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PubMed2004

Classifying recommendations for clinical practice guidelines.

Clinical practice guidelines are intended to improve the quality of clinical care by reducing inappropriate variations, producing optimal outcomes for patients, minimizing harm, and promoting cost-effective practices. This statement proposes an explicit classification of recommendations for clinical practice guidelines of the American Academy of Pediatrics (AAP) to promote communication among guideline developers, implementers, and other users of guideline knowledge, to improve consistency, and to facilitate user understanding. The statement describes 3 sequential activities in developing evidence-based clinical practice guidelines and related policies: 1) determination of the aggregate evidence quality in support of a proposed recommendation; 2) evaluation of the anticipated balance between benefits and harms when the recommendation is carried out; and 3) designation of recommendation strength. An individual policy can be reported as a "strong recommendation," "recommendation," "option," or "no recommendation." Use of this classification is intended to improve consistency and increase the transparency of the guideline-development process, facilitate understanding of AAP clinical practice guidelines, and enhance both the utility and credibility of AAP clinical practice guidelines.

Evidence-Based Medicine↗

PubMed2006

Compliance with American Academy of Pediatrics and American Public Health Association illness exclusion guidelines for child care centers in Maryland: who follows them and when?

BACKGROUND: In 1992, the American Academy of Pediatrics and the American Public Health Association jointly published guidelines for temporary exclusion of sick children from child care. However, little is known about key stakeholders' compliance with these guidelines. OBJECTIVES: The purpose of this work was to compare pediatricians', parents', and child care providers' compliance with American Academy of Pediatrics guidelines and determine predictors for higher rates of compliance. METHODS: We conducted a cross-sectional survey of 215 randomly selected Maryland pediatricians, 223 parents, and 192 child care providers from 22 Baltimore, Maryland, child care centers from January to July 2004. Questionnaires contained the following 6 case vignettes depicting common child care illnesses: upper respiratory infection, conjunctivitis, gastroenteritis, mild febrile illness, tinea capitis, and atopic dermatitis. The instrument measured the correctness of exclusion and inclusion decisions (using American Academy of Pediatrics/American Public Health Association guidelines as gold standard) according to varying levels of fever, disease severity (eg, clear versus yellow eye discharge), familiarity with the child, and parent work schedule flexibility. RESULTS: Response rates were 71% for pediatricians, 56% for parents, and 85% for child care providers. Guideline compliance was higher for pediatricians (74%) than for child care providers (60%) and parents (61%). Only 23% of pediatricians and parents and 29% of child care providers reported familiarity with American Academy of Pediatrics/American Public Health Association guidelines by name. In general, child care providers and parents had lower false-negative rates (allowed fewer children to attend who met criteria for exclusion) than pediatricians, suggesting that pediatricians may underexclude. Child care providers and parents correctly excluded in 65%-98% of cases requiring exclusion, whereas pediatricians correctly excluded 31%-86% of cases requiring exclusion, depending on the vignette. Yet pediatricians were much more specific about which children met criteria (pediatricians correctly included 61%-93% of cases requiring inclusion versus child care providers and parents who correctly included 20%-75% of such cases), suggesting that child care providers and parents may overexclude. Compliance rates varied significantly by stakeholder, vignette (disease), level of fever, and disease severity but did not vary with the stakeholder's familiarity with the child or the flexibility of the parent's work schedule. CONCLUSIONS: Pediatricians, parents, and child care providers were unfamiliar with American Academy of Pediatrics/American Public Health Association illness exclusion guidelines by name but moderately compliant with them. When noncompliant, child care providers and parents generally overexcluded, and pediatricians underexcluded. Stakeholder- and disease-specific predictors for noncompliance gleaned from this study suggest how educational interventions aiming to increase guideline compliance could be individually tailored to child care providers, parents, and pediatricians.

Academies and Institutes↗

PubMed2007

Hospitals' compliance with prophylaxis guidelines for venous thromboembolism.

PURPOSE: A study was conducted to evaluate compliance with the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy guidelines for the prevention of venous thromboembolism (VTE) in hospitals. METHODS: Using the HealthFacts database, hospitalized patients, age 40 years or more, with medical conditions at risk for VTE (surgical, trauma, and acute spinal injury patients) were identified. Hospital admissions on or after January 1, 2001, and concluded by March 31, 2005, were included if they met any of the following conditions as defined in the ACCP Consensus Conference on Antithrombotic Therapy guidelines: patients at risk of VTE medical conditions, major orthopedic surgery, general surgery, gynecological surgery, urologic surgery, trauma, neurosurgery, and acute spinal cord injury. Hospitalizations were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The primary objective was to examine whether patients received one of the indicated anticoagulants at the proper dosage and during the relevant hospital days as determined in the ACCP guidelines. Rates of compliance were assessed, and the reasons for guideline noncompliance were also determined. RESULTS: The overall compliance rate with ACCP guidelines was 13.3% (ranging from 2.8% for neurosurgery to 52.4% for orthopedic surgery) in the 123,304 hospital admissions that were reviewed. Only 15.3% of patients with at-risk medical conditions received prophylaxis in accordance with ACCP guidelines. Potential reasons for guideline noncompliance among selected conditions included the omission of prophylaxis, inadequate prophylaxis duration, and the wrong type of anticoagulant. CONCLUSION: A retrospective study found low rates of compliance with guidelines for thromboprophylaxis.

Adult↗

PubMed2004

Public awareness about depression: the effectiveness of a patient guideline.

OBJECTIVE: To evaluate the effectiveness of a patient guideline for educating the public in the recognition and treatment of depression. METHOD: Lay subjects were interviewed regarding their knowledge and beliefs about depression through the use of a semi-structured questionnaire. They were asked to "think aloud" while evaluating two clinical scenarios about depression, both with and without the use of a patient guideline. All interviews were audio taped, transcribed, and analyzed for subjects' thought processes and accuracy of responses in the presence and absence of the guideline. RESULTS: Subjects with no prior history of depression identified fewer symptoms of depression listed in the patient guideline than did subjects with a history of depression. In the absence of the guideline, only 50% and 38% of subjects provided accurate diagnosis of depression for the simple and complex problems respectively. In the presence of the guideline, 92% and 83% of subjects provided an accurate diagnosis of depression for the simple and complex problems respectively. CONCLUSIONS: Lay people have a limited knowledge of depression and its treatment, and are less able to recognize symptoms of depression without the help of patient guideline. The guideline primes lay people to better recognize these symptoms and their relationship to diagnosis. This level of understanding about depression by lay people will facilitate improved communication between physicians and their patients.

Adult↗

PubMed2003

Practice guidelines: pedantic pontification or pragmatic progress? 2003 Ryley-Jeffs Memorial Lecture.

Development and use of practice guidelines is one strategy to assist health professionals in translating research into practice. There has been a significant growth in the number of practice guidelines developed, with the increased focus on justifying health care costs and demonstrating outcomes. Quality and influence on established practice, however, has sometimes been lacking. Recognizing both the importance of practice guidelines and some of the controversies surrounding their quality and use, Dietitians of Canada convened a task group to make recommendations on future development. They reviewed the practice guideline programs of others and identified the key elements needed to ensure any dietetics-produced guidelines would be credible, feasible and applicable to clinical counselling, administration and community health promotion. In this memorial lecture, the chair of that task group briefly reviews the history of dietetic practice guidelines, new innovations in systematic review and consensus development methods, and specifically the Delphi process used to develop a new Dietetic Practice Guidelines Framework. The 34 elements of the framework direct overall management of the guideline development process, including topic nomination, systematic literature review, group judgment, and pilot testing.

Canada↗

PubMed2000

History of the development of antiemetic guidelines at Mayo Clinic Rochester.

This article describes the historic experience of the development of antiemetic guidelines for patients taking chemotherapy drugs at Mayo Clinic Rochester. The initial guidelines for the use of serotonin (5-hydroxytryptamine3) receptor antagonists for the prevention of chemotherapy-induced nausea and vomiting were developed in early 1995 and implemented in September 1995. In February 1997, the guidelines were reviewed and modified. In the spring of 1998, major changes were made based on new data from the literature and discussions with antiemetic authorities in the United States. These guidelines were implemented in July 1998. The guidelines were again reviewed and modified in December 1998. In addition, we compared costs associated with the 1997 guidelines and the December 1998 guidelines. The developed guidelines, utilizing clinically available agents, seem to provide high-quality patient care at a reasonable cost.

Antiemetics↗

PubMed2002

Are internists in an non-prescriptive setting favourable to guidelines? A survey in a Department of Internal Medicine in Switzerland.

A cross-sectional anonymous postal survey was carried out in a Department of Internal Medicine in order to assess physicians' knowledge about and attitudes towards clinical practice guidelines and to evaluate the role of age in determining their use and opinions. The study took place in a Swiss University Hospital where exposure to guidelines had been limited. The questionnaire was sent to the 174 physicians of the Department. The response rate was 67% (116/174). The spontaneous definitions of guidelines were heterogeneous and referred to information of uncertain validity. Most participants, especially the younger groups of junior and senior residents, reported using guidelines and were favourable to their development. Less favourable attitudes were observed among senior staff physicians and consultants. For instance, the latter more often held the opinion that guidelines are too rigid to apply to individual patients, were likely to decrease physician reimbursement and to hamper research (respectively, 32% vs 24%, 50% vs 31% and 18% vs 7% when compared with the opinions of residents). In conclusion, in a non-prescriptive hospital setting, where the development, dissemination and implementation of guidelines are emerging, the concept of 'guideline' was heterogeneous. Despite generally positive attitudes towards guidelines, the opinion of senior staff physicians constitute a barrier to their dissemination and implementation.

Adult↗

PubMed2003

Impact of a chest-pain guideline on clinical decision-making.

OBJECTIVE: To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain. DESIGN: Before-and-after guideline implementation study. SETTING: Bankstown-Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001. PARTICIPANTS: Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation. MAIN OUTCOME MEASURES: Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months. RESULTS: After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%-20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%-31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%-30%) and senior doctors (11%; 95% CI, 2%-19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%). CONCLUSIONS: The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.

Angina Pectoris↗

PubMed1994

Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. An interventional trial.

OBJECTIVE: The acceptability, safety, and efficacy of practice guidelines have rarely been evaluated. Moreover, despite the recent development of guidelines and decision aids for patients admitted to coronary care and intermediate care units, few have been tested in clinical practice. DESIGN: A prospective, controlled clinical trial with an alternate-month design. SETTING: A large teaching community hospital. PATIENTS: Patients admitted to coronary care and intermediate care units with chest pain who were considered at low risk for complications according to a practice guideline (n = 375). INTERVENTION: Physicians caring for patients with chest pain who were at low risk for complications received concurrent, personalized written and verbal reminders regarding a guideline that recommended a 2-day hospital stay. RESULTS: Use of the practice guideline recommendation with concurrent reminders was associated with a 50% to 69% increase in guideline compliance (P < 0.001) and a decrease in length of stay from 3.54 +/- 4.1 to 2.63 +/- 3.0 days (0.91-day reduction, 95% CI, 0.18 to 1.63; P = 0.02) for all patients with chest pain considered at low risk for complications. The intervention was associated with a total (direct and indirect) cost reduction of $1397 per patient (CI, $176 to $2618; P = 0.03). No significant difference was found in the hospital complication rate between patients admitted to the hospital during control and intervention periods, and no significant difference was noted in complications, patient health status, or patient satisfaction when measured 1 month after hospital discharge. CONCLUSION: These results suggest that implementation of this practice guideline through concurrent reminders reduced hospital costs for patients with chest pain considered at low risk for complications. Further study of the guideline is warranted.

Aged↗

PubMed1999

Clinical practice guidelines: moving into the 21st century.

Clinical practice guidelines affect every aspect of healthcare. Practitioners, third-party payors, regulatory bodies, governments, and accrediting agencies increasingly use these guidelines, which are developed by a wide variety of organizations. The majority of guidelines are based on consensus and a nonsystematic literature review, but some, including those developed by the Agency for Health Care Policy and Research, are evidence based. Both types of guidelines have distinct advantages and limitations. Consensus-based guidelines are less time consuming to develop but may lack crucial information and result in a wide variety of outcomes; whereas, the type of evidence used to develop strength-of-evidence ratings for evidence-based guidelines may result in ambiguous recommendations and cause ethical concerns. Outcomes research on the use of guidelines and issues related to their timeliness need to be addressed. Studies that include a wide variety of outcome indicators and care variables and contributions of clinicians are needed to develop practice guidelines that are clinically useful and improve patient care.

Forecasting↗

PubMed1995

Practice guidelines and the emperor's new clothes.

Clinical guidelines are problematic because it is difficult to get people to follow them, effective mechanisms are usually not in place to determine guideline compliance, and the belief that guideline compliance is associated with higher clinical quality or lower cost is usually based on faith rather than data. These issues can be addressed by combining practice guidelines with outcome research and clinical information system technology which can result in a method to track adherence to and variance from guidelines; determine the effectiveness of guidelines in improving quality and decreasing costs; and create a dynamic system for guidelines development and differentiation based on empirical results related to which guidelines and variations are most effective for different types of patients.

Cost Control↗

PubMed1995

Practice guidelines and healthcare telematics: towards an alliance.

This chapter reviews the motives behind the promotion, development and application of practice guidelines, defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. It surveys the state of progress and future prospects for telematics applications in this area, and reports the action points recommended by the 1994 AIM Conference. There exists significant evidence that use of guidelines can improve healthcare process and outcome, and that computerised aids assist this effect, they may also enhance the potential uses of guidelines and protocols for audit, resource management and shared care. A standard generic model for computerised representation of guidelines as knowledge bases in a common format has been proposed and may be a key factor in future progress. The development of computerised patient records of adequate scope and quality is generally recognised as an essential condition for computer-aided guideline use. Support for development, dissemination and application of healthcare guidelines and use has emerged, notably through the AIM EPISTOL study, as a feasible and useful application area of medical knowledge-based systems. It is essential that telematics developments in this field are grounded in an understanding of the healthcare practices to which guidelines are being applied, and of the changes in practice which guideline use may entail.

Artificial Intelligence↗

PubMed1997

Standards of performance for new stationary sources and emission guidelines for existing sources: hospital/medical/infectious waste incinerators--EPA. Final rule.

This action promulgates new source performance standards (NSPS or standards) and emission guidelines (EG or guidelines) to reduce air emissions from hospital/medical/infectious waste incinerator(s) (HMIWI) by adding subpart Ec, standards of performance for new HMIWI, and subpart Ce, emission guidelines for existing HMIWI, to 40 CFR part 60. The standards and guidelines implement sections 111 and 129 of the Clean Air Act (CAA) as amended in 1990. The standards and guidelines apply to units whose primary purpose is the combustion of hospital waste and/or medical/infectious waste. Sources are required to achieve emission levels reflecting the maximum degree of reduction in emissions of air pollutants that the Administrator has determined is achievable, taking into consideration the cost of achieving such emission reduction, any nonair-quality health and environmental impacts, and energy requirements. The promulgated standards and guidelines establish emission limits for particulate matter (PM), opacity, sulfur dioxide (SO2), hydrogen chloride (HCl), oxides of nitrogen (NOx), carbon monoxide (CO), lead (Pb), cadmium (Cd), mercury (Hg), dioxins and dibenzofurans (dioxins/ furans), and fugitive ash emissions. Some of the pollutants being regulated are considered to be carcinogens and at sufficient concentrations can cause toxic effects following exposure. The standards and guidelines also establish requirements for HMIWI operator training/qualification, waste management plans, and testing/monitoring of pollutants and operating parameters. Additionally, the guidelines for existing HMIWI contain equipment inspection requirements and the standards for new HMIWI include sitting requirements.

Air Pollutants↗

PubMed1999

[Practice guidelines in western countries].

The concept of clinical practice guidelines was established in the 1960's to reduce medical costs that had been increasing dramatically in the US. To reduce medical expenses without lowering the quality of medical care, thorough control of medical practices was undertaken by rationalization of these practices. Guidelines were started initially for social and economical reasons, but were eventually accepted widely by society for several reasons. First, the concept of patients' autonomy was widely accepted after 1970, which supported full disclosure of information to patients. Second, there was too much information, necessitating ranking by scientific certainty. Third, the risk of litigation for doctors in the USA increased dramatically during these years. Whether a medical practice follows the guidelines or not has become one of the most important issues in medical lawsuits. Fourth, there is a constant demand for the effective use of social resources. Methods for developing clinical practice guidelines are already established in many societies. The first step is an intensive review of relevant articles to generate evidence-based recommendations (EBR). Then, to formulate practice guidelines, these EBR are ratified and modified by clinicians to whom they apply. They are then reviewed by independent experts. After final adjustment of the EBR or guidelines for administrative reasons, they are adopted with a future expiry date. Practice guidelines are not actually adopted in European countries. However, the concept of guidelines is well appreciated and medical practice is based on scientific evidence. In socialistic European countries like Sweden, Denmark or the Netherlands, there is huge pressure to control limited social resources, leading to aggressive efforts to reduce unexplained and inappropriate variations in medical practice.

Evidence-Based Medicine↗

PubMed1999

Impact of different blood lipid evaluation and treatment guidelines on the proportion of Canadians identified and treated for elevated blood cholesterol. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To report on the impact of different blood lipid evaluation and treatment guidelines on the proportion of Canadians identified and treated for high blood cholesterol. DESIGN, SETTING AND PARTICIPANTS: The Canadian Heart Health Surveys were carried out in Canada between 1986 and 1991. The data used in this study were from cross-sectional probability samples of adults aged 18 to 74 years, gathered in four provincial health surveys (Quebec, Alberta, Manitoba and Ontario) between 1989 and 1992, which obtained information on family history of heart disease. Data reported are for 7238 subjects fasting 8 h or more and providing a blood sample. All blood lipid analysis were done at the J Alick Little Lipid Research Laboratory, University of Toronto, which is standardized according to the National Heart, Lung, and Blood Institute, Centers for Disease Control (Atlanta) Lipid Standardization Program. OUTCOME MEASURES: With respect to the four guidelines examined--the Canadian Consensus Conference on Cholesterol (CCCC), 1987; the Toronto Working Group on Cholesterol Policy (TWG), 1990; the Canadian Task Force on the Periodic Health Examination (PHE), 1993; and the National Cholesterol Education Program (NCEP), 1993, in the United States--a comparison of the proportion of individuals in the population for whom a lipid profile was constructed, and who were prescribed a diet and drug therapy under different assumptions of success with dietary therapy for each guideline. MAIN RESULTS: Major differences were observed in the impact of the various guidelines with respect to the percentage of subjects who were tested, provided with a lipid profile, and eligible for diet and/or drug therapy. In general the percentages in each group were higher for the CCCC and the NCEP guidelines than for the PHE and TWG guidelines. CONCLUSION: The divergent results obtained from the application of the various guidelines are cause for concern and explain in part the confusion that surrounds the topic of blood cholesterol in public health and clinical contexts. Public health policy in the area of cardiovascular disease prevention would benefit from explicit consideration of various types of criteria for formulation of identification and treatment guidelines.

Adolescent↗

PubMed1999

A flexible approach to guideline modeling.

We describe a task-oriented approach to guideline modeling that we have been developing in the EON project. We argue that guidelines seek to change behaviors by making statements involving some or all of the following tasks: (1) setting of goals or constraints, (2) making decisions among alternatives, (3) sequencing and synchronization of actions, and (4) interpreting data. Statements about these tasks make assumptions about models of time and of data abstractions, and about degree of uncertainty, points of view, and exception handling. Because of this variability in guideline tasks and assumptions, monolithic models cannot be custom tailored to the requirements of different classes of guidelines. Instead, we have created a core model that defines a set of basic concepts and relations and that uses different submodels to account for differing knowledge requirements. We describe the conceptualization of the guideline domain that underlies our approach, discuss components of the core model and possible submodels, and give three examples of specialized guideline models to illustrate how task-specific guideline models can be specialized and assembled to better match modeling requirements of different guidelines.

Asthma↗

PubMed2000

[Practice guidelines--legal aspects].

Medical guidelines of professional institutions establish rules for good medical treatment (quality of care). They take the form of international, national, regional and local guidelines and are set up by international and national medical organisations, mainly by medical societies but also by regional (e.g. medical associations in the states) and local institutions (up to hospital departments). The rules of good medical treatment (guidelines) conform to the corresponding medical standard which is defined by scientific knowledge (evidence based medicine), practical experience and professional acceptance. The binding character of the standard for medical practice increases with the reliability of scientific evidence and practical experience. Insofar, medical guidelines which correspond to the standard fulfil a quality assurance function for medical treatment as a means of communication in the medical profession, an implementation function for the enforcement of standards and thus also a protective function for patients. Furthermore, they rationalize decisions of the courts by increasing the transparency of their medical basis and thus also contribute to the quality improvement of legal decisions on medical malpractice. Medical guidelines can also influence social law directives. On principle. Medical guidelines do not include any economic considerations (efficiency) and should be strictly separated from these (principle of separation and transparency). Medical guidelines have to be differentiated from health insurance law directives and recommendations. In addition to the quality assurance function, the function of guaranteeing the efficiency of treatment is a priority for health insurances. These objectives may be in conflict with each other. This paper is mainly concerned with the significance of medical guidelines for medical malpractice law.

Germany↗

PubMed2000

[Guidelines in clinical practice. Legal considerations].

The paper analyses the role and implications of the application of these guidelines from a legal point of view. After an introduction based on the legal concepts of the causal nexus and guilt in jurisdiction, the authors highlight the main arcas of influence that these guidelines can have on evaluations of a torensic nature. In jurisdictional terms, the first step in the evaluation of medical conduct is to reconstruct the causal nexus between the doctor's conduct (active or omissive) and the injury/death in question. The identification of the causal nexus is based on the application of the laws of probability according to which it is possible to affirm, with a reasonable margin of logical and rational plausibility, that a given conduct is the causal condition of a particular harmful event. With this in mind, the guidelines assume the role of law of probability in the sense that their adoption, depending on an evaluation of the probabilistic regularity of the causal series, would have prevented the occurrence of the injury/death that is the object of the legal inquiry. Another essential step in the jurisdictional process, is the evaluation of guilt. Bearing in mind that the evaluation of guilt is by definition linked not to the actual doctor in question, but to an abstract model of a doctor and namely the knowledge and skills that a doctor is expected to possess, it can be seen that the adoption of these guidelines may facilitate this evaluation. The application of the guidelines would represent compliance with the ordinary conditions of knowledge and skill expected of a doctor to which should be logically added the need for an adequate motivation for any deviation from the indications expressed in the guidelines. In conclusion, the main influences of these guidelines for the doctor-patient relationship are evaluated, together with the role that these guidelines may play in terms of patient information and the informed consent given by the latter.

Guidelines as Topic↗