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PubMedDate not supplied

Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage.

CONTEXT: Upper gastrointestinal tract hemorrhage (UGIH) is a common and potentially life-threatening disorder. Resource utilization can vary without adverse effect on patient outcome. Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes. OBJECTIVE: To validate prospectively the safety, acceptability, and impact of a clinical practice guideline defining the medically appropriate length of stay (LOS) for patients hospitalized with UGIH. DESIGN: Prospective, controlled time-series study with an alternate-month design. Outcome surveyors and patients were blinded to study group allocation. GUIDELINE: A retrospectively validated scoring system using 4 independent variables: hemodynamics, time from bleeding, comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk of adverse events. The quantitative risk for the low-risk subset was 0.6% (95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and 0% (95% CI, 0.0%-0.9%) for life-threatening complications from this retrospective evaluation. SETTING: A 1000-bed, not-for-profit, university-affiliated teaching hospital. PATIENTS: Consecutive adult patients hospitalized for acute UGIH. INTERVENTION: Concurrent feedback of guideline recommendation (same-day hospital discharge) to physicians caring for patients at low risk for complication. No risk information was provided during control months. RESULTS: Seventy percent (209/299) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital. Providing real-time quantitative risk information (intervention group only) was associated with an increase in guideline compliance from 30% to 70% (P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9 (1.3) days (mean reduction of 1.7 days per patient; P<.001). No differences in complications, patient health status, or patient satisfaction were found when measured 1 month after discharge. An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD. CONCLUSIONS: Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH. Further prospective validation in other settings is warranted.

Adult↗

PubMed1998

Guidelines for the nonpharmacologic management of migraine in clinical practice. Canadian Headache Society.

OBJECTIVE: To provide physicians and allied health care professionals with guidelines for the nonpharmacologic management of migraine in clinical practice. OPTIONS: The full range and quality of nonpharmacologic therapies available for the management of migraine. OUTCOMES: Improvement in the nonpharmacologic management of migraine. EVIDENCE AND VALUES: The creation of the guidelines followed a needs assessment by members of the Canadian Headache Society and included a statement of objectives; development of guidelines by multidisciplinary working groups using information from literature reviews and other resources; comparison of alternative clinical pathways and description of how published data were analysed; definition of the level of evidence for data in each case; evaluation and revision of the guidelines at a consensus conference held in Ottawa on Oct. 27-29, 1995; redrafting and insertion of tables showing key variables and data from various studies and tables of data with recommendations; and reassessment by all conference participants. BENEFITS, HARMS AND COSTS: Augmentation of the use of nonpharmacologic therapies for the acute and prophylactic management of migraine is likely to lead to substantial benefits in both human and economic terms. RECOMMENDATIONS: Both the avoidance of migraine trigger factors and the use of nonpharmacologic therapies have a part to play in overall migraine management. VALIDATION: The guidelines are based on consensus of Canadian experts in neurology, emergency medicine, psychiatry, psychology and family medicine, and consumers. Previous guidelines did not exist. Field testing of the guidelines is in progress.

Acupuncture Therapy↗

PubMedDate not supplied

Patterns of care study decision tree and management guidelines for esophageal cancer. American College of Radiology.

PURPOSE: The Patterns of Care Study (PCS) of the American College of Radiology periodically develops a decision tree and current management guidelines for major malignancies where radiation has an important role. The decision tree is a framework which depicts the division of patients into treatment groups. The treatment guidelines are useful in management and also serve as a starting point for quality assessment. For the first time, PCS decided to develop consensus management guidelines for esophageal cancer. MATERIALS AND METHODS: A consensus panel was convened to define the key issues and develop guidelines for esophageal cancer management. A modified Delphi process was used to achieve consensus. RESULTS: The consensus panel developed guidelines for the management of patients with adenocarcinoma or squamous cell carcinoma of the esophagus with a Karnofsky performance status of over 50. Patients with clinical stage I or II esophageal cancer can be treated with curative intent using either a primary surgical or primary chemoradiation approach. For patients with clinical stage III malignancy, where the most common approaches are palliative, surgical resection is generally not recommended and chemoradiation is the preferred treatment. CONCLUSION: The PCS has developed treatment guidelines for esophageal cancer based on consensus committee deliberations. These guidelines can be useful for those who manage esophageal cancer.

Adenocarcinoma↗

PubMedDate not supplied

Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine.

BACKGROUND: Primary care physician treatment practices affect the rate of hypertension control to the goal of 140/90 mm Hg. Awareness of and agreement with national hypertension management guidelines, and grounding in evidence-based medicine principles, may be important determinants of practice. METHODS: A 26-item mail questionnaire was sent to a national sample of 1200 primary care physicians. The questionnaire elicited (1) the blood pressure (BP) criteria physicians use to initiate and intensify hypertension treatment, (2) first-line drug treatment choices, (3) familiarity with the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) hypertension treatment guidelines, and (4) familiarity with research methods used to develop evidence-based medicine guidelines. The analysis focused on (1) determining the percentage of physicians who reported treatment practices consistent with JNC recommendations and (2) the relation between familiarity with JNC guidelines, evidence-based medicine methods, and reported treatment practices. RESULTS: The overall response rate was 34%, with no important differences in demographic or professional training variables between respondents and nonrespondents. For middle-aged patients with uncomplicated hypertension, 33% of physicians would not start drug therapy unless the diastolic BP was greater than 95 mm Hg, and 43% would not start unless the systolic BP was greater than 160 mm Hg. In patients without complications who were receiving drug treatment, 25% of physicians would not intensify therapy for a persistent diastolic BP of 94 mm Hg, and 33% would not intensify therapy for a systolic BP of 158 mm Hg. Physicians were generally less aggressive in older patients. Angiotensin-converting enzyme inhibitors were the most common first-line drug choice. Forty-one percent of physicians had not heard of or were not familiar with the JNC guidelines. In multiple logistic regression models, familiarity with the JNC guidelines was associated with lower treatment thresholds, and increased familiarity with research methods was associated with greater use of diuretics or beta-blockers as first-line agents. CONCLUSIONS: Many physicians have higher BP thresholds for the diagnosis and treatment of hypertension than the 140/90 mm Hg criterion recommended by the JNC. Therefore, further improvements in population hypertension control will require physician behavior change. Physician practice is associated with awareness of practice guidelines and familiarity with evidence-based medicine methods, but the precise nature and extent of this relation requires further study.

Adrenergic beta-Antagonists↗

PubMed2000

Variation of flow cytometric DNA measurement in 1,485 primary breast carcinomas according to guidelines for DNA histogram interpretation.

From 1990-1996, 1,485 previously untreated invasive breast carcinomas were sampled by a pathologist for flow cytometric DNA analysis. The aim of the present work was to study the variations of flow cytometric DNA ploidy and S-phase evaluation according to the conditions of DNA histogram interpretation. Results obtained with the American Consensus guidelines of 1993 and the François Baclesse Department of Pathology's own guidelines are presented. According to the percentage of events taken into account to identify a DNA aneuploid peak, the proportion of DNA diploid cases can change from 35-39%. For S-phase evaluation, although the two guidelines were quite different, the results of S-phase cutoff were identical. Whichever guidelines were used, there was a strong relationship between DNA ploidy and/or S-phase and classical clinicopathological factors (T, N, histological type, grade, receptor status, or lymphatic invasion), with the exception of age, whose correlation was discrepant with S phase according to the set of guidelines. Whichever guidelines were used, ploidy and S phase correlated strongly with survival (overall, metastasis-free, or recurrence-free). Hence we recommend the use of the American consensus guidelines, despite minor imperfections, because they are now well-known, allow a high yield in the ratio of assessable S phases, and permit standardization in the technical processing and reporting of S phases, thanks to the use of terciles.

Aneuploidy↗

PubMed2004

A review of clinical guidelines.

BACKGROUND: Clinical guidelines are increasingly used in patient management but few clinicians are familiar with their origin or appropriate application. METHODS: A Medline search using the terms 'clinical guidelines' and 'practice guidelines' was conducted. Additional references were sourced by manual searching from the bibliographies of articles located. RESULTS AND CONCLUSION: Clinical guidelines originated in the USA in the early 1980s, initially as a cost containment exercise. Significant improvements in the process and outcomes of care have been demonstrated following their introduction, although the extent of improvement varies considerably. The principles for the development of guidelines are well established but many published guidelines fall short of these basic quality criteria. Guidelines are only one aspect of improving quality and should be used within a wider framework of promoting clinical effectiveness. Understanding their limitations as well as their potential benefits should enable clinicians to have a clearer view of their place in everyday practice.

Evaluation Studies as Topic↗

PubMed1999

Antiplatelet therapy in the prevention of ischemic vascular events: literature review and evidence-based guidelines for drug selection.

BACKGROUND: New antiplatelet drugs are being developed and many clinical trials evaluating the benefits of antiplatelet drugs for the secondary prevention of ischemic events in patients with atherosclerotic vascular disease have been performed. HYPOTHESIS: An updated systematic review and evidence-based guidelines for the appropriate selection of antiplatelet drugs may be beneficial to physicians and healthcare organizations attempting to create or update current clinical practice guidelines or clinical pathways aimed at caring for these patients. METHODS: (1) A systematic review of the recent literature on the relative efficacy and safety of aspirin, ticlopidine, and clopidogrel was undertaken; (2) an evidence-based, expert panel approach using a modified Delphi technique to create explicit guidelines for prescribing antiplatelet therapy was instituted; and (3) the recommendations of an expert panel were summarized. RESULTS: Consensus guidelines were developed for the utilization of aspirin, ticlopidine, or clopidogrel for the prevention of ischemic events in patients with manifestations of atherosclerotic vascular disease (prior myocardial infarction, prior ischemic stroke, or established peripheral arterial disease) who are at increased risk for recurrent ischemic events. Based on efficacy and safety, clopidogrel was recommended as the drug of choice for patients with established peripheral arterial disease; aspirin or clopidogrel should be considered in patients with prior myocardial infarction (with clopidogrel favored for patients who have had a recurrent event while on aspirin or in whom aspirin is contraindicated); aspirin or clopidogrel should be considered as first-line treatment in patients with prior ischemic (nonhemorrhagic) stroke--however, clopidogrel is the favored drug in patients in whom other antiplatelet drugs are either contraindicated or who have had recurrent events while on therapy. CONCLUSIONS: Myocardial infarction, ischemic stroke, and peripheral arterial disease are all clinical manifestations of the same underlying disease process (atherosclerosis), with thrombus formation on the disrupted atherosclerotic plaque (atherothrombosis) being a common precipitating factor of ischemic events in patients suffering from these disorders. An evidence-based approach was used to develop a practice guideline, based on available published evidence, for the appropriate utilization of antiplatelet agents (aspirin, ticlopidine, or clopidogrel). These guidelines may be of use to multidisciplinary teams wishing to create or update clinical guidelines or clinical pathways which address the care of patients with atherosclerotic vascular disease. New antiplatelet agents such as clopidogrel may be more effective and associated with lower risk of selected adverse effects (such as gastrointestinal distress, gastrointestinal hemorrhage, and neutropenia) than those previously used to prevent thrombus formation in the setting of atherosclerotic arterial disease. Combination antiplatelet therapy is being evaluated as an option for those patients who experience recurrent events on a single antiplatelet agent.

Algorithms↗

PubMed1997

Implementation of EPA Revised Cancer Assessment Guidelines: Incorporation of Mechanistic and Pharmacokinetic Data.

A workshop entitled "Implementation of EPA Revised Cancer Assessment Guidelines: Incorporation of Mechanistic and Pharmacokinetic Data" was held in Anaheim, California, in 1996 at the 35th Annual Meeting of the Society of Toxicology (SOT). This workshop was jointly sponsored by the Carcinogenesis, Risk Assessment, and Veterinary Specialty Sections of the SOT. The thrust of the workshop was to discuss the scientific basis for the revisions to the EPA Guidelines for cancer assessment and EPA's plans for their implementation. This is the first revision to the original EPA guidelines which have been in use by EPA since 1986. The principal revisions are intended to provide a framework for an increased ability to incorporate biological data into the risk assessment process. Two cases were presented, for chloroform and triclioroethylene, that demonstrated the use of the revised guidelines for specific cancer risk assessments. Using these new guidelines, nonlinear margin of exposure analyses were proposed for these chemicals instead of the linearized multistage model previously used by the EPA as the default method. The workshop participants generally applauded the planned revisions to the EPA guidelines. For the most part, they considered that the revised guidelines represented a positive step which should allow for and encourage the use of biological information in the conduct of cancer risk assessments. Several participants cautioned however that the major problem with cancer risk assessments would continue to be the inadequacy of available data on which to conduct more scientific risk assessments.

Animals↗

PubMed2001

Methods of cognitive analysis to support the design and evaluation of biomedical systems: the case of clinical practice guidelines.

This article provides a theoretical and methodological framework for the use of cognitive analysis to support the representation of biomedical knowledge and the design of clinical systems, using clinical-practice guidelines (CPGs) as an example. We propose that propositional and semantic analyses, when used as part of the system-development process, can improve the validity, usability, and comprehension of the resulting biomedical applications. The framework we propose is based on a large body of research on the study of how people mentally represent information and subsequently use it for problem solving. This research encompasses many areas of psychology, but the more important ones are the study of memory and the study of comprehension. Of particular relevance is research devoted to investigating the comprehension and memory of language, expressed verbally or in text. In addition, research on how contextual variables affect performance is informative because these psychological processes are influenced by situational variables (e.g., setting, culture). One important factor limiting the acceptance and use of clinical-practice guidelines (CPGs) may be the mismatch between a guideline's recommended actions and the physician-user's mental models of what seems appropriate in a given case. Furthermore, CPGs can be semantically complex, often composed of elaborate collections of prescribed procedures with logical gaps or contradictions that can promote ambiguity and hence frustration on the part of those who attempt to use them. An improved understanding of the semantics and structure of CPGs may help to improve such matching, and ultimately the comprehensibility and usability of CPGs. Cognitive methods of analysis can help guideline designers and system builders throughout the development process, from the conceptual design of a computer-based system to its implementation phases. By studying how guideline creators and developers represent guidelines, both mentally and in text, and how end-users understand and make decisions with such guidelines, we can inform the development of technologies that seek to improve the match between the representations of experts and practitioners. We urge informaticians to recognize the potential relevance of cognitive analysis methods and to begin more extensive experimentation with the their use in biomedical informatics research.

Cognition↗

PubMed1994

How to structure clinical practice guidelines for continuous quality improvement?

The purpose of this study was to evaluate the relevance of available practice guidelines to clinical quality improvement programs. A sample of 19 guidelines was evaluated in four prominent primary care areas. Two research assistants independently coded the clinical conditions and recommended/not recommended procedures abstracted from the guidelines (Cohen's kappa .67 and .50, respectively). An average of 35.1 (+/- 25.8) medical conditions and 48.4 (+/- 41.5) clinical procedures were defined by the guidelines. Most conditions were defined by using ICD-9-CM, age/sex group, or therapy, but 29% of definitions included symptoms which are not coded routinely. CPT codes alone were unable to identify most procedures. AHCPR guidelines mentioned significantly more procedures (p < .001) and fewer symptoms (p < .001) per clinical condition than other guidelines. The difficulty of finding codes for conditions and procedures, the high rate of non-codable items, and the lack of recommended measures limit the applicability of published clinical practice guidelines to continuous quality improvement programs.

Age Factors↗

PubMed2006

Canadian guidelines for training in adult perioperative transesophageal echocardiography. Recommendations of the Cardiovascular Section of the Canadian Anesthesiologists' Society and the Canadian Society of Echocardiography.

PURPOSE: To establish Canadian guidelines for training in adult perioperative transesophageal echocardiography (TEE). METHODS: Guidelines were established by the Canadian Perioperative Echocardiography Group with the support of the cardiovascular section of the Canadian Anesthesiologists' Society (CAS) in conjunction with the Canadian Society of Echocardiography. Guidelines for training in echocardiography by the American Society of Echocardiography, the American College of Cardiology and the Society of Cardiovascular Anesthesiologists were reviewed, modified and expanded to produce the 2003 Quebec expert consensus for training in perioperative echocardiography. The Quebec expert consensus and the 2005 Guidelines for the provision of echocardiography in Canada formed the basis of the Canadian training guidelines in adult perioperative TEE. RESULTS: Basic, advanced and director levels of expertise were identified. The total number of echocardiographic examinations to achieve each level of expertise remains unchanged from the 2002 American Society of Echocardiography-Society of Cardiovascular Anesthesiologists guidelines. The increased proportion of examinations personally performed at basic and advanced levels, and the level of autonomy at the basic level suggested by the Quebec expert consensus are retained. These examinations can be performed in a perioperative setting and are not limited to intraoperative TEE. Training "on the job", the role of the perioperative transesophageal echocardiography examination, requirements for maintenance of competence, and duration of training are also discussed for each level of training. The components of a TEE report and comprehensive TEE examination are also outlined. CONCLUSION: The Canadian guidelines for training in adult perioperative TEE reflect the unique Canadian practice profile in perioperative TEE and address the training requirements to obtain expertise in this field.

Adult↗

PubMed2003

[Surgical pain management. A Germany-wide survey including the effect of clinical guidelines].

INTRODUCTION: Over the last few years, various studies have aimed at improving the diagnosis and therapy of perioperative and posttraumatic pain. METHODS: In an anonymous postal survey, 2,393 German surgical clinics were asked to describe several aspects of their clinical pain treatment. In order to assess the influence of interdisciplinary guidelines on surgical pain therapy, the results of this survey were compared to a survey from 1997. RESULTS: The response rate was 30.8% ( n=738). Pain was measured quantitatively in 11.4% ( n=80) of hospitals, a figure which is unchanged since 1997. In pain treatment,however, some changes were discernible: while 46.6% of all hospitals in 1997 used patient-controlled analgesia often or occasionally, this proportion has risen to 64.5%.Both, the national acute pain guidelines and the WHO chronic pain guidelines were well known (71.3% and 74.7%) and accepted (98.8% and 98.5%, respectively). Among those surgeons who knew the national guidelines,93.7% reported that they used them clinically. In 149 hospitals (20.2%), local guidelines have been developed either anew or from existing guidelines. CONCLUSIONS: Although clinical guidelines are widely used, pain therapy in surgical patients has improved only marginally.

Acute Disease↗

PubMed1998

Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care.

OBJECTIVE: To develop, implement and evaluate a practice guideline for stress ulcer prophylaxis. DESIGN: Before-after study. SETTING: Ten-bed Intensive Care Unit (ICU) and 4-bed Step-down Unit in a teaching hospital. PATIENTS AND PARTICIPANTS: Fifty patients admitted during 1 year before and 50 patients admitted 3-6 months after introduction of the guideline. INTERVENTION: Introduction of the practice guideline by dissemination of pocket cards, seminars and "academic detailing". MEASUREMENTS AND RESULTS: Appropriateness (defined as proportion of days in which the prophylaxis met the criteria in the guideline), incidence of gastrointestinal bleeding and of ventilator-associated pneumonia, length of stay in ICU and in hospital, ventilator days. ICU mortality and medication costs for stress ulcer prophylaxis. After the introduction of the guideline, appropriateness increased from 75.8% to 91.1%, and medication costs decreased from C $2.50/day to C $1.30/day. There were no differences in any clinical outcomes. Predictors of appropriate use or the withholding of prophylaxis were the introduction of the guideline, lack of an indication for prophylaxis and number of days studied. CONCLUSIONS: Introduction of this guideline was associated with an increase in appropriateness of prophylaxis and a decrease in medication costs.

Algorithms↗

PubMed2003

Tamoxifen: 28-day oral toxicity study in the rat based on the Enhanced OECD Test Guideline 407 to detect endocrine effects.

The main objective of this 28-day oral gavage toxicity study in the rat was to investigate which of the current and/or additional parameters of the OECD Test Guideline 407 would reliably and sensitively detect the endocrine-mediated effects of the nonsteroidal antiestrogen tamoxifen. In addition, as this study was performed using two subgroups of five animals of each sex run concurrently, it enabled an assessment of the intralaboratory reproducibility while also assessing the potential value of using ten animals of each sex per group instead of using the standard five animals of each sex per group stipulated by the current guideline. Tamoxifen was administered daily by gavage to groups of 7-week-old Wistar rats for at least 28 days at dose levels of 5, 30, or 200 microg/kg body weight. Additional parameters specified in the enhanced OECD Test Guideline 407 were spermatozoa enumeration and morphology of the cauda epididymis, hormonal analysis of the thyroid-stimulating hormone (TSH), triiodothyronine (T3) and thyroxine (T4) levels, monitoring of the estrous cycle during week 4 of treatment to ensure females were in diestrus on the day of terminal sacrifice, organ weight of ovary, uterus, thyroid gland, prostate gland (ventral and dorsolateral parts), seminal vesicles with coagulation glands and pituitary gland, and microscopic investigation of the pituitary gland, vagina, mammary gland, seminal vesicles with coagulating glands, epididymis, and prostate gland (ventral and dorsolateral parts). Overall, 200 microg/kg per day was considered to be the Maximum Tolerated Dose (MTD) in both sexes, resulting in a marked reduction of body weight gain, together with slight effects on clinical signs, hematology, plasma chemistry, and microscopic changes in some endocrine tissues. Five micrograms per kilogram per day represented the No Observed Adverse Effect Level (NOAEL) in males and the No Observed Effect Level (NOEL) in females. At the intermediate dose level (30 microg/kg per day), the current OECD Test Guideline 407 was appropriate to detect the specific endocrine-related changes induced by tamoxifen in females, based on the histopathology findings observed in the ovary and the uterus. The additional parameters which were found to be changed in females (thyroid hormone levels, ovary and uterus weights, and histopathology of vagina) provided supplementary information further confirming tamoxifen-mediated endocrine effects. In males, when data from the current Test Guideline 407 were considered at the intermediate dose level, specific endocrine effects were only indicated on the basis of the histopathology findings observed in the prostate gland. The additional parameters examined which were found to be changed (prostate gland and seminal vesicle weights, and histopathology of seminal vesicle and mammary gland) were necessary to confirm the specific tamoxifen-mediated endocrine effects. Hence, amongst the additional parameters contained in the enhanced OECD Test Guideline 407, organ weights and histopathological examination of endocrine-related organs were the most helpful in confirming the detection of tamoxifen-mediated endocrine effects. The reproducibility evaluation showed that a group size of five animals of each sex consistently allowed the detection of endocrine effects with the current Test Guideline in both sexes at the high dose level and in females at the intermediate dose level. Doubling the animal number from five to ten of each sex per dose level did not notably increase the sensitivity of detection of endocrine-mediated effects.

Administration, Oral↗

PubMed2004

Hemodynamically unstable pelvic fractures: recent care and new guidelines.

Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidence-based best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intra-abdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 +/- 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.

Adult↗

PubMed2005

[Use of the World Health Organization guidelines on cancer pain relief before referral to a specialized pain service].

In 1986 the World Health Organization (WHO) released guidelines for cancer pain relief. Since then, several controlled studies on effectiveness and practicability of these guidelines have been published. Various authors described inadequate use of these guidelines. We analysed, whether the pain medication of 160 cancer patients referred to the anesthesiological pain clinic at the university hospital of Vienna corresponded to the WHO guidelines or not. Adequacy of pain treatment was assessed using the pain management index (PMI). Multiple criteria were chosen to assess the conformity of the treatment with the guidelines. Furthermore we studied the effect of a strict use of the WHO guidelines in these patients. The average pain intensity of the referred patients was 75 mm (VAS). Negative PMI scores, indicating inadequate pain therapy, were found in 39 % of cases. A violation of the rules was found in 38% of the therapy schedules. Pain medication was then modified by switching to fixed time intervals, escalation of the steps of the WHO ladder, increasing the dosage or treating neuropathic pain with adjuvant drugs. Two weeks later the average pain score of the patients was reduced to 27 mm (VAS). At that time 72% of the patients quoted an adequate reduction of pain. Inadequate knowledge or disregard of the WHO guidelines for cancer pain relief are common and result in unnecessary and prolonged suffering in these patients.

Female↗

PubMed1993

Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders.

There are few available data on the effectiveness and safety of medical practice guidelines when used for patient care in the coronary and intermediate care units. The aim of this study was to examine the effect of educating physicians about practice guidelines to promote shorter lengths of stay for "low-risk" patients hospitalized with chest pain. Such guidelines were disseminated to physicians working in a health maintenance organization (HMO) by educational conferences, written memoranda, endorsement by opinion leaders, concurrent written feedback, and nursing-to-physician cues. A total of 208 patients were enrolled in the study. Following implementation of the practice guidelines, hospital lengths of stay were reduced from 2.51 +/- 2.1 to 1.96 +/- 1.3 days (22% reduction, p = 0.03) and intermediate care unit lengths of stay from 33.9 +/- 19 to 28.2 +/- 14 hours (17% reduction, p = 0.02) for patients with low-risk chest pain. The reduction in length of stay for patients with low-risk chest pain exceeded reductions in stay for patients hospitalized with cardiac conditions for which no guidelines were introduced. None of the patients treated according to guideline recommendations had unexpected "life-threatening" adverse events in the 2-week period after hospital discharge (95%, confidence interval 0%, 3%). This study supports the effectiveness and possible safety of practice guidelines to reduce lengths of stay for patients with low-risk chest pain.

Aged↗

PubMed2006

The influence of risk status on guideline adherence for patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: Practice guidelines for patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) recommend targeting evidence-based therapies for the highest-risk patients. We characterized guideline adherence for NSTE ACS by risk status. METHODS: We analyzed inhospital treatments and outcomes for 77760 patients with NSTE ACS (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE initiative from January 2001 to September 2003 at 457 US hospitals. Compliance with the American College of Cardiology/American Heart Association Class guideline recommendations for NSTE ACS was evaluated in subgroups of eligible patients without listed contraindications at increased risk for mortality and among risk categories designated by an adapted version of the PURSUIT risk model designed to predict inhospital mortality. RESULTS: Inhospital mortality was increased in patients with diabetes mellitus (5.8% vs 4.3%), renal insufficiency (10.0% vs 3.9%), signs of congestive heart failure on presentation (10.6% vs 3.1%), and age > or = 75 years (8.6% vs 2.7%), compared with patients without these features. Use of guideline-recommended acute medications, invasive cardiac procedures, and discharge medications and interventions was significantly lower in patients with these high-risk features. Patients designated as high-risk for inhospital mortality were less likely to be treated with guideline-recommended therapies compared with low-risk and moderate-risk patients. CONCLUSIONS: Patients with NSTE ACS with the highest risk of mortality are less likely to receive guideline-recommended therapies and interventions. These findings highlight the need to clarify guideline recommendations for high-risk patients and to develop novel quality improvement approaches that target undertreated subgroups of patients with NSTE ACS.

Acute Disease↗