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PubMed1995

A model for adapting clinical guidelines for electronic implementation in primary care.

Medical informaticians who seek to implement clinical guidelines by computer must be aware of a significant gap that exists between guideline development and utilization. In order to be effective, guideline recommendations must be followed by clinicians; in order for clinicians to follow willingly, they must agree with the guidelines. This paper presents a model process for building consensus among clinicians that can be used to obtain support for guideline recommendations prior to their electronic implementation. This approach involves initial presentation of the guidelines by a specialist, iterative cycles of surveying clinicians' opinions about the guidelines and revising the guidelines, supervision of the process by a practice opinion leader, and final group discussion of the revised guidelines to reach consensus. This model was successfully used to adapt guidelines for the continuing care of patients with diabetes mellitus that were subsequently implemented electronically with broad support of the primary care clinicians using them. The model minimized the need for lengthy group discussion by surveying individuals' attitudes and working through a practice opinion leader to gain consensus support for the guidelines. An efficient approach for developing support for guidelines among practitioners will facilitate the electronic implementation of guidelines and lead to enhanced compliance with guidelines after implementation.

Delphi Technique↗

PubMed1996

Do actions reported by physicians in training conflict with consensus guidelines on ethics?

OBJECTIVE: To assess the extent to which actions reported by internal medicine trainees conflict with published guidelines on ethics. METHODS: A confidential survey was sent to a random sample (N = 1000) of associate members of the American College of Physicians (ACP). Questions were asked about ethical decision making in areas addressed by the guidelines in the ACP Ethics Manual. Quoted manual guidelines were provided, followed by 55 yes or no questions, such that a yes answer represented an action that conflicted with a guideline. There were two follow-up mailings to nonresponders. RESULTS: Forty percent (n = 397) completed the questionnaire; 17% indicated they were aware of the guidelines on ethics. On average, associates responded yes to 16% of questions where a yes response indicated they have acted outside guidelines on ethics one or more times. The mean number of responses (n = 55) that conflicted with a guideline was 7.6 per person (SD, 4.7 responses; range, 0 to 33 responses). Ninety-eight percent of respondents reported actions falling outside a guideline one or more times and 80% did so four or more times. The most frequently reported reason (965/3219 [30%]) from a list of four choices for acting outside a guideline was "I was aware of the guideline, but this did not represent an ethical dilemma to me." CONCLUSIONS: Few responding ACP associates indicated awareness of the ACP guidelines on ethics. Physicians in training nevertheless reported acting according to the presented guidelines most of the time, although nearly all respondents acted outside a guideline at least once, and some did so many times. Reported behaviors were sometimes inconsistent with consensus ethical standards that apply to internists. Physicians in training need to know more about ethical standards that apply to their own practice and should be aware when their actions deviate from ethical norms. Before acting outside guidelines on ethics, trainees should discuss their conflicts with others, such as attending physicians, clinical ethicists, or hospital ethics committees.

Codes of Ethics↗

PubMed2003

European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts).

Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organisations--European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilisation of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific task force. The ESC Committee for practice guidelines (CPG) supervises and coordinates the preparation of new guidelines and expert consensus documents produced by task forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements.

Adult↗

PubMed2005

Knowledge and acceptance of hypertension guidelines in clinical practice: experience from Slovenia.

BACKGROUND: Arterial hypertension, which is an important risk factor for cardiovascular disease, is mainly treated by general practitioners. The initial step in an optimal therapeutic strategy for patients with arterial hypertension is the recognition and acceptance of hypertension guidelines by the physicians themselves. AIMS: To find out how well Slovene general practitioners know the current hypertension guidelines and to what extent they accept them. PARTICIPANTS AND METHODS: Knowledge of current recommendations in hypertension diagnosis, treatment, follow-up and special indications was assessed for 813 general practitioners in Slovenia using a questionnaire. The Slovene National Guidelines were taken as the reference standard. Adequate knowledge of the guidelines' recommendations was defined as correct answers to at least seven out of eleven items; the correct answers had to include the appropriate target blood pressure, the elements of the "minimal diagnostic program" in hypertension and the correct estimation of cardiovascular risk. Acceptance of the guidelines was estimated on a five-grade scale: 5 meaning very useful, 1 meaning useless. RESULTS: A total of 321 questionnaires were suitable for analysis from 327 that were returned (a response rate of 40.2%). The mean number of correct answers was 7.8 (SD, 1.8, range, 4-11), but only 124 (38.8%) of the participating physicians answered the three key questions correctly. The physicians who answered the key questions correctly also answered more of the other questions correctly (6.1 vs. 5.4, p < 0.001). Adequate knowledge of the guidelines was found in 116 (36.8%) of the total study population; mean score for acceptance on the five-grade scale was 4.25. Knowledge of the guidelines was influenced by the physicians' acceptance of the guidelines' recommendations (p = 0.024). No other characteristics of physicians or organizational factors influencing knowledge of the guidelines were identified. Most of the participating physicians (72%) were willing to attend a workshop on managing hypertension and there was no connection between knowledge of the guidelines and willingness to attend the workshop. CONCLUSION: Knowledge of the hypertension guidelines among Slovene general practitioners is limited, and is comparable to the results of similar studies. The physicians' acceptance of the guidelines is high and correlates with their knowledge of the guidelines. A workshop is an accepted form of continuing medical education among general practitioners.

Family Practice↗

PubMed2004

Approaches for creating computer-interpretable guidelines that facilitate decision support.

During the last decade, studies have shown the benefits of using clinical guidelines in the practice of medicine. Although the importance of these guidelines is widely recognized, health care organizations typically pay more attention to guideline development than to guideline implementation for routine use in daily care. However, studies have shown that clinicians are often not familiar with written guidelines and do not apply them appropriately during the actual care process. Implementing guidelines in computer-based decision support systems promises to improve the acceptance and application of guidelines in daily practice because the actions and observations of health care workers are monitored and advice is generated whenever a guideline is not followed. Such implementations are increasingly applied in diverse areas such as policy development, utilization management, education, clinical trials, and workflow facilitation. Many parties are developing computer-based guidelines as well as decision support systems that incorporate these guidelines. This paper reviews generic approaches for developing and implementing computer-based guidelines that facilitate decision support. It addresses guideline representation, acquisition, verification and execution aspects. The paper describes five approaches (the Arden Syntax, GuideLine Interchange Format (GLIF), PROforma, Asbru and EON), after the approaches are compared and discussed.

Artificial Intelligence↗

PubMed2006

Adoption of a sedation scoring system and sedation guideline in an intensive care unit.

AIM: The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline. BACKGROUND: Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data. METHOD: A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004. FINDINGS: The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both. CONCLUSION: Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.

Adolescent↗

PubMed2005

Provider adherence to COPD guidelines: relationship to organizational factors.

RATIONALE, AIMS AND OBJECTIVES: A clinical practice guideline for chronic obstructive pulmonary disease (COPD) was implemented in all Veterans Health Administration (VHA) hospitals in the US. The aim of the current analyses is to describe current adherence rates and the organizational factors related to provider adherence to the COPD guideline. METHODS: We administered a survey to key informants that assessed adherence to the COPD guideline, approaches to disseminating and implementing the COPD guideline, providers' views of the COPD guideline and guidelines in general, and attitudes about the organizational climate. RESULTS: Surveys were returned by 242 key informants (58%) at 130 of the 143 VHA hospitals (91%). Adherence to the COPD clinical practice guideline is perceived by quality managers within the VHA to be good. The final multivariable predictor model identified five measures that were related to provider adherence with the COPD guideline (R(2) = 0.43): responsibilities were changed to support adherence to the COPD guideline, physicians believe that guidelines implemented in the past year were applicable to their practice, patient care providers consistently participate in activities to improve the quality of care, the regional network office monitors the pace at which guidelines are implemented, and there is a system to provide feedback on routinely collected guideline adherence data collected in addition to External Peer Review Program data. CONCLUSIONS: Organizations can play an important role in providing a supportive climate to facilitate their providers' adherence to guidelines by implementing processes and culture changes that involve these five measures.

Data Collection↗

PubMed2004

Clinical practice guidelines for managing dyslipidemias in kidney transplant patients: a report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative.

The incidence of cardiovascular disease (CVD) is very high in patients with chronic kidney (CKD) disease and in kidney transplant recipients. Indeed, available evidence for these patients suggests that the 10-year cumulative risk of coronary heart disease is at least 20%, or roughly equivalent to the risk seen in patients with previous CVD. Recently, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) published guidelines for the diagnosis and treatment of dyslipidemias in patients with CKD, including transplant patients. It was the conclusion of this Work Group that the National Cholesterol Education Program Guidelines are generally applicable to patients with CKD, but that there are significant differences in the approach and treatment of dyslipidemias in patients with CKD compared with the general population. In the present document we present the guidelines generated by this workgroup as they apply to kidney transplant recipients. Evidence from the general population indicates that treatment of dyslipidemias reduces CVD, and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemias. Dyslipidemias are very common in CKD and in transplant patients. However, until recently there have been no adequately powered, randomized, controlled trials examining the effects of dyslipidemia treatment on CVD in patients with CKD. Since completion of the K/DOQI guidelines on dyslipidemia in CKD, the results of the Assessment of Lescol in Renal Transplantation (ALERT) Study have been presented and published. Based on information from randomized trials conducted in the general population and the single study conducted in kidney transplant patients, these guidelines, which are a modified version of the K/DOQI dyslipidemia guidelines, were developed to aid clinicians in the management of dyslipidemias in kidney transplant patients. These guidelines are divided into four sections. The first section (Introduction) provides the rationale for the guidelines, and describes the target population, scope, intended users, and methods. The second section presents guidelines on the assessment of dyslipidemias (guidelines 1-3), while the third section offers guidelines for the treatment of dyslipidemias (guidelines 4-5). The key guideline statements are supported mainly by data from studies in the general population, but there is an urgent need for additional studies in CKD and in transplant patients. Therefore, the last section outlines recommendations for research.

Adolescent↗

PubMedDate not supplied

What factors influence provider knowledge of a congestive heart failure guideline in a national health care system?

Provider knowledge is a potential barrier to adherence to clinical guidelines. The purpose of this study is to assess the impact of organizational, provider, and guideline factors on provider knowledge of a congestive heart failure (CHF) clinical practice guideline (CPG) in the Veterans Health Administration (VHA) health care system. We developed a survey to investigate institution-level factors influencing the effectiveness of guideline implementation, including characteristics of the guideline, providers, hospital culture and structure, and regional network. Survey participants were quality managers, primary care administrators, and other individuals involved in primary care CPG implementation at 143 VHA hospitals with ambulatory care clinics. Potential explanatory variables were grouped into 11 factors. Multivariate regression models assessed the association between these factors and reported levels of provider knowledge regarding the CHF guideline at the hospital level. Two hundred forty surveys from 126 of 143 (88%) VHA hospitals were returned. Provider knowledge of the CHF guideline was estimated as "great" or "very great" by 58% of respondents. Three predictor factors (dissemination approaches, use of technology in guideline implementation, and hospital culture) were independently associated (P < or = .05) with provider knowledge. Specific variables within these categories that were related to greater knowledge included physician belief that guidelines were applicable to their practice, distribution of guideline summaries, use of guideline storyboards in clinic areas, the use of technology (eg, electronic patient records) in CPG implementation, and establishment of implementation checkpoints and deadlines. Provider knowledge of guidelines is affected by factors at various organizational levels: dissemination approaches, use of technology, and hospital culture. Guideline implementation efforts that target multiple organizational levels may increase provider knowledge.

Ambulatory Care Facilities↗

PubMed1996

Use of clinical practice guidelines in managed care physician groups.

There is increasing interest in the use of clinical guidelines as a tool to improve the quality and cost-effectiveness of health care. Yet, relatively little data are available regarding the use of guidelines by health care provider organizations. We developed a written descriptive survey investigating the development, implementation, and evaluation of clinical guidelines that was administered to medical directors or their designees from physician medical groups and independent practice associations. Eighty-seven percent of physician organizations were reported to be developing or implementing clinical guidelines. The reasons most often cited for developing clinical guidelines were quality improvement and cost containment. Local expert opinion or judgment was rated as the most important influence in the development of clinical guidelines, followed by medical and scientific literature and externally developed guidelines. Feedback of information was the most popular method of increasing compliance with clinical guidelines, although 19% of physician organizations reported imposing sanctions on physicians who did not use guidelines. Most of the physician organizations surveyed have embraced clinical guidelines. Local development or adaptation of clinical guidelines may be common. There has been disproportionately little attention paid to guideline implementation and to evaluation of guideline effects relative to their development.

California↗

PubMed2000

Prevalence and content analysis of guidelines on handling requests for euthanasia or assisted suicide in Dutch nursing homes.

BACKGROUND: The growing number of requests for euthanasia or assisted suicide (EAS) makes it imperative for health care institutions, such as nursing homes, to have written guidelines on how to handle requests for EAS. The objective of this study was to determine the prevalence of EAS guidelines in Dutch nursing homes and to analyze the content. METHODS: Directors of patient care in 324 Dutch nursing homes were asked, by means of a mailed short list of questions, if they had an institutional guideline on EAS and, if so, to provide a copy. Guidelines were analyzed according to a structured list of items based on current jurisprudence, model documents, and opinions of experts. RESULTS: Of the 324 directors, 313 (97%) responded. In 58% of the nursing homes that responded, there existed written guidelines for EAS. Of those guidelines, 74% concerned EAS; in 26%, EAS was integrated in a guideline on terminal care. Of the guidelines, 165 (90%) were based on the policy that EAS is acceptable under specific conditions, and 18 (10%) banned EAS completely. Of the first-mentioned guidelines, 81% described one or more procedures for in-principle objections. In 65% of these guidelines, all official requirements for prudent practice were described. CONCLUSIONS: Despite the rapidly growing number of nursing-home guidelines on EAS and the existence of model documents, there is still considerable variation in the guidelines, and they can be improved in many aspects. A basic prerequisite is that the guidelines include all the official requirements for prudent practice.

Decision Making↗

PubMed1995

The adoption of preventive care practice guidelines by primary care physicians: do actions match intentions?

OBJECTIVE: To measure primary care physicians' familiarity with, attitudes toward, and confidence in preventive care practice guidelines for the elderly and to determine whether their attitudes are associated with implementation of guidelines into clinical practice. DESIGN: A self-administered survey of physicians employed by a health maintenance organization (HMO) and of patients cared for by those physicians. Medical records were also reviewed to assess compliance with practice guidelines. SETTING: An HMO in Southern California. PARTICIPANTS: Forty-eight primary care physicians completed the survey (100% response rate). The medical records of 3,249 randomly selected elderly patients (65 to 75 years old) were studied. Of these patients, 2,799 completed a preventive care survey (response rate 86.1%). MEASUREMENT AND RESULTS: Most HMO primary care physicians agreed or strongly agreed that guidelines will improve quality of medical care (88%) and that guidelines have caused them to change their care of patients (73%). Although the physicians' general attitudes about guidelines did not often correlate with their use of preventive care guidelines, the physicians who stated that practice guidelines had changed their practices were more likely to offer their patients clinical breast examinations (75.9% vs 67.2%, p = 0.04) and to counsel their patients to exercise (70% vs 58%, p = 0.01) than were the physicians who did not. There was a significant association between physicians' support for and adoption of specific practice guidelines regarding mammography (r = 0.34, p = 0.02) and immunizations against influenza (r = 0.42, p < 0.005), pneumococcal pneumonia (r = 0.47, p < 0.001), and tetanus (r = 0.31, p = 0.03). CONCLUSIONS: Physicians employed by an HMO were familiar with and hopeful about the role of guidelines for improving patient care. Physicians' attitudes toward specific preventive care guidelines and admission that guidelines had caused them to change their practice did at times, but not always, correlate with their implementation of guidelines into clinical practice.

Adult↗

PubMed2005

Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care?

Description of a workshop entitled "Sharing Guidelines for Low Back Pain Between Primary Health Care Providers: Toward a Common Message in Primary Care" that was held at the Fifth International Forum on Low Back Pain in Primary Care in Canada in May 2002. Despite a considerable degree of acceptance of current evidence-based guidelines, in practice, primary health care providers still do not share a common message. The objective of the workshop was to describe the outcomes of a workshop on the sharing of guidelines in primary care. The Fifth International Forum on Low Back Pain Research in Primary Care focused on relations between stakeholders in the primary care management of back pain. Participants in this workshop contributed to an open discussion on "how and why" evidence-based guidelines about back pain do or do not work in practice. Ways to minimise the factors that inhibit implementation were discussed in the light of whether guidelines are mono-disciplinary or multidisciplinary. Examples of potential issues for debate were contained in introductory presentations. The prospects for improving implementation and reducing barriers, and the priorities for future research, were then considered by an international group of researchers. This paper summarises the conclusions of three researcher subgroups that focused on the sharing of guidelines under the headings of: (1) the content, (2) the development process, and (3) implementation. How to share the evidence and make it meaningful to practice stakeholders is the main challenge of guideline implementation. There is a need to consider the balance between the strength of evidence in multidisciplinary guidelines and the utility/feasibility of mono-disciplinary guidelines. The usefulness of both mono-disciplinary and multidisciplinary guidelines was agreed on. However, in order to achieve consistent messages, mono-disciplinary guidelines should have a multidisciplinary parent. In other words, guidelines should be developed and monitored by a multidisciplinary team, but may be transferred to practice by mono-disciplinary messengers. Despite general agreement that multi-faceted interventions are most effective for implementing guidelines, the feasibility of doing this in busy clinical settings is questioned. Research is needed from local implementation pilots and quality monitoring studies to understand how to develop and deliver the contextual understanding required. This relates to processes of care as well as outcomes, and to social factors and policymaking as well as health care interventions. We commend these considerations to all who are interested in the challenges of achieving better-integrated, evidence-based care for people with back pain.

Back Pain↗

PubMed2005

A critical review of guidelines for low back pain treatment.

MAIN PROBLEM: Little is known about the methodological quality of guidelines for low back pain treatment. We evaluated the methods used by the developers according to established standards. METHODS: PubMed, guideline databases, and the World Wide Web were used to identify guidelines. Seventeen guidelines met the inclusion criteria: interventions for low back pain stated, recommendations based on or explicitly linked to evidence, and English version available. Guidelines were evaluated independently by two appraisers using a practical tool for this purpose, Users' Guides to the Medical Literature, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. RESULTS: Thirteen guidelines (76%) specified the most important therapies applied, but only nine (53%) included a complete description of the target population. Explicit processes to identify, select, and combine evidence were described in only six guidelines (35%). Few guidelines (3; 18%) explicitly considered all main outcomes when formulating therapeutic recommendations, and none contained a process to determine the relative value of different outcomes. Methodological criteria for grading the strength of the recommendations varied, and were often insufficiently specified. None of the guidelines assessed the impact of uncertainty associated with the evidence and values used. According to AGREE the quality score was highest for the scope and purpose, and clarity and presentation domains, and lowest for editorial independence and applicability. With regard to the recommendations, there was consensus for some of the interventions for acute pain (analgesics and NSAIDs, maintaining physical activity, and avoiding excessive bed rest), but explicit recommendations were lacking or ambiguous for 41% of the interventions. Most of the guidelines did not contemplate specific recommendations for chronic pain. CONCLUSIONS: A small number of the available guidelines for low back pain treatment achieved acceptable results for specific quality criteria. In general, the methods to develop the guidelines' therapeutic recommendations need to be more rigorous, more explicit and better explained. In addition, greater importance should be placed on the recommendations for chronic pain.

Activities of Daily Living↗

PubMed2003

An independent assessment of chiropractic practice guidelines.

OBJECTIVE: To evaluate the quality of Recommended Clinical Protocols and Guidelines for the Practice of Chiropractic (ICA guidelines) published by the International Chiropractors Association (ICA), August, 2000. METHODS: The Appraisal Instrument for Clinical Guidelines (Cluzeau instrument) was applied to the ICA guidelines by 10 independent experienced evaluators. An independent, global assessment was also made by each evaluator. RESULTS: Mean scores (with 95% confidence limit) for each of the instrument's 3 dimensions were Rigor of Development, 27% (5.1); Context and Content, 18.3% (9.4); and Application, 2% (3.9). The unanimous global assessment was "not recommended as suitable for utilization in practice." Comparison of the ICA guideline scores with the Council on Chiropractic Practice's Clinical Practice Guideline No. 1, Vertebral Subluxation in Chiropractic Practice (CCP guidelines) scores and Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy guidelines) Cluzeau instrument-based scores revealed that the ICA guidelines received slightly higher scores than the CCP guidelines but substantially lower scores than the Mercy guidelines for all dimensions. CONCLUSION: The ICA guidelines were assessed as not suitable for utilization in chiropractic practice.

Chiropractic↗

PubMed2001

Factors influencing hospital implementation of acute pain management practice guidelines.

STUDY OBJECTIVE: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. DESIGN: Two questionnaire surveys. SETTING: Healthcare Association of New York State, Albany, NY. MEASUREMENT: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage. MAIN RESULTS: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. CONCLUSIONS: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Decision Making, Organizational↗

PubMed2000

Developing clinical guidelines: issues and challenges.

Clinical guidelines are viewed as an important tool in the quest to promote evidence based practice. Consequently, there has been a proliferation in guideline development at a national and local level. This paper describes what clinical guidelines are and how they have been developed by a national organisation--the Royal College of Nursing (RCN). Drawing on the development of two tissue viability guidelines: The Management of Patients with Venous Leg Ulcers and Risk Assessment and Prevention of Pressure Ulcers, some challenges inherent in guideline development are outlined. Certain desirable attributes that a clinical guideline should exhibit in order for it to be utilisable and effective in practice are outlined as these provide a standard for guideline developers. In reality the practice of guideline development will depend upon the topic, the experience of the guideline group, the purpose of the guidelines and the evidence available. Our experience suggests that producing a clinically valid and utilisable guideline is a labour and resource intensive process. It is also time consuming. An alternative strategy to developing local guidelines from scratch would be to adapt an existing guideline to local circumstances. A stepwise process is presented in the paper to assist people with this process.

Evidence-Based Medicine↗

PubMed2004

[Quality of guidelines for the treatment of alcohol related disorders -- a systematic review and content analysis].

BACKGROUND: Alcohol related disorders (dependent, harmful or at risk drinking) display a high prevalence in the community. We systematically reviewed and assessed the quality of available guidelines in the context of developing an evidence-based pathway of care for the treatment of those disorders in primary care. METHODS: We searched the internet for guidelines published in English, German, Italian, French or Spanish. The search was performed using the following sources: Internet Search engines, guideline providing agencies via internet, MEDLINE, PsychInfo and Cochrane Library. In addition, national professional societies were contacted to provide existing guidelines. We used a standardized instrument to assess methodological quality in three dimensions using dichotomous items: methodology of guideline development (21 items), content of guideline (17 items) and application (6 items). Each guideline was evaluated independently by two reviewers (MB, SH). Disagreement was documented using a disagreement protocol and resolved by discussion. Results were expressed as percent of total (domain) score. RESULTS: We included 9 published guidelines and 2 drafts. The methodological quality was heterogeneous. The mean quality score was below 50 % of the maximum score. Major flaws were lack of clear grounding in evidence-based medicine, too much information provided, lack of consumer involvement or insufficient involvement of all care providers as well as lack of implementation strategies. The scores of the guidelines published by professional societies for primary care were higher than the others. DISCUSSION: As demonstrated by the identified guidelines, more interdisciplinary panels and evidence-based processes need to be incorporated in the development process of guidelines for the treatment of alcohol related disorders. Our findings suggest that it might be advisable and effective to adapt already available valid and evidence-based guidelines or to collaborate with international working groups for the development of guidelines. There is a strong need for the scientific evaluation of implementation processes.

Alcoholism↗