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Guideline Summary
Guideline Title
Bone cancer and soft tissue sarcoma. In: Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities.
Bibliographic Source(s)
Bone cancer and soft tissue sarcoma. In: New Zealand Guidelines Group. Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2009. p. 103-9.
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Suspected bone cancer (primary or secondary)
  • Suspected soft tissue sarcoma
Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Clinical Specialty
Family Practice
Internal Medicine
Oncology
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
  • To produce evidence-based best practice guidelines to help health care practitioners, policy makers, and consumers make decisions about health care in specific clinical circumstances
  • To help practitioners in primary care:
    • Recognise the signs and symptoms that are suggestive of a cancer diagnosis in primary care
    • Refer people in a timely manner where cancer is suspected
    • Be aware of the investigations that may be appropriate to undertake in the primary care setting
  • To present specific recommendations for bone cancer and soft tissue sarcoma investigation and referral

Note: Cancer screening, health promotion and prevention, case-finding in asymptomatic people, recurrence of a previous cancer and metastatic cancer were beyond the guideline scope and therefore are not included. Furthermore, the guideline does not cover all clinical scenarios or medical emergencies. Referral between secondary and tertiary care, and within each of these settings, is also not covered.

Target Population

Patients in New Zealand (including ethnic minorities such as Māori and Pacific peoples) in primary care setting suspected of having bone cancer or soft tissue sarcoma

Interventions and Practices Considered
  1. Assessment of signs and symptoms
  2. Referral for investigations (x-ray if bone cancer is suspected and ultrasound, magnetic resonance imaging [MRI], or computed tomography [CT] if soft tissue sarcoma is suspected)
  3. Biopsy of lumps in subcutaneous tissue only
  4. Referral to a specialist
Major Outcomes Considered
  • Incidence of bone cancer in Māori and non-Māori peoples
  • Mortality rate in Māori and non-Māori peoples

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Review of the Literature

General Comments

Two relevant, general guidelines were identified as part of the scoping process: Referral Guidelines for Suspected Cancer published by the Scottish Cancer Group in 2002 and by the National Institute for Health and Clinical Excellence (NICE) in 2005. These guidelines were developed for use within the National Health Service in Scotland and within the National Health Service in England and Wales, respectively. The NICE guideline, being the more recent and extensive, was appraised for methodological quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. As it was deemed to be well-developed and suitable for updating, the decision was made following review and Guideline Development Team (GDT) discussion that it should be used as the 'seeding' or base guideline for this New Zealand guideline. However, the GDT noted that disparity and access to care were not covered, and that the guideline would need further, in-depth review, taking account of the New Zealand context. The GDT decided that the New Zealand guideline should include all common cancers and exclude 'cancer of unknown origin' (i.e., metastatic cancer). All cancers covered in the NICE guideline were therefore included. In addition, the GDT viewed it necessary to consider primary liver cancer due to its high prevalence in the Māori and Pacific populations and hence relevance in the New Zealand context.

The New Zealand GDT and research team, just as the Guideline Development Group from the NICE guideline, experienced difficulty in developing search strategies for locating relevant and meaningful evidence. Little evidence was found from study designs located at higher points of the level of evidence hierarchy. Most of the literature was therefore of case-series design, rather than systematic review or meta-analysis, and therefore was not amenable to quality assessment using formal critical appraisal methods. Furthermore, it was inappropriate to extrapolate findings from secondary care, yet only a small volume of evidence was sited in the primary care setting. In light of these factors, reliance needed to be placed on the clinical and practical experience of the GDT, and their expert knowledge of the literature, to direct the research team to appropriate literature where gaps were perceived in the evidence presented by NICE.

The research team determined inclusion criteria for each clinical question and designed literature searches with the help of the Wellington School of Medicine Information Specialist. Only studies published in English were included.

Full details of the following are available on request: search strategies with the search date; inclusion criteria; excluded studies (including the reason for exclusion).

The following databases were searched from 1996 (or later) depending on the key question:

  • Medline
  • EMBASE
  • Cinahl
  • Cochrane Library
  • Australasian Medical Index
  • Index New Zealand
  • National Guideline Clearinghouse
  • Kings Fund Guidelines
  • Turning Research Into Practice [TRIP]
  • International Network of Agencies for Health Technology Assessment [INAHTA]
  • New Zealand Health Technology Assessment [HTA]
  • Guidelines International Network [GIN]

Refer to Appendix A of the original guideline document for more information.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

+ Assigned when all or most of validity criteria met

~ Assigned when some of criteria met and where unmet criteria are not likely to affect the validity, magnitude/precision or applicability of the results markedly

x Assigned when few or none of the criteria met

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Once clinical questions were defined (see Appendix A of the original guideline document for the full list of clinical questions), a literature review of the evidence for each clinical question was undertaken, relevant studies and guidelines were appraised for quality, and evidence tables were compiled. For study designs where no appraisal checklist was available (e.g., case-series) a brief narrative overview was prepared. Guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. An overall summary of the body of evidence for each question (a 'Considered Judgment Form') was then prepared. Before each meeting of the Guideline Development Team (GDT), evidence tables for a set of clinical questions were circulated to team members, together with the Considered Judgment Forms. The GDT reviewed and discussed the evidence in the light of their clinical experience, and recommendations and good practice points were drafted by consensus.

Details of the Grading System

The evidence was assessed and graded, and recommendations were developed using the three-step process described in the New Zealand Guidelines Group (NZGG) Handbook for the Preparation of Explicit Evidence-based Clinical Practice Guidelines (New Zealand Guidelines Group, 2003).

Step 1: Study Appraisal

Studies that met the inclusion criteria for each clinical question were appraised and graded for quality, using relevant checklists developed by the Scottish Intercollegiate Guidelines Network (SIGN). These were modified to incorporate summary levels of evidence for the validity, magnitude/precision of effect and applicability of each study. An overall summary level of evidence was assigned to each study (see the "Rating Scheme for the Strength of the Evidence" field).

Intermediate grades (+/~, ~/x) were assigned when overall study quality fell between these categories. Studies that met few or none of the quality criteria were excluded.

For every study included in the evidence review, the level of evidence assigned is listed alongside the citation in the reference list at the end of the original guideline document.

Step 2: Weighing the Evidence

Evidence tables were prepared for each clinical question and were summarised on 'Considered Judgment Forms.' The GDT considered the body of evidence and made recommendations, based on the validity, quantity, consistency and clinical impact of the whole body of evidence.

Step 3: Developing Recommendations

Grading of the recommendations was based on the quality of the evidence, which does not equate to the importance of the recommendation. When there was no evidence to answer a specific question, recommendations were based on the consensus of the GDT and were classified as 'good practice points'.

Methods Used to Formulate the Recommendations
Informal Consensus
Description of Methods Used to Formulate the Recommendations

In January 2007, New Zealand Guidelines Group convened a multidisciplinary Guideline Development Team (GDT). GDT members were nominated by a diverse range of stakeholder groups, including the Royal New Zealand College of General Practitioners, Royal Australian and New Zealand College of Radiologists, oncology specialists, Pasifika Medical Association, Te Ora and consumers (see Appendix B of the original guideline for a list of the GDT members).

Seven meetings of the full GDT were held. The aim of the first meeting was to train members of the GDT in the processes of guideline development, make decisions about the scope of the guideline and identify relevant clinical questions within the parameters initially set by the Ministry of Health. The Referral Guidelines for Suspected Cancer published by the National Institute for Health and Clinical Excellence (NICE) in 2005 and developed in relation to the National Health Service in England and Wales, is acknowledged as the 'seeding document' for this New Zealand guideline. Other relevant clinical guidelines were identified and some preliminary literature searching conducted to help in defining appropriate clinical questions.

Once clinical questions were defined (see Appendix A of the original guideline document for the full list), a literature review of the evidence for each clinical question was undertaken, relevant studies and guidelines were appraised for quality, and evidence tables were compiled. For study designs where no appraisal checklist was available (e.g., case-series) a brief narrative overview was prepared.

Development of Recommendations and Good Practice Points

The GDT reviewed the available evidence and systematically discussed each of the NICE guideline recommendations and the recommendations from any other relevant national clinical guidelines in the context of their clinical practice. The recommendations for this New Zealand guideline were developed by informal consensus.

In formulating recommendations if, in the opinion and experience of the GDT, significant or material changes to the English or other national guidance was deemed appropriate for New Zealand, the recommendation was framed as a good practice point. In cases where other national recommendations were accepted, minor wording modification was often required to reflect the style of New Zealand Guidelines Group recommendations.

In line with the NICE guidance, recommendations were rarely made on risk factors in their own right. Due to the difficulties of establishing the degree of risk attributable to various factors for different cancers (in particular the complex interaction between risk factors such as age and environmental exposure) the GDT decided not to routinely document relative or absolute risk. With respect to developing recommendations, the GDT were cautious in their inclusion of risk factors. Risk factors were considered to be most useful when combined with specific signs or symptoms.

Summary

The aim of the GDT was to produce a relevant, evidence-based, clinically useful and user-friendly document for practitioners in primary care. By necessity, the expert knowledge and experience of the GDT was invaluable in bridging the gap between international expert opinion (the NICE guideline recommendations), limited robust evidence and practice in the New Zealand context. For this reason, no recommendation in this guideline received a rating higher than a C grading. See the "Rating Scheme for the Strength of the Recommendations" field.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendations

Description Grade
The recommendation is supported by good evidence (based on a number of studies that are valid, consistent, applicable and clinically relevant) A
The recommendation is supported by fair evidence (based on studies that are valid, but there are some concerns about the volume, consistency, applicability and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence) B
The recommendation is supported by international expert opinion C
Grades indicate the strength of the supporting evidence rather than the importance of the recommendation

Good Practice Points

Where no evidence is available, best practice recommendations are made based on the experience of the Guideline Development Team, or feedback from consultation within New Zealand.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

A draft of this guideline was circulated to 337 individuals and organisations for comment in August 2008 as part of the peer review process. Refer to Appendix C in the original guideline document for the list of organisations and individuals who sent comments.

Recommendations

Major Recommendations

Definitions for the Grades of Recommendation (A-C) and Good Practice Points are provided at the end of the "Major Recommendations" field.

Bone Cancer and Soft Tissue Sarcoma

A person presenting with increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp, should undergo urgent investigation by the practitioner*. (Grade C)

* Recommendation consistent with: Referral guidelines for suspected cancer. NICE clinical guideline 27. 2005.

Bone Cancer

A practitioner should urgently refer a person to a specialist if their x-ray result indicates possible bone cancer.* (Grade C)

A person with a normal x-ray but persistent symptoms should undergo follow-up and/or a repeat x-ray, or should be referred to a specialist. Other investigations may be useful dependent upon the clinical findings.* (Grade C)

* Recommendation consistent with: Referral guidelines for suspected cancer. NICE clinical guideline 27. 2005.

Good Practice Points

  • A person with symptoms or signs suggestive of primary or secondary bone cancer should have an x-ray completed and reported within 5 days.
  • A practitioner should consider primary or secondary bone cancer in a person where a fracture is suspected in the absence of a history of trauma.

Soft Tissue Sarcoma

A person with human immunodeficiency virus (HIV) disease and suspected Kaposi's sarcoma should be referred to a specialist.* (Grade C)

* Recommendation consistent with: Referral guidelines for suspected cancer. NICE clinical guideline 27. 2005.

Good Practice Points

  • A person with an unexplained palpable soft tissue lump (i.e., excluding a sebaceous cyst or lipoma) that is increasing in size, or hard, fixed or tethered should undergo an appropriate imaging investigation of the lump (ultrasound, magnetic resonance imaging [MRI] or computed tomography [CT] scan) and should be referred to a specialist before any biopsy or fine needle aspirate.
  • For a person presenting with symptoms and/or signs suggestive of soft tissue sarcoma, referral for an ultrasound, MRI or CT scan may be made, but this should not delay referral to a specialist.
  • A practitioner may excise or biopsy lumps in subcutaneous tissue, but should refer a person with a lump beneath deep fascia to a specialist.

Definitions:

Grades of Recommendations

Description Grade
The recommendation is supported by good evidence (based on a number of studies that are valid, consistent, applicable and clinically relevant) A
The recommendation is supported by fair evidence (based on studies that are valid, but there are some concerns about the volume, consistency, applicability and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence) B
The recommendation is supported by international expert opinion C
Grades indicate the strength of the supporting evidence rather than the importance of the recommendation

Good Practice Points

Where no evidence is available, best practice recommendations are made based on the experience of the Guideline Development Team, or feedback from consultation within New Zealand.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field). The recommendations are either supported by international opinion (grade C) or are "Good Practice Points" that represent the opinion of the Guideline Development Team or were developed after feedback from consultation within New Zealand.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Increased clinician readiness to consider a cancer diagnosis
  • Reduced disparity in cancer diagnosis and outcomes amongst ethnic minorities
  • Improved access to care
  • Appropriate care of patients with symptoms or signs suggestive of bone cancer and soft tissue sarcoma, including timely referral to specialists or investigations
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • While New Zealand Guidelines Group (NZGG) guidelines represent a statement of best practice based on the latest available evidence (at the time of publishing), they are not intended to replace the health practitioner's judgment in each individual case.
  • The development of this guideline proved to be particularly challenging for both the Guideline Development Team (GDT) and research team for several reasons. Developing appropriate search strategies to answer the clinical questions was problematic, and there were often limitations in the evidence located in terms of quality and scope. It was identified that for many cancers there has been a dearth of evidence published since the National Institute for Health and Clinical Excellence (NICE) guideline. Furthermore, the bulk of the research literature identified used research designs that precluded critical appraisal using formal assessment tools. In addition, little research was conducted in the primary care setting.

Implementation of the Guideline

Description of Implementation Strategy

At the time of writing this chapter of the original guideline document, the Ministry of Health has advised it intends to contract out the development of an implementation plan for this guideline. This section therefore provides only a brief overview of implementation issues.

Overview

If guidelines are to achieve their intended objectives, they must be implemented in ways that support, encourage, and facilitate their use. Factors at individual, regional and organisational levels have been identified as influencing guideline implementation. One of the difficulties encountered internationally is that guideline implementation occurs in the context of conflicting pressures for clinical autonomy, professional standardisation and quality improvement. Adopting any new innovation or medical knowledge needs to be considered in context. Principled and structured approaches to the development of implementation solutions are necessary following guideline development, where key steps include:

  • Analysis of gaps between current and best practice
  • Prioritisation of these gaps in terms of impact on population health; in the context of this guideline, prioritisation needs to take into account issues of disparity in access and health outcomes between Māori, Pacific people and people who are non-Māori and non-Pacific
  • Identification of actions, barriers and enablers that either exacerbate or ameliorate gaps; in the context of this guideline, barriers which reinforce disparity are likely to include costs of care; communication; structural barriers; cultural fit (see Box 1.1 in the original guideline document)
  • Development of strategies to reduce barriers, and to close gaps; in the context of this guideline, specific action is likely to be required to improve the access and care of Māori and Pacific populations.

Organisational level barriers can include inappropriate skill levels to implement recommendations, a lack of facilities or equipment, or time and resource constraints. Structural change also impacts on implementation as changing roles and responsibilities make it difficult to know where to focus implementation activities and to provide the support needed for change. Regional issues may include a misalignment between local current practice and desired practice.

Both practitioner and patient variables can reinforce individual barriers to guideline implementation. Practitioners' attitudes and beliefs, their opinions about best practice, and their skill level and previous experience all influence how likely they are to implement guideline recommendations in their everyday practice. Patients can also influence implementation with their own knowledge and attitudes about what they expect. For example, a person may not feel they have received an appropriate level of care unless they receive 'treatment' from a general practitioner, often in the form of medication or referral, even when this is not clinically indicated.

Multilevel Approach

Guideline implementation initiatives are unlikely to achieve their objectives without explicit consideration of a multilevel approach to change. To this end, the New Zealand Guidelines Group (NZGG) has identified four principles which should characterise implementation. These are:

  1. Strong visibility of the guideline
  2. Multifaceted approaches to support both health care professionals and patients to adopt guideline recommendations
  3. Recognition that all implementation activities should be considered across their national, regional and local contexts. Central agencies (such as the Ministry of Health or NZGG) should trust, facilitate and create opportunities for change, not attempt to 'direct' it
  4. A commitment to supporting the sector to measure performance in implementing guideline recommendations.

Key Priorities for Implementation of This Guideline

This guideline offers several key recommendations for practitioners relevant to all of the cancers addressed in this guideline. Four overarching priorities are common to these key recommendations:

  • That all indications for referral are picked up
  • That timely and appropriate investigations are ordered, and followed-up as appropriate
  • In view of disparities in access and health outcomes between Māori and non-Māori, that Māori-specific cancer services or service components should be provided where a need is identified, and that service providers should improve culturally competent, patient-centred care by monitoring practice, including review of patient experiences
  • That patients, families and carers can access appropriate support and information.

Broad Guideline Dissemination

In the experience of the New Zealand Guidelines Group, a guideline's key messages should be disseminated as widely as possible, as part of the initial awareness-raising of a new guideline and to support implementation activities. In this case, key audiences are primary health practitioners, patients and support services throughout New Zealand, via dissemination in multiple formats.

NZGG has been funded to develop summary statements of the most important recommendations for general practitioners. This should be followed up by the production of materials for use in primary care clinical training. Publicity of this guideline should also be sought in the academic, clinical professional and public media, and consideration should be given to production of materials for other audiences, including patients, their family/whänau and carers, professional associations, health care and social service agencies, and the voluntary sector.

See the "Implementation" chapter in the original guideline document for information on other potential implementation activities and the implementation plan.

Implementation Tools
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Bone cancer and soft tissue sarcoma. In: New Zealand Guidelines Group. Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2009. p. 103-9.
Adaptation

This guideline has been adapted from Clinical Guideline 27: Referral Guidelines for Suspected Cancer; published by the National Institute for Health and Clinical Excellence (NICE), June 2005 and available from www.nice.org.uk External Web Site Policy. Extracts from the NICE clinical guideline have been reproduced with the permission of NICE. The original NICE recommendations were prepared in relation to the National Health Service (NHS) in England and Wales. NICE has not been involved in the development or adaptation of the NICE recommendations for use in New Zealand or in checking that its recommendations have been reproduced accurately.

Date Released
2009 Sep 1
Guideline Developer(s)
New Zealand Guidelines Group - Nonprofit Organization
Source(s) of Funding

Ministry of Health

Guideline Committee

Guideline Development Team

Composition of Group That Authored the Guideline

Team Members: Jim Vause (Chair), General Practitioner, Blenheim, Medical Web Editor, WONCA (World Organisation of National Colleges and Academies of General Practice/Family Practice), Member of the NZGG Advisory Board, Invited by NZGG; David Bratt, Primary Care Advisor, Capital & Coast Health, Wellington, Invited by NZGG; Trevor FitzJohn, Radiologist, Pacific Radiology, Wellington, Nominated by the Royal Australian and New Zealand College of Radiologists; Helen Gemmell, General Practitioner, Auckland, Nominated by the Royal New Zealand College of General Practitioners; Josephine Aumea Herman, Pacific Perspective, Chief Executive Officer, Pasifika Medical Association, Auckland, Nominated by the Pasifika Medical Association; Peter Jansen, Māori Perspective, General Practitioner, Mauri Ora Associates, Auckland, Nominated by Te ORA; Scott MacFarlane, Paediatric Oncologist, Starship Children's Hospital, Auckland, Nominated by the Paediatric Oncology Steering Group; Brian McAvoy, General Practitioner, Auckland, Invited by NZGG; Maureen Morris, Nurse, Auckland District Health Board, Auckland, Nominated by the College of Nurses Aotearoa (NZ) Inc.; Kathy O'Sullivan, Cancer Information Nurse, Cancer Society of New Zealand, Auckland, Nominated by the Cancer Society of New Zealand and New Zealand Cancer Control Trust; Joy Percy, Palliative Care Specialist, MidCentral Health, Palmerston North, Nominated by the Australian and New Zealand Society of Palliative Medicine; Nic Russell, Consumer Perspective, Chairperson of Kenzie's Gift, Auckland, Nominated by Breast Cancer Aotearoa Coalition Steering Committee; Richard Sullivan, Medical Oncologist, Auckland Hospital, Auckland, Nominated by the Royal Australasian College of Physicians; New Zealand Society for Oncology; Tane Taylor, Māori Perspective, General Practitioner, Auckland, Nominated by Te ORA; Michelle Thomas, Consumer Perspective, Member Services Manager, Canteen National Office, Grafton, Auckland, Nominated by Canteen National Office; Jocelyn Tracey, General Practitioner and Clinical Director of PHOcus on Health, Golden Bay, Invited by NZGG

Financial Disclosures/Conflicts of Interest

Dr Peter Jansen is a Director of Mauri Ora Associates and is Medical Advisor to ACC Treatment Injury Unit.

Guideline Endorser(s)
Cancer Society of New Zealand - Disease Specific Society
New Zealand Association of Cancer Specialists - Disease Specific Society
Royal Australian and New Zealand College of Radiologists - Professional Association
Royal New Zealand College of General Practitioners - Medical Specialty Society
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) and as an e-book from the New Zealand Guidelines Group Web site External Web Site Policy.

Print copies (New Zealand only): Available from the New Zealand Guidelines Group Inc., Level 10, 40 Mercer Street, PO Box 10-665, The Terrace, Wellington, New Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail: info@nzgg.org.nz or through Wickliffe by phoning (04) 496 2277, quote order no. HP: 4768.

Availability of Companion Documents

The following is available:

Print copies: Available from the New Zealand Guidelines Group Inc., PO Box 10-665, The Terrace, Wellington, New Zealand; Tel: 64 4 471 4188; Fax: 64 4 471 4185; e-mail: info@nzgg.org.nz or through Wickliffe by phoning (04) 496 2277, quote order no. HP: 4769.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 15, 2010. The information was verified by the guideline developer on December 3, 2010.

Copyright Statement

The copyright owner of this publication is the Ministry of Health, which is part of the New Zealand Crown. Content may be reproduced in any number of copies and in any format or medium provided that it is not changed, sold, used to promote or endorse any product or service, used in any inappropriate or misleading context, and a copyright acknowledgement to the New Zealand Ministry of Health is included.

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