Clinical decision making: from theory to practice. Designing a practice policy. Standards, guidelines, and options

Layperson Views about the Design and Evaluation of Decision Aids: A Public Deliberation

PURPOSE

We carried out the first public deliberation to elicit lay input regarding guidelines for the design and evaluation of decision aids, focusing on the example of colorectal ("colon") cancer screening.

METHODS

A random, demographically stratified sample of 28 laypeople convened for 4 days, during which they were informed about key issues regarding colon cancer, screening tests, risk communication, and decision aids. Participants then deliberated in small and large group sessions about the following: 1) What information should be included in all decision aids for colon screening? 2) What risk information should be in a decision aid and how should risk information be presented? 3) What makes a screening decision a good one (reasonable or legitimate)? 4) What makes a decision aid and the advice it provides trustworthy? With the help of a trained facilitator, the deliberants formulated recommendations, and a vote was held on each to identify support and alternative views.

RESULTS

Twenty-one recommendations ("deliberative conclusions") were strongly supported. Some conclusions matched current recommendations, such as that decision aids should be available for use with and without providers present (conclusions 1-4) and should support informed choice (conclusion 9). Some conclusions differed from current recommendations, at least in emphasis-for example, that decision aids should disclose cost of screening (conclusion 11) and should be kept simple and understandable (conclusion 14). Deliberants recommended that decision aids should disclose the baseline risk of getting colon cancer (conclusions 15, 17).

LIMITATIONS

Single location and medical decision.

CONCLUSIONS

Guidelines for design of decision aids should consider putting a greater focus on disclosing cost and keeping decision aids simple, and they possibly should recommend disclosing less extensive amounts of quantitative information than currently recommended.

Practical challenges in oral immunotherapy resolved through patient-centered care

Oral immunotherapy (OIT) is now widely recognized as a valid option for the management of IgE-mediated food allergies. However, in real-life practice, OIT can lead to a variety of unique situations where the best course of action is undetermined. In patient-centered care, individual patient preferences, needs and values, should guide all clinical decisions. This can be achieved by using shared-decision making and treatment customization to navigate areas of uncertainty in a way that is responsive to patient’s needs and preferences. However, in the context of OIT, lack of awareness of potential protocol adaptability or alternatives can become a barrier to treatment personalization. The purpose of this article is to review the theoretical bases of patient-centered care and shared decision-making and their practical implication for the patient-centered delivery of OIT. Clinical cases highlighting common challenges in real-life OIT practice are presented along with a discussion of potential personalized management options to be considered. While the practice of OIT is bound to evolve as additional scientific and experiential knowledge is gained, it should always remain rooted in the general principles of patient-centered care.

Patient Preference Distribution for Use of Statin Therapy

IMPORTANCE

Thresholds for initiating statin therapy should be informed by patients' preferences.

OBJECTIVE

To define the preference distribution for statin therapy across the spectrum of cardiovascular disease (CVD) risk after participants were informed about the benefits and harms of statin therapy.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional survey was conducted from May 13 to June 2, 2020. Participants included 304 individuals aged 40 to 75 years drawn from a nonprobability opt-in panel who had not taken a statin or proprotein convertase subtilisin/kexin type 9 inhibitor in the past 3 years and knew the results of their total cholesterol, high-density lipoprotein cholesterol, and blood pressure measurements.

EXPOSURES

Personalized 10-year CVD risk with and without statin therapy and potential harms of statins.

MAIN OUTCOMES AND MEASURES

The primary outcome was self-reported preference for statin therapy.

RESULTS

The 304 participants had a mean (SD) age of 54.8 (9.9) years; 152 were women (50.0%), 130 (42.8%) non-White, 50 (16.6%) had a high school degree or less education, and 153 (50.8%) reported never needing help reading health materials. When asked their preference for using statin therapy after reviewing their benefit and risk information, 45% of the participants reported they would definitely or probably choose statin therapy. As the risk increased, the proportion who would choose statin therapy generally increased (from 31.1% for a risk <5% to 82.6% for a risk >50%). The minimum risk threshold had to increase to 20% before 75% of respondents in that risk group would want statin therapy. For participants with a risk greater than 10%, the desire to use statin therapy decreased as participants' health literacy, subjective numeracy, and knowledge scores increased.

CONCLUSIONS AND RELEVANCE

In this study, preferences for statin therapy for primary prevention of CVD appeared to vary across the spectrum of 10-year cardiovascular risk, but they were relatively flat at intermediate levels of risk. This preference distribution suggests a broad risk range for shared decision-making.

Mixing qualitative methods versus methodologies: A critical reflection on communication and power in inpatient care

This paper offers an illustrative example to demonstrate one way of combining qualitative methods. The context for the study was a UK inpatient psychiatric hospital. Data set one was collected from weekly ward rounds where inpatient staff met with autistic patients to review medication, listen to patient concerns and make plans or adjustments in light of this. Data set two was reflective discursive interviews with patients and staff. The research objective was to critically consider the potential reasons for discrepancies in dissatisfaction reports from patients in the interviews, compared to relative compliance exhibited by patients in the ward rounds. Utilising a video-reflexive design and critical discursive psychology approach, both data sets were analysed together. It is possible to simultaneously analyse two different data sets, one naturally occurring and one researcher generated because of the epistemological congruence in the overall design. We have presented an argument for the benefits of mixing two qualitative methods, thereby extending the mixed-methods evidence base beyond the traditional discussions of quantitative and qualitative paradigms.

Trends in descriptions of palliative care in the cancer clinical practice guidelines before and after enactment of the Cancer Control Act (2007): content analysis

BACKGROUND

Palliative care was a priority issue in the Cancer Control Act enacted in 2007 in Japan, and this has resulted in efforts being made toward educational goals in clinical settings. An investigation of how descriptions of palliative care for the treatment of cancer have changed in clinical practice guidelines (CPGs) could be expected to provide a better understanding of palliative care-related decision-making. This study aimed to identify trends in descriptions of palliative care in cancer CPGs in Japan before and after enactment of the Cancer Control Act.

METHODS

Content analysis was used to count the lines in all relevant CPGs. We then compared the number of lines and the proportion of descriptions mentioning palliative care at two time points: the first survey (selection period: February to June 2007) and the second survey (selection period: February to December 2015). Descriptions from the CPGs were independently selected from the Toho University Medical Media Center and Medical Information Network Distribution Service databases, and subsequently reviewed, by two investigators.

RESULTS

Descriptions were analyzed for 10 types of cancer. The proportion of descriptions in the first survey (4.4%; 933/21,344 lines) was similar to that in the second survey (4.5%; 1325/29,269 lines).

CONCLUSIONS

After the enactment of the Cancer Control Act, an increase was observed in the number, but not in the proportion, of palliative care descriptions in Japanese cancer CPGs. In the future, CPGs can be expected to play a major role in helping cancer patients to incorporate palliative care more smoothly.

Implications of True and Perceived Treatment Burden on Cardiovascular Medication Use

Background: Clinical decisions require weighing possible risks and benefits, which are often based on the provider's sense of treatment burden. Patients often have a different view of how heavily treatment burden should be weighted. Objective: To examine how much small variations in patient treatment burden would influence optimal use of antihypertensive medications and how much over- and undertreatment can result from clinicians misunderstanding their patients' values. Methods: Analysis-Markov chain model. Data sources-Existing literature, including an individual-level meta-analysis of blood pressure trials. Target population-US representative sample, ages 40 to 85, no history of cardiovascular disease. Time horizon-Effect of 10 years of treatment on estimated lifetime quality-adjusted life-year (QALY) burden. Perspective-Patient.

OUTCOME MEASURES

QALYs gained by treatment. Results: Fairly small differences in true patient burden from blood pressure treatment alter the number of blood pressure medications that should be recommended and alters treatment's potential benefit dramatically. We also found that a clinician misunderstanding the patient's burden could lead to almost 30% of patients being treated inappropriately. Limitations: Our results are based on simulation modeling. Conclusions: Clinical decisions that fail to account for patient treatment burden can mistreat a very large proportion of the public. Successful treatment choices closely depend on a clinician's ability to accurately gauge a patient's treatment burden.

Evidence-based neurosurgery. Basic concepts for the appraisal and application of scientific information to patient care (Part II)

Medical evidence is obtainable from approaches, which might be descriptive, analytic and integrative and ranked into levels of evidence, graded according to quality and summarized into strengths of recommendation. Sources of evidence range from expert opinions through well-randomized control trials to meta-analyses. The conscientious, explicit, and judicious use of current best evidence in making decisions related to the care of individual patients defines the concept of evidence-based neurosurgery (EBN). We reviewed reference books of clinical epidemiology, evidence-based practice and other previously related articles addressing principles of evidence-based practice in neurosurgery. Based on existing theories and models and our cumulative years of experience and expertise conducting research and promoting EBN, we have synthesized and presented a holistic overview of the concept of EBN. We have also underscored the importance of clinical research and its relationship to EBN. Useful electronic resources are provided. The concept of critical appraisal is introduced.

Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation

In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.

Who and when should we screen for prostate cancer? Interviews with key opinion leaders

Prostate cancer screening using prostate-specific antigen (PSA) is highly controversial. In this Q & A, Guest Editors for BMC Medicine's 'Spotlight on Prostate Cancer' article collection, Sigrid Carlsson and Andrew Vickers, invite some of the world's key opinion leaders to discuss who, and when, to screen for prostate cancer. In response to the points of view from the invited experts, the Guest Editors summarize the experts' views and give their own personal opinions on PSA screening.

Patient Admission Preferences and Perceptions

INTRODUCTION

Understanding patient perceptions and preferences of hospital care is important to improve patients' hospitalization experiences and satisfaction. The objective of this study was to investigate patient preferences and perceptions of hospital care, specifically differences between intensive care unit (ICU) and hospital floor admissions.

METHODS

This was a cross-sectional survey of emergency department (ED) patients who were presented with a hypothetical scenario of a patient with mild traumatic brain injury (TBI). We surveyed their preferences and perceptions of hospital care related to this scenario. A closed-ended questionnaire provided quantitative data on patient preferences and perceptions of hospital care and an open-ended questionnaire evaluated factors that may not have been captured with the closed-ended questionnaire.

RESULTS

Out of 302 study patients, the ability for family and friends to visit (83%), nurse availability (80%), and physician availability (79%) were the factors most commonly rated "very important," while the cost of hospitalization (62%) and length of hospitalization (59%) were the factors least commonly rated "very important." When asked to choose between the ICU and the floor if they were the patient in the scenario, 33 patients (10.9%) choose the ICU, 133 chose the floor (44.0%), and 136 (45.0%) had no preference.

CONCLUSION

Based on a hypothetical scenario of mild TBI, the majority of patients preferred admission to the floor or had no preference compared to admission to the ICU. Humanistic factors such as the availability of doctors and nurses and the ability to interact with family appear to have a greater priority than systematic factors of hospitalization, such as length and cost of hospitalization or length of time in the ED waiting for an in-patient bed.

Effect of patients' risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes mellitus

IMPORTANCE

Type 2 diabetes mellitus is common, and treatment to correct blood glucose levels is standard. However, treatment burden starts years before treatment benefits accrue. Because guidelines often ignore treatment burden, many patients with diabetes may be overtreated.

OBJECTIVE

To examine how treatment burden affects the benefits of intensive vs moderate glycemic control in patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

We estimated the effects of hemoglobin A1c (HbA1c) reduction on diabetes outcomes and overall quality-adjusted life years (QALYs) using a Markov simulation model. Model probabilities were based on estimates from randomized trials and observational studies. Simulated patients were based on adult patients with type 2 diabetes drawn from the National Health and Nutrition Examination Study.

INTERVENTIONS

Glucose lowering with oral agents or insulin in type 2 diabetes.

MAIN OUTCOMES AND MEASURES

Main outcomes were QALYs and reduction in risk of microvascular and cardiovascular diabetes complications.

RESULTS

Assuming a low treatment burden (0.001, or 0.4 lost days per year), treatment that lowered HbA1c level by 1 percentage point provided benefits ranging from 0.77 to 0.91 QALYs for simulated patients who received a diagnosis at age 45 years to 0.08 to 0.10 QALYs for those who received a diagnosis at age 75 years. An increase in treatment burden (0.01, or 3.7 days lost per year) resulted in HbA1c level lowering being associated with more harm than benefit in those aged 75 years. Across all ages, patients who viewed treatment as more burdensome (0.025-0.05 disutility) experienced a net loss in QALYs from treatments to lower HbA1c level.

CONCLUSIONS AND RELEVANCE

Improving glycemic control can provide substantial benefits, especially for younger patients; however, for most patients older than 50 years with an HbA1c level less than 9% receiving metformin therapy, additional glycemic treatment usually offers at most modest benefits. Furthermore, the magnitude of benefit is sensitive to patients' views of the treatment burden, and even small treatment adverse effects result in net harm in older patients. The current approach of broadly advocating intensive glycemic control should be reconsidered; instead, treating patients with HbA1c levels less than 9% should be individualized on the basis of estimates of benefit weighed against the patient's views of the burdens of treatment.

Missed lung cancer on chest radiography and computed tomography

Missed lung cancer raises an important medicolegal issue and contributes to one of the most common causes for malpractice actions against radiologists. Lung cancer may be missed on either chest radiography or computed tomography. Although most malpractice cases involve lesions overlooked on the former, a small and increasing portion of cases are related to chest computed tomography scan. Factors contributing to overlooked lung cancer can be attributed to observer performance, lesion characteristics, and technical considerations.

Practice variation in common fracture presentations: a survey of orthopaedic surgeons

BACKGROUND

Practice variation may indicate a lack of clear evidence to guide treatment. This study aims to quantify practice variation for common orthopaedic fractures, and to explore possible predictors of the variation.

MATERIALS AND METHODS

A nationwide electronic survey of Australian orthopaedic surgeons was performed. Five common fractures (ankle, scaphoid, distal radius, neck of humerus, and clavicle) were presented. Data on management preferences and surgeon background were gathered. Potential predictors of operative (vs. non-operative) treatment were explored.

RESULTS

358 of 760 (47%) surgeons responded. For the ankle, undisplaced scaphoid, distal radius, neck of humerus and clavicle fractures, operative treatment was chosen in 40%, 44%, 77%, 26% and 38%, respectively. Operative treatment was significantly more likely to be chosen by more junior surgeons, and by surgeons specialising in the affected area (i.e., shoulder surgeons for clavicle and neck of humerus fractures, and hand surgeons for scaphoid and distal radius fractures).

CONCLUSIONS

Variations exist in the management of common fractures. Variation may represent legitimate improvisation for varying clinical scenarios, but it may reflect clinician bias, which in turn, may contribute to varying standards of care for the management of common conditions.

"What lies beneath it all?"--an interview study of GPs' attitudes to the use of guidelines

Background

General practitioners (GPs) adopt clinical practice guidelines to varying degrees. Several factors have been found to influence application of guidelines in practice and the GP is apparently the key actor. Studies are needed to increase our understanding of how GPs' attitudes influence their use of guidelines. In this study we explored GPs' attitudes to guidelines.

Methods

In 2007 we conducted six semi-structured group interviews with a purposive sample of 27 Norwegian GPs. The participants were encouraged to discuss guidelines they were familiar with, the evidence base of guidelines, professional autonomy and doctor-patient relations. We used thematic content analysis to extract central themes and arguments.

Results

When deciding whether tfollow guideline recommendations, GPs consider whether guidelines are trustworthy, whether they suit patients and whether the recommended action is feasible. There were two important findings. First, the GP's were concerned that guidelines may be more heavily influenced by economic considerations than clinical ones. Second, in contrast to earlier findings, changes in recommendations and disagreement between experts were mostly viewed positively.

Conclusion

This study underscores the need for transparency in the process of development and implementation of guidelines. To enhance the use of guidelines, primary care physicians should be involved in the process of developing guidelines and the process should be transparent and explicit regarding the evidence base and economic considerations.

Providers' perceptions of spinal cord injury pressure ulcer guidelines

BACKGROUND/OBJECTIVE

Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators.

METHODS

This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators.

RESULTS

The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources.

CONCLUSIONS

Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.

Strategies and algorithms for management of the difficult airway

Management of the difficult airway is the most important patient safety issue in the practice of anaesthesia. Many national societies have developed algorithms and guidelines for management of the difficult airway. The key issues of this chapter are definition of terms, the advantages and disadvantages of the use of guidelines, and a comparison of different algorithms and guidelines for management of the most important clinical airway scenarios. Although there is no strong evidence of benefit for any specific strategy or algorithm for management of the difficult airway, there is strong agreement that a pre-planned strategy may lead to improved outcome.

A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts

PURPOSE

To survey leaders in sports medicine who perform anterior cruciate ligament (ACL) reconstructions to determine the preferred management when ACL graft contamination occurs.

TYPE OF STUDY

Survey study of expert opinions and experiences on the management of ACL graft contamination.

METHODS

We mailed 337 surveys to directors of academic sports medicine programs and graduates from an accredited sports medicine fellowship. The survey questioned the incidence, treatment, and outcome of ACL graft contamination.

RESULTS

Twelve surveys were returned to sender; 196 surgeons responded from the remaining 325 surveys (60%). Forty-nine of 196 (25%) surgeons reported at least 1 contamination during their career. Of those 49, 43 surgeons (88%) had 1 contaminated graft, 5 (10%) had 2, and 1 had 4, for a total of 57 reported contaminated grafts. Of the surgeons who reported a contaminated graft, 22 (45%) performed between 40 and 100 ACL reconstructions annually, and 17 (35%) performed more than 100 ACL reconstructions annually. Forty-three of the 57 (75%) contaminated grafts were managed with cleansing of the graft and proceeding with reconstruction. Ten (18%) were managed by harvesting a different graft, and 4 (7%) were substituted with an allograft. No infections in any of the contaminated grafts were reported. Sixty-five of the 147 (43%) surgeons without graft contamination gave hypothetical management responses. Thirty-eight (58%) would cleanse the graft and proceed with the procedure, 22 (34%) would harvest a different graft, and 5 (8%) would use an allograft.

CONCLUSIONS

Surgeons who perform a high volume of ACL reconstruction surgery most often choose graft cleansing as the preferred management for intraoperative ACL graft contamination.

LEVEL OF EVIDENCE

Level V, expert opinion.

Guidelines for maintenance treatment of bipolar disorder: are there discrepancies between European and North American recommendations?

Practice policies and guidelines for the long-term management of bipolar patients have appeared in many parts of Europe and North America. Although recommendations in most areas do concur remarkable differences are apparent both regarding diagnostic practice and pharmacological management. Differences among recommendations point towards professional and cultural differences between Europe and North America but also towards areas with unresolved research questions and lack of scientific evidence.

Multidisciplinary guidelines in Dutch mental health care: plans, bottlenecks and possible solutions

Purpose

This article describes the Dutch ‘Multidisciplinary Guidelines in Mental Health Care’ project and its first products (multidisciplinary guidelines on depressive and anxiety disorders).

Context of case

In the early 1990s, disciplines in Dutch mental health care formulated their first monodisciplinary guidelines, which disagreed on essential features. In 1998, the Dutch government invited representatives of the five core disciplines in mental health care (psychiatrists, general practitioners, psychotherapists (clinical), psychologists and psychiatric nurses) to start a joint project aimed at the development of new integrated multidisciplinary guidelines.

Data sources

The vision document, presented in 2000 by the five core disciplines, describes the directions for the development of new guidelines. The guidelines on depressive and anxiety disorders will appear in 2004.

Case description

The first draft guidelines were presented in May 2003, in line with the vision document (2000). However, it is still not certain whether they will be authorised by all professional groups. Some disciplines do not recognise themselves in these guidelines. It is argued that these problems can be attributed at least in part to the evidence-based method that was used in drafting the guidelines. Interventions are compared on the basis of their ‘level of evidence’, the consequence of which is that cognitive behavioural therapy and drug treatment are almost always seen as the only appropriate interventions. Other interventions are excluded because of their lower level of evidence.

Conclusions and discussion

The conclusion is that guidelines cannot be based on empirical evidence alone. It is argued that the collective sense of professions involved should also be integrated into the guideline, for example in relation to goal differentiation. It is finally argued that multidisciplinary guidelines must also offer a hierarchy between those goals, i.e. a vision of the appropriate type of care and the order in which the various care components should be administered.

Impoverished diabetic patients whose doctors facilitate their participation in medical decision making are more satisfied with their care

OBJECTIVE

Greater participation in medical decision making is generally advocated for patients, and often advocated for those with diabetes. Although some studies suggest that diabetic patients prefer to participate less in decision making than do healthy patients, the empirical relationship between such participation and diabetic patients' satisfaction with their care is currently unknown. We sought to characterize the relationship between aspects of diabetic patients' participation in medical decision making and their satisfaction with care.

DESIGN

Cross-sectional observational study.

SETTING

A general medical county hospital-affiliated clinic.

PARTICIPANTS

One hundred ninety-eight patients with type 2 diabetes.

MAIN MEASURES

Interviews conducted prior to the doctor visit assessed patients' desire to participate in medical decision making, baseline satisfaction (using a standardized measure), and sociodemographic and clinical characteristics. Postvisit interviews of those patients assessed their visit satisfaction and perception of their doctor's facilitation of patient involvement in care. A discrepancy score was computed for each subject to reflect the difference between the previsit stated desire regarding participation and the postvisit report of their experience of participation.

RESULTS

Overall, patients reported low postvisit satisfaction relative to national standards (mean of 70 on a 98-point scale). Patients perceived a high level of facilitation of participation (mean 88 on a 100-point scale). Facilitation of participation and the discrepancy score both independently predicted greater visit satisfaction. In particular, a 13-point (1 SD) increase in the perceived facilitation score resulted in a 12-point (0.87 SD) increase in patient satisfaction, and a 1.22 point increase (1 SD) in the discrepancy score (the extent to which the patient was allowed more participation than, at previsit, he or she desired) resulted in a 6-point (0.5 SD) increase in the satisfaction score, even after controlling for initial desire to participate. For women, but not for men, physician facilitation of participation was a positive predictor of satisfaction; for men, but not women, desire to participate was a significant positive predictor of visit satisfaction.

CONCLUSION

Clinicians may feel reassured that encouraging even initially reluctant patients with diabetes to participate in medical decision making may be associated with increased patient satisfaction. Greater patient participation has the potential to improve diabetic self-care because of the likely positive effect of patient satisfaction on adherence to treatment. Further research to assess the prospective effects of enhancing physician facilitation of patient participation is likely to yield important information for the effective treatment of chronically ill patients.

Low-grade hemispheric gliomas in adults: a critical review of extent of resection as a factor influencing outcome

OBJECT

The goal of this study was to perform a critical review of literature pertinent to low-grade gliomas of the cerebral hemisphere in adults and, on the basis of this review, to evaluate systematically the prognostic effect of extent of resection on survival and to determine if treatment-related guidelines could be established for patients in whom these tumors have been newly diagnosed. Quality of evidence for current treatment options, guidelines, and standards as well as methodological limitations were evaluated.

METHODS

Several prognostic factors thought to affect outcome in patients with low-grade gliomas include the patient's age and neurological status, tumor volume and histological characteristics, and treatment-related variables such as timing of surgical intervention, extent of resection, postoperative tumor volume, and radiation therapy. Patient age and the histological characteristics of the lesion are generally accepted prognostic factors. Among treatment-related factors, timing and extent of resection are controversial because of the lack of randomized controlled trials addressing these issues and the difficulty in obtaining information from available studies that have methodological limitations. All English-language studies on low-grade gliomas published between January 1970 and April 2000 were reviewed. Thirty studies that included statistical analyses were further evaluated with regard to the prognostic effect of extent of resection. Of these 30 studies, those that included pediatric patients, unless adults were analyzed separately, were excluded from further study because of the favorable outcome associated with the pediatric age group. Also excluded were studies including pilocytic and gemistocytic astrocytomas, because the natural histories of these histological subtypes are significantly different from that of low-grade gliomas. Series in which there were small numbers of patients (< 75) were also excluded. Results for oligodendrogliomas are reported separately. Currently, for patients with low-grade glial tumors located in the cerebral hemisphere, the only management standard based on high-quality evidence is tissue diagnosis. All other treatment methods are practice options supported by evidence that is inconclusive or conflicting. The majority of published series that the authors identified had design-related limitations including a small study size, a small number of events (that is, deaths for survival studies), inclusion of pediatric patients, and/or inclusion of various histological types of tumors with different natural histories. Of the 30 series addressing the issue of timing and extent of surgery, almost all had additional design limitations. Methods used to determine the extent of resection were subjective and qualitative in almost all studies. Only five of the 30 series met the authors' criteria, and these studies are discussed in detail.

CONCLUSIONS

Management of low-grade gliomas is controversial and practice parameters are ill defined. This is caused by limited knowledge regarding the natural history of these tumors and the lack of high-quality evidence supporting various treatment options. Although a prospective randomized study seems unlikely, both retrospective matched studies and prospective observational trials will improve the clinician's ability to understand the importance of various prognostic factors.

Practice parameters for the management of single brain metastasis

Object

In January 1998 the Guidelines and Outcomes Committee of the American Association of Neurological Surgeons (AANS) issued a charge for the development of evidence-based practice parameters focusing on the treatment of patients with single metastasis to the brain. The charge was imposed in response to the significant controversy surrounding questions relating to the optimal management strategies for patients with single brain metastasis.

Methods

A team consisting of physicians from the AANS, the American Academy of Neurology, and the American Association of Therapeutic Radiation Oncology convened and the literature was reviewed. Methodically drawing from the best of Class I, II, and III levels of available evidence, authors sought to determine how the literature addressed and disposed of the question of the optimal management for an adult with a known history of cancer and a single meta-static brain lesion. Framing the question in this specific manner allowed researchers to focus directly on treatment issues, without having to consider diagnostic issues.

Conclusions

The results of the evidence-based analysis demonstrated that there was insufficient information to establish standards of care. Data from the literature does, however, support a guideline stating that surgical resection accompanied by whole brain radiation therapy is associated with the best survival rate. Additional lower-quality evidence supports an option for management with radiosurgery.

Attitudes toward clinical guidelines among obstetricians in Northern Ireland

OBJECTIVES

To evaluate the attitudes of, and the influences on decisions made by, obstetricians in Northern Ireland in order to understand the feasibility of applying guidelines to obstetric practice.

DESIGN

Cross-sectional postal survey.

SETTING

Northern Ireland.

POPULATION

Consultants, senior registrars, registrars, and senior house officers in obstetrics in Northern Ireland (n = 170). Responses were received from 68 x 8% (n = 117), with complete data available for 67 x 1% (n = 114).

MAIN OUTCOME MEASURES

An attitudes score was constructed by consolidating responses to a variety of statements about guidelines. Individual responses to guidelines statements and the standardised attitudes T-score were analysed by demographic and practice characteristics.

RESULTS

Attitudes toward guidelines were generally positive, with women practitioners more likely to have positive attitudes toward guidelines than did their male counterparts. Younger obstetricians were more likely to report that practitioners should incorporate guidelines into their practices. Doctors who responded that their decisions were influenced by specific tools related to guidelines, such as computerised databases, during the previous three months had more positive attitudes toward guidelines than doctors who did not use such tools. Furthermore, doctors based in teaching hospitals were more likely than others to have been influenced by the guidelines of professional societies.

CONCLUSIONS

Generally guidelines appear to be quite well received, with doctors reporting that their practice often is influenced by them. Doctors who reported that their decisions were influenced by guidelines had an especially positive attitude toward them. However, some tools which target the application of evidence-based methods (e.g. computerised databases) are used infrequently by obstetricians. The challenge remains to encourage the further development of guidelines and tools that are useful and appropriate for practitioners.

Management of vitiligo. Results of a questionnaire among dermatologists in The Netherlands

BACKGROUND

Several therapeutic options are available for the treatment of vitiligo. Concern exists that there is no uniform approach towards the management of vitiligo among Dutch dermatologists.

METHODS

A written survey concerning the management of vitiligo was sent to 332 dermatologists in The Netherlands.

RESULTS

The response rate was 86%. "Giving information and reassurance concerning the nature of disease" was regarded by most dermatologists (68%) as being the most important goal in the management of vitiligo. Only 16% of the dermatologists aimed for active treatment in vitiligo. The reported therapy choices in children resembled those of adults, except that slightly more dermatologists did not prescribe active therapy in children. Nine different therapeutic modalities were mentioned as first choice therapies. Topical corticosteroids were indicated by most dermatologists as first choice therapy (241 out of 266, i.e. 91%); however, only 2% indicated that 50% or more of the patients achieved a successful treatment; 66% found that less than 25% of the patients were successfully treated with topical corticosteroids. Only 15% of the respondents reported that 50% or more of the patients were treated successfully with narrow-band UVB. The observed response profile to broad-band UVB therapy was found to be comparable with that of narrow-band UVB. The classical therapy with oral psoralen plus UVA (PUVA) was prescribed as first choice therapy by only 12% (32 out of 266) of the dermatologists. Only 6% of these respondents observed that 50% or more of the patients achieved successful therapy using oral PUVA. The recommended maximum treatment duration for topical corticosteroids, oral PUVA, and UVB therapy was found to vary from 3 to 12 months.

CONCLUSIONS

Most dermatologists in The Netherlands do not offer active treatment in vitiligo, probably because the estimated effectiveness of (nonsurgical) repigmentation therapy is low. In cases where treatment is prescribed, there appears to be no consensus on the choice of therapies and treatment strategies. The development of practice guidelines may be helpful in reducing inappropriate care and improving treatment outcome.

Clinical guidelines and the law: advice, guidance or regulation?

Proliferation of clinical guidelines has given rise to a number of concerns about the status of clinical advisory statements. Are guidelines advisory or mandatory? What regulatory functions do guidelines serve; do they allow clinical discretion a large enough role? Relationships between legislation and guidelines, and the way courts go about determining the legal status of guidelines, are explained. The following questions in the context of the law of negligence are addressed. Do doctors who deviate from guidelines place themselves at increased risk of being found liable in negligence if patients suffer injury as a result? Could compliance with guidelines protect health care workers from liability in such circumstances? What legal responsibility do the developers and issuers of guidelines have if their guidance is found to be faulty? Common law cases featuring clinical guidelines or protocols have been identified from the database Lexis, which searches the full text of the transcripts and reports of court cases in UK, Commonwealth and United States jurisdictions. Secondary literature, identified from the bibliography of clinical guidelines maintained by the Department of Health Services Research at the University of Aberdeen (assembled from DHSS-DATA, Embase, Grateful Med, Medline and SIGLE) has also been consulted. The legal status of a guideline turns on whether its development and application have statutory backing, and whether the guideline embodies clinical practices accepted as proper by a responsible body of doctors. The mandatory effects of guidelines can be gauged, to some extent, by the sanctions that apply in the event of non-compliance. US courts have ruled that guideline developers can be held liable for faulty guidelines, and that doctors cannot pass off their liability by claiming that adherence to guidelines has corrupted clinical judgement. Protocols and guidelines provide the courts with examples of clinical standards across a wide range of medical practice. As guidelines proliferate, so they will increasingly be used in court. However, adherence to guidelines has not automatically been equated with reasonable practice, and the courts seem unlikely to follow the standards enunciated in clinical guidelines without critically evaluating their authority, flexibility and scope of application.

Clinical guidelines: proliferation and medicolegal significance

Guidelines seeking to influence and regulate clinical activity are currently gaining a new cultural ascendancy on both sides of the Atlantic. Statutory agencies may be charged with developing clinical guidelines, and civil courts, in deciding actions in negligence, could be influenced by standards of care expressed in guideline statements. Clinical guidelines are not accorded unchallengeable status: they have been subject to careful scrutiny by British and American courts to establish their authenticity and relevance. In the United States, compliance with clinical guidelines cannot be used as a defence against liability if a physician's conduct is held to have been negligent, and third party organisations can be held liable if their clinical guidelines are found to be a contributory cause of patient harm. Guidelines have not usurped the role of the expert witness in court. The importance the law attaches to customary practice means that atypical or bizarre guidelines are unlikely to be accepted as embodying a legally required standard of clinical care.

Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia

OBJECTIVE

To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals.

DESIGN

Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour.

SETTING

Southampton and South West Hampshire Health District, United Kingdom.

SUBJECTS

179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group.

MAIN MEASURES

Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines.

RESULTS

Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents.

CONCLUSION

Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.

Development of clinical guidelines in a health district: an attempt to find consensus

OBJECTIVE

To formulate consensus based guidelines for antenatal care in a health district.

DESIGN

Prospective formulation of draft guidelines by a working group of consultant obstetricians and general practitioners with an obstetric interest, canvassing opinions of all GPs in the district by questionnaire, and revision and final circulation of the guidelines.

SETTING

One health district.

SUBJECTS

All 160 GPs in the district and members of the working party.

MAIN MEASURES

Questionnaire responses to specific proposals within the draft guidelines for managing anaemia, antepartum haemorrhage, and hypertension.

RESULTS

136 GPs responded (response rate 85%); responders and nonresponders did not differ in age, sex, or presence on obstetric list. Overall they favoured more conservative management than suggested in the guidelines. For example, only 38% (44/116) prescribed iron routinely and 34% (38/113) referred to hospital for haemoglobin concentration of < or = 10 g/l; 10% referred women unnecessarily for oedema unassociated with proteinuria; and 20% managed active bleeding progressing to old brown staining as an urgent admission. The guidelines were revised according to the relative weight of the views obtained.

CONCLUSION

Establishing guidelines is mainly a political process. Canvassed views influenced guidelines most when internal disagreement existed within the working party.

IMPLICATIONS AND ACTION

Regular revising of the guidelines is planned, which, in conjunction with repeating the questionnaire to monitor changing practice, will allow a long term district wide clinical review.