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Results for “Practice Guideline”

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PubMed1996

The role of psychotherapy in the treatment of depression: review of two practice guidelines.

We review two recent practice guidelines' assessments of the role of psychotherapy in the treatment of major depression in adults. We examine the practice guideline published by the American Psychiatric Association (APA) and that published by the Depression Guideline Panel of the Agency for Health Care Policy and Research. We focus on the guidelines' evaluations of psychotherapies, their statements about the role of psychotherapy in first-line treatment of depression, and the procedures they recommend for choosing among psychotherapies. We argue that the APA guideline understates the value of cognitive, behavioral, brief psychodynamic, and group therapies. Both guidelines understate the value of psychotherapy alone in the treatment of more severely depressed outpatients. The APA guideline overvalues the role of combined psychotherapy-pharmacotherapy regimens, particularly in view of the greater cost of this strategy. The APA guideline also makes recommendations about choosing among psychotherapies that are not well supported by empirical evidence. We conclude with some guidelines for guideline development.

Adult↗

PubMed2002

Verification of temporal scheduling constraints in clinical practice guidelines.

The computerization of clinical practice guidelines is a significant scientific challenge for the medical informatics community. One frequently reported factor hindering this objective is the existence of deficiencies within guideline knowledge. In this paper, we focus on the detection of flaws within temporal scheduling constraints. Temporal scheduling constraints are important elements of therapy management, and are frequently incorporated in clinical practice guidelines. We present a suitable verification method that is based on calculating the minimal network of temporal constraints on the execution of guideline activities. Our method serves three purposes: (1) it checks whether temporal scheduling constraints are consistent with scheduling constraints implied by control flow operators and the hierarchical structuring of a guideline; (2) it yields suggestions for an equivalent, yet more explicit representation of non-minimal constraints; (3) it can be used by the guideline interpreter to assemble feasible time intervals for the execution of each guideline activity. We evaluate our approach by applying it to a guideline specified in the Asbru language. For this purpose, we implemented a prototype verifier. Although we concentrate on the guideline representation language Asbru as the demonstration medium of our method within this paper, our approach can be reused to verify several alternative guideline representation formats.

Humans↗

PubMed1999

Evolution of physicians' attitudes towards practice guidelines.

OBJECTIVES: To assess changes in physicians' attitudes towards practice guidelines and towards the role of empirical evidence in their development. METHODS: The findings from two surveys carried out in 1993 and 1997 on the same random sample from two Italian medical specialty societies were compared. In both studies, physicians were mailed a questionnaire asking their views on the goals and role of practice guidelines in influencing clinical decision-making, and the role of empirical evidence versus subjective clinical experience in their development. RESULTS: One hundred and seventy physicians participated in both surveys. An increasing proportion of physicians accepted that cost containment could be a legitimate goal of practice guidelines (from 26% in 1993 to 40% in 1997; P = 0.010). More clinicians (43% in 1993 and 57% in 1997; P < 0.01) supported the use of empirical evidence, as opposed to subjective clinical experience, as the primary basis for practice guidelines. Although only a tiny minority of physicians (6% in 1993 and 1997) supported the view that practice guidelines should reflect patient preferences, an increased proportion of physicians supported the participation of representatives from outside the medical profession in their development. The level of support increased from 6% in 1993 to 26% in 1997 (P < 0.001) in the case of consumers, from 24% to 38% (P = 0.015) for patient involvement and from 16% to 33% (P = 0.003) in the case of health care administrators. CONCLUSIONS: The documented changes suggest that more clinicians acknowledge the role of empirical evidence and the need for a dialogue with other professionals and patient groups in the development of practice guidelines than was the case in the recent past.

Adult↗

PubMed2000

Clinical practice guidelines and the cost of care. A growing alliance.

UNLABELLED: Healthcare policy, medical practice, and cost of care are no longer considered distinct entities. Each is an integral factor in determining not only what, but how, patient care will be delivered. Clinical practice guidelines are the lynchpin that connects them. This paper addresses the various components of the clinical practice guideline--cost alliance. OBJECTIVE: To examine the bidirectional influence of choice of care on costs and of cost of care on decision making. METHODS: The literature was used to identify cost-related factors that influence development of guidelines and change in physician practice behavior. In a MEDLINE search with modifiers to the keywords "clinical practice guidelines," particular attention was paid to identifying surveys of practitioners. An analysis, prompted by a recently published guideline, of treating penetrating intraperitoneal colon injuries by different surgical approaches (primary repair versus diverting colostomy) exemplified how implementation of a guideline can affect the cost of care. Inpatient cost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in 1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases from California and Massachusetts. RESULTS: The results showed that a substantial savings in hospital costs was achieved when a primary repair surgical technique, as advocated by the guideline, was used. The effect of cost influences on the development of clinical practice guidelines was established by demonstrating the cyclical effect between usual and customary practices, guideline implementation, changing practice patterns, and the economic considerations influencing the process. CONCLUSIONS: A growing, albeit uneasy, alliance between costs and clinical practice guidelines is evident.

Colon↗

PubMed2003

Keeping cancer guidelines current: results of a comprehensive prospective literature monitoring strategy for twenty clinical practice guidelines.

OBJECTIVES: To describe a methodology used to keep practice guidelines up to date and to summarize data collected during the first year of implementing this plan with a cancer practice guidelines program. METHODS: The updating strategy includes regular searches of peer-reviewed literature and meeting proceedings, review and interpretation of new evidence, review and revision of clinical recommendations, and notification to practitioners and policy makers about new evidence and its impact on recommendations. RESULTS: Eighty pieces of new evidence were found relating to seventeen of the twenty guidelines included in this study. On average, four pieces of new evidence were found per guideline, but there was considerable variation across the guidelines. Of the eighty pieces, nineteen contributed to modifications of clinical recommendations in six practice guidelines, whereas the remaining evidence served to support the original recommendations. None of the modifications led to changes that advised against original recommendations. MEDLINE, the Cochrane Library, and meeting proceedings yielded many pieces of evidence, whereas CancerLit and HealthStar did not contribute significantly to the overall yield. Furthermore, key pieces of evidence that led to modifications to the recommendations were often identified by members of the disease site groups before appearing in electronic databases. CONCLUSIONS: The updating process is resource intensive but yields important findings. In response to this evaluation, the updating protocol has been revised such that literature searches are conducted quarterly and the scope of sources searched routinely is restricted to MEDLINE, the Cochrane Library, and meeting proceedings.

Diffusion of Innovation↗

PubMedDate not supplied

Implementing nursing practice guidelines: a complex undertaking.

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.

Canada↗

PubMed2000

Evidence-based clinical practice guidelines.

Evidence-based practice is a process, encompassing research utilization, clinical expertise, and appreciation of the unique needs of patients. Clinical practice guidelines are tangible evidence of an environment that fosters evidence-based practice. Development and evaluation of guidelines need to be research-based, and the implementation needs to be styled for the particular organization.

Evidence-Based Medicine↗

PubMed1997

[Practice guidelines in dentistry. An insight into the Dutch situation].

Practice guidelines provide opportunities for monitoring and improving dental health care. A survey was conducted among 78 departments at dental societies, scientific dental associations and health care insurance companies in the Netherlands to obtain insight into the number and quality of practice guidelines available. The response rate was 67%. Written materials were analysed and 21 practice guidelines were identified as such. The results of the analysis indicate that many initiatives to construct and implement practice guidelines have been taken. However, these initiatives were insufficiently coordinated and existing guidelines may be subject to improvement. Main improvement would be to demonstrate the validity and reliability of the existing guidelines and, more in general, to provide a sound scientific basis to the development and implementation of practice guidelines.

Data Collection↗

PubMed1995

Primary care HMO clinicians' opinions about clinical practice guidelines.

OBJECTIVE: To assess primary care clinicians' opinions about the principal goals that national guideline developers foresee for clinical practice guidelines, and about possible effects of guideline implementation that are known to concern practicing clinicians. DESIGN: Preintervention survey of attitudes conducted as part of a larger study to evaluate alternative strategies for implementing clinical practice guidelines. SETTING: Kaiser Permanente, Northwest Region, a large, group model HMO. PARTICIPANTS: Primary care clinicians (N = 211) with at least 1 year of work experience in the HMO. The response rate was 80% (N = 168). RESULTS: Clinicians' responses suggest they will not object to the implementation of specific practice guidelines in the HMO. Guidelines' information-synthesizing and consensus-building functions are likely to be welcomed. Increased guideline implementation is apparently not perceived as a threat to professional autonomy. CONCLUSIONS: Further research is recommended, using this measure, or refined versions of it, in diverse practice settings. In addition, studies are needed of the relationship between clinicians' general expectations about the effects of guidelines and their level of adherence to specific guidelines.

Adult↗

PubMed2006

Critical look at the clinical practice guidelines for allergic rhinitis.

Allergic rhinitis (AR) is a major health concern and numerous guidelines have been developed to standardize and to improve the management of this disease. As in many other areas of medicine, the methodology of the AR guidelines has evolved from opinion-based to evidence-based medicine. Although evidence-based medicine has many benefits, it also has limitations and cannot cancel the value of the individual clinical expertise. More important than the methodology of guideline development is the efficacy of guidelines to change patient and physician behaviour and to improve clinical outcomes. At present, however, studies on the effectiveness of guidelines are few. The International Consensus on Rhinitis from 1994 is the only guideline for AR that has been assessed for its effects on health outcomes. Furthermore, there is a lack of valid and reliable instruments to assess physician's and patient's attitude towards and compliance with guideline recommendations. There is no single effective way to ensure the use of guidelines into practice, but a carefully developed and multifaceted dissemination and implementation strategy and targeting and adapting guideline recommendations to the local and individual level are key elements. The final and most important step of putting guidelines into practice occurs at the level of the patient. Patients should be considered as effective partners in health care. Education of the patient and efforts to change patient's behaviour can maximize compliance, increase satisfaction and optimize health outcomes.

Evidence-Based Medicine↗

PubMed2002

[The Dutch College of General Practitioners practice guideline 'The menopause'; reaction of the field of general practice].

The Dutch College of General Practitioners' practice guideline on the menopause will not be any major cause for discussion. The hot issue of giving oestrogens to peri- and postmenopausal women to prevent osteoporosis or cardiovascular disease was already covered in the practice guideline on osteoporosis. This guideline on the menopause shows that there is no consensus on when it is safe to stop contraception. The advice to use supplementary contraception, such as condoms, until 1 year after the last menstruation will not be met with a high rate of compliance. If oestrogen therapy is necessary in women with serious vasomotor symptoms who still have their uterus, calendar packets containing 14-16 oestrogen-only pills and 12-14 oestrogen/progesterone combination pills can be used. Administration of transdermal oestrogens has no added value and is more expensive. Tibolone is even more expensive and has more side effects. Clonidine is less effective but can be an alternative for women who choose not to take hormones or in whom oestrogens are contraindicated.

Cardiovascular Diseases↗

PubMed2002

Ethical practice guidelines: an evaluation.

Ethical practice guidelines (EPGs) were developed for use in Central Sydney Area Mental Health Service to guide contemporary mental health nursing practice and serve as a resource for clinical mental health nurses in relation to their professional conduct and practice. This survey of mental health nurses aimed to ascertain feedback on the application of the EPGs in the clinical arena. Nurses from the Central Sydney Area Mental Health Service (n = 350) were asked to complete a 15-item survey developed by the authors. A total of 121 nurses completed the survey. Findings from the survey reveal that the information provided in the EPGs is useful (91%) and the EPGs provide sufficient guidance for practice (94%). Most respondents (96%) reported feeling confident dealing with ethical practice situations and 75% indicated interest in further education and training in this domain. Findings from this survey support the need to explore avenues to facilitate education, discussion and reflective practice in relation to ethical mental health nursing practice.

Attitude of Health Personnel↗

PubMed2005

Using clinical practice guidelines to improve patient care.

Clinical practice guidelines incorporate the best available evidence for the management of a disease or an aspect of disease treatment or prevention into a single document for health care providers. The quality of practice guidelines has improved by adopting standard approaches to the development of guidelines and reviewing their quality for use in patient care. Implementing guidelines into clinical practice can improve quality and efficiency of care and will likely benefit from a multidisciplinary, multifaceted approach.

Decision Making↗

PubMed1999

[Practice guidelines in western countries].

The concept of clinical practice guidelines was established in the 1960's to reduce medical costs that had been increasing dramatically in the US. To reduce medical expenses without lowering the quality of medical care, thorough control of medical practices was undertaken by rationalization of these practices. Guidelines were started initially for social and economical reasons, but were eventually accepted widely by society for several reasons. First, the concept of patients' autonomy was widely accepted after 1970, which supported full disclosure of information to patients. Second, there was too much information, necessitating ranking by scientific certainty. Third, the risk of litigation for doctors in the USA increased dramatically during these years. Whether a medical practice follows the guidelines or not has become one of the most important issues in medical lawsuits. Fourth, there is a constant demand for the effective use of social resources. Methods for developing clinical practice guidelines are already established in many societies. The first step is an intensive review of relevant articles to generate evidence-based recommendations (EBR). Then, to formulate practice guidelines, these EBR are ratified and modified by clinicians to whom they apply. They are then reviewed by independent experts. After final adjustment of the EBR or guidelines for administrative reasons, they are adopted with a future expiry date. Practice guidelines are not actually adopted in European countries. However, the concept of guidelines is well appreciated and medical practice is based on scientific evidence. In socialistic European countries like Sweden, Denmark or the Netherlands, there is huge pressure to control limited social resources, leading to aggressive efforts to reduce unexplained and inappropriate variations in medical practice.

Evidence-Based Medicine↗

PubMed2000

Clinical practice guidelines--an organizational effort.

In response to the national trend toward developing clinical practice guidelines, AORN set out to create practice guidelines specific to perioperative nursing. In this effort, a designated group of individuals began defining and reviewing guidelines from other organizations and determining parameters for developing AORN's own patient-focused, comprehensive, research-based guidelines. Clinical practice guidelines now have been published in AORN's Standards, Recommended Practices, and Guidelines, and a template has been established to help other AORN members create and implement guidelines for clinical conditions, common procedures, or patient populations specific to perioperative nursing practice.

Evidence-Based Medicine↗

PubMed2000

Clinical judgment and clinical practice guidelines.

Clinicians make judgments under conditions of uncertainty. Decision research has shown that in uncertain situations individuals do not always act rationally, coherently, or to maximize their expected utility. Advocates of clinical guidelines believe that these guidelines will eliminate some of the cognitive biases that the practitioner may introduce into the medical decision-making process in an attempt to reduce its uncertainty. Other physicians have grave doubts about guidelines' application in practice. Guideline implementation lags well behind their development. Studies of practicing physicians and a survey of clinicians in one specialty and setting indicate that experienced clinicians may be implementing guidelines selectively. Many clinicians are concerned that guidelines are based on randomized trials and do not reflect the complexity of the real world, in which a decision's context and framework are important. Their reluctance also may be due to the difficulty of applying general guidelines to specific clinical situations. The problem will only increase in the future. The patients of the 21st century will be older and have more complex disease states. Physicians will have more patient-specific therapies and need to exercise more sophisticated clinical judgment. They may be more willing to use guidelines in making those judgments if research can demonstrate guidelines' effectiveness in improving decision making for individual patients.

Attitude of Health Personnel↗

PubMed1995

The adoption of preventive care practice guidelines by primary care physicians: do actions match intentions?

OBJECTIVE: To measure primary care physicians' familiarity with, attitudes toward, and confidence in preventive care practice guidelines for the elderly and to determine whether their attitudes are associated with implementation of guidelines into clinical practice. DESIGN: A self-administered survey of physicians employed by a health maintenance organization (HMO) and of patients cared for by those physicians. Medical records were also reviewed to assess compliance with practice guidelines. SETTING: An HMO in Southern California. PARTICIPANTS: Forty-eight primary care physicians completed the survey (100% response rate). The medical records of 3,249 randomly selected elderly patients (65 to 75 years old) were studied. Of these patients, 2,799 completed a preventive care survey (response rate 86.1%). MEASUREMENT AND RESULTS: Most HMO primary care physicians agreed or strongly agreed that guidelines will improve quality of medical care (88%) and that guidelines have caused them to change their care of patients (73%). Although the physicians' general attitudes about guidelines did not often correlate with their use of preventive care guidelines, the physicians who stated that practice guidelines had changed their practices were more likely to offer their patients clinical breast examinations (75.9% vs 67.2%, p = 0.04) and to counsel their patients to exercise (70% vs 58%, p = 0.01) than were the physicians who did not. There was a significant association between physicians' support for and adoption of specific practice guidelines regarding mammography (r = 0.34, p = 0.02) and immunizations against influenza (r = 0.42, p < 0.005), pneumococcal pneumonia (r = 0.47, p < 0.001), and tetanus (r = 0.31, p = 0.03). CONCLUSIONS: Physicians employed by an HMO were familiar with and hopeful about the role of guidelines for improving patient care. Physicians' attitudes toward specific preventive care guidelines and admission that guidelines had caused them to change their practice did at times, but not always, correlate with their implementation of guidelines into clinical practice.

Adult↗

PubMed2000

Translating practice guidelines into patient care : guidelines at the bedside.

Practice guidelines have been developed by a myriad of government, subspecialty, and local organizations in an attempt to reduce undesirable variations in care and to improve the quality of care. Despite the current enthusiasm driving the creation of thousands and thousands of guidelines, their longevity will depend on the ability to demonstrate measurable improvements in patient care caused by the dissemination and implementation of guidelines. In order for guidelines to improve care, they must influence the decisions that physicians and other health-care providers make as they care for patients on a day-to-day basis. Studies on this topic show that some guideline implementation strategies are consistently effective, meaning that they lead to changes in care that benefit patients. Other strategies have been shown to be consistently ineffective. Using an evidence-based approach to selecting guideline dissemination and implementation strategies may facilitate the greatest chance of success, and enhance the probability that patient care will be meaningfully improved as a result of these efforts.

Evidence-Based Medicine↗