several organizations responsible for designing, disseminating and/or implementing clinical practice guidelines (CPGs) :

• Hospitals and primary care doctors
• Nurses and pharmacists
• Professional societies
• Academic institutions
• Pharmaceutical industry
• Government
• General Directorate of Health
• High Commissariate of Health
• Primary Care Management Department
• Private institutions

Most CPGs are national in scope, but quite a few are developed locally, with varying methodologies. The majority of CPGs are thought as health quality development and maintenance tools, to be used at all levels of the NHS. Very frequently CPGs are used as basis for audit and certification processes, and a national health quality indicators system is widely implemented.

The selection of topics for CPGs depends on the issuing organization, but most are therapeutic, followed in number by diagnostic and finally clinical management. Most of the diseases/conditions selected to be addressed by a CPG are prevalent pathologies, with significant burden and cost, present wide practice variations and have good quality evidence to support them. Table 1 shows the topics developed on CPGs over the last 2 years.

Table 2 – Clinical practice guidelines at primary and hospital care

CPGs dissemination techniques in Portugal follow the patters normally found in these instances: as a printed format, electronic (pdf), online access and publication in medical journals and in medical media.

Depending on the issuing organization, CPGs are implemented in diverse ways, always considering 3 strategic points:

• The health professional and the patient population
• The quality of the local health system
• The characteristics of management (clinical and administrative)

Implementation strategies at the Portuguese NHS encompass several techniques, alone or combined:

1. Direct personal contact between CPGs developers and final users (practical courses, workshops, etc.)
2. Electronic or paper memorandum alerts
3. Small group practical teaching with advanced teaching/learning systems (problem-based learning, decision analysis, simulations, case discussion, etc.)
4. Audit and feedback
5. Involvement of opinion leaders as well as other stakeholders
6. Patient information and education
7. Mass media campaigns for the general public.

The degree of compulsoriness of CPGs depends on the topics as well as the responsible organization. For example, the vaccination scheduled recommended by the General Directorate of Health is mandatory for primary care physicians, while the CPGs for diagnosis and treatment of arterial hypertension from the Portuguese Society of Cardiology are optional.

There are several recent examples of the role of CPGs in the Portuguese NHS, illustrating several possible contexts of its use. Two of the most relevant are the primary care reform and the recently created Department of Quality in Health of the General Directorate of Health:

• there was recently introduced a major reform in primary care in Portugal, with the creation of Health Family Units. These are composed by doctors, nurses and administrative personnel, working autonomously with defined budgets based on periodic audits, with local implementation of CPGs (concerning most prevalent diseases). In this system, evidence-based guidelines are of utmost importance, since they are linked with the clinical activities financing
• the newly created Department of Quality in Health of the General Directorate of Health has developed a quality system with clinical indicators, CPGs implementation, patient safety procedures, recertification of health units and hospitals, etc. and soon there will be a national certification system based on well tested variables, taken from CPGs.

All these developments at the Portuguese NHS will assure a central role for Clinical Practice Guidelines not only in the present, but also in the future.

The Ibero American Network for Clinical Practice Guidelines (Red/E Iberoamericana de Guias para la Calidad de La Asistencia Sanitaria/Rede de Diretrizes para a Qualidade Sanitária)

The Ibero American Network for Clinical Practice Guidelines (IberoGPC) is a platform for systematization, communication and interchange of scientific knowledge and research on clinical practice guidelines, as well as health quality systems and initiatives, among Portuguese and Spanish speaking countries.

Its mission is to improve communication among its members and with the Guideline International Network (G-I-N).

The objectives of the IberoGPC include (briefly):

• Development of a virtual network among countries and organizations devoted to guideline production and implementation, namely on health quality assurance and maintenance
• Sharing methodological data on guideline production, dissemination and implementation facilitated by common languages
• Creation and maintenance of a database on guideline development in all participating countries
• Identification and promotion of topics of cooperation among partners, as well as experiences on continuous medical education in guidelines
• Strengthening the cooperation with GIN
• Increasing international visibility of health research in Spanish and Portuguese languages.

The IberoGPC was founded in 2003 at a meeting in Porto Alegre, Brazil, promoted by 7 countries (Portugal, Brazil, Spain, Colombia, Panama, Chile and Ecuador). It is based in Seville, Spain and its President is Dr. Ignacio Marin Leon, also from Seville.

Presently the IberoGPC has 49 members from 17 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Honduras, Mexico, Paraguay, Peru, Portugal, Spain, Uruguay and Venezuela. The Pan-American Health Organization (OPS/OMS-USA) is also a Member.

The IberoGPC has organized annual meetings since 2004 in the following places: 2004 in Porto Alegre (Brazil), 2005 in Santiago de Chile (Chile), 2006 in La Habana (Cuba), 2007 in Cartagena de las Indias (Colombia) and 2008 in San Juan (Costa Rica). In 2009 the IberoGPC meeting will be held in Lisbon, Portugal on the 30-31 October, right before the GIN Annual Conference. For the first time the two networks will have their annual scientific meetings back-to-back, allowing easy attendance to both events.

The IberoGPC publishes several documents and positions papers on scientific areas pertaining to its activities, and offers a significant number of courses and workshops on guideline development and implementation. It has also close links with Evidence-Based Medicine Centers in various countries, as well as Cochrane Centers for Portugal and Spain as well as Central and South Americas.

Further information can be found at the IberoGPC website www.iberoamericanagpc.org/.