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Michaels JA, Maheswaran R. Conflicting perspectives during guidelines development are an important source of implementation failure. Health Policy 2023; 131:104801. [PMID: 36990043 DOI: 10.1016/j.healthpol.2023.104801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Abstract
In recent years many countries have created national bodies that provide evidence-based guidance and policy relating to the commissioning and provision of healthcare services. However, such guidance often fails to be consistently implemented. The differing perspectives from which guidance is developed is suggested as a significant contributor to these failures. A societal perspective is, necessarily, taken by policy makers, while patients and their healthcare professionals are primarily concerned with an individual perspective. This is particularly likely to impair implementation where national policy objectives, such as cost effectiveness, equity, or the promotion of innovation, are embodied in the guidance, while patients and healthcare professionals may consider it appropriate to over-ride these, based upon individual circumstances and preferences. This paper examines these conflicts with reference to guidance issued by the National Institute of Health and Care Excellence in England. Conflicts are identified between the objectives, values, and preferences of those who develop and those who implement such guidance, with consequent difficulties in providing helpful personalised recommendations. The implications of this for the development and implementation of guidance are discussed and recommendations are made regarding the ways in which such guidance is framed and disseminated.
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Li DK, Ong SY, Hughes ML, Hung KW, Agarwal R, Alexis J, Damianos J, Sharma S, Pires J, Nanna M, Laine L. Deprescription of aspirin for primary prevention is uncommon at discharge in hospitalised patients with gastrointestinal bleeding. Aliment Pharmacol Ther 2023; 57:94-102. [PMID: 36394111 DOI: 10.1111/apt.17278] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines recommend against aspirin for primary prevention of cardiovascular events in individuals with a history of gastrointestinal bleeding (GIB). It is unknown how often patients on primary prevention aspirin hospitalised with GIB have aspirin discontinued at discharge. AIMS To determine the rate of aspirin deprescription and explore long-term outcomes in patients taking aspirin for primary prevention of cardiovascular events. METHODS We evaluated all patients hospitalised at Yale-New Haven Hospital between January 2014 and October 2021 with GIB who were on aspirin for primary prevention. Our primary endpoint was the frequency of aspirin deprescription at discharge. Our secondary endpoints were post-discharge hospitalisations for major adverse cardiovascular events (MACE) or GIB. Time-to-event analysis was performed using Kaplan-Meier curves and the log-rank test. RESULTS We identified 320 patients with GIB on aspirin for primary prevention: median age was 72 (interquartile range [IQR] 61-81) years and 297 (92.8%) were on aspirin 81 mg daily. Only 25 (9.0%) patients surviving their hospitalisation were deprescribed aspirin at discharge. Among 260 patients with follow-up (median 1103 days; IQR 367-1670), MACE developed post-discharge in 2/25 (8.0%) with aspirin deprescription versus 37/235 (15.7%) with aspirin continuation (log-rank p = 0.28). 0/25 patients with aspirin deprescription had subsequent hospitalisation for GIB versus 17/235 (7.2%) who continued aspirin (log-rank p = 0.13). CONCLUSIONS Aspirin for primary cardiovascular prevention was rarely deprescribed at discharge in patients hospitalised with GIB. Processes designed to ensure appropriate deprescription of aspirin are crucial to improve adherence to guidelines, thereby improving the risk-benefit ratio in patients at high risk of subsequent GIB hospitalisations with minimal increased risk of MACE.
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Affiliation(s)
- Darrick K Li
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shawn Y Ong
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michelle L Hughes
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kenneth W Hung
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Jamil Alexis
- Section of Gastroenterology, Department of Medicine, Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - John Damianos
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Shreyak Sharma
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Jacqueline Pires
- Section of Cardiovascular Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Nanna
- Section of Cardiovascular Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
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