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PubMed2004

Lessons learned in implementing SCI clinical practice guidelines.

While clinical practice guidelines (CPGs) were designed as a tool to improve patient outcomes, decrease practice variation, and optimize resource utilization, providers often encounter significant barriers to integrating these into clinical practice. A study was conducted at six spinal cord injury (SCI) centers in the Department of Veterans Affairs (VA) to improve provider adherence and patient outcomes of two CPGs: Prevention of Thromboembolism in Spinal Cord Injury and Neurogenic Bowel Management in Adults With Spinal Cord Injury. To design effective implementation strategies, focus groups were conducted to identify provider-perceived barriers and facilitators to implementing recommendations for each of the SCI guidelines. Based on this information, four guideline implementation strategies were designed: (a) use of local opinion leaders ("clinical champions"), (b) patient-mediated interventions, (c) standardized documentation template/standing orders, and (d) social marketing/outreach visits. These strategies were implemented at each site. This article identifies "lessons learned" during the process of trying to get these CPGs embedded into clinical practice.

Attitude of Health Personnel↗
PubMed1997

Legal and policy considerations in using clinical practice guidelines.

The increased use of clinical practice guidelines has implications for both public policy and for litigation. Physicians are concerned that the introduction of practice guidelines will reduce their clinical decision-making authority and that the failure to follow clinical practice guidelines will lead to medical liability. Although practice guidelines are an increasing part of medical practice, there has been only limited litigation to determine the extent to which guidelines will be used to set the applicable standard of care. This article discusses the potential legal and public policy issues raised by the introduction and use of clinical practice guidelines. From a legal perspective, the primary issue is whether guidelines will be used to set the "standard of care" or will be one piece of evidence that a jury would use to determine the outcome of medical liability litigation. Based on an assessment of the applicable legal and policy considerations, the article concludes that courts should admit guidelines into evidence, but that they should not be used as the sole determinant of the standard of care. Instead, guidelines should be treated as one piece of evidence to be weighed by the jury. This approach will facilitate physician acceptance of guidelines by not imposing liability for the failure to follow guidelines without additional evidence to determine the standard of care.

Clinical Medicine↗
PubMed2003

Primary care clinician attitudes towards electronic clinical reminders and clinical practice guidelines.

Compliance with outpatient practice guidelines is low and clinical reminders have had variable success in improving adherence rates. We surveyed primary care physicians (PCPs) regarding practice guidelines and the perceived utility of electronic reminders for both routine health maintenance (HM) items and chronic disease management. Most PCPs preferred receiving reminders in an electronic format rather than a paper format. Electronic reminders were felt to be more useful for HM items than for diabetes management. The majority of clinicians felt that electronic reminders significantly improved overall health care quality.

Attitude of Health Personnel↗
PubMed2003

Can surveying practitioners about their practices help identify priority clinical practice guideline topics?

BACKGROUND: Clinical practice guidelines are systematically developed statements designed to assist in patient and physician clinical decision making for specific clinical circumstances. In order to establish which guideline topics are priorities, practitioners were surveyed regarding their current practice. METHODS: One hundred ninety-seven practitioners in Ontario, Canada were mailed a survey exploring their current practice or opinion regarding the prophylactic use of anticonvulsant drugs in patients with malignant glioma who had never had a seizure. The survey consisted of seven questions regarding the relevance of a guideline on the subject to the practitioner's practice, the proportion of clinical cases involving anticonvulsant use, knowledge of existing guidelines on this topic, interest in reviewing a completed practice guideline and three clinical scenarios. RESULTS: There were 122 respondents who returned the survey (62% rate of return). Eighty percent of the practitioners who responded indicated that less than 25% of their clinical cases involved the use of anticonvulsants; however, only 16% of respondents indicated that a practice guideline would be irrelevant to their practice. Eighty percent of respondents volunteered to review a draft version of a practice guideline on the use of anticonvulsants. The survey presented the practitioners with three scenarios where anticonvulsants in patients with brain tumours may be appropriate: peri-operatively in patients without seizures, postoperatively in patients currently using anticonvulsants, and thirdly in patients not currently using anticonvulsants or undergoing surgery. In contrast to the third situation, the first two situations yielded considerable variation in practitioner response. CONCLUSION: The survey established that there is some variation present in the current practice of anticonvulsant use in the patients with brain tumours. Whether there is an optimal treatment practice has yet to be determined. Practitioners do seem to feel that a guideline on anticonvulsant use in warranted, and most practitioners would be interested in being part of the guideline development process.

Anticonvulsants↗
PubMed1998

An interactive workshop: An effective means of integrating the Canadian Cardiovascular Society clinical practice guidelines on congestive heart failure into Canadian family physicians' practice.

OBJECTIVE: To use an interactive workship as a means of integrating clinical practice guidelines on congestive heart failure into Canadian family physicians' practice. SETTING: Interested practitioners from the Association des Médecins Omnipraticiens de Québec, the Centre de Santé Publique de Québec and the continuing medical education (CME) department, Merck Frosst Canada, Montreal, formed the initial task force. Train-the-trainer sessions took place in many provinces in a variety of CME settings. DESIGN: The interactive, problem-based workshop was facilitated by local interested general practitioners, while local experts served as consultants to reinforce key messages from clinical practice guidelines and to guide participants through the learning process. MAIN RESULTS: By December 31, 1996, 187 family practitioners and 81 specialists had been trained in train-the-trainer sessions across the country. A total of 1698 general practitioners had participated in over 52 workshops during the same time. Pre- and postworkshop testing indicate that the workshops improved knowledge, and that the knowledge gained during the workshop was retained at three- and six-months' follow-up. Separate chart evaluations conducted before and after the workshop showed that participants provided more complete chart information related to congestive heart failure and that they significantly increased their use of angiotensin-converting enzyme inhibitor therapy after the workshop. Participant evaluation of the workshop also indicates a high index of satisfaction with the presentation and the content of the workshop as being relevant to clinical practice. CONCLUSION: An interactive, problem-based, small group workshop developed by a core group of interested practitioners and guided by local trained facilitators and experts is an effective teaching tool through which clinical practice guidelines can be successfully transferred into clinical practice in a timely and meaningful way.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2006

ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation.

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Adolescent↗
PubMed2004

The investigation of short stature: a survey of practice in Wales and suggested practical guidelines.

AIM: To survey the investigation of short stature in Wales and suggest guidelines to improve practice. METHODS: Questionnaires were circulated to paediatricians and consultant clinical biochemists or consultant chemical pathologists at 13 Welsh hospitals where children with short stature are investigated. RESULTS: A 100% response was obtained from laboratory and clinical staff. Clinicians screened 1-50 patients each year (median, 10). Growth hormone (GH) deficiency was subsequently diagnosed in 0-30% (median, 10%) and GH treatment started in 30-100% (median, 100%) of patients. Five paediatricians and eight laboratories had written investigative protocols. Investigation of GH secretion was initiated in some centres before a complete clinical evaluation was carried out. Various screening tests for GH deficiency, including insulin-like growth factor 1 (IGF-1), random GH, and exercise tests were used. The clonidine stimulation test was used to assess the GH axis in most centres but eight different protocols were described. GH was measured in four Welsh laboratories using two automated immunoassay methods. However, nine different ranges of cutoff values for defining abnormal GH responses were quoted, and in three centres laboratories and paediatricians quoted different cutoffs. CONCLUSION: This survey demonstrates the need for practical guidelines for the investigation and management of short stature in children, agreed by paediatricians and their laboratory colleagues. The guidelines should encompass the initial clinical investigation, assessment of the GH-IGF-1 axis (using standardised protocols), and provision for the transition to adult management. This article presents practical guidelines based on published points for good practice.

Child↗
PubMed1996

The Ontario Cancer Treatment Practice Guidelines Initiative.

The Ontario Cancer Treatment Practice Guidelines Initiative was established in 1993 to develop clinical practice guidelines for cancer treatment in Ontario, Canada. First, an organizational structure, consisting of a coordinating committee, a methods resource group, and disease site groups, was put in place. Central to the development of guidelines are the 10 provincial site groups, which use a methodologic framework, the practice guidelines development cycle, to formulate the guidelines. When a preliminary evidence-based recommendation is developed by a site group, it is sent out to a sample of community practitioners for input and is modified based on their feedback. The final product is the practice guideline. Further research is required to determine optimal dissemination strategies and evaluate the impact of these guidelines.

Evidence-Based Medicine↗
PubMed1996

Practice guidelines: patients' perspective.

Although practice guidelines are important road maps for the management of patients with specific cancers, numerous ethical questions surrounding their use need to be resolved. Perhaps the most basic of these questions is, what constitutes quality cancer care and who will define it? A survey conducted by the National Coalition of Cancer Survivorship (NCCS) has identified three elements essential to quality cancer care: (1) access to services; (2) appropriate, timely referrals; and (3) access to clinical trials. One of the goals of practice guidelines should be to help empower patients; ie, to educate patients about what questions to ask in order to be informed healthcare consumers. Also, quantitative and qualitative data on the patient experience, elicited by well-developed methodologies, should be used to inform the guideline development process. Finally, guideline developers need to keep in mind that the focus of clinical guidelines is not the disease itself, but rather, the patient with that disease.

Clinical Trials as Topic↗
PubMed2003

[The significant of practical guideline in social context].

After drawing clinical practice guideline, we are going to face the significant of practice guideline in social context, both negative aspect and positive aspect. Negative aspect is the worry about misuse concerning medical malpractice lawsuits in courtroom. By analyzing the resent 3 Supreme Court decisions, I explain that practice guideline is the only one of recourses to determine medical negligence. Positive aspect is that practical guidelines would be the one of tools, which improves informed consent between medical practitioners and patients under the some conditions. Proper using practice guideline could reduce the conflict on informed consent.

Evidence-Based Medicine↗
PubMed2002

The economic benefit of practice guidelines for stress ulcer prophylaxis.

The development of practice guidelines is an effective way to provide consistent and cost-effective patient care. Despite much progress in developing practice guidelines for various other clinical problems data documenting the efficacy of these guidelines are lacking. The purpose of this study was to compare usage patterns and cost effectiveness of a stress ulcer prophylaxis guideline in a trauma intensive care unit. The trauma intensive care unit team was observed for a 50-day period. Immediately after this period a stress ulcer prophylaxis guideline was implemented, and the team was again observed for a 50-day period. All information was recorded prospectively. The trauma intensive care unit team was blind to the existence of the study. The days of appropriate use of prophylaxis (ulcer prophylaxis prescribed per the practice guidelines) and inappropriate use (use other than per the practice guidelines) in each study phase and the resulting costs were calculated as the primary measurement of outcome. Forty-six patients were studied. The use of practice guidelines in the period after the guideline was implemented of the study reduced overall stress ulcer prophylaxis by 17 per cent (P = 0.04). The appropriate prophylaxis was not significantly different when comparing the two periods of study; however, inappropriate use of prophylaxis (and associated charges) was statistically significantly less frequent after implementation of the practice guidelines. No patients developed clinically important gastrointestinal bleeding. The estimated annual savings of $102,895 in patient charges and $11,333 in actual drug costs in our trauma intensive care unit were due to the implementation of stress ulcer prophylaxis guidelines. We conclude that use of practice guidelines can significantly reduce patient charges without compromising patient care.

Adult↗
PubMed1998

Spine update. Patient preferences and the development of practice guidelines.

One shortcoming of clinical practice guidelines is that generic, one-for-all guideline recommendations do not account for differences among patients' views about the desirability (or undesirability) of specific health outcomes, such as low back pain. Because differences in patients' preferences may lead to differences in the preferred therapy, a clinical practice guideline that does not consider patients' preferences may provide recommendations that are not optimal. Recently developed methodologic approaches enable guideline developers to assess the role of patients' preferences in clinical decisions and guideline recommendations, and to develop preference-based guidelines. Preference-based guidelines are more likely to meet criteria for high-quality guidelines than are guidelines developed without consideration of the role of patients' preferences. Guideline developers should identify decisions in which patient preferences are important and note these decisions clearly in the written guideline; indicate the specific health states for which preferences are important; and, if possible, provide recommendations about options for preference assessment. These options range from informal discussions with patients to computer-based utility assessments. Patients' preferences are an important factor in clinical decisions regarding management of low-back pain, particularly in decisions about surgical management and symptom control. Although further research is needed to define the role of techniques for assessing patients' preferences in routine clinical practice, guideline developers can determine when patients' preferences should play a prominent role in guideline recommendations.

Decision Making↗
PubMed2006

Knowledge content of advance practice nurse and physician experts: A cognitive evaluation of clinical practice guideline comprehension.

Clinical practice guidelines (CPGs) are intended to provide evidence based knowledge for decision making for patient care. However, these guidelines have been poorly adopted by healthcare providers. One reason for this may be the static paper-based formats, isolated from the point of care. Biomedical informatics has provided a solution to this limitation through Computer Interpretable Guidelines (CIGs). An essential component of this process is CPG translation to a computer interpretable model. From the guideline modeling literature, the translators of CPGs typically are physicians. It is not known if other healthcare providers (i.e., Advance Practice Nurses [APNs]) comprehend CPGs similarly. This descriptive study utilized novice and expert APN and physician participants (varied by level of expertise) in a CPG comprehension task. Demographic data, verbal protocols, and recall model drawings were obtained and analyzed by description, protocol analysis, discourse analysis, and content analysis. The findings of this study indicate similar comprehension by the expert APNs and physicians suggesting that either type of expert may be utilized for modeling CPGs.

Comprehension↗
PubMed1994

Development and implementation of practice guidelines (Part 1).

Development and implementation of practice guidelines should be a team effort that includes pharmacists, the medical staff, and hospital administration. Described in this article are the steps involved in developing and successfully implementing practice guidelines. Also briefly presented are some practice guidelines developed by the staff at Cedars-Sinai Medical Center for the use of ondansetron in the post-op setting, colony stimulating factors, and sumatriptan for the treatment of migraine. Finally, discussion of a few practice guidelines that are in the implementation phase and future directions with regard to evolution of practice guidelines are presented.

Acquired Immunodeficiency Syndrome↗