AHCPR announces two new guidelines. Clinical practice guidelines on the evaluation and management of early HIV infection.
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AIDS-Related Opportunistic Infections↗
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Results for “clinical practice guidelines”
Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.
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[The Cologne Guidelines Conference: computer-assisted clinical practice guidelines in clinical diagnosis].
Eighteen clinical practice guidelines on interdisciplinary diagnostic issues were developed at the University Hospital of Cologne, Germany. The guideline committee is organized and directed by the quality control program, which also includes the local Cochrane initiative and a wide range of organizational topics. During guideline development, questions of differential diagnosis were addressed to the same extent as the organizational and financial realization. Broad consideration was given to medicolegal implications, but need for interspecialty cooperation was judged to be more critical and even more relevant in this regard. Guidelines were primarily developed as algorithms and translated to text versions secondarily. Critical steps in the decision tree were supported by rated literature and recommendations weighte by criteria as used in evidence-based medicine. For implementation, guidelines were presented to colleagues in a series of short lectures, as print versions containing all literature used in the developing process, and in hypertext format, which is accessible via intranet. Three levels of presentation were chosen in the html-version: algorithm, decision, and information. The former is due to orientation in the guideline, the second displays the binary question, and the latter makes the scientific background available, together with literature and links for more information. Efforts to check effectiveness are currently been made, questions of efficiency will be addressed in future.
Algorithms↗
The evaluation of living renal transplant donors: clinical practice guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians.
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Algorithms↗
Role of clinical practice guidelines and clinical profiling in facilitating optimal laboratory use.
Many studies have demonstrated the potential benefits of clinical practice guidelines in improving clinical practice. Moreover, several different kinds of clinical profiles have been developed to address issues related to quality, utilization, and outcomes of specific healthcare practices. With this expanded use of clinical practice guidelines and clinical profiles, clinical laboratory specialists have an opportunity to play an influential leadership role.
Chemistry, Clinical↗
Clinical practice guidelines vs actual clinical practice : the asthma paradigm.
In recent years, a multitude of practice guidelines, statements, position papers, and "best practices" have been promulgated for a number of disease entities by a variety of medical societies and managed care organizations. In the case of asthma, for example, the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) initially published guidelines for the diagnosis and management of asthma in 1991; these recommendations were updated in 1997. However, health-care providers have not widely and consistently adhered to these guidelines. Several recent publications suggest that this underutilization of the NIH asthma guidelines may in part be related to a lack of understanding. This lack of understanding appears to span the spectrum of physicians in private practice, physicians working in health maintenance organizations, as well as university-affiliated physicians. Moreover, both primary-care physicians and "asthma specialists" share deficits in their knowledge base. To compound the problem, patients with asthma also demonstrate poor adherence to the guidelines. This poor adherence is evident irrespective of the patient's socioeconomic status. These types of data clearly indicate a need for further educational programs directed to both physicians and patients. However, as with the development and promulgation of any practice guideline, physicians need to be convinced that there exists compelling evidence from well-controlled clinical trials, for example, or from evidence-based medicine, to substantiate implementation of these guidelines.
Adult↗
Lessons learned in implementing SCI clinical practice guidelines.
While clinical practice guidelines (CPGs) were designed as a tool to improve patient outcomes, decrease practice variation, and optimize resource utilization, providers often encounter significant barriers to integrating these into clinical practice. A study was conducted at six spinal cord injury (SCI) centers in the Department of Veterans Affairs (VA) to improve provider adherence and patient outcomes of two CPGs: Prevention of Thromboembolism in Spinal Cord Injury and Neurogenic Bowel Management in Adults With Spinal Cord Injury. To design effective implementation strategies, focus groups were conducted to identify provider-perceived barriers and facilitators to implementing recommendations for each of the SCI guidelines. Based on this information, four guideline implementation strategies were designed: (a) use of local opinion leaders ("clinical champions"), (b) patient-mediated interventions, (c) standardized documentation template/standing orders, and (d) social marketing/outreach visits. These strategies were implemented at each site. This article identifies "lessons learned" during the process of trying to get these CPGs embedded into clinical practice.
Attitude of Health Personnel↗
Levels of evidence in cardiovascular clinical practice guidelines.
BACKGROUND: Clinical practice guidelines (CPGs) can be helpful in distilling the medical research literature for clinicians; however, the guidelines should acknowledge the variable methodological quality used in clinical research by tempering their recommendations with a 'levels of evidence' scale. OBJECTIVE: To evaluate the proportion of English-language cardiovascular CPGs that provide the user with recommendations graded according to a defined levels of evidence scale. In addition, to evaluate other key aspects important in the critical appraisal of CPGs. METHODS: CPGs for atrial fibrillation, congestive heart failure and myocardial infarction were identified by searching MEDLINE, a reference text of CPGs and the Internet. Each CPG was evaluated using a priori-defined criteria based on the Evidence-Based Medicine Working Group's paper on critical appraisal of CPGs, including use of a reproducible search strategy, method of obtaining consensus, peer review and testing in practice. RESULTS: A total of 95 CPGs were evaluated. Only 13% graded their recommendations using a defined levels of evidence scale. In addition, few CPGs documented a reproducible search strategy or peer review process, and none had been formally tested in practice. CONCLUSIONS: Reporting the levels of evidence for recommendations is an important component of CPGs, yet this system is not widely used.
Atrial Fibrillation↗
Consensual validation of clinical practice model practice guidelines.
Clinical Practice Model (CPM) Practice Guidelines facilitate the delivery of consistent, high-quality patient care by clarifying nursing services and supporting the practice and documentation of each step of the nursing process. CPM Practice Guidelines are unique because they are part of an integrated interactive systems thinking framework to support professional practice; they are reviewed and improved routinely using multiple sources of data and are used by hundreds of nurses daily throughout the United States and Canada. Guidelines are developed using a rigorous standardized format and process. Consensual validation is an important part of establishing and maintaining the credibility of these Guidelines.
Humans↗
Acute sinusitis: Finnish clinical practice guidelines.
These clinical practice guidelines aim at providing assistance mainly to primary health care physicians for the diagnosis and management of acute sinusitis. Despite the huge impact of upper respiratory infections, criteria for diagnoses are often vague, and physicians are often uncertain of their diagnoses. This is not surprising, as the sole definition of acute sinusitis is somewhat confusing, not to mention the existing discrepancies between treatments, even among specialists. The Finnish Society of Otorhinolaryngology has set up a committee to evaluate existing data on acute sinusitis and to formulate these guidelines. The committee comprised Finnish experts in adult and paediatric otorhinolaryngology, clinical microbiology, radiology, paediatrics, and epidemiology. Recommendations given are based on the principles of evidence-based medicine, with the level of evidence presented.
Acute Disease↗
Risk factor-based selective screening program for gestational diabetes mellitus in Siriraj Hospital: result from clinical practice guideline.
A clinical practice guideline for the screening and diagnosis of gestational diabetes mellitus (GDM) is currently implemented at Siriraj Hospital. During the year 2000, a total of 9325 pregnant women were screened for clinical risk factors during their first antenatal visits, and 3770 had at least 1 risk. After the 50 g glucose challenge test and 100 g oral glucose tolerance test, GDM was diagnosed in 235 women. The incidence of GDM was 6.2 per cent (95% CI 5.5-7.1) among high-risk pregnant women, and 2.5 per cent (95% CI 2.2-2.9) of all pregnant women. Significant risk factors identified from the present study were family history of DM (adjusted OR 1.86, 95% CI 1.38-2.51), age > or = 30 years (adjusted OR 2.41, 95% CI 1.72-3.39), history of unexplained intrauterine fetal death (adjusted OR 4.30, 95% CI 2.04-9.04), and obesity (adjusted OR 2.83, 95% CI 1.88-4.25). The risk of developing GDM also increased when more than 1 clinical risk factor was identified. The results support the value of this screening program for GDM. Every obstetrician should be aware of the need to screen for GDM in every pregnant woman and a similar program should also be introduced to other settings.
Adult↗
The management of early breast carcinoma before and after the introduction of clinical practice guidelines.
BACKGROUND: Clinical practice guidelines for the management of breast carcinoma were introduced in Australia in October, 1995. This article describes the management of early-stage breast carcinoma both before and after the introduction of these guidelines. METHODS: All cases of early breast carcinoma that were diagnosed over the same 6-month period in 1995 and 1999 and registered with a state-based cancer registry were identified. Treating surgeons completed a survey assessing tumor characteristics and primary treatment. In 1995, 95% of 188 surgeons who were approached participated and 96% of the surveys were returned. In 1999, 92% of 159 surgeons who were approached participated and 91% of the surveys were returned. Analyses are based on 1066 cases from 1995 and 1001 cases from 1999. RESULTS: The pathologic disease stage of the patients was similar in both study years. The proportion of patients who underwent breast-conserving therapy (BCT) increased from 54% in 1995 to 69% in 1999. This increase was noted across most levels of disease characteristics but was not evident among those patients treated by the least active surgeons. The proportion of patients treated with BCT who received radiotherapy increased from 59% in 1995 to 80% in 1999. This trend was observed across most levels of tumor characteristics and surgeon caseload. The proportion of women with receptor-positive tumors who were treated with endocrine therapy increased, whereas the proportion of patients with receptor-negative tumors who received this therapy decreased from 39% in 1995 to 17% in 1999. CONCLUSIONS: The management of early breast carcinoma in the state of Victoria appeared to change between 1995 and 1999 in the direction expected if the national guidelines had been incorporated into the practice patterns of surgeons treating breast carcinoma patients.
Adult↗
Family physicians' opinions and attitudes to three clinical practice guidelines.
BACKGROUND: Clinical practice guidelines (CPGs) have been promoted as a strategy to measure and improve the quality of patient care. However, more effort has been expended on creating guidelines than implementing them. We surveyed family physicians about their knowledge of and attitudes toward 3 well-publicized CPGs. METHODS: A survey questionnaire was sent to a national sample of 600 family physicians selected at random from a file from the American Academy of Family Physicians (AAFP). RESULTS: After 2 mailings, the response rate was 71%. For each of the 3 guidelines, roughly 60% of respondents were familiar or somewhat familiar with the CPG. More than half of family physicians studied said they have changed their medical practices based on CPGs, and only 3% said they do not believe in guidelines and would not use them. Use of CPGs was lowest among physicians in solo practice and among those working in rural areas. However, no significant differences in CPG use or familiarity were noted based on number of years in practice. Many respondents indicated an interest in keeping CPGs current via the internet. CONCLUSIONS: Most American family physicians find CPGs to be helpful, and familiarity with them is fairly uniform across most subgroups studied.
Attitude of Health Personnel↗
Knowledge content of advance practice nurse and physician experts: A cognitive evaluation of clinical practice guideline comprehension.
Clinical practice guidelines (CPGs) are intended to provide evidence based knowledge for decision making for patient care. However, these guidelines have been poorly adopted by healthcare providers. One reason for this may be the static paper-based formats, isolated from the point of care. Biomedical informatics has provided a solution to this limitation through Computer Interpretable Guidelines (CIGs). An essential component of this process is CPG translation to a computer interpretable model. From the guideline modeling literature, the translators of CPGs typically are physicians. It is not known if other healthcare providers (i.e., Advance Practice Nurses [APNs]) comprehend CPGs similarly. This descriptive study utilized novice and expert APN and physician participants (varied by level of expertise) in a CPG comprehension task. Demographic data, verbal protocols, and recall model drawings were obtained and analyzed by description, protocol analysis, discourse analysis, and content analysis. The findings of this study indicate similar comprehension by the expert APNs and physicians suggesting that either type of expert may be utilized for modeling CPGs.
Comprehension↗
The future impact of clinical practice guidelines.
Clinical guidelines are a very hot topic. Many guidelines are being published, but many concerns about guidelines still exist. Guidelines may be able to increase the quality of health care while eliminating unnecessary or inappropriate care. Critics wonder if the process will instead lead to poorer care and a waste of time and effort. Although guidelines are targeted on providers of care, those with other roles will use guidelines for optimizing patient care and outcomes, assuring quality, cutting costs and tracking liability and risk management. Examination of guidelines and their impact suggest that the process and product are imperfect and that the impact is difficult to measure. The chiropractic profession will continue in its guideline efforts. The direct effects of guidelines will be on certain aspects of doctor knowledge, attitude, belief and behavior. The indirect effects will be largely attitudinal in nature at first but will eventually lead to action. The profession will embrace the need to (a) develop a more comprehensive and useful research database and (b) to develop sophisticated means for obtaining profession-wide consensus on fundamental clinical issues.
Chiropractic↗
The impact of clinical practice guidelines and clinical trials on treatment decisions.
With increasing numbers of clinical practice guidelines (CPGs) becoming available to guide physicians, it is important to understand how guidelines are developed. Of importance, is evaluation of the scientific evidence on which guidelines are based, indeed whether the guideline is evidence based or based on expert opinion alone. This report will review in general, guideline development. The impact of CPGs, including expected outcomes, as well as potential harms is discussed. Clinical trials, meta analyses and CPGs relevant to the treatment of lung cancer are reviewed.
Antineoplastic Protocols↗
Can surveying practitioners about their practices help identify priority clinical practice guideline topics?
BACKGROUND: Clinical practice guidelines are systematically developed statements designed to assist in patient and physician clinical decision making for specific clinical circumstances. In order to establish which guideline topics are priorities, practitioners were surveyed regarding their current practice. METHODS: One hundred ninety-seven practitioners in Ontario, Canada were mailed a survey exploring their current practice or opinion regarding the prophylactic use of anticonvulsant drugs in patients with malignant glioma who had never had a seizure. The survey consisted of seven questions regarding the relevance of a guideline on the subject to the practitioner's practice, the proportion of clinical cases involving anticonvulsant use, knowledge of existing guidelines on this topic, interest in reviewing a completed practice guideline and three clinical scenarios. RESULTS: There were 122 respondents who returned the survey (62% rate of return). Eighty percent of the practitioners who responded indicated that less than 25% of their clinical cases involved the use of anticonvulsants; however, only 16% of respondents indicated that a practice guideline would be irrelevant to their practice. Eighty percent of respondents volunteered to review a draft version of a practice guideline on the use of anticonvulsants. The survey presented the practitioners with three scenarios where anticonvulsants in patients with brain tumours may be appropriate: peri-operatively in patients without seizures, postoperatively in patients currently using anticonvulsants, and thirdly in patients not currently using anticonvulsants or undergoing surgery. In contrast to the third situation, the first two situations yielded considerable variation in practitioner response. CONCLUSION: The survey established that there is some variation present in the current practice of anticonvulsant use in the patients with brain tumours. Whether there is an optimal treatment practice has yet to be determined. Practitioners do seem to feel that a guideline on anticonvulsant use in warranted, and most practitioners would be interested in being part of the guideline development process.
Anticonvulsants↗
The relation between systematic reviews and practice guidelines.
Clinical practice guidelines have been developed to improve the process and outcomes of health care and to optimize resource utilization. By addressing such issues as prevention, diagnosis, and treatment, they can aid in health care decision making at many levels. Several other decision aids are cast in the guideline lexicon, regardless of their focus, formulation, or format; this can foster misunderstanding of the term "guideline." Whether created or adapted locally or nationally, most guidelines are an amalgam of clinical experience, expert opinion, and research evidence. Approaches to practice guideline development vary widely. Given the resources required to identify all relevant primary studies, many guidelines rely on systematic reviews that were either previously published or created de novo by guideline developers. Systematic reviews can aid in guideline development because they involve searching for, selecting, critically appraising, and summarizing the results of primary research. The more rigorous the review methods used and the higher the quality of the primary research that is synthesized, the more evidence-based the practice guideline is likely to be. Summaries of relevant research incorporated into guideline documents can help to keep practitioners up to date with the literature. Systematic reviews have also been published on the dissemination and implementation strategies most likely to change clinician behavior and improve patient outcomes. These can be useful in more effectively translating research evidence into practice.
Evidence-Based Medicine↗
Evaluating best practice guidelines.
Clinical practice guidelines are developed with the purpose of improving patient care. The Registered Nurses Association of Ontario (RNAO) Nursing Best Practice Guidelines (BPG) Project was implemented in 1999. It has resulted in the development, implementation and evaluation of 17 BPGs with agencies in different healthcare sectors. This article describes the process, challenges and lessons learned by the team responsible for evaluating the BPGs.
Benchmarking↗