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PubMed2004

Classifying recommendations for clinical practice guidelines.

Clinical practice guidelines are intended to improve the quality of clinical care by reducing inappropriate variations, producing optimal outcomes for patients, minimizing harm, and promoting cost-effective practices. This statement proposes an explicit classification of recommendations for clinical practice guidelines of the American Academy of Pediatrics (AAP) to promote communication among guideline developers, implementers, and other users of guideline knowledge, to improve consistency, and to facilitate user understanding. The statement describes 3 sequential activities in developing evidence-based clinical practice guidelines and related policies: 1) determination of the aggregate evidence quality in support of a proposed recommendation; 2) evaluation of the anticipated balance between benefits and harms when the recommendation is carried out; and 3) designation of recommendation strength. An individual policy can be reported as a "strong recommendation," "recommendation," "option," or "no recommendation." Use of this classification is intended to improve consistency and increase the transparency of the guideline-development process, facilitate understanding of AAP clinical practice guidelines, and enhance both the utility and credibility of AAP clinical practice guidelines.

Evidence-Based Medicine↗
PubMed2002

Outcomes research in the development and evaluation of practice guidelines.

BACKGROUND: Practice guidelines have been developed in response to the observation that variations exist in clinical medicine that are not related to variations in the clinical presentation and severity of the disease. Despite their widespread use, however, practice guideline evaluation lacks a rigorous scientific methodology to support its development and application. DISCUSSION: Firstly, we review the major epidemiological foundations of practice guideline development. Secondly, we propose a chronic disease epidemiological model in which practice patterns are viewed as the exposure and outcomes of interest such as quality or cost are viewed as the disease. Sources of selection, information, confounding and temporal trend bias are identified and discussed. SUMMARY: The proposed methodological framework for outcomes research to evaluate practice guidelines reflects the selection, information and confounding biases inherent in its observational nature which must be accounted for in both the design and the analysis phases of any outcomes research study.

Biomedical Research↗
PubMed1997

Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact.

OBJECTIVE: To determine Australian general practitioners' (GPs') views about and recall of clinical practice guidelines. DESIGN: Self-administered questionnaire survey. SUBJECTS: Randomly selected Australian GPs. RESULTS: 286 of 373 GPs returned questionnaires (77% response rate). GPs' recall of each of nine guidelines ranged from 52% to 94%; 49% considered that their practice had changed as a result of a guideline. While 92% of respondents agreed that guidelines were "good educational tools", 85% indicated that guidelines were "developed by experts who don't understand general practice". Factors most frequently identified as important in deciding whether to follow the guideline recommendations were whether the guideline was based on evidence and credible endorsement. CONCLUSIONS: Australian GPs have positive views about the purpose of clinical practice guidelines and an evidence-based approach to guidelines development. However, respondents rating of the perceived impact of available guidelines in everyday practice was low. The dissemination of specific guidelines is patchy and there is little evidence of systematic implementation.

Adult↗
PubMedDate not supplied

Using a clinical practice guideline to measure physician practice: translating a guideline for the management of heart failure.

BACKGROUND: Effective clinical practice guidelines should improve clinical outcomes, and measures of physician use of clinical practice guidelines should correlate with improved outcomes. This study translates a clinical practice guideline on heart failure into review criteria to measure physician performance and the effectiveness of the clinical practice guideline. METHODS: A panel of 11 family physicians and 1 cardiologist systematically reviewed the clinical practice guideline for its clinical importance, educational relevance, and evaluative appropriateness. Then a subset of 4 family physicians rigorously applied each recommendation to established criteria for measurability and developed an evaluation tool useful in medical record review. RESULTS: The heart failure clinical practice guideline was found to be an excellent educational tool. Using it to measure physician performance, however, was limited to diagnostic tests and drug prescribing. Of 45 recommendations, 5 fulfilled criteria for measurability; 1 recommendation had A-level evidence, whereas 2 recommendations had B-level and 2 had C-level evidence. CONCLUSION: This study illustrates the logistic issues and challenges in developing a measure of physician adherence to clinical practice guidelines. Medical record review is inadequate to measure many recommendations. Physicians use of this clinical practice guideline must be evaluated as an intermediate step to measuring the effectiveness of clinical practice guidelines based on patient outcomes.

Evidence-Based Medicine↗
PubMed1997

Clinical practice guidelines.

Clinical practice guidelines are becoming an important determinant of how we practice medicine and surgery. They are the strategy of our federal agencies to reduce variability in care, improve quality, measure outcomes, and reduce costs. The payors and entrepreneurs of medicine have endorsed the use of practice guidelines as the most efficacious way to manage costs, and variability. This economic force alone will perpetuate their development in the foreseeable future. It could be tempting to recoil from these pressures that may seem outside the realm of the individual surgeon trying to do the best for the individual patient. However, when viewed as a way to work with our colleagues and use scientific evidence and expert opinion to achieve consensus about best practice, this effort is very much in line with the way we practice surgery. The surgical community should not be concerned with participating but, in fact, should lead. The surgical tradition with outcomes assessment-the Morbidity and Mortality Conference-is a fundamental principle used to improve care. The process of practice guideline development is designed to do the same to continuously improve care.

General Surgery↗
PubMed1997

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↗
PubMed2001

Finding and evaluating clinical practice guidelines.

Clinical practice guidelines are valuable, clinical decision-making aids for preventive, diagnostic, therapeutic, and palliative patient care. This article identifies ways to access clinical practice guidelines and discusses evaluative criteria for identifying gold-standard evidence-based practice guidelines. Finally, clinicians are reminded of crucial questions to ask before applying any guidelines to patient care.

Databases, Factual↗
PubMed1998

Use of medical informatics to implement and develop clinical practice guidelines.

Clinical practice guidelines have enormous potential to improve the quality of and accountability in health care. Making the most of this potential should become easier as guideline developers integrate guidelines within information systems and electronic medical records. A major barrier to such integration is the lack of computing infrastructure in many clinical settings. To successfully implement guidelines in information systems, developers must create more specific recommendations than those that have been required for traditional guidelines. Using reusable software components to create guidelines can make the development of protocols faster and less expensive. In addition, using decision models to produce guidelines enables developers to structure guideline problems systematically, to prioritize information acquisition, to develop site-specific guidelines, and to evaluate the cost-effectiveness of the explicit incorporation of patient preferences into guideline recommendations. Ongoing research provides a foundation for the use of guideline development tools that can help developers tailor guidelines appropriately to their practice settings. This article explores how medical informatics can help clinicians find, use, and create practice guidelines.

Decision Trees↗
PubMed2003

Does attribution theory explain physicians' nonacceptance of clinical practice guidelines?

Clinical practice guidelines can potentially lead to reductions in healthcare costs and improved patient outcomes if adopted by physicians into their clinical practice. This research study provides data that gives healthcare administrators a basic understanding of how physicians perceive clinical practice guidelines (CPGs) and gives practical suggestions to obtain physician adherence to CPGs.

Attitude of Health Personnel↗
PubMed2004

Integrating clinical practice guidelines into daily practice: impact of an interactive workshop on drafting of a written action plan for asthma patients.

INTRODUCTION: Written action plans (WAPs) are instructions that enable asthmatics to manage their condition appropriately and are recommended by current asthma clinical practice guidelines (CPGs). However, general practitioners (GPs) rarely draft WAPs for their patients. An interactive, case-based workshop for asthma, combined with an objective structured clinical examination (OSCE), was developed to increase GPs' knowledge and use of WAPs in Québec. METHODS: The study compared 24 GPs receiving an OSCE preworkshop and 12 months post-workshop (group 1) with 16 GPs receiving an OSCE preworkshop and at 6 and 12 months post-workshop (group 2). Participants received no feedback on their OSCE performance. During the workshop, which presented a preformatted tool to aid drafting of the WAPs, all 40 GPs worked individually and in small groups to answer questions on a hypothetical clinical case and then discussed the responses with a facilitator and an asthma specialist. RESULTS: Only group 2 GPs showed a significant improvement in knowledge of WAPs 12 months post-workshop (p = .01). The likelihood of prescribing WAPs to patients increased in group 2 to a degree approaching statistical significance (p = .070), and there was a borderline nonsignificant trend for prescribing practice to improve more among group 2 GPs than among group 1 GPs (p = .052). There was also a nonsignificant trend for 6-month OSCE to increase attendance at the 12-month OSCE. DISCUSSION: An interactive workshop employing a preformatted WAP tool and a reinforcing OSCE at 6 months yielded improved knowledge of WAPs at 1 year. Although originally developed as a form of evaluation, the OSCE appears to have formative value even when correction is not provided and may increase the effectiveness of continuing medical education interventions to enhance CPG implementation.

Adult↗
PubMed2000

Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial.

BACKGROUND: Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression. METHODS: We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat. FINDINGS: The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve. INTERPRETATION: Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.

Antidepressive Agents, Tricyclic↗
PubMedDate not supplied

The KDOQI clinical practice guidelines and clinical practice recommendations for treating anemia in patients with chronic kidney disease: implications for nurses.

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative recently published revised clinical practice guidelines and recommendations for the treatment of anemia. This article provides an overview of the new guidelines and recommendations, with a focus on the hemoglobin treatment range, iron status, use of erythropoiesis-stimulating agents, and adjuvant therapies.

Anemia↗