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PubMed1995

GAP: a computer-assisted design tool for the development and analysis of evidence-based automated questionnaires.

This paper describes the design and use of a computer-assisted design tool for developing evidence-based automated questionnaires that may assist health practitioners to implement clinical practice guidelines. The Guideline Application Program (GAP) facilitates the design, development, testing, customization, and implementation of interactive patient-computer questionnaires, the analysis of patient-derived information, and the clinical application of practice guidelines that require knowledge of multiple patient-specific characteristics. GAP is being used to create a variety of software applications for HealthQuiz and Microsoft Windows-compatible computers. GAP-generated applications are presently used to support preventive care guideline implementation in primary care settings, preoperative screening in anesthesia clinics, student health screening in Universities, hormone replacement counseling for peri-menopausal women, and patient-reported data collection in various clinical research projects.

Algorithms↗
PubMed2006

Acceptable respiratory physiologic limits for children during weaning from mechanical ventilation.

OBJECTIVE: The aim of this survey was to characterize the physiological limits considered appropriate during weaning from mechanical ventilation in children. DESIGN: Two hundred twenty-two (222) intensivists from 63 pediatric intensive care units (PICUs) were asked to provide the limits they considered acceptable for respiratory rate (RR), tidal volume (V(T)) and end-tidal CO(2) (PetCO(2)) during weaning from mechanical ventilation of a 3-month-old, a 2-year-old and a 10-year-old patient. SETTING: Pediatric intensivists working in Canada, France, Switzerland and Belgium. PATIENTS: None. INTERVENTIONS: None. RESULTS: Ninety-seven intensivists (43%) from 49 PICUs responded to the survey. The median minimal RR (25th;75th percentile) was: 20 breaths per minute (bpm) (15;25) for the 3-month-old, 15 bpm (10;15) for the 2-year-old and 10 bpm (10;15) for the 10-year-old patient. The median maximal RR was 50 bpm (40;60) for the 3-month-old, 40 bpm (30;40) for the 2-year-old and 30 bpm (30;40) for the 10-year-old child. The median minimal V(T) was 5 ml/kg (4;6) for the 3-month-old and 2-year-old patients and 5 ml/kg (5;6) for the 10-year-old. The median maximal PetCO(2) was 55 mmHg (50;60) for the 3-month-old, 50 mmHg (45;50) for the 2-year-old and 50 mmHg (50;55) for the 10-year-old. CONCLUSION: This survey indicated that acceptable weaning limits are broad, as stated by the responders. We need to organize and consolidate our thinking on weaning children from mechanical ventilation before guidelines can be established.

Attitude of Health Personnel↗
PubMed2005

[The development of handbooks of health care guidelines].

This article is an experiment report on the author's development of health care guideline manuals, focusing on a methodological description. These guiding manuals aim to support health care professionals to provide oral teaching to patients and family members, thus enhancing health education.

Manuals as Topic↗
PubMedDate not supplied

The "NICE Guideline" on the treatment of depression.

The National Institute of Clinical Excellence (NICE) in the UK is responsible for producing evidence based guidelines for the treatment of most common illnesses, both physical and psychological. NICE uses a hierarchy of evidence, ranging from data from meta-analyses of randomised controlled trials (RCT's) at the apex, to the opinions of acknowledged experts at the bottom. The task of preparing guideline for depression involved us in performing clean meta-analyses of around 8,000 published RCTs of the treatment of this disorder. Where drug treatments were concerned we used three indicators of efficacy, as well as considering toxicity, tolerability and cost. We also distinguished between studies carried out in primary care, and studies in patients treated by the mental health services. We found it helpful to arrange our report in terms of a "stepped care" model, addressing the indications for patients being referred on for more specialised, and expensive, treatments. In the full guideline we included our doubts that depression was a homogenous clinical entity, and our awareness of the limitations of relying on randomised controlled trials (RCT's) as the only source of evidence. This Editorial summarises the content of the guideline on the treatment of depression and discusses how it was received and also what it did not say.

Adult↗
PubMed1993

The impact of asthma guidelines on clinical practice. A review prepared for the GEPOR working group meeting, Milan, June 22-23 1993.

Guidelines on asthma management may be useful in defining optimal standards of care and as a basis for audit. They also have a role in the education of health professionals and offer a common approach for use by all who care for those with asthma. They should define the goals and outcomes expected from treatment and preferably outline several ways in which they may be achieved. It should be made clear when the recommendations are based upon the results of clinical trials and where they merely reflect current clinical practice. Areas for future research should be clearly outlined. The production of guidelines is only likely to influence patient care, if the guidelines are adapted and made relevant to individual districts or health establishments. There needs to be a realisation that they contain much more than advice about drug treatments. A more patient centred approach to management and attention to patient education is necessary if they are to be effective in reducing the morbidity associated with this common condition.

Asthma↗
PubMed1998

Advances, opportunities, and the new asthma guidelines.

A main tenet of the National Asthma Education and Prevention Program's approach is to integrate proper management of acute asthma into overall asthma care. Accordingly, we maintain that emergency physicians should be aware of emerging chronic management strategies, especially newer treatment regimens, so as to understand pre-ED treatments, provide optimum ED care, and make appropriate prescriptions and referral on discharge. This commentary discusses limitations to the new guidelines and identifies important areas for further study.

Acute Disease↗
PubMed1998

Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy.

Guidelines on the out-patient management of diabetic peripheral neuropathy have been developed from an international consensus meeting attended by diabetologists, neurologists, primary care physicians, podiatrists and diabetes specialist nurses. A copy of the full document follows this summary (Appendix 1). The document arose out of suggestions from Neurodiab, a subgroup of the European Association for the Study of Diabetes, that there was a need for guidelines developed by consensus, for the outpatient management of patients with diabetic neuropathy. An international consensus group was created, chaired by two of the authors. A pilot working party met in 1995, followed by a full working party of 39 experts, neurologists and diabetes physicians (Appendix 2). This compiled a draft guideline document which was circulated to a number of international bodies. After consultation with its members, the final guidelines were approved by Neurodiab (chairman F.A. Gries) towards the end of 1997.

Ambulatory Care↗
PubMedDate not supplied

Improving the management of chronic obstructive pulmonary disease.

As the fourth leading cause of death in the United States, chronic obstructive pulmonary disease (COPD) represents a major burden to the healthcare system and society at large. Underdiagnosis and undertreatment lead to an increased economic burden, with exacerbations being a key driver of costs. COPD symptoms compromise quality of life (QOL), which affects both patients and caregivers. Appropriate management decreases healthcare utiization and improves QOL. This article provides an overview of COPD and promotes understanding of opportunities to optimize patient health and outcomes for those with the disease. Specific interventions that have been demonstrated to improve clinical and economic outcomes for COPD include improved implementation of guidelines, optimized pharmacologic treatment, and risk-factor reduction.

Cost of Illness↗
PubMed2006

Life stories of depressed adult women in peri-urban Namibia.

The problems women in peri-urban Namibia are faced with are multi-dimensional. Like women in other communities they face the pressure of having a number of responsibilities, namely working, being a wife and mother, taking care of their families and perhaps caring for aging parents. Sometimes the pressure can be too overwhelming to manage. As a result, many women become depressed. Studies on depression among black African women in Namibia could not be traced. It was therefore considered to find out how women suffering from depression from this part of the world tell their life stories. The purpose of the study was two-fold: Firstly, to explore and describe the life stories of depressed adult women in peri-urban Namibia, and secondly to use the information obtained to describe guidelines for psychiatric nurses working with these patients at psychiatric outpatient clinics as well as in the community. A qualitative phenomenological research design of an explorative, descriptive and contextual nature was used. The researcher approached the subjects and their experiences with an open mind. Ten depressed adult women between 21-55 years were involved in the research. The researcher strived to adhere to the principles of trustworthiness. To ensure this Guba's model (in Krefting, 1991: 217) of trustworthiness was adopted. All the interviews were analysed following Tesch's method (Creswell, 1994: 154-55). The services of an independent coder were obtained. The results indicated that impaired interpersonal interactions and stressful life events have a negative influence on the daily life of women leading to the development of depressive symptoms. Guidelines to support psychiatric nurses working with depressed women were drawn up.

Adult↗
PubMedDate not supplied

Adequacy of evolving national standardized terminologies for interdisciplinary coded concepts in an automated clinical pathway.

PURPOSE: The purpose of this analysis was to determine the adequacy of evolving national standardized terminologies with regard to coded data elements (concepts) in an automated clinical pathway designed to drive adherence with the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Evaluation and Management of Chronic Heart Failure. METHOD: Concepts were identified in a previously developed automated clinical pathway and associated tools. Once identified, concepts were categorized according to the conceptual domains identified by Campbell et al. (1997). A review of evolving national standardized terminologies and coding systems was initiated to determine if the identified concepts had corresponding representation in one of these coding systems. Available codes were then evaluated for adequacy with respect to national guideline adherence measures put forth by the Centers for Medicare/Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO). RESULTS: The concept domain model put forth by Campbell et al. (1997) worked well for organizing concepts and for providing a useful framework for data analysis. Using our method, 260 unique pathway concepts were identified, of which, 91.9% (239) are represented by one or more of the standardized coding systems. Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT alone represented 86.2% of the concepts. Seventy percent (70%) of the clinical pathway concepts are represented using the Health Insurance Portability and Accountability Act (HIPAA) mandated national terminologies alone. Less than 50% of CMS and JCAHO guideline adherence concepts were found to have representation in the HIPAA mandated terminologies. The addition of Logical Observation Identifier Names and Codes (LOINC) and SNOMED CT improved representation up to 86.4%, but did not include representation of all concepts necessary for complete electronic monitoring of guideline adherence. CONCLUSIONS: Evolving national standardized terminologies provided matching terms for the majority of the data elements in the automated clinical pathway. Standard clinical terminologies with granular terms such as LOINC and SNOMED CT are required to represent the depth and detail of certain procedures and guideline-based care. Gaps exist in Health Insurance Portability and Accountability Act (HIPAA) mandated terminologies for representing interdisciplinary concepts in national adherence measures.

Computational Biology↗
PubMedDate not supplied

Assessment and management of obsessive compulsive disorder.

This article outlines the nature of obsessive compulsive disorder and sets out an evidence-based approach to assessment and treatment. The article also examines the key elements of the National Institute for Health and Clinical Excellence (2005) guideline on this condition.

Causality↗
PubMed2003

Evidence-based medicine: its effect on treatment recommendations as illustrated by the changing role of postmastectomy irradiation to treat breast cancer.

PURPOSE: To illustrate the effect that the quality of evidence has on clinical practice, we examined how the role of radiotherapy in treating breast cancer has changed over the years as the quality of evidence evolved from anecdotal evidence based on expert opinion to randomized clinical trials and meta-analyses. METHODS: We searched the medical literature for key randomized studies and meta-analyses that have influenced the clinical use of postmastectomy irradiation since the first randomized trials in breast cancer in the 1950s. We discuss how clinical practice changed based on the outcomes of these trials, and then discuss the quality of those trials based on the criteria currently used to assess evidence from randomized trials (CONSORT) and meta-analysis (QUORUM). RESULTS: Evidence published from the early trials and meta-analyses on the role of postmastectomy irradiation had a strong effect on clinical practice. Examination of these studies, however, continues to show significant flaws in trial design that, by today's evidence-based standards, would not meet standards of quality. CONCLUSION: The quality of evidence has a strong effect on shaping clinical practice and needs to be continually assessed. Current guidelines developed to critique both individual randomized trials and meta-analyses are helping to establish high standards for trial design and interpretation. Evidence from older trials that were not guided by well-developed guidelines need to be reviewed, particularly when results from those trials are continually updated and used to generate evidence on which to base current clinical practice.

Breast Neoplasms↗
PubMed2006

Improved preventive care for asthma: a randomized trial of clinician prompting in pediatric offices.

OBJECTIVE: To determine whether clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit improves the delivery of preventive asthma care. DESIGN: Randomized controlled trial. SETTING: Two inner-city pediatric practices in Rochester, NY. PARTICIPANTS: Two hundred twenty-six children with persistent asthma (aged 2-12 years) presenting to the clinics for well-child care, asthma care, or non-asthma-related illness care. Intervention We assigned children randomly to a clinician-prompting group (single-page prompt including the child's symptoms and guideline recommendations given to the clinician at the time of the visit) or a standard-care group (no prompt given). Interviewers called parents after the visit to inquire about preventive measures taken, and medical charts were reviewed. MAIN OUTCOME MEASURES: Any preventive action related to asthma taken at the visit. RESULTS: Children in the clinician-prompting group were more likely to have had any preventive measures taken at the visit compared with children in the standard-care group (87% vs 69%). Specifically, visits for children in the clinician-prompting group were more likely to include delivery of an action plan (50% vs 24%), discussions regarding asthma (87% vs 76%), and recommendations for an asthma follow-up visit (54% vs 37%). In a regression model, children in the clinician-prompting group had 3-fold greater odds of receiving any preventive action compared with the standard-care group. CONCLUSION: Clinician prompting regarding asthma severity and care guidelines at the time of an office visit significantly improved the delivery of preventive asthma care.

Asthma↗
PubMed2002

Decision-making in early breast cancer: guidelines and decision tools.

The meta-analysis of trials of adjuvant systemic therapy for early breast cancer provides robust information on the impact of both cytotoxic chemotherapy and tamoxifen on relapse-free and overall survival to 15 years from diagnosis. These data are described in terms of relative risk reduction and are not meant to be viewed as a prescription for therapy. To translate relative risk reductions into absolute benefits for the individual patient and then trade off the gains against the long-term and short-term side-effects and toxicities is a highly complex process for the clinician, and current guidelines are formatted in such a way that they fail to use current information in a way that allows a quantitative assessment of the benefits and risks of adjuvant therapy. This review article explores current guidelines and describes some aids that may be used to help inform women about their treatment options for early breast cancer.

Breast Neoplasms↗
PubMed1996

Foot care in the home: nursing and agency responsibilities.

Foot care is an integral component of overall patient care provided in the home. This article categorizes three levels of foot care that can be provided and gives nurses and agencies guidelines for developing policies and procedures that direct this type of care.

Aged↗