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PubMed1996

Automated application of clinical practice guidelines for asthma management.

Clinical practice guidelines will be more beneficial when they are integrated with the electronic medical record. We applied natural language processing (NLP) techniques to extract clinical findings from outpatient progress notes in an attempt to: 1) select outpatient chart notes appropriate for evaluation against the National Heart, Lung, and Blood/National Asthma Education Program clinical practice guidelines for the diagnosis and management of asthma, 2) determine patient need for inhaled anti-inflammatory agents, and 3) quantify the severity of asthma. Our results were compared to judgements by an expert panel of practitioners. We were able to correctly identify the need for inhaled anti-inflammatory agents 76% of the time. The success of this pilot project could have broad implications for the application of clinical practice guidelines.

Administration, Inhalation↗
PubMed2003

The impact of stroke practice guidelines on knowledge and practice patterns of acute care health professionals.

RATIONALE, AIMS AND OBJECTIVES: The Agency for Healthcare Research and Quality's Post-Stroke Rehabilitation Guidelines were developed to improve the quality, appropriateness and effectiveness of rehabilitation practices. An important goal of the guidelines process is to disseminate information to practitioners in order to encourage adoption of effective practices. To date, no systematic evaluation of these guidelines has been completed, nor has a programme been designed to evaluate the effectiveness of an educational programme about the guidelines. The objective was to evaluate changes in knowledge and practice following presentation of a lecture-based, educational programme about post-stroke rehabilitation guidelines. METHODS: The research design was a single group, pre-test-post-test design without a comparison group. A knowledge and referral practices questionnaire was developed specifically for this study. RESULTS: Lecture attendance was not associated with an increase in knowledge or referrals. However, we found that respondents who made more referrals at follow-up had a higher knowledge level at pre-test. Also, those who completed a follow-up assessment knew more about the guidelines at the initial assessment than did those who did not complete the follow-up assessment. In addition, doctors knew more about stroke rehabilitation than the non-doctors, both at the pre-test and follow-up. DISCUSSION AND CONCLUSIONS: Encouraging behaviour change among doctors and allied health professionals in referrals and clinical practice is a complicated process. Providing individual follow-up and lengthier contacts, assuring that care providers receive high-quality evidence that guidelines improve care, and consulting with key decision-makers about guideline implementation might enhance behaviour change.

Chicago↗
PubMed1996

The political anatomy of a guideline: a collaborative effort to develop the AHCPR-sponsored practice guideline on otitis media with effusion.

BACKGROUND: In July 1991 the Agency for Health Care Policy and Research (AHCPR) invited private organizations to develop a practice guideline on otitis media. The American Academy of Pediatrics (AAP) collaborated with the American Academy of Family Physicians, the American Academy of Otolaryngology-Head and Neck Surgery, and the Department of Pediatric Otolaryngology at the University of Pittsburgh in preparing a proposal. The AAP--the prime contractor--and the consortium were awarded the contract in October 1991. The 19-member panel assessed evidence and achieved consensus on most recommendations and maintained positive relationships that helped them function as a group. DISCUSSION: The practice guideline project has influenced the AAP's own evidence-based practice parameter methodology. Many lessons were learned. For example, since any project is only as strong as its weakest link, it was important to build the proposal on organizational strengths--including access to a combined 244,000 members and other resources. The weak links were the large number of persons involved in the project, their varying time commitments, and the wide geographic distribution of those involved. Also, neither AHCPR nor any of the organizations involved in the consortium had previous government contract experience in developing practice guidelines, so that much of the process became "on-the-job training". UPDATE: Research is needed to determine the extent to which the otitis media guideline is being used. The three academies are conducting a follow-up practice pattern variation study of pediatricians, family physicians, and otolaryngologists, which may provide data on behavior change with regard to managing the condition.

Family Practice↗
PubMed2000

A critical approach to clinical practice guidelines.

The rate of publication of clinical practice guidelines for the management of common medical illnesses continues to accelerate. The appropriate dissemination and uptake of high quality practice guidelines can synthesize evidence, improve patient outcomes and enhance the efficiency of health care delivery. However, the methodological rigour and relevance of the growing number of publications labelled 'clinical practice guidelines' vary widely. Health care payers, providers and advocates must learn to appraise and interpret guideline recommendations critically. A simple and practical nine-question approach to evaluating the quality, relevance and effectiveness of clinical practice guidelines is presented.

Practice Guidelines as Topic↗
PubMed1997

Development and use of a Guideline Entry Wizard to convert text clinical practice guidelines to a relational format.

Computerization of clinical practice guidelines (CPGs) has been proposed as one solution to enhance the use of guidelines in influencing standard clinical care. However, the conversion of text guidelines to the format required by a computer program is a major barrier. Clinicians who best understand the content of CPGs are typically ill equipped to convert textual guidelines into a computer accessible format. The potential of knowledge acquisition tools to assist in this process has been documented in the literature. In this paper we describe an application prototype, the Guideline Entry Wizard, created to assist in the conversion of text CPGs to a structured format within a relational database. We have tested this application through the input of information from several CPG. The application is a prototype for a more advanced tool. We have used this prototype to enter several CPGs and have demonstrated its effectiveness in inputting guideline content into a knowledge base.

Artificial Intelligence↗
PubMedDate not supplied

[Practice guidelines, CME and epidemiologic research in general practice: a consistent triad?].

A multidisciplinary effort involving epidemiologists, general practitioners and specialists is critical for finding valid and feasible answers, by asking the right questions through observational and experimental studies. Clinical practice guidelines may represent a good starting point of this research process, highlighting which information needs exist in everyday practice; logically, guidelines also represent an ideal end, as a means of transferring any useful knowledge produced into practice. In between, this research process may have an added educational value and represent an active and valuable means of achieving continuing medical education credits. Consistency of the research-education-guidelines triad is discussed in this paper by describing methods and results of a practical research experience--a cohort study for evaluating prevalence, incidence, chronicity and management of digestive disorders--involving epidemiologists, gastroenterologists and thirty-five general practitioners of the Emilia-Romagna region.

Education, Medical, Continuing↗
PubMed1993

Nursing specialty practice guidelines: the implications for clinical scholarship and early intervention practice. American Nurses' Association.

Specialty practice guidelines provide the nursing profession with the opportunity to examine, document, and revise practice, thus contributing to clinical scholarship and nursing science. The development and evaluation of one particular specialty practice guideline, the Children with Special Health Care Needs Guidelines, and the implications for early intervention practice are described. Recommendations for clinical research and usage for the Education of the Handicapped Act Amendment of 1986 (Public Law 99-457) are included.

Child↗
PubMed1997

The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses.

BACKGROUND: Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes. METHODS: A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper. RESULTS: A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained. CONCLUSIONS: This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

Anesthesiology↗
PubMed1994

Clinical practice guidelines: a review.

The development of clinical practice guidelines has spread from utilization review agencies to physician specialty societies, federal agencies, managed care organizations, and academic health centers as their usefulness in accomplishing the goals of healthcare reform become clear. The author reviews the mounting evidence that variation in the practice of medicine suggests that patients in some areas are not receiving all needed services, while others are receiving unnecessary services. He explores the implications of practice guidelines for improving the quality of care while controlling cost. Practice guidelines are defined and distinguished from medical review criteria. The author explores the challenges in governance, funding, and guideline development and communication that will have to be overcome to establish the credibility of practice guidelines. Finally, he addresses the opportunities for the osteopathic medical profession to establish its uniqueness in this setting.

Education, Medical↗
PubMed1999

Clinical practice guidelines and Helicobacter pylori infection in children.

The objective of this paper is to review the principles, methods and issues behind the development of clinical practice guidelines. Practice guidelines have been defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances". The ultimate goal of guidelines is to improve patient outcomes; however, they may also be used as tools to decrease health care costs, improve medical education and enhance quality assurance. Evidence-based guidelines use explicit methods to link recommendations to the quality of the underlying research. Following development of the guideline, implementation and evaluation are key steps. The ultimate aim of guideline development is to influence physician knowledge, attitudes and behaviour.

Child↗
PubMed2005

A model of ambiguity and vagueness in clinical practice guideline recommendations.

Ambiguity and vagueness in clinical practice guidelines reduce the likelihood of clinician adherence. They lead to inconsistent interpretation and, in turn, to inappropriate practice variation and medical errors. Resolving ambiguity and vagueness is an essential step in the computerized implementation of clinical practice guidelines. Successful resolution of ambiguity and vagueness requires an understanding of their characteristics, yet ambiguity and vagueness have not been differentiated, classified and described in medical context. In this paper, we propose a tri-axial model to describe ambiguity and vagueness in clinical practice guidelines: differentiation of true ambiguity from vagueness, classification of ambiguity and vagueness, intentionality and components involved. Our goals in introducing this model are: (a) to provide guidance to guideline authors to enable them to reduce inadvertent use of ambiguous or vague language, (b) to improve transparency when vague language is used deliberately and (c) to create a framework for the development of tools to apply the model during authoring and implementation of clinical practice guidelines.

Decision Making, Computer-Assisted↗
PubMed1995

The effectiveness initiative. I. Medical practice guidelines.

We examined the impact of the "effectiveness initiative" and medical practice guidelines on the practice of ophthalmology. The effectiveness initiative asserts that much of current medical practice is unnecessary or harmful, too costly, and unresponsive to patient desires. It promotes more critical review of the medical literature, research on outcomes, and stringent practice guidelines. Whereas current practice guidelines are helpful in codifying accepted procedures, they tend to sanction interventions of unproved value. Future guidelines will probably reject unproved interventions, especially if they are expensive. Although such guidelines may limit physicians' freedom of choice, they may protect them against capricious malpractice claims and unreasonable patient expectations.

Health Planning↗
PubMed1995

Practice guidelines: what the family physician should know.

Practice guidelines that specify how to treat medical conditions and perform procedures are appearing with greater frequency in the medical literature. Their use by managed care plans, hospitals and government programs is expected to affect the practice of medicine substantially in the coming years. This article reviews the key information that family physicians should have in order to evaluate and use practice guidelines effectively: how they are developed; how they differ from textbooks, review articles and other sources of expert consultation; whether they promote "cookbook medicine"; when to modify one's clinical practice in response to new guidelines, and how to cope with conflicting recommendations. Practice guidelines can improve the quality of care by summarizing current evidence and expert opinion, but they can also reduce the quality of care if the recommendations are poorly supported by scientific evidence and clinical reasoning. Economic and medicolegal concerns can also influence the potential benefits and harms of practice guidelines. Since hundreds of practice guidelines are anticipated to be developed in the coming years, family physicians should become informed consumers of guidelines, avoid accepting them on face value, and ask specific questions to judge their quality.

Family Practice↗
PubMed1997

An evidence-based approach to clinical practice guidelines in periodontics.

The use of clinical practice guidelines has received considerable attention in medicine and dentistry for improving clinical decision making and cost-effective care. Leaders in dentistry are increasingly calling for improved standardization of treatment through the development of clinical practice guidelines based on empiric clinical evidence. Guidelines have been shown to minimize treatment variability and ensure the quality and cost-effectiveness of care. Other potential applications include educating individuals or groups; development of quality indicators; improved allocation of resources such as insurance payment decisions; and reduced risk of liability for negligent care. Recently, a series of evidence-based clinical algorithms and practice guidelines were developed for regenerative periodontal treatment. Such guidelines have the potential to improve outcomes of periodontal care for providers, patients, and other interested parties. This review discusses the rationale for guideline development and the role of clinical practice guidelines in the area of periodontal decision making and provision of care.

Decision Making↗
PubMed1996

Social work with suicidal clients: challenges of implementing practice guidelines and standards of care.

Practice guidelines and standards of care are detailed models of intervention processes that describe goals, objectives, processes procedures, and interactions. Disciplines other than social work have developed practice guidelines, and it is appropriate for social work to also define standards or guidelines. This article describes an attempt by hospital social work staff to enact social work standards of care for suicidal clients. The difficulties and challenge of developing standards and guidelines are discussed and reasons for the lack of success of the attempt are highlighted.

Humans↗
PubMed2001

A prospective cohort study of practice guidelines in inflammatory bowel disease.

OBJECTIVES: Practice guidelines should improve care, but they are not routinely followed, in part because of lack of proven benefit. We evaluated the effect of introducing guidelines for inflammatory bowel disease (IBD) on practice variation and the IBD Quality of Life (IBDQ) score. METHODS: This was a prospective, controlled, cohort study. A total of 65 patients were matched according to month of visit, diagnosis, and disease activity with control subjects seen 1 yr earlier. Physicians were educated throughout the study regarding the guidelines. Variation was measured by the Mayo Practice Guideline Score (MPGS), a 15-point assessment of documentation of diagnosis, nutrition, social support, education, functional status, and treatment. The IBDQ was measured at baseline and at 1 yr in the intervention group and after 1 yr in the control group. RESULTS: The MPGS was significantly higher in the intervention group compared to the controls (p = 0.002), with median values of 12 versus 11. The IBDQ median score increased significantly in the intervention group (p < 0.001), baseline median of 133 versus 15-month median of 184. However, the final IBDQ was not significantly higher in the intervention group than in the controls (p = 0.33). CONCLUSIONS: Practice guidelines for IBD reduce practice variation. The quality of life improved significantly compared to baseline with practice guidelines, but not compared to controls, perhaps because of the small sample size and homogenous practice setting. The MPGS is a tool that can be used in day-to-day management of IBD patients.

Adult↗