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PubMed1999

Forum of the End-Stage Renal Disease Networks' role in implementing the National Kidney Foundation-Dialysis Outcomes Quality Initiative Clinical Practice Guidelines.

The development and release of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines marks an important step in the on-going process of improving the renal dialysis patient's outcomes. The Forum of End-Stage Renal Disease (ESRD) Networks' role in this process should be considered within the context of its mission and the ESRD Networks' Congressional mandate. In addition, facilitating the implementation of the NKF-DOQI Guidelines is one component of the Forum's current quality-related agenda. Environmental trends and current research indicate a variety of factors critical to the successful implementation of the NKF-DOQI Guidelines. The Forum's plan encompasses each of the following key elements: defining and evaluating the Guidelines and clinical performance measures (CPMs); prioritizing and locally disseminating NKF-DOQI Guidelines; converting NKF-DOQI Guidelines into CPMs; expanding the information infrastructure; and conducting quality activities and engaging local physicians. Keeping in mind the broader national agenda for quality improvement in the renal community, including continuing medical education programs focused on quality measurement and improvement tools and techniques, developing decision support tools and increasing on-line access to evidence-based reports and literature is important as well. Carrying out the Forum's plan for implementing the NKF-DOQI Guidelines, in collaboration with national nephrology professional and patient organizations, will facilitate Guideline adoption and use across the renal community.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2005

Compliance with guidelines is related to better local recurrence-free survival in ductal carcinoma in situ.

The aim was to study the effect of compliance with guidelines on local recurrence (LR)-free survival in patients treated for ductal carcinoma in situ (DCIS). From January 1992 to December 2003, 251 consecutive patients had been treated for DCIS in two hospitals in the North Netherlands. Every case in this two-hospital sample was reviewed in retrospect for its clinical and pathological parameters. It was determined whether treatment had been carried out according to clinical guidelines, and outcomes in follow-up were assessed. In addition, all patients treated for DCIS in this region (n=1389) were studied regarding clinical parameters, in order to determine whether the two-hospital sample was representative of the entire region. In the two-hospital sample, 31.4% (n=79) of the patients had not been treated according to the guidelines. Positive margins were associated with LR (hazard ratio (HR)=4.790, 95% confidence interval (CI) 1.696-13.531). Breast-conserving surgery and deviation from the guidelines were independent predictors of LR (HR=7.842, 95% CI 2.126-28.926; HR=2.778, 95% CI 0.982-6.781, respectively). Although the guidelines changed over time, time was not a significant factor in predicting LRs (HR=1.254, 95% CI 0.272-5.776 for time period 1992-1995 and HR=1.976, 95% CI 0.526-7.421 for time period 1996-1999). Clinical guidelines for the treatment of patients with DCIS have been developed and updated from existing literature and best evidence. Compliance with the guidelines was an independent predictor of disease-free survival. These findings support the application of guidelines in the treatment of DCIS.

Adult↗

PubMed2000

The development of a national guideline on the management of leg ulcers.

This paper describes the development of an evidence-linked clinical guideline for the management of uncomplicated venous leg ulcers. Guidelines are developed to provide recommendations for clinical practice which are based on summaries of good quality research evidence. The aim of the guideline discussed in this article is to direct primary health care practitioners to the most effective method of assessment and treatment of venous leg ulcers and to discourage practices that do not have convincing or sufficient evidence of effectiveness. The three most important steps to the development of a valid clinical guideline are: basing recommendations on the best available evidence; explicit linkage between guideline recommendations and quality of evidence; and the involvement of a multidisciplinary group. The steps are discussed in relation to the development of the guideline alongside an introductory presentation on the role guidelines can play in improving practice. Issues arising from guideline development such as valid ways of obtaining patient input and lack of evidence are also discussed.

Algorithms↗

PubMed2002

Implementation research for 'evidence-based' guideline development by dietitians: a pilot study to test an instrument.

AIM: To improve the quality of dietetic care, dietitians in the University Medical Center Utrecht (UMCU) are encouraged to develop and implement 'evidence-based' guidelines. The aim of this pilot study was to develop and test a questionnaire for implementation research to monitor the process of developing and implementing these guidelines. METHODS: A questionnaire was developed and distributed to 15 dietitians, who have started developing an 'evidence-based' guideline. The questionnaire measures determinants of dietitians' behaviour and the presence of conditions facilitating the development of a guideline. Cronbach's alpha with a cut-off point of 0.7 was used to analyse the internal consistence between the items related to behavioural determinants. A panel of professionals such as a member of staff from the UMCU, a communication expert and project-managers ensured the completeness of the questionnaire. RESULTS: The internal consistency was high (alpha > 0.7) between the items related to the determinants of behaviour. The questionnaire gives a structured overview of factors affecting positively or negatively the process of guideline development. Although dietitians have a positive behaviour towards guideline development, they perceived barriers related to the presence of conditions to develop a guideline. CONCLUSION: We concluded that the applied questionnaire is appropriate for implementation research and has given a structured overview of factors that influence the development of dietetic guidelines by dietitians in the UMCU.

Attitude of Health Personnel↗

PubMed1998

The regulation of drugs and medicines in horse racing in the United States. The Association of Racing Commissioners International Uniform Classification of Foreign Substances Guidelines.

The primary reason for developing the ARCI Uniform Classification of Foreign Substances was to give stewards and other racing regulators guidelines to assist them in understanding the relative performance effects and general offensiveness to the Rules of Racing of various drugs and medications. As such, these guidelines have been very useful in the world of racing regulation--officially or unofficially--because this classification system, for the first time, places a relative number on the inappropriateness of any one of more than 750 agents appearing in forensic samples taken from racing horses. The guidelines set up by this system established the first framework for dialogue among veterinary pharmacologists reviewing these drugs. Prior to development of the guidelines, pharmacologists had their own opinions about these agents and their effects on performance. The guidelines, however, established a framework for discussion, and there has been surprising unanimity about the classification of each of these agents. Not only does this classification system provide a useful basis for dialogue among experts, it is also useful for regulators, horsemen and other laymen, most of whom have little training or experience with drugs and their effects on horses. The system is easily understandable and communicates the relative possibility of any classified substance to affect the performance of a horse. Consequently, the system has made it possible for laymen to understand the degree of impropriety of all drugs and medicines with which they may have contact. Grouping a large number of drugs into specific classes has greatly facilitated discussion about regulations and penalties, and the classification system is related to proposed penalty guidelines which were developed in parallel. With regard to penalties for Class 1 agents, it is easy to assign and defend substantial penalties after examining the guideline statement describing the possible performance effects of this group of agents as well as the fact that they have no well recognized therapeutic role. Similarly, the relatively modest effects of class 4 and 5 agents, combined with the fact that these groups encompass a large number of well recognized therapeutic agents, helps in understanding the possible presence of trace levels of these agents in post-race samples. In summary, the ARCI Uniform Classification of Foreign Substances Guidelines condenses data on drugs and medications and places them into a simple five class system. This system has made it possible to confidently discuss the regulatory implications of the identification of any one of the approximately 750 classified substances potentially found in forensic samples from a performance horse. As such it facilitates both the development and implementation of more understandable and equitable regulatory processes.

Animals↗

PubMed2002

[Developing evidence based guidelines on cardiac rehabilitation - phase 1: a qualitative review].

BACKGROUND: Guidelines are a means to support effective clinical practice and can be used to implement evidence-based medicine in rehabilitative practice. In 1998 a study on cardiac rehabilitation, funded by Bundesversicherungsanstalt für Angestellte, BfA, concluded that the AHCPR's Guideline on Cardiac Rehabilitation published in 1995 could be used as a reference guideline for the rehabilitation of coronary patients. The AHCPR Guideline and other systematic reviews showed cardiac rehabilitation to be an effective means in coronary care. However, no detailed information is given with regard to the structural and processual details that are required for a multidimensional and comprehensive cardiac rehabilitation scheme. To define those central characteristics, therapeutic interventions that had been proven to be effective for cardiac rehabilitation were analysed. The information derived from these analyses will then be used to develop a more detailed evidence-based guideline. METHODS: The analysis was based on the research cited in the AHCPR Guideline. Additionally, a systematic search of the literature identified (randomised) controlled studies published after 1995 for the analysis. Using criteria that had been developed prior to our review, one third (n = 53) of the 159 studies identified were considered suitable for further analysis. Characteristics of the study design, the interventions and the outcomes reported were extracted on a standardised data sheet. In order to facilitate comparisons, studies were arranged according to main intervention and target groups. As it is not possible to present the results in their entirety, this publication focuses on the main aspects which illustrate the method applied. RESULTS: 32 of the 53 studies included dealt with patients after myocardial infarction (MI). In these 32 studies a total of 40 interventions (in 2,912 patients) were investigated. 28 of these interventions dealt with exercise training or exercise training combined with other physical training (i. e. strength training). 7 interventions dealt with counselling only, and 5 interventions had exercise training and counselling as integral parts. Exercise training starts mainly three to four weeks after MI, for 30 - 60 minutes three to 5 times a week. Usually, training intensity is set at 65 - 80 % of the maximum heart rate (or 70 % of the maximum oxygen consumption) reached in standardised exercise testing. All interventions lead to gains in exercise tolerance. Compared to untreated control groups the net benefit ranges from + 11 % to + 30 %. The higher the intensity of the training, the larger the net benefit. The majority of the studies on the effectiveness of exercise training after MI do not report outcomes like psychological well-being, return to work or modification of risk factors. DISCUSSION: Despite limitations in report quality and methodology in some of the studies included, a detailed analysis of the interventions investigated can be used to substantiate optimal cardiac rehabilitation. It is possible to quantify important characteristics of the main elements and to define lower and upper limits of treatment. While formulating these limits, it is intended to maintain compatibility with the BfA Classification of therapeutic measures in medical rehabilitation (KTL). As a next step the data from the KTL statistics will be used to assess the scope of German rehabilitative care to define areas which do not comply with the limits defined in the guideline. The results will be consented with experts from science and clinical practice in order to develop an evidence-based, empirically founded, practicable and acceptable guideline for cardiac rehabilitation.

Coronary Disease↗

PubMed2003

[Assessment and implementation of guidelines].

The importance of guidelines increases continuously on the political level whereas on the user level reservations and uncertainty persist. Consequently guidelines are not considered as they should be. Guidelines will develop their effectiveness only if they are firmly implemented in the delivery process. Acceptance problems spring from problems in development and from aspects of dissemination and implementation not sufficiently considered so far. Therefore a lot of countries have developed quality criteria for guidelines and programmes for quality promotion. To further the use of guidelines in the care process aspects of dissemination and implementation have to be recognized even in the development process. This has not been recognized sufficiently so far. Implementation of guidelines is a systematic approach which has to be connected seamlessly with other activities (e. g. quality management). The implementation process should be accompanied and evaluated so that a continuous adjustment is possible. Most of the existing guideline programmes do not consider this sufficiently. The following contribution gives a survey of results and introduces means and instruments for assessment and implementation of guidelines.

Forecasting↗

PubMed2005

[Guidelines and the psychology of medical decision making in the treatment of depressive disorders].

Guidelines aim at improving medical decision making. Guidelines try to influence medical behaviour in contrast to textbooks and reviews which want to improve medical knowledge. Scientific models of medical decision making such as the action theory and empirical data on the effects of guidelines suggest that guidelines will not always reach their goal but instead can even deteriorate medical quality. The problem of guidelines in medicine is discussed in reference to depressive disorders. The problems at stake are nevertheless valid for medicine as a whole. Therefore it must be tested in controlled clinical trials whether guideline exposed physicians have better results with their patients than guideline naive physicians. Only such guidelines should be called evidence based for which positive effects have been empirically demonstrated.

Clinical Trials as Topic↗

PubMed2001

Introduction of the new Centers for Disease Control and Prevention group B streptococcal prevention guideline at a large West Coast health maintenance organization.

OBJECTIVE: Our purpose was to assess the impact of new consensus guidelines issued by the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics to prevent perinatal group B streptococcal disease. STUDY DESIGN: We performed a descriptive analysis and a before-and-after analysis of implementation of the group B streptococcal disease prevention guidelines among singleton-birth pregnancies in 2 Group Health Cooperative hospitals from October 1, 1995, through December 31, 1997. We studied the speed and completeness of implementation and the effect on pregnancy care practices including intrapartum antibiotic use, test ordering, and maternal and neonatal health. RESULTS: Guideline implementation occurred rapidly. The proportion of term pregnancies screened according to the guideline increased markedly, and overall intrapartum antibiotic use more than doubled. Among group B streptococci-positive women, intrapartum antibiotic prophylaxis increased from 24% before to 74% after guideline implementation. Median duration of treatment before delivery increased from 1.8 to 4.3 hours. The rate of rash did not increase, and there were no cases of anaphylaxis or pseudomembranous colitis. The proportion of infants undergoing evaluation decreased after implementation of the neonatal guidelines; among infants of group B streptococci-negative women, test ordering dropped by almost 40%. CONCLUSIONS: Implementation of the new guidelines is feasible and can be accomplished rapidly. The guidelines were associated with increased maternal intrapartum antibiotic use, particularly among women at highest risk, and with a decrease in laboratory use for infants.

Adult↗

PubMed2000

Guidelines for perioperative cardiac evaluation from the American College of Cardiology/American Heart Association task force are effective for stratifying cardiac risk before aortic surgery.

PURPOSE: We assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) task force guidelines for perioperative cardiac evaluation could reliably stratify cardiac risk before aortic surgery. METHODS: We retrospectively applied the guidelines to a closed database, set up prospectively. The setting was a referral center in an institutional practice with hospitalized patients. The closed database included 133 patients who had a routine cardiac examination, which comprised an estimation of functional capacity and noninvasive testing, before aortic surgery. This cardiac evaluation led to the proposal of coronarography in 23 patients and to treating an underlying coronary artery disease in 21 patients (including three myocardial revascularizations). One patient died after myocardial revascularization, and two patients died of cardiac causes after aortic surgery. The algorithm of the ACC/AHA guidelines was applied independently by two investigators to each patient's file that was included in the existing database. The main outcome measure was a comparison between cardiac risk stratification with the ACC/AHA guidelines and the results of the routine cardiac evaluation. RESULTS: The ACC/AHA guidelines were successfully applied to all 133 files by the two investigators. After applying the algorithm, 73 patients were stratified as low cardiac risk, and 60 patients were stratified as high risk. The 21 patients who had undergone a preoperative coronary artery disease optimization were stratified as high risk by means of the ACC/AHA guidelines. The patients who died from cardiac causes were stratified as high risk by means of the ACC/AHA guidelines, whereas none of the patients stratified as low risk died during hospitalization. CONCLUSION: The ACC/AHA guidelines were effective in stratifying cardiac risk by using clinical predictors and an estimate of the physical capacity of the patient. Their use may allow a reduction in unnecessary noninvasive testing in patients stratified as being at low risk, while permitting the selection of all patients likely to benefit from preoperative coronary artery disease optimization.

Algorithms↗

PubMed2004

How well do Australian women comply with dietary guidelines?

OBJECTIVE: To investigate the proportion of middle-aged Australian women meeting national dietary recommendations and its variation according to selected sociodemographic and behavioural characteristics. DESIGN: This cross-sectional population-based study used a food-frequency questionnaire to investigate dietary patterns and compliance with 13 commonly promoted dietary guidelines among a cohort of middle-aged women participating in the Australian Longitudinal Study on Women's Health. SETTING: Nation-wide community-based survey. SUBJECTS: A total of 10,561 women aged 50-55 years at the time of the survey in 2001. RESULTS: Only about one-third of women complied with more than half of the guidelines, and only two women in the entire sample met all 13 guidelines examined. While guidelines for meat/fish/poultry/eggs/nuts/legumes and 'extra' foods (e.g. ice cream, chocolate, cakes, potatoes, pizza, hamburgers and wine) were met well, large percentages of women (68-88%) did not meet guidelines relating to the consumption of breads, cereal-based foods and dairy products, and intakes of total and saturated fat and iron. Women working in lower socio-economic status occupations, and women living alone or with people other than a partner and/or children, were at significantly increased risk of not meeting guidelines. CONCLUSIONS: The present results indicate that a large proportion of middle-aged Australian women are not meeting dietary guidelines. Without substantial changes in their diets, and help in making these changes, current national guidelines appear unachievable for many women.

Australia↗

PubMed2004

Evaluating occupational 60-hertz electric-field exposures for guideline compliance.

This article examines determination of compliance of 60-Hz electric-field exposures with occupational guideline limits. The guidelines are expressed as a limit on the unperturbed electric field without allowance for the severity of potential spark discharges. A line worker on a 500-kV transmission-line tower provided a practical example of an occupational exposure. In this realistic case, the worker's posture, the uniformity of the field, and the field orientation differed from the guideline exposure scenario of standing erect in a vertical uniform field. An accurate estimate of the unperturbed nonuniform fields in the climbing space of a lattice steel structure was computed using Monte Carlo methods that modeled surface and spatial electric fields on and near standard geometrical elements. Fields were computed at 20 points in a three-dimensional array, simulating the location of the human body on the tower. We estimated the average unperturbed electric field, space potential, induced short-circuit current, induced open-circuit voltage, and the stored charge and energy available for a discharge over a range of capacitances to ground. The on-tower exposure parameters were compared with those from the idealistic guideline exposure scenario. The average electric field of 24.4 kV/m for the on-tower exposure exceeded the limit of 20 kV/m stated in the recently adopted IEEE Standard C95.6 2002. However, the charge available for a spark discharge during the on-tower exposure was less than that for the guideline exposure scenario. Thus, for an exposure limit based on a constant-charge criterion for adverse reaction to spark discharges, guideline on-tower exposure would be below the limit established for the guideline exposure scenario. Evaluation of electric-field exposures in terms of the charge associated with spark discharges provides a means of comparing any electric-field exposure scenario with the ideal guideline scenario in terms of an effects-related physical quantity. This approach is consistent with the exposure limit/basic restriction methodology that employs a basic restriction on a physical quantity as the ultimate determinant of compliance.

Electric Power Supplies↗

PubMed2004

Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design study.

BACKGROUND: Studies investigating the impact of guideline implementation for inpatient management of community-acquired pneumonia (CAP) usually have methodological limitations. We present a controlled study that compared interventions before and after the implementation of a practice guideline. METHODS: Clinical and demographic characteristics, as well as process-of-care and outcome indicators, were recorded for all patients with CAP who were admitted to Galdakao Hospital (Galdakao, Spain) in the 19-month period after the implementation, on 1 March 2000, of a guideline for the treatment of CAP. These data were also recorded for all patients with CAP who were admitted to this hospital during the year before the guideline was implemented, as well as for randomly selected inpatients with CAP at 4 other hospitals during both periods (i.e., before and after guideline implementation) who were chosen as an external comparison group. Multivariate linear and logistic regression models were employed for adjustment. RESULTS: Guideline implementation resulted in shorter durations of antibiotic treatment (P<.001) and intravenous treatment (P<.001), better coverage of atypical pathogens (P<.001), and improved appropriateness of antibiotic treatment (P<.001), compared with the period before the guideline was implemented. The adjusted analyses revealed decreases in 30-day mortality (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.23-3.72) and in-hospital mortality (OR, 2.46; 95% CI, 1.37-4.41) and a 1.8-day reduction in the duration of hospital stay. In the control hospitals, there were small but statistically insignificant changes in these indicators for admitted patients. CONCLUSIONS: This study, which was performed with an adequate, controlled before-and-after intervention design, demonstrated significant improvements in both process-of-care and outcome indicators after implementation of a guideline for treating CAP.

Aged↗

PubMed2002

Role of JCAHO standards and clinical practice guidelines in promoting appropriate antimicrobial use.

The role of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards and clinical practice guidelines in promoting appropriate antimicrobial use and the development of such standards and guidelines are described. JCAHO is committed to continuously improve the safety and quality of patient care. Reducing antimicrobial resistance in health systems often requires change, something that many health care practitioners are reluctant to embrace. Current JCAHO standards suggest that the use of clinical practice guidelines be considered, but guideline use is not required. JCAHO's standards development process is lengthy and involved. Therefore, it is easier to effect change by modifying the statements of intent that accompany the standards than the standards themselves. Concerns about antimicrobial resistance can be addressed through performance measurement. In July 2002, core measures of patient care processes and outcomes will be implemented for the first time. JCAHO requires hospital laboratories to be accredited, which increases the stature of the laboratory in the eyes of hospital administration. JCAHO laboratory standards directly relate to clinical practice guidelines, antimicrobial resistance, and NCCLS (formerly known as the National Committee for Clinical Laboratory Standards) and support efforts to reduce inappropriate antimicrobial use. Hospital laboratories play a vital role in effecting change in antimicrobial use. JCAHO laboratory standards for clinical practice guidelines and quality control support efforts to reduce inappropriate antimicrobial use. Hospitals have been reluctant to require the use of clinical practice guidelines in JCAHO standards, although guidelines promote appropriate antimicrobial use and reduce antimicrobial resistance. Pharmacists should work with laboratory staff and JCAHO to effect the changes needed to stem antimicrobial resistance.

Anti-Infective Agents↗

PubMed1996

Local clinical guidelines: description and evaluation of a participative method for their development and implementation.

BACKGROUND: National guidelines are rarely followed by immediate change in clinical behaviour. We present our experience of an active educational method for local development and implementation of a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method for developing local clinical guidelines. METHODS: A trial in a district of the effect of guideline development incorporating active participation of intended recipients on subsequent relevant prescribing. It was carried out in Wirral Family Health Services Authority district (the Wirral peninsula) comprising 69 general practices covering a population of 345,763. An exemplar guideline on 'hypertension in the elderly' was developed by the method described. The principal recommended drug was bendrofluazide 2.5 mg once daily. The differences in prescribed daily doses (PDD) of bendrofluazide 2.5 mg tablets per quarter per 1000 prescribing units (age-weighted population) between the intervention district and England as a whole was measured. RESULTS: Comparison of the intervention district with England data demonstrates a median difference of 122.49 PDD before and 206.34 PDD after guideline production, this change is statistically highly significant (Mann-Whitney two-tailed P < 0.0001; 95% CI = 36.51-104.77). Grouped regression analysis shows no significant difference (0.89) in slope gradients before guideline production (P = 0.35, 95% CI = -3.97-5.76), but the difference in slope gradients after (12.95) is statistically highly significant (P < 0.0001; 95% CI = 8.17-17.73). The data suggests that the change in clinical behaviour persisted for at least two years. CONCLUSION: Participation of intended recipient general practitioners and local specialists in the development of a guideline by an active educational method as described was followed by a favourable change in clinical behaviour which persisted for at least two years.

Aged↗

PubMed2002

Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey.

BACKGROUND: Although primary care is the major target of coronary heart disease (CHD) clinical recommendations, little is known of how community physicians view guidelines and their implementation. The REACT survey was designed to assess the views, and perceived implementation, of CHD and lipid treatment guidelines among primary care physicians. METHODS: Semi-structured validated telephone interviews were conducted, in the relevant native tongue, with 754 randomly selected primary care physicians (GPs and family doctors) in five European countries (France, Germany, Italy, Sweden and the UK). RESULTS: Most physicians (89%) agreed with the content of current guidelines and reported use of them (81%). However, only 18% of physicians believed that guidelines were being implemented to a major extent. Key barriers to greater implementation of guidelines were seen as lack of time (38% of all physicians), prescription costs (30%), and patient compliance (17%). Suggestions for ways to improve implementation centred on more education, both for physicians themselves (29%) and patients (25%); promoting, publicizing or increasing guideline availability (23%); simplifying the guidelines (17%); and making them clearer (12%). Physicians perceived diabetes to be the most important risk factor for CHD, followed by hypertension and raised LDL-C. Most physicians (92%) believe their patients do associate high cholesterol levels with CHD. After establishing that a patient is 'at risk' of CHD, physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required. Factors preventing this included insufficient time (42%), having too many other patients to see (27%) and feeling that patients did not listen or understand anyway (21%). CONCLUSIONS: Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations. This need is recognized by clinicians.

Analysis of Variance↗

PubMed2003

The relationship between primary care physicians' adherence to guidelines for the treatment of diabetes and patient satisfaction: findings from a pilot study.

BACKGROUND: Adherence to clinical guidelines improves health care outcomes, reduces expenditure and prevents the complication of unnecessary interventions. It is uncertain what effect the adherence to guidelines for treating diabetes has on patient satisfaction. Some authors have reported that the use of guidelines does not affect patient satisfaction with care, and have concluded that satisfaction is related to a physician's interpersonal skills, rather than to the quality of care. Others have reported that structured intervention programmes improve patient satisfaction with care. OBJECTIVE: The purpose of our study was to explore the association between adherence to clinical guidelines and satisfaction with care among diabetics. METHODS: The study population included 135 randomly sampled diabetes patients listed with 12 primary care physicians at two health plans in Israel, which together insure >80% of the population. Telephone interviews were conducted with the patients between August and November 2000, using structured questionnaires. Patients were asked to report on the extent to which their primary care physician treated them as indicated by the clinical guidelines of these health plans. They were also asked to rate their satisfaction with their primary care physician and the treatment of their disease. Bi-variate analysis was conducted using the chi-square statistical significance test. Multivariate analysis was conducted using logistic regression models. RESULTS: Adherence to guidelines for diabetes was associated with patient satisfaction with care, independently of the patient's ethnicity (first language), age, gender, education, medication (insulin versus other) and health plan affiliation. CONCLUSION: Patients who report being treated as recommended in practice guidelines were more likely to be satisfied with their care. This finding may encourage primary care physicians to adhere to clinical practice guidelines.

Adult↗

PubMed2003

Validity and reliability of guidelines for neck pain treatment in primary health care. A nationwide empirical analysis in Spain.

OBJECTIVES: To assess the reliability and validity of existing clinical guidelines on neck-pain physiotherapy treatment and follow-up in Spain. DESIGN: We identified existing guidelines through a nationwide census and listed their recommendations, grouped according to the main steps of the process flow-chart. To assess reliability we analysed the variability of statements. To analyse validity we assessed the type of scientific evidence supporting the recommendations, and we compared them with a list of evidence-based recommendations that was elaborated for this study. SETTING AND PARTICIPANTS: Primary health care centres (n = 24) with guidelines for neck-pain treatment and follow-up. MAIN OUTCOME MEASURES: We quantified the number of recommendations, the proportion of valid statements, the frequencies of non-evidence-based recommendations, and the absence of the evidence-based recommendations we had identified. RESULTS: The 34 identified guidelines contained 325 recommendations, with great variation between guidelines with respect to the number, type (for up to 26 different clinical decisions), and content of the recommendations they provided. Direct assessment of the scientific evidence was not possible because no specific reference was given to support any recommendation. When compared with our list, only 20.9% of the recommendations could be considered evidence-based. No guideline contained all the eight evidence-based recommendations we identified. CONCLUSIONS: The results question the guidelines' reliability and validity, and their usefulness in ensuring quality. We conclude that guidelines should be reviewed and re-designed with greater scientific rigour.

Continuity of Patient Care↗