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At least 811 records · Page 45Linked to original sources

PubMed1999

Change in physician knowledge and attitudes after implementation of a pneumonia practice guideline.

OBJECTIVE: To assess physicians' response to implementation of an emergency department (ED) pneumonia practice guideline and determine if the guideline changed physicians' knowledge and attitudes about pneumonia care. DESIGN: Prospective intervention study with cross-sectional and longitudinal physician surveys. SETTING: An urban, university teaching hospital ED. PARTICIPANTS: One hundred forty physicians who were responsible for the triage of at least one of 166 patients presenting to the ED with community-acquired pneumonia. MEASUREMENTS: Physician characteristics, attitudes about pneumonia care and guidelines, and ratings of guideline helpfulness and effects on patient care were obtained by self administered questionnaire before, during, and after a yearlong intervention. MAIN RESULTS: More than 73% of the physicians reported the guideline as helpful and more than 94% wanted it to be continued in the future. Most reported that the guideline would decrease costs and improve quality without any increase in adverse outcomes. Two thirds said they were more likely to treat patients with pneumonia as outpatients in the future because of the guideline. Among the 58 physicians with matching preintervention and postintervention survey data, the guideline decreased the beliefs that "all patients> 65 years old with pneumonia should be admitted," from 52% to 14% ( p <. 001), and that "patients with pneumonia have a> 15% mortality rate," from 11% to 5% ( p <.007). The intervention did not significantly change general attitudes about practice guidelines. House officers rated the guideline as more helpful than attending physicians ( p <. 02). CONCLUSIONS: This locally developed, actively implemented guideline was well regarded by physicians. Guidelines can change practice and also alter underlying knowledge and attitudes about disease management. They may be most useful to those with less experience.

Attitude of Health Personnel↗

PubMed2000

Clinical guidelines: a must for rheumatology?

Clinical guidelines are sets of recommendations, backed by medical evidence, to aid physicians in patient-care decisions. There has been a proliferation of practice guideline development in all fields of medicine, including rheumatology. This chapter will discuss the need for guidelines in rheumatology, the methodology of guideline development, validation and implementation, the various guidelines published in rheumatology, and the role of the rheumatologist in guideline development. Clinical guidelines can serve to inform practitioners of the latest medical evidence and minimize harmful practice variation. Guidelines must rely on good evidence to be credible to the medical community, yet there are still many barriers to guideline acceptance by practitioners. The theories behind guideline development and validation are well described, although not always practised. Guideline dissemination and implementation methods are still being explored. It remains unclear how best to implement guidelines and convince physicians to accept and incorporate evidence-based recommendations into their practice.

Evidence-Based Medicine↗

PubMed2004

Physicians' views on joint treatment guidelines for primary and secondary care.

OBJECTIVE: Joint drug formularies and treatment guidelines have been developed to reduce problems arising at the interface between primary and secondary care. The aim is to compare the willingness of hospital specialists and general practitioners to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. STUDY DESIGN: A structured survey, consisting of questions about the use of guidelines and formularies in general, and possible barriers and facilitators for using a specific joint guideline. These specific guidelines concerned the treatment of hypertension, heart failure, or diabetes mellitus. SETTING AND STUDY PARTICIPANTS: One hundred and ninety-seven general practitioners and 34 general internists and cardiologists from the north of the Netherlands. RESULTS: Most hospital specialists relied for their prescribing on international guidelines and agreements within their own department, while general practitioners relied more on national and regional guidelines. General practitioners were more supportive than specialists of the initiative to develop joint treatment guidelines, although both groups had concerns regarding the development process. An important barrier for specialists was that they did not perceive a need for these guidelines. As enabling factors, physicians stated that these joint guidelines can lead to harmonization between specialists and general practitioners, and that they can be useful as an educational tool. CONCLUSION: Specialists are less ready to adopt joint treatment guidelines than general practitioners, indicating the need for a different approach to implement such guidelines in the two sectors.

Attitude of Health Personnel↗

PubMed2000

Attitudes toward clinical guidelines among obstetricians in Northern Ireland.

OBJECTIVES: To evaluate the attitudes of, and the influences on decisions made by, obstetricians in Northern Ireland in order to understand the feasibility of applying guidelines to obstetric practice. DESIGN: Cross-sectional postal survey. SETTING: Northern Ireland. POPULATION: Consultants, senior registrars, registrars, and senior house officers in obstetrics in Northern Ireland (n = 170). Responses were received from 68 x 8% (n = 117), with complete data available for 67 x 1% (n = 114). MAIN OUTCOME MEASURES: An attitudes score was constructed by consolidating responses to a variety of statements about guidelines. Individual responses to guidelines statements and the standardised attitudes T-score were analysed by demographic and practice characteristics. RESULTS: Attitudes toward guidelines were generally positive, with women practitioners more likely to have positive attitudes toward guidelines than did their male counterparts. Younger obstetricians were more likely to report that practitioners should incorporate guidelines into their practices. Doctors who responded that their decisions were influenced by specific tools related to guidelines, such as computerised databases, during the previous three months had more positive attitudes toward guidelines than doctors who did not use such tools. Furthermore, doctors based in teaching hospitals were more likely than others to have been influenced by the guidelines of professional societies. CONCLUSIONS: Generally guidelines appear to be quite well received, with doctors reporting that their practice often is influenced by them. Doctors who reported that their decisions were influenced by guidelines had an especially positive attitude toward them. However, some tools which target the application of evidence-based methods (e.g. computerised databases) are used infrequently by obstetricians. The challenge remains to encourage the further development of guidelines and tools that are useful and appropriate for practitioners.

Adult↗

PubMedDate not supplied

Analysis of the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests.

OBJECTIVE: To determine the consistency among the practice guidelines of the Dutch College of General Practitioners with respect to the use of blood tests. METHODS: The authors evaluated 64 practice guidelines of the Dutch College of General Practitioners. For each guideline, they analyzed each sentence that contained a reference to a blood test to determine the clinical situation in which the test should be performed (the indication) and to determine the tests that should be performed in that situation (the recommended test). An incomplete recommendation refers to a guideline that mentioned a blood test but did not identify the indication for that test. An inconsistency refers to the situation in which one guideline recommended a certain test for a given indication whereas another guideline mentioned the same indication but did not recommend the same test. RESULTS: Twenty-seven practice guidelines mentioned blood tests. Of these, three explicitly recommended not to request blood tests. Five guidelines contained incomplete recommendations, and the authors encountered two inconsistencies among the guidelines. Twenty-three guidelines mentioned blood tests and allowed the authors to identify indications and recommended tests. CONCLUSION: The identification of indications and recommended tests allows evaluation of consistency among practice guidelines. Although some incomplete recommendations and inconsistencies were discovered, the majority of the guidelines provide clear and unambiguous recommendations for blood-test ordering in primary care.

Family Practice↗

PubMedDate not supplied

GEM: a proposal for a more comprehensive guideline document model using XML.

OBJECTIVE: To develop a guideline document model that includes a sufficiently broad set of concepts to be useful throughout the guideline life cycle. DESIGN: Current guideline document models are limited in that they reflect the specific orientation of the stakeholder who created them; thus, developers and disseminators often provide few constructs for conceptualizing recommendations, while implementers de-emphasize concepts related to establishing guideline validity. The authors developed the Guideline Elements Model (GEM) using XML to better represent the heterogeneous knowledge contained in practice guidelines. Core constructs were derived from the Institute of Medicine's Guideline Appraisal Instrument, the National Guideline Clearinghouse, and the augmented decision table guideline representation. These were supplemented by additional concepts from a literature review. RESULTS: The GEM hierarchy includes more than 100 elements. Major concepts relate to a guideline's identity, developer, purpose, intended audience, method of development, target population, knowledge components, testing, and review plan. Knowledge components in guideline documents include recommendations (which in turn comprise conditionals and imperatives), definitions, and algorithms. CONCLUSION: GEM is more comprehensive than existing models and is expressively adequate to represent the heterogeneous information contained in guidelines. Use of XML contributes to a flexible, comprehensible, shareable, and reusable knowledge representation that is both readable by human beings and processible by computers.

Algorithms↗

PubMed1993

An audit of distribution and use of guidelines for management of head injury.

Ensuring effective distribution of guidelines is an important step towards their implementation. To examine the effectiveness of dissemination of a guidelines card on management of head injury and determine its usefulness to senior house officers (SHOs), a questionnaire survey was performed in May 1990, after distribution of the cards in induction packs for new doctors and at postgraduate lectures and displaying the guidelines in accident and emergency departments and wards. A further survey, in March 1992, assessed the impact of modifying the distribution. All (175) SHOs working in general surgery, accident and emergency medicine, orthopaedics, and neurosciences on 1 February 1990 in 19 hospitals including two neurosurgical units in Northern region were sent self completion questionnaires about awareness, receipt, use, and perceived usefulness of the guidelines. 131 of 163(80%) SHOs in post responded (median response from hospitals 83% (range 50%-100%)). Over three quarters (103, 79%) of SHOs were aware of the guidelines and 82(63%) had ever possessed a guidelines card. Only 36(44%) acquired the card in the induction pack. 92%(98/107) found them useful and 81% (89/110) referred to them to some extent. Owning and carrying the card and referring to guidelines were associated with departmental encouragement to use the guidelines. Increasing the displays of guidelines in wards and departments and the supply of cards to consultants in accident and emergency medicine as a result of this survey did not increase the number of SHOs who received cards (52/83, 63%), but more (71/83, 86%) were aware of the guidelines. The guidelines were welcomed by SHOs and used in treating patients with head injury, but their distribution requires improvement. Increased use of the guidelines may be achieved by introducing other distribution methods and as a result of encouragement by senior staff.

Craniocerebral Trauma↗

PubMed2002

Updating evidence-based clinical guidelines.

OBJECTIVES: To report on the updating of two evidence-based guidelines. METHODS: Development of multi-disciplinary evidence-based guidelines within the North of England Evidence Based Guideline Development Programme. RESULTS: The guideline updating groups were multi-disciplinary although the balance of disciplines was different from the original development groups; the convening of the updating groups allowed refinement of both the skills within the groups and the overall size of the groups. As both groups were starting with a previous version of the guideline, defining the scope of the guideline was more straightforward and faster than when developing the guideline de novo. The process of evidence identification for both guidelines was again by systematic review. Updating the guidelines influenced recommendations in two ways: new evidence required new recommendations; and supplementary evidence in an existing area allowed refinement of recommendations. Overall savings within the guideline updating process (compared with initial development) were modest. The major costs of both the initial guideline development and the updating process were staff costs, which were identical for the two processes. CONCLUSIONS: There is little other experience to set alongside this paper. There is a need for further sharing of experiences and the development of explicit methods for informing decisions on when and how to update evidence-based guidelines.

Adult↗

PubMed1993

The economic benefit of practice guidelines for stress ulcer prophylaxis.

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent (P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.

Adult↗

PubMed2003

[Clinical practice guidelines in Japan: toward their appropriate use and diffusion].

In Japan, the governmental report on health technology assessment in 1999 referred to the need to develop evidence-based clinical practice guidelines. The Ministry of Health and Welfare established priorities for the development of clinical practice guidelines, and started several projects. About 20 clinical practice guidelines are to be developed by 2004. However, what "guideline" means and how "guidelines" work are unclear because the word "guideline" is ambiguous in Japan. Although it is generally accepted that "directives are stronger than recommendations, which are stronger than guidelines" in the western countries, Japanese people do not usually recognize these distinctions and tend to regard guidelines as mandatory directives even in individual cases. Patients, consumers and legal professionals may overestimate the authority of clinical practice guidelines when they see them. What clinical practice guidelines are, or are not should be clarified appropriately. Autumn 2003, the Japan Council for Quality Health Care will open the information service that provides practice guidelines and related literature. This will be accessible to both healthcare professionals and the general public. Much remains to be done to bring other stakeholders to the table. All of Japanese society can, and needs to, participate in the process of developing a consensus on clinical practice guidelines.

Community Participation↗

PubMed2004

Clinical guidelines of depression: a qualitative study of GPs' views.

BACKGROUND: Clinical guidelines have become an increasingly familiar component of health care, although their passive dissemination does not ensure implementation. This study is concerned with general practitioners' (GPs) views of guideline implementation in general practice. It focuses specifically on their views about guidelines for the management of patients with depression. OBJECTIVE: To elicit and explore GPs' views about clinical guidelines for the management of depression, their use in practice, barriers to their use, and how best to implement guidelines. DESIGN: Qualitative study using in-depth interviews with a purposive sample of GPs. SETTING: General Practices across the Scottish Grampian region, and Northeast England. METHODS: Eleven GPs who had participated in a previous questionnaire based depression study were interviewed. Interviews were transcribed and analyzed using the "framework technique." RESULTS: Several participating GPs did not agree with recommendations of the current depression guidelines; some thought they were insufficiently flexible to use with the variety of patients they see. The volume of guidelines received, lack of time and resources (particularly mental health professionals for referrals) were seen as the main barriers to guideline use. CONCLUSIONS: A range of factors contributes to variability in compliance with guidelines for the management of depression. For guideline use to increase, GPs in this study said they would like to see more resources put in place; a reduction in the number of guidelines they receive; incorporation of guideline recommendations onto computer decision support systems; and regular audit and feedback to allow them to monitor their practice.

Attitude of Health Personnel↗

PubMed2004

Modeling guidelines for integration into clinical workflow.

The success of clinical decision-support systems requires that they are seamlessly integrated into clinical workflow. In the SAGE project, which aims to create the technological infra-structure for implementing computable clinical practice guide-lines in enterprise settings, we created a deployment-driven methodology for developing guideline knowledge bases. It involves (1) identification of usage scenarios of guideline-based care in clinical workflow, (2) distillation and disambiguation of guideline knowledge relevant to these usage scenarios, (3) formalization of data elements and vocabulary used in the guideline, and (4) encoding of usage scenarios and guideline knowledge using an executable guideline model. This methodology makes explicit the points in the care process where guideline-based decision aids are appropriate and the roles of clinicians for whom the guideline-based assistance is intended. We have evaluated the methodology by simulating the deployment of an immunization guideline in a real clinical information system and by reconstructing the workflow context of a deployed decision-support system for guideline-based care. We discuss the implication of deployment-driven guideline encoding for sharability of executable guidelines.

Decision Making, Computer-Assisted↗

PubMed2005

Intrapartum prophylaxis of group B streptococcal disease in Israel: guidelines and practice.

BACKGROUND: The incidence of perinatal, early-onset Group B streptococcal sepsis is very low in Israel and there are no local guidelines for prevention of the disease. OBJECTIVES: To determine to what extent the current Centers for Disease Control guidelines are practiced in Israel, the reasons for their adoption or rejection, and the need for local official guidelines. METHODS: A telephone questionnaire was conducted of all 27 delivery units in Israel. Answers were obtained from 26, either from the clinical director or the senior obstetrician in charge at the time of the interview. RESULTS: Only in 2 of the 26 delivery units (8%) are the CDC guidelines adhered to exactly; in 6 units they are deliberately rejected, and in 8 units they are not practiced although they are allegedly implemented. Thus, the CDC guidelines are not practiced in 14 delivery units (54%). Medico-legal consideration is the sole or major reason for adopting these guidelines in 80% (16/20) of the delivery units where they are seemingly implemented. In the majority of these units (18/20) there is readiness to abandon current practice, should local guidelines differ from those of the CDC, provided that local guidelines are issued by an authoritative source. CONCLUSION: CDC guidelines are either deliberately rejected or incorrectly practiced in most Israeli delivery units. The medico-legal argument is one of the main reasons for practicing these guidelines. Since the CDC guidelines probably do not apply in Israel, official local guidelines are urgently needed.

Delivery, Obstetric↗

PubMed2005

Otitis media and the new guidelines.

Otitis media, including recurrent acute otitis media (AOM) and otitis media with effusion (OME), is one of the most common reasons for an illness-related visit to the primary care clinician. Until recently, antibacterial therapy was the standard treatment for most episodes of AOM and often for OME. However, in 1994, a clinical practice guideline on OME was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality) and applied to normal children aged 1 to 3 years. The recommendations in the 1994 guideline were evidence based, widely discussed, and somewhat controversial but also acted as a starting point for some ideas about standardization of management of this very common disease. In 2004, revised clinical practice guidelines were published for OME that applied to children aged 2 months to 12 years and included children with developmental disabilities and underlying conditions that predispose them to OME. In addition, a new evidence-based clinical practice guideline for AOM was published in 2004. This guideline recognized that many episodes of AOM will resolve on their own without antimicrobial therapy, and on that basis, one of the recommendations for initial treatment of AOM in specified situations was watchful waiting without antibacterial therapy. This article briefly discusses the current knowledge about AOM and OME and then addresses the new AOM and OME guidelines point by point. It is important to remember that although important, these clinical practice guidelines are just guidelines and that actual management of the patient with otitis media depends on clinical judgement, the severity of the illness, other underlying medical conditions, ready access to adequate follow-up care, and other features, such as cultural differences. Surgical recommendations were not included in the AOM guidelines but were addressed in the OME guidelines. Further information about the efficacy and effectiveness of both sets of guidelines will likely include the results of prospective studies using the guidelines in both normal children and those with underlying medical conditions.

Acoustic Impedance Tests↗

PubMed2005

[Systemic validation of clinical practice guidelines: the AGREE network].

INTRODUCTION: Over recent decades, the number of available clinical practice guidelines has enormously grown. Guidelines should meet specific quality criteria to ensure good quality. There is a growing need for the developement of a set of criteria to ensure that potential biases inherent in guideline development have been properly addressed and that the recommendations for practice are valid and reliable. AIM: The AGREE-collaboration is an international network that developed an instrument to critically appraise the methodological quality of guidelines. AGREE promotes a clear strategy to produce, disseminate and evaluate guidelines of high quality. METHOD: In the first phase of the international project the AGREE-instrument was tested in 11 different countries. Based on this experience the instrument was refined and optimised. In the second phase it was disseminated, promoted and evaluated in 18 participating countries. Belgium was one of them. RESULTS: The Belgian partner in the AGREE-project developed 3 workshops and established 13 validation committees to validate guidelines from Belgian developer groups. We collected 33 questionnaires from participants of the workshops and the validation committees, in which we asked for primary experiences and information on the usefulness and applicability of the instrument. We were also interested in the shortcomings of the instrument and potential strategies to bridge them. DISCUSSION: More efforts should be made to train methodological experts to gain certain skills for a critical appraisal of clinical practice guidelines. Promoting the AGREE-instrument will lead to a broader knowledge and use of quality criteria in guideline development and appraisal. CONCLUSION: The development and dissemination of an international list of criteria to appraise the quality of guidelines will stimulate the development of methodologically sound guidelines. International comparisons between existing guidelines will lead to a better collaboration between guideline developers throughout the world.

Canada↗

PubMed1995

Report on activities and attitudes of organizations active in the clinical practice guidelines field.

The organizing committee of a workshop on clinical practice guidelines (CPGs) surveyed invited organizations on their attitudes and activities related to five topics to be covered during the workshop sessions: organizational roles, priority setting, guidelines implementation, guidelines evaluation and development of a network of those active in the CPG field. Organizational roles: The national specialty societies were felt to have the largest role to play; the smallest roles were assigned to consumers, who were seen to have a role mainly in priority setting, and to industry and government, both of which were seen to have primarily a funding role. Many barriers to collaboration were identified, the solutions to all of which appeared to be better communication, establishment of common principles and clear role definitions. Priority setting: There was considerable agreement on the criteria that should be used to set priorities for CPG activities: the burden of disease on population health, the state of scientific knowledge, the cost of treatment and the economic burden of disease on society were seen as important factors, whereas the costs of guidelines development and practitioner interest in guidelines development were seen as less important. Organizations were unable to give much information on how they set priorities. Guidelines implementation: Most of the organizations surveyed did not actively try to ensure the implementation of guidelines, although a considerable minority devoted resources to implementation. The 38% of organizations that implemented guidelines actively listed a wide variety of activities, including training, use of local opinion leaders, information technology, local consensus processes and counter detailing. Guidelines evaluation: Formal evaluation of guidelines was undertaken by fewer than 13% of the responding organizations. All the evaluations incorporated assessments before and after guideline implementation, and some used primary patient data. Barriers to evaluation included lack of money, time, data or expertise. CPG Network: Most of the respondents felt that all organizations and individuals interested or involved in guidelines should form the membership of the network. The three most important functions of such a network were deemed to be (a) to facilitate collaboration among those involved in the CPG process, (b) to maintain an information centre on CPGs and (c) to provide expertise to the CPG process. It was felt that the network should have some formal structure and communicate through e-mail and print media.

Attitude↗

PubMed2004

Laboratory assays evaluate the influence of physical guidelines on subterranean termite (Isoptera: Rhinotermitidae) tunneling, bait discovery, and consumption.

Laboratory assays were conducted to determine whether physical guidelines could direct subterranean termite foraging behavior. Several materials (wood, plastics, and wood thermoplastic composites) were evaluated for their potential to serve as termite guidelines. Termite tunneling along the different types of guidelines was measured. The proportion of baits discovered when connected by a guideline was compared with the proportion of unconnected baits discovered. Termite consumption of baits also was quantified. Assay results indicated that the termites did not respond to all guideline materials in the same way. Termites built significantly longer tunnels along wood guidelines than they did along any of the plastic guidelines tested. However, tunnel length along the wood and the wood thermoplastic composites was not significantly different. The probability of two baits being discovered when they were connected by wood guidelines was significantly greater than when the baits were connected by plastic guidelines or left unconnected (no guideline). Pairs of baits connected by wood thermoplastic composites were also significantly more likely to be discovered than unconnected baits. Bait consumption was not enhanced by the presence of the guidelines. It is likely that guidelines made of wood competed with the baits as a termite food resource.

Animals↗