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Lorenz C, Gaigl G, Güler D, Halms T, Khorikian-Ghazari N, Röh A, Schneider M, Wagner E, Schneider-Axmann T, Kapfhammer A, Flick M, Pielenz C, Salveridou-Hof E, Falkai P, Gaebel W, Hasan A, Leucht S. Structured implementation of digital, systematically updated guideline recommendations for enhanced adherence in schizophrenia (SISYPHOS)—protocol of a cluster-randomized trial. Trials 2022; 23:807. [PMID: 36153555 PMCID: PMC9509647 DOI: 10.1186/s13063-022-06749-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background Despite high acceptance rates in the field, the implementation of the 2019 published German evidence and consensus-based S3 guideline is unsatisfactory. This study aims to assess the superiority of an adaptive online version with a better visualization of the recommendations in terms of guideline conformity, application of shared decision making, and digital health expertise compared to the classic pdf print version of the guideline. Methods The study is a multicenter, controlled, cluster-randomized trial with two arms: one arm investigating the implementation of the German schizophrenia guideline in form of a digital format (intervention group using the evidence ecosystem MAGICapp), the other arm in form of the classic print pdf version (control group). Physicians and psychologists working in specialized hospitals will be included in the study. The guideline-knowledge before and after the intervention is defined as primary outcome measure. Secondary endpoints include digital health expertise and application of shared decision making. Discussion This is the first study evaluating if an adaptive-digital version of the schizophrenia guideline is superior to the classic pdf print version. Therefore, the guideline is digitally prepared in the evidence-ecosystem MAGICapp, which covers the whole process of the development of a living guideline. We intend to use the results of the cluster-randomized trial for developing the German S3 guideline for schizophrenia in form of a living guideline in future. Trial registration The study is registered (10 May 2022) in the German Clinical Trials Register (DRKS) and the WHO International Clinical Trials Registry Platform (ICTRP) under registration number DRKS00028895. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06749-0.
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Korppi M. Local healthcare professionals need to work together to implement bronchiolitis guidelines that stop unnecessary tests and treatments. Acta Paediatr 2022; 111:1319-1323. [PMID: 35263462 DOI: 10.1111/apa.16322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022]
Abstract
AIM This mini review summarised studies published over a 10-year period on the impact of guidelines for diagnosing and managing bronchiolitis in children, with a special focus on interventions that enhanced adherence during implementation. METHODS PubMed was searched from 1 December 2011 to 31 November 2021 for papers published in English that used the terms bronchiolitis, child or infant, guidelines and either implementation or impact. After the exclusion criteria had been applied, 27 articles were reviewed in more detail. Eight described protocols without any comparisons and were excluded. Ten of the 19 remaining studies evaluated the impact of bronchiolitis guidelines, and 9 examined the effects of interventions linked to their publication. RESULTS Just releasing evidence-based guidelines had a poor impact, but this improved when local tailored current care, clinical practice or best-practice guidelines were issued. Even better results were achieved when all the staff treating bronchiolitis patients participated in the preparation and implementation of local guidelines. Adherence to the guidelines was as high as 85% when multidisciplinary, and multifaceted interventions were used to complement the publication of guidelines. CONCLUSION Healthcare professionals need to work together to avoid children receiving bronchiolitis management that is unnecessary and not based on evidence.
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Affiliation(s)
- Matti Korppi
- Centre for Child Health Research Faculty of Medicine and Life Sciences University of Tampere and University Hospital Tampere Finland
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3
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Azhar N, Aref H, Brorsson A, Lydrup ML, Jörgren F, Schultz JK, Buchwald P. Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study. BMC Emerg Med 2022; 22:28. [PMID: 35189812 PMCID: PMC8862329 DOI: 10.1186/s12873-022-00584-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/11/2022] [Indexed: 12/23/2022] Open
Abstract
Methods Recent randomized control trials (RCTs) have confirmed that antibiotics in acute uncomplicated diverticulitis (AUD) neither accelerate recovery nor prevent complications or recurrences. A retrospective cohort study was conducted, including all consecutive AUD patients hospitalized 2015- 2018 at Helsingborg Hospital (HH) and Skåne University Hospital (SUS), Sweden. HH had implemented a non-antibiotic treatment protocol in 2014 while SUS had not. Main outcomes were proportion of patients treated with antibiotics, complications, recurrences, and adherence to routinely colon evaluation. Results A total of 583 AUD patients were enrolled, 388 at SUS and 195 at HH. The diagnosis was CT-verified in 320 (83%) vs. 186 (95%) patients respectively (p < 0.001). Forty-three (11%) and 94 (48%) of patients respectively did not receive antibiotics during hospitalization (p < 0.001). CRP was higher in the antibiotic group compared to the non-antibiotic group, both at admission and peak (90 mg/L vs 65 mg/L; p = 0.016) and (138 mg/L and 97 mg/L; p < 0.001). There were no significant differences in recurrences (22.0% vs. 22.6%; p = 0.87) and complications (2.5% vs. 2.9%; p = 0.77) between the antibiotic/non-antibiotic groups. Conclusion The structured treatment protocol led to reduced antibiotic use and a higher standard of care in terms of CT-verification. Clinicians’ compliance to the treatment protocol and best clinical practice was poor and warrants further studies.
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Affiliation(s)
- Najia Azhar
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden. .,Department of Surgery, Skåne University Hospital, Malmö, Sweden.
| | - Hager Aref
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Adam Brorsson
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Marie-Louise Lydrup
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Jörgren
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | | | - Pamela Buchwald
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Cough and cold medicine prescription rates can be significantly reduced by active intervention. Eur J Pediatr 2022; 181:1531-1539. [PMID: 34913111 PMCID: PMC8673918 DOI: 10.1007/s00431-021-04344-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/31/2021] [Accepted: 12/09/2021] [Indexed: 12/26/2022]
Abstract
UNLABELLED Our aim was to construct and test an intervention programme to eradicate cough and cold medicine (CCM) prescriptions for children treated in a nationwide healthcare service company. The study was carried out in the largest private healthcare service company in Finland with a centralised electronic health record system allowing for real-time, doctor-specific practice monitoring. The step-by-step intervention consisted of company-level dissemination of educational materials to doctors and families, educational staff meetings, continuous monitoring of prescriptions, and targeted feedback. Outreach visits were held in noncompliant units. Finally, those physicians who most often prescribed CCM were directly contacted. During the intervention period (2017-2020), there were more than one million paediatric visits. Prescriptions of CCMs to children were completely eradicated in 41% of units and the total number of CCM prescriptions decreased from 6738 to 744 (89%). During the fourth intervention year, CCMs containing opioid derivatives were prescribed for only 0.2% of children aged < 2 years. The decrease in prescriptions was greatest in general practitioners (5.2 to 1.1%). In paediatricians, the prescription rates decreased from 1.5 to 0.2%. The annual costs of CCMs decreased from €183,996 to €18,899 (89.7%). For the intervention, the developers used 343 h and the attended doctors used 684 h of work time during the 4-year intervention. The costs used for developing, implementing, reporting, evaluating, communicating, and data managing formed approximately 11% of total intervention costs. CONCLUSION The study showed that a nationwide systematic intervention to change cough medicine prescription practices is feasible and requires only modest financial investments. WHAT IS KNOWN • Cough and cold medicines (CCM) are not effective or safe, especially for children aged 6 years. • Although the use of CCMs has been declining, caregivers continue to administer CCMs to children, and some physicians still prescribe them even for preschool children. WHAT IS NEW • A nationwide systematic intervention can significantly and cost effectively change CCM prescription habits of paediatricians, general practitioners, and other specialists. • Electronic health records provide additional tools for operative guideline implementation and real-time quality monitoring, including recommendations of useless or harmful treatments.
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LaGrone LN, McIntyre L, Riggle A, Robinson BRH, Maier RV, Bulger E, Cuschieri J. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg 2021; 89:1046-1053. [PMID: 32773673 DOI: 10.1097/ta.0000000000002902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A fundamental goal of continuous process improvement programs is to evaluate and improve the ratio of actual to expected mortality. To study this, we examined contributors to error-associated deaths during two consecutive periods from 1996 to 2004 (period 1) and 2005 to 2014 (period 2). METHODS All deaths at a level I trauma center with an anticipated probability of death less than 50% and/or identified through process improvement committees were examined. Demographics were assessed for trend only because period 1 data were only available in median and interquartile range. Each death was critically appraised to identify potential error, with subsequent classification of error type, phase, cause, and contributing cognitive processes, with comparison of outcomes made using χ test of independence. RESULTS During period 1, there were a total of 44,401 admissions with 2,594 deaths and 64 deaths (2.5%) associated with an error, compared with 60,881 admissions during period 2 with 2,659 deaths and 77 (2.9%) associated with an error. Deaths associated with an error occurred in younger and less severely injured patients in period 1 and were likely to occur during the early phase of care, primarily from failed resuscitation and hemorrhage control. In period 2, deaths occurred in older more severely injured patients and were likely to occur in the later phase of care primarily because of respiratory failure from aspiration. CONCLUSION Despite injured patients being older and more severely injured, error-associated deaths during the early phase of care that was associated with hemorrhage improved over time. Successful implementation of system improvements resolved issues in the early phase of care but shifted deaths to later events during the recovery phase including respiratory failure from aspiration. This study demonstrates that ongoing evaluation is essential for continuous process improvement and realignment of efforts, even in a mature trauma system. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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Affiliation(s)
- Lacey N LaGrone
- From the Medical Center of the Rockies (L.N.L., L.M., B.R.H.R., R.V.M., E.B., J.C., A.R.), UCHealth, University of Colorado, Trauma & Acute Care Surgery, Loveland, CO
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Kim DW, Lee BJ. Recognition Investigation of Community Pharmacists Implementing Good Pharmacy Practice in Korea. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2020; 52:372-382. [PMID: 32660305 DOI: 10.1177/0020731420941459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to verify, for the first time, the need for Good Pharmacy Practice (GPP) regulations as guidelines to provide pharmaceutical care services in community pharmacies in Korea. Statistical analyses were performed with demographic characteristics, institutional factors, and diversity factors of 3 pharmaceutical care services as independent variables and the favorability of GPP implementation as a dependent variable. In assessing the diversity of methods of providing pharmaceutical care services as an indicator of willingness to provide these services, this study understood such diversity as an innovative behavior that represents the efforts and willingness of pharmacists to provide better services. The results of descriptive statistics showed that most pharmacists in community pharmacy recognize that guidelines are necessary to provide better pharmaceutical care services. The statistical correlation analysis results confirmed that a greater need for guidelines was strongly related to higher GPP favorability. The institutional factors had the greatest influence on GPP favorability, rather than diversity factors of pharmaceutical care services, ultimately with the Korean perspectives to equate the GPP with the guidelines for pharmaceutical care services. Our study confirmed that it is a wish and a policy task of community pharmacists in Korea to enact GPP as soon as possible.
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Affiliation(s)
- Dae-Won Kim
- College of Pharmacy, Ajou University, Suwon, Republic of Korea
| | - Beom-Jin Lee
- College of Pharmacy, Ajou University, Suwon, Republic of Korea.,Institute of Pharmaceutical Science and Technology, Ajou University, Suwon, Republic of Korea
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Uchmanowicz I, Hoes A, Perk J, McKee G, Svavarsdóttir MH, Czerwińska-Jelonkiewicz K, Janssen A, Oleksiak A, Dendale P, Graham IM. Optimising implementation of European guidelines on cardiovascular disease prevention in clinical practice: what is needed? Eur J Prev Cardiol 2020; 28:426-431. [PMID: 33611449 DOI: 10.1177/2047487320926776] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/24/2020] [Indexed: 11/16/2022]
Abstract
Abstract
Cardiovascular disease is a model example of a preventable condition for which practice guidelines are particularly important. In 2016, the joint task force created by the European Society of Cardiology (ESC) together with 10 other societies released the new version of the European guidelines on cardiovascular disease prevention. To facilitate the implementation of the ESC guidelines, a dedicated prevention implementation committee has been established within the European Association of Preventive Cardiology. The paper will first explore potential barriers to the guidelines’ implementation. It then develops a discussion that seeks to inform the future development of the committee’s work, including a new definition of the guidelines’ stakeholders (health policy-makers, healthcare professionals and health educators, patient organisations, entrepreneurs and the general public), future activities within four specific areas: strengthening awareness of the guidelines among stakeholders; supporting organisational changes to facilitate the guidelines’ implementation; motivating stakeholders to utilise the guidelines; and present ideas on new implementation strategies. Providing multifaceted cooperation between healthcare professionals, healthcare management executives and health policy-makers, the novel approach proposed in this paper should contribute to a wider use of the 2016 ESC guidelines and produce desired effects of less cardiovascular disease morbidity and mortality. Furthermore, the solutions presented within the paper may constitute a benchmark for the implementation of practice guidelines in other medical disciplines.
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Affiliation(s)
| | - Arno Hoes
- Department of General Practice, University Medical Center Utrecht, The Netherlands
| | - Joep Perk
- Faculty of Health and Life Sciences, Linnaeus University, Sweden
| | - Gabrielle McKee
- School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | | | | | - Arne Janssen
- Clinical Research Department Cardiology, Heartcentre Hasselt, Belgium
| | - Anna Oleksiak
- Department of Intensive Cardiac Therapy, Institute of Cardiology, Poland
| | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital and Hasselt University, Belgium
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Mahtta D, Rodriguez F, Jneid H, Levine GN, Virani SS. Improving adherence to cardiovascular guidelines: realistic transition from paper to patient. Expert Rev Cardiovasc Ther 2020; 18:41-51. [PMID: 31941396 DOI: 10.1080/14779072.2020.1717335] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: The emphasis on clinical trials to inform evidence-based medicine remains paramount within the cardiovascular community. Although such high-quality evidence is often translated into national and international guidelines, there exists a large gap between guideline development and guideline implementation into daily clinical practice.Areas covered: This article outlines barriers that impede guideline adherence and possible strategies to overcome such barriers. Barriers intrinsic and extrinsic to clinicians are discussed. The structured process of guideline implementation including guideline adoption, diffusion, and dissemination is discussed. Lastly, the authors review in detail the current and potential future elements of guideline diffusion and dissemination.Expert opinion: Improving guideline adherence remains challenging as it requires understanding of and navigation through various barriers. However, further research specific to cardiovascular medicine guidelines is necessary to better understand the objective effectiveness of various strategies employed by guideline writers and medical societies to improve adherence. The cost-effectiveness of nationwide dissemination strategies in improving guideline adherence and patient outcomes is also necessary but is largely unknown.
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Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, TX, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Glenn N Levine
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, TX, USA.,Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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9
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Thorvaldsen NØ, Flingtorp LD, Wisborg T, Jeppesen E. Implementation of new guidelines in the prehospital services: a nationwide survey of Norway. Scand J Trauma Resusc Emerg Med 2019; 27:83. [PMID: 31464620 PMCID: PMC6716817 DOI: 10.1186/s13049-019-0660-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/20/2019] [Indexed: 12/01/2022] Open
Abstract
Background A debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. “The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury” was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process. Method An electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline. Results In all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents. Conclusion Although the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline. Electronic supplementary material The online version of this article (10.1186/s13049-019-0660-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Øye Thorvaldsen
- Emergency Medical Services, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway. .,Faculty of Health Science, University of Stavanger, Stavanger, Norway.
| | - Lars Didrik Flingtorp
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo, Norway
| | - Torben Wisborg
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Anesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø - the Arctic University of Norway, Tromsø, Norway
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10
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Maric J, Childs J, Esterman A. Barriers and facilitators to the implementation of clinical practice guidelines in sonography. SONOGRAPHY 2019. [DOI: 10.1002/sono.12179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Jovana Maric
- School of Health SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Jessie Childs
- SANSOM Research InstituteUniversity of South Australia Adelaide South Australia Australia
| | - Adrian Esterman
- UniSA Cancer Research InstituteUniversity of South Australia Adelaide South Australia Australia
- Australian Institute of Tropical Health and MedicineJames Cook University Townsville Queensland Australia
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11
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Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework. BMC Health Serv Res 2018; 18:890. [PMID: 30477492 PMCID: PMC6258411 DOI: 10.1186/s12913-018-3684-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022] Open
Abstract
Background Uptake of clinical guideline recommendations into routine practice requires changes in attitudes and behaviors of the health care providers. The World Health Organization (WHO) has heavily invested in public health and health promotion globally by developing policy recommendations to guide clinical practice; however, clinical guidelines are often not applied. The success of the implementation of any guidelines depends on consideration of existing barriers and adequately addressing them. Therefore, exploring the context specific barriers and facilitators affecting the primary care providers (PCPs) in Mbarara district, Uganda may provide a practical way of addressing the identified barriers thus influence the PCPs action towards integration of mental healthcare services into PHC. Methods We adopted a theoretical model of behavior change; Capability, Opportunity and Motivation developed to understand behavior (COM-B). This was a cross-sectional study which involved using a semi-structured qualitative interview guide to conduct in-depth interviews with PCP’s (clinical officers, nurses and midwives). Results Capability - inadequacy in knowledge about mental disorders; more comfortable managing patients with a mental problem diagnosis than making a new one; knowledge about mental health was gained during pre-service training; no senior cadre to consultations in mental health; and burdensome to consult the Uganda Clinical Guidelines (UCG). Opportunity - limited supply of hard copies of the UCG; guidelines not practical for local setting; did not regularly deal with clients having mental illness to foster routine usage of the UCG; no sensitization about the UCG to the intended users; and no cues at the health centers to remind the PCPs to use UCG. Motivation - did not feel self-reliant; not seen the UCG at their health facilities; lack of trained mental health specialists; conflicting priorities; and no regulatory measures to encourage screening for mental health. Conclusions Efforts to achieve successful integration of mental health services into PHC need to fit in the context of the implementers; thus the need to adapt the UCG into local context, have cues to enforce implementation, and optimize the available expertize (mental healthcare providers) in the process. Electronic supplementary material The online version of this article (10.1186/s12913-018-3684-7) contains supplementary material, which is available to authorized users.
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Geary RS, Knight HE, Carroll FE, Gurol‐Urganci I, Morris E, Cromwell DA, van der Meulen JH. A step-wise approach to developing indicators to compare the performance of maternity units using hospital administrative data. BJOG 2018; 125:857-865. [PMID: 29105913 PMCID: PMC6001534 DOI: 10.1111/1471-0528.15013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
Hospital administrative data are attractive for comparing performance of maternity units because of their often large sample sizes, lack of selection bias and the relatively low costs of accessing these data compared with conducting primary data collection. However, using administrative data to develop indicators can also present challenges including varying data quality, the limited detail on clinical risk factors and a lack of structural and user experience measures. This review illustrates how to develop performance indicators for maternity units using hospital administrative data, including methods to address the challenges that administrative data pose. TWEETABLE ABSTRACT How to develop maternity indicators from administrative data.
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Affiliation(s)
- RS Geary
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - HE Knight
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - FE Carroll
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - I Gurol‐Urganci
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
| | - E Morris
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
- Norfolk and Norwich University HospitalNorwichUK
| | - DA Cromwell
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Surgeons of EnglandClinical Effectiveness UnitLondonUK
| | - JH van der Meulen
- Department of Health Services Research and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Royal College of Obstetricians and GynaecologistsLindsay Stewart Centre for Audit and Clinical InformaticsLondonUK
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Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and Strategies in Guideline Implementation-A Scoping Review. Healthcare (Basel) 2016; 4:healthcare4030036. [PMID: 27417624 PMCID: PMC5041037 DOI: 10.3390/healthcare4030036] [Citation(s) in RCA: 479] [Impact Index Per Article: 59.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/20/2016] [Accepted: 06/24/2016] [Indexed: 01/11/2023] Open
Abstract
Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed.
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Affiliation(s)
- Florian Fischer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Kerstin Lange
- Department of Public Health Medicine, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Kristina Klose
- Department of Health Care Management, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Wolfgang Greiner
- Department of Health Care Management, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Alexander Kraemer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
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A combined paging alert and web-based instrument alters clinician behavior and shortens hospital length of stay in acute pancreatitis. Am J Gastroenterol 2014; 109:306-15. [PMID: 24594946 PMCID: PMC5565843 DOI: 10.1038/ajg.2013.282] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There are many published clinical guidelines for acute pancreatitis (AP). Implementation of these recommendations is variable. We hypothesized that a clinical decision support (CDS) tool would change clinician behavior and shorten hospital length of stay (LOS). DESIGN/SETTING Observational study, entitled, The AP Early Response (TAPER) Project. Tertiary center emergency department (ED) and hospital. PARTICIPANTS Two consecutive samplings of patients having ICD-9 code (577.0) for AP were generated from the emergency department (ED) or hospital admissions. Diagnosis of AP was based on conventional Atlanta criteria. The Pre-TAPER-CDS-Tool group (5/30/06-6/22/07) had 110 patients presenting to the ED with AP per 976 ICD-9 (577.0) codes and the Post-TAPER-CDS-Tool group (5/30/06-6/22/07) had 113 per 907 ICD-9 codes (7/14/10-5/5/11). INTERVENTION The TAPER-CDS-Tool, developed 12/2008-7/14/2010, is a combined early, automated paging-alert system, which text pages ED clinicians about a patient with AP and an intuitive web-based point-of-care instrument, consisting of seven early management recommendations. RESULTS The pre- vs. post-TAPER-CDS-Tool groups had similar baseline characteristics. The post-TAPER-CDS-Tool group met two management goals more frequently than the pre-TAPER-CDS-Tool group: risk stratification (P<0.0001) and intravenous fluids >6L/1st 0-24 h (P=0.0003). Mean (s.d.) hospital LOS was significantly shorter in the post-TAPER-CDS-Tool group (4.6 (3.1) vs. 6.7 (7.0) days, P=0.0126). Multivariate analysis identified four independent variables for hospital LOS: the TAPER-CDS-Tool associated with shorter LOS (P=0.0049) and three variables associated with longer LOS: Japanese severity score (P=0.0361), persistent organ failure (P=0.0088), and local pancreatic complications (<0.0001). CONCLUSIONS The TAPER-CDS-Tool is associated with changed clinician behavior and shortened hospital LOS, which has significant financial implications.
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Andersson B, Andrén-Sandberg A, Nilsson J, Andersson R. Survey of the management of acute pancreatitis in surgical departments in Sweden. Scand J Gastroenterol 2012; 47:1064-70. [PMID: 22631566 DOI: 10.3109/00365521.2012.685752] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Several international guidelines concerning the treatment of acute pancreatitis has been published during the last decades. However, Scandinavian guidelines are still lacking. The aim of the present study is to identify current treatment strategies for acute pancreatitis in Sweden and to evaluate if there is a need for improvement and the role of guidelines. MATERIAL AND METHODS A questionnaire was e-mailed to the surgical departments at all Swedish hospitals (n = 58) managing patients with acute pancreatitis. Comparisons were made both between university and non-university hospitals, and between hospitals with more versus less than 150,000 persons in the primary catchment population. RESULTS Fifty-one hospitals responded (88%). In median, 65 (12-200) patients with acute pancreatitis are treated yearly at each hospital. Of 51 hospitals, 18 perform a severity classification, with APACHE II being the most commonly used. A majority are of the opinion that a scoring system is not better than the judgment of a senior consultant. In severe acute pancreatitis, 29/48 routinely administer antibiotics, 29/48 use enteral nutrition, and 25/49 have a standardized follow-up plan. The majority considered administration of intravenous fluids as the most important treatment in severe acute pancreatitis. After mild gallstone-induced acute pancreatitis, the corresponding response was cholecystectomy, especially at larger hospitals (p = 0.002). Of 47, 42 are interested in developing a Scandinavian quality register. CONCLUSIONS The results from this first Swedish national survey provide an insight into current traditions of treatment of acute pancreatitis and points, for example, at the lack of early severity stratification. A majority of hospitals are interested in developing a quality register in acute pancreatitis.
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Affiliation(s)
- Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden.
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Boulkedid R, Sibony O, Bossu-Salvador C, Oury JF, Alberti C. Monitoring healthcare quality in an obstetrics and gynaecology department using a CUSUM chart. BJOG 2010; 117:1225-35. [PMID: 20560945 DOI: 10.1111/j.1471-0528.2010.02632.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To use cumulative sum (CUSUM) charts for the early detection of variations in quality of care in a maternity department. DESIGN Retrospective analysis of prospectively collected data. SETTING Maternity department of a teaching hospital in Paris (France). POPULATION Data from 20 519 women and 21 448 infants were collected between January 2000 and December 2007. METHODS CUSUM charts were used to monitor the rate of 19 pre-selected quality indicators over 3 years (2005-2007), against standards developed by department obstetrician gynaecologists. Periods with adverse event rates that did not meet the standards were identified. MAIN OUTCOME MEASURES Quality indicator rates. RESULTS Indicators fell into three groups based on the number of periods with unacceptable rates: less than one per year [e.g. the rate of intensive care unit (ICU) admission of mothers and rate of third- or fourth-degree perineal tears]; one every 2-12 months on average (e.g. blood transfusion and sulprostone use in the overall population of women); and at least one per month (insufficient availability of epidural analgesia). CONCLUSION CUSUM charts for a broad range of quality indicators can be used to monitor the quality of care in an obstetrics department. A prospective study investigating the ability of CUSUM-based monitoring to improve maternal and neonatal outcomes would be of interest.
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Affiliation(s)
- R Boulkedid
- AP-HP, Hôpital Robert Debré, Unité d'Epidémiologie Clinique, Paris, France.
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Abstract
OBJECTIVE To study the influence of local guidelines on the behaviour of nursing and medical staff to optimize the oxygen use in patients admitted to hospital. METHODS Study was performed in a district teaching hospital. Guidelines produced suggested indications, monitoring, use of arterial blood gases (ABGs) and advice on when to stop oxygen therapy. The guidelines were implemented both verbally and in writing to all the nursing and medical staff before and after an audit studying the oxygen use by patients on medical and surgical wards. RESULTS Ninety patients were included in pre-intervention audit and 59 in post-intervention study. Oxygen prescription did not change with guidelines 30% (27/90) vs. 32% (19/59). Nurses administered oxygen better 95% (18/19) vs. 70% (19/27) (P = 0.043) and monitored more frequently using oximetry 91% (54/59) vs. 69% (62/90) (P = 0.001) after the guidelines. Patients with airway disease had their ABGs checked more frequently 87% (14/16) vs. 65% (15/23) on admission and after they started oxygen inhalation 68% (11/16) vs. 34% (8/23). CONCLUSION The guidelines disseminated verbally and in writing had no influence on oxygen prescription but improved the practice of close monitoring of patients with airway disease. Nurses improved their performance of both administration of oxygen according to the prescribed dose and monitoring with oximetry.
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Affiliation(s)
- Fazal A Kbar
- Llandough Hospital, Penarth, Cardiff, Welsh, UK.
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BootsMiller BJ, Yankey JW, Flach SD, Ward MM, Vaughn TE, Welke KF, Doebbeling BN. Classifying the effectiveness of Veterans Affairs guideline implementation approaches. Am J Med Qual 2005; 19:248-54. [PMID: 15620076 DOI: 10.1177/106286060401900604] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hospitals use numerous guideline implementation approaches with varying success. Approaches have been classified as consistently, variably, or minimally effective, with multiple approaches being most effective. This project assesses the Department of Veterans Affairs (VA) use of effective guideline implementation approaches. A survey of 123 VA quality managers assessed the approaches used to implement the chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and major depressive disorder guidelines. Approaches were categorized based on their effectiveness, and the total number of approaches used was calculated. Commonly used approaches were clinical meetings, summaries, and revised forms. Consistently and minimally effective approaches were used most frequently. Most hospitals used 4-7 approaches. Odds ratios demonstrated that consistently effective approaches were paired with minimally and variably effective approaches. The frequent use of consistently effective approaches and multiple approaches benefits VA adherence. However, VA hospitals should consider selective combinations of approaches to ensure the use of the most effective implementation methods.
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Affiliation(s)
- Bonnie J BootsMiller
- Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City Veterans Affairs Medical Center, Iowa City, IA 52246, USA.
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Kuilboer MM, van Wijk MAM, Mosseveld M, van der Lei J. AsthmaCritic: issues in designing a noninquisitive critiquing system for daily practice. J Am Med Inform Assoc 2003; 10:419-24. [PMID: 12807811 PMCID: PMC212778 DOI: 10.1197/jamia.m1273] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The noninquisitive critiquing system, AsthmaCritic, uses routinely recorded electronic patient data to select and analyze records of patients with asthma or chronic obstructive pulmonary disease (COPD). The system generates critiquing comments and adds these comments to the patient record. The system was developed by using and expanding an existing generic critiquing system. After a brief overview of the system, this report focuses on the authors' design choices in light of existing literature and the issues that underlie these design choices. Currently, AsthmaCritic is used by primary care physicians and is undergoing clinical evaluation.
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Affiliation(s)
- Manon M Kuilboer
- Department of Medical Informatics, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
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Campbell SM, Braspenning J, Hutchinson A, Marshall M. Research methods used in developing and applying quality indicators in primary care. Qual Saf Health Care 2002; 11:358-64. [PMID: 12468698 PMCID: PMC1758017 DOI: 10.1136/qhc.11.4.358] [Citation(s) in RCA: 420] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Quality indicators have been developed throughout Europe primarily for use in hospitals, but also increasingly for primary care. Both development and application are important but there has been less research on the application of indicators. Three issues are important when developing or applying indicators: (1). which stakeholder perspective(s) are the indicators intended to reflect; (2). what aspects of health care are being measured; and (3). what evidence is available? The information required to develop quality indicators can be derived using systematic or non-systematic methods. Non-systematic methods such as case studies play an important role but they do not tap in to available evidence. Systematic methods can be based directly on scientific evidence by combining available evidence with expert opinion, or they can be based on clinical guidelines. While it may never be possible to produce an error free measure of quality, measures should adhere, as far as possible, to some fundamental a priori characteristics (acceptability, feasibility, reliability, sensitivity to change, and validity). Adherence to these characteristics will help maximise the effectiveness of quality indicators in quality improvement strategies. It is also necessary to consider what the results of applying indicators tell us about quality of care.
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Affiliation(s)
- S M Campbell
- National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, UK.
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Doebbeling BN, Vaughn TE, Woolson RF, Peloso PM, Ward MM, Letuchy E, BootsMiller BJ, Tripp-Reimer T, Branch LG. Benchmarking Veterans Affairs Medical Centers in the delivery of preventive health services: comparison of methods. Med Care 2002; 40:540-54. [PMID: 12021680 DOI: 10.1097/00005650-200206000-00011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify consistent provision of clinical preventive services, we sought to benchmark all acute care Veterans Affairs Medical Centers (VAMCs) against each other nationally on the basis of multiple evidence-based, performance measures to identify facilities performing consistently higher and lower than expected. METHODS The 1998 Veterans Health Survey assessed the self-reported delivery of evidence-based clinical preventive services in a stratified national sample of 450 ambulatory care patients seen at each VAMC. Proportions appropriately receiving each service within the recommended time interval were calculated for 138 VAMCs. Percentile ranks for each outcome were assigned. Two approaches were used for benchmarking performance. First, a scaled score for each facility was calculated across the set of 12 measures. Second, facilities were ranked based on the sum of the percentile ranks over a range of specific high cutoffs (eg, 70-80%) and above a range of lower cutoffs (eg, 40-50%). Ranking was validated by comparing with deciles of ranks on chart audit (External Peer Review Program, EPRP) data using Kendall's tau-b and chi2 quality-of-fit test. Differences between consistently high adherence (CHA) and low adherence (CLA) facilities were compared using the Wilcoxon rank sum test on 14 VHS and 11 EPRP outcomes. RESULTS Data from 39,939 patients (67% response rate) were examined. In combination, cutoffs of greater than 50th percentile and greater than 75th percentile rank yielded 12 of 14 VHS and 6 of 11 EPRP measures different between CHA and CLA facilities. The scaled-score approach resulted in 20 CHA and 14 CLA facilities. The sum of outcomes ranked above 50th percentile and over 75th percentile for CHA facilities (n = 17) was 15 or more. The sum of outcomes ranked above the same cutoffs for CLA facilities (n = 16) was 3 or less. EPRP and 1998 VHS data demonstrated that the survey measures and benchmarking approaches were both reliable and valid. Both approaches resulted in multiple differences between CHA and CLA facilities; differences were greater using the percentile rank approach. CONCLUSIONS The VA has successfully encouraged adoption of evidence-based clinical preventive services throughout its health care system. However, facilities show wide variation in their levels of delivery and can be distinguished on the basis of their consistently high or low levels of adherence. Examining service delivery across multiple performance indicators allows identification of opportunities to improve clinical practice guideline implementation and the delivery of preventive services. This approach identifies model institutions where focused investigation of factors associated with consistent performance may be particularly fruitful.
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Affiliation(s)
- Bradley N Doebbeling
- Iowa City Veterans Affairs Medical Center, REAP Program for Interdisciplinary Research in Health Care Organization, Iowa 52242, USA.
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van Wijk MAM, van der Lei J, Mosseveld M, Bohnen AM, van Bemmel JH. Compliance of General Practitioners with a Guideline-based Decision Support System for Ordering Blood Tests. Clin Chem 2002. [DOI: 10.1093/clinchem/48.1.55] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background: Guidelines are viewed as a mechanism for disseminating a rapidly increasing body of knowledge. We determined the compliance of Dutch general practitioners with the recommendations for blood test ordering as defined in the guidelines of the Dutch College of General Practitioners.
Methods: We performed an audit of guideline compliance over a 12-month period (March 1996 through February 1997). In an observational study, a guideline-based decision support system for blood test ordering, BloodLink, was integrated with the electronic patient records of 31 general practitioners practicing in 23 practices (16 solo). BloodLink followed the guidelines of the Dutch College of General Practitioners. We determined compliance by comparing the recommendations for test ordering with the test(s) actually ordered. Compliance was expressed as the percentage of order forms that followed the recommendations for test ordering.
Results: Of 12 668 orders generated, 9091 (71%) used the decision-support software rather than the paper order forms. Twelve indications accounted for >80% of the 7346 order forms that selected a testing indication in BloodLink. The most frequently used indication for test ordering was “vague complaints” (2209 order forms; 30.1%). Of the 7346 order forms, 39% were compliant. The most frequent type of noncompliance was the addition of tests. Six of the 12 tests most frequently added to the order forms were supported by revisions of guidelines that occurred within 3 years after the intervention period.
Conclusions: In general practice, noncompliance with guidelines is predominantly caused by adding tests. We conclude that noncompliance with a guideline seems to be partly caused by practitioners applying new medical insight before it is incorporated in a revision of that guideline.
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Affiliation(s)
| | | | | | - Arthur M Bohnen
- Department of General Practice, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, 3000 DR Rotterdam, The Netherlands
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Fleuren M, van der Meulen M, Wijkel D. Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage. Qual Health Care 2000; 9:106-10. [PMID: 11067248 PMCID: PMC1743515 DOI: 10.1136/qhc.9.2.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. DESIGN Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. SETTING General practices and midwifery practices in the Netherlands. SUBJECTS 73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. MAIN MEASURES Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. RESULTS In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. CONCLUSIONS The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.
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Affiliation(s)
- M Fleuren
- Public Health Division, TNO Prevention and Health, Leiden, The Netherlands.
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Campbell SM, Roland MO, Shekelle PG, Cantrill JA, Buetow SA, Cragg DK. Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice. Qual Health Care 1999; 8:6-15. [PMID: 10557672 PMCID: PMC2483627 DOI: 10.1136/qshc.8.1.6] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus. SUBJECTS AND METHODS Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses. RESULTS The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence. CONCLUSION The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available.
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Affiliation(s)
- S M Campbell
- National Primary Care Research and Development Centre, University of Manchester, UK.
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Abstract
This article emphasizes the emerging facets of disease-management practice that impact directly on establishing a measured care system that can produce the information needed to establish a continuous quality improvement program. The areas discussed are risk assessment, clinical management guidelines and carepaths, and the measurement of system output known as clinical outcomes. The remainder of the article details the aspects of risk assessment, guideline function, and outcome assessment, critical in a disease-managed measured care system.
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Affiliation(s)
- F W Bowen
- Paidos Health Management Services, Inc., Paoli, PA, USA
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Christakis DA, Rivara FP. Pediatricians' awareness of and attitudes about four clinical practice guidelines. Pediatrics 1998; 101:825-30. [PMID: 9565409 DOI: 10.1542/peds.101.5.825] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research's "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care). OBJECTIVES 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines? DESIGN A national survey of 600 pediatricians selected at random from the American Medical Association master file. RESULTS A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. CONCLUSION In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.
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Affiliation(s)
- D A Christakis
- Division of General Pediatrics, University of Washington, Seattle, Washington 98195-7183, USA
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