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Warkentin L, Hueber S, Kühlein T, Scherer M. Insights on the German College of General Practitioners and Family Physicians (DEGAM) guideline addressing medical overuse. BMJ Evid Based Med 2024:bmjebm-2023-112697. [PMID: 38395593 DOI: 10.1136/bmjebm-2023-112697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Lisette Warkentin
- Institute of General Practice, Uniklinikum Erlangen, Erlangen, Germany
| | - Susann Hueber
- Institute of General Practice, Uniklinikum Erlangen, Erlangen, Germany
| | - Thomas Kühlein
- Institute of General Practice, Uniklinikum Erlangen, Erlangen, Germany
| | - Martin Scherer
- Institute and Polyclinic for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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van der Lee L, Patman S, Hill AM. Development of a clinical practice guideline for physiotherapy management of adults invasively ventilated with community-acquired pneumonia. Physiotherapy 2024; 122:57-67. [PMID: 38244417 DOI: 10.1016/j.physio.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 11/09/2023] [Accepted: 12/11/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND AND SETTING Patients hospitalised with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit (ICU) for invasive mechanical ventilation and receive treatment by physiotherapists. However, clinical physiotherapy practice is variable for this ICU cohort. OBJECTIVES To develop a clinical practice guideline for physiotherapy management of adults invasively ventilated with CAP using the best available evidence. METHODS Guideline development using evidence synthesis according to the GRADE and JBI approaches, incorporating findings from four preceding phases of a mixed-methods research program: systematic review and meta-analysis, national survey of Australian ICU physiotherapy practice, e-Delphi study to determine expert consensus, and multidisciplinary peer-review of the expert consensus statements by senior ICU clinicians to determine validity and applicability of the statements for translation into practice. RESULTS The guideline comprises 26 recommendations, encompassing physiotherapy assessment, patient selection and prioritisation, and treatment. Physiotherapy treatment covers domains of humidification, patient positioning, hyperinflation techniques, manual chest wall techniques, normal saline instillation, active treatment, and mobilisation. Recommendations are rated as strong or conditional based on JBI criteria, and certainty of evidence according to GRADE. Considerations for practice are provided within the guideline to enhance clarity and practicality, particularly for conditional recommendations where evidence is limited or conflicting. CONCLUSION This guideline, based on the best available evidence for clinical physiotherapy practice for adults invasively ventilated with CAP, is intended to support clinicians with clinical decision making. Further research is required to evaluate guideline implementation into clinical practice, and incorporate the values and preferences of ICU patients and their families. CONTRIBUTION OF PAPER.
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Affiliation(s)
- Lisa van der Lee
- The University of Notre Dame Australia, School of Health Sciences and Physiotherapy, 19 Mouat Street (PO Box 1225), Fremantle, WA 6959, Australia; Fiona Stanley Hospital, Physiotherapy Department, Locked Bag 100, Palmyra DC, WA 6961, Australia; Curtin University, School of Allied Health, 208 Kent St, Bentley, WA 6102, Australia; Sir Charles Gairdner Hospital, Physiotherapy Department, Hospital Avenue, Nedlands WA 6009, Australia.
| | - Shane Patman
- The University of Notre Dame Australia, School of Health Sciences and Physiotherapy, 19 Mouat Street (PO Box 1225), Fremantle, WA 6959, Australia
| | - Anne-Marie Hill
- The University of Western Australia, School of Allied Health, Western Australia Centre for Health & Ageing, 35 Stirling Highway, Crawley, WA 6000, Australia
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Seneviratne O, Das AK, Chari S, Agu NN, Rashid SM, McCusker J, Franklin JS, Qi M, Bennett KP, Chen CH, Hendler JA, McGuinness DL. Semantically enabling clinical decision support recommendations. J Biomed Semantics 2023; 14:8. [PMID: 37464259 DOI: 10.1186/s13326-023-00285-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 03/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Clinical decision support systems have been widely deployed to guide healthcare decisions on patient diagnosis, treatment choices, and patient management through evidence-based recommendations. These recommendations are typically derived from clinical practice guidelines created by clinical specialties or healthcare organizations. Although there have been many different technical approaches to encoding guideline recommendations into decision support systems, much of the previous work has not focused on enabling system generated recommendations through the formalization of changes in a guideline, the provenance of a recommendation, and applicability of the evidence. Prior work indicates that healthcare providers may not find that guideline-derived recommendations always meet their needs for reasons such as lack of relevance, transparency, time pressure, and applicability to their clinical practice. RESULTS We introduce several semantic techniques that model diseases based on clinical practice guidelines, provenance of the guidelines, and the study cohorts they are based on to enhance the capabilities of clinical decision support systems. We have explored ways to enable clinical decision support systems with semantic technologies that can represent and link to details in related items from the scientific literature and quickly adapt to changing information from the guidelines, identifying gaps, and supporting personalized explanations. Previous semantics-driven clinical decision systems have limited support in all these aspects, and we present the ontologies and semantic web based software tools in three distinct areas that are unified using a standard set of ontologies and a custom-built knowledge graph framework: (i) guideline modeling to characterize diseases, (ii) guideline provenance to attach evidence to treatment decisions from authoritative sources, and (iii) study cohort modeling to identify relevant research publications for complicated patients. CONCLUSIONS We have enhanced existing, evidence-based knowledge by developing ontologies and software that enables clinicians to conveniently access updates to and provenance of guidelines, as well as gather additional information from research studies applicable to their patients' unique circumstances. Our software solutions leverage many well-used existing biomedical ontologies and build upon decades of knowledge representation and reasoning work, leading to explainable results.
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Affiliation(s)
| | | | - Shruthi Chari
- Rensselaer Polytechnic Institute, 110 8th St, 12180, Troy, NY, USA
| | | | - Sabbir M Rashid
- Rensselaer Polytechnic Institute, 110 8th St, 12180, Troy, NY, USA
| | - Jamie McCusker
- Rensselaer Polytechnic Institute, 110 8th St, 12180, Troy, NY, USA
| | - Jade S Franklin
- Rensselaer Polytechnic Institute, 110 8th St, 12180, Troy, NY, USA
| | - Miao Qi
- Rensselaer Polytechnic Institute, 110 8th St, 12180, Troy, NY, USA
| | | | | | - James A Hendler
- Rensselaer Polytechnic Institute, 110 8th St, 12180, Troy, NY, USA
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Sturmberg JP, Kissling B, Kühlein T. Shared decision-making in the realm of uncertainty: The example of coronary artery disease through an EBM and complexity science lens. J Eval Clin Pract 2022. [PMID: 36419338 DOI: 10.1111/jep.13794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
Patients look to their clinicians for explanations and treatments that achieve predictable cures with certainty. Clinicians usually respond accordingly. Acknowledging uncertainty, while necessary, is difficult, anxiety-provoking and at times overwhelming for patients and clinicians alike. We here present three case studies to illustrate the uncertainties of managing patients with potentially life-threatening illnesses. Research aims to provide answers to clinical problems. But, conducting research almost inevitably entails a reduction of real-world complexities. Research ultimately can only provide 'partial or in general answers' mostly revealing new questions. Due to the complexity of clinical care, research cannot really achieve certainty and predictability for an individual within his specific living context and values. In an unavoidably uncertain environment, instead of oversimplifying, clinicians like patients-as far as possible-ought to better embrace a complexity thinking frame. This provides a deeper understanding how living bodies function as-a-whole within their living contexts. Uncertainty and unpredictability, being inherent elements of complexity thinking, cannot be overcome. However, it may be made easier to cope with uncertainty by at least adopting the thinking in probabilities for benefits and harms of patient related outcomes as introduced in Sackett's Evidence-Based Medicine framework. Through the lenses of evidence-based medicine and complexity sciences this paper critically explores the clinical management of three patients diagnosed as having coronary artery disease. They all received the same treatment even though they presented with very different clinical complaints arising from different disease manifestations. Looking at these case studies the authors reflect on the reasons behind this astonishing, but widely seen medical behaviour of 'one size fits all'. They critically reflect the importance of research and evidence in view of a person-centred solution.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | | | - Thomas Kühlein
- Allgemeinmedizinisches Institut, Universitätsklinikum Erlangen, Erlangen, Germany
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van der Keylen P, Zeschick N, Schlenz AR, Kühlein T. Treatment thresholds and minimal clinically important effect sizes of antiosteoporotic medication–Survey among physicians and lay persons in Germany. PLoS One 2022; 17:e0272985. [PMID: 35951613 PMCID: PMC9371311 DOI: 10.1371/journal.pone.0272985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 08/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background Patient decisions to take preventative treatments for osteoporosis depend on their perceptions of fracture risk, medication effect sizes (ES) of benefits and harms. However, physicians and lay persons may have differing perceptions of risks and medication efficacy. Both tend to overestimate medication benefits. This study surveyed at what risk physicians would prescribe and lay persons would be willing to take bisphosphonates, the minimum ES both groups do demand and the physicians estimates of the actual benefit of bisphosphonates. Design Cross-sectional online questionnaire survey. Methods Respondents were confronted with a case vignette with an osteoporotic patient (10-year femoral fracture risk: 32%). They were asked at what threshold of 10-year-risk of femoral neck fracture they would prescribe or take a drug. They were asked for the minimum ES (absolute risk reduction, ARR) they demand from bisphosphonates to prescribe or take them. Physicians were asked to provide their estimate of the actual ARR of bisphosphonates. Results 114 physicians and 140 lay persons answered (convenience sample/snowball distribution). The 10-year-risk threshold of lay persons (Mdnlay = 60%) willing to take medication was twice as high as the physicians’ threshold (Mdnphy = 30%) to prescribe it (p < .001). The median minimum ARR physicians demanded for bisphosphonates prescription was 17%, whereas lay persons demanded 22% (p < .001). Physicians estimated the actual ARR of bisphosphonates to be 12%. This estimated effect size was below their own minimum threshold for prescription. Conclusions Lay persons tolerate a higher fracture risk and demand a larger benefit of antiosteoporotic medication for fracture prevention than physicians. Physicians demand higher minimum benefits than their own estimates which in turn are above the benefit evidence suggests. Physicians should be more familiar with ES of antiosteoporotic drugs concerning patient outcomes and actively advise lay persons before preventive treatment decisions are taken.
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Affiliation(s)
- Piet van der Keylen
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- * E-mail:
| | - Nikoletta Zeschick
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Ruth Schlenz
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Kühlein
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Raittio E, Raittio L. Statements considering intervention effects in Finnish clinical practice guidelines: Recommending interventions with non-numeric effect-sizes or unspecified outcomes. J Eval Clin Pract 2021; 27:751-758. [PMID: 32735367 DOI: 10.1111/jep.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Representation of benefits and harms associated with specific interventions in an understandable and comparable way is crucial for informed decision making that clinical practice guidelines (CPGs) aim to enhance. Therefore, we investigated how statements concerning the effects of interventions considered and described benefits and harms, magnitude of effect and its uncertainty, numeric and non-numeric information, and outcomes in Finnish CPGs. METHODS We selected 10 CPGs on common diseases and risk factors published by The Finnish Medical Society, Duodecim. All the statements which were graded with the level of evidence from high to very low (levels A-D) were included in analyses. From these statements, assessments were made regarding whether the statement considered benefits or harms, whether relative or absolute numeric measures were shown, whether the statement supported or was against the intervention considered, and what outcome was reported. RESULTS Of the 10 CPGs, 448 statements were assessed. Most of the statements of effects considered intervention benefits (87%) rather than harms. Half of the statements considering harms were represented in a way that supported the intervention. Most of the statements (94%) did not include numeric estimates of magnitude of the effect. When numeric estimates of magnitude of the effect were present, they were most frequently relative measures and were typically placed in a statement considering (a) intervention benefits with a primary outcome, (b) given the grade of A for level of evidence, and (c) that supported the use of intervention. CONCLUSIONS In the Finnish CPGs, the statements were rarely framed with both absolute and relative numeric measures of an intervention's effect. Harms were rarely reported with a grade indicating the level of evidence. The users of CPGs would benefit from more consistent and understandable framing of statements considering both benefits and harms of interventions.
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Affiliation(s)
- Eero Raittio
- The University of Eastern Finland, Institute of Dentistry, Kuopio, Finland.,City of Tampere, Oral Health Care, Tampere, Finland
| | - Lauri Raittio
- Tampere University, The Faculty of Medicine and Health Technology, Tampere, Finland
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