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PubMed1995

The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation.

PURPOSE: To develop a conceptual tool for the systematic development of cancer treatment practice guidelines. MATERIALS AND METHODS: The guidelines development tool, the Practice Guidelines Development Cycle, was derived from observing an evidence-based practice guidelines initiative at a comprehensive cancer center in Ontario, Canada, and from a literature review that uncovered barriers to guidelines development and implementation. Based on the literature findings and direct observations of how clinicians struggled with evidence-based guidelines development, we evolved a framework to incorporate clinical and administrative factors (eg, costs) into evidence-based guidelines. Use of the Practice Guidelines Development Cycle is illustrated with a clinical example (the use of adjuvant systemic therapy in good-risk, node-negative premenopausal breast cancer patients). RESULTS: The result is the Practice Guidelines Development Cycle, which consists of eight sequential steps, from topic selection to policy formulation. Independent validation of guidelines is included. The cycle products are the evidence-based recommendation, the practice guideline, and the practice policy. The main features of the cycle are emphasis on scientific evidence, acknowledgment of the roles of clinical experience and nonclinical (administrative) factors through consensus, and explicit separation of clinical and cost considerations in guidelines development. Twenty guidelines are currently in development. CONCLUSION: Attention to the barriers of guidelines development and the sociocultural nature of clinical practice, and respect for clinical experience, can lead to improved strategies for guidelines development.

Cancer Care Facilities↗
PubMed2000

Do practice guidelines guide practice? A prospective audit of induction of labor three years experience.

BACKGROUND: To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures. METHOD: Guidelines for induction of labor were implemented in January 1996 following an audit report identifying inconsistency in clinical practice. A prospective audit was carried out following the implementation of a new strategy directed towards pre-induction cervical ripening in nulliparae with unfavorable cervices and the use of low dosages of vaginal prostaglandin E2 for induction of labor. Level of compliance and outcome measures were compared before and after implementation of guidelines. RESULTS: In the period of January 1995 to November 1997, 1,230 women were induced with a singleton viable pregnancy in a cephalic presentation with a gestational age > or = 37 weeks with no history of rupture of membranes or cesarean section. Completed forms were available for 1,147 women (370, 421 and 356 in 1995, 1996 and 1997, respectively). Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit. CONCLUSION: Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Adolescent↗
PubMed1995

Internists' evaluation of guidelines: the IMCARE Practice Guidelines Network.

This paper presents the attitudes and experiences of one group of practicing internists, the IMCARE Practice Guidelines Network, with clinical practice guidelines. From its beginning the Network has enjoyed close ties to both the Agency for Health Care Policy and Research (AHCPR) and the Institute of Medicine (IOM) with their guideline mandates. The Network is a self-selected group of 471 internists and their subspecialty colleagues, dispersed throughout the U.S. Network member evaluations of draft clinical practice guidelines present a compelling case for the need for clarity of language and a more condensed guideline structure. As Network members' critique indicates, once published, guidelines have become communication tools.

Attitude of Health Personnel↗
PubMed2003

Effectiveness of report cards based on chart audits of residents' adherence to practice guidelines on practice performance: a randomized controlled trial.

BACKGROUND: Medical record audits have been used to provide physicians with feedback about their compliance with preventive health and disease management recommendations. PURPOSE: To determine if report cards summarizing medicine residents' preventive health and disease management practices can be used as a feedback tool to improve practice performance. METHODS: Randomized, blinded, controlled study of 44 internal medicine residents using an individualized 78-item report card based on outpatient record audits. RESULTS: Four hundred ninety-seven charts were retrospectively audited at baseline and 284 charts in follow-up. There were no significant differences in baseline performance between the residents in the intervention and control group. There were no differences in performance scores between residents receiving report cards and those who had not in immunizations, counseling, total preventive health, diabetes, hypertension, and total disease management. CONCLUSIONS: Intensive data-based feedback using report cards may not be a successful way to improve ambulatory performance of medical house officers.

Adult↗
PubMed2002

The role of high-dose chemotherapy and stem-cell transplantation in patients with multiple myeloma: a practice guideline of the Cancer Care Ontario Practice Guidelines Initiative.

The Hematology Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative has systematically reviewed the published literature and, through a consensus process, developed an evidence-based practice guideline assessing the role of stem-cell transplantation in patients with multiple myeloma. The conclusions were validated by solicited feedback from 221 practitioners across Ontario, Canada. The guideline comprises six recommendations: 1) Autologous transplantation is recommended for patients with stage II or III myeloma and good performance status. Evidence of benefit is strongest for patients who are younger than 55 years of age and have a serum creatinine level less than 150 micromol/L (<1.7 mg/dL). Physicians must use clinical judgment in recommending transplantation to other patients. 2) Allogeneic transplantation is not recommended as routine therapy. 3) Patients potentially eligible for transplantation should be referred for assessment early after diagnosis and should not be extensively exposed to alkylating agents before collection of stem cells. 4) Autologous peripheral blood stem cells should be harvested early in the patient's treatment course. The best available data suggest that transplantation is most advantageous when performed as part of initial therapy. 5) The comparative data addressing the specifics of the transplantation process are insufficient to allow definitive recommendations. In the absence of such data, a single transplant with high-dose melphalan, with or without total-body irradiation, is suggested for patients undergoing transplantation outside a clinical trial. 6) At this time, no conclusions can be reached about the role of interferon therapy after transplantation.

Age Factors↗
PubMed1998

US family physicians' experiences with practice guidelines.

BACKGROUND: Practice guidelines were developed to improve medical outcomes and cost-effectiveness. The experiences of family physicians, who may need to use multiple guidelines in their practices, are crucial for effective development and implementation of practice guidelines. We surveyed a national sample of US family physicians about factors that affect their adoption and use of practice guidelines. METHODS: We mailed a structured survey to a national random sample of 400 family physician members of the American Academy of Family Physicians. RESULTS: The response rate was 51%. Most respondents (69%) reported a positive attitude about practice guidelines, but only 44% reported using any guidelines. More younger physicians thought that guidelines could be useful tools. Most preferred guidelines that could be modified (87%) and that were no longer than two pages. Only 27% of respondents knew where to locate a guideline on a particular topic. Forty-three percent of respondents reported that it would be useful if guidelines were a component of an electronic medical record. CONCLUSIONS: If guidelines are to be used by practicing family physicians, a generalist perspective needs to be considered in future guideline development and implementation. Younger physicians had more positive attitudes toward guidelines.

Adult↗
PubMed1994

Guidelines, practice policies, and parameters: the case for geriatrics.

OBJECTIVE: As the population ages, the care of older persons becomes more important. At the same time, practice guidelines that provide recommendations for appropriate care are being published in greater numbers. The purpose of this work is to determine the proportion of guidelines that contain specific information about older persons. DESIGN: Through a random sample of published guidelines listed in the AMA Directory of Practice Parameters, 1992 Edition, we determined the proportion of guidelines that contain specific age-related information. We also determined if, over time, there was a difference in the proportion of practice guidelines containing information about older persons. RESULTS: 45.9% (95% CI, range 33.4-58.4) of guidelines that could conceivably pertain to older persons contain no age information; 24.6% (95% CI, range 13.8-35.4) of guidelines contain information only about persons less than 65 years of age; 29.5% (95% CI, range 18.1-41.0) of guidelines contain specific information about older persons. Moreover, there were no secular trends in the proportion of guidelines pertaining to older persons. CONCLUSIONS: Only a minority of practice guidelines contain information about older persons. Possible causes and solutions to this shortfall are discussed.

Age Factors↗
PubMed1998

The philosophy of clinical practice guidelines: purposes, problems, practicality and implementation.

There are a number of technical and professional challenges to the use of clinical practice guidelines in the United Kingdom. Until recently, many guidelines have been consensus-based rather than being explicitly linked to evidence of effectiveness and have also been of variable quality. Moreover, clarity of purpose has been lacking with some guidelines being developed as a means of limiting access to secondary care rather than as a means of assisting clinical decision-making. Implementation of new research into practice and of clinical practice guideline recommendations shares many of the same barriers to changing clinician behaviour. Without local support systems to assist with implementation, including clinical audit programmes and methods of feeding back information on current practice, it is unlikely that guidelines will change practice in the majority of clinicians. Progress on the implementation of guidelines in the British National Health Service is discussed.

Employee Performance Appraisal↗
PubMed2001

Utilization of incontinence clinical practice guidelines.

Clinical practice guidelines (CPGs) are evidence-based recommendations for best practice and have been developed with the assumption they will be embraced by practitioners; a further assumption is that clinical practice guidelines will improve the delivery of care. In this article, we provide a working definition of evidence-based practice, discuss the strengths and limitations of CPGs, describe the implementation of CPGs in the context of urinary incontinence, and consider the steps that the WOCN has taken to initiate evidence-based practice. Current issues are presented along with initiatives that have resulted in clinical practice guidelines on incontinence from the United States, United Kingdom, and Canada. On the basis of the current literature, it is concluded that clinical practice guidelines can play an important role in WOCN practice and that the implementation of guidelines may improve clinical practice. However, guidelines are only as valid as the evidence on which they are based and may not take into account gender or cultural differences or the effect that comorbid conditions can have on treatment outcomes. Finally, guidelines must follow a comprehensive approach that involves management and staff and includes education, facilitation, evaluation, feedback, and an understanding of change strategies.

Adult↗