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PubMed1995

Serving our communities better. Guidelines for planning and developing integrated delivery networks.

In 1994 the Daughters of Charity National Health System-East Central (DCNHS-East Central) adopted 11 guidelines to help corporate staff and local leaders plan and develop integrated networks. Guideline 1 emphasizes needs-based strategic planning. Guideline 2 focuses on the community-based network planning process, recommending a team approach and ongoing communication with the local ordinary. In guidelines 3 through 5, the DCNHS-East Central Board of Directors spells out key issues that must be covered in proposals ultimately presented for governance action. Guideline 6 presents three core elements that should characterize all CBNs in which DCNHS-East Central institutions participate. Guideline 7 emphasizes that all CBN proposals and agreements must be clear with respect to the Catholic identity of DCNHS-East Central institutions. Guidelines 8 and 9 require that proposed changes to traditional policies and management practices be explicit in CBN proposals. The tenth guideline requires that all CBN proposals indicate an explicit evaluation function. The final guideline underscores that regardless of the strategic fit or how well a CBN is designed, it is unlikely to succeed unless both internal and external relationships are based on a solid foundation of honesty, mutual respect, and trust.

Catholicism↗

PubMed1995

Primary care HMO clinicians' opinions about clinical practice guidelines.

OBJECTIVE: To assess primary care clinicians' opinions about the principal goals that national guideline developers foresee for clinical practice guidelines, and about possible effects of guideline implementation that are known to concern practicing clinicians. DESIGN: Preintervention survey of attitudes conducted as part of a larger study to evaluate alternative strategies for implementing clinical practice guidelines. SETTING: Kaiser Permanente, Northwest Region, a large, group model HMO. PARTICIPANTS: Primary care clinicians (N = 211) with at least 1 year of work experience in the HMO. The response rate was 80% (N = 168). RESULTS: Clinicians' responses suggest they will not object to the implementation of specific practice guidelines in the HMO. Guidelines' information-synthesizing and consensus-building functions are likely to be welcomed. Increased guideline implementation is apparently not perceived as a threat to professional autonomy. CONCLUSIONS: Further research is recommended, using this measure, or refined versions of it, in diverse practice settings. In addition, studies are needed of the relationship between clinicians' general expectations about the effects of guidelines and their level of adherence to specific guidelines.

Adult↗

PubMed1999

[The guideline clearing programme of the self-governmental bodies in the German health care system--a project to promote quality assurance in medicine].

Within the German health system guidelines are increasing considered as a meaningful and necessary aid to decision making. In this context the effectiveness of guidelines essentially depends on their methodical quality. Because of the fact that most of the German-language guidelines introduced within the past years show obvious methodological defects, the Agency for Quality in Medicine developed within the last two years the following programme for quality-assurance and promotion of guidelines: 1. Definition of quality policies for clinical practice guidelines in Germany 2. Establishment of quality demands for guidelines 3. Methods and instruments for quality promotion of guideline programmes 4. Measures to promote and check the quality of guidelines ("German Guidelines Clearinghouse") The following article reports on background, aims, instruments, method development and acceptance of the programme.

Delivery of Health Care↗

PubMed1999

The development of radiology guidelines in Canada, Part 2.

In the second part of a two-part article on the development of Canadian clinical practice guidelines in radiology, the author discusses the implementation of guidelines. The aim is to translate guidelines into practice policies, but nation-wide implementation is difficult because of the regional circumstances and constraints in Canadian health care. One approach to making guidelines more effective tools and preventing conflict is to distinguish between effectiveness (benefit of an intervention under average conditions of use) and efficiency (value of an intervention compared with other things that could be done with the same resources). Clinical practice guidelines are based on effectiveness criteria alone, whereas practice policies can be based on efficiency criteria and are made by those responsible for allocating resources. From an ethical point of view, guidelines have an important feature in common with applied ethics: neither can give the right answer in a situation, but both can indicate the right decision-making process, including who should decide, on what basis, using which process and for what purpose. From a legal standpoint, if the medical community views guidelines as constituting reasonable medical care and jurists see them as a medical and legal norm, they can have significant influence in malpractice litigation. At the last annual meeting of the CAR, the executive committee decided that an integrated national approach to guidelines is needed because of the considerable confusion in this field. It supports the National Framework Development Committee's efforts to set national principles and operating rules for development and implementation. This necessitates an organizational structure consisting of a coordinating group representing consumers, service providers, regulators and funding agencies; multidisciplinary guidelines-development groups; and methodology resource groups.

Canada↗

PubMed1999

Architecture for a multipurpose guideline execution engine.

Integration of guideline knowledge into the clinical workflow is essential, for improving adherence to guidelines. Guidelines in structured formats can be utilized by computer programs to provide decision support in clinical information systems, as well as to facilitate workflow. We have designed an architecture for a flexible guideline execution engine that can be utilized in clinical decision support applications. The engine may be utilized for other applications such as referral management, medical education, and conducting clinical trials. The engine executes guidelines that are defined in an extension of the Guideline Interchange Format (GLIF). GLIF was extended to support representation of constructs that are essential to the execution of the guideline. A prototype of the engine was implemented based on this architecture. The engine is being utilized in two clinical applications that draw on guidelines for decision support. The engine was also used for developing an educational application aimed at testing knowledge of guideline recommendations.

Computer Systems↗

PubMed2000

[Depression and clinical practice guidelines: evidence or confusion. Study group on the prescription and psychotropic in primary care].

BACKGROUND: The need of designing clinical practice guidelines in the context of the evidence based medicine relates to different aspects concerning the characteristics of the clinical condition, the health care context, the utilization of health services, and the existing knowledge about the topic of study. The objective of this study was to review the guideline development method for managing depression in care and its implications in clinical practice. MATERIAL AND METHODS: Review and classification of scientific articles published between 1990 and 1997 about depression guidelines according to its method of development. RESULTS: Between 1990 and 1997, 2 clinical practice guidelines on the management of depression were published using systematic review, 3 guidelines were developed through unsystematic review, 4 guidelines were developed from experts' consensus, and 19 published articles reviewed the applicability of the existing guidelines in the primary health care sector. Different points of view about the use of these guidelines had been detected. CONCLUSIONS: In the context of the evidence-based medicine, one should take into account that the overall goal of guidelines development is to ensure its validity in different health care levels, as well as to gather professionals' acceptance of its use and applicability.

Depression↗

PubMed2000

A systematic process for converting text-based guidelines into a linear algorithm for electronic implementation.

Clinical practice guidelines are increasingly important for improving the quality and the process of healthcare delivery. Unfortunately, most guidelines are available only in a text-based format, which is difficult to integrate into clinical practice. Computers can facilitate guideline integration into clinical practice; however, this migration to computers requires translating text into intermediary representations. One type of representation that is readily adaptable for computerization is a linear algorithm. This paper describes a systematic process to convert text-based clinical practice guidelines into a linear algorithm with structured content, as an intermediate step to electronic implementation. The process includes: 1) defining applicability criteria, 2) identifying entry points, 3) defining decision points, 4) defining actions, 5) creating a linear algorithm that links decision points and actions, and 6) adding supporting resources. This process has been used successfully to prepare more than two dozen guidelines for computerization. It has been tested by several physicians and informaticians and shown to be transferable to various user groups. The availability of a systematic process to convert text-based guidelines into a structured intermediary format for electronic implementation can facilitate the computerization of guidelines and can inform guideline content developers regarding the critical elements that need to be explicitly stated in guidelines to support electronic implementation.

Algorithms↗

PubMed2001

The place of guidelines and their means of dissemination.

INTRODUCTION: The literature shows that physicians do not change their patterns of practice quickly. With thousands of conflicting guidelines available, many disseminated by print, there has been little measurable impact of new guidelines on physician prescribing patterns. METHODS: A series of interventions designed to improve physician uptake of guidelines is described. Interventions evaluated in a series of trials include mail dissemination, small group continuing medical education sessions, academic detailing by both academic detailers and pharmaceutical detailers, and a whole community program known as the Program for Appropriate Anti-Infective Community Therapy. RESULTS: Only the whole community intervention had significant impact on physician prescribing patterns. The changes involved a significant reduction in anti-infective use and a significant change from the use of second- and third-line drugs to first-line drugs, as specified in the Ontario Anti-Infective Guidelines. CONCLUSIONS: Acceptable guidelines disseminated by a multidisciplinary community program can have a positive impact on physician prescribing patterns. To increase the acceptability of guidelines for whole community dissemination, a new innovation (Guideline Advisory Committee) that scores the quality of guidelines and selects the most objectively produced guideline is described.

Attitude of Health Personnel↗

PubMed2001

[Comparison of five guidelines of community-acquired pneumonia].

The aim of this retrospective study was to elucidate the characteristics of five guidelines of community-acquired pneumonia: ATS (1993), ATS (2001), IDSA (1998), IDSA (2000) and the guidelines of the Japan Respiratory Society (2000). One hundred community-acquired pneumonia patients admitted to the International Medical Center of Japan were investigated in accordance with each set of guidelines based on the physical, laboratory, and chest radiography findings on the first day of treatment. According to the ATS (1993) guidelines, 33% of the cases were classified as "severe" pneumonia. On the other hand, according to the ATS (2001) guidelines, only 8% of the cases were classified as "severe" pneumonia. According to the IDSA guidelines, 35% of the patients were classified as "outpatients". Fluoroquinolone appears to be a very important antibiotic drug in the new guidelines of both ATS and IDSA. The scoring system of IDSA suggested a correlation between the patient's score and the pathogenic bacteria. According to the guidelines of the Japan Respiratory Society, 42% of the cases were classified as "severe" pneumonia. There are evident differences between these guidelines, and clinicians need to have a full understanding of their respective characteristics.

Community-Acquired Infections↗

PubMedDate not supplied

Guidelines in diagnostics: formulation methodology proposal.

In healthcare the term "guideline" is used in numerous circumstances and for different purposes. The most commonly accepted definition is provided by the American Agency for Healthcare Research and Quality, which defines guidelines as "recommendations developed in order to assist doctors and patients in the decision-making process, while choosing an appropriate assistance in specific clinical circumstances". At present, in Italy and foreign countries, guidelines are considered an effective tool. Guidelines contribute with a qualitative improvement in performances, standardizing healthcare criteria, enabling also rationalisation and optimisation in both human and economical resources. The achievement of these aims depends on a thorough examination of both meaning and role played by guidelines in clinical practice, and of the essential methodological criteria of their processing. Unfortunately, these objectives can be attained only after the overcoming of obstacles, due to both limits in the formulation of such documents (use of inadequate methodology, choice of the paper-based collection of documents rather than computer-based data-processing support), and to the opposition of the medical personnel. The latter problem being caused by a poor knowledge of the role played by guidelines and by the difficulty of a critical evaluation of their validity. In fact, the success of a guideline is also determined by its development, implementation and introduction strategies, and by the consence of the medical community. Once formulated by an interdisciplinary group of experts, a guideline should be necessarily revised according to already coded procedures. A reliable contribution to the diffusion of such guidelines derives from the use of computer-based data-processing supports, which contribute to their interactivity, user friendliness, user-adaptivity and updatebility. The above illustrated procedures represent an unquestionable contribution to the clinical decision-making process. In fact, these represent the basic development tools for the harmonisation of cultural qualification and clinical practice, aiming at quality improvement and rationalisation in health-related activities.

Practice Guidelines as Topic↗

PubMed2003

STD prevention and treatment guidelines: a review from a managed care perspective.

OBJECTIVE: To conduct a standardized review of sexually transmitted disease (STD) clinical practice guidelines from a managed care perspective. STUDY DESIGN: Eight guidelines that address STD prevention and care received dual review on selected content and formatting criteria. Content criteria included currency of information, coverage of 7 selected STDs, attention to primary prevention areas (risk assessment, patient education, counseling), attention to system/implementation issues (time/costs/training) of integrating STD practices into routine clinical care, and referencing of scientific literature. Format/presentation criteria included ease of accessing STD information, clear identification of STD recommendations, availability of handbook/pocket versions, and availability of online version. Chlamydia screening and treatment recommendations were compared for 3 guidelines. RESULTS: The 8 guidelines addressed a variety of target populations. Two focused exclusively on STDs. Three were current at the time of the review (1998 or later), 2 covered all selected STDs, 3 gave considerable emphasis to primary prevention, and 4 cited relevant scientific sources. One guideline was classed as having good coverage of system/implementation issues. Information for specific STDs was readily located and concisely presented in 2 of the guidelines. Four sources had handbook/pocket versions, and 5 had on-line versions. Based on these findings, we suggest modifications for future versions of these guidelines that may increase their usefulness to managed care settings. CONCLUSIONS: Currently available STD guidelines potentially can be of great use to managed care providers and decisionmakers. The relevance to managed care organizations of a number of guidelines could be increased in several areas, particularly by greater focus on primary prevention and by providing access to tools and strategies to foster integration of STD services into routine clinical care.

Canada↗

PubMed2003

[International comparison of 19 clinical guideline programs--a survey of the AGREE Collaboration].

Clinical practice guidelines are being developed in many countries throughout the world to improve quality of patient care. However, the methods used to develop guidelines vary among organisations. Therefore an international task group, the AGREE (Appraisal Guideline Research and Evaluation Europe) Collaboration, started in 1998 to work on the harmonisation and coordination of guideline development. Within this context a survey of national guideline programmes was conducted. Nineteen programmes from nine European countries, Australia, Canada, New Zealand and United States were described using a questionnaire. The items concerned the type of organisation, scope and purpose of the guidelines, people involved, methodology, products, implementation, evaluation, update procedure, and future plans. The results of this survey revealed a growing international consensus on the essential features of good guideline programmes. Most guideline programmes combine an evidence-based approach with informal and/or formal consensus procedures. No significant differences were found between governmental agencies and professional organisations. The budget for developing a single guideline varies from 10,000 to 200,000 EURO.

Europe↗

PubMedDate not supplied

The electronic medical record: decision support and the effective use of clinical guidelines.

Embedding clinical guidelines into an electronic medical record is a form of clinical decision support that has the potential to improve the quality and consistency of care provided at the clinical encounter. The manuscript describes the consensus method of developing clinical guidelines and its components that have an impact on its output. These include questions asked, participants, the presentation of information, method of structuring group interaction, and method of synthesizing judgments. Clinicians need to be aware of how these elements can affect guideline development. The quality of research on guideline development is varied. The process of guideline development is poorly documented, not evidence-based, and lacks the transparency that allows users to judge the output and quality of local adherence. The manner in which the presentation of guidelines is structured and implemented is also important in determining adherence. Monitoring guidelines by building a feedback loop is critical for ongoing guideline improvement. The literature on the long-term impact of electronic guidelines on clinician behavior is lacking.

Decision Support Systems, Clinical↗

PubMed2003

[Less ethnic knowledge in the Dutch College of General Practitioner's practice guidelines on type 2 diabetes mellitus, hypertension and asthma in adults than in the supporting literature].

OBJECTIVE: To assess whether ethnic differences present in the scientific literature used as the basis for the Dutch College of General Practitioner's (NHG) practice guidelines were reflected in the ethnic-specific information the guidelines contained. DESIGN: Analysis of published information. METHOD: The scientific literature used as the basis for the guidelines about type 2 diabetes mellitus, hypertension and asthma in adults was collected and carefully screened. Relevant ethnic-specific information was compared to the content of the guidelines. RESULTS: Several relevant ethnic differences were stated in the scientific literature used as the basis for the guidelines. Differences in prevalence and clinical progress were stated for type 2 diabetes mellitus, differences in lung-volume were stated for asthma and differences in prevalence, onset, complications, response to pharmacological treatment and dietary salt restriction were stated for hypertension. The type 2 diabetes mellitus guideline stated a higher prevalence of diabetes in Hindustani people and recommended earlier screening in this group. The asthma guideline stated that the lung volume is dependent of ethnicity. The hypertension guideline did not state any ethnic-specific information. CONCLUSION: The guidelines on type 2 diabetes mellitus, hypertension and asthma in adults only adopted a limited number of the ethnic differences contained in the scientific literature on which they were based. Possible explanations are that information was only included if there was a clear scientific basis, and that ethnic distinctions were found to be politically and socially undesirable. However, this lack of information might lead to ineffective or sub-optimal care for ethnic minorities.

Asthma↗

PubMed2003

[Medical outcomes and antimicrobial compliance according to the Chilean Society of Respiratory Diseases guidelines for hospitalized patients with community acquired pneumonia].

BACKGROUND: The Chilean Society of Respiratory Diseases (SER) developed guidelines for the empirical treatment of community acquired pneumonia (CAP). AIM: To evaluate the degree of adherence to antibiotic treatment recommended by SER guidelines and its influence on medical outcomes. PATIENTS AND METHODS: We prospectively evaluated 453 consecutive immunocompetent adults (mean age +/- SD: 69 +/- 19 years) hospitalized for CAP. Patients were stratified according to the Pneumonia Severity Index (PSI), and initial antibiotic regimen was classified as being consistent or inconsistent with the SER guidelines. Rate of medical complications, switch therapy rate, length of stay (LOS), and 30 days mortality were compared between those treated consistently or inconsistently with the SER guidelines. RESULTS: Adherence to SER guidelines was 46%. Patients treated consistently with the SER guidelines were older (mean age +/- SD: 72 +/- 16 v/s 65 +/- 20 years), had more comorbidities (84 v/s 69%) and a higher proportion belonged to the high-risk PSI categories (69 v/s 49%). There were no significant differences in medical complication rate, switch therapy rate or LOS between both groups. Adherence to SER guidelines did not affect mortality after adjusting for PSI and for prognostic factors associated with 30 days mortality by multivariate analysis. CONCLUSIONS: The degree of adherence to antibiotic treatment recommended by SER guidelines was moderate and they were applied mainly in patients with high risk CAP. This fact can explain the lack of evidence of improved medical outcome in patients treated according to SER guidelines.

Adolescent↗

PubMed2003

GESDOR - a generic execution model for sharing of computer-interpretable clinical practice guidelines.

We developed the Guideline Execution by Semantic Decomposition of Representation (GESDOR) model to share guidelines encoded in different formats at the execution level. For this purpose, we extracted a set of generalized guideline execution tasks from the existing guideline representation models. We then created the mappings between specific guideline representation models and the set of the common guideline execution tasks. Finally, we developed a generic task-scheduling model to harmonize the existing approaches to guideline task scheduling. The evaluation has shown that the GESDOR model can be used for the effective execution of guidelines encoded in different formats, and thus realizes guideline sharing at the execution level.

Decision Making, Computer-Assisted↗

PubMed2003

Developing primary care review criteria from evidence-based guidelines: coronary heart disease as a model.

BACKGROUND: National Health Service (NHS) initiatives such as Clinical Governance, National Service Frameworks and the National Institute of Clinical Excellence (NICE) clinical guidelines programme create demand for tools to enable performance review by healthcare professionals. Ideally such tools should enable clinical teams to assess quality of care and highlight areas of good practice or where improvement is needed. They should also be able to be used to demonstrate progress towards goals and promote quality, while not unnecessarily increasing demand on limited resources or weakening professional control. AIM: To formulate and evaluate a method for developing, from clinical guidelines, evidence-based review criteria that are proritised, useful and relevant to general practices assessing quality of care for the primary care management of coronary heart disease (CHD). DESIGN OF STUDY: A two-stage study comprising, first, a review of available evidence-based guidelines for CHD and, second, the definition and prioritization of associated review criteria from the most highly rated guidelines. SETTING: Primary healthcare teams in England. METHODS: Using structured methods, evidence-based clinical guidelines for CHD were identified and appraised to ensure their suitability as the basis for developing review criteria. Recommendations common to a number of guidelines were priortszid by a panel of general practitioners to develop review criteria suitable for use in primary care. RESULTS: A standardised method has been developed for constructing evidence-based review criteria from clinical guidelines. A limited, prioritized set of review criteria was developed for the primary care management of CHD. This was distributed around the NHS through the Royal College of General Practitioners for use by primary care teams across the United Kingdom. CONCLUSION: Developing useful, evidence-based review criteria is not a straightforward process, partly because of a lack of consistency and clarity in guidelines currently available. A method was developed which accommodated these limitations and which can be applied to the development and evaluation of review criteria from guidelines for other conditions.

Coronary Disease↗

PubMed2003

[Problems in development and use of guidelines for clinical practice].

According to the Agency for Healthcare Research and Quality in the USA, the characteristics to be fulfilled by clinical guidelines are validity, reproducibility, reliability, clinical flexibility, clarity and scheduled review. However, most clinical guidelines do not necessarily fully satisfy these factors. I have been engaged in the development of evidence-based guidelines for the management of stroke in Japan. Problems in development of guidelines are as follows. The first is the lack of high level evidence such as randomized controlled trials, which influences recommendation grade. In the case of clinical guidelines for treatment of cerebral hemorrhage in the acute stage, the recommendation grade (C1, C2), which means a lack of sufficient scientific evidence, covered 86% of all recommendation items. The second is ease of clinical application. Evidence based clinical guidelines are not likely to be easy to use if sufficient high-level scientific evidence is not available. It must be realized that guidelines can only be applied to 60 to 95% of patients. Depending on the patient, setting, and other factors, guidelines can and should be tailored to fit individual needs. Deviations from guidelines will be fairly common and can be justified by differences in individual circumstances.

Bibliography of Medicine↗