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PubMed2005

Quality of guidelines for the laboratory management of diabetes mellitus.

BACKGROUND: There is increasing concern about the quality and reliability of practice guidelines, especially in the field of laboratory medicine, as most recommendations are developed by clinical specialty societies, often without involving laboratory professionals. Little information is available on the methodological quality of guidelines for the use of laboratory investigations in the care of specific diseases. We describe a pilot assessment of the most well-known guidelines for the diagnosis and monitoring of diabetes mellitus (DM). METHODS: Practice guidelines on DM published in English between 1999 and 2005 April were identified by systematic searching in Medline and international guideline databases. Fifty four DM guidelines were retrieved, of which 29 met our inclusion criteria. The four most widely used international guidelines (WHO, ADA, NACB, NICE) were selected for a critical appraisal of their methodological quality. This was carried out by seven independent assessors using a validated checklist, the AGREE Instrument. Twenty three guideline attributes arranged in six independent domains were investigated and the mean scores of assessors for each attribute and the aggregated scores for each domain were calculated. Cronbach's alpha and interclass correlations were calculated to measure internal consistency and reliability within each domain. The four guidelines were compared using one-way ANOVA and ANOVA using repeated measurements. RESULTS: The selected four guidelines on DM have significant shortcomings in demonstrating and/or reporting multidisciplinary stakeholder involvement in the guideline development process, evidence-based methodology for formulating recommendations, applicability of statements, and disclosing any conflicts of interest or reporting editorial independence. CONCLUSIONS: Poor quality and lack of explicitness of recommendations in laboratory medicine call for methodological standards of guideline development and reporting, and for an international collaboration of guideline development activities, to increase the internal and external validity of recommendations in laboratory practice.

Diabetes Mellitus↗

PubMedDate not supplied

GASTON: an architecture for the acquisition and execution of clinical guideline-application tasks.

Recently, studies have shown the benefits of using clinical guidelines in the practice of medicine. There have been numerous efforts to develop clinical decision support systems that support guideline-based care in an automated fashion, covering a wide range of clinical settings and tasks. Despite these efforts, only a few systems progressed beyond the prototype stage and the research laboratory. For guideline-based clinical decision support systems to be successful, a balance must be made between intuitive but imprecise representations usually encountered by most of today's systems and representations that support a strong underlying clinical performance model. The project described in this paper tries to achieve such a balance. It presents the GASTON architecture that contains a set of reusable software components for the application of guidelines, including design-time components to facilitate the guideline authoring process based on guideline representation models along with execution-time components for building decision support systems that incorporate these guidelines. This architecture was used to develop several guideline representation models such as a rule-based representation to model rule-based guidelines and guideline representation models that address more complex tasks. Also, decision support systems that incorporate these models were developed with the architecture. For the representation and application of various classes of guidelines, rules were also viewed as instances of more complex tasks. By identifying similar characteristics of sets of rules, we developed several tasks such as a drug intera ction and drug contraindication task. Based on these models, we have developed and validated guidelines and decision support systems for use in several application domains such as intensive care, family physicians and psychiatry. In order to be able to represent more complex time-oriented plans, new guideline representation models are being developed.

Algorithms↗

PubMed1999

The assessment of genetic risk of breast cancer: a set of GP guidelines.

BACKGROUND: Assessing a genetic risk for developing breast cancer is not an easy task for a GP. Current expert guidelines for referring and counselling women with a family history positive for breast cancer are complex and difficult to apply in general practice, and have only two strategies (to refer or not to refer for genetic counselling), giving no guidance for the GP on the management of women with a moderately increased risk of familial breast cancer. OBJECTIVES: We aimed to develop a set of simple practical guidelines for use in primary care for assessing risk and advising women with a positive family history in general practice and aimed to explore its performance. METHODS: Based on a consensus meeting of the Leiden working party of hereditary tumours, the GPs of a university-related health care centre developed a set of GP guidelines to assess risk and advise women with a family history positive for breast cancer in general practice. The GP guidelines include four therapeutic strategies (reassuring, starting surveillance, starting surveillance and contacting a family cancer clinic, referring to a family cancer clinic). Its performance was tested in 67 patients whose pedigrees were available together with the risk assessment of a clinical geneticist using Claus' tables as a gold standard. The gold standard was dichotomized regarding (i) referral to a family cancer clinic and (ii) surveillance. Two existing expert guidelines were similarly compared. RESULTS: Regarding referral to a family cancer clinic, the GP guidelines were very specific, whereas the expert guidelines were more sensitive. Regarding surveillance, the GP guidelines were very sensitive, whereas the expert guidelines were very specific. The total number of misclassified patients was lowest when using the GP guidelines, and higher when using the expert guidelines. CONCLUSIONS: The GP guidelines provide a simplification of current guidelines. Before using them on a larger scale, more testing and refining are needed to increase their sensitivity regarding a referral to a family cancer clinic and their specificity regarding surveillance. They incorporate a role for the GP in the care for women with a family history positive for breast cancer with a moderately increased risk.

Adolescent↗

PubMed2000

Influence of postal distribution of the Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial.

BACKGROUND: The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care. OBJECTIVES: To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year; and to explore GPs'attitudes to the guidelines. METHODS: Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines. RESULTS: A total of 43 778 radiological requests were made during the two years 1994-1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance. CONCLUSIONS: Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one year. Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients.

Attitude of Health Personnel↗

PubMed1998

Spine update. Patient preferences and the development of practice guidelines.

One shortcoming of clinical practice guidelines is that generic, one-for-all guideline recommendations do not account for differences among patients' views about the desirability (or undesirability) of specific health outcomes, such as low back pain. Because differences in patients' preferences may lead to differences in the preferred therapy, a clinical practice guideline that does not consider patients' preferences may provide recommendations that are not optimal. Recently developed methodologic approaches enable guideline developers to assess the role of patients' preferences in clinical decisions and guideline recommendations, and to develop preference-based guidelines. Preference-based guidelines are more likely to meet criteria for high-quality guidelines than are guidelines developed without consideration of the role of patients' preferences. Guideline developers should identify decisions in which patient preferences are important and note these decisions clearly in the written guideline; indicate the specific health states for which preferences are important; and, if possible, provide recommendations about options for preference assessment. These options range from informal discussions with patients to computer-based utility assessments. Patients' preferences are an important factor in clinical decisions regarding management of low-back pain, particularly in decisions about surgical management and symptom control. Although further research is needed to define the role of techniques for assessing patients' preferences in routine clinical practice, guideline developers can determine when patients' preferences should play a prominent role in guideline recommendations.

Decision Making↗

PubMedDate not supplied

Adapting national and international leg ulcer practice guidelines for local use: the Ontario Leg Ulcer Community Care Protocol.

BACKGROUND: Because of growing resources devoted to individuals requiring community care for leg ulcers, the authority responsible for home care in Ottawa, Ontario, Canada, established and evaluated a demonstration leg ulcer service. In an effort to provide current and evidence-based care, existing leg ulcer clinical practice guidelines were identified and appraised for quality and suitability to the new service. PROCESS: The Practice Guideline Evaluation and Adaptation Cycle guided development of a local protocol for leg ulcer care, which included: (1) systematically searching for practice guidelines, (2) appraising the quality of identified guidelines using a validated guideline appraisal instrument, (3) conducting a content analysis of guideline recommendations, (4) selecting recommendations to include in the local protocol, and (5) obtaining practitioner and external expert feedback on the proposed protocol. Updating the protocol followed a similar process. RESULTS: Of 19 identified leg ulcer practice guidelines, 14 were not evaluated because they did not meet the criteria (ie, treatment-focused guidelines, written in English and developed after 1998). Of the 5 remaining guidelines, 3 were fairly well developed and made similar recommendations. The level of evidence supporting specific recommendations ranged from randomized clinical trial evidence to expert opinion. By comparing the methodologic quality and content of the guidelines, the Task Force reached consensus regarding recommendations appropriate for local application. Two additional guidelines were subsequently identified and incorporated into the local protocol during a scheduled update. CONCLUSIONS: Local adaptation of international and national guidelines is feasible following facilitation of the Practice Guidelines Evaluation and Adaptation Cycle.

Community Health Services↗

PubMed2006

Initiating highly active antiretroviral therapy in human immunodeficiency virus type 1-infected children in Europe and the United States: comparing clinical practice to guidelines and literature evidence.

Several guidelines are available to guide the initiation of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected children. The recommendations in these guidelines show significant variability. Because there is no well-established evidence on when to start HAART, it is left to the discretion of the pediatrician which guidelines to follow. We conducted a survey concerning the indications for starting antiretroviral therapy among pediatricians involved in the treatment of HIV-infected patients in Europe and the United States. We compared the results of this survey with the guidelines available at the time, the recently adapted guidelines and literature evidence. Our results indicate that in clinical practice HAART was initiated at higher viral loads and lower CD4 counts than recommended by the guidelines. American guidelines recommended and still recommend more aggressive treatment than the European guidelines, and this is reflected in clinical practice. Until recently all guidelines were based on long term risk analyses of progression to acquired immunodeficiency syndrome (AIDS) and death performed in cohort data. A recent short term risk analysis makes it possible to calculate the 6 or 12-month risk for progression to AIDS or death for an individual child. Because viral load and CD4 count are typically measured every 3 months, one can argue that it is clinically more relevant to base the decision of when to start HAART on the short term probability of disease progression. Guidelines in Europe are now based on this type of analysis. The American guidelines only adopted the thresholds for CD4 and viral load. The short term risk analysis also shows that the risk for developing AIDS varies markedly with age. This should be reflected in all guidelines. Determining the acceptable risk of disease progression is difficult and influenced by patient-, doctor- and culture-related factors. The controversy over whether or not to treat asymptomatic infants is unresolved as well. All infants have a very high risk of disease progression regardless of their viral load or CD4 count, but lifelong treatment with a potential for significant toxicities and risk of developing resistance is also not an appealing option. We recommend an attempt to achieve a consensus among the different working groups to reduce the number of different guidelines, which should be based on the literature evidence. Because all risk analyses are based on information from the pre-HAART era, a head-to-head trial comparing early versus deferred HAART would be useful. This may be difficult to accomplish. The first step could be an analysis of retrospective data from collaborative cohort data.

Antiretroviral Therapy, Highly Active↗

PubMed1999

Implementation of nationally developed guidelines in cardiology: a survey of NSW cardiologists and cardiothoracic surgeons.

BACKGROUND: In July 1996, the National Health and Medical Research Council (NHMRC) published clinical practice guidelines for 'The Procedural and Surgical Management of Coronary Heart Disease'. Despite increasing interest in dissemination and implementation of guidelines, initial reactions to these specific Guidelines and factors critical to their successful implementation had not been determined until our study. AIMS: To determine views of New South Wales (NSW) clinicians towards these NHMRC Guidelines; to identify perceptions about local relevance, usefulness and likely impact and to elicit preferred implementation strategies. METHODS: A postal survey in November 1997 of all cardiologists and cardiothoracic surgeons in NSW. RESULTS: One hundred and ten of 174 clinicians returned the questionnaire (63% response rate). Forty-eight per cent indicated that they were aware of the Guidelines before receiving a copy with the questionnaire while 26% had commented on the draft version of the Guidelines when distributed in November 1995. More than half of respondents 'agreed' or 'strongly agreed' with six of nine statements about potential strengths of the Guidelines. While at least 25% 'disagreed' or 'strongly disagreed' on 11 out of the 13 statements about potential criticisms of the Guidelines, more than half agreed or 'strongly' agreed that the Guidelines did not tell them 'anything they didn't already know'. Fifty-two per cent 'agreed' or 'strongly agreed' that guidelines will be misinterpreted by lawyers. At least 30% rated nine out of 11 implementation strategies as important. Local audits of care and regular feedback, reports from colleagues at conferences and hospital workshops outranked other implementation strategies in encouraging uptake of the Guidelines. CONCLUSIONS: Clinicians in NSW have generally positive views about the Guidelines, however, medicolegal concerns are apparent. To strengthen evidence-based decision-making as exemplified by the Guidelines, audits, presentations by opinion leaders and hospital-based workshops are recommended.

Attitude of Health Personnel↗

PubMed2003

Clinical practice guidelines in dentistry: opinions of dental practitioners on their contribution to the quality of dental care.

OBJECTIVES: To assess the opinions of general dental practitioners regarding the development and importance of clinical practice guidelines and their contribution to the quality of dental care. METHODS: A questionnaire was sent to a representative sample of 1656 dentists in the Netherlands. Factor analysis was conducted to identify scales of variables, and a reliability analysis was conducted to verify the reliability of the identified scales. The effect of the independent variables is expressed as odds ratio per scale part (standard deviation, SD). Regression analyses were conducted to study determinants of the opinions on clinical guidelines. RESULTS: The response rate was 73%; 54% of the respondents supported the development of clinical practice guidelines for dentists. Most respondents indicated that clinical practice guidelines could be used as a checklist, as a support in daily clinical decision making, and as a basis for continuing dental education. The factor analyses yielded four scale factors-contribution of guidelines to effectiveness of care (OR 1.95/SD), contribution of guidelines to professional autonomy (OR 1.70/SD), contribution of guidelines to quality of care (OR 2.52/SD), and contribution of guidelines to collaboration (OR 1.49/SD)-which complied with the criterion of Cronbach's alpha >0.60. Multiple regression analysis with the four scale factors as dependent variables yielded only extremely low correlations for practice and dentist characteristics (R(2)=0.01-0.04). CONCLUSIONS: Only about 50% of dentists support the development and implementation of clinical guidelines. Guidelines are seen as helpful in the provision of continuing dental education and as a support in daily clinical decision making. The most important barrier to successful implementation of clinical practice guidelines is the fear of dental practitioners that guidelines will reduce their professional autonomy. Practice and dentist characteristics are unrelated to dentists' opinions on clinical practice guidelines.

Adult↗

PubMed1995

Attitudes and behaviors towards clinical guidelines: the clinicians' perspective.

Objectives--To find out what attitudes hospital doctors have towards the culture of clinical guidelines; to ascertain perceived knowledge and use of clinical guidelines; and to investigate why hospital doctors think that clinical guidelines may not be used and how they think that the use of guidelines can be encouraged. Design--Postal questionnaire survey be tween October 1993 and January 1994. Setting--Hospitals within Oxford region. Subjects--409 doctors of all grades working in one of six specialties (anaesthetics, paediatrics, general surgery, general medicine, obstetrics and gynaecology and accident and emergency medicine). 47 were randomly picked as part of the pilot study, 362 were extracted from hospital staffing lists. Results--268 clinicians (66%) responded to the questionnaire. Most respondents (77%, 208) expressed welcoming attitudes towards guidelines but 51%(136) perceived the attitudes of their colleagues as being less favourable. Over three quarters of respondents claimed to use guidelines at least once a month. Most respondents learnt about guidelines from discussions with their peers (50%, 134 respondents) or senior doctors 37%, 99) or from journals (39%, 105). Reasons why guidelines may not be used included being unaware of particular guidelines (80%, 213 respondents) and the fact that guidelines had been poorly developed (64%, 171) or were impractical (49%, 132). The best ways to encourage the use of guidelines were thought to be encouragement from senior doctors (72%, 193 respondents) and peers (59%, 157) and by monitoring behaviour and providing feedback (68%, 181). Conclusion--The decision to use a guide line was based on the perceived value of each guideline and was influenced by other clinicians' behaviour. The results provide an insight into aspects of dissemination and implementation which are perceived as influential by the recipients of guidelines.

Attitude of Health Personnel↗

PubMed2006

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support.

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23-30, 2005. The "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the "International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations." The recommendations in the "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. During CPR with an advanced airway in place, rescuers will no longer perform "cycles" of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6-8 seconds). Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support. Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available. Induced hypothermia (32-34 degrees C for 12-24 hours) may be considered if the child remains comatose after resuscitation. Indications for the use of inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air. Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn. An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered. It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines. In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.

Cardiopulmonary Resuscitation↗

PubMed1997

Do general practitioners want guidelines? Attitudes toward a county-based and a national college-based approach.

OBJECTIVE: We carried out two studies (a and b) to assess general practitioners' attitudes towards a) regionally developed guidelines and b) guidelines developed by the Danish College of General Practitioners. DESIGN: a) A randomized study among all GPs in Aarhus county comparing their attitudes towards guidelines in general and towards regional multidisciplinary developed guidelines on Pap-testing for cervical cancer, and b) a survey among all Danish GPs on attitudes towards earlier submitted guidelines for diabetes Type 2. SETTING: GPs in Aarhus county and in all Denmark. SUBJECTS: a) Questionnaires sent to 370 doctors in Aarhus county, and b) to 3471 GPs in all Denmark. MAIN OUTCOME MEASURES: a) Attitudes to the known Pap guidelines compared with general attitudes. Themes in question were acceptance of guidelines, acceptance of multidisciplinary involvement, especially from the administrative staff, perceived effect on the consultation and the quality of care. In study b) remembrance of receiving, having read and used previous guidelines. Wishes with respect to future updates. RESULTS: a) GPs were very positive towards the Pap guidelines they knew, and only few resisted. The number of positive answers was significantly fewer when doctors were asked about guidelines in general. b) There was an overwhelmingly positive attitude towards guidelines from the College on diabetes care and other topics relevant to GP work. CONCLUSION: Danish GPs reported a very positive attitude towards the presented well-known guidelines on Pap testing and diabetes Type 2, and a fairly positive attitude towards hypothetical questions on guidelines in general.

Attitude of Health Personnel↗

PubMed1999

Impact of clinical practice guidelines on clinicians' behaviour: tonsillectomy in children.

OBJECTIVE: This study was conducted to assess the extent to which developing and implementing clinical practice guidelines for listing children for tonsillectomy (with or without adenoidectomy) influenced the behaviour of participating ENT surgeons. METHOD: A before and after study in which the intervention (the development and dissemination of local practice guidelines) was introduced sequentially into different hospitals and surgical practice. The study was conducted in four ear, nose, and throat surgical services in the North of England, with 16 consultant ENT surgeons and their junior staff on 1190 children aged 0 to 14 years who were judged, prior to consultation with an ENT surgeon, to have been referred for throat-related problems for which tonsillectomy was one possible treatment option were included in the study. Decision reached by surgeons and proportion of decisions that complied with new guidelines. RESULTS: Of the clinical decisions to list children for tonsillectomy taken before introduction of locally agreed guidelines, 73% (486/660) conformed to the criteria in the subsequent guidelines, 15% (97/660) did not, and in 12% (77/660), it was impossible to judge. After the intervention, the corresponding figures were 73% (386/530), 14% (73/53), and 13% (71/530), respectively. When decisions were taken to break the guidelines, this was more often to list for tonsillectomy when it was not indicated--83% (141/170)--than to withhold tonsillectomy when it was indicated--17% (29/170). The aspects of guidelines that were breached in decisions to carry out tonsillectomy were: the age of the child was younger than the guidelines recommended--54% (75/141); there had been fever attacks of tonsillitis than the guidelines recommended--22% (32/141); and there were "significant" symptoms not included in the guidelines--20% (29/141). CONCLUSIONS: In spite of strong evidence to the contrary, local guidelines were formulated at a level that the majority of surgeons already attained. Guideline development and implementation, therefore, had very little impact on clinical practice. The process of local formulation of guidelines was not sufficient to achieve change toward evidence-based practice; clinical preference proved to be quite intractable. There is a need to enhance the ability of clinicians in the assessment and interpretation of research evidence. Previous work has emphasized the need to explore factors that influence clinical behaviour toward evidence-based practice. Our study suggests the need for more research into why clinicians continue to follow clinical preference even when invited to base agreed local clinical policies on evidence.

Adolescent↗

PubMed2004

Analysis of Dutch general practice guidelines for inconsistencies with respect to the management of cardiovascular disease risk factors.

UNLABELLED: Presenting guidelines relating to cardiovascular disease (CVD) in a clinical decision support system (CDSS) is viewed as a mechanism for introducing evidence based practice in to daily practice. Analysis of guidelines on consistency is needed before constructing such a system. We analyzed 74 electronically available Dutch general practice guidelines for statement inconsistencies with respect to the management of CVD, and for each inconsistency, whether incomplete cross referencing existed between the guidelines. RESULTS: Six of the 74 guidelines had either CVD or CVD risk factors as subject of the guideline, all adhering to a common structure corresponding to four sections reflecting distinctive clinical management stages, which correspond to the subjective, objective, assessment and plan stages of SOAP methodology for structured patient data recording. Ten statement inconsistencies were found and for each a reference inconsistency was present. CONCLUSIONS: In a CDSS, statement inconsistencies will lead to poor system functioning. With electronically published guidelines, guideline developers could link statements in guidelines, to comparable statements in previously issued guidelines, facilitating the review process with respect to inconsistencies in related guidelines, and consistent cross referencing. Furthermore, it could enable the updating of existing guidelines with new evidence. Despite the determined statement inconsistencies, the authors would be able to construct a CDSS based on the DCGP guidelines dealing with the management of CVD risk factors

Cardiovascular Diseases↗

PubMed1998

US family physicians' experiences with practice guidelines.

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

Adult↗

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↗

PubMedDate not supplied

Practice guidelines to reduce testing in the hospital.

OBJECTIVE: To reduce testing among hospitalized patients using practice guidelines for any of 14 medical problems. DESIGN: Comparison of test use before and after implementation of guidelines. The guidelines were developed by consensus panels of self-selected participating physicians. Non-participating physicians were monitored during the same periods. In addition, the two groups of physicians were evaluated similarly for their management of three medical problems for which guidelines were not developed. SETTING: Acute care hospital. PATIENTS/PARTICIPANTS: 1,638 hospitalized patients and their 79 physicians. INTERVENTION: Implementation of practice guidelines for the care of hospitalized patients. MEASUREMENT AND MAIN RESULTS: Geometric mean charges expressed in inflation-adjusted dollars were used as measures of test use. For the intervention group, laboratory tests decreased by 20.6%, x-rays by 42.3%, and EKGs by 34.2%. All the decreases were significant (p = 0.001). The non-participating physicians who were higher test users during both years of the study also achieved significant (p less than 0.05) but smaller reductions during the intervention year: 13.9% for laboratory tests, 30.3% for x-rays, and 21.8% for EKGs, perhaps because the same residents were involved in the care of both groups of patients. For the non-guideline diagnoses, the participating physicians achieved reductions of 11.1% for laboratory tests and 19.2% for x-rays, and a 3.5% increase in EKGs. Two-way analyses of variance that took into account the reductions in testing achieved by non-participants, or by participants with non-guideline diagnoses, revealed no significant reduction in testing attributable directly to the guidelines except for EKGs. Follow up of the participating physicians during the six months after the end of the intervention revealed that testing remained at the lower level achieved while the guidelines were in use. Outcome of care, as measured by deaths in the hospital, deaths within 90 days of discharge, and readmissions within 90 days of discharge, was not affected by the use of the guidelines. CONCLUSIONS: 1) A large group of physicians could be recruited in a hospital to establish practice guidelines by group consensus. 2) These self-selected physicians were willing to use the guidelines (or allow the housestaff to use them) while caring for their patients. 3) Participating physicians were able to achieve substantial and significant reductions in testing without any demonstrable adverse effect on quality of care as measured by deaths and readmissions, and without any demonstrable shifting of resources from the inpatient to the outpatient setting of care. 4) The reductions in testing, whether caused by the guidelines or not, persisted for at least six months beyond the end of the period of implementation.

Analysis of Variance↗

PubMed1999

The development of guidelines for the treatment of vitiligo. Clinical Epidemiology Unit of the Istituto Dermopatico dell'Immacolata-Istituto di Recovero e Cura a Carattere Scientifico (IDI-IRCCS) and the Archives of Dermatology.

OBJECTIVE: To develop and introduce evidence-based guidelines for the treatment of vitiligo in children and in adults. PATIENTS AND SETTING: Patients, residents, and dermatologists from the Department of Dermatology, Academic Medical Center, University of Amsterdam, and the Netherlands Institute for Pigmentary Disorders in Amsterdam. DESIGN: Scientific evidence obtained from 3 systematic reviews of the literature was combined with the results of 2 questionnaires and interviews of potential users of the guidelines, 3 internal expert meetings, and 1 local expert meeting, during which preliminary guidelines were presented and commented on. A final version of the guidelines was synthesized and disseminated among potential users. Six months after the introduction of these guidelines, their use was evaluated. RESULTS: Before the development of the guidelines, there was no uniformity in treatment selection, and there was a variability in estimates of treatment outcome. The metaanalysis showed class 3 corticosteroids and narrowband UV-B to be the most effective and safest therapies for localized and for generalized vitiligo, respectively. From another systematic review, it could be concluded that patients with segmental, stable, or lip-tip vitiligo could be successfully treated with most autologous transplantation methods. For vitiligo universalis, results of the systematic review showed that depigmentation using monobenzone or a Q-switched ruby laser was equally effective. The final version of the guidelines consisted of a treatment scheme together with detailed treatment protocols. Implementation of the guidelines was evaluated in 5 physicians. After the introduction of these guidelines, they were followed in most adult cases with vitiligo (71% of patients with localized vitiligo, 82% with generalized vitiligo, 100% with stable or segmental vitiligo, and 80% with universal vitiligo). In children with vitiligo, the physicians adhered to the guidelines for 52% of the cases. CONCLUSIONS: Guidelines for the treatment of vitiligo can be successfully developed and disseminated for daily clinical practice. The results of the implementation of these guidelines should be confirmed in other centers involving more clinicians.

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