Clinical guidelines: proliferation and medicolegal significance

Role of practice standardization in outcome optimization for CDH

Standardization of care seeks to improve patient outcomes and healthcare delivery by reducing unwanted variations in care as well as promoting the efficient and effective use of healthcare resources. There are many types of standardization, with clinical practice guidelines (CPGs), based on a stringent assessment of evidence and expert consensus, being the hallmark of high-quality care. This article outlines the history of CPGs, their benefits and shortcomings, with a specific focus on standardization efforts as it relates to congenital diaphragmatic hernia management.

Awareness Regarding Medicolegal Aspects of Medical Services Among Reproductive Age Women: A Population-Based Cross-Sectional Study

INTRODUCTION

The government has implemented various laws to regulate medical practice and improve the quality of health care services. This study evaluated the general population's awareness of various medicolegal aspects related to the medical profession.   Methods: A cross-sectional study was conducted. Knowledge of laws and ethics related to medical practice was assessed based on a well-structured questionnaire including 25 items. Women were categorized based on their score into low (below 50th percentile), medium (50th -75th percentile), and high (above 75th percentile) awareness.    Results: A total of 334 women were recruited. The mean age of the women in the study was 30.29±6.58 SD years; most women were between 20-30 (56.28%). Most women were graduates (33.23%), followed by postgraduates (29.04%). The majority of women were unemployed (housewives: 64.67%, students: 4.49%), followed by skilled workers (22.75%), semi-professional, and professionals (8.08%). High awareness about the various medicolegal aspects was seen in 25.1% of women, while 29.04% had medium awareness and 45.80% had low awareness. It was also seen that the women with higher education(p=0.002) and those employed (0.001) had better knowledge. Further, graduate housewives had better awareness than non-graduate housewives.   Conclusion: Education and self-independence significantly affected awareness of medicolegal issues among our women. Assuring the right to education and empowering women with self-independence will go a long way in ensuring active participation in medical decision-making.

Using clinical guidelines

Guidelines are statements which help people to decide what to do. Familiar examples include the Highway Code, or the ‘How to Prepare’ instructions on a jar of coffee. Traditionally, clinicians have sought knowledge from their senior colleagues, tutors and mentors, textbooks and published articles. They will continue to do so. However, there has been a recent surge of interest in guidelines on specific clinical topics. This has been driven by interest in unexplained variation in patterns of care, concern that some care is inappropriate, and the growing demand for routine, clinically effective practice. Because clinicians have limited time and resources, it can be helpful to summarise evidence for effectiveness where it is available and provide it in a concise format (see Box 1).

Trends in Pediatric Versus Adult Ophthalmology Publications Over 15 Years

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Consensus development for healthcare professionals

Consensus development sprang from a desire to synthesize clinician and expert opinions on clinical practice and research agendas in the 1950s. And since the American Institute of Medicine formally defined "guidelines" in 1990, there has been a proliferation of clinical practice guidelines (CPG) both formally and informally. This modern decision-making tool used by both physicians and patients, requires extensive planning to overcome the challenges of consensus development while reaping its rewards. Consensus allows for a group approach of multiple experts sharing ideas to form consensus on topics ranging from appropriateness of procedures to research agenda development. Disagreements can shed light on areas of controversy and launch further discussions. It has five main components: three inputs (defining the task, participant identification and recruitment, and information synthesis), the approach (consensus development by explicit or implicit means), and the output (dissemination of results). Each aspect requires extensive planning a priori as they influence the entire process, from how information will be interpreted, the interaction of participants, the resulting judgment, to whether there will be uptake of results. Implicit approaches utilize qualitative methods and/or a simple voting structure of majority wins, and are used in informal consensus development methods and consensus development conferences. Explicit approaches aggregate results or judgments using explicit rules set a priori with definitions of "agreement" or consensus. Because the implicit process can be more opaque, unforeseen challenges can emerge such as the undue influence of a minority. And yet, the logistics of explicit approaches may be more time consuming and not appropriate when speed is a priority. In determining which method to use, it is important to understand the pros and cons of different approaches and how it will affect the overall input, approach, and outcome.

Knowledge Management of Healthcare by Clinical-Pathways

Healthcare is a knowledge-intensive service provided by professionals, such as medical doctors, nurses, and pharmacists. Clinical-pathways are used by many healthcare organisations (HCOs) as a tool for performing the healthcare process, sharing and utilising knowledge from different professionals. In this paper, case studies were performed at two HCOs that use clinical-pathways actively in the healthcare process. Theoretical model construction, sharing, utilisation, and creation of the knowledge by different professionals, were tested by the case study of two HCOs which use clinical pathways actively. The theoretical model was a knowledge creation model which creates new knowledge continuously. In this theoretical model, clinical-pathways are suggested to be an effective tool for knowledge management in healthcare.

Clinical guidelines in dentistry: their benefits, limitations and dentolegal implications

This paper examines and reviews the benefits, limitations and legal implications of guidelines formulated specifically for general dental practitioners. As more guidelines are developed and become more influential in the way dentists practise and become more accountable, it is of paramount importance that that they are scientifically valid, relevant to the practitioners who use them, and are rigorously evaluated before adoption.

Factors influencing community nurses' treatment of leg ulcers

Clinical effectiveness and evidence-based practice are a central feature of the clinical governance framework. Few studies have examined factors that motivate nurses to change practice in line with evidence-based guidelines. The overall aim of this exploratory study was to examine community nurses' experience of taking part in a clinical effectiveness programme for the management of leg ulcers in the community and to identify factors most likely to ensure a change in practice. The implementation programme was conducted in the general practices within one district of a primary care audit group. Face-to-face interviews were conducted with all practice nurses and district nurses involved in the care of patients with leg ulcers from the participating practices. Nurses identified the presence of a credible facilitator, visible benefits for patients and a desire to carry out their work in an evidence-based way as factors likely to influence change. However, the degree of change achieved was not uniform across all participants and three typologies of nurses were identified according to their attitudes and level of involvement.

Do guidelines for community-acquired pneumonia improve the cost-effectiveness of hospital care?

There is growing pressure to demonstrate the value of practice guidelines. We have reviewed the evidence that guidelines for the treatment of community-acquired pneumonia (CAP) change current practices and that the standardization of practices reduces costs and/or improves outcome. The most obvious barrier to implementation of the guidelines is lack of knowledge about their content; equally important are the attitudes and behavior of professionals, patients, and their caregivers. Guidelines may improve the outcome of CAP, provided that there is an association between variations in outcome and some specific processes of care. Conversely, when there is no such relationship, guidelines may reduce the cost of care without having an adverse effect on outcome. The cost-effectiveness of CAP guidelines in an individual hospital depends on the systems that are available to identify patients with CAP and to measure the processes of care. There is good evidence that following the recommendations of the CAP guidelines does improve the cost-effectiveness of care and, therefore, that an audit of CAP may be worth the effort.

Guidelines on euthanasia and pain alleviation: compliance and opinions of physicians

The objectives of this study are to describe: (a) the presence of; and (b) compliance with guidelines in cases of euthanasia and intensifying the alleviation of pain and symptoms; (c) the opinions of physicians about written guidelines; and (d) the relationship between meeting the requirements for prudent practice and presence of, and compliance with guidelines for euthanasia or assisted suicide (EAS). In 1990 and 1995 interviews were held with 405 physicians (general practitioners, nursing home physicians and clinical specialists). The response rate for the 2 years was 91 and 89%, respectively. The percentage of physicians who reported the existence of EAS guidelines increased from 50% in 1990 to 59% in 1995, and the compliance with these guidelines increased from 51 to 75%, respectively. Of the physicians, 17% stated that there were written guidelines for intensifying the alleviation of pain and symptoms. With regard to meeting the requirements for prudent practice, we found mostly no differences between cases of euthanasia in which EAS guidelines were present, and cases in which there were no guidelines. However, when guidelines did exist and were actually used, it seems there was a better adherence to consultation and notification, although numbers were small. The increase since 1990 in agreement with the statement that an institution should formulate a policy with regard to euthanasia, may reflect the growing awareness of the specific role of the management, and not only the physician, in this matter.

Impact of management guidelines on the outcome of severe community acquired pneumonia

BACKGROUND

Ten years ago we published a study of 50 adults with severe community acquired pneumonia admitted to our intensive care unit and subsequently introduced guidelines for the management of severe community acquired pneumonia which are largely in accordance with those of the British Thoracic Society. The results of a follow up study are now reported in order to assess their impact on the outcome of this disease.

METHODS

Fifty seven cases of severe community acquired pneumonia admitted to our ICU between 1984 and 1993 were studied. Causal pathogens, clinical and laboratory features of severity, antibiotic therapy and mortality were studied and, where possible, compared with results from the previous study.

RESULTS

Streptococcus pneumoniae, Legionella pneumophila and Staphylococcus aureus were the most frequent causes of severe community acquired pneumonia, as in the previous study. The intensity of microbial investigation has increased, particularly with regard to pneumococcal and Legionella antigen testing, the latter allowing earlier diagnosis of Legionella infection than previously. In spite of this, no pathogen was identified in 33% of cases compared with 18% previously. Indices of severity of illness were widely recognised, and a decrease in unplanned transfers to the ICU following "unexpected" cardiorespiratory arrest from 25% to 7% (p < 0.02) was found. Antibiotic therapy largely reflected guideline recommendations with 98% receiving a beta-lactam agent and 91% erythromycin. The overall mortality was 58% compared with 54% previously.

CONCLUSIONS

Management guidelines for severe community acquired pneumonia have been widely adopted but without a reduction in mortality in our hospital. Factors other than early diagnosis, appropriate antibiotics, or prompt ICU transfer may influence the outcome in severe community acquired pneumonia.

Central dimensions of clinical practice evaluation: efficiency, appropriateness and effectiveness--II

That a treatment selected for a given condition works, or that it works better than alternative treatments, or that it was selected because it works as well as but is cheaper than alternative treatments, should be of pivotal concern to clinicians and is of central concern to patients and to health care managers. Attempts to address these concerns have resulted in what is now widely termed the 'effectiveness movement'. The protagonists of the movement have been concerned to create a culture of evaluation and inquiry within which the formulation of evidence-based clinical guidelines and their introduction into routine practice have played a prominent part. The need to ensure cost effectiveness of clinical intervention has been at least as emphasized as the need to ensure the clinical effectiveness of health care interventions. Although cost-effectiveness analyses are now an indispensable feature of practice guideline formulation and treatment evaluation, few studies have examined any deterioration in patient outcome associated with successful cost containment. An adequate understanding of the concept of clinical effectiveness and the associated aims of the 'effectiveness movement' is central to an understanding of the future nature and extent of health service provision, not simply in the UK but also internationally. Having examined the concepts of efficiency and appropriateness previously (O'Neill, Miles & Polychronis 1996, Journal of Evaluation in Clinical Practice 2, 13-27) we move in this second of two articles to a detailed explanation of the concept of effectiveness, and to an examination of the derivation and use of clinical practice guideline, concluding with a consideration of the role of practice guidelines in ensuring the cost effectiveness of health care intervention. The reservation is expressed that a 'guidelines culture', when established, will be manipulated by health care commissioners for largely political purposes, creating a systematic bias in the purchasing process that will actively disadvantage a range of patient groups.

Beyond guidelines: promoting clinical change in the real world

There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment.

Clinical guidelines and the law: advice, guidance or regulation?

Proliferation of clinical guidelines has given rise to a number of concerns about the status of clinical advisory statements. Are guidelines advisory or mandatory? What regulatory functions do guidelines serve; do they allow clinical discretion a large enough role? Relationships between legislation and guidelines, and the way courts go about determining the legal status of guidelines, are explained. The following questions in the context of the law of negligence are addressed. Do doctors who deviate from guidelines place themselves at increased risk of being found liable in negligence if patients suffer injury as a result? Could compliance with guidelines protect health care workers from liability in such circumstances? What legal responsibility do the developers and issuers of guidelines have if their guidance is found to be faulty? Common law cases featuring clinical guidelines or protocols have been identified from the database Lexis, which searches the full text of the transcripts and reports of court cases in UK, Commonwealth and United States jurisdictions. Secondary literature, identified from the bibliography of clinical guidelines maintained by the Department of Health Services Research at the University of Aberdeen (assembled from DHSS-DATA, Embase, Grateful Med, Medline and SIGLE) has also been consulted. The legal status of a guideline turns on whether its development and application have statutory backing, and whether the guideline embodies clinical practices accepted as proper by a responsible body of doctors. The mandatory effects of guidelines can be gauged, to some extent, by the sanctions that apply in the event of non-compliance. US courts have ruled that guideline developers can be held liable for faulty guidelines, and that doctors cannot pass off their liability by claiming that adherence to guidelines has corrupted clinical judgement. Protocols and guidelines provide the courts with examples of clinical standards across a wide range of medical practice. As guidelines proliferate, so they will increasingly be used in court. However, adherence to guidelines has not automatically been equated with reasonable practice, and the courts seem unlikely to follow the standards enunciated in clinical guidelines without critically evaluating their authority, flexibility and scope of application.