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PubMed2002

Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders.

STUDY DESIGN: A clinical practice guideline. OBJECTIVES: To assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with whiplash-associated disorders Grades I and II. SUMMARY OF BACKGROUND DATA: Whiplash constitutes a considerable problem in health care. Many interventions are used in physiotherapy practice, despite increasing evidence for the use of active interventions. There is still no clinical practice guideline for the management of patients with whiplash-associated disorders. METHOD OF DEVELOPMENT: A computerized literature search of Medline, Cinahl, Cochrane Controlled Trial Register, Cochrane Database of Systematic Reviews, and the Database of the Dutch National Institute of Allied Health Professions was performed to search for information about the diagnostic process and the therapeutic process in whiplash patients. When no evidence was available, consensus between experts was achieved to develop the guideline. Practicing physiotherapists reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it. RECOMMENDATIONS: The diagnostic process consists of systematic history taking and a physical examination supported by reliable and valid assessment tools to document symptoms and functional disabilities. The primary goals of treatment are a quick return to normal activities and the prevention of chronicity. Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery. The biopsychosocial model is used to address the consequences of whiplash trauma. CONCLUSIONS: Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline. The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.

Acceleration↗

PubMed1999

Clinical practice guidelines: moving into the 21st century.

Clinical practice guidelines affect every aspect of healthcare. Practitioners, third-party payors, regulatory bodies, governments, and accrediting agencies increasingly use these guidelines, which are developed by a wide variety of organizations. The majority of guidelines are based on consensus and a nonsystematic literature review, but some, including those developed by the Agency for Health Care Policy and Research, are evidence based. Both types of guidelines have distinct advantages and limitations. Consensus-based guidelines are less time consuming to develop but may lack crucial information and result in a wide variety of outcomes; whereas, the type of evidence used to develop strength-of-evidence ratings for evidence-based guidelines may result in ambiguous recommendations and cause ethical concerns. Outcomes research on the use of guidelines and issues related to their timeliness need to be addressed. Studies that include a wide variety of outcome indicators and care variables and contributions of clinicians are needed to develop practice guidelines that are clinically useful and improve patient care.

Forecasting↗

PubMed2005

Clinical practice guidelines for the psychosocial care of adults with cancer.

Clinical practice guidelines are increasingly being developed in medical settings to provide evidence-based recommendations to guide the clinical care of patients. The development of Clinical practice guidelines for the psychosocial care of patients with medical illness is a newer initiative, and more complex as the target audience includes health care professionals from diverse backgrounds. In Australia, the National Breast Cancer Centre and National Cancer Control Initiative have collaborated to develop Clinical practice guidelines for the psychosocial care of adults with cancer, funded by the Australian Government Department of Health and Ageing. This paper outlines the development of these guidelines in the international context, gives an overview of their content, and describes strategies for their implementation and evaluation.

Adult↗

PubMed1996

Evaluating the use of the appropriateness method in the Agency for Health Care Policy and Research Clinical Practice Guideline Development process.

OBJECTIVE: To assess the feasibility of the appropriateness method in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Development process, and to compare the results of the appropriateness method with those obtained using evidence tables and an informal consensus method. SETTING: AHCPR Low Back Problems Clinical Practice Guideline. DESIGN: Two different group process methods with the same panel of experts were used in observational comparison of results of and satisfaction with guideline development. DATA COLLECTION: Practice guideline statements were created for topics using the conventional AHCPR method; then six months later new guideline statements for four topics were created using the appropriateness method. Panelist satisfaction with each process and resulting set of guideline statements was assessed. PRINCIPAL FINDINGS: Results of the appropriateness method for TENS, discography, and traction showed no disagreement among panel members and no appropriate indications for their use in the patient scenarios considered. These results are qualitatively similar to the guideline statements produced using evidence tables and informal consensus. Clinical practice guideline statements about electro-diagnostics created from appropriateness ratings were much more clinically specific than those created using evidence tables and informal consensus. Neither informal consensus building nor the appropriateness method was clearly preferred by a majority of panelists. CONCLUSIONS: It is feasible to use the appropriateness method in the AHCPR Clinical Practice Guideline Development process, and in some instances it produces more clinically specific guideline statements than does informal consensus.

Acute Disease↗

PubMed2004

HELEN, a modular framework for representing and implementing clinical practice guidelines.

OBJECTIVES: In order to implement clinical practice guidelines for the Department of Neonatology of the Heidelberg University Medical Center we developed a modular framework consisting of tools for authoring, browsing and executing encoded clinical practice guidelines (CPGs). METHODS: Based upon a comprehensive analysis of literature, we set up requirements for guideline representation systems. Additionally, we analyzed further aspects such as the critical appraisal and known bridges and barriers for implementing CPGs. Thereafter we went through an evolutionary spiral model to develop a comprehensive ontology. Within this model each cycle focuses on a certain topic of management and implementation of CPGs. RESULTS: In order to bring the resulting ontology into practice we developed a framework consisting of a tool for authoring, a server for web-based browsing, and an engine for the execution of certain elements of CPGs. Based upon this framework we encoded and implemented several CPGs in varying medical domains. CONCLUSIONS: This paper shall present a practical framework for both authors and implementers of CPGs. We have shown the fruitful combination of different knowledge representations such as narrative text and algorithm for implementing CPGs. Finally, we introduced a possible approach for the explicit adaptation of CPGs in order to provide institution-specific recommendations and to support sharing with other medical institutions.

Academic Medical Centers↗

PubMed1999

Focal lymphoid aggregates (nodules) in bone marrow biopsies: differentiation between benign hyperplasia and malignant lymphoma--a practical guideline.

AIMS: To provide practical guidelines for the differentiation between benign and malignant focal lymphoid aggregates (lymphoid nodules) in routinely referred bone marrow trephine biopsies, using a synoptic approach including clinical data and histological workup. METHODS: For easy identification of very small lymphoid infiltrates the chloroacetate esterase stain was applied as a screening procedure. This allowed the identification of 491 formalin fixed, paraffin wax embedded specimens with one or more lymphoid nodules. Examination of lymphoid infiltrates included such variables as histotopography, demarcation, cytology, reticulin fibres, and immunohistochemistry with a set of monoclonal antibodies (CD20, CD45R, CD45R0, CD3, CD43). Evaluation of clinical and morphological data was carried out independently. In case of malignant lymphomas, a correlation with corresponding lymph node findings was made. RESULTS: 352 patients had benign focal lymphoid aggregates usually associated with systemic autoimmune diseases, chronic myeloproliferative disorders, toxic myelopathy, and viral infections. Discrete nodular infiltrates of (small cell) malignant lymphomas (n = 93) simulating benign hyperplasia were found in chronic lymphocytic leukaemia, germinal centre cell lymphomas (CB-CC), and lymphoplasmacytic/cytoid lymphomas (LPI). In addition to immunoreactivity, certain histological variables proved distinctive. These were: (1) histotopography, that is, localisation of the lymphoid aggregates within the bone marrow space; (2) relation to the surrounding tissue: margination or interstitial spillage of lymphoid cells; and (3) increase in reticulin fibres. CONCLUSIONS: A combined diagnostic procedure identifying several distinctive features, in particular histotopography and immunohistochemistry, provides a most promising way of discriminating reactive from neoplastic lymphoid nodules in the bone marrow.

Bone Marrow↗

PubMed2004

[Practice guidelines in rehabilitation: infringement upon physicians' autonomy or foundation for better outcomes?].

Clinical practice guidelines - seen as an aggregation of scientific evidence - and evidence based medicine are of relevance and importance for everybody involved in health care. Nevertheless, the discussion of their pros and cons is controversial. Major criticisms concern methodological aspects, a disregard of the patients' perspective, potentially increasing costs and the limitation of doctors' autonomy possibly caused by streamlining therapy. Supporters emphasize the improvement of care that comes with using proven therapies, patients' empowerment, cost reduction and equity in the distribution of resources. Following medical practice guidelines the liability for medical malpractice may be limited, but non-adherence to guidelines does not entail liability per se. Clinical practice guidelines in the rehabilitative sector differ from those in curative medicine by being required to achieve more complex goals than maintenance, recovery and improvement of health. Activities in the rehabilitation sector address two main topics: The integration of rehabilitation into curative guidelines, e. g. by participating in the German clearing process for guidelines, and the development of guidelines specific to rehabilitation. There are a number of guideline initiatives, e. g. with the Association of the Scientific Medical Societies (AWMF), the Federation of German Pension Insurance Institutes (VDR) and the Federal Insurance Institute for Salaried Employees (BfA). The BfA project is the first to allow integration of evidence based medicine into the quality assurance programme of the German Pension Insurance complementing it with differentiated criteria for the assessment of therapeutic processes. Taking evidence based medicine increasingly into consideration and the continuous process of introducing rehabilitative clinical practice guidelines are going to improve health care for people with chronic diseases.

Chronic Disease↗

PubMed2006

Seeking a second opinion: do patients need a second opinion when practice guidelines exist?

INTRODUCTION: Patients often search for a second opinion (i.e., a search for additional information on the diagnosis and/or treatment options and the potential prognosis, which will help the patient decide what to do or not to do, where, with whom and how). The scope of this phenomenon is not well documented. Also it is not clear if this is warranted or not. This paper aims to explore whether knowing that his clinician follows practice guidelines eliminates the need of a patient's to seek a second opinion. Given that practice guidelines should allow each patient to benefit from the best current clinical evidence, one might wonder if in such a context a second opinion is still necessary, and if so, for what reasons? METHODS: We review the literature to find the reasons that may prompt a patient to seek a second opinion before the implementation of practice guidelines. We then analyse, from a conceptual point of view, whether for 'informed patient' (i.e., one who knows about and understands practice guidelines) these reasons still hold after the implementation of practice guidelines and if new reasons for seeking a second opinion have emerged. We also discuss practical limitations to searching for a second opinion. RESULTS: We show that even if some reasons, like the search for a second opinion to check whether the treatment prescribed by the first physician is appropriate or not, can be questioned after the implementation of practice guidelines, an 'informed patient' may still wish to seek a second opinion stemming from new reasons which have emerged after the introduction of practice guidelines, e.g., to determine which practice guidelines his physician follows and whether they are appropriate to his case. SUMMARY AND CONCLUSION: We conclude that the implementation of practice guidelines will not eliminate the need for a second opinion consultation. On the contrary, the use of guidelines can even stimulate a broader request for second opinions. This conclusion however needs to be validated in an empirical study.

France↗

PubMed1999

Attitudes of faculty, housestaff, and medical students toward clinical practice guidelines.

PURPOSE: To examine attitudes of faculty, housestaff, and medical students toward clinical practice guidelines. METHOD: In a 1997 cross-sectional survey, a two-part, 26-item, self-administered questionnaire was mailed to all faculty, housestaff, and medical students in the department of internal medicine at Case Western Reserve University School of Medicine. The questionnaire asked for demographic information and attitudes toward clinical guidelines. RESULTS: Of 379 persons surveyed, 254 (67%) returned usable questionnaires: 56% of the medical students, 70% of the housestaff, and 73% of the full-time faculty. Medical students reported learning about guidelines predominantly during clerkships in internal medicine (71%) and pediatrics (68%). Overall, the respondents agreed most strongly that guidelines are "useful for the care of common problems," and least strongly that guidelines are "difficult to apply to individual patients" and "reduce physician options in patient care." Faculty were more likely to consider guidelines a "good educational tool" and less likely than were medical students and housestaff to agree that they promote "cookbook medicine." Of 11 influences on clinical decision making, the three groups together rated practice guidelines eighth or ninth. The use of guidelines for academic investigations was rated most appropriate, overall. In terms of their appropriateness, faculty consistently rated the use of guidelines more favorably except for use in malpractice suits. CONCLUSION: Faculty, housestaff, and medical students have significantly different perceptions of and attitudes toward clinical practice guidelines. Further studies are needed to explain the reasons for these differences. Considerable education and involvement must occur at all levels for practice guidelines to be successfully implemented and understood.

Analysis of Variance↗

PubMed2000

Are nonspecific practice guidelines potentially harmful? A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making.

OBJECTIVE: To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain. DATA SOURCES/STUDY DESIGN: Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes. Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians, and general internists. INTERVENTION: Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel. The two guidelines were similar in content but varied in the specificity of their recommendations. DATA COLLECTION: The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline, or vignettes plus the specific version of the guideline. PRINCIPAL FINDINGS: The response rate to the survey was 71 percent. The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group, and 79 percent for the specific guideline group (p = .002). The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent, and 26 percent, respectively (p = .08). Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02). Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04). CONCLUSIONS: The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines.

Decision Making↗

PubMed2000

Canadian oncologists and clinical practice guidelines: a national survey of attitudes and reported use. Provincial Lung Disease Site Group of Cancer Care Ontario.

PURPOSE: To determine (1) Canadian oncologists' attitudes toward practice guidelines, (2) oncologists' self-reported use of practice guidelines and, (3) physicians' characteristics and attitudes associated with self-reported use of practice guidelines. PARTICIPANTS AND METHODS: A cross-sectional, self-administered postal survey was administered to Canadian oncologists. Main outcome measures were level of agreement with 8 descriptive statements about guidelines, score on the attitudinal scale of the guideline of Tunis et al., and physicians' stated use of guideline. chi(2) and logistic regression procedures were used to explore the relationship between physician characteristics and use of guidelines. RESULTS: Over 80% of respondents agreed that they were good educational tools, convenient sources of advice, intended to improve quality of care; over 40% agreed that they were unbiased syntheses of expert opinion. Conversely, 42, 26, 20 and 16% felt they were intended to cut costs, were oversimplified cookbook medicine, were too rigid to apply to individual patients, and a challenge to physicians' authority, respectively. Forty-one percent reported using practice guidelines routinely or most of the time. Use was associated with positive attitudes about guidelines, receiving medical school training abroad and being a radiation oncologist. CONCLUSION: Canadian oncologists were quite positive about practice guidelines and reported using them frequently. Our results suggest that use of guidelines by oncologists may be related to attitudes about guidelines in general, specialty within oncology and country of medical school training.

Adult↗

PubMed1997

Ulcerative colitis practice guidelines in adults. American College of Gastroenterology, Practice Parameters Committee.

Guidelines for clinical practice are intended to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate use reports and expert review articles are utilized in a through review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject without regard to specialty training or interests and are intended to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standard of care, which are inflexible and rarely violated. Given the wide range of specifies in any health care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision of analysis. The recommendations of each guideline are therefore considered valid at the time of their production based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity.

Acute Disease↗

PubMed2003

Postmenopausal osteoporosis risk management in primary care: how well does it adhere to national practice guidelines?

OBJECTIVE: The National Osteoporosis Foundation (NOF) practice guideline provides explicit recommendations for postmenopausal osteoporosis risk assessment and management. This study evaluated primary care adherence to the recommendations and factors associated with such adherence. METHOD: Postmenopausal women 40 years old and older were sampled in the primary care clinic of a US tertiary hospital. We received 469 completed questionnaires that measured the respondent's demographics and osteoporosis risk factors; current and historical osteoporosis counseling, testing, and treatment; and whether or not she had a primary care clinician. Based on information provided, we determined whether each woman was receiving care that followed the NOF guideline. Univariate and multivariate analyses identified factors associated with guideline adherence. RESULTS: Mean age was 69 years; 53% were white and 38% black; 15% had prior fractures. Using NOF criteria, 19.8 % were at moderate risk and 80.2 % were at high risk for osteoporosis. Overall, 57.6% (95% confidence interval 53.1, 62.1) of patients received risk management in accordance with the NOF guideline. The adherence rate was higher in the high-risk group (60.9% v 44.1%, p=.003), in those who had primary care clinicians (62.0% v 43.5%, p=.006), and in nonblack patients (white v black 67.1% v 43.0%, p<.001; other v black 65.0% v 43.0%, p=.012). These associations remained statistically significant after multivariate adjustments. Adherence was not associated with the sex of the primary care clinician. CONCLUSIONS: More than half of postmenopausal women in our study were receiving osteoporosis risk management that followed the NOF practice guideline. Those who were at higher risk, who were not black, or who had primary care clinicians were more likely to receive care in accordance with the NOF guideline, regardless of the sex of the clinician.

Adult↗

PubMed1992

The case for intensive dissemination: adoption of practice guidelines in the coronary care unit.

Medical practice guidelines are being embraced enthusiastically by subspecialty and government organizations, but although hundreds have been developed at great public and private expense, there are few examples of how they have improved the quality of care or reduced health care costs. This article reports documented experience in changing physician behavior after implementing medical practice guidelines in the coronary care unit without altering physician incentives or imposing the threat of sanctions. Guideline adoption did require significant attention to the implementation process, including endorsement of guidelines by local "opinion leaders," validation by local data, and an intensive and concurrent implementation strategy.

Chest Pain↗

PubMed2006

Evaluation of a multiple component intervention to support the implementation of a 'Therapeutic Relationships' best practice guideline on nurses' communication skills.

OBJECTIVE: To determine if there was an improvement in nurses' communication skills 5 months after a multiple component intervention to implement the Registered Nurses' Association of Ontario best practice guideline 'Establishing Therapeutic Relationships'. METHODS: A matched pair, before and after design was used. Eight client scenarios with corresponding client comments were read aloud to nurses who were asked to respond verbally, as though they were interacting with the client. Responses were audio-taped and transcribed. The frequency and quality of nurses' active listening, initiating and assertiveness skills were measured pre- and post-implementation of the guideline. RESULTS: Twenty-two nurses responded at both time points. Active listening skills were most frequently used. There was a statistically significant decrease in the number of active listening skills used, but a statistically significant improvement in the quality of active listening and initiating statements and frequency of initiating skills. CONCLUSION: Nurses demonstrated improvements in selected communication skills following the implementation of a multiple component intervention that included a best practice guideline. PRACTICE IMPLICATIONS: A combination of strategies that support the implementation of a best practice guideline is described. Results indicate some improvement in communication skills that are essential to the establishment of therapeutic nurse-client relationships.

Attitude of Health Personnel↗

PubMedDate not supplied

[From scientific knowledge of clinical research to the bedside: clinical practice guidelines and their implementation].

Clinical practice guidelines (CPG) are targeted at health professionals and patients providing information for decision-making. They are aimed at reducing variations in medical practice in order to guarantee an optimum level of quality and improve health care. CPG are based on systematic reviews of biomedical literature and they recommend different clinical intervention strategies depending on the quality of scientific evidence on which they are based. However, we must bear in mind that scientific knowledge is only one of the elements that influence medical practice. Thus, it is not easy neither to recommend an intervention strategy for a specific circumstance (reality) from what has been studied in some rather ideal conditions (randomized controlled trial), nor to translate the context-dependent research evidence --effectiveness or cost-effectiveness studies- into a recommendation. These difficulties will be always present, as each patient (and his/her circumstances) is different from the others; but they can be lessened if more research is carried out to reduce uncertainty in clinical decision making. Finally, another difficulty that should be mentioned is that of CPG implementation, and in order to succeed in it, there is still much left to do in the health sciences field. Nevertheless, if there is not a good product to implement, the strategies used to do it will not be very helpful. Thus, we need to focus our efforts on the development of high quality CPG.

Biomedical Research↗

PubMed2003

Practice Guidelines for Parkinson's disease.

'Practice Guidelines (PG) or treatment guidelines' are not infallible guidelines but tools with which to support a clinical decision, i.e. one factor when making a clinical decision. When making a clinical decision, medical practice is determined by taking into consideration PG, a patient's preferences, and a country's social and healthcare systems. Even if a PG provides a treatment method based on a high-level of evidence, the method simply represents a mean result obtained from past clinical studies, which are not always uniformly applicable to all patients. When consulting a PG, it is advisable to know in advance what group/society/organization prepared it, the purpose of its preparation, and the developmental method, including social equity, whether healthcare costs are assumed in the PG or whether the pharmaceutical industry had substantial involvement in its development. Thus, PGs need to be developed according to the actual conditions in a country or institution. As to the questions whose answers are not provided in a PG, these issues have to be defined and assessed through a literature search. This is the so-called implementation of Evidence-Based Medicine (EBM). The concepts of EBM further require the provision of better evidence. A PG is always fated to be out of date by the time it is published because new evidence is continually being published. It is therefore, always necessary to search for the most up to date evidence available.

Decision Making↗

PubMed2006

Adoption of a ventilator-associated pneumonia clinical practice guideline.

CONCEPTUAL FRAMEWORK: The Academic Center for Evidence-based Practice (ACE) Star Model was used to implement an evidence-based clinical practice guideline (CPG) in order to decrease ventilator-associated pneumonia (VAP) incidence rates and ventilator days. The goal was to interrupt person-to-person transmission of bacteria and bacterial colonization using low-cost, evidence-based strategies to prevent VAP. DISCOVERY: Two geographically proximate medical centers, inclusive of five intensive care units located in the southwestern region of the United States had significant variations in their VAP rates. EVIDENCE SUMMARY: Using the U.S. Preventive Services Task Force grading criteria, the results of 69 studies were used to establish a clinical practice guideline to prevent ventilator-associated pneumonia. TRANSLATION: A clinical practice guideline was developed for the prevention of VAP and included five nursing activities: (a) head-of-bed elevation; (b) oral care; (c) ventilator tubing condensate removal; (d) hand hygiene; and (e) glove use. The effect of the CPG, inclusive of an educational intervention, was measured using an observational, prospective, quasi-experimental design. INTEGRATION: A multidisciplinary education team developed a self-learning packet, educational materials, and storyboards for the staff as dissemination strategies. Strategies also included e-mail, one-on-one teaching with clinicians, and feedback on guideline adoption and VAP rate reports. EVALUATION: Observation data were collected to evaluate adoption of the CPG while caring for 106 ventilated patients. VAP rates changed at both hospitals although the change was not statistically significant. Additionally, the ICU length of stay declined at both facilities, causing cost savings. DISCUSSION: These results support the idea that adoption of evidence-based practices contributes to decreased VAP rates. For a successful program, ICU leaders should emphasize strategies that routinize adoption of evidence-based CPGs.

Adolescent↗