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PubMed1996

The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations.

OBJECTIVES: This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times. METHODS: Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states. RESULTS: The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations. CONCLUSIONS: These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.

Awareness↗

PubMed1999

The rural health care workforce implications of practice guideline implementation.

BACKGROUND: Rural health care workforce forecasting has not included adjustments for predictable changes in practice patterns, such as the introduction of practice guidelines. PURPOSE: To estimate the impact of a practice guideline for a single health condition on the needs of a rural health professional workforce. METHODS: The current care of a cohort of rural Medicare recipients with diabetes mellitus was compared with the care recommended by a diabetes practice guideline. The additional tests and visits that were needed to comply with the guideline were translated into additional hours of physician services and total physician full-time equivalents. RESULTS: The implementation of a practice guideline for Medicare recipients with diabetes in rural Minnesota would require over 30,000 additional hours of primary care physician services and over 5,000 additional hours of eye care professionals' time per year. This additional need represents a 1.3% to 2.4% increase in the number of primary care physicians and a 1.0% to 6.6% increase in the number of eye-care clinicians in a state in which the rural medical provider to population ratios already meet some recommended workforce projections. CONCLUSIONS: The implementation of practice guidelines could result in an increased need for rural health care physicians or other providers. That increase, caused by guideline implementation, should be accounted for in future rural health care workforce predictions.

Aged↗

PubMedDate not supplied

Implementing nursing practice guidelines: a complex undertaking.

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.

Canada↗

PubMed2006

Guidelines for severe infections: are they useful?

PURPOSE OF REVIEW: The large variability in clinical practice plus the increasing awareness that certain processes of care are associated with improved medical outcomes has led to the development of clinical practice guidelines in serious infection. The evolution of guidelines and their impact on delivery of care in severe infection is reviewed. RECENT FINDINGS: Guidelines development has centered around community- and hospital-acquired pneumonia as well as sepsis. The Institute of Healthcare Improvement has emerged as an international leader in changing healthcare professional behavior to be consistent with clinical recommendations in infection-related morbidity. These educational programs are designed to increase awareness of guidelines recommendations and to optimize their implementation. Change bundles are selected sets of interventions or processes distilled from evidence-based practice guidelines that are likely to improve outcome. As new evidence is published, and as experts ponder how the guidelines should best be expressed in the bundles, the bundles will be adapted to optimize their utility. SUMMARY: The change bundle approach to performance improvement (guidelines-based) is the key to change in practice. The Surviving Sepsis Campaign/Institute of Healthcare Improvement sepsis change bundles are an excellent example of progress along these lines.

Anti-Infective Agents↗

PubMed1999

Knowledge and attitudes of Malaysian private medical practitioners toward guidelines-based medicine.

This paper describes a study of the knowledge and attitudes of a sample of private medical practitioners in Malaysia in relation to questions posed on guidelines-based medicine. The study was conducted through a postal questionnaire sent to a sample of 2,000 private practitioners. Placing the research in context, a description of Malaysia and its health-care system is provided. Issues surrounding guidelines-based medicine in the Malaysian context are discussed. An analysis of the sample population's personal and professional characteristics is presented. Key research findings include identifying a substantial knowledge deficit--less than half of the respondents claimed to understand "guidelines". A majority of doctors (64 per cent) think guidelines are useful. Only 29 per cent of respondents knew where to find guidelines, with 22 per cent claiming to have used guidelines. The paper concludes with a discussion of issues in the implementation of guidelines-based medicine in Malaysia based on the study's findings.

Attitude of Health Personnel↗

PubMed2003

Tumor response to chemotherapy: the validity and reproducibility of RECIST guidelines in NSCLC patients.

We investigated the validity and inter-criteria reproducibility between RECIST (Response Evaluation Criteria in Solid Tumors) guidelines and WHO (World Health Organization) criteria, considering the decrease in patient numbers resulting from inclusion of the minimum lesion size criterion introduced in RECIST guidelines. RECIST guidelines are based on unidimensional measurement and exclusion of small lesions from measurement. The aims of the study were to examine: (1) the effect of the minimum lesion size criterion, (2) the validity of unidimensional and bidimensional measurements, i.e., their relationship with tumor volume, (3) the inter-criteria reproducibility between current RECIST guidelines and previous WHO criteria. One hundred and twenty patients with non-small cell lung cancer (NSCLC) in clinical trials were evaluated. By applying the minimum lesion size criterion, six cases became ineligible without any influence on precision of tumor volume measurement. In the validity study, actual tumor volume was regarded as the gold standard. Although the unidimensional measurement had a lower correlation with tumor volume value than the bidimensional measurement, both the unidimensional measurement and bidimensional measurement correlated sufficiently well with tumor volume changes and the assessed tumor volume response. In the inter-criteria reproducibility study between RECIST guidelines and WHO criteria, the response rate assessed by RECIST guidelines (19.3%) was almost the same as that assessed by WHO criteria (20.0%). In conclusion, RECIST guidelines are adequate for evaluating tumor response to chemotherapy in terms of both validity in relation to tumor volume and inter-criteria reproducibility with the WHO criteria.

Adult↗

PubMed1997

Guidelines and cardiac anaesthetists. Not in my back yard.

Guidelines for cardiac anaesthesia could reduce irrational variation in practice and so improve cardiac surgical outcome. In October 1994, a postal survey was undertaken to determine the views and attitudes of consultant cardiac anaesthetists in the United Kingdom towards guidelines. One hundred and forty correctly completed questionnaires were returned (minimum response rate 64%). Eighty-nine per cent believed that guidelines were of value in medicine whilst only 21% wanted national guidelines for cardiac anaesthesia. Responses to other parts of the questionnaire showed that those against guidelines for cardiac anaesthesia were less positive towards their advantages and more negative to their disadvantages compared with those in their favour. The majority of cardiac anaesthetists, although believing them to be valuable in medicine, do not want guidelines for cardiac anaesthesia because they are concerned that guidelines would be inflexible and would neither reduce variation in, nor improve the quality of, cardiac anaesthesia.

Anesthesiology↗

PubMed2005

Analysis and overview of the guidelines for assessing fitness to drive for commercial and private vehicle drivers.

Guidelines on fitness to drive were released by AUSTROADS and the National Road Transport Commission in September 2003. No recognised legal medical authority was cited. There are three parts in the document: (i) background information, (ii) specific medical conditions and (iii) appendices of relevant documents and contacts. This paper analyses the relevance of the guidelines for physicians and notes that the disclaimer exonerates its authors from potential repercussions. Guidelines for both private and commercial drivers are combined in the document and the basis for such delineation is defined. A lack of universal Australian standards with no State indicating the driver's responsibility to report changes in health standards on the issued licences is confirmed by the guidelines. Not all States indemnify physicians for reporting contrary to patients' wishes, while South Australia and the Northern Territory mandate reporting those at risk. Much of the language is patronizing, expecting '... conciliatory and supportive ...' behaviour even with recalcitrant patients. No allowance is made for patients who may not fulfil the guidelines but whom the doctor may consider fit to drive. Ambiguity regarding responsibility to report, as identified in the background section, may leave the doctor vulnerable for not reporting a patient who subsequently may cause injury. Attempt is made to differentiate the role of the specialist from the family general practitioner (GP), advocating specialists for commercial drivers, although this is largely left to the discretion of the GP. There is an implied onus on doctors to report all patients with the conditions under review. Some diagnoses, such as syncope, are discussed in different sections with application of conflicting limitations. Inappropriate language, such as reference to a seizure being '... an isolated non-epileptiform event ...', or withdrawal of medications failing to be restricted to anti-epileptic medications confounds interpretation. Some sections, such as that on sleep and epilepsy, are effectively analysed, while illnesses such as dementia are considered superficially. The guidelines are an attempt to assess fitness to drive, but contain serious flaws and provide limited information upon which to base decisions. Ambiguous language complicates application of the guidelines and places the health care professional at risk, despite a disclaimer protecting its authors.

Australia↗

PubMed1993

An approach to the use of the DO IT Study Group guidelines for supporting the optimal implementation of information systems in diabetes care.

The usefulness of the 1992 DO IT Study Group guidelines for diabetes data information systems was assessed using two established diabetes databases designed for different purposes. The recommendations detailed in the guidelines, written in four separate but overlapping modules, were applied individually to each database in turn. Percentage compliance with the recommendation to collect the DIABCARE dataset was high, after discounting specialist areas. While on the whole the information systems complied with the guidelines within the purposes for which they were designed, areas highlighted as demanding further action in at least one of the two systems included password protection, data validation checks, screen design, and communication with those whose records were held on the systems. Application of the guidelines is already stimulating attention to some of these areas. Some of the guidelines proved rather vague in construction to be applied in any formal sense, while others (for example in relation to international accreditation of datasets) were not applicable to individual systems. The results suggest the importance of a structured approach to the design, development, and ongoing assessment of information systems in diabetes, but require the present guidelines to develop a more formal structure to be fully effective. The widespread adoption and further testing and refinement of these guidelines (both within and outside Europe) should promote the ultimate goal of improved diabetes care.

Communication↗

PubMed2006

Comparison of international and New Zealand guidelines for the care of pregnant women with diabetes.

OBJECTIVE: To compare international guidelines for the care of women with diabetes and pregnancy with reported current practice among New Zealand tertiary centres. RESEARCH DESIGN AND METHODS: A literature review of national and international guidelines for the care of women with diabetes in pregnancy was undertaken. Guideline activities were placed within nine facets of care, from preconception advice, through pregnancy from screening to follow-up. New Zealand tertiary centres guidelines were obtained and placed in the same framework. RESULTS: International guideline consensus was inconsistent across most facets of care. Those for the detection and diagnosis of gestational diabetes mellitus (GDM) were particularly discordant internationally, although intranational agreement has occurred. CONCLUSIONS: International guidelines for the care of women with diabetes in pregnancy remain fragmented. The development of one set of guidelines based on the consensus of international best practice could overcome many of the misconceptions associated with diabetes in pregnancy.

Consensus↗

PubMed1997

Clinical guidelines and self-assessment in dental education.

This paper describes an educational programme where clinical guidelines are used in dental education and assesses the value of these guidelines as perceived by undergraduate students. It presents a comparison of students' own assessments of their performance with those of their instructors, according to such guidelines. The educational programme at the Faculty of Odontology, Lund University, is described through 3 main principles: problem-based learning, adoption of a holistic attitude to patient care and the promotion of oral health. The dental curriculum occupies 5 years comprising 10 semesters. 41, 5th semester students (16 male and 25 female) participated in the study. Students were introduced to guidelines in group discussions at the beginning of the semester. At the completion of a patient's planned course of treatment, the outcome was formally assessed both by students and clinical instructors. Performance was scored in various categories as "excellent", "acceptable" or "unacceptable" according to the standards defined. A total of 1373 scores were made by both students and instructors. 88% cent of students used the guidelines often or almost always and found them useful. Overall, no students received an "unacceptable" score and 40% of students achieved a score of "excellent". Female students tended towards a higher score, but this was not significant. Instructors' and students' scores agreed in almost 90% of instances. Students under-scored their performance more frequently than they over-scored it. It appears that the use of clinical guidelines may encourage an increased awareness of the decision-making processes involved in clinical practice, but it must be acknowledged that these guidelines are complex both in derivation and application.

Curriculum↗

PubMed2004

Partnership working in the production of clinical guidelines.

This article describes a working partnership between the Cairns Clinical Librarian Service, Health Care Libraries, University of Oxford and the Emergency Department (ED) at the John Radcliffe Hospital, Oxford. This collaboration resulted in the establishment of a guideline development group in June 2002. The aim of the group is to produce a set of easily accessible, user-orientated, evidence-based guidelines for the use of clinicians in the Emergency Department, within a realistic timescale. The Cairns Clinical Librarian Project was built on previous models of clinical librarianship and incorporated an evaluation of previous programmes. The objective was to provide information to clinicians at the time and point of need. Consultation with the ED from the outset determined the approach adopted by the Cairns team. Clinical guidelines have been shown to improve clinical practice. Pending the introduction of nationally available protocols, we have begun to establish a collection of evidence-based guidelines using web-based architecture in conjunction with the Oxford Radcliffe Hospitals NHS Trust's IT department. A piece of diagnostic analysis was undertaken to ensure a coherent strategy was developed for the guideline project. An 'intermediate approach' was adopted, where existing valid guidelines were modified to fit local circumstances. We strove to be transparent at all times about all aspects of the guideline development process. Formative evaluation has shown how the application of evidence-based health care needs adequate resources and requires people with appropriate knowledge and skills. This article charts the progress of the project and highlights how the partnership between the clinical team and the Clinical Librarian has been deemed to be essential to the success of the project.

Cooperative Behavior↗

PubMed2004

Developing health website quality assessment guidelines for the voluntary sector: outcomes from the Judge Project.

BACKGROUND: This paper describes the Judge project, the aim of which was to explore the need for health website quality assessment guidelines for the voluntary sector. Such guidelines would enable health consumers to assess the quality of health sites and assist support groups to produce their own good quality sites. The project was a partnership between the Information Management Research Institute, School of Informatics, Northumbria University and Contact a Family. It was supported by the Health Foundation. METHODS: The views of health consumers and support group members and workers were obtained by focus groups (35 attendees) and questionnaires (55 responses). They were asked questions about quality issues and concerns about Internet health information and any help they needed with judging the quality of health websites. RESULTS: The results supported the need for guidelines. The guidelines were written to reflect the requirements of health consumers and support groups articulated from the focus group and questionnaire data. They were then disseminated via a website. CONCLUSIONS: There is a need to improve communication and information exchange between health consumers and professionals and official organizations; publicise support groups to patients and carers; set up local Webs of Trust, linking together voluntary and statutory organizations within a locality. Professionals and official organizations in the public sector should make information provision to patients and health consumers a priority. Information provision should be embedded in the clinical setting via guidelines, protocols and administrative structures. Professionals should be trained in the role of information and how to provide it in appropriate ways. Support groups should use the Judge guidelines to assist them in producing good quality websites. Support groups should promote the Judge guidelines to health consumers, to help them make their own quality judgement about health-information websites.

Community Participation↗

PubMed2006

2005 Japanese Society for Dialysis Therapy guidelines for vascular access construction and repair for chronic hemodialysis.

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, 'Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis'. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2-3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

Arteriovenous Shunt, Surgical↗

PubMed2004

The implications of NICE guidelines on the management of children presenting with head injury.

BACKGROUND: NICE guidelines for the management of head injury were published in June 2003. Their recommendations differ markedly from previous guidelines published by the Royal College of Surgeons (RCS). In place of skull radiography and admission, computed tomography (CT) is advocated. The impact of these guidelines on service provision in the UK is unknown. METHODS: Data on all clinical correlates of children presenting with any severity of head injury was collected in three hospitals in the northwest of England. The current skull radiograph (SXR), CT scan, and admission rates were determined. The rates of SXR, CT scan, and admission that should have occurred when following either the RCS or NICE guidelines were then determined. RESULTS: Data from 10 965 patients who attended three hospitals between February 2000 and August 2002 was studied. Twenty five per cent of patients received a SXR, 0.9% a CT scan, and 3.7% were admitted. Strict adherence to the RCS guidelines would have resulted in a 50% SXR rate, a 1.6% CT scan rate, and a 7.1% admission rate. Adherence to NICE guidelines would result in a 0.3% SXR rate, an 8.7% CT scan rate, and a 1.4% admission rate, although the CT rate would drop to 6.3% if vomiting three or more times in the under 12s was used instead of more than one vomit. CONCLUSIONS: The new NICE guidelines do not increase the workload caused by patients attending with head injury but they move their management from the observation ward to the radiology department.

Adolescent↗

PubMed1998

Implications of applying widely accepted cholesterol screening and management guidelines to a British adult population: cross sectional study of cardiovascular disease and risk factors.

OBJECTIVE: To compare the implications of four widely used cholesterol screening and treatment guidelines by applying them to a population in the United Kingdom. DESIGN: Guidelines were applied to population based data from a cross sectional study of cardiovascular disease and risk factors. SETTING: Newcastle upon Tyne, United Kingdom. SUBJECTS: General population sample (predominantly of European origin) of 322 men and 319 women aged 25-64 years. MAIN OUTCOME MEASURES: Proportions recommended for screening and treatment. METHODS: Criteria from the British Hyperlipidaemia Association, the British Drugs and Therapeutics Bulletin (which used the Sheffield table), the European Atherosclerosis Society, and the American national cholesterol education programme were applied to the population. RESULTS: Proportions recommended for treatment varied appreciably. Based on the British Drugs and Therapeutics Bulletin guidelines, treatment was recommended for 5.3% (95% confidence interval 2.9% to 7.7%) of men and 3.3% (1.5% to 5.3%) of women, while equivalent respective values were 4.6 (2.3 to 6.9) and 2.8 (1.0 to 4.6) for the British Hyperlipidaemia Association, 23% (18.4% to 27.6%) and 10.6% (7.3% to 14.0%) for the European Atherosclerosis Society, and 37.2% (31.9% to 42.5%) and 22.2% (17.6% to 26.8%) for the national cholesterol education programme. Only the British Hyperlipidaemia Association and Drugs and Therapeutics Bulletin guidelines recommend selective screening. Applying British Hyperlipidaemia Association guidelines, from 7.1% (4.3% to 9.9%) of men in level one to 56.7% (51.3% to 62.1%) of men in level three, and from 4.4% (2.1% to 6.7%) of women in level one to 54.4% (48.9% to 59.9%) of women in level three would have been recommended for cholesterol screening. Had the Drugs and Therapeutics Bulletin guidelines been applied, 22.2% (16.5% to 27.9%) of men and 12.2% (8. 6% to 15.8%) of women would have been screened. CONCLUSIONS: Without evidence based guidelines, there are problems of variation. A consistent approach needs to be developed and agreed across the United Kingdom.

Adult↗

PubMed2001

Use of systematic reviews in clinical practice guidelines: case study of smoking cessation.

OBJECTIVE: To examine the extent to which recommendations in the national guidelines for the cessation of smoking are based on evidence from systematic reviews of controlled trials. DESIGN: Retrospective analysis of recommendations for the national guidelines for the cessation of smoking. MATERIALS: National guidelines in clinical practice on smoking cessation published in English. MAIN OUTCOME MEASURES: The type of evidence (systematic review of controlled trials, individual trials, other studies, expert opinion) used to support each recommendation. We also assessed whether a Cochrane systematic review was available and could have been used in formulating the recommendation. RESULTS: Four national smoking cessation guidelines (from Canada, New Zealand, the United Kingdom, and the United States) covering 105 recommendations were identified. An explicit evidence base for 100%, 89%, 68%, and 98% of recommendations, respectively, was detected, of which 60%, 56%, 59%, and 47% were based on systematic reviews of controlled studies. Cochrane systematic reviews could have been used to develop between 39% and 73% of recommendations but were actually used in 0% to 36% of recommendations. The UK guidelines had the highest proportion of recommendations based on Cochrane systematic reviews. CONCLUSIONS: Use of systematic reviews in guidelines is a measure of the "payback" on investment in research synthesis. Systematic reviews commonly underpinned recommendations in guidelines on smoking cessation. The extent to which they were used varied by country and there was evidence of duplication of effort in some areas. Greater international collaboration in developing and maintaining an evidence base of systematic reviews can improve the efficiency of use of research resources.

Controlled Clinical Trials as Topic↗

PubMedDate not supplied

Domain-constrained generation of clinical condition sets to help test computer-based clinical guidelines.

The paper describes T/Gen, a prototype computer-based tool designed to help maintain the knowledge in a computer-based clinical practice guideline that provides patient-specific recommendations. T/Gen takes as input a set of clinical conditions to which a guideline must react, and allows the user to specify domain-specific constraints as to which combinations of conditions do not make sense or do not need to be exhaustively tested against one another. T/Gen automatically generates constrained sets of combinations of clinical conditions, each corresponding to a clinical case (or to several closely related clinical cases) that can be used to help test the computer-based guideline. The combinations can be used to test the guideline logic using T/Gen's built-in logic interpreter, or to generate a set of test cases for use in testing an operational guideline system. T/Gen has been developed and tested with five pilot guidelines, for two childhood immunization series, for influenza vaccination, for primary thyroid screening, and for embryo transplantation. The paper describes how T/Gen's approach is implemented for the five pilot guidelines, outlines the current status and future directions of the project, and discusses the design issues that arose in the course of carrying out the work.

Bacterial Capsules↗