Clinical practice guidelines in practice and education

Appropriate Use Criteria Committees: The professional society role in the development and implementation of Appropriate Use Criteria

Vascular surgeons have the ability to manage and intervene on numerous vascular diseases of both the arterial and venous systems. With the growing number of interventions available as endovascular technology evolves, it is important to determine when a procedure is safely indicated for a vascular surgery patient. Appropriate Use Criteria (AUC) offer synthesized clinical information and practice standards that can aid clinicians in making these management decisions. Professional societies, such as the Society for Vascular Surgery, bring experts in the field together to collaborate and create AUC for various vascular diseases and interventions. It is essential to publish these criteria in peer-reviewed journals, as well as make them available on public websites so the information is available to vascular surgeons and interventionalists from other specialties who also treat patients with vascular disease. Cardiology, interventional radiology, and interventional nephrology are some other specialties that perform procedures for vascular disease, and vascular interventions by nonsurgeon specialists continue to increase. The Society for Vascular Surgery has published AUC on intermittent claudication, carotid disease, and abdominal aneurysm management. These are intended to guide practice, but also have highlighted areas for improvement that would allow for more universal implementation of AUC in vascular patient care across medical specialties. Increased intersocietal participation and perhaps inclusion of government and other payer participation will allow professional society-sponsored AUC to evolve, resulting in coordinated, appropriate care for vascular surgery patients.

Patients' requests for radiological imaging: A qualitative study on general practitioners' perspectives

BACKGROUND

With the increasing availability of information, patients are becoming more informed about radiology procedures and requesting imaging studies. This qualitative study aims to explore factors that influence general practitioners' (GPs) decisions to fulfil patient requests for imaging studies during clinical consultation.

METHODS

Semi-structured interviews were conducted with 10 GPs working across five private medical centres in Northwest Sydney. Conventional content analysis was used with emergent themes to identify GPs perspectives.

RESULTS

Six themes stood out from the interviews with GPs fulfilling patient requests for imaging studies. They included four pertaining to patient factors: patient expectations, 'therapeutic scans', 'impressive labels' and entitled. Two further themes pertained to the GP perspective and included defensive medicine, and 'new patients'. Requests are fulfilled from anxious or health-obsessed patients, with GPs worrying about litigation if they refuse. However, GPs decline requests from patients with entitlement attitudes or during first visits.

DISCUSSION

The findings suggest that GPs struggle to balance their responsibilities as gatekeepers of imaging with patients' expectations of request fulfilment. Clear guidelines on the appropriate use of diagnostic imaging and its limitations could help patients understand its proper use and ease anxiety. Additionally, education and training for GPs could help them manage patient expectations and provide appropriate care.

PATIENT CONTRIBUTIONS

Patients, service users, caregivers, people with lived experiences or members of the public were not directly involved in the design, conduct, analysis or interpretation of the study. However, our study was conducted in primary care facilities where the GPs were interviewed about patients' requests for diagnostic imaging based on their own initiatives. GPs' perspectives in managing patient expectations and healthcare utilisation were explored within the Australian Medicare system, where medical imaging and image-guided procedures come at little to no cost to the individual. The study findings contribute to a better understanding of the challenges faced by GPs in dealing with patient consumerism and requests for diagnostic imaging, as well as factors influencing request fulfilment or denial. Insights gained from this study may inform future research about delivering patient-centred care within a similar context.

'Some of my patients only come to renew their prescriptions. They are not interested in any additional advice or support'. Physicians' perceptions on their roles in cardiovascular diseases risk reduction and management in Fiji

BACKGROUND

Primary health care (PHC) physicians' perceptions are vital to understand as they are the first-line health care providers in cardiovascular diseases (CVD) risk assessment and management. This study aims to explore PHC physicians' perceptions on their roles and their perceptions on management and risk reduction approaches on CVD risk reduction and management in Fiji.

METHODS

This is a qualitative study conducted in the Suva Medical area among 7 health centers from 1 August to 31 September, 2021. Purposive sampling was used to recruit physicians who worked in the Suva medical area as PHC physicians with at least 6 months' experience in the Special Outpatients Department clinics. In-depth interview were conducted using a semi-structured questionnaire over the telephone and recorded on a tablet device application. The interview content was then transcribed, and thematic analysis was done.

RESULTS

This study included 25 PHC physicians. From the thematic analysis, 2 major themes emerged with 6 subthemes. Theme 1 was CVD management skills with 3 subthemes including education, experience and trainings, beliefs and attitudes of physicians, self-confidence and effectiveness in CVD risk reduction and management. Theme 2 was roles and expectations with 3 subthemes including perceptions of effective treatment, perceptions of physicians' roles and perceptions of patients' expectations. Physicians generally see their role as central and imperative. They perceive to be important and leading toward combating CVDs.

CONCLUSIONS

Physicians' perceptions on their commitment to prevention and management of CVDs through their skills and knowledge, beliefs and motivation should be acknowledged. It is recommended that the physicians are updated on the current evidence-based medicine. Limitations include results that may not be the reflection of the entire physician and multidisciplinary community and the difficulties in face-to-face interviews due to the coronavirus diseases of 2019 pandemic.

A method for structuring complex clinical knowledge and its representational formalisms to support composite knowledge interoperability in healthcare

INTRODUCTION

The use and interoperability of clinical knowledge starts with the quality of the formalism utilized to express medical expertise. However, a crucial challenge is that existing formalisms are often suboptimal, lacking the fidelity to represent complex knowledge thoroughly and concisely. Often this leads to difficulties when seeking to unambiguously capture, share, and implement the knowledge for care improvement in clinical information systems used by providers and patients.

OBJECTIVES

To provide a systematic method to address some of the complexities of knowledge composition and interoperability related to standards-based representational formalisms of medical knowledge.

METHODS

Several cross-industry (Healthcare, Linguistics, System Engineering, Standards Development, and Knowledge Engineering) frameworks were synthesized into a proposed reference knowledge framework. The framework utilizes IEEE 42010, the MetaObject Facility, the Semantic Triangle, an Ontology Framework, and the Domain and Comprehensibility Appropriateness criteria. The steps taken were: 1) identify foundational cross-industry frameworks, 2) select architecture description method, 3) define life cycle viewpoints, 4) define representation and knowledge viewpoints, 5) define relationships between neighboring viewpoints, and 6) establish characteristic definitions of the relationships between components. System engineering principles applied included separation of concerns, cohesion, and loose coupling.

RESULTS

A "Multilayer Metamodel for Representation and Knowledge" (M*R/K) reference framework was defined. It provides a standard vocabulary for organizing and articulating medical knowledge curation perspectives, concepts, and relationships across the artifacts created during the life cycle of language creation, authoring medical knowledge, and knowledge implementation in clinical information systems such as electronic health records (EHR).

CONCLUSION

M*R/K provides a systematic means to address some of the complexities of knowledge composition and interoperability related to medical knowledge representations used in diverse standards. The framework may be used to guide the development, assessment, and coordinated use of knowledge representation formalisms. M*R/K could promote the alignment and aggregated use of distinct domain-specific languages in composite knowledge artifacts such as clinical practice guidelines (CPGs).

Design of a Clinical Practice Guideline in Nurse-Led Ventilator-Weaning for Nursing Training

Cardiothoracic intensive care unit (CICU) nurses have shared the role and responsibility for ventilator-weaning to expedite decision-making in patient care. However, the actions taken are based on individual's unstructured training experience as there is no clinical practice guideline (CPG) for nurses in Malaysia. Hence, this study aims to design a CPG for the process of weaning from mechanical ventilation (MV) for a structured nursing training in a CICU at the National Heart Institute (Institut Jantung Negara, IJN) Malaysia. The Fuzzy Delphi Method (FDM) was employed to seek consensus among a panel of 30 experts in cardiac clinical practice on the guidelines. First, five experts were interviewed and their responses were transcribed and analyzed to develop the items for a FDM questionnaire. The questionnaire, comprising of 73 items, was distributed to the panel and their responses were analyzed for consensus on the design of the CPG. The findings suggested that the requirements expected for the nurses include: (a) the ability to interpret arterial blood gases, (b) knowledge and skills on the basics of mechanical ventilation, and (c) having a minimum 1-year working experience in the ICU. On the other hand, the CPG should mainly focus on developing an ability to identify criteria of patient eligible for weaning from MV. The learning content should focus on: (a) developing the understanding and reasoning for weaning and extubating and (b) technique/algorithm for extubating and weaning. Also, the experts agreed that the log book/competency book should be used for evaluation of the program. The CPG for structured nursing training at IJN in the context of the study is important for developing the professionalism of CICU nurses in IJN and could be used for training nurses in other CICUs, so that decision for ventilator-weaning from postcardiac surgery could be expedited.

Systematic review and appraisal of clinical practice guidelines on pelvic organ prolapse using the AGREE II tool

AIMS

To systematically evaluate the content and quality of national and international clinical guidelines on pelvic organ prolapse (POP).

METHODS

We searched medical databases and organizations websites, to identify national and international guidelines on diagnosis and management of POP. Five authors independently assessed guidelines using the validated AGREE II tool. Its six domains include (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence.

RESULTS

Eight guidelines met the inclusion criteria. Three hundred and thirteen different recommendations were identified. One hundred and ninety-nine recommendations were comparable across guidelines. Thirty-one recommendations were not supported by research evidence. Assessment by history and physical examination using the POP quantification system and consideration of imaging were recommendations featuring in all guidelines. Conservative treatment recommendations namely pelvic floor muscle training and vaginal pessaries were also found in all guidelines. Regarding surgical management, patient counseling, treating only symptomatic POP, consideration of apical fixation during surgical treatment, and use of biological or synthetic implants in recurrent cases were recommendations in all guidelines. Overall, the highest median scores were in the domains "scope and purpose" and "rigor of development". The lowest median score was for applicability (28.3%). Although the median score of "editorial independence" was high (85.4%), variability was also substantial (interquartile range: 12.5-100).

CONCLUSION

We identified variations in quality and deficiencies in certain areas, especially "applicability" and "editorial independence." Improvements in these key domains may enhance the quality and clinical impact of clinical practice guidelines.

New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision Support Versus Guidelines for Human Immunodeficiency Virus Treatment Selection by Trainees

BACKGROUND

Support for clinicians in human immunodeficiency virus (HIV) medicine is critical given national HIV-provider shortages. The US Department of Health and Human Services (DHHS) guidelines are comprehensive but complex to apply for antiretroviral therapy (ART) selection. Human immunodeficiency virus antiretroviral selection support and interactive search tool (HIV-ASSIST) (www.hivassist.com) is a free tool providing ART decision support that could augment implementation of clinical practice guidelines.

METHODS

We conducted a randomized study of medical trainees at Johns Hopkins University, in which participants were asked to select an ART regimen for 10 HIV case scenarios through an electronic survey. Participants were randomized to receive either DHHS guidelines alone, or DHHS guidelines and HIV-ASSIST to support their decision making. ART selections were graded "appropriate" if consistent with DHHS guidelines, or concordant with regimens selected by HIV experts at 4 academic institutions.

RESULTS

Among 118 trainees, participants randomized to receive HIV-ASSIST had a significantly higher percentage of appropriate ART selections compared to those receiving DHHS guidelines alone (percentage of appropriate responses in DHHS vs HIV-ASSIST arms: median [Q1, Q3], 40% [30%, 50%] vs 90% [80%, 100%]; P < .001). The effect was seen for all case types, but most pronounced for complex cases involving ART-experienced patients with ongoing viremia (DHHS vs HIV-ASSIST: median [Q1, Q3], 0% [0%, 33%] vs 100% [66%, 100%]).

CONCLUSIONS

Trainees using HIV-ASSIST were significantly more likely to choose appropriate ART regimens compared to those using guidelines alone. Interactive decision support tools may be important to ensure appropriate implementation of HIV guidelines.

CLINICAL TRIALS REGISTRATION

NCT04080765.

Utilization of BPM+ Health for the Representation of Clinical Knowledge: A Framework for the Expression and Assessment of Clinical Practice Guidelines (CPG) Utilizing Existing and Emerging Object Management Group (OMG) Standards

Clinical Practice Guidelines (CPG), meant to express best practices in healthcare, are commonly presented as narrative documents communicating care processes, decision making, and clinical case knowledge. However, these narratives in and of themselves lack the specificity and conciseness in their use of language to unambiguously express quality clinical recommendations. This impacts the confidence of clinicians, uptake, and implementation of the guidance. As important as the quality of the clinical knowledge articulated, is the quality of the language(s) and methods used to express the recommendations. In this paper, we propose the BPM+ family of modeling languages as a potential solution to this challenge. We present a formalized process and framework for translating CPGs into a standardized BPM+ model. Further, we discuss the features and characteristics of modeling languages that underpin the quality in expressing clinical recommendations. Using an existing CPG, we defined a systematic series of steps to deconstruct the CPG into knowledge constituents, assign CPG knowledge constituents to BPM+ elements, and re-assemble the parts into a clear, precise, and executable model. Limitations of both the CPG and the current BPM+ languages are discussed.

Diagnosis and treatment of pediatric myelodysplastic syndromes: A survey of the North American Pediatric Aplastic Anemia Consortium

BACKGROUND

Myelodysplastic syndromes (MDS) represent a group of clonal hematopoietic stem cell disorders that commonly progress to acute myeloid leukemia (AML). The diagnostics, prognostics, and treatment of adult MDS are established but do not directly translate to children and adolescents. Pediatric MDS is a rare disease, characterized by unique cytogenetics and histology compared with adult MDS, and often arises secondary to germline predisposition or cytotoxic exposures. Our objective was to highlight aspects of diagnosis/management that would benefit from further systematic review toward the development of clinical practice guidelines for pediatric MDS.

PROCEDURE

The North American Pediatric Aplastic Anemia Consortium (NAPAAC) is composed of collaborative institutions with a strong interest in pediatric bone marrow failure syndromes and hematologic malignancies. The NAPAAC MDS working group developed a national survey distributed to 35 NAPAAC institutions to assess data on (1) clinical presentation of pediatric MDS, (2) diagnostic evaluation, (3) criteria for diagnosis, (4) supportive care and treatment decisions, and (5) role of hematopoietic stem cell transplantation (HSCT).

RESULTS

Twenty-eight of 35 institutions returned the survey. Most centers agreed on a common diagnostic workup, though there was considerable variation regarding the criteria for diagnosis. Although there was consensus on supportive care, treatment strategies, including the role of cytoreduction and HSCT, varied across centers surveyed.

CONCLUSIONS

There is lack of national consensus on diagnosis and treatment of pediatric MDS. This survey identified key aspects of MDS management that will warrant systematic review toward the goal of developing national clinical practice guidelines for pediatric MDS.

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.

Systematic review of the appropriateness of eye care delivery in eye care practice

BACKGROUND

Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts' practice and to describe the methods used to measure appropriateness of eye care.

METHODS

A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts' practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974.

RESULTS

Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2-100% for glaucoma, 0-100% for diabetic retinopathy and 0-100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery.

CONCLUSIONS

These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives.

Development and Implementation of Clinical Practice Guidelines: An Update and Synthesis of the Literature With a Focus in Application to Spinal Conditions

STUDY DESIGN

Review.

OBJECTIVES

The objectives of this review are to (a) summarize the role of clinical practice guidelines (CPGs), (b) outline the methodology involved in formulating CPGs, (c) provide an illustration of these principles using a CPG developed for degenerative cervical myelopathy, and (d) highlight the importance of knowledge translation.

METHODS

A review of the literature was conducted to summarize current standards in CPG development and implementation.

RESULTS

CPGs are systematically developed statements intended to affect decisions made by health care providers, policy makers, and patients. The main objectives of CPGs are to synthesize and translate evidence into recommendations, optimize patient outcomes, standardize care, and facilitate shared decision making among physicians, patients, and their caregivers. The main steps involved in the development of CPGs include defining the clinical problem, assembling a multidisciplinary guideline development group and systematic review team, conducting a systematic review of the literature, translating the evidence to recommendations, critically appraising the CPG and updating the document when new studies arise. The final step in developing a CPG is to implement it into clinical practice; this step requires an assessment of the barriers to implementation and the formulation of effective dissemination strategies.

CONCLUSION

CPGs are an important component in the teaching and practice of medicine and are available for a wide spectrum of diseases. CPGs, however, can only be used to influence clinical practice if the recommendations are informed by a systematic review of the literature and developed using rigorous methodology. The opportunity to transform clinical management of spinal conditions is an attractive outcome of the application of high-quality CPGs.

Can the appropriateness of eye care be measured through cross-sectional retrospective patient record review in eye care practices in Australia? The iCareTrack feasibility study

OBJECTIVES

The CareTrack study found that a wide range of appropriateness of care (ie, care in line with evidence-based or consensus-based guidelines) was delivered across many health conditions in Australia. This study therefore aimed to demonstrate the feasibility of using the CareTrack method (a retrospective onsite record review) to measure the appropriateness of eye care delivery.

DESIGN

Cross-sectional feasibility study.

SETTING AND PARTICIPANTS

Two hundred and thirteen patient records randomly selected from eight optometry and ophthalmology practices in Australia, selected through a combination of convenience and maximum variation sampling.

METHODS

Retrospective record review designed to assess the alignment between eye care delivered and 93 clinical indicators (Delphi method involving 11 experts) extracted from evidence-based clinical practice guidelines.

PRIMARY OUTCOME MEASURE

Number of eligible patient records, sampling rates and data collection time. This feasibility study also tested the ability of 93 clinical indicators to measure percentage appropriate eye care for preventative, glaucoma and diabetic eye care. A secondary outcome was the percentage of practitioner-patient encounters at which appropriate eye care was received.

RESULTS

A median of 20 records (range 9 to 63) per practice were reviewed. Data collection time ranged from 3 to 5.5 hours (median 3.5). The most effective sampling strategy involved random letter generation followed by sequential sampling. The appropriateness of care was 69% (95% CI 67% to 70%) for preventative eye care, 60% (95% CI 56% to 58%) for glaucoma and 63% (95% CI 57% to 69%) for diabetic eye care.

CONCLUSIONS

Appropriateness of eye care can be measured effectively using retrospective record review of eye care practices and consensus-based care indicators.

Barriers and facilitators for guideline adherence in diagnostic imaging: an explorative study of GPs' and radiologists' perspectives

Background

Diagnostic imaging has been a part of medicine for the last century. It has been difficult to implement guidelines in this field, and unwarranted imaging has been a frequent problem. Some work has been done to explain these phenomena separately. Identifying the barriers to and facilitators of guideline use has been one strategy. The aim of this study is to offer a more comprehensive explanation of deviations from the guideline by studying the two phenomena together.

Methods

Eight general practitioners and 10 radiologists from two counties in Norway agreed to semi-structured interviews. Topics covered in the interviews were knowledge of the guideline, barriers to and facilitators of guideline use, implementation of guidelines and factors that influence unwarranted imaging.

Results

Several barriers to and facilitators of guideline use were identified. Among these are lack of time, pressure from patients, and guidelines being too long, rigid or unclear. Facilitators of guideline use were easy accessibility and having the guidelines adapted to the target group. Some of the factors that influence unwarranted imaging are lack of time, pressure from patients and availability of imaging services.

Conclusion

There are similarities between the perceived barriers for guideline adherence and the perceived factors that influence unwarranted imaging. There may be a few reasons that explains the deviation from guidelines, and the amount of unwarranted imaging.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3372-7) contains supplementary material, which is available to authorized users.

Involving general practice trainees in clinical practice guideline adaptation

BACKGROUND

It is unclear whether it is feasible to involve residents in guideline development or adaptation. We designed a multifaceted training program that combines training sessions, a handbook and a documentation tool to assist general practice (GP)-trainees in the adaptation of clinical practice guidelines (CPGs). The aim of this study is to adapt a database of CPGs by involving GP-trainees and to build evidence-based practice (EBP) learning capacity.

METHODS

We assessed each adaptation process and surveyed all GP-trainees who enrolled in our training program on their views on the program. They were asked to formulate an overall rating for the training and were asked to rate individual aspects of the training program (the training sessions, the handbook and the documentation tool).

RESULTS

To date, 122 GP-trainees followed the training and have adapted 60 different CPGs. Overall quality of their work was good. Based on an assessment of the content of the documentation tool, 24 (40%) adapted CPGs rated as good quality and 30 (50%) rated as moderate quality. Only 3 adapted CPGs (5%) were evaluated as being of poor quality. 51 (42%) GP-trainees completed the survey on user satisfaction. 98% (50) of the GP-trainees found the training to be of good overall quality. 86% of the GP-trainees were satisfied with the handbook but satisfaction was lowest for the documentation tool (47% satisfied).

CONCLUSION

It is possible to engage GP-trainees in CPG adaptation using a formal process when provided with training, feedback and documentation tools.

High prevalence of latent tuberculosis and bloodborne virus infection in a homeless population

Introduction

Urban homeless populations in the UK have been shown to have high rates of active tuberculosis, but less is known about the prevalence of latent tuberculosis infection (LTBI). This study aimed to estimate the prevalence of LTBI among individuals using homeless hostels in London.

Methods

We performed a cross-sectional survey with outcome follow-up in homeless hostels in London. Our primary outcome was prevalence of LTBI. Recruitment for the study took place between May 2011 and June 2013. To estimate an LTBI prevalence of 10% with 95% CIs between 8% and 13%, we required 500 participants.

Results

491/804 (61.1%) individuals agreed to be screened. The prevalence of LTBI was 16.5% (81/491; 95% CI 13.2 to 19.8). In UK-born individuals, a history of incarceration was associated with increased risk of LTBI (OR 3.49; 95% CI 1.10 to 11.04; P=0.018) after adjusting for age, length of time spent homeless and illicit drug use. Of the three subjects who met English treatment guidelines for LTBI at the time of the study, none engaged with services after referral for treatment. Prevalence of past hepatitis B infection was 10.4% (51/489; 95% CI 7.7 to 13.1), and 59.5% (291/489; 95% CI 55.1 to 63.9) of individuals were non-immune. Prevalence of current hepatitis C infection was 10.4% (51/489; 95% CI 7.8 to 13.1).

Conclusions

This study demonstrates the high prevalence of LTBI in homeless people in London and the associated poor engagement with care. There is a large unmet need for LTBI and hepatitis C infection treatment, and hepatitis B vaccination, in this group.

The effect of electronic health record software design on resident documentation and compliance with evidence-based medicine

This study aimed to determine the role of electronic health record software in resident education by evaluating documentation of 30 elements extracted from the American Academy of Ophthalmology Dry Eye Syndrome Preferred Practice Pattern. The Kresge Eye Institute transitioned to using electronic health record software in June 2013. We evaluated the charts of 331 patients examined in the resident ophthalmology clinic between September 1, 2011, and March 31, 2014, for an initial evaluation for dry eye syndrome. We compared documentation rates for the 30 evidence-based elements between electronic health record chart note templates among the ophthalmology residents. Overall, significant changes in documentation occurred when transitioning to a new version of the electronic health record software with average compliance ranging from 67.4% to 73.6% (p < 0.0005). Electronic Health Record A had high compliance (>90%) in 13 elements while Electronic Health Record B had high compliance (>90%) in 11 elements. The presence of dialog boxes was responsible for significant changes in documentation of adnexa, puncta, proptosis, skin examination, contact lens wear, and smoking exposure. Significant differences in documentation were correlated with electronic health record template design rather than individual resident or residents’ year in training. Our results show that electronic health record template design influences documentation across all resident years. Decreased documentation likely results from “mouse click fatigue” as residents had to access multiple dialog boxes to complete documentation. These findings highlight the importance of EHR template design to improve resident documentation and integration of evidence-based medicine into their clinical notes.

Rethinking the Role of Clinical Practice Guidelines in Pharmacy Education

Clinical practice guidelines (CPGs) play a major role in pharmacy education. Students learn to locate, retrieve, and apply CPGs in didactic coursework and practice experiences. However, they often memorize and quote recommendations without critical analysis, which tends to undermine their clinical growth. Students should become genuine drug experts, based on strong critical-thinking skills and the ability to assimilate extensive clinical and scientific knowledge. Clinical practice guidelines improve health care, and students should be familiar with them, but there are legitimate criticisms of CPGs, stemming largely from potential conflicts of interest and limitations in the quality and scope of available evidence. Despite such flaws, CPGs can be used to facilitate the clinical growth of students if the emphasis is placed on critically analyzing and evaluating CPG recommendations, as opposed to blindly accepting them. From that perspective, the role that CPGs have come to play in education may need to be reconsidered.

Benchmarks for ethically credible partnerships between industry and academic health centers: beyond disclosure of financial conflicts of interest

Relationships between industry and university-based researchers have been commonplace for decades and have received notable attention concerning the conflicts of interest these relationships may harbor. While new efforts are being made to update conflict of interest policies and make industry relationships with academia more transparent, the development of broader institutional partnerships between industry and academic health centers challenges the efficacy of current policy to effectively manage these innovative partnerships. In this paper, we argue that existing strategies to reduce conflicts of interest are not sufficient to address the emerging models of industry-academic partnerships because they focus too narrowly on financial matters and are not comprehensive enough to mitigate all ethical risk. Moreover, conflict-of-interest strategies are not designed to promote best practices nor the scientific and social benefits of academic-industry collaboration. We propose a framework of principles and benchmarks for "ethically credible partnerships" between industry and academic health centers and describe how this framework may provide a practical and comprehensive approach for designing and evaluating such partnerships.

Trends in Pediatric Versus Adult Ophthalmology Publications Over 15 Years

PURPOSE

To evaluate and compare trends in different categories of pediatric and adult ophthalmology publications.

METHODS

Publications in ophthalmology between January 1, 1998, and December 31, 2012, were retrieved from PubMed. An age filter separated pediatric from adult articles.

RESULTS

There was a significant linear increase in the number of publications in both pediatric and adult publications. There was an increase over time in pediatric and adult clinical trials, letters to the editor, meta-analyses, and systematic reviews. There was a significant increase in adult randomized controlled trials only. No meaningful statistical analyses could be conducted for practice guidelines.

CONCLUSIONS

Pediatric and adult ophthalmology have demonstrated a significant increase in annual published articles. Practicing ophthalmologists have an increasing number of articles to read and might become more and more dependent on search engines and reviews to remain informed, emphasizing the need for official practice guidelines that are, unfortunately, seldom published.

A New Disability-related Health Care Needs Assessment Tool for Persons With Brain Disorders

Objectives

This study aimed to develop a health needs assessment (HNA) tool for persons with brain disorders and to assess the unmet needs of persons with brain disorders using the developed tool.

Methods

The authors used consensus methods to develop a HNA tool. Using a randomized stratified systematic sampling method adjusted for sex, age, and districts, 57 registered persons (27 severe and 30 mild cases) with brain disorders dwelling in Seoul, South Korea were chosen and medical specialists investigated all of the subjects with the developed tools.

Results

The HNA tool for brain disorders we developed included four categories: 1) medical interventions and operations, 2) assistive devices, 3) rehabilitation therapy, and 4) regular follow-up. This study also found that 71.9% of the subjects did not receive appropriate medical care, which implies that the severity of their disability is likely to be exacerbated and permanent, and the loss irrecoverable.

Conclusions

Our results showed that the HNA tool for persons with brain disorders based on unmet needs defined by physicians can be a useful method for evaluating the appropriateness and necessity of medical services offered to the disabled, and it can serve as the norm for providing health care services for disabled persons. Further studies should be undertaken to increase validity and reliability of the tool. Fundamental research investigating the factors generating or affecting the unmet needs is necessary; its results could serve as basis for developing policies to eliminate or alleviate these factors.

Computerized clinical decision support: a technology to implement and validate evidence based guidelines

Faced with a documented crisis of patients not receiving appropriate care, there is a need to implement and refine evidence-based guidelines (EBGs) to ensure that patients receive the best care available. Although valuable in content, among their deficiencies, EBGs do not provide explicit methods to bring proven therapies to the bedside. Computerized information technology, now an integral part of the US healthcare system at all levels, presents clinicians with information from laboratory, imaging, physiologic monitoring systems, and many other sources. It is imperative that we clinicians use this information technology to improve medical care and efficacy of its delivery. If we do not do this, nonclinicians will use this technology to tell us how to practice medicine. Computerized clinical decision support (CCDS) offers a powerful method to use this information and implement a broad range of EBGs. CCDS is a technology that can be used to develop, implement, and refine computerized protocols for specific processes of care derived from EBGs, including complex care provided in intensive care units. We describe this technology as a desirable option for the trauma community to use information technology and maintain the trauma surgeon/intensivist's essential role in specifying and implementing best care for patients. We describe a process of logical protocol development based on standardized clinical decision making to enable EBGs. The resulting logical process is readily computerized, and, when properly implemented, provides a stable platform for systematic review and study of the process and interventions.

CONCLUSION

: CCDS to implement and refine EBG derived computerized protocols offers a method to decrease variability, test interventions, and validate improved quality of care.

Practice guidelines as multipurpose tools: A qualitative study of noninvasive ventilation*

OBJECTIVE

Although practice guidelines for noninvasive ventilation (NIV) for patients with acute respiratory failure (ARF) have the potential to improve processes of care and patient outcomes, clinicians' views about life support technology guidelines are not well understood. The objective was to understand the knowledge about and attitudes toward an NIV guideline for patients with ARF and potential barriers to its use.

DESIGN

Qualitative study based on individual, in-depth, semistructured interviews.

SETTING

St. Joseph's Healthcare, Hamilton, Ontario.

SUBJECTS

Thirty clinicians (six attending physicians, five residents, 12 nurses, and seven respiratory therapists) who used NIV for chronic obstructive pulmonary disease and congestive heart failure patients with ARF, before and after NIV guideline implementation.

INTERVENTIONS

We elicited knowledge and attitudes about, behaviors toward, and barriers to our institutional NIV guideline. We transcribed all interviews and analyzed data in triplicate using grounded theory to identify themes and develop a framework for understanding clinicians' views on guidelines.

MEASUREMENTS AND MAIN RESULTS

The NIV guideline was perceived to define individual clinical responsibilities, improve clinician comfort with use of technology, increase patient safety, and reduce practice variability. Barriers to guideline use included lack of awareness of the guideline, unclear guideline format and presentation, and reluctance about changing practice. Contrary to previous research, participants in this study did not report that the practice guideline limited clinical autonomy. Clinicians used the guideline variously as an educational resource, to access monitored beds, to avoid clinical conflict, or to leverage professional credibility.

CONCLUSIONS

This qualitative study illustrated how the NIV guideline at our institution is understood as a tool that facilitates the multidisciplinary care of patients with ARF. Guideline use may be enhanced through education to improve guideline awareness and increase comfort with recommended practices. Developers should be aware of the role of guidelines for purposes other than bedside decision making for individual patients.

Advancing practice inquiry: Research foundations of the practice doctorate in nursing

The University of Washington Doctor of Nursing Practice program entails 3 curricular dimensions: advanced practice, leadership, and practice inquiry. In this article, the practice inquiry dimension is discussed and defined as a type of clinical investigation that closely aligns with the realities and complexities of everyday practice by advanced practice nurses (APNs). The advancement of APNs' practice inquiry competencies is timely for its interfaces with the national scientific agenda's emphasis on translating science to clinical practice, health care delivery systems and policy. A framework for conceptualizing a practice inquiry curriculum and competencies is proposed. In addition, the divergent and convergent comparisons with Doctor of Philosophy (PhD) nursing programs are discussed, with emphasis placed on potential collaborative clinical research endeavors.

Consensus meeting for the management of gastrointestinal stromal tumors. Report of the GIST Consensus Conference of 20-21 March 2004, under the auspices of ESMO

BACKGROUND

The management of gastrointestinal stromal tumors (GIST) has evolved very rapidly in the last 4 years. The objectives of this international consensus meeting were to describe the optimal management procedures for patients with GIST in localized and advanced stages, as well as research issues for the future.

MATERIALS AND METHODS

A panel of experts from six specialties, including pathology, molecular biology, imaging, surgery, medical oncology and methodologists for clinical practice guidelines from different European and extra European sarcoma societies were invited to a 2-day workshop. Several questions were selected by the organizing committee prior to the conference. Selected panelists reviewed the current levels of evidence for each point, and presented their conclusions during the meeting. These proposals were discussed, and consensus points were identified and categorized according to the Standard Options Recommandations (SOR) of the French Federation of Cancer Centers and National Comprehensive Cancer Network (NCCN).

RESULTS

Thirty-two consensus points were identified, most from categories 2A of the NCCN and B2 of the SOR. Among these, the standard histological examination with immunohistochemical analysis using CD117, CD34, PS100, desmin and smooth muscle actin is considered standard. Molecular biology for the identification of KIT and PDGFRA mutation is an optional diagnostic procedure for GIST with negative CD117 staining, and otherwise is considered a research procedure. Complete tumor resection with negative tumor margins is the standard surgical treatment. Adjuvant imatinib after optimal tumor resection as well as neo-adjuvant imatinib remain experimental approaches to be performed within prospective clinical studies. Imatinib should be started at the date of diagnosis of metastatic relapse and given until development of intolerance or progressive disease. The optimal criteria for tumor response to imatinib remain to be delineated, and should include not only tumor size reduction or disease stabilization, but also reduction of tumor density (Hounsfield Units) on computed tomography and metabolic activity (i.e. reduction of FDG uptake on positron emission tomography). In a substantial proportion of patients, stable disease and even increase in tumor size may be associated with pathologic response to imatinib therapy, and available survival data indicate that the survival of these patients is similar to that of patients with conventional tumor response. Metastasis resection is an experimental procedure.

CONCLUSIONS

Consensus points in clinical management of GIST as well as questions for future clinical trials were identified during this consensus conference on GIST management.

Disease management for chronic pain: barriers of program implementation with primary care physicians

OBJECTIVE

This study investigated the implementation of a disease management (DM) program for chronic pain among primary care physicians. Its aim was the dissemination of guidelines for the treatment of chronic pain to help primary care physicians identify, treat, and manage patients highly impaired by pain. The goals of the program were: 1) To identify those pain patients who are at greatest disability due to pain; 2) To assess the impact of a DM program for pain on clinical practice; and 3) To evaluate the effect of the program on physician's use, compliance, and satisfaction with guidelines.

METHODS

Thirty primary care physicians followed 82 patients who were identified as having chronic migraine headaches, back pain, or painful peripheral neuropathy. All patients were categorized according to their level of disability based on ratings of pain intensity, activity interference, emotional distress, perceived support, and work disability. Treatment algorithms developed for this study were placed in the charts of those patients considered to have moderate or high disability. Physicians completed pre- and poststudy questionnaires.

RESULTS

Chronic pain patients could be successfully classified according to the disability from their pain and physicians were open to accepting guidelines for treatment. By the end of the study, primary care physicians reported improved confidence in treating chronic pain. Most felt that chronic pain management was a problem in their practice, and they recognized the benefit of treatment algorithms. Many of the physicians, however, expressed reluctance to regularly consult the algorithms when treating chronic pain.

DISCUSSION

The identification of barriers for implementation of DM programs for pain is presented, and recommendations for future implementation are discussed.

Expanding developmental and behavioral services for newborns in primary care: implications of the findings

BACKGROUND

In two other papers in this issue, the rationale, development, implementation, experimental design, approach to evaluation, and early results of a program to deliver developmental and behavioral services to all infants in primary care practice were described. Positive effects were seen for parental satisfaction, including decreased disenrollment, provider satisfaction, parenting practices, and health outcomes.

METHODS

In the present article, the results are reviewed and implications of our findings for the delivery of care, families, healthcare systems, and further research are discussed.

RESULTS

Findings that have broad implications are as follows: (1) developmental and behavioral services can be delivered successfully in practice using dedicated professionals to deliver and integrate services; (2) the "planned care model" was useful in program implementation for making "the right thing to do, the easy thing to do"; (3) the added focus on satisfaction and cost helps to develop the "business case" for broad scale implementation; (4) bonding of parents to organizations has marketing implications; (5) the program provides positive effects for all parents, not just high-risk parents; and (6) several research questions emerge, including persistence of effects on health outcomes, costs, and utilization.

CONCLUSIONS

The authors conclude that study results have implications for preventive services, families, child healthcare in office practice, healthcare systems, and healthcare policy. In this ongoing study, examination of intervention effects at 30 months of age shoud be informative. Further research is warranted as it remains to be seen whether or not these interventions can become viable ongoing programs.

An evidence-based approach to the development of national dietary guidelines

It has become apparent that confusing and conflicted nutritional advice from the media in combination with a quick reversal of policymakers' national nutrition recommendations have the potential to lead to public disbelief and cynicism for both the process and the conclusions. Consequently, poor design of policy can lead to ineffective communications with health professionals and the public. The ultimate result is that the public will ignore the recommendations with potentially adverse outcomes. Formal evidence-based clinical practice guidelines are being used regularly in the medical community. The methodology used to develop these guidelines includes a systematic review of the literature, filtering the literature for relevant articles, assessing the scientific quality of the available evidence, and rating the strength or weakness of the final recommendation. This article suggests that national dietary guidelines may be improved if they are based on a more formal evidence-based approach. Current research that is being conducted to test components of a generic, standardized methodology for developing evidence-based population targeted dietary guidelines is described.

Guidelines in the intensive care unit

The recent movement toward standardization of critical care practice is associated with a growth in the use of guidelines and protocols. Although complex, the process of guideline development, implementation, evaluation, and maintenance can be systematic. Guideline implementation can improve the processes and outcomes of care; however, guideline adherence represents a major challenge to their success. The quality of the growing number of practice guidelines in critical care is important to assess and several useful instruments are available for this purpose.

Does a clinical pathway improve the quality of care for sickle cell anemia?

BACKGROUND

Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.

RESULTS

Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.

DISCUSSION

Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.

Adapting a national guideline for local use: a comparative case study in a US and an Israeli health maintenance organization

OBJECTIVES

We compared the way a US and an Israeli health maintenance organization (HMO) used the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (the JNC-V) in developing a hypertension guideline.

METHODS

Comparative case study. We describe and contrast the two HMOs, the social contexts in which they function, their motivations for creating a local guideline and their guideline development processes. We then compare the two HMO guidelines with each other and with the JNC-V. Based on this analysis, we offer provisional answers to some key concerns raised by local adaptations of national or international guidelines. These include whether adaptations will reflect local cost-containment concerns in ways that could threaten quality of care, whether guidelines constitute a threat to physician autonomy and the relationship between local adaptations and the evolution of national or international guidelines.

RESULTS

The HMO guidelines differed substantially, and in similar ways, from the JNC-V in format, coverage and emphasis of topics. They differed from it minimally, but also in similar ways, in the content of their recommendations. Each HMO guideline 'improvised' on the JNC-V in ways that differed to reflect local needs and objectives but did not significantly distort the original. Quality of care considerations appeared to predominate over cost considerations, and we found no evidence that guidelines threatened physician autonomy.

CONCLUSIONS

Local adaptations may function as part of the iterative process through which national or international guidelines evolve in ways more suitable for potential local use.

Expediting the transfer of evidence into practice: building clinical partnerships

A librarian/clinician partnership was fostered in one hospital through the formation of the Evidence-based Practice Committee, with an ulterior goal of facilitating the transfer of evidence into practice. The paper will describe barriers to evidence-based practice and outline the committee's strategies for overcoming these barriers, including the development and promotion of a Web-based guide to evidence-based practice specifically designed for clinicians (health professionals). Educational strategies for use of the Web-based guide will also be addressed. Advantages of this partnership are that the skills of librarians in meeting the needs of clinicians are maximized. The evidence-based practice skills of clinicians are honed and librarians make a valuable contribution to the knowledge-base of the clinical staff. The knowledge acquired through the partnership by both clinicians and librarians will increase the sophistication of the dialogue between the two groups and in turn will expedite the transfer of evidence into practice.

Pediatric Milliman and Robertson length-of-stay criteria: are they realistic?

OBJECTIVE

Guidelines for inpatient length of stay (LOS) have been developed by several groups; among the most widely applied are those published by Milliman and Robertson (M&R). Few published reports have examined the relationship of actual practice to such guidelines, none in pediatric populations. This study was designed to compare pediatric practice in a large and defined population to M&R LOS criteria.

METHODS

Administrative data from New York State in 1995 were used to examine LOS for discharges corresponding to 16 selected pediatric diagnoses for which M&R publishes guidelines. Outliers, defined as the 2% of discharges with the longest LOS, were eliminated. The distribution of LOS for each diagnosis was compared with M&R LOS guidelines.

RESULTS

In New York State during 1995, pediatric LOS was markedly divergent from M&R guidelines. In general, the percentage of discharges in excess of the criterion LOS was less for nonmandatory admissions (croup: 23%, gastroenteritis: 44%, and pneumonia: 48%) than for those requiring surgery (uncomplicated appendectomy: 67%, pyloromyotomy: 62%, and major but noncritical burns: 64%) or prolonged treatment with antibiotics (bacterial meningitis: 91% and osteomyelitis: 86%).

CONCLUSIONS

In New York State during 1995, LOS for selected pediatric conditions was generally in excess of published M&R guidelines. This raises concern about the potential effects of such guidelines on both patients and the hospitals caring for them. While endorsing the need for cost-effective practice, we call attention to the methods used to develop and validate guidelines.length of stay, pediatrics, managed health care, administrative data, practice guidelines.

Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression

BACKGROUND

The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms.

METHODS

Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the setting's two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis.

RESULTS

Most of the CQI team's recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status.

CONCLUSIONS

New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.

The importance of randomized clinical trials and evidence-based medicine: a clinician's perspective

Clinical evaluation of therapies for patient care has evolved during the twentieth century from a variety of scientific methods. As a result of medical, political, and economic changes that occurred in the 1990s, randomized clinical trials and evidence-based methods are presently in the forefront of the physician's thinking in the decision-making process for therapeutic interventions. A new standard of patient care has emerged during this process. This report provides a clinician's viewpoint of the importance and interpretation of evidence-based methods and suggests a strategy when such evidence does not exist.

Including practice data to improve evidence-based guidelines. Example of guidelines on the management of thyroid nodules

Although clinical guidelines are based on the best evidence available, their proliferation has often failed to change actual practice. One of the many explanations suggested is that there is a gap between the expectations of the targeted professionals and the recommendations in the guidelines. In this study, we attempted to take into account the state of current practice and the physicians' priorities. Using the example of guidelines on the management of thyroid nodules, three different surveys have been conducted: (1) an analysis of physicians' expectations and practice through a postal questionnaire to define appropriate questions; (2) a survey of the professionals' expert opinions, and (3) a prospective study of the use of these guidelines in the management of 253 patients. The results of these surveys have modified the development of the guidelines, and helped us to adapt the content of the guidelines to match physicians' practices more closely.

The future of end-stage renal disease care: nephrology enters a new millennium

There are many challenges facing the discipline of nephrology as we enter the next millennium. There will be a continuing increase in the number of patients requiring renal replacement therapy, with older, sicker patients predominating. At the same time the available workforce to provide care to these patients is not growing quickly enough to keep up with the demand. In the broader health care delivery system, consolidation of services, vertical and horizontal integration, a continued move to for-profit entities, and constant pressure on cost containment will increasingly characterize the immediate future. The rapidity with which health care delivery and financing are changing will make it difficult for patients and health care professionals alike, but it will also offer opportunities. In nephrology, development of a collaborative model of care has already begun and will be an important part of the response to this changing care environment. Collaborative care and the application of the principles of chronic disease management to renal patients will provide the best opportunities to capitalize on new technologies and treatments as they become available and to streamline and improve the care delivery process. This should lead to improved quality of care for renal patients, while constraining costs and providing for continued professional growth and satisfaction.