Developing guidelines for local use: algorithms for cost-efficient outpatient management of cardiovascular disorders in a VA Medical Center

Are clinical practice guidelines valid for primary care?

Development of evidence-based clinical practice guidelines has emphasized treatment efficacy under methodologically rigorous conditions; internal validity (i.e., efficacy) has been assessed well. Despite their experimental foundations, guidelines originally were considered physician education tools relevant to singular, idealized encounters. Now, in rushing to generalize, quantify, and regulate quality, guidelines are being applied to whole populations as quality review criteria. Clinical guidelines do not make operational how, or even make clear whether they should be so used. We studied the external validity, the generalizability and measurability for primary care, of a guideline for treatment of systolic heart failure. Patient and clinical factors reducing generalizability were examined. Imprecise definition and reliance on single measures of recommendations were studied as limits to measurability. Patient, physician, organizational, and system factors influenced guideline validity. Attention to myriad invalidity sources undermining implementation and evaluation of efforts to improve quality and outcomes of primary care is critical.

Teaching symptom management of HIV/AIDS using algorithms

Management of patients infected with the human immunodeficiency virus (HIV) or with acquired immunodeficiency syndrome (AIDS) presents a complex set of challenges to the health-care professional, especially in the area of patient education. Lack of resources, time constraints, and/or patients' willingness to learn about the disease are all factors that can impact the teaching/learning process. Creative and effective teaching strategies must be implemented so that adequate information and support is provided to the patient and/or the caregiver. Algorithms were developed for the patient and/or caregiver to use as a quick reference for decision making regarding symptom management of common manifestations of HIV/AIDS.

Implementation of local guidelines for cost-effective management of hypertension. A trial of the firm system

OBJECTIVE

To evaluate the effects of an intensive intervention to implement guidelines for cost-effective management of hypertension on medication use and cost, blood pressure control, and other resource use.

DESIGN

Retrospective cohort trial based on the Cleveland Veterans' Affairs Medical Center Firm System.

SETTING

General internal medicine teaching clinic in a large university-affiliated Department of Veterans Affairs Medical Center.

PARTICIPANTS

All patients seen in the intervention firm (n = 1273) and control firm (n = 884) clinics in the 3-month period following the introduction of the guidelines.

INTERVENTIONS

The control firm received guidelines and usual education for the cost-effective outpatient management of hypertension. The intervention firm received guidelines plus intensive guideline-based education and supervision.

MEASUREMENTS AND MAIN RESULTS

The use of guideline medications was greater in the intervention firm as compared with the control. The intervention firm initiated more hydrochlorothiazide (HCTZ), 17.4% (95% confidence interval [CI] 14.8, 20.1) of patients versus 11.9% (CI 9.3, 14.8) in the control firm (p = .002). Atenolol was initiated in 7.2% (CI 5.6, 9.0) in intervention firm versus 4.7% (CI 3.2, 6.6) in the control (p = .03). In addition, the use of nonguideline medications was less in the intervention firm. The intervention firm initiated less long-acting nifedipine, 7.8% (CI 6.0, 9.8) versus 10.6% (CI 8.2, 13.5) in the control (p = .04). Blood pressure control demonstrated greater improvement in the intervention firm (p = .02). Use of guidelines was associated with decreased costs for antihypertensive medications in the intervention firm as a whole as compared with the control firm. There was no increased use in other measured resources in the intervention firm including the number of outpatient laboratory services obtained, clinic visits, emergency room visits, or hospitalizations.

CONCLUSIONS

Intensive implementation of guideline-based education and supervision was associated with an increased use of guideline medications, decreased use of costly alternative agents, and no decrement in the measured outcomes of care.

Informatics: essential infrastructure for quality assessment and improvement in nursing

In recent decades there have been major advances in the creation and implementation of information technologies and in the development of measures of health care quality. The premise of this article is that informatics provides essential infrastructure for quality assessment and improvement in nursing. In this context, the term quality assessment and improvement comprises both short-term processes such as continuous quality improvement (CQI) and long-term outcomes management. This premise is supported by 1) presentation of a historical perspective on quality assessment and improvement; 2) delineation of the types of data required for quality assessment and improvement; and 3) description of the current and potential uses of information technology in the acquisition, storage, transformation, and presentation of quality data, information, and knowledge.