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PubMed1994

Guidelines for clinical preventive services. Essential for nurse practitioners in practice, education, and research.

Guidelines for clinical preventive services, including counseling, screening, and immunizations, are important to nurse practitioner practice, education, and research. Delivery of clinical preventive services can be improved by the use of evidence-based guidelines, which provide recommendations on what services should be provided and who should receive them. Development of guidelines by the U.S. Preventive Services Task Force is discussed, as well as principal findings that evolved from their deliberations. The authors provide a rationale and options for the development of nursing guidelines for clinical preventive services. Implementation of guidelines can be facilitated by use of the "Put Prevention Into Practice" materials.

Delivery of Health Care↗

PubMed1994

Appropriate screening tests in infants, children, and adolescents.

Specific recommendations and the rationale for targeted screening procedures in infants, children, and adolescents have been reviewed. The utility of many tests is uncertain, often because of poor characterization of the disease or problem targeted. For example, the optimum time for treatment and whether treatment results in long-term benefits frequently are unknown. The development of recommendations based on evidence-based approaches promises to rationalize the delivery of preventive health care services in the pediatric population.

Adolescent↗

PubMed1995

Periodic health examination, 1995 update: 1. Screening for human papillomavirus infection in asymptomatic women. Canadian Task Force on the Periodic Health Examination.

OBJECTIVE: To develop recommendations for practising physicians on the advisability of screening for human papillomavirus (HPV) infection in asymptomatic women. OPTIONS: Visual inspection, Papanicolaou testing, colposcopy or cervicography, use of HPV group-specific antigen, DNA hybridization, dot blot technique, Southern blot technique or polymerase chain reaction followed by physical or chemical therapeutic intervention. OUTCOMES: Evidence for a link between HPV infection and cervical cancer, sensitivity and specificity of HPV screening techniques, effectiveness of treatments for HPV infection, and the social and economic costs incurred by screening. EVIDENCE: MEDLINE was searched for articles published between January 1966 to June 1993 with the use of the key words "papillomavirus," "cervix neoplasms," "mass screening," "prospective studies," "prevalence," "sensitivity," "specificity," "human" and "female." VALUES: Proven cost-effective screening techniques that could lead to decreased morbidity or mortality were given a high value. The evidence-based methods and values of the Canadian Task Force on the Periodic Health Examination were used. BENEFITS, HARMS AND COSTS: Potential benefits are to prevent cervical cancer and eliminate HPV infection. Potential harmful effects include the creation of an unnecessary burden on the health care system and the labelling of otherwise healthy people as patients with a sexually transmitted disease for which therapy is generally ineffective. Potential costs would include expense of testing, increased use of colposcopy and treatment. RECOMMENDATIONS: There is fair evidence to exclude HPV screening (beyond Papanicolaou testing for cervical cancer) in asymptomatic women (grade D recommendation). VALIDATION: The report was reviewed by members of the task force and three external reviewers who were selected to represent different areas of expertise. SPONSORS: These guidelines were developed and endorsed by the task force, which is funded by Health Canada and the National Health Research and Development Program. The principal author (K.J.) was supported in part by the National Health Research and Development Program through a National Health Fellowship (AIDS).

DNA, Viral↗

PubMed1994

Periodic health examination, 1994 update: 4. Secondary prevention of elder abuse and mistreatment. Canadian Task Force on the Periodic Health Examination.

OBJECTIVE: To provide recommendations for family physicians on the detection, assessment and management of abuse or mistreatment in patients over 65 years of age. OPTIONS: Detection of elder abuse by history and examination or by specific protocols; intervention through mandatory reporting, removing the victim from the situation or acting as an advocate for the patient. OUTCOMES: Termination of abusive situation and prevention of further abuse. EVIDENCE: A MEDLINE search was conducted with the use of medical subject headings "elder abuse" and "epidemiology" for articles published from January 1980 to October 1992 and headings "elder abuse" and "clinical trials" for articles published from January 1980 to February 1994. Standard references and review articles and their bibliographies were scrutinized, and experts were consulted. VALUES: The evidence-based methods and values of the Canadian Task Force on the Periodic Health Examination were used. Since senior citizens are among the most disadvantaged people in Canadian society, prevention of abuse and promotion of their autonomy were the highest values selected. BENEFITS, HARMS AND COSTS: The principal benefits are cessation and prevention of abuse. Potential harms include the loss of a personal residence, the erosion of an established family structure and the loss of autonomy for the victim. RECOMMENDATIONS: There is poor evidence to include case finding for elder abuse in or exclude it from the periodic health examination. However, it is prudent for physicians to be alert for indications of elder abuse and, if such abuse is discovered, to take measures to prevent further abuse.

Aged↗

PubMedDate not supplied

An approach to the development of practice guidelines for community health interventions.

The Community Health Practice Guidelines (CHPG) project was initiated to develop a systematic approach to the critical evaluation of evidence on the effectiveness and efficiency of community health interventions and to the formulation of evidence-based practice recommendations. Three community health interventions--immunization delivery methods, partner notification for sexually transmitted diseases and the combination of restaurant inspection and education of food handlers--were used as prototypes to develop a standardized approach. The CHPG process consists of three components: a review of scientific evidence, a practice survey and formulation of practice guidelines. Imperatives for further development of the CHPG and define research priorities process include creating a coalition of public health organizations to sponsor the process and refining the consensus process so that the practice guidelines accurately reflect both the scientific basis of public health practice and the values of those affected.

Canada↗

PubMedDate not supplied

Development of sexually transmitted diseases treatment guidelines, 1993. New methods, recommendations, and research priorities. STD Treatment Guidelines Project Team and Consultants.

To develop the 1993 Sexually Transmitted Diseases Treatment Guidelines, experts from the Centers for Disease Control and Prevention reviewed the literature on sexually transmitted disease treatment, assembled tables of evidence, and listed key questions on therapeutic outcome: microbiologic cure, alleviation of symptoms, and prevention of sequelae and transmission. At a meeting with external experts, evidence was systematically assessed and guidelines developed. Quality of evidence for microbiologic cure was generally good for gonorrhea and chlamydia, poor for syphilis, and fair for most other diseases. Evidence on preventing sequelae and transmission was limited. The Guidelines include new recommendations for single-dose oral therapy of gonorrhea (cefixime, ciprofloxacin, and ofloxacin), chlamydia (azithromycin), and chancroid (azithromycin); outpatient therapy of pelvic inflammatory disease (ofloxacin and either clindamycin or metronidazole); and patient-applied therapy of genital warts (podofilox). Syphilis therapy did not change substantially. Several global issues that emerged during the development of the World Health Organization Recommendations for the Management of Sexually Transmitted Diseases also are discussed. This evidence-based approach clarified important treatment issues and the rationale for recommendations, and identified research priorities.

Anti-Infective Agents↗

PubMed1994

An overview of clinical policies with implications for clinical practice, medical education, and research.

Clinical policies, also known as practice parameters or practice guidelines, are gaining notoriety out of a desire to control escalating medical costs, lessen wide practice variations, and improve quality of care. The clinical policies are supposed to influence medical decision making by summarizing scientific data about a clinical problem in a format that is easily understood by patient and physician alike. Developing an evidence-based policy involves: a clearly defined clinical problem, a comprehensive literature review, a summary table of the data (known as an evidence table), a presentation of this data as outcome possibilities from alternative decisions (in the form of a balance sheet), and creation of clinical recommendations that incorporate both financial costs and patient preferences. Well-developed policies can be used by family physicians as guides in areas of clinical uncertainty and by medical educators as up-to-date literature syntheses for teaching critical appraisal and for outlining approaches to common problems. Explicit policy formulation also highlights the shortcomings of existing literature and can suggest more appropriate future research. The future of the clinical policy movement rests on its ability to reduce costs of care and improve patient outcomes. Explicit clinical policy formulation incurs significant development and implementation costs and the evidence on which many policies are based is lacking. Nevertheless, clinical policies in some form are likely to play an increasing role in medical care.

Curriculum↗

PubMed1993

Guidelines for the transfer of critically ill patients. Guidelines Committee of the American College of Critical Care Medicine; Society of Critical Care Medicine and American Association of Critical-Care Nurses Transfer Guidelines Task Force.

OBJECTIVE: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient. DATA SOURCES: A task force of experts in the field of patient transport drawn from the membership of the Society of Critical Care Medicine and the American Association of Critical-Care Nurses provided the personal experience and published literature from which these guidelines were developed. STUDY SELECTION: Study design was not a factor in selecting the literature to validate the experts' personal experience. The lack of well-designed clinical outcome studies was an important factor in determining the method of practice policy development we utilized. DATA EXTRACTION: The expert task force met and developed a draft of these guidelines based on their experiences and the available literature. This draft document was then reviewed by an additional group of experts whose input was used by the task force to develop this final consensus report. DATA SYNTHESIS: Each hospital should have a formalized plan for intra- and interhospital transport that addresses the following elements: pretransport coordination and communication, transport equipment, accompanying personnel, monitoring during the transport, and documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined by the continuous quality improvement process. CONCLUSION: The available data have allowed us to develop an evidence-based practice policy for the intra- and interhospital transport of the critically ill.

Algorithms↗

PubMed1994

Periodic health examination, 1994 update: 1. Obesity in childhood. Canadian Task Force on the Periodic Health Examination.

OBJECTIVE: To update the 1979 Canadian Task Force on the Periodic Health Examination recommendation on screening for childhood obesity by reviewing any new evidence concerning health risks in childhood and adulthood, and effective preventive or therapeutic interventions. OPTIONS: Detection: routine measurement of height and weight, use of skinfold thickness measurements, calculation of body mass index (BMI). INTERVENTION: diet, exercise, behaviour modification and comprehensive family-based weight-reduction programs. Components of these interventions could be offered routinely or reserved for children and families who perceive obesity to be a present or potential problem. OUTCOMES: The task force reviewed the probability of obese children become obese adults as a risk factor for adult heart disease and overall related illness and death in adult life as well as obesity as a risk factor for physical and psychologic illness in childhood. EVIDENCE: A MEDLINE search for relevant articles published between January 1981 and February 1991 was undertaken. VALUES: The task force's evidence-based rules for recommendations were used. BENEFITS, HARMS AND COSTS: If weight reduction in childhood were shown to prevent physical or psychologic illness in childhood, or illness and death in adult life, screening and treatment should be recommended. Screening for obesity may cause anxiety on the part of the child and family; malnutrition in children as a result of parents becoming overly anxious about the health risks of obesity has been reported. Most weight reduction programs have limited long-term effectiveness and can be costly. RECOMMENDATIONS: There is insufficient evidence of short-term or long-term benefits from screening for or treatment of childhood obesity to recommend such screening or recommend against it. There is fair evidence to recommend against very-low-kilojoule diets for preadolescents. There is insufficient evidence to recommend for or against exercise programs or intensive family-based programs for most obese children. VALIDATION: These recommendations are similar to those of the American Academy of Pediatrics and the US Preventive Services Task Force. SPONSOR: These guidelines were developed and endorsed by the Canadian task force, which is funded by Health Canada.

Adolescent↗

PubMedDate not supplied

Sickle cell disease: screening, diagnosis, management, and counseling in newborns and infants. The Agency for Health Care Policy and Research.

The AHCPR guideline on sickle cell disease has several strengths and many weaknesses. For the practicing physician it is strongest in recommending medical management of infants with sickle cell disease but weakest on screening and education and counseling. The evidence-based methodology should have been presented in more detail. Until that occurs, family physicians are left with this guideline as a summary of expert opinions with variable documentation of the underlying science.

Algorithms↗

PubMed1993

Periodic health examination, 1993 update: 3. Periodontal diseases: classification, diagnosis, risk factors and prevention. Canadian Task Force on the Periodic Health Examination.

OBJECTIVE: To review the 1979 Canadian Task Force on the Periodic Health Examination recommendations on the diagnosis and prevention of periodontal disease. OPTIONS: Self-care at home, professional care, treatment with antimicrobial agents and management of patients at high risk. OUTCOMES: Maintaining the gingiva, alveolar bone and periodontal ligament in a healthy state (absence of gingival bleeding and no loss of epithelial attachment). EVIDENCE: A literature search for articles published from 1980 to 1993 was conducted. Selected studies published before 1980 were also reviewed if there were no recent updates. Evidence was evaluated and classified as good, fair or poor according to the criteria of the task force. VALUES: The task force's evidence-based rules for recommendations were used. In addition, whenever feasible, and on the basis of advice from the reviewers and experts, recommendations were modified in the interest of maintaining oral health (e.g., dental flossing in children). BENEFITS, HARMS AND COSTS: The recommendations are not expected to increase the costs of preventing periodontal diseases for the general population. They could benefit dental patients and reduce costs because they are based on the periodontal needs of patients rather than on the current universal application approach.

Adult↗

PubMed1993

Guidelines for the transfer of critically ill patients. Guidelines Committee, American College of Critical Care Medicine, Society of Critical Care Medicine and the Transfer Guidelines Task Force.

OBJECTIVE: The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient. DATA SOURCES: A task force of experts in the field of patient transport drawn from the membership of the Society of Critical Care Medicine and the American Association of Critical-Care Nurses provided the personal experience and published literature from which these guidelines were developed. STUDY SELECTION: Study design was not a factor in selecting the literature to validate the experts' personal experience. The lack of well-designed clinical outcome studies was an important factor in determining the method of practice policy development utilized. DATA EXTRACTION: The expert task force met and developed a draft of these guidelines based on their experiences and the available literature. This draft document was then reviewed by an additional group of experts whose input was used by the task force to develop this final consensus report. RESULTS OF DATA SYNTHESIS: Each hospital should have a formalized plan for intra- and interhospital transport that addresses the following elements: pretransport coordination and communication, transport equipment, accompanying personnel, monitoring during the transport and documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined by the continuous quality improvement process. CONCLUSION: The available data has allowed the authors to develop an evidence-based practice policy for the intra- and interhospital transport of the critically ill.

Algorithms↗

PubMed1993

Report of the Canadian Hypertension Society Consensus Conference: 4. Hypertension in the elderly.

Several knowledge gaps, which made evidence-based guidelines impossible in 1985, have since been filled. There is now unequivocal evidence that treatment of isolated systolic hypertension benefits elderly patients, as does treatment beyond the age of 75 years. Pseudohypertension, although occasionally problematic, is not common and is not a reason to neglect the treatment of elderly patients, including those with isolated systolic hypertension. In general, long-term antihypertensive treatment of the elderly is well tolerated and does not cause important decreases in mental function. Comparative drug studies continue to accumulate; most show no clinically significant general differences between drugs, aside from the somewhat decreased efficacy and tolerability of beta-blockade in elderly patients. As in the young, certain drugs may be preferred in the presence of other conditions--e.g., congestive heart failure or diabetes.

Aged↗

PubMed1993

Whither ultrasonic prediction of fetal macrosomia?

During the past 15-20 years, ultrasonic estimation of fetal weight (EFW) has been used increasingly to make management decisions regarding the induction of labor or delivery route. The propriety of this approach depends on proof that its use improves newborn or maternal outcome without disproportionate increases in morbidity and mortality. A barrier to achieving this goal is the inaccuracy associated with ultrasonic EFW. The current ultrasonic EFW procedures are not accurate enough for detecting macrosomia defined by weight criteria. Even if clinicians could determine fetal weight accurately, the frequency of persistent fetal injuries associated with vaginal birth of the macrosomic fetus is so low that induction of labor or cesarean birth is not justified on that basis. Furthermore, the inaccurate ultrasonic determination of fetal weight leads to inappropriate obstetric interventions. Evidence-based decision-making should be an important goal for all obstetric care givers. Delivery decisions based on inaccurate EFW should be avoided.

Body Weight↗

PubMed1993

A model for technology assessment applied to pulse oximetry. The Technology Assessment Task Force of the Society of Critical Care Medicine.

OBJECTIVES: To test a model for the assessment of critical care technology. To develop practice guidelines for the use of pulse oximetry. DATA SOURCES: A computer-assisted search of the English language literature and interviews with recognized experts in the field of pulse oximetry. STUDY SELECTION: Those studies that addressed one or more of the seven questions contained in our technology assessment template were analyzed. Study design was not a factor in article selection. However, the lack of well-designed clinical outcome studies was an important factor in determining the method of practice policy development we utilized. DATA EXTRACTION: A focus person summarized the data from the selected studies that related to each of the seven assessment questions. The preliminary data summary developed by the focus person was further analyzed and refined by the task force and then sent to 16 expert reviewers for comment. These expert comments were considered by the task force, and this final consensus report was developed. DATA SYNTHESIS: Pulse oximetry combines the principles of spectrophotometry and plethysmography to noninvasively measure oxygen saturation with a high degree of accuracy over the range of 80% to 100% saturation, assuming the device is being used according to the manufacturer's instructions and without any adverse operating conditions. The appropriate clinical uses of pulse oximetry fall into one of two broad categories: as a warning system based on continuous real-time measurement of arterial desaturation, or as an end-point for titration of therapeutic interventions. There are no published studies that allow for definitive, outcome-based conclusions concerning either the clinical impact or cost-benefit ratio of pulse oximetry. CONCLUSIONS: The model developed for technology assessment proved to be appropriate for assessing pulse oximetry. The available data have allowed us to develop an evidence-based practice policy for the use of pulse oximetry in critical care. Critical care clinicians, researchers, and industry have a shared responsibility to provide valid outcome and efficacy studies of new technologies.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1993

Dissemination of guidelines on cholesterol. Effect on patterns of practice of general practitioners and family physicians in Ontario. Ontario Task Force on the Use and Provision of Medical Services.

A telephone survey of a random sample of Ontario family physicians was conducted 6 to 8 months after disseminating evidence-based guidelines for screening and managing asymptomatic hypercholesterolemia. Seventy-eight percent of respondents stated they followed these guidelines. However, specific questions revealed as few as 5% of respondents actually followed the guidelines.

Adult↗

PubMed2026

What's the meta now? More updates on the problems with systematic reviews.

BACKGROUND: Systematic reviews are intended to provide trustworthy evidence synthesis, yet previous iterations of this living review have identified numerous recurring problems in their conduct and reporting. This article presents the third version and second update of the living systematic review examining issues raised across the academic literature. METHODS: Using consistent eligibility criteria and methods from earlier versions, literature searches were updated to May 2025. Eligible meta-research and editorial articles describing problems with systematic reviews were analyzed to identify emerging themes. Additionally, four basic indicators of methodological quality of the included meta-research were presented across review versions. RESULTS: The update included 209 additional articles. Critically low methodological quality and absence of protocols remained among the most frequently reported issues in systematic reviews across disciplines and journals but notably in evidence underpinning clinical practice guidelines. Spin in abstracts and conflicts of interest continued to be common. Apparent improvements in reporting quality were inconsistent, with modest gains in some full-text reporting but persistent deficiencies in abstracts. Authorship diversity of systematic reviews improved in gender representation but remained geographically concentrated in high-income countries, and primary research included in reviews similarly lacked global representativeness. The issue of misalignment between systematic review evidence bases and global burden of disease bring the total number of problems with systematic reviews to 69. Emerging use of automation and artificial intelligence was variably reported. Descriptive comparison of meta-research articles over the three versions of this living review suggests a greater proportion meeting basic quality indicators in more recent updates. CONCLUSION: Across successive updates, problems with systematic reviews remain widespread and consistent rather than isolated. Incremental reporting improvements coexist with persistent concerns about transparency, bias, and representativeness. Future efforts should prioritize evaluating interventions and aligning research incentives to support genuinely trustworthy evidence synthesis.

Humans↗

PubMed2026

Interventions with a significant mortality difference in acute respiratory distress syndrome: A systematic review and comparison with Guidelines.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) has a high mortality rate. European Society of Intensive Care Medicine (ESICM) and American Thoracic Society (ATS) Guidelines are the worldwide reference for clinicians in management of ARDS. Mortality represents one of the most important outcomes in intensive care practice and randomized controlled trials (RCTs) the highest level of evidence. We compared Guidelines recommendations with RCT results to highlight differences and find potential new therapeutic opportunities. METHODS: We performed a systematic review of all RCTs reporting a statistically significant mortality difference in ARDS and a subsequent comparison with ESICM and ATS Guidelines recommendations. RESULTS: We identified 33 RCTs and 23 interventions with mortality difference in ARDS patients. Seven interventions relate to invasive ventilation strategies, two to noninvasive ventilation strategies, one to extracorporeal membrane oxygenation (ECMO), 12 to drugs and one to nutritional support. In 25/33 (76%) RCTs the intervention was associated with mortality reduction and in 8/33 with mortality increase (24%). Multicenter studies were 24/33 (73%) while blinding was adopted in 19/33 (58%) studies. Guidelines recommendations supported by RCTs with mortality impact include: the use of low tidal volume ventilation, prone positioning, venovenous ECMO, steroids and the avoidance of high frequency oscillatory ventilation. Eight of the interventions identified were not mentioned by Guidelines but demonstrated reduced mortality, and five further interventions demonstrated increased mortality. CONCLUSIONS: This systematic review highlights potential gaps between RCTs results and Guidelines that could be used to plan future research or highlight topics to be discussed in future Guidelines.

Humans↗