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PubMed2003

Multidisciplinary guidelines in Dutch mental health care: plans, bottlenecks and possible solutions.

PURPOSE: This article describes the Dutch 'Multidisciplinary Guidelines in Mental Health Care' project and its first products (multidisciplinary guidelines on depressive and anxiety disorders). CONTEXT OF CASE: In the early 1990s, disciplines in Dutch mental health care formulated their first monodisciplinary guidelines, which disagreed on essential features. In 1998, the Dutch government invited representatives of the five core disciplines in mental health care (psychiatrists, general practitioners, psychotherapists (clinical), psychologists and psychiatric nurses) to start a joint project aimed at the development of new integrated multidisciplinary guidelines. DATA SOURCES: The vision document, presented in 2000 by the five core disciplines, describes the directions for the development of new guidelines. The guidelines on depressive and anxiety disorders will appear in 2004. CASE DESCRIPTION: The first draft guidelines were presented in May 2003, in line with the vision document (2000). However, it is still not certain whether they will be authorised by all professional groups. Some disciplines do not recognise themselves in these guidelines. It is argued that these problems can be attributed at least in part to the evidence-based method that was used in drafting the guidelines. Interventions are compared on the basis of their 'level of evidence', the consequence of which is that cognitive behavioural therapy and drug treatment are almost always seen as the only appropriate interventions. Other interventions are excluded because of their lower level of evidence. CONCLUSIONS AND DISCUSSION: The conclusion is that guidelines cannot be based on empirical evidence alone. It is argued that the collective sense of professions involved should also be integrated into the guideline, for example in relation to goal differentiation. It is finally argued that multidisciplinary guidelines must also offer a hierarchy between those goals, i.e. a vision of the appropriate type of care and the order in which the various care components should be administered.

Journal Article↗

PubMed1998

Nutrition Practice Guidelines for Type 1 Diabetes Mellitus positively affect dietitian practices and patient outcomes. The Diabetes Care and Education Dietetic Practice Group.

OBJECTIVES: Assess the acceptance and ease of use of Nutrition Practice Guidelines for Type 1 Diabetes Mellitus by dietitians in a variety of settings; determine if nutrition care activities of dietitians change when practice guidelines are available; measure changes in patient control of blood glucose level, measured as glycated hemoglobin (HbA1c); compare patient satisfaction with care and perceptions about quality of life. DESIGN: Using the approach of outcomes research, volunteer dietitians were recruited and assigned randomly to a usual care group or a practice guidelines group. Patients with type 1 diabetes were enrolled by dietitians and followed up for a 3-month period. Outcome measures included dietitian care activities, changes in patient HbA1c levels, and patient satisfaction and perceptions about quality of life. SUBJECTS/SETTINGS: Dietitians from across the United States who responded to a recruitment notice participated. Their work settings included diabetes referral centers, endocrinology clinics, primary care and community health clinics, hospitals, and a worksite clinic. They recruited patients from their setting for the study. Outcome data were available from dietitians providing care to 24 patients using the new practice guidelines and dietitians providing care to 30 patients using more traditional methods. STATISTICAL ANALYSIS: chi 2 Test, t test, and analysis of covariance. RESULTS: Dietitians in the practice guidelines group spent 63% more time with patients and were more likely to do an assessment and discuss results with patients than dietitians in the usual care group. Practice guidelines dietitians paid greater attention to glycemic control goals. Levels of HbA1c improved at 3 months in 21 (88%) of practice guidelines patients compared with 16 (53%) of usual care patients. Practice guidelines patients achieved greater reductions in HbA1c level than usual care patients (-1.00 vs -0.33). This difference was statistically significant and clinically meaningful. CONCLUSIONS/APPLICATIONS: Dietitians responded positively to practice guidelines for type 1 diabetes. Use of guidelines resulted in changes in dietitian practices and produced greater improvements in patient blood glucose outcomes at 3 months compared with usual care. Practice guidelines did not significantly influence patient satisfaction with care of perceived quality of life.

Adolescent↗

PubMed1997

Legal and policy considerations in using clinical practice guidelines.

The increased use of clinical practice guidelines has implications for both public policy and for litigation. Physicians are concerned that the introduction of practice guidelines will reduce their clinical decision-making authority and that the failure to follow clinical practice guidelines will lead to medical liability. Although practice guidelines are an increasing part of medical practice, there has been only limited litigation to determine the extent to which guidelines will be used to set the applicable standard of care. This article discusses the potential legal and public policy issues raised by the introduction and use of clinical practice guidelines. From a legal perspective, the primary issue is whether guidelines will be used to set the "standard of care" or will be one piece of evidence that a jury would use to determine the outcome of medical liability litigation. Based on an assessment of the applicable legal and policy considerations, the article concludes that courts should admit guidelines into evidence, but that they should not be used as the sole determinant of the standard of care. Instead, guidelines should be treated as one piece of evidence to be weighed by the jury. This approach will facilitate physician acceptance of guidelines by not imposing liability for the failure to follow guidelines without additional evidence to determine the standard of care.

Clinical Medicine↗

PubMed2006

Compliance with the guidelines for acute ankle sprain for physiotherapists is moderate in the Netherlands: an observational study.

QUESTION: What is the compliance with guidelines for acute ankle sprain for physiotherapists? DESIGN: Survey of random sample of physiotherapists. PARTICIPANTS: 400 physiotherapists working in extramural health care in the Netherlands. OUTCOME MEASURES: Questions covered attitude towards guidelines in general, familiarity with the guidelines for acute ankle sprain,compliance with the guidelines, advantages and disadvantages of the guidelines, and factors relating to compliance with the guidelines. RESULTS: The majority of the physiotherapists were familiar with the content of the guidelines to some degree and 66%applied it to more than half of their patients with acute ankle sprain. The recommendations to determine both the prognosis and the necessity of treatment by using the function score were the least followed. Some physiotherapists thought the function score was not completely clear, which may have been a barrier for implementation. Factors relating positively to compliance were a positive attitude towards guidelines in general, and having colleagues who implemented the guidelines for acute ankle sprain. CONCLUSION: Although compliance with the guidelines for acute ankle sprain was fair/moderate, compliance may be enhanced by improving clarity of the function score, including it in the short version and improving the attitude of physiotherapists towards guidelines in general.

Acute Disease↗

PubMed1999

Clinical practice guidelines in unstable angina improve clinical outcomes by assuring early intensive medical treatment.

OBJECTIVES: To determine the influence of clinical practice guidelines on treatment patterns and clinical outcomes in unstable angina and the effectiveness of guideline reminders on implementing practice guidelines, two groups of medium and high risk patients with unstable angina were compared. BACKGROUND: New guidelines have been published by the Agency for Health Care Policy and Research (AHCPR) for evaluating and managing patients with unstable angina. The impact of these guidelines to improve the quality of care has never been tested. METHODS: Group 1 included 338 consecutive medium or high risk patients admitted before publication of the AHCPR guidelines, and group 2 consisted of 181 consecutive similar risk patients admitted after institution of the AHCPR guideline reminders at this institution. Dissemination of clinical practice guidelines was ensured by a grand rounds lecture and by posting guideline reminders on all group 2 patients' charts within 24 h of admission. RESULTS: The two groups were similar in terms of most baseline characteristics, including hypercholesterolemia, diabetes, hypertension, smoking history, baseline ST segment depression and previous coronary artery bypass graft surgery. Group 1 patients were older (68+/-13 vs. 63+/-16 years, p = 0.001) and more frequently had a previous myocardial infarction (39% vs. 22%, p = 0.001). Group 2 patients more frequently required intravenous nitroglycerin to control the index episode of chest pain (43% vs. 34%, p = 0.003). Group 2 patients more frequently received aspirin (96% vs. 88%, p = 0.009) during admission and underwent coronary angiography (71% vs. 58%, p = 0.006). More importantly, group 2 patients received oral beta-blockers (p = 0.008), aspirin and coronary angiography (p = 0.001) earlier than group 1 patients and experienced recurrent angina (29% vs. 54%) and myocardial infarction or death less frequently (3% vs. 9%, p = 0.028). CONCLUSIONS: In unstable angina, clinical practice guidelines were associated with greater use of aspirin and coronary angiography and greater use and earlier administration of beta-blockers. Variation in drug use over time was also reduced. Objective improvement in clinical outcome was also noted. Thus, practice guidelines improve the quality of care of patients with unstable angina.

Adrenergic beta-Antagonists↗

PubMed2003

Barriers to the implementation of clinical guidelines.

Clinical guidelines in wound care have recently been formulated at the national and international level, reflecting a shift from locally derived guidelines common during the 1990s. There remains considerable uncertainty regarding the extent of implementation and monitoring of these new guidelines. This paper presents the results of a survey of members of the Tissue Viability Society that sought their views upon the guidelines in place within their workplace--how were these guidelines developed, was the impact of guidelines monitored and how and finally what barriers limited their full implementation. Of the 1500 members, 476 returned completed questionnaires (34.0% response rate). Most (n = 422, 88.4%) worked within environments that implemented clinical guidelines in some aspect of wound care, with guidance upon pressure ulcer prevention being most commonly reported (n = 351). The use of national guidelines (either in their original format or locally modified to reflect local circumstances) was relatively common--reported by 307 of the 476 respondents. Few reported that guidelines were fully implemented (n = 77; 18.3%) with lack of resources, lack of awareness of the content of the guidelines and, when aware, lack of acceptance of their recommendations being the most commonly cited reasons for the failure to implement. However, it should be noted that only 34.0% of the surveyed population responded--this may question how far the results can be considered to reflect the current status of guideline implementation in the UK given the unreported views of 66% of all those surveyed.

Guideline Adherence↗

PubMed2000

Guideline development in Europe. An international comparison.

OBJECTIVES: To identify major differences and similarities in the development of clinical guidelines in different European countries. METHODS: A collaboration of researchers is funded by the European Commission to compare the approaches to guideline development in collaborators' countries. The program encompasses a series of tasks, the first being to identify and document current guideline procedures in the collaborating countries. A survey gathered information on guideline production, dissemination, and implementation in the 10 European countries involved in the project consortium: Denmark, England and Wales, Finland, France, Germany, Italy, the Netherlands, Scotland, Spain (both the Basque Country and Catalonia), and Switzerland. RESULTS: Seven countries have a national policy on guideline production, dissemination, and implementation, and three countries are discussing their policies. A majority of guidelines are currently produced at the national level in six of the countries and at the regional or local level in the other four. Central or national funding supports guideline production in six countries. Additional sources of funding include medical societies, pharmaceutical companies, and health insurance companies. Several of the countries have published or are preparing evaluations of their dissemination strategies. CONCLUSIONS: The survey highlighted wide variation in the methods and policies of guideline development in Europe. The Appraisal of Guidelines, Research, and Evaluation in Europe (AGREE) Collaboration research program will identify the characteristics of the "better" guideline programs and will provide the basis for more research-generated policy initiatives in the future, helping to ensure that guidelines play a major role in improving patient care in the millennium.

Cross-Cultural Comparison↗

PubMed2005

[Physicians' attitudes concerning guidelines. An empirical survey in neurologic clinics].

BACKGROUND: Guidelines gain importance for medical services. Their perception and use by physicians does not only rely on their attitudes towards guidelines, but also on other parameters of influence. PURPOSE: to assess hospital physicians's attitudes concerning clinical guidelines and physician- and hospital- related factors of influence. METHODS: multicenter survey with 99 junior and senior registrars from 30 departments of neurology (taking regional random samples). RESULTS: A majority of physicians regarded guidelines as a means of quality improvement and medical education. However, there were no generally positive or negative attitudes, but the physicians differentiated between the individual and the health system level. These patterns of attitudes did not depend upon aspects of the respective departments (such as size, internal guidelines, access to sources of information) and did not vary significantly between hospitals. Instead, there was a marked influence of personality traits on individual opinions concerning guideline utility. Senior registrars, less team-oriented physicians, younger physicians and the more prestige-motivated expressed positive attitudes. On the other hand, a sceptical and more negative attitude was found with professionals who expressed strong team orientation and scientific interest. CONCLUSIONS: The overall positive attitude is probably related to the identification of guideline users with their authors and also to the their present status as non-binding recommendations. The independence of attitudes from hospital characteristics, especially the existence of internal guidelines, may indicate either voluntary guideline use or rather a low impact of guidelines as management instruments or frequently used tools. The potential of guidelines for medical education does not seem to be fully utilised.

Attitude of Health Personnel↗

PubMed2005

The use of clinical guidelines for asthma, diabetes, and hypertension in primary health care.

OBJECTIVE: To investigate which clinical guidelines primary health care staff refer to regarding asthma, diabetes, and hypertension, the number of existing guidelines, and the organizational level at which they were drawn up, and whether there are different guidelines for the same disease, either in different primary health care centres or within individual centres. DESIGN: The study is descriptive. Data were obtained by telephone interviews and by procuring clinical guidelines regarding asthma, diabetes, and hypertension from primary health care centres. SETTING: Forty-one primary health care centres in one county in southeastern Sweden. STUDY PARTICIPANTS: General practitioners and registered nurses in primary health care. RESULTS: The telephone interviews showed that the staff referred to several guidelines covering each of the three diseases and these guidelines had been drawn up at five different organizational levels. The length of the clinical guidelines varied from 1 to 257 pages, and the number of guidelines for each disease ranged between 1 and 5. CONCLUSION: It was found that there were several documents covering the same disease that primary care staff referred to as 'guidelines', and that the length of the guidelines varied and they had been drawn up at different levels. A finding with possible serious consequences was that an old version of an asthma guideline was used in all primary health care centres in the study.

Asthma↗

PubMed2006

Adherence to mental health guidelines by Dutch occupational physicians.

BACKGROUND: In 2000, the Dutch Association of Occupational Physicians published a national guideline for the management of employees with mental health problems. OBJECTIVES: To examine predictors of adherence to this guideline by Dutch occupational physicians (OPs). METHODS: Using the Theory of Planned Behaviour, a questionnaire was developed about self-reported guideline adherence of OPs and possible predictors of this behaviour. A total of 165 OPs were approached to complete the questionnaire and registration forms of first consultations of workers with mental health problems. Performance indicators based on the guideline were developed to calculate performance rates of guideline adherence by OPs. RESULTS: Eighty of 165 (48%) OPs approached completed the questionnaire. Fifty-six OPs returned one or more registration forms, totalling 344 consultations. On a five-point Likert scale, ranging from never (1) to always (5), the mean score on self-reported guideline adherence was 2.35, compared to a mean score of 4.06 on the intention to comply with the guideline. The mean performance rate of OPs ranging from 0 to 2 was 1.27 on diagnosis and 0.60 on guidance. No relation was found between self-reported guideline adherence and performance rates. Self-reported guideline adherence correlated significantly with perceived behaviour control (r = 0.48, P < 0.05), subjective norms (r = 0.33, P < 0.05) and positive job stress (r = 0.35, P < 0.05). CONCLUSIONS: Guideline adherence by Dutch OPs lags behind its acceptance. Further implementation efforts need to focus on diminishing barriers and enhancing social norms of OPs to work according to the guideline.

Adult↗

PubMed1999

Attitudes of faculty, housestaff, and medical students toward clinical practice guidelines.

PURPOSE: To examine attitudes of faculty, housestaff, and medical students toward clinical practice guidelines. METHOD: In a 1997 cross-sectional survey, a two-part, 26-item, self-administered questionnaire was mailed to all faculty, housestaff, and medical students in the department of internal medicine at Case Western Reserve University School of Medicine. The questionnaire asked for demographic information and attitudes toward clinical guidelines. RESULTS: Of 379 persons surveyed, 254 (67%) returned usable questionnaires: 56% of the medical students, 70% of the housestaff, and 73% of the full-time faculty. Medical students reported learning about guidelines predominantly during clerkships in internal medicine (71%) and pediatrics (68%). Overall, the respondents agreed most strongly that guidelines are "useful for the care of common problems," and least strongly that guidelines are "difficult to apply to individual patients" and "reduce physician options in patient care." Faculty were more likely to consider guidelines a "good educational tool" and less likely than were medical students and housestaff to agree that they promote "cookbook medicine." Of 11 influences on clinical decision making, the three groups together rated practice guidelines eighth or ninth. The use of guidelines for academic investigations was rated most appropriate, overall. In terms of their appropriateness, faculty consistently rated the use of guidelines more favorably except for use in malpractice suits. CONCLUSION: Faculty, housestaff, and medical students have significantly different perceptions of and attitudes toward clinical practice guidelines. Further studies are needed to explain the reasons for these differences. Considerable education and involvement must occur at all levels for practice guidelines to be successfully implemented and understood.

Analysis of Variance↗

PubMed2000

Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence.

OBJECTIVE: To determine physician and nurse adherence with sedative, analgesic, and neuromuscular blocking agent guidelines in the management of mechanically ventilated patients in a medical intensive care unit. DESIGN: Prospective cohort study. SUBJECTS: One hundred consecutively admitted patients to a medical intensive care unit who required mechanical ventilatory support. A sample of 29 nurses, residents, and attending physicians were interviewed regarding their attitudes and perceptions of the guidelines. MEASUREMENT: Data were collected from concurrent medical records and included the following: demographic characteristics; clinical variables; physician prescriptions of sedative, analgesic, and/or neuromuscular blocking agents; nurse administration of these medications; documentation of monitoring; and assessment of patient hemodynamic status and behaviors. A semistructured interview was elicited from both nurses and physicians about their rationale for the use or nonuse of the guidelines. RESULTS: Patients ranged in age from 24 to 87 yrs, mean 60.7 (+15.3) yrs. Admission Acute Physiology and Chronic Health Evaluation III scores ranged from 36 to 192, mean 93.8 ( 30.5) and median 88. Length of mechanical ventilatory support ranged from 1 to 112 days, mean 14.8 ( 20.0) days, and median 8 days; medical intensive care unit length of stay ranged from 1 to 46 days, with a mean of 9.8 ( 8.1) days and a median of 8 days. Of the 100 patients, 47% died, 28% returned home, and 25% were discharged to a nursing facility. Eighty-five patients were administered one or more sedative, analgesic, and/or neuromuscular blocking agent, range 1-9 drugs, mean 2.5 (+1.5) drugs. Physicians prescribed 14 different medications; the most commonly administered drug was lorazepam (n = 71), followed by morphine (n = 39). Physicians and nurses had partial or total adherence to the guidelines in 58% of patients. The initial choice of the drug followed the guidelines in 60% of patients; the overall guideline was followed in 23% of patients. The most common rationales for nonadherence to the guidelines stated by both physicians and nurses were patient-specific factors, resident guideline learning curve, and physician medication preferences. CONCLUSION: Most patients required treatment for agitated behaviors. The majority of treatment regimens partially or totally adhered to the guidelines. Factors such as patient-specific disease states, resident guideline learning curve, and physician preferences of medications may have decreased adherence. Improving adherence to the guidelines is essential to assess their effectiveness in improving clinical outcomes.

Adult↗

PubMed2005

Knowledge and perception of guidelines and secondary prevention of coronary heart disease among general practitioners and internists. Results from a physician survey in Germany.

AIMS: This study investigated knowledge and perception of guidelines in secondary prevention of coronary heart disease and the impact of guideline knowledge on treatment practices in coronary patients among primary care physicians. DESIGN AND METHODS: A representative questionnaire survey was performed in 2002-2003 among all 1023 general practitioners and office-based internists in the Region of Münster, Germany. The survey instrument contained questions on knowledge and attitudes toward guidelines, risk factors and treatment practices in secondary prevention of coronary heart disease. RESULTS: In total, 681 (66.6%) physicians participated. Seventy percent of physicians reported knowledge of at least one guideline. Participants expressed mainly positive attitudes toward guidelines but also reported important barriers to their implementation such as lack of reimbursement. Only 63 and 32%, respectively, reported to start antihypertensive and lipid-lowering treatment according to guidelines. Physicians reporting guideline knowledge were more likely to initiate lipid-lowering treatment of elevated low-density lipoprotein (LDL)-cholesterol [odds ratio (OR) 2.3; 95% confidence interval (CI) 1.5-3.5], to intensively advise overweight patients (OR 1.5; 95% CI 1.0-2.5), to make use of nicotine replacement therapy or cessation courses in smoking patients (OR 1.7; 95% CI 1.2-2.4), and to comply with an overall measure of guideline adherence (OR 1.8; 95% CI 1.1-2.8). CONCLUSIONS: In this study, guideline knowledge led to improved cardiovascular risk factor treatment among GPs and internists. Many physicians, however, do not treat coronary patients according to evidence-based guidelines. Further dissemination of guidelines and educational efforts are essential to improve secondary prevention of coronary heart disease.

Adult↗

PubMed2004

Agreement of four competing guidelines on prevention of venous thromboembolism and comparison with observed physician practices: a cross-sectional study of 1,032 medical inpatients.

OBJECTIVE: To assess the degree of agreement between four competing guidelines regarding the recommendation for prophylactic heparin therapy and to report to what extent actual practice agreed with or differed from the recommendations made before these guidelines were disseminated. DESIGN: Four French guidelines were applied to data from a cross-sectional study conducted before their dissemination. SETTING: Twenty-six medical units of a teaching and a nonteaching hospital. PATIENTS: One thousand thirty-two medical inpatients. MAIN MEASUREMENTS: Interguideline agreement rated by the kappa coefficient and percentage of patients receiving prophylactic heparin treatment. RESULTS: The percentage of patients requiring prophylactic treatment ranged from 35.4% to 54.6% (overall kappa coefficient, 0.65 [0.63 to 0.68]), depending on the guideline. The four guidelines agreed in recommending prophylactic heparin treatment in 330 patients (32.0%). The corresponding rate of prophylactic treatment use was 57.0% (188/330). None of the guidelines recommended prophylactic heparin treatment in 385 patients (37.3%). The physicians did not order prophylactic treatment in 80.3% of these patients (309/385). The guidelines disagreed in recommending prophylactic treatment in 317 patients (30.7%). The corresponding rate of prophylactic treatment use was 32.8% (104/317). CONCLUSION: The four guidelines agreed in 69.3% of patients but physician practices were already quite appropriate in these patients before the guidelines were disseminated. Active dissemination of the guidelines can be expected to improve physician practices in the treatment of these patients, but likely with limited impact. In contrast, the four guidelines disagreed in 30.7% of patients. Further clinical trials are needed in this subgroup of patients.

Aged↗

PubMed2004

Inpatient care of community-acquired pneumonia: the effect of antimicrobial guidelines on clinical outcomes and drug costs in Canadian teaching hospitals.

BACKGROUND: Evidence supporting antibiotic treatment guidelines and respiratory quinolones (RQs) in community-acquired pneumonia (CAP) is limited. OBJECTIVE: To study associations among guideline adherence, specific antibiotics, clinical outcomes and antibiotic costs. METHODS: A retrospective cohort study in three tertiary care university teaching hospitals in Toronto, Ontario, studying CAP inpatients between November 1997 and June 2000. The period encompassed 12 months when an early version of empirical antibiotic guidelines was used (early cohort) and 18 months when recent guidelines (including RQs) were used (recent cohort). RESULTS: Six hundred ninety-eight cases of CAP were reviewed, and 91% were guideline adherent. In multivariable analyses, no association was observed between guideline adherence and mortality or duration of hospitalization. Guideline-adherent cases received fewer antibiotics in both cohorts and 0.9 days less of intravenous antibiotics (P=0.04) in the recent cohort. There was no significant difference in antibiotic cost according to guideline adherence, but recent cohort guideline-adherent cases had lower drug costs than early cohort guideline-adherent cases. Antibiotic selection was associated with illness severity and was mirrored by clinical outcomes, despite controlling for the pneumonia severity index (PSI). Treatment with anaerobic agents (odds ratio 2.7, P=0.001) or cephalosporin plus macrolide (odds ratio 2.7, P=0.02) was associated with higher mortality. Treatment with RQ monotherapy was associated with a 2.3 day shorter duration of intravenous therapy (P<0.0001) and a 19.19 dollars lower total antibiotic cost (P<0.0001). CONCLUSION: Findings support empirical treatment guidelines for CAP and their recommendations regarding RQs. The association between mortality and anaerobic coverage or combination therapy may reflect prognostic information available at presentation but not captured by the PSI.

Aged↗

PubMed2004

Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a clinical practice guideline.

BACKGROUND: Carcinoma of the esophagus is an aggressive malignancy with an increasing incidence. Its virulence, in terms of symptoms and mortality, justifies a continued search for optimal therapy. A clinical practice guideline was developed based on a systematic review investigating neoadjuvant or adjuvant therapy on resectable thoracic esophageal cancer. METHODS: A systematic review with meta-analysis was developed and clinical recommendations were drafted. External review of the practice guideline report by practitioners in Ontario, Canada was obtained through a mailed survey, and incorporated. Final approval of the practice guideline was obtained from the Practice Guidelines Coordinating Committee. RESULTS: The systematic review was developed and recommendations were drafted, and the report was mailed to Ontario practitioners for external review. Ninety percent of respondents agreed with both the evidence summary and the draft recommendations, while only 69% approved of the draft recommendations as a practice guideline. Based on the external review, a revised document was created. The revised practice guideline was submitted to the Practice Guidelines Coordinating Committee for review. All 11 members of the PGCC returned ballots. Eight PGCC members approved the practice guideline report as written and three members approved the guideline conditional on specific concerns being addressed. After these recommended changes were made, the final practice guideline report was approved. CONCLUSION: In consideration of the systematic review, external review, and subsequent Practice Guidelines Coordinating Committee revision suggestions, and final approval, the Gastrointestinal Cancer Disease Site Group recommends the following:For adult patients with resectable thoracic esophageal cancer for whom surgery is considered appropriate, surgery alone (i.e., without neoadjuvant or adjuvant therapy) is recommended as the standard practice.

Adenocarcinoma↗

PubMed2000

Organizational interventions to encourage guideline implementation.

Evidence-based guidelines hold considerable promise for continued improvement of health-care delivery. However, the availability of clinical practice guidelines does not automatically lead to changes in practice patterns. Using a "push-pull-capacity" model, this article describes strategies to improve guideline implementation for three types of organizations: national organizations, insurer and health-care organizations, and health-care purchasers. Push strategies focus on the guideline development process and include rigorous review and meta-analysis of peer-reviewed research, and use of multidisciplinary expert teams, subjecting guidelines to peer review and comment and using measurable clinical outcomes to define guidelines. PULL: strategies focus on creating a demand for guideline implementation and include professional organization endorsement, quality measures based on guideline-related outcomes, and guideline-based performance objectives in purchaser contracts and physician compensation agreements. Capacity strategies focus on systems that facilitate guideline implementation. Example strategies are providing benefit coverage and reimbursement for guideline-based treatment protocols, and implementing clinical information systems for population-based tracking, outcomes monitoring, and benchmarking feedback.

Delivery of Health Care↗

PubMed2006

Drug costs associated with non-adherence to cholesterol management guidelines for primary prevention of cardiovascular disease in an elderly population: the Rotterdam study.

BACKGROUND: In The Netherlands, costs of HMG-CoA reductase inhibitor (statin) use have recently increased sharply compared with costs of other drugs. However, several studies have established both undertreatment and non-guidelines-indicated treatment with statins, suggesting a suboptimal use of resources. OBJECTIVE: To estimate the drug costs associated with non-guidelines-indicated treatment and undertreatment with statins in an elderly population. PATIENTS AND SETTING: Data were obtained from the Rotterdam Study, a population-based prospective cohort study which began in 1990 with 7983 participants aged > or =55 years. Subjects with a history of cardiovascular disease (CVD) were excluded. Pharmacy records were used to assess patterns of medication use in daily medical practice. MAIN OUTCOME MEASURE: Non-guidelines-indicated treatment and undertreatment with statins were established in relation to Dutch cholesterol management guidelines for all participants. We calculated the costs of statin therapy associated with non-guidelines-indicated treatment, and the costs of statins if all those undertreated were to receive statins. The results were projected on to the Dutch population to determine the economic implications of non-adherence to cholesterol management guidelines in the elderly. RESULTS: Of the participants who started treatment with statins for the primary prevention of CVD during follow-up, 69% received non-guidelines-indicated treatment. More men (7.5%) were undertreated than women (1.6%) and more women (6.2%) received non-guidelines-indicated treatment than men (1.5%). Among the participants without CVD who were still alive at 1 January 2002, 14% were eligible for statin therapy but were untreated. After projection of the prevalence of non-guidelines-indicated treatment and undertreatment to the Dutch population, the absolute costs for non-guidelines-indicated treatment with statins in 2005 were estimated to be approximately 23 million euro(uncertainty limits [UL]: 19-28 million euro), while the cost to eliminate undertreatment was also 23 million euro (UL: 19-28 million euro). CONCLUSION: Reallocation of resources used for statin therapy from those receiving non-guidelines-indicated treatment to those being undertreated could lead to a more efficient use of resources.

Aged↗