Dementia diagnostic guidelines: methodologies, results, and implementation costs

The quality of hereditary haemochromatosis guidelines: a comparative analysis

BACKGROUND AND OBJECTIVES

Hereditary haemochromatosis (HH) is the most prevalent genetic liver disease, with an incidence of 1/200 to 1/400 in the Caucasian population. HH patients are treated by family physicians as well as different specialists. When left untreated or insufficiently treated, the complications can become life threatening. To support and evaluate qualitative care for HH, we evaluated and compared the available structured guidelines on screening, diagnosis and management of HH patients.

METHODS

Seven appraisers systematically reviewed the retrieved guidelines. The Appraisal of Guidelines Research and Evaluation II (AGREE II) was used to score and discuss the quality and reach consensus. The content of recommendations and the evidence behind them, were evaluated.

RESULTS

Three guidelines, developed by the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL) and a DUTCH guideline were found. Fifty-seven percent of the recommendations were not shared between the guidelines, pointing to inconsistency of their content. Only two references supporting the recommendations were shared between all three guidelines. The AASLD guideline contains no information about management and follow-up. Moreover, the methodological quality of the AASLD guideline was rated insufficient, except for 'clarity and presentation' (77%). Applicability of the guidelines was scored very low in all three (AASLD: 31%, EASL: 23%, DUTCH: 35%). The DUTCH guideline was judged best.

CONCLUSIONS

Very poor consistency between available guidelines for HH hampers qualitative care and its evaluation. An updated high-quality and evidence-based guideline that covers follow-up and management of patients with HH is needed.

Guidelines for guideline developers: a systematic review of grading systems for medical tests

BACKGROUND

A variety of systems have been developed to grade evidence and develop recommendations based on the available evidence. However, development of guidelines for medical tests is especially challenging given the typical indirectness of the evidence; direct evidence of the effects of testing on patient important outcomes is usually absent. We compared grading systems for medical tests on how they use evidence in guideline development.

METHODS

We used a systematic strategy to look for grading systems specific to medical tests in PubMed, professional guideline websites, via personal correspondence, and handsearching back references of key articles. Using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument as a starting point, we defined two sets of characteristics to describe these systems: methodological and process ones. Methodological characteristics are features relating to how evidence is gathered, appraised, and used in recommendations. Process characteristics are those relating to the guideline development process. Data were extracted in duplicate and differences resolved through discussion.

RESULTS

Twelve grading systems could be included. All varied in the degree to which methodological and process characteristics were addressed. Having a clinical scenario, identifying the care pathway and/or developing an analytical framework, having explicit criteria for appraising and linking indirect evidence, and having explicit methodologies for translating evidence into recommendations were least frequently addressed. Five systems at most addressed these, to varying degrees of explicitness and completeness. Process wise, features most frequently addressed included involvement of relevant professional groups (8/12), external peer review of completed guidelines (9/12), and recommendations on methods for dissemination (8/12). Characteristics least often addressed were whether the system was piloted (3/12) and funder information (3/12).

CONCLUSIONS

Five systems for grading evidence about medical tests in guideline development addressed to differing degrees of explicitness the need for and appraisal of different bodies of evidence, the linking of such evidence, and its translation into recommendations. At present, no one system addressed the full complexity of gathering, assessing and linking different bodies of evidence.

Alzheimer's disease dementia guidelines for diagnostic testing: a systematic review

Alzheimer's disease dementia (AD dementia) is one of the most common neurodegenerative diseases worldwide, with a growing incidence during the last decades. Clinical diagnosis of cognitive impairment and presence of AD biomarkers have become important issues for early and adequate treatment. We performed a systematic literature search and quality appraisal of AD dementia guidelines, published between 2005 and 2011, which contained diagnostic recommendations on AD dementia. We also analyzed diagnostic recommendations related to the use of brief cognitive tests, neuropsychological evaluation, and AD biomarkers. Of the 537 retrieved references, 15 met the selection criteria. We found that Appraisal of Guidelines Research and Evaluation (AGREE)-II domains such as applicability and editorial independence had the lowest scores. The wide variability on assessment of quality of evidence and strength of recommendations were the main concerns identified regarding diagnostic testing. Although the appropriate methodology for clinical practice guideline development is well known, the quality of diagnostic AD dementia guidelines can be significantly improved.

Finding dementia in primary care: the results of a clinical demonstration project

OBJECTIVES

To assess the effect of screening on diagnosing cognitive impairment.

DESIGN

Quality improvement initiative.

SETTING

Seven Veterans Affairs Medical Centers.

PARTICIPANTS

Veterans aged 70 or older without a prior diagnosis of cognitive impairment.

MEASUREMENTS

Veterans failing a brief cognitive screen (Mini-Cog score <4/5) at a routine primary care visit were offered a further, comprehensive evaluation with an advance practice registered nurse trained in dementia care and integrated into the primary care clinic. Veterans completing the evaluation were reviewed in a consensus conference and assigned a diagnosis of dementia; cognitive impairment, no dementia; or no cognitive impairment. Total numbers of screens, associated scores (0-5), and the consensus diagnoses were tallied. New cognitive impairment diagnoses were also tracked for veterans who passed the screen but requested further evaluation, failed but declined further evaluation, or were not screened. Primary care provider satisfaction with the program also was assessed.

RESULTS

Of 8,342 veterans offered screening, 8,063 (97%) accepted, 2,081 (26%) failed the screen, 580 (28%) agreed to further evaluation, and 540 (93%) were diagnosed with cognitive impairment, including 432 (75%) with dementia. For screen passes requesting further evaluation, 87% (103/118) had cognitive impairment, including 70% (82/118) with dementia. Screen failures declining further evaluation had 17% (259/1,501) incident cognitive impairment diagnosed through standard care, bringing the total newly documented cognitive impairment in all screens to 11% (902/8,063), versus 4% (1,242/28,349) in similar clinics without this program. Eighty-two percent of primary care providers in clinics with this program agreed that it provided a useful service.

CONCLUSION

Screening combined with offering further evaluation increased new diagnoses of cognitive impairment in older veterans two to three times. Veterans accepted screening well, and providers found the program useful.

The systematic guideline review: method, rationale, and test on chronic heart failure

BACKGROUND

Evidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources -- especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development -- the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF).

METHODS

A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline.

RESULTS

Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) - the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer.

CONCLUSION

The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines.

Translating dementia research into practice

There is a gap between the knowledge obtained in dementia research and the practical use of it. This review examines the concept of knowledge translation (KT) and the process of translating research into practice in the field of dementia. KT in dementia practice involves key players including researchers, educators, clinicians, policy-makers, the general public and consumers who act within a multidimensional network, disseminating findings widely to effect changes in community awareness, clinical practice and health policy. Challenges include the volume of dementia research; difficulties in determining who is responsible for KT; the problems of premature KT; the lack of resources to perform KT; the paucity of research about effective KT strategies; and the characteristics of the dementia care workforce. Key features of effective KT include a simple compelling message; use of interpersonal contact and roles; a practical framework with an emphasis on "know-how"; and the provision of resources and support. More effective dementia KT will require a commitment by key players to engage in the process, a better understanding of effective KT strategies, adequate resources, and judicious selection of appropriate evidence-based information.

Differences among international pharyngitis guidelines: not just academic

PURPOSE

Many countries have national guidelines for the treatment of pharyngitis. We wanted to compare the recommendations and the reported evidence in national guidelines for the management of acute sore throat in adults.

METHODS

Guidelines were retrieved via MEDLINE and EMBASE and through a Web-based search for guideline development organizations. The content of the recommendations and the underlying evidence were analyzed with qualitative and bibliometric methods.

RESULTS

We included 4 North American and 6 European guidelines. Recommendations differ with regard to the use of a rapid antigen test and throat culture and with the indication for antibiotics. The North American, French, and Finnish guidelines consider diagnosis of group A streptococcus essential, and prevention of acute rheumatic fever remains an important reason to prescribe antibiotics. In 4 of the 6 European guidelines, acute sore throat is considered a self-limiting disease and antibiotics are not recommended. The evidence used to underpin these guidelines was different in North America and Europe. North American guidelines cited more North American references than did European guidelines (87.2% vs 48.0%; ods ratio, 4.6-11.9; P<.001).

CONCLUSION

Although the evidence for the management of acute sore throat is easily available, national guidelines are different with regard to the choice of evidence and the interpretation for clinical practice. Also a transparent and standardized guideline development method is lacking. These findings are important in the context of appropriate antibiotic use, the problem of growing antimicrobial resistance, and costs for the community.

Improving the use of research evidence in guideline development: 1. Guidelines for guidelines

BACKGROUND

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the first of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.

OBJECTIVES

We reviewed the literature on guidelines for the development of guidelines.

METHODS

We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments.

KEY QUESTIONS AND ANSWERS

We found no experimental research that compared different formats of guidelines for guidelines or studies that compared different components of guidelines for guidelines. However, there are many examples, surveys and other observational studies that compared the impact of different guideline development documents on guideline quality. WHAT HAVE OTHER ORGANIZATIONS DONE TO DEVELOP GUIDELINES FOR GUIDELINES FROM WHICH WHO CAN LEARN?: Establish a credible, independent committee that evaluates existing methods for developing guidelines or that updates existing ones. Obtain feedback and approval from various stakeholders during the development process of guidelines for guidelines. Develop a detailed source document (manual) that guideline developers can use as reference material. WHAT SHOULD BE THE KEY COMPONENTS OF WHO GUIDELINES FOR GUIDELINES?: Guidelines for guidelines should include information and instructions about the following components: 1) Priority setting; 2) Group composition and consultations; 3) Declaration and avoidance of conflicts of interest; 4) Group processes; 5) Identification of important outcomes; 6) Explicit definition of the questions and eligibility criteria ; 7) Type of study designs for different questions; 8) Identification of evidence; 9) Synthesis and presentation of evidence; 10) Specification and integration of values; 11) Making judgments about desirable and undesirable effects; 12) Taking account of equity; 13) Grading evidence and recommendations; 14) Taking account of costs; 15) Adaptation, applicability, transferability of guidelines; 16) Structure of reports; 17) Methods of peer review; 18) Planned methods of dissemination & implementation; 19) Evaluation of the guidelines. WHAT HAVE OTHER ORGANIZATIONS DONE TO IMPLEMENT GUIDELINES FOR GUIDELINES FROM WHICH WHO CAN LEARN?: Obtain buy-in from regions and country level representatives for guidelines for guidelines before dissemination of a revised version. Disseminate the guidelines for guidelines widely and make them available (e.g. on the Internet). Develop examples of guidelines that guideline developers can use as models when applying the guidelines for guidelines. Ensure training sessions for those responsible for developing guidelines. Continue to monitor the methodological literature on guideline development.

Rivastigmine: an open-label, observational study of safety and effectiveness in treating patients with Alzheimer's disease for up to 5 years

Background

Rivastigmine, a butyl- and acetylcholinesterase inhibitor, is approved for symptomatic treatment of Alzheimer's disease (AD). Data supporting the safety and efficacy of second-generation cholinesterase inhibitors, such as rivastigmine, are available for treatment up to 1 year, with limited data up to 2 1/2 years. The purpose of this report is to present safety and effectiveness data for rivastigmine therapy in patients with mild to moderately severe AD receiving treatment for up to 5 years.

Methods

An observational approach was used to study 37 patients with originally mild to moderate AD receiving rivastigmine as a therapy for AD in an open-label extension (ENA713, B352 Study Group, 1998).

Results

The initial trial demonstrated rivastigmine was well-tolerated and effective in terms of cognition, global functioning and activities of daily living. In this open label extension, high-dose rivastigmine therapy was safe and well tolerated over a 5-year period. Two thirds of the participants still enrolled at week 234 were in the original high-dose rivastigmine group during the double-blind phase, suggesting that early therapy may confer some benefit in delaying long-term progression of symptoms.

Conclusions

Long-term cholinesterase inhibition therapy with rivastigmine was well tolerated, with no dropouts due to adverse effects past the initial titration period. Early initiation of treatment, with titration to high-dose therapy, may have an advantage in delaying progression of the illness.

Overview of Alzheimer's disease

In conclusion, many researchers from multiple disciplines are addressing AD at many levels, ranging from prevention, to cellular alterations, to treatment modalities, and coping and care giving with the consequences of the ravages left by the disease. Although much has been learned in the last several decades of active research, much remains to be learned. In its current status, AD is a chronic disease without a cure, which provides ample opportunities for nursing management throughout the course progression.

Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries

OBJECTIVE

To compare guidelines on diabetes from different countries in order to examine whether differences in recommendations could be explained by use of different research evidence.

RESEARCH DESIGN AND METHODS

We analyzed 15 clinical guidelines on type 2 diabetes from 13 countries using qualitative methods to compare the recommendations and bibliometric methods to measure the extent of overlap in citations used by different guidelines. A further qualitative analysis of recommendations and cited evidence for two specific issues in diabetes care explored the apparent discrepancy between recommendations and evidence.

RESULTS

The recommendations made in the guidelines were in agreement about the general management of type 2 diabetes, with some important differences in treatment details. There was little overlap in evidence cited by the guidelines, with 18% (185/1,033) of citations shared with any other guideline, and only 10 studies (1%) appearing in six or more guidelines. The measurable overlap in evidence between guidelines increases if multiple publications from the same study and the use of reviews are taken into account. Research originating from the U.S. predominated (40% of citations); however, nearly all (11/12) guidelines were significantly more likely to cite evidence originating from their own countries.

CONCLUSIONS

Despite the variation in cited evidence and preferential citation of evidence from a guideline's country of origin, we found a high degree of international consensus in recommendations made for the clinical care of type 2 diabetes. The influence of professional bodies such as the American Diabetes Association may be an important factor in explaining international consensus. Globalization of recommended management of diabetes is not a simple consequence of the globalization of research evidence.

The future history of gerontological nursing

Having established an academic and clinical infrastructure, geriatric nursing is well positioned to play a central role in improving the health of the nation's older adults now and in the future. Currently, whether working independently, in collaborative practice with physicians, or as members of geriatric teams, geriatric nurse practitioners and clinical specialists have been shown to improve care to older adults in the community, in hospitals, and in skilled nursing facilities. Sixty-three master's programs now prepare advanced practice geriatric nurses. Geriatric nurse researchers have contributed to our understanding of the most pressing problems that impact profoundly on the health and quality of life of older adults. Despite these advances, the number of geriatric nurse specialists remains small, with only 4200 certified specialists and a serious shortage of geriatric nursing faculty. Geriatric nursing is moving to ensure geriatric competency in all nurses who work with older adults in the future. The future should see the benefits of current efforts to infuse geriatric content into baccalaureate programs that prepare registered nurses, into master's programs that prepare adult and family nurse practitioners, and into the day-to-day practice of the nation's 2.2 million practicing registered nurses.

How well are clinicians following dementia practice guidelines?

Although there are numerous clinical guidelines regarding the management of dementia, there have been few studies on their implementation in practice. Clinicians in six United States Department of Veterans Affairs medical centers (n = 200, 85% response rate) were surveyed regarding their use of practices recommended in the California Workgroup Guidelines for Alzheimer's Disease Management. The majority of providers (89% to 73%) reported that they routinely conducted neurological examinations, obtained histories from caregivers, discussed the diagnosis with the patient's family, discussed durable power of attorney, and made legally-required reports of drivers with dementia. Roughly two-thirds of providers said they routinely conducted cognitive screening examinations, screened for depression, reported elder abuse, and discussed care needs and decision-making issues with patients' families. Only half of all outpatient providers implemented caregiver support practices for at least half of their patients. Clinicians' choices of medications for cognition, mood, and behavior problems were broadly consistent with current practice guidelines. These results suggest possible priorities for quality improvement efforts. Further research is needed to clarify reasons for particular gaps between guidelines and practice and to identify specific targets for intervention.