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PubMed2005

Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury.

BACKGROUND/OBJECTIVES: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine METHODS: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention. RESULTS: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1. CONCLUSIONS: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.

Aged↗

PubMed1998

Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America.

This is part of the series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians in the diagnosis and treatment of community-acquired pneumonia. The targeted providers are internists and family practitioners. The targeted groups are immunocompetent adult patients. Criteria are specified for determining whether the inpatient or outpatient setting is appropriate for treatment. Differences from other guidelines written on this topic include use of laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel members and consultants are experts in adult infectious diseases. The guidelines are evidence based where possible. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations. The guidelines will be listed on the IDSA home page at http://www.idsociety.org.

Adult↗

PubMed1997

Quality standards for immunization. Guidelines from the Infectious Diseases Society of America.

This is the third in a series of guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. It is presented as a standard of care rather than a practice guideline because the case for following these recommendations is very strong and it should be followed with rare exceptions. The purpose of this guideline is to provide assistance to clinicians when making decisions on providing immunizations to healthy infants, children, and adults. The document is a summary of guidelines already developed by national organizations. The targeted providers are pediatricians, family practitioners, internists, and other physicians who provide immunizations. The IDSA provided the funding. Panel members represent experts in adult and pediatric infectious diseases. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations. Indicators for measuring compliance with the standards are included.

Adolescent↗

PubMed2005

Evidence-based vs. 'impressionist' medicine: how best to implement guidelines.

Implementing clinical practice guidelines improves outcomes. This has been shown by several large scale registries. However, in spite of this, guidelines are poorly implemented in clinical practice for a wide variety of reasons. We examine the reasons behind the low uptake of guidelines into routine medical practice. Many physicians are simply not aware that guidelines exist; or they do not believe in them; or they simply do not care to implement them. Economic and social factors may also influence uptake of guidelines. It is the role of professional societies to disseminate best scientific knowledge, and ensure optimum implementation of guidelines. This can be achieved through educational activities and CME credit. Close collaboration between the profession, health authorities, and maybe even the industry could improve uptake of clinical practice guidelines, and thereby improve patient outcome.

Coronary Disease↗

PubMed2006

The impact of guideline compliant medical therapy on clinical outcome in patients with stable angina: findings from the Euro Heart Survey of stable angina.

AIMS: The European Society of Cardiology published guidelines for the management of stable angina in 1997, with the objective of promoting an evidence-based approach to the condition. This study focuses on the impact of guideline compliant medical treatment on clinical outcome in patients with stable angina. METHODS AND RESULTS: The Euro Heart Survey of Stable Angina is a multicentre prospective observational study conducted between 2002 and 2003. Patients with a clinical diagnosis of stable angina by a cardiologist were enrolled and follow-up was conducted at 1 year. The primary outcome of interest was death or myocardial infarction (MI). The increasing intensity of guideline compliant medical therapy was quantified by means of a simple treatment score based on the use of guideline advocated therapies: antiplatelets, statins, and beta-blockers. A total of 3779 patients were included in the initial survey. Increasing intensity of guideline compliant therapy at initial assessment was associated with a reduction in death and MI during follow-up in patients with angina and confirmed coronary disease (HR 0.68; 95% CI 0.49-0.95 per unit increase in treatment score). All cardiovascular events were also significantly reduced in this subgroup (HR 0.82; 95% CI 0.69-0.97). The benefits of guideline compliant therapy were only observed in patients with objective evidence of coronary disease. CONCLUSION: Guideline compliant medical therapy improves clinical outcome in patients with stable angina and objective evidence of coronary disease.

Analysis of Variance↗

PubMed2000

Guidelines for evaluation.

Before implementing a guideline, reassurance is needed that the guideline is valid, reproducible and reliable. A method for assessing guideline validity has now been developed for general use. Guideline producers need to consider suitable strategies for implementing their guidelines. When designing and evaluating a guideline implementation strategy, three key questions need to be addressed: what are the most suitable intervention techniques; what are the desired effects of the guideline; and what will be the relevance of changes achieved? The time scale for the evaluation should also be determined carefully.

Evidence-Based Medicine↗

PubMed2000

Guidelines on the management of H.pylori in primary care: development of an implementation strategy.

BACKGROUND: Clinical guideline programmes as being developed in many European countries contribute to quality of care in general practice. The applicability of multicountry guidelines will depend on country-specific circumstances. Implementation programmes are required for optimal compliance with guidelines. OBJECTIVE: In order to achieve optimal follow-up of the European Society for Primary Care Gastroenterology (ESPCG) Helicobacter pylori guidelines in general practice, we analysed factors that might obstruct compliance at national level, and integrated this in implementation programmes. METHOD: Discussion groups in eight participating countries reviewed epidemiological characteristics and diagnostic and therapeutic resources that would hinder applicability. The groups also indicated potential constraints to optimal compliance and developed a national implementation programme. RESULTS: Helicobacter pylori infection rates and peptic ulcer incidence vary widely across Europe, as do the availability, access and reimbursement of diagnostic test facilities for H.pylori Minor adaptation of the ESPCG guidelines is required in some countries. Implementation programmes have been developed and partially carried out in all countries. CONCLUSION: A pan-European approach to H.pylori guideline development should result in a framework of best practice into which nationally specific details can be incorporated, thus guaranteeing optimal follow-up of the guidelines and true improvement of dyspepsia management in primary care.

Benchmarking↗

PubMed1999

Feasibility of a national cholesterol guideline in daily practice. A randomized controlled trial in 20 general practices.

OBJECTIVE: To evaluate the feasibility and implementation needs of a cholesterol guideline by assessing the effectiveness of simple dissemination as well as extensive implementation of this guideline on actual performance of general practitioners (GPs). DESIGN: Randomized controlled trial. SETTING AND SUBJECTS: Thirty-two Dutch GPs in 20 general practices, 3950 patient records. INTERVENTIONS: Guideline dissemination to all 32 GPs, and a 5-month programme for improvement in the intervention group. This programme was developed after barriers to working according to the guideline had been investigated, and consisted of group education, desktop supportive materials, feedback on performance, and face-to-face instruction on location. MAIN OUTCOME MEASURES: The outcome parameters were defined as quality of selective case finding and quality of diagnostic procedures, and were measured by chart audit. RESULTS: The quality of selective case finding, especially the targeting of cholesterol testing to those with positive cardiovascular risk profiles, did not improve following intervention. Performance of the procedure necessary to diagnose hypercholesterolaemia even deteriorated. The quantity of cholesterol testing increased in both groups, but this was probably explained by the increased availability of desktop cholesterol analysers. CONCLUSIONS: Neither simple dissemination nor an intensive programme for improvement had measurable impact on actual performance on working according to the cholesterol guideline. Both the validity and the opinion about feasibility of the guideline in daily practice deserve more attention during guideline development.

Family Practice↗

PubMed2002

Specialists' expectations regarding joint treatment guidelines for primary and secondary care.

OBJECTIVE: To identify factors that may hinder or facilitate specialists' use of joint treatment guidelines for primary and secondary care. DESIGN: Qualitative study using focus group discussions based on a topic guide with open-ended questions. MAIN OUTCOME MEASURES: Themes identified by two researchers that specify the specialists' views on the use and implementation of treatment guidelines in general, and transmural guidelines in particular. SETTING: Departments of Cardiology and Internal Medicine in three Dutch hospitals. STUDY PARTICIPANTS: Ten general internists, 11 cardiologists, and six gastroenterologists participating in seven group discussions. RESULTS: Specialists did not perceive the treatment guidelines as useful for their own field of expertise, but expected that joint guidelines might improve integration between primary and secondary care. Furthermore, the guidelines could be useful for areas outside their expertise, for specialists in training, and for general practitioners. Concerns were expressed regarding their content and development process. In addition, specialists feared negative consequences, such as loss of autonomy, extra administrative workload, and organizational and financial barriers such as loss of industry-sponsored research and conferences. CONCLUSION: Specialists are not very motivated to use the guidelines themselves. This is a major obstacle that should be addressed in an implementation programme. Furthermore, negative outcomes at the organizational and financial levels must be minimized or compensated for. A joint implementation programme seems worthwhile, making use of the advantage seen by specialists in making agreements with general practitioners.

Adult↗

PubMed2004

Effect of a clinical practice guideline on physician compliance.

OBJECTIVES: To evaluate the effect of a clinical practice guideline for cesarean section due to dystocia on physician compliance, pregnancy outcome, and cesarean delivery rates, and to identify factors associated with physician non-compliance. DESIGN: A cross-sectional study. SETTING: A university hospital, Southern Thailand. STUDY PARTICIPANTS: All 719 medical records of women undergoing a cesarean section due to dystocia (failure to progress; cephalopelvic disproportion) before and after implementation of the guideline, from 1 January 1998 to 31 December 2000. INTERVENTION: A clinical practice guideline for cesarean section due to dystocia was implemented on 1 June 1999. MAIN OUTCOME MEASURES: Physician compliance, pregnancy outcomes, and cesarean section rates. Multivariate logistic regression was used to identify factors associated with physician non-compliance. Independent variables consisted of maternal age, height, parity, type of service, and birthweight. RESULTS: Physician compliance with the guideline was 89.2%. Maternal complications were less in the period after implementation of the guideline. Fetal outcomes were not different between the two periods. The cesarean section rates due to dystocia decreased after implementation of the guideline, from 10.7% in 1999 to 8.6% in 2002. Private practice, maternal short stature, and birthweight > or = 3500 g were significant predictors of physician non-compliance. CONCLUSIONS: Physician compliance was high. A clinical practice guideline can reduce the cesarean section rates due to dystocia without increasing adverse outcomes. Physician non-compliance was more common in women with well known risk for cephalopelvic disproportion, and private practice.

Cesarean Section↗

PubMed2000

Local antibiotic guidelines for adult community-acquired pneumonia (CAP): a survey of UK hospital practice in 1999.

We investigated the guidelines in British hospitals for the management of adults admitted with community-acquired pneumonia (CAP). A questionnaire was sent to one consultant respiratory physician in each of the 263 hospitals in the British Thoracic Society (BTS) Directory of Training Posts and Services. Two hundred and thirteen (81%) responses were received: 178 (84%) had written CAP guidelines, of which 123 (69%) printed copies were received. For non-severe CAP a single antibiotic (74% of guidelines-most frequently amoxycillin or ampicillin) was the usual recommendation with the combination of a beta-lactam and a macrolide the second most frequent (24%). The latter combination was recommended for severe CAP in 81% of guidelines. Clostridium difficile-associated diarrhoea had influenced guideline recommendations, or was commented on as a concern, in 18% of responses. Written guidelines for antibiotic therapy in adults with CAP exist in most British hospitals and follow broadly the 1993 BTS guidelines, although combination therapy is used not infrequently for non-severe CAP.

Adult↗

PubMed2002

Clerkship directors' perceptions of the impact of HCFA documentation guidelines.

PURPOSE: Chart notes are used to support billing codes under the evaluation and management guidelines of the Health Care Financing Administration (HCFA), in addition to serving as a record of the visit. To better understand the effect of the HCFA documentation guidelines, the authors collected data on how the guidelines affect participation by university- and community-based faculty in clinical education programs. METHOD: In 2000, the authors sent six copies of their questionnaire to the associate deans of the 125 U.S. medical schools and requested they distribute them to all core clerkship directors. The questionnaire consisted of multiple-choice and short-answer questions regarding documentation of medical visits, participation of community-based faculty, understanding of HCFA documentation guidelines, and effects on education programs. RESULTS: The response rate was about 50%. Most of the 379 clerkship directors who responded (77%) stated they were aware the HCFA documentation guidelines include specifications regarding the role medical students can play and documentation of medical visits, and 64% indicated they were concerned the guidelines would affect their educational programs. Concerns included the loss of student independence and active participation in the patient care environment (37), time constraints and the changing balance between education and service (16), loss of faculty and decreased morale (11), and decreased quality of care for patients (7). CONCLUSION: Leaders of medical education must work to modify these guidelines to protect the quality of patients' care, while maximizing students' educational opportunity and participation.

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

PubMedDate not supplied

Control mechanisms for guideline implementation.

OBJECTIVES: One approach to reducing health care costs while ensuring high-quality patient care is the use of medical practice guidelines. This study focuses on mechanisms that facilitate the implementation of guidelines primarily intended to reduce cost without increasing patient risk, using a multiinstitutional case study of a single guideline. SUBJECTS AND METHODS: We conducted semistructured interviews with physicians and administrators involved with guideline implementation in 61 academic medical centers. The interviews included questions on both implementation methods and the final success of implementation at each center. RESULTS: We identified 5 factors likely to be of importance to the guideline implementation process: (1) the use of a written form to routinize the process; (2) the acquisition of informed consent; (3) the presence of an active department chair (or section chief) to serve as an opinion leader; (4) the use of individual-level monitoring; and (5) the granting of financial incentives. CONCLUSIONS: This study allowed the identification of four processes for guideline implementation. For hospitals contemplating implementation of guidelines aimed toward cost reduction or selective use of various agents for other purposes, a decision process to identify the control mechanism best suited to an individual institution is a crucial step toward success.

Cost Control↗

PubMed2005

Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomized controlled trial.

STUDY DESIGN: Cluster randomized controlled trial for a multifaceted implementation strategy. OBJECTIVES: To assess the effectiveness of tailored interventions (multifaceted implementation strategy) to implement the Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations. SUMMARY OF BACKGROUND DATA: Guidelines for the management of low back pain in primary care have been developed in various countries, but little is known about the optimal implementation strategy. A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners. METHODS: General practitioners were randomized to an intervention or a control group. The general practitioners in the intervention group (n = 21) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners, a 2-hour educational and clinical practice workshop; two scientific articles on low back pain management; the guideline for occupational physicians; a tool for patient education; and a tool for reaching agreement on low back care with physical, exercise, and manual therapists. The control group (n = 20) received no intervention. The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation. General practitioners completed registration forms of each individual consultation with regard to the main outcome measures: advice and information, referral to other health-care providers, and prescription of medication. RESULTS: Forty-one of the 67 randomized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain. The advice and explanation provided by the general practitioners, the prescription of paracetamol or nonsteroidal anti-inflammatory drugs, and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups. There were also no differences in overall referral rate. However, in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group. CONCLUSIONS: The multifaceted intervention strategy modestly improved implementation (for parts of the recommendations in) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management. The implementation strategy produced fewer referrals to therapists during follow-up consultations.

Adolescent↗

PubMed2005

Management of women with epilepsy: Are guidelines being followed? Results from case-note reviews and a patient questionnaire.

PURPOSE: Several international guidelines for the management of women with epilepsy (WWE) have been developed since 1989. We aimed to determine whether guidelines for the management of WWE are followed and whether active implementation of such guidelines makes a difference to clinical practice. METHODS: The study covered a 2-year period of "passive dissemination" of guidelines followed by a 2-year period of "active implementation." Documentation reflecting adherence to the guidelines was abstracted retrospectively from electronic medical records on 215 WWE aged 16-42 years. Data abstracted from case notes included counselling on contraception and pregnancy-related issues; follow-up during pregnancy; advice on supplementation of folic acid, calcium, and vitamin D; and serum folate measurements. A questionnaire assessing the knowledge of WWE issues was completed by 112 (71%) of 157 patients. RESULTS: Documentation that WWE issues had been addressed was found in approximately one third of medical case records with no measurable effect of active implementation. Only the follow-up during pregnancy seemed to have improved. Serum folate measurements in 51 women treated with enzyme-inducing antiepileptic drugs (AEDs) revealed folate deficiency in 11 (22%). Respondents to the questionnaire recalled having received information from their neurologists on the interaction between AEDs and oral contraceptives (46%), need to plan pregnancy (63%), and folic acid requirement (56%). CONCLUSIONS: Judged by a review of documentation in case notes, active implementation of guidelines had no measurable effect on clinical practice. However, the follow-up during pregnancy seemed to have improved. Patients' knowledge of WWE issues compared favorably with published studies. Better strategies are needed to secure successful implementation of guidelines.

Abnormalities, Drug-Induced↗

PubMed2005

NICE head injury guidelines: review of the legal mandate.

This paper, while reviewing the legal authority held by clinical guidelines, examines the NICE head injury guidelines with respect to the likely consequences of non-compliance. Conversely, the effect on medical practice of rigid adherence to guidelines is also explored. Debate about the appropriateness of NICE head injury guidelines has highlighted the extent to which existing practices will need to change if compliance is to be achieved. Although a degree of resistance remains, there is perhaps a sense of resignation that the management of patients with head injuries will follow nationally prescribed guidance, whether in its current form or following its review next June. There will undoubtedly be those who remain unconvinced of the validity of these guidelines. Despite this, a possible reason for compliance may arise from concerns about the consequences of non-conformity. With the aid of a fictional scenario, this article seeks to remind the reader of the legal authority held by guidelines, the likely consequences of non-compliance and the liability held by their authors should compliance result in an untoward outcome. Finally, consideration is given to the possible long term effects that the adoption of guidelines may have on the medical profession.

Craniocerebral Trauma↗

PubMed2005

A sampling of Canadian practice in managing nonvariceal upper gastrointestinal bleeding before recent guideline publication: is there room for improvement?

BACKGROUND: There are few recent published consensus guidelines regarding nonvariceal upper gastrointestinal bleeding. In 2003, the Canadian Association of Gastroenterology sponsored a set of 20 recommendations. AIM: To compare current Canadian clinical practice patterns with these most recent guidelines. METHODS: Data obtained from the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), complemented by a questionnaire sent out to the 18 participating RUGBE sites, were used to compare present practice with all 20 guidelines. RESULTS: Only three RUGBE sites had an explicit written protocol for nonvariceal upper gastrointestinal bleeding, and only 40% of the sites had support staff available after hours. The Blatchford prognostic scale was not used routinely, and only one site used the Rockall score for risk stratification. Most patients classified as low-risk according to the literature had endoscopy within 24 h and a median length of stay of two days compared with high-risk patients who underwent endoscopy approximately 4 h earlier, had a median length of stay of 4.3 days and displayed a higher mortality. Nineteen per cent of all patients had a routine second-look endoscopy. Proton pump inhibitors were frequently used in the acute setting. Thirteen per cent of all patients rebled and only 34% of these received a second endoscopy. One-half of all patients were tested for Helicobacter pylori while in hospital, mostly by histology, and one-third of those who tested positive received H pylori eradication during their hospitalization. CONCLUSION: Compared with recommendations put forward in the new guidelines, clinical practice before guideline publication was variable. The future level of guideline adherence and patient outcome data should be quantified and monitored as the guidelines are disseminated.

Canada↗

PubMed2005

The EPAGE internet guideline as a decision support tool for determining the appropriateness of colonoscopy.

BACKGROUND: Few studies have examined how physicians perceive guidelines, much less their perceptions of an Internet presentation of such guidelines. This study assessed physicians' acceptance ofan Internet-based guideline on the appropriateness of colonoscopy. METHODS: Gastroenterologists participating in an international observational study consulted an Internet-based guideline for consecutive patients referred for colonoscopy. The guideline was produced by the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE), using a validated method (RAND). Through the use of questionnaires, physicians were asked their opinions and perspectives of the guideline and website. RESULTS: There were 289 patients included in the study. The mean time for consulting the website was 1.8 min, and it was considered easy to use by 86% of physicians. The recommendations were easily located for 82% of patients and physicians agreed with the appropriateness in 86% of cases. According to the EPAGE criteria, colonoscopy was appropriate, uncertain, and inappropriate in 59, 28, and 13% of patients, respectively. CONCLUSIONS: The EPAGE guideline was considered acceptable and user-friendly and the use, usefulness and relevance of the website were considered acceptable. However, its actual use will depend on the removal of certain organizational and cultural obstacles.

Adolescent↗