SEARCH · PubMed Health

Results for “Guidelines”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,207 records · Page 67Linked to original sources

PubMed2004

Design and implementation of the GLIF3 guideline execution engine.

We have developed the GLIF3 Guideline Execution Engine (GLEE) as a tool for executing guidelines encoded in the GLIF3 format. In addition to serving as an interface to the GLIF3 guideline representation model to support the specified functions, GLEE provides defined interfaces to electronic medical records (EMRs) and other clinical applications to facilitate its integration with the clinical information system at a local institution. The execution model of GLEE takes the "system suggests, user controls" approach. A tracing system is used to record an individual patient's state when a guideline is applied to that patient. GLEE can also support an event-driven execution model once it is linked to the clinical event monitor in a local environment. Evaluation has shown that GLEE can be used effectively for proper execution of guidelines encoded in the GLIF3 format. When using it to execute each guideline in the evaluation, GLEE's performance duplicated that of the reference systems implementing the same guideline but taking different approaches. The execution flexibility and generality provided by GLEE, and its integration with a local environment, need to be further evaluated in clinical settings. Integration of GLEE with a specific event-monitoring and order-entry environment is the next step of our work to demonstrate its use for clinical decision support. Potential uses of GLEE also include quality assurance, guideline development, and medical education.

Database Management Systems↗

PubMed2005

Guidelines on anaemia: effect on primary-care midwives in The Netherlands.

OBJECTIVE: To assess the adherence and perceived barriers for implementation of a clinical-practice guideline on anaemia, which was the first national guideline for primary-care midwifery in The Netherlands. DESIGN: Cross-sectional survey study. SETTING: Primary-care midwifery in The Netherlands. PARTICIPANTS: 160 midwives (60% response rate). MEASUREMENTS: Questionnaire on the knowledge of, and attitudes and self-reported adherence to, 14 key recommendations in the guideline; attitudes to guidelines in general; and perceived barriers to implementation. FINDINGS: The number of midwives agreeing with and adhering to specific recommendations varied between 29 and 90%. Most midwives had a positive attitude to the guidelines. The most relevant general barriers were related to the behaviour of general practitioners and obstetricians (32% of the midwives reported this). Larger numbers of midwives mentioned barriers to specific aspects of the guideline, particularly alternative iron supplementation or dietary supplements (59%), and not prescribing iron supplementation if haemoglobin was low but mean corpuscular volume was normal (49%). KEY CONCLUSIONS: The guideline on anaemia was well received by primary-care midwives in The Netherlands, but implementation of specific recommendations needs further attention. IMPLICATIONS FOR PRACTICE: The study provides evidence for the national organisation of midwives to continue with the development and implementation of clinical guidelines.

Adult↗

PubMed2006

European first aid guidelines.

AIM: Our objectives were to determine the most effective, safe, and feasible first aid (FA) techniques and procedures, and to formulate valid recommendations for training. We focussed on emergencies involving few casualties, where emergency medical services or healthcare professionals are not immediately present at the scene, but are available within a short space of time. Due to time and resource constraints, we limited ourselves to safety, emergency removal, psychosocial FA, traumatology, and poisoning. Cardiopulmonary resuscitation (CPR) was not included because guidelines are already available from the European Resuscitation Council (ERC). The FA guidelines are intended to provide guidance to authors of FA handbooks and those responsible for FA programmes. These guidelines, together with the ERC resuscitation guidelines, will be integrated into a European FA Reference Guide and a European FA Manual. METHODS: To create these guidelines we used an evidence-based guideline development process, based on the methodology of the Scottish Intercollegiate Guidelines Network (SIGN). RESULTS: The recommendations cover FA for bleeding, wounds, burns, spinal and head trauma, musculoskeletal trauma, and poisoning, as well as safety and psychosocial FA. CONCLUSIONS: Where good evidence was available, we were able to turn science into practice. Where evidence was lacking, the recommendations were consensus-based. These guidelines provide systematically developed recommendations and justifications for the procedures and techniques that should be included in FA manuals and training programmes.

Europe↗

PubMed2005

Primary care physicians' awareness and adherence to cervical cancer screening guidelines in Texas.

BACKGROUND: Cervical cancer screening guidelines were created to help healthcare professionals in appropriate screening utilizing the PAP test. However, significant variation in cervical cancer screening among primary care physicians has been noted. Knowledge of the awareness of and adherence to cervical cancer screening guidelines by primary care physicians will help determine how best to disseminate and educate these physicians regarding the guidelines in hopes of reducing unnecessary screening and improving screening for under screened populations. METHODS: A cross-sectional, mailed survey involving Family Medicine (FP), Community Internal Medicine (CIM), and Obstetrics/Gynecology (OB) physicians practicing in a large University-affiliated, multi-specialty group practice associated with an 186,000-member HMO in Central Texas (n = 177) was conducted in 2001-2002. RESULTS: Most physicians performed PAP testing (50.4%). PAP screening was noted to vary significantly by specialty (P < 0.0001). All OBs were aware of at least one published guideline, compared to 96% of FPs and 91% of CIMs (P < 0.05). A wide variation was reported regarding adherence to published guidelines. In addition, there was significant intraspecialty variation regarding adherence to the physicians' own specialty's guidelines. CONCLUSIONS: While most physicians in the primary care setting perform PAP tests and are aware of published guidelines for PAP screening, adherence to the published guidelines varies considerably even in the same clinical setting.

Adult↗

PubMed2001

Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.

PURPOSE: We developed a pneumonia guideline at Intermountain Health Care that included admission decision support and recommendations for antibiotic timing and selection, based on the 1993 American Thoracic Society guideline. We hypothesized that guideline implementation would decrease mortality. SUBJECTS AND METHODS: We included all immunocompetent patients > 65 years with community-acquired pneumonia from 1993 through 1997 in Utah; nursing home patients were excluded. We compared 30-day mortality rates among patients before and after the guideline was implemented, as well as among patients treated by physicians who did not participate in the guideline program. RESULTS: We observed 28,661 cases of pneumonia, including 7,719 (27%) that resulted in hospital admission. Thirty-day mortality was 13.4% (1,037 of 7,719) among admitted patients and 6.3% (1,801 of 28,661) overall. Mortality rates (both overall and among admitted patients) were similar among patients of physicians affiliated and not affiliated with Intermountain Health Care before the guideline was implemented. For episodes that resulted in hospital admission after guideline implementation, 30-day mortality was 11.0% among patients treated by Intermountain Health Care-affiliated physicians compared with 14.2% for other Utah physicians. Analysis that adjusted by logistic regression for age, sex, rural versus urban residences, and year confirmed that 30-day mortality was lower among admitted patients who were treated by Intermountain Health Care-affiliated physicians (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.49 to 0.97; P = 0.04) and was somewhat lower among all pneumonia patients (OR: 0.81; 95% CI: 0.63 to 1.03; P = 0.08). CONCLUSION: Implementation of a pneumonia practice guideline in the Intermountain Health Care system was associated with a reduction in 30-day mortality among elderly patients with pneumonia.

Aged↗

PubMed1999

The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women.

PURPOSE: Acute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconvenience, a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing. We sought to evaluate the effects of the guideline. SUBJECTS AND METHODS: We performed a population-based, before-and-after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on resource utilization and on the occurrence of potential adverse outcomes. We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis. Relative risks (RR) and 95% confidence intervals (CI) were estimated, adjusting for the effects of clustering within clinics. RESULTS: A total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated. As compared with baseline, guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis (RR = 0.75; CI, 0.70 to 0.80), urine culture (RR = 0.73; CI, 0.68 to 0.79), and an initial office visit (RR = 0.67; CI, 0.62 to 0.73), while increasing the proportion who received a guideline-recommended antibiotic 2.9-fold (CI, 2.4 to 3.7-fold). In the prospective comparison of the 22 intervention and two control clinics, the guideline decreased the proportion of patients who had urinalyses performed (RR = 0.80; CI, 0.65 to 0.98) and increased the proportion of patients who were prescribed a guideline-recommended antibiotic (RR = 1.53; CI, 1.01 to 2.33). Adverse outcomes did not increase significantly in either comparison. CONCLUSION: Guideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis.

Adult↗

PubMed2001

European soil sampling guidelines for soil pollution studies.

The soil sampling guidelines used in European countries (ESSG), as kindly provided by the national institutions which participated in the project, have been recorded, studied, evaluated and presented in this paper. The aim has been to ascertain what soil sampling guidelines exist in Europe; to detect similarities and differences (comparable results), advantages and deficiencies; to identify incompatible strategies and evaluate how methodologies might affect data quality; to investigate sources of deviations or uncertainties; to improve comparability and representativeness of soil sampling; to investigate the need for harmonised sampling guidelines; and to develop suggestions for standard operating procedures (SOP). Soil sampling guidelines throughout Europe differ as to whether they are applied by law, or used throughout the country. In some countries these are ISO/DIS related or based (ISO 10381-1, 1995; ISO 10381-2, 1995), or are produced by a scientific society or a standardisation body. As far as sampling strategy is concerned, not all sampling guidelines clearly describe the sampling scale, the specifications for contamination risk precautions, the sampling plan and protocol structure and the pre-analysis treatment of the soil samples. The purpose for sampling, in descending order of frequency, is soil pollution, soil fertilisation, general soil monitoring, background risk assessment, or else it is not specified. The majority of countries do not sample the top organic matter separately. Sampling depth is either related to the morphogenetic horizon or to ad hoc sampling depth, which is not specified in all cases. They suggest mass- and volume-related soil sampling, while the sampling pattern is not presented in all national guidelines. The criteria for area, site, unit, sub-unit, and point selection are mainly based on pedology and land use, following the history and pre-screening information or geology, or is site related. Some guidelines suggest the division of sampling units into sub-units. The sampling pattern is mainly grid sampling, grid and random sampling, or not mentioned. Sampling density inside the sampling unit either varies greatly or it is not mentioned, while the size of the sampling unit varies widely. Most guidelines require the collection of composite instead of simple samples, while some prefer sampling soil profiles. In the European SSG many technical details and steps are either not defined or vary, while in the pre-analysis treatment quality assurance (QA) and quality control (QC) approaches are used either both in the lab and in the field, or only in the field, or are not mentioned. The common points and the points in which harmonisation could be started or achieved are discussed.

Agriculture↗

PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗

PubMed1999

Meeting the information needs of drug purchasers: the evolution of formulary submission guidelines.

The emergence of formulary submission guidelines in the 1990s has been seen by many as an attempt to come to grips with the issue of drug management within health systems and to provide, for the first time, a coherent and methodologically rigorous approach to formulary selection. Judging from the available evidence, however, guidelines have fallen far short of their potential. The purpose of this paper is to consider what role guidelines have played in health system management and whether they play a useful role in providing a methodologically sound basis for drug-impact assessment. Two polar cases in guideline development are examined: the Australian guidelines first published in 1992 and now undergoing a second major revision and the guidelines recently published by Blue Cross and Blue Shield of Colorado and Nevada. The former guidelines represent what can be described as the traditional, clinical paradigm of drug-impact assessment; the latter represent what can be called the system-impact paradigm. The argument put forward is that the Australian guidelines are essentially an anachronism, offering little to those whose principal concern is with the management of health systems. In their emphasis on a hierarchy of evidence and a clinical trial-focused, cost-effectiveness evaluation perspective, they represent a methodologic dead end in a number of important respects. The systems-based approach, on the other hand, with its emphasis on validation of claims and the need to consider a range of drug-impact and risk-management scenarios, offers an analytic framework that, while possibly less rigorous, is likely to contribute significantly to the management of health care systems.

Australia↗

PubMed2000

The most important changes in the international ECC and CPR guidelines 2000.

Many people involved with resuscitation have specific interests and enthusiasm. They will review the new guidelines to see how their favorite interventions fared. This essay lists a number of the new guidelines that merit special attention: support for family presence at resuscitations, pronouncing death at the scene rather than after futile transport efforts, honoring advance directives, comparable effectiveness of bag-mask ventilation versus tracheal intubation, revision of compression rates and compression-ventilation ratios, and devices to confirm tracheal intubation and prevent tube dislodgment. Even more important are the new principles and concepts that the International Guidelines 2000 endorse: international guideline science, international guideline development, evidence-based guidelines, training by objectives, expanded scope of ECC to first aid and periarrest conditions, avoidance of false-negative (type II) errors, video-mediated instruction, and a philosophy to 'do no harm.' The number and magnitude of these new guidelines reflect the dynamic nature of resuscitation at the start of the 21st century. There is great optimism that these new and revised guidelines will help achieve our ultimate objective. This objective is to be ready when fate brings some lives to a premature end. If we are, we can restore more of these people to a high-quality life, ready for many more years of living.

Humans↗

PubMed2000

Screening for gestational diabetes: variation in guidelines.

OBJECTIVE: To compare published guidelines concerning screening for gestational diabetes. STUDY DESIGN: Systematic search and comparative analysis of published guidelines. Appraisal of guidelines quality. Simulation analysis. RESULTS: Ten published guidelines proposed either universal screening (5), selective screening (3) or screening when clinically indicated (2). Variations of testing schedules and blood glucose thresholds were observed. The quality of the published guidelines was low, on average 22 (8-51) percentage points on the assessment scale. These differences would have led to large variations in the number of patients to be screened. CONCLUSIONS: Large variations between guidelines have been observed which would translate in large practice variations, if the guidelines were systematically applied. These variations are partially explained by the absence of definite evidence that universal or selective screening for gestational diabetes do more good than harm on infant and maternal health. The methodology of developing guidelines should be more evidence based, systematic and explicit.

Adult↗

PubMed2002

Development and use of evidence-based clinical practice guidelines for thyroid disease.

Clinical practice guidelines offer recommendations for optimizing health care. Guideline panels can rely on several methods for gathering information about current practice and synthesizing evidence that addresses specific questions. Clinical practice guidelines, including many that address thyroid disease, often rely on conventional narrative literature reviews and expert opinion rather than systematic evaluation of the published literature as the basis for their recommendations. This undermines the authority of practice guidelines and potentially results in disparate, invalid, or misleading recommendations. In contrast, incorporation of rigorous systematic reviews of literature and guidance by groups with multidisciplinary expertise decreases bias in evidence selection and increases precision of treatment effect estimates. Improved reliability and accuracy of evidence assessment, in turn, strengthens ultimate guideline recommendations. Cost-effective analyses further contribute to useful clinical practice guidelines and may encourage the explicit acknowledgment of values and preferences. Valid recommendations, however, prove futile in the absence of implementation. Adherence to guidelines may be improved with integration of user-friendly computer applications into clinical practice. By overcoming barriers to implementation and addressing the limitations of current guidelines, endocrinologists can play an essential role in improving the quality, efficiency, and cost-effectiveness of clinical practice related to thyroid disorders.

Endocrinology↗

PubMed2000

Guideline-based careflow systems.

This paper describes a methodology for achieving an efficient implementation of clinical practice guidelines. Three main steps are illustrated: knowledge representation, model simulation and implementation within a health care organisation. The resulting system can be classified as a 'guideline-based careflow management system'. It is based on computational formalisms representing both medical and health care organisational knowledge. This aggregation allows the implementation of a guideline, not only as a simple reminder, but also as an 'organiser' that facilitates health care processes. As a matter of fact, the system not only suggests the tasks to be performed, but also the resource allocation. The methodology initially comprehends a graphical editor, that allows an unambiguous representation of the guideline. Then the guideline is translated into a high-level Petri net. The resources, both human and technological necessary for performing guideline-based activities, are also represented by means of an organisational model. This allows the running of the Petri net for simulating the implementation of the guideline in the clinical setting. The purpose of the simulation is to validate the careflow model and to suggest the optimal resource allocation before the careflow system is installed. The final step is the careflow implementation. In this phase, we show that the 'workflow management' technology, widely used in business process automation, may be transferred to the health care setting. This requires augmenting the typical workflow management systems with the flexibility and the uncertainty management, typical of the health care processes. For illustrating the proposed methodology, we consider a guideline for the management of patients with acute ischemic stroke.

Artificial Intelligence↗

PubMed2001

ONCODOC: a successful experiment of computer-supported guideline development and implementation in the treatment of breast cancer.

Originally published as textual documents, clinical practice guidelines have poorly penetrated medical practice because their editorial properties do not allow the reader to easily solve, at the point of care, a given medical problem. However, despite the proliferation of implemented clinical practice guidelines as decision support systems providing an easy access to patient-centered information, there is still little evidence of high physician compliance to guidelines recommendations. Apart from physicians' psychological reluctance, the incompleteness of guideline knowledge and the impreciseness of the terms used, another reason may be that, although suited to average patients, clinical practice guideline recommendations are not a substitute for the physician-controlled clinical judgement that should be applied to each actual individual patient. Therefore, computer-based approaches based on the automation of context-free operationalization of guideline knowledge, although providing uniform optimal strategies to problem-focused care delivery, may generate inappropriate inferences for a specific patient that the physician does not follow in practice. Rather than providing automated decision support, ONCODOC allows the clinician to control the operationalization of guideline knowledge through his hypertextual reading of a knowledge base encoded as a decision tree. In this way, he has the opportunity to interpret the information provided in the context of his patient, therefore, controlling his categorization to the closest matching formal patient. Experimented in life-size ONCODOC demonstrated good appropriation of the system by physicians with significantly high scores of compliance. We successfully tested the implemented strategy and the knowledge base in a second medical institution, giving then a noticeable example of reuse and sharing of encoded guideline knowledge across institutions.

Artificial Intelligence↗

PubMedDate not supplied

Supporting tools for guideline development and dissemination.

This paper describes a methodology for representing clinical practice guidelines and facilitating their introduction into the medical routine. Since this methodology can be exploited in a www environment, it can represent the basis for sharing clinical guidelines both between different institutions and between human and software agents cooperating within a clinical context. In addition, the proposed guideline formalization is intended to deal with patient and organization preferences. This goal is achieved by augmenting the guideline with decision analytic models and by linking the guideline with an organizational model of the clinical setting. The designed framework allows guideline development, tailoring and implementation, real-time access to the guideline prescriptions and guideline validation.

Algorithms↗

PubMed1996

Cancer pain management: pilot implementation of the AHCPR guideline in Utah.

BACKGROUND: Using the Agency for Health Care Policy and Research's (AHCPR's) 1994 Clinical Practice Guideline for Management of Cancer Pain, HealthInsight, the peer review organization for Utah and Nevada, organized a cooperative project with physicians and nurses from seven acute care hospitals in Utah. The project's purpose was to adapt the guideline into action plans for participating hospitals and provide the tools necessary to address six "core" guidelines-to assess and relieve pain, educate the patient/family and health care workers, measure patient satisfaction, and provide a continuum of care postdischarge. GUIDELINE DEVELOPMENT: The guidelines were further adapted to meet the needs of the individual hospitals and were implemented in January 1995. Baseline data was collected on 10 patient records per hospital. RESULTS: Survey results confirmed that although attitudes about cancer pain management were changing, more needed to be done to prevent patient suffering. Follow-up data after one year showed significantly more compliance on all six core guidelines. CASE STUDY: The oncology nurse manager and the hematology/oncology physician chief at one hospital joined the project team to support their own ongoing efforts to implement the guidelines. At that hospital, patient satisfaction with pain management has since increased from the 60%-80% level to at least 90%. STATEWIDE PROJECT EXPANSION: Statewide expansion was planned in fall 1995 to extend implementation to the remaining acute care hospitals and to other health care settings in Utah and to ease a patient's transition from one setting to another. CONCLUSION: The project team continues to monitor progress in guideline implementation. Surveys demonstrate that, at the time of diagnosis, up to 45% of cancer patients experience moderate to severe pain; 65%-90% experience severe pain when cancer reaches the advanced stages. Unrelieved cancer pain can cause intense suffering, diminished activity, loss of appetite, and loss of sleep.

Attitude↗

PubMed1997

A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic.

BACKGROUND: Simple distribution of clinical practice guidelines to physicians does not change practice behavior. A low-cost, continuous peer review feedback method was used to promote resident physicians' compliance with nine preventive care guidelines at the ambulatory care clinic at the Marshall University School of Medicine (Huntington, West Virginia). METHODS: Preventive care guidelines were distributed and a peer review feedback program was instituted in the resident physician primary care practice. The frequency of resident physician use of nine preventive care services was assessed and compared during three periods: preguideline (September 1, 1993, to March 1, 1994; 148 patients), guideline (September 1, 1994, to March 1, 1995; 148 patients), and one-year follow-up (September 1, 1995, to March 1, 1996; 150 patients). The patients in the three periods were similar in age, gender, and risk for influenza and pneumococcal infection. RESULTS: During the guideline period, resident physicians offered patients four preventive care services-tetanus toxoid immunization, clinical breast examination, Papanicolaou smear testing, and hemoccult testing significantly more often than during the preguideline period. All services were offered significantly more often during the one-year follow-up period compared with the preguideline period and as often as in the guideline period. CONCLUSION: A low-cost, continuous peer review feedback program significantly and durably improves resident physician compliance with clinical practice guidelines on preventive care services. However, the effectiveness of the poor review feedback method may not generalize to private practice or other settings. Research on other methods to promote compliance with clinical practice guidelines and to influence physician behavior in general should continue.

Adolescent↗

PubMed1999

Issues in the development, dissemination, and effect of an evidence-based guideline for managing sore throat in adults.

BACKGROUND: In October 1995 the University of Michigan Healthcare System initiated a program to develop and implement guidelines for primary care in an effort to improve the quality and cost-effectiveness of care for common conditions associated with wide variations in clinical practice. One of these conditions was Group A beta-hemolytic streptococcus (GABHS), present in 5% to 20% of adults complaining of sore throat. METHODS: A draft guideline was developed on the basis of a theoretical model of sore throat management, local data, and research evidence. The guideline was revised to reflect physicians' beliefs and practices regarding sore throat management. Guideline recommendations depended only on the number of clinical signs experienced by the patient and included testing only if it was likely to provide additional information about the probability of GABHS. Data on pre- and postdissemination data on patients presenting with sore throat were collected. RESULTS: When physicians believed testing or antibiotics were unnecessary, only 7% of patients demanded screening and only 6% of patients wanted antibiotics. Physician beliefs about a patient's need for testing agreed with guideline recommendations in 63% of patients both before and after guideline dissemination. DISCUSSION: Disseminating locally modified, evidence-based guidelines may not be sufficient to produce practice changes. If the guideline had been followed, the amount of testing would have been reduced by 17% and the appropriateness of testing improved for 32% of sore throat patients. The results indicate the need for implementation efforts that go beyond presenting evidence, even when that evidence is from both the literature and the local practice setting.

Adult↗