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PubMed1998

Pediatricians' awareness of and attitudes about four clinical practice guidelines.

BACKGROUND: The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research's "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care). OBJECTIVES: 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines? DESIGN: A national survey of 600 pediatricians selected at random from the American Medical Association master file. RESULTS: A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. CONCLUSION: In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.

Attitude of Health Personnel↗

PubMed2001

What is the quality of drug therapy clinical practice guidelines in Canada?

BACKGROUND: The Canadian Medical Association maintains a national online database of clinical practice guidelines developed, endorsed or reviewed by Canadian organizations within 5 years of the current date. This study was designed to identify and describe guidelines in the database that make recommendations related to the use of drug therapy, and to assess their quality using a standardized guideline appraisal instrument. METHODS: Drug therapy guidelines in the database were identified with the use of search terms and hand searching. Descriptive information about the developers, endorsement by other organizations, publication status, disease and drug focus was abstracted. Each guideline was independently assessed by 3 appraisers (a physician, a pharmacist and a methodologist) with the use of the Appraisal Instrument for Clinical Guidelines. Conditions were classified according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems. RESULTS: We identified 217 drug therapy guidelines produced or reviewed from 1994 to 1998. Guideline developers included national organizations (47.0%), paragovernment organizations (39.6%) and professional associations (30.9%); 31.3% of the guidelines were published, and 10.6% stated drug company sponsorship. The most common conditions addressed by the guidelines were infections and parasitic diseases (39.6%), neoplasms (11.5%) and diseases of the circulatory system (11.5%). Drugs most commonly cited were anti-infective agents (42.9%), antiviral agents (15.2%) and cardiovascular drugs (16.1%). Eleven organizations produced 176 (81.1%) of the guidelines. In all, 14.7% of the guidelines met half or more of the 20 items assessing rigour of guideline development on the appraisal instrument (mean quality score 30.0% [95% confidence interval (CI) 27.5%-32.6%]), 61.8% met half or more of the 12 items assessing guideline context and content (mean score 57.0% [95% CI 54.6%-59.3%]), and none met half or more of the 5 items assessing guideline application (mean score 5.6% [95% CI 4.7%-6.5%]). Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. The quality of the guidelines assessed varied significantly by developer, publication status and drug company sponsorship. No substantial improvement in guideline quality was observed over the 5-year study period. INTERPRETATION: Developers of Canadian drug therapy guidelines are producing guidelines that are often perceived to be clinically useful to physicians and pharmacists, although the methods (or the description of the methods) by which they are developed need to be more rigorous and thorough.

Canada↗

PubMedDate not supplied

[Guidelines and jurisprudence: advice, guidance or regulation?].

Proliferation of clinical guidelines has given rise to a number of concerns about the status of clinical advisory statements. Are guidelines advisory or mandatory? What regulatory functions do guidelines serve; do they allow clinical discretion a large enough role? Relationships between legislation and guidelines, and the way courts go about determining the legal status of guidelines, are explained. The following questions in the context of the law of negligence are addressed. Do doctors who deviate from guidelines place themselves at increased risk of being found liable in negligence if patients suffer injury as a result? Could compliance with guidelines protect health care workers from liability in such circumstances? What legal responsibility do the developers and issuers of guidelines have if their guidance is found to be faulty? Common law cases featuring clinical guidelines or protocols have been identified from the databese Lexis, which searches the full text of the transcripts and reports of court cases in UK, Commonwealth and United States jurisdictions. Secondary literature, identified from the bibliography of clinical guidelines maintained by the Department of Health Services Research at the University of Aberdeen (assembled from DHSS-DATA, Embase, Grateful Med, Medline and SIGLE) has also been consulted. The legal status of a guideline turns on whether its development and application have statutory backing, and whether the guideline embodies clinical practices accepted as proper by a responsible body of doctors. The mandatory effects of guidelines can be gauged, to some extent, by the sanctions that apply in the event of non-compliance. US courts have ruled that guideline developers can be held liable for faulty guidelines, and that doctors cannot pass off their liability by claiming that adherence to guidelines has corrupted clinical judgement. Protocols and guidelines provide the courts with examples of clinical standards across a wide range of medical practice. As guidelines proliferate, so they will increasingly be used in court. However, adherence to guidelines has not automatically been equated with reasonable practice, and the courts seem unlikely to follow the standards enunciated in clinical guidelines without critically evaluating their authority, flexibility and scope of application. What usually is done may be evidence of what ought to be done ... but what ought to be done is fixed by a standards of reasonable prudence, whether it is complied with or not.

Jurisprudence↗

PubMed2006

[Acceptance and practicability of a guideline for rehabilitation in coronary artery disease].

BACKGROUND: Developed within the German Pension Insurance scheme's Guidelines programme, the Guideline for Rehabilitation in Coronary Artery Disease has been publicly available since January 2005. Pension Insurance routine data on the therapeutic benefits and services provided (based on the Classification of Therapeutic Procedures, KTL) were analyzed to assess the extent to which rehabilitation facilities had complied with Guideline requirements already in 2004. In January 2005, the results were disseminated together with the Guideline to the rehabilitation facilities which had participated in Pension Insurance rehabilitation of patients with coronary artery disease in 2004. In an accompanying survey information was requested concerning acceptability and applicability of the Guideline, of the presentation of KTL data, as well as reasons for non-adherence to Guideline requirements. METHODS: In February 2005 a written, anonymous survey was conducted among 72 clinical directors of rehabilitation facilities. The survey instrument contained three standardized questionnaires covering the aspects cited above. The response rate was 73.6 % (n = 53). Descriptive analyses were performed. RESULTS: Views of the Guideline: The Guideline fulfils most of the seven quality attributes surveyed (completely fulfilled: 11.3-32.7 %, basically fulfilled: 49.1-64.2 %). Volume, structure and clarity of the guideline are judged to be "very good" by 62.3 %, 50.9 % and 36.5 % of the respondents. The KTL-procedure codes forming part of the Guideline to be used to assess guideline adherence, were considered appropriate by 88.5 % to 98 %. Consent to Guideline requirements varies between 80.8 and 34.6 %. Views of the audit feedback based on KTL-data: Depending on the various data table types, 37.7 % to 20.0 % of the respondents stated that the tables should remain unchanged in future evaluations. 28.0 % to 39.0 % consider the tables to be very useful for quality management. Reasons for non-adherence to Guideline recommendations: according to the clinicians, the most important reason for deviation from Guideline requirements is incomplete or incorrect coding of therapeutic procedures. DISCUSSION: The Guideline for Rehabilitation in Coronary Artery Disease basically fulfils the formal, methodological and content-related quality criteria considered to be most relevant by the clinical directors. As expected, the greatest need for discussion is focussed on the actual Guideline requirements. Form and content of the KTL-feedback are well accepted, and the feedback itself is considered relevant for everyday practice. The main reason given for non-adherence to guideline requirements (i. e., inaccurate coding) should not be overstated as the KTL-analyses was based on data from 2004, when the guideline had not yet been published. CONCLUSION: The Guideline for Rehabilitation in Coronary Artery Disease is acceptable and practicable, and it is moreover tied in with external quality assurance activities in place (i. e., the quality assurance programme of the statutory Pension Insurance scheme). The audit feedback given in this framework provides rehabilitation facilities participating in the programme not only with comparative analyses but also with input for their internal quality management actions. Future activities within the external quality assurance programme should inter alia focus on more targeted implementation activities and repeated KTL-based appraisals.

Attitude of Health Personnel↗

PubMed2005

Quality of evidence-based pediatric guidelines.

OBJECTIVE: To identify evidence-based pediatric guidelines and to assess their quality. METHODS: We searched Medline, Embase, and relevant Web sites of guideline development programs and national pediatric societies to identify evidence-based pediatric guidelines. A list with titles of identified guidelines was sent to 51 leading pediatricians in the Netherlands, who were asked to select the 5 most urgent topics for guideline development. Three pediatrician reviewers appraised the available guidelines on the 10 most frequently mentioned topics with the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. RESULTS: A total of 215 evidence-based pediatric guidelines were identified; of these, 17 guidelines on the 10 most frequently mentioned topics were appraised. The AGREE instrument rates guidelines among 6 domains. For the scope and purpose domain, the mean score was 84% of the maximal mark. For stakeholder involvement, the mean score was 42%, with 12 guidelines (71%) scoring <50%. For rigor of development, the mean score was 54%, with 5 guidelines (29%) scoring <50%. For clarity and presentation, the mean score was 78%, with 4 guidelines (24%) scoring <50%. For applicability and editorial independence, performance was poor, with mean scores of 19% and 40%, respectively. Low scores were partly attributable to poor reporting. After considering all domain scores, the reviewers recommended 14 of 17 guidelines (82%) to be used in local practice. CONCLUSIONS: The current volume of pediatric guidelines categorized as evidence based in popular databases is large. Overall, these guidelines scored well, compared with other studies on guideline quality in fields outside pediatrics, when assessed for quality with the AGREE instrument. This holds especially for guidelines published or endorsed by the American Academy of Pediatrics or registered in the National Guideline Clearinghouse.

Child↗

PubMed1997

Canadian physicians' attitudes about and preferences regarding clinical practice guidelines.

OBJECTIVE: To assess Canadian physicians' confidence in, attitudes about and preferences regarding clinical practice guidelines. DESIGN: Cross-sectional, self-administered mailed survey. PARTICIPANTS: Stratified random sample of 3000 Canadian physicians; 1878 (62.6%) responded. SETTING: Canada. OUTCOME MEASURES: Physicians' use of various information sources; familiarity with and confidence in guidelines; attitudes about guidelines and their effect on medical care; rating of importance of guidelines and other sources of information in clinical decision-making; rating of importance of various considerations in deciding whether to adopt a set of guidelines; and rating of usefulness of different formats for presenting guidelines. MAIN RESULTS: In all, 52% of the respondents reported using guidelines at least monthly, substantially less frequently than traditional information sources. Most of the respondents expressed confidence in guidelines issued by various physician organizations, but 51% to 77% were not confident in guidelines issued by federal or provincial health ministries or by health insurance plans. The respondents were generally positive about guidelines (e.g., over 50% strongly agreed that they are a convenient source of advice and good educational tools); however, 22% to 26% had concerns about loss of autonomy, the rigidity of guidelines and decreased satisfaction with medical practice. Endorsement by respected colleagues or major organizations was identified as very important by 78% and 62% of the respondents respectively in deciding whether to adopt a set of guidelines in their practice. User friendliness of the guidelines format was thought to be very important by 62%; short pamphlets, manuals summarizing a number of guidelines, journal articles and pocket cards summarizing guidelines were the preferred formats (identified as most useful by 50% to 62% of the respondents). CONCLUSIONS: Canadian physicians, although generally positive about guidelines and confident in those developed by clinicians, have not yet integrated the use of guidelines into their practices to a large extent. Our results suggest that respected organizations and opinion leaders should be involved in the development of guidelines and that the acceptability of any proposed format and medium for guidelines presentation should be pretested.

Attitude of Health Personnel↗

PubMed2001

The relationship between introduction of American society of clinical oncology guidelines and the use of colony-stimulating factors in clinical practice in a Paris university hospital.

BACKGROUND: Clinical practice guidelines are issued periodically by professional medical societies or committees to assist practitioners in clinical decision making. However, it is unclear whether such guidelines have any lasting impact on clinical practice. OBJECTIVE: The purpose of this study was to assess the impact of the American Society of Clinical Oncology (ASCO) guidelines regarding use of hematopoietic colony-stimulating factors (CSF) on cancer care in a university hospital in Paris. METHODS: The study was performed at Hĵpital Tenon, an 830-bed university hospital in Paris, in 1996 and 1997, both before and after the ASCO guidelines were implemented. The guidelines were first disseminated as a continuing medical education program and then actively implemented using a CSF prescription order form summarizing the guidelines. This form had to be used during the patient consultation and was sent to the Hĵpital Tenon pharmacy for CSF dispensation. Even if CSF use did not comply with the ASCO guidelines, the pharmacy filled the prescription. Seven other university hospitals in Paris, where the ASCO guidelines were not actively implemented, comprised the control group. The main outcome measure was the proportion of prescriptions in compliance with the 1996 update of the ASCO guidelines. Secondary outcome measures were the proportions of prescriptions in compliance with ASCO guidelines regarding primary prophylactic, secondary prophylactic, and therapeutic CSF administration. RESULTS: Before implementation of the ASCO guidelines, CSF use in compliance with the guidelines was 39% (41/105) at the study site and 31% (16/51) at the control sites (P > 0.05). Six months after dissemination and implementation of the guidelines, the proportion of CSF prescriptions complying with ASCO guidelines increased significantly versus baseline (P = 0.003) in the study group, to 61% (50/82). However, even after the guidelines were implemented, compliance with guidelines on primary prophylactic CSF administration did not change significantly versus before implementation in the study group (12% [5/41] before implementation vs 6% [2/33] after implementation; P > 0.05). CONCLUSIONS: The results suggest an association between the active implementation strategy (continuing medical education and CSF prescription reminder form) and physician compliance with the ASCO guidelines. Implementation of the ASCO guidelines appears to have had some impact on medical practice.

Colony-Stimulating Factors↗

PubMed2003

The development of evidence-based guidelines for over-the-counter treatment of vulvovaginal candidiasis.

OBJECTIVE: The purpose of this study was to develop evidence-based guidelines for over-the-counter (OTC) treatment of vulvovaginal candidiasis with non-prescription anti-fungal medicines purchased from community pharmacies. METHOD: A multidisciplinary guideline development group was recruited from the locality where the guidelines were to be tested. A Nominal Group Technique (NGT) was used to achieve formal consensus within the group regarding the issues that the guidelines would address. Guideline recommendations were developed from the results of two systematic literature reviews that assessed which symptoms were predictive of vulvovaginal candidiasis (using data from epidemiological studies) and estimated the relative effectiveness of oral and intra-vaginal anti-fungals using data from randomised controlled trials. MAIN OUTCOME MEASURES: Evidence-based guideline recommendations. The guideline statements were linked to the evidence using a standard hierarchy. RESULTS: The guideline development group met four times. The use of NGT was an effective way of achieving consensus on guideline content. Two systematic reviews carried out as part of the guideline development process identified evidence for the guidelines on the efficacy of OTC treatments and symptoms suggestive of vulvovaginal candidiasis. The guideline recommendations were presented as a booklet and a laminated algorithm. In summary, the guidelines highlighted symptoms suggestive of vulvovaginal candidiasis, and symptoms associated with other vaginal conditions that should be referred to the GP. The guidelines stated that oral treatment and intra-vaginal treatment are equally effective, and that selection of an anti-fungal should be based upon safety, cost and patient preference. Many of the recommendations were influenced by OTC license restrictions of each antifungal product. Contra-indications to, and special precautions with, antifungals were also listed. In addition, the guidelines stated that the male sexual partner does not require treatment unless symptomatic. CONCLUSION: There is sufficient evidence available to develop evidence-based guidelines for the treatment of vulvovaginal candidiasis in the community pharmacy setting. The NGT is a useful component in the guideline development process.

Administration, Intravaginal↗

PubMed2002

Systematic assessment of the quality of osteoporosis guidelines.

BACKGROUND: Numerous agencies have developed clinical practice guidelines for the management of postmenopausal osteoporosis. The study objective was to conduct a systematic assessment of the quality of osteoporosis guidelines produced since 1998. METHODS: Guidelines were identified by searching MEDLINE (1998+), the world wide web, known guideline developer websites, bibliographies of retrieved guidelines, and through consultation with content experts. Each guideline was then assessed by three independent appraisers using the 'Appraisal Instrument for Clinical Guidelines' (version 1) by Cluzeau. RESULTS: We identified 26 unique guidelines from 1998-2001 and 21 met our inclusion criteria. Of the 21 guidelines reviewed, 8 were developed by medical societies, 6 by national groups, 6 by government agencies, and 1 by an international group. Twelve of the guidelines were published, 7 were organizational reports, and 2 were accessible only from the web. Half or more of the 20 items assessing the rigor of guideline development were met by 15% (median quality score 23%, range 5-80%, (95% CI 16.5, 34.7)), 81% met at least half of the 12 items assessing guideline content and context (median score 58%, range 17-83%, (95% CI 50.8, 65.5)), and none met half or more of the items assessing guideline application (median score 0%, range 0-47%, (95% CI -0.5 to 12.6)). Eight guidelines described the method used to assess the strength of evidence, and in 6 there was an explicit link between recommendations and the supporting evidence. Ten guidelines were judged not suitable for use in practice, 10 were acceptable with modification, and one was acceptable for use without modification. CONCLUSION: The methodological quality of current osteoporosis guidelines is low, although their scores for clinical content were higher. Virtually no guidelines covered dissemination issues. Few guidelines were judged as acceptable for use in their current format.

Journal Article↗

PubMed2006

Extraction and use of linguistic patterns for modelling medical guidelines.

OBJECTIVE: The quality of knowledge updates in evidence-based medical guidelines can be improved and the effort spent for updating can be reduced if the knowledge underlying the guideline text is explicitly modelled using the so-called linguistic guideline patterns, mappings between a text fragment and a formal representation of its corresponding medical knowledge. METHODS AND MATERIAL: Ontology-driven extraction of linguistic patterns is a method to automatically reconstruct the control knowledge captured in guidelines, which facilitates a more effective modelling and authoring of medical guidelines. We illustrate by examples the use of this method for generating and instantiating linguistic patterns in the text of a guideline for treatment of breast cancer, and evaluate the usefulness of these patterns in the modelling of this guideline. RESULTS: We developed a methodology for extracting and using linguistic patterns in guideline formalization, to aid the human modellers in guideline formalization and reduce the human modelling effort. Using automatic transformation rules for simple linguistic patterns, a good recall (between 72% and 80%) is obtained in selecting the procedural knowledge relevant for the guideline model, even though the precision of the guideline model generated automatically covers only between 20% and 35% of the human-generated guideline model. These results indicate the suitability of our method as a pre-processing step in medical guideline formalization. CONCLUSIONS: Modelling and authoring of medical texts can benefit from our proposed method. As pre-requisites for generating automatically a skeleton of the guideline model from the procedural part of the guideline text, to aid the human modeller, the medical terminology used by the guideline must have a good overlap with existing medical thesauri and its procedural knowledge must obey linguistic regularities that can be mapped into the control constructs of the target guideline modelling language.

Artificial Intelligence↗

PubMed2026

Assessing the public health impact of routinely collected electronic healthcare record data in NICE guidelines: A systematic review of CPRD research.

OBJECTIVES: Evidence used in NICE guidance has traditionally prioritised randomised controlled trials, but increasing availability of electronic health record (EHR) data has expanded opportunities for real-world evidence. The Clinical Practice Research Datalink (CPRD) is a commonly used UK primary care EHR resource, yet the extent to which CPRD studies have informed NICE guidelines in the past decade is unclear. STUDY DESIGN: The systematic review was conducted in accordance with PRISMA guidelines. METHODS: We conducted a systematic review of CPRD studies in PubMed, MEDLINE, and Embase published between 04/16-09/25. For each eligible CPRD study, targeted searches of NICE guidelines were performed to identify explicit citations in NICE guidelines. Two reviewers screened and extracted data independently, resolving disagreements by consensus or third reviewer. Guideline information, number of guidelines over time, type of guidelines, and disease area guidelines (using British National Formulary (BNF) chapters) were described. RESULTS: 7181 records were identified. After de-duplication, 2704 unique CPRD studies were screened against NICE guidelines. Of these, 92 CPRD-based studies met inclusion criteria and were cited across 67 NICE documents. The annual number of NICE guidelines citing CPRD studies increased between 2016 and 2025; 1.5% of identified guidelines published in 2016 and 27.7% in 2025. The guideline citing the most CPRD studies was cancer related. The most common types of guidelines included clinical guidelines (49.3%) and technology appraisals (32.8%). Guidelines made up 12 different BNF categories, most frequently central nervous system related (23.9%; n = 16). CONCLUSION: Observational CPRD studies are increasingly referenced in NICE guidelines across multiple disease areas, supporting the growing role of EHR data in national guideline development.

Clinical studies↗

PubMed2003

The state of the science and art of practice guidelines development, dissemination and evaluation in Canada.

The Canadian Medical Association (CMA) maintains a database of clinical practice guidelines (CPGs) developed or endorsed by Canadian organizations. The study purpose was to describe how these guidelines were developed, disseminated and evaluated. A survey was mailed to the developer of each CPG registered in the CMA Infobase between June 1996 and December 1999. Data were received for 730 unique guidelines (response rate of 70%) developed by 75 organizations. Of these, 72% were developed by committees that had a formal process for selecting their members. The scientific literature was reviewed for all of the guidelines, a computerized search undertaken for 88% and the search strategy included 34% of CPG documents. An attempt was made to grade the quality of the evidence underpinning 54% of the guidelines. For most guidelines, consensus about values or judgements was reached by expert opinion through open discussion (78% of guidelines). The most common strategies used to disseminate the guidelines were direct mailing of guidelines to members of the developing organization (80% of all guidelines), publishing guidelines in newsletters/journals (76%), direct mailing to others (73%), electronic dissemination (62%), educational or continuing medical education activities (50%), and providing information about guidelines to patients/consumers (47%). Overall, 5% of the guidelines have been evaluated to determine their impact on health outcomes. During the 5-year study period (1994-99), the more recent guidelines were more likely to use multidisciplinary development panels, report the literature search strategies and grade the quality of the evidence. The CPG development process in Canada is becoming more rigorous and reproducible, but there is still considerable room for improvement. In addition to encouraging Canadian guideline developers to use more rigorous and transparent methods, considerably more attention must be focused on using and identifying effective and cost-effective strategies to promote and facilitate the uptake of guidelines by practitioners and to evaluate the impact of guidelines on patient outcomes.

Canada↗

PubMed2003

Physician awareness and self-reported use of local and national guidelines for community-acquired pneumonia.

OBJECTIVES: To assess physician awareness and reported use of medical guidelines for community-acquired pneumonia (CAP), and to identify factors associated with variations in awareness and use of these guidelines. DESIGN: A questionnaire was administered during the preintervention phase of a randomized clinical trial of a pneumonia guideline implementation strategy. PARTICIPANTS: Three hundred and fifty-two physicians who managed CAP patients at 7 Pittsburgh, PA hospitals completed the questionnaire. Physician and practice setting characteristics, and physician awareness and reported use of national American Thoracic Society (ATS) and local (hospital-developed) guidelines for CAP were assessed. RESULTS: Overall, 48% reported being influenced by ATS guidelines and 20% reported using these guidelines; 48% were uncertain whether a local pneumonia guideline existed. Only 28% of physicians who knew a local guideline existed reported frequently using the guideline. Use of national ATS guidelines was independently associated with practice as an infectious disease or pulmonary medicine specialist, nonpatient care-related professional activities, and intellect personality score. Use of local guidelines was independently negatively associated with practice as an infectious disease or pulmonary medicine specialist, and positively associated with positive attitudes toward practice guidelines. CONCLUSIONS: Results indicate low levels of awareness and use of guidelines for the management of CAP. Key indicators (e.g., medical specialty, fewer clinical duties, and positive attitudes about guidelines) were associated with greater use of national and local guidelines. If replicated with data on actual physician management practices, more effective guideline implementation strategies will be necessary to encourage compliance with practice guidelines for the management of CAP.

Anti-Bacterial Agents↗

PubMed2006

Adaptation of clinical guidelines: literature review and proposition for a framework and procedure.

PURPOSE: The development and updating of high-quality clinical practice guidelines require substantial resources. Many guideline programmes throughout the world are using similar strategies to achieve similar goals, resulting in many guidelines on the same topic. One method of using resources more efficiently and avoiding unnecessary duplication of effort would be to adapt existing guidelines. The aim was to review the literature on adaptation of guidelines and to propose a systematic approach for adaptation of guidelines. DATA SOURCES: We selected and reviewed reports describing the methods and results of adaptation of guidelines from those found by searching Medline, Internet, and reference lists of relevant papers. On the basis of this review and our experience in guideline development, we proposed a conceptual framework and procedure for adaptation of guidelines. RESULTS: Adaptation of guidelines is performed either as an alternative to de novo guideline development or to improve guideline implementation through local tailoring of an international or national guideline. However, no validated process for the adaptation of guidelines produced in one cultural and organizational setting for use in another (i.e. trans-contextual adaptation) was found in the literature. The proposed procedure is a stepwise approach to trans-contextual adaptation, including searching for existing guidelines, quality appraisal, detailed analysis of the coherence between the evidence and the recommendations, and adaptation of the recommendations to the target context of use, taking into account the organization of the health care system and cultural context. CONCLUSIONS: Trans-contextual adaptation of guidelines is increasingly being considered as an alternative to de novo guideline development. The proposed approach should be validated and evaluated to determine if it can reduce duplication of effort and inefficient use of resources, although guaranteeing a high-quality product, compared with de novo development.

Diffusion of Innovation↗

PubMed1998

Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment.

OBJECTIVE: To describe the content of guidelines on the use of anticoagulant treatment in patients with atrial fibrillation and the impact of variations in guidelines on treatment. DESIGN: Postal survey of guidelines, semistructured interview with lead developers of guidelines, and application of guidelines to patient sample. SUBJECTS: 15 lead developers of the 20 guidelines identified in the postal survey were interviewed. 100 patients over 65 with atrial fibrillation to whom the guidelines were applied. MAIN OUTCOME MEASURES: Evaluation of guidelines and the methods of dissemination, implementation, review, and evaluation; proportion of patients recommended for anticoagulant treatment by each guideline; and level of agreement between guidelines. RESULTS: There was considerable variation in whether anticoagulant treatment was recommended for subjects (range 13% to 100%, kappa = 0.12). Guidelines varied greatly in advice on treatment by age, the use of echocardiography, and the target value or range of the international normalised ratio (8 of the 20 guidelines included values unlikely to be effective). Development was unsystematic; evidence based approaches were rarely used, 9 of the 15 lead developers had developed the guidelines themselves, and the 6 guidelines developed by groups relied on informal consensus. Methods to support effective dissemination, implementation, and evaluation were limited. CONCLUSION: The widespread non-systematic production of guidelines has led to considerable variation with implications for the quality of care and clinical decision making. There is a need for a central, well funded programme of guideline development to ensure that valid guidelines are produced and disseminated.

Aged↗

PubMed1999

The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK.

BACKGROUND: Despite research evidence that guidelines can improve patient care, concerns remain over their cost-effectiveness. This is particularly so when there is a proliferation of guidelines for the same condition. Faced with differing recommendations, users will wish to make informed decisions on which guideline to follow. In creating a guideline appraisal instrument we have assessed guidelines developed in the United Kingdom (UK) for the management of a range of disorders including depression in primary care. AIM: To identify the number of UK clinical guidelines for the management of depression in primary care and to describe their quality and clinical content. METHOD: A survey was undertaken to identify all depression guidelines developed in the UK between January 1991 and January 1996. All guidelines produced by national organizations and a random sample of local guidelines were appraised using a validated instrument by six assessors: a national expert in the disease area, a general practitioner, a public health physician, a hospital consultant, a nurse specializing in the disease area, and a researcher on guideline methodology. The clinical content of each guideline was then assessed by one of the researchers (RB) according to a defined framework. RESULTS: Forty-five depression guidelines were identified. While there was a considerable range in the quality of the six national and three local guidelines appraised, at a group level their performance was similar to guidelines for other diseases. Clinical recommendations tended to reflect the joint consensus statement produced by the Royal College of General Practitioners and Royal College of Psychiatrists in 1992. The most obvious difference was in the style in which the guidelines were written and presented. CONCLUSION: A 'national template' was the starting place for most guidelines. Steps need to be taken to ensure that these templates are based on the best possible research evidence and professional opinion. Local clinicians should concentrate on effective dissemination and implementation strategies, rather than creating new guidelines.

Depressive Disorder↗

PubMedDate not supplied

Evaluating the quality of clinical practice guidelines.

OBJECTIVE: To review and identify established methods for evaluating the quality of practice guidelines and to use a selected assessment tool to assess 2 chiropractic practice guideline documents. METHODS: A search of the medical literature was performed to identify current methods and procedures for practice guideline evaluation. Two chiropractic practice guideline documents, Vertebral Subluxation in Chiropractic Practice (CCP) and Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy) were then independently evaluated for validity by 10 appraisers using the identified appraisal tool. The appraisal scores were tabulated, and consensus appraisals were generated for the CCP and Mercy guideline documents. RESULTS: The "Appraisal Instrument for Clinical Guidelines" (Cluzeau instrument) was identified as a reliable and valid method of guideline evaluation. The result of the application of this appraisal tool in the assessment of the CCP and Mercy guideline documents was that the former scored notably lower than the latter. On the basis of the results of the guideline appraisals, the CCP document is not recommended, and its guidelines are not considered suitable for application in chiropractic practice. The Mercy guidelines are recommended for application in chiropractic practice, with the proviso that new scientific data should be considered. CONCLUSIONS: The literature reviewed suggests that professional organizations or groups should undertake a critical review of guidelines using available critical guideline appraisal tools. Guideline validity appraisal should be done before acceptance by the chiropractic profession. To avoid unwarranted utilization of poorly constructed guidelines, it is strongly recommended that all future guidelines be reviewed for validity and scientific accuracy with the findings published in a medically indexed journal before they are adopted by the chiropractic community.

Chiropractic↗

PubMed2001

Design and implementation of a framework to support the development of clinical guidelines.

This paper describes and discusses a framework that facilitates the development of clinical guideline application tasks. The framework, named GASTON covers all stages in the guideline development process, ranging from the definition of models that represent guidelines to the implementation of run-time systems that provide decision support, based on the guidelines that were developed during the earlier stages. The GASTON framework consists of (1) a newly developed guideline representation formalism that uses the concepts of primitives, problem-solving methods (PSMs) and ontologies to represent the guidelines of various complexity and granularity and different application domains, (2) a guideline authoring environment that enables guideline authors to define the guidelines, based on the newly developed guideline representation formalism and (3) a guideline execution environment that translates defined guidelines into a more efficient symbol level representation, which can be read in and processed by an execution time engine. The paper describes a number of design criteria that were formulated regarding the aspects of guideline representation, guideline authoring and guideline execution and explains the framework by example in terms of the four stages that were identified in the guideline development process and the tools that were developed to support each stage. It also shows examples of systems that were developed by means of the GASTON framework.

Artificial Intelligence↗