Achieving health gain through clinical guidelines II: Ensuring guidelines change medical practice

Guidelines for Caring for the Social Well-Being of Adolescents and Young Adults with Cancer in Australia

More than 1000 Australian adolescents and young adults (AYAs) are diagnosed with cancer annually. Many report unmet social well-being needs, which impact their mental health. Australian AYA cancer care providers lack guidance to address these needs well. We aimed to develop guidelines for caring for the social well-being of AYAs with cancer in Australia. Following the Australian National Health and Medical Research Council guidance, we formed a multidisciplinary working group (n = 4 psychosocial researchers, n = 4 psychologists, n = 4 AYA cancer survivors, n = 2 oncologists, n = 2 nurses, and n = 2 social workers), defined the scope of the guidelines, gathered evidence via a systematic review, graded the evidence, and surveyed AYA cancer care providers about the feasibility and acceptability of the guidelines. The guidelines recommend which AYAs should have their social well-being assessed, who should lead that assessment, when assessment should occur with which tools/measures, and how clinicians can address AYAs' social well-being concerns. A key clinician, who is knowledgeable about AYAs' developmental needs, should lead the assessment of social well-being during and after cancer treatment. The AYA Psycho-Oncology Screening Tool is recommended to screen for social well-being needs. The HEADSSS Assessment (Home, Education/Employment, Eating/Exercise, Activities/Peer Relationships, Drug use, Sexuality, Suicidality/Depression, Safety/Spirituality Assessment) can be used for in-depth assessment of social well-being, while the Social Phobia Inventory can be used to assess social anxiety. AYA cancer care providers rated the guidelines as highly acceptable, but discussed many feasibility barriers. These guidelines provide an optimal care pathway for the social well-being of AYAs with cancer. Future research addressing implementation is critical to meet AYAs' social well-being needs.

The impact of the 2015 ACOG screening guidelines on the diagnosis of postpartum depression among privately insured women

BACKGROUND

Postpartum depression (PPD), is underdiagnosed and undertreated. In 2015, the American College of Obstetricians and Gynecologists (ACOG) recommended that women be screened for PPD at least once during the perinatal period. The effect of the recommendation on PPD diagnosis is unknown.

METHODS

Using the MerativeTM MarketScan® database, PPD prevalence was identified in privately insured women ages 13-45 with a live birth between 2013 and 2016. Postpartum depression was defined as an ICD diagnosis code for PPD or other depression, or a new pharmacy claim for an antidepressant medication during the first 12 months following delivery. Multivariable logistic regression was used to estimate the likelihood of PPD both before and after the ACOG PPD Committee Opinion.

RESULTS

The study included 244,624 women ages 13-45 who had a live birth in 2013 through 2016. PPD prevalence before and after the 2015 ACOG Committee Opinion was 15.1 % and 17.2 %, respectively. The likelihood of PPD was not statistically different following the 2015 Committee Opinion (adjusted OR, 1.00, 95 % CI, 0.97-1.03) when controlling for age, year, delivery complications, and geographic region.

LIMITATIONS

Sociodemographic variables are not included in the MarketScan database and therefore could not be analyzed as covariates. Re-defining a PPD diagnosis as above interfered with the ability to measure a prior history of mood disorders as a covariate.

CONCLUSION

Implementation of the ACOG recommendations was not associated with a significant increase in PPD diagnosis. This suggests that physician organization recommendations alone are not sufficient to increase detection of PPD.

Learning by Connecting: How Rule Networks Evolve Through Discovery of Relevance

Learning-by-connecting, the formation of connections between lessons, is a fairly common phenomenon, but how does it evolve? We argue that learning-by-connecting unfolds as the relevance of lessons to other lessons is gradually discovered over time. The process of “relevance discovery” unfolds through a dynamic interplay between lessons and their context that provides opportunities to discover the relevance of lessons to other lessons. We develop a theoretical model in which the availability of these opportunities and their sorting in time drive the formation of connections. We explore and test our model in the context of organizational rules that we conceptualize, following rule-based learning theories, as repositories of lessons learned. Our empirical context is the formation of citation ties between clinical practice guidelines (CPGs), a type of organizational rules in healthcare, in a Canadian regional healthcare organization. We find that citation tie formation intensifies when opportunities to discover relevance become available. We also find that learning-by-connecting creates rule networks in which the formation of new ties slows down due to the sorting of opportunities in time. Our findings support our assumption that learning-by-connecting is shaped by relevance discovery. Our study extends models of rule-based learning and contributes to discussions on the formation of connections in contexts of dispersed learning and knowledge.

European Registry on Helicobacter pylori management (Hp-EuReg): patterns and trends in first-line empirical eradication prescription and outcomes of 5 years and 21 533 patients

OBJECTIVE

The best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care.

DESIGN

International multicentre prospective non-interventional registry starting in 2013 aimed to evaluate the decisions and outcomes in H. pylori management by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap. Variables included demographics, previous eradication attempts, prescribed treatment, adverse events and outcomes. Data monitoring was performed to ensure data quality. Time-trend and geographical analyses were performed.

RESULTS

30 394 patients from 27 European countries were evaluated and 21 533 (78%) first-line empirical H. pylori treatments were included for analysis. Pretreatment resistance rates were 23% to clarithromycin, 32% to metronidazole and 13% to both. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (39%), achieving 81.5% modified intention-to-treat eradication rate. Over 90% eradication was obtained only with 10-day bismuth quadruple or 14-day concomitant treatments. Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates. Time-trend analysis showed a region-dependent shift in prescriptions including abandoning triple therapies, using higher acid-inhibition and longer treatments, which was associated with an overall effectiveness increase (84%-90%).

CONCLUSION

Management of H. pylori infection by European gastroenterologists is heterogeneous, suboptimal and discrepant with current recommendations. Only quadruple therapies lasting at least 10 days are able to achieve over 90% eradication rates. European recommendations are being slowly and heterogeneously incorporated into routine clinical practice, which was associated with a corresponding increase in effectiveness.

Health care personnel's perception of guideline implementation for musculoskeletal imaging: a process evaluation

Background

The increasing complexity and variability in radiology have significantly fueled the need for guidelines. There are many methods for disseminating and implementing guidelines however; and obtaining lasting changes has been difficult. Implementation outcome is usually measured in a decrease in unwarranted examinations, and qualitative data are rarely used. This study’s aim was to evaluate a guideline implementation process and identify factors influencing implementation outcome using qualitative data.

Methods

Seven general practitioners and five radiological personnel from a Norwegian county participated in four focus group interviews in 2019. The data were analyzed using qualitative content analysis, where some categories were predetermined, while most were drawn from the data.

Results

Four main categories were developed from the data material. 1) Successful/unsuccessful parts of the implementation, 2) perceived changes/lack of changes after the implementation, 3) environment-related factors that affected guideline use, and 4) User related factors that affect guideline use.

Conclusions

Our findings show that clinical guideline implementation is difficult, despite the implementation strategy being tailored to the target groups. Several environment- and user-related factors contributed to the lack of changes experienced in practice for both general practitioners and radiological personnel.

Knowledge and practices of primary care physicians on the current referral system of diabetic retinopathy in Islamabad and Rawal-Pindi, Pakistan

AIM

To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy (DR) in health centers of Islamabad and Rawal-Pindi.

METHODS

A cross-sectional study was carried out in 4 government and private health centers in Rawalpindi-Islamabad from May 2018 to Oct. 2018. A total of 38 Primary Care Physicians (general practitioners, family physicians, and internists) were recruited out of which data for 2 were either not returned, or were missing partially. Data were collected through a 27-item consented & validated, multiple-choice questionnaire based on physician characteristics, knowledge and practice of diabetic eye care and challenges faced due current DR referral system. Descriptive analyses for all variables were performed including, mean and standard deviation. Analytical analyses were also conducted to study association between different study variables.

RESULTS

Mean scores of knowledge for general practitioners, family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A lack of knowledge, and suboptimal practices were observed regarding signs, symptoms, screening, testing, evaluation and referral of DR regardless of physicians' specialty, or years in practice. Lack of expertise regarding direct ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist were noted. Physicians who performed consultation and counselling according to patients' needs referred more patients to an ophthalmologist than those who restricted their consultation to a fixed amount of time and had more patients per unit time (P=0.01). Physicians who had taken care of less than 5 number of patients with DR marked less incorrect answers with no significantly greater number or correct answers compared to physicians who had taken care of more than 5 number of patients with DR (P=0.044). An association of more than 5 patients with DR taken care of with more need based patient consultation and counselling was also noted (P=0.017). An evaluation of the current referral system for DR revealed major loopholes in the health care infrastructure, proper guidelines, properly functioning equipment, check and balances, and lack of guidance to physicians regarding acquiring and updating knowledge regarding DR.

CONCLUSION

Lack of updated and adequate knowledge, practices among primary care physicians, and suboptimal diabetic eye care and referral system have contributed to late presentation of DR. Interventions are needed to improve current diabetic eye care, and knowledge and practices of primary care physicians.

Buruli ulcer treatment: Rate of surgical intervention differs highly between treatment centers in West Africa

Background

Antibiotic treatment proved itself as the mainstay of treatment for Buruli ulcer disease. This neglected tropical disease is caused by Mycobacterium ulcerans. Surgery persists as an adjunct therapy intended to reduce the mycobacterial load. In an earlier clinical trial, patients benefited from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic.

Methods

A retrospective study was conducted in six different Buruli ulcer (BU) treatment centers in Benin and Ghana. BU patients clinically diagnosed between January 2012 and December 2016 were included and surgical interventions during the follow-up period, at least one year after diagnosis, were recorded. Logistic regression analysis was carried out to estimate the effect of the treatment center on the decision to perform surgery, while controlling for interaction and confounders.

Results

A total of 1193 patients, 612 from Benin and 581 from Ghana, were included. In Benin, lesions were most frequently (42%) categorized as the most severe lesions (WHO criteria, category III), whereas in Ghana lesions were most frequently (44%) categorized as small lesions (WHO criteria, category I). In total 344 (29%) patients received surgical intervention. The percentage of patients receiving surgical intervention varied between hospitals from 1.5% to 72%. Patients treated in one of the centers in Benin were much more likely to have surgery compared to the clinic in Ghana with the lowest rate of surgical intervention (RR = 46.7 CI 95% [17.5–124.8]). Even after adjusting for confounders (severity of disease, age, sex, limitation of movement at joint at time of diagnosis, ulcer and critical sites), rates of surgical interventions varied highly.

Conclusion

The decision to perform surgery to reduce the mycobacterial load in BU varies highly per clinic. Evidence based guidelines are needed to guide the role of surgery in the treatment of BU

Buruli ulcer is a necrotizing and disabling skin infection, caused by Mycobacterium ulcerans. The infection, a skin-related Neglected Tropical Diseases, affects mostly people living in limited resources settings. Since the introduction of rifampicin based combination antibiotic therapy as standard care, the role of surgery as adjunct therapy to kill M. ulcerans is less defined and understood. A randomized controlled trial showed benefit from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic. We present the differences in rate of surgical interventions in six different Buruli ulcer treatment centers in Ghana and Benin. We demonstrate that these differences mainly depend on the opinion of the health care workers working in the treatment centers even after adjusting for disease severity.

Protocol of the European Registry on the management of Helicobacter pylori infection (Hp-EuReg)

INTRODUCTION

Helicobacter pylori selectively infects the human stomach, being the most prevalent chronic infection in the world. H pylori presence causes chronic gastritis in 100% of infected patients and is the major cause of relevant diseases such as atrophic gastritis, peptic ulcer disease, and gastric cancer; it is for this reason that from a public health standpoint, it is considered a high-impact pathogen, responsible of a significant morbidity and mortality. Nowadays, there are consensus and clinical guidelines regarding the infection management at a European level and in most of European countries, but no data have shown the level of implementation of these recommendations. The high costs that this infection carries both socially and to the health system require the continuous and systematic assessment of the diagnostic and treatment strategies, as well as the accessibility to diagnostic methods and most efficient drugs.

AIM

To register the diagnosis, management strategies, and treatment of H pylori-infected adult patients in the Digestive Services outpatient clinics throughout Europe.

METHODS

Noninterventionist prospective multicentre international Registry promoted by the European Helicobacter and Microbiota Study Group. National Coordinators will select recruiting gastroenterologists in their country that will register the H pylori-related routine clinical practice consultations they receive in an electronic case report form (e-CRF) provided by AEG-REDCap. Variables retrieved will include clinical, diagnostic, treatment, eradication confirmation, and outcome data. The database will allow researchers to perform specific subanalyses after approval by the Scientific Committee of the study.

Spanish primary care survey on the management of Helicobacter pylori infection and dyspepsia: Information, attitudes, and decisions

INTRODUCTION

Dyspepsia and Helicobacter pylori are two of the most relevant digestive conditions in primary care. Several consensuses on the subject have been published, but the assimilation/implementation of these guidelines is uncertain.

AIMS AND METHODS

To evaluate the attitudes, perceptions, limitations, and adherence to recommendations of Spanish primary care physicians using an open online survey. Responses were anonymously codified. Estimated margin of error was 3.4%. Responses were weighted by province, gender, age, and type of practice. Survey was performed using the AEG-REDCap platform.

RESULTS

A total of 1445 responses, received between December 2017 and April 2018, were analyzed. Women represented 54%, and the average age was 48 years; 59% were from urban context, 20% from semi-urban, and 21% from rural; 93% provided public practice. Over 40% had read at least one Maastricht consensus (24% Maastricht V), and 34% had attended a course related to H. pylori. 16% reported no direct access to any validated diagnostic method, only 44% to urea breath test, and 33% did not systematically refer to eradication confirmation test. The first-line treatment of choice was standard triple therapy in 56%, followed by concomitant therapy (28%). Only 20% of physicians had optimal adherence to recommendations.

CONCLUSION

Even though some improvements from guidelines have been partially incorporated, the level of penetration of recommendations is still poor and delayed. To provide optimal primary care, the barriers for implementation, access to diagnostic tests and to continuous medical education, should be removed. Rigorous dissemination, implementation, and evaluation programs are desired in future consensuses.

Clinical practice guidelines for surgical antimicrobial prophylaxis: Qualitative appraisals and synthesis of recommendations

RATIONALE, GOALS, AND OBJECTIVES

Clinical practice guidelines (CPGs) for preoperative care have been developed for surgical antimicrobial prophylaxis (SAP). The objective of this study was to synthetize recommendations for SAP based on best-evaluated CPGs.

METHODS

A systematic literature search for documents related to SAP, published between January 2011 and December 2016, was conducted on MEDLINE (PubMed), EMBASE, and specific CPG websites. Three reviewers independently assessed the rigour of development and editorial independence of CPGs based on domains 3 and 6 of the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. CPGs with domain 3 scores of 50% and greater were selected for synthesis of recommendations. Two reviewers independently extracted CPG recommendations from among these documents. A third reviewer performed the synthesis of recommendations.

RESULTS

The search retrieved 363 documents, of which 29 CPGs were appraised using AGREE II. Only eight (28%) scored 50% and greater in domain 3. Most CPGs addressed topics related to preoperative care, including SAP. No conflicting recommendations were found, and most recommendations were based on clinical practice. The only recommendation for which there was a difference among CPGs was with respect to the time to initiate the administration of antibiotics (1 hour before or close to the time of the surgical incision). Four CPGs provide recommendations that demonstrate concern about inadequate SAP prolongation.

CONCLUSION

Several CPGs for SAP were developed without the desired methodological rigour or transparency. Synthesis of recommendations for best-evaluated CPGs provides a broad approach owing to the complementarity of the recommendations.

Trustworthiness of randomized trials in endocrinology-A systematic survey

Background

Trustworthy (i.e. low risk of bias) randomized clinical trials (RCTs) play an important role in evidence-based decision making. We aimed to systematically assess the risk of bias of trials published in high-impact endocrinology journals.

Methods

We searched the MEDLINE/PubMed database between 2014 and 2016 for phase 2–4 RCTs evaluating endocrine-related therapies. Reviewers working independently and in duplicate used the Cochrane Risk of Bias Tool (CCRBT) to determine the extent to which the methods reported protected the results of each RCT from bias.

Results

We assessed 292 eligible RCTs, of which 40% (116) were judged to be at low risk, 43% (126) at moderate, and 17% (50) at high risk of bias. Blinding of outcome assessment was the least common domain reported 43% (125), while selective reporting of outcomes was the most common 97% (282). In multivariable analysis, RCTs with a parallel design (OR 2.4; 95% CI; 1.2–4.6) and funded by for-profit sources (OR 2.2; 95% CI; 1.3–3.6) were more likely to be at low risk of bias.

Conclusions

Trustworthy evidence should ultimately shape care to improve the likelihood of desirable patient outcomes. Six out-of 10 RCTs published in top endocrine journals are at moderate/high-risk of bias. Improving this should be a priority in endocrine research.

Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview

Opioid analgesics and antibiotics prescribed by dentists is a useful and cost-effective measure when prescribed appropriately. Common dental conditions are best managed by extracting the offending tooth, restoring the tooth with an appropriate filling material, performing root canal therapy, and/or fabricating a prosthesis for the edentulous space. Unnecessary prescription of opioid analgesics and antibiotics to treat dental pain and bacterial infection is a growing public health concern. This article highlights the state of the literature on opioid analgesic and antibiotic prescribing practices in dentistry, the impact of opioid analgesic overdose, and prevention strategies to reduce opioid analgesics and antibiotic overprescription.

Development and conduction of an active re-implementation of the Norwegian musculoskeletal guidelines

Objective

Significant geographical variations in the use of diagnostic imaging have been demonstrated in Norway and elsewhere. Non-traumatic musculoskeletal conditions is one area where this has been demonstrated. A national musculoskeletal guideline was implemented in response by online publishing and postal dissemination in Norway in 2014 by national policy makers. The objective of our study was to develop and conduct an intervention as an active re-implementation of this guideline in one Norwegian county to investigate and facilitate guideline adherence. The development and implementation process is reported here, to facilitate understanding of the future evaluation results of this study.

Results

The consolidated framework for implementation research guided the intervention development and implementation. The implementation development was also based on earlier reported success factors in combination with interviews with general practitioners and radiologists regarding facilitators and barriers to guideline adherence. A combined implementation strategy was developed, including educational meetings, shortening of the guideline and easier access. All the aspects of the implementation strategy were adapted towards general practitioners, radiological personnel and the Norwegian Labor and Welfare Administration. Sixteen educational meetings were held, and six educational videos were made for those unable to attend, or where meetings could not be held.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3894-4) contains supplementary material, which is available to authorized users.

Encouraging the implementation of clinical standards into practice

The articles by Geddes & Wessely (2000, this issue) and Lelliott (2000, this issue) describe the current evidence base and guidelines from which clinical standards can be developed in mental health. They highlight some of the issues and complexity surrounding the development of standards. It could be argued, however, that an even greater challenge lies in getting clinical standards used in routine practice.

Adherence to Clinical Practice Guidelines (CPG) management of dengue infection in adults (revised 2nd edition)

The Malaysian Dengue Clinical Practice Guidelines (CPG) have been developed to provide evidence-based guidance in the management of dengue infections. The use of these guidelines is essential to ensure its recommendations are being practiced. However, the adherence to the guidelines for management of dengue (revised 2^nd edition) by healthcare providers still remains unknown. Therefore, the aim of this study was to evaluate the proportion among healthcare providers that adhere to this Dengue CPG. A retrospective cohort study of dengue cases registered from 1 January 2014 to 1 June 2015 was conducted in public hospitals and health clinics in Selangor, Putrajaya and Kuala Lumpur. Adherence to the CPG recommendations were recorded by reviewing patients’ case notes. Overall proportion of adherence in clinical components of the recommendation were (7.1 to 100.0% versus 7.7 to 73.8%) in history taking, (6.7 to 100.0% versus 12.3 to 60.0%) in physical examinations, (18.4 to 100.0% versus 23.1 to 83.2%) in assessment of warning signs, (0.6 to 100.0% versus 12.3 to 87.7%) in assessment of haemodynamic status, (60.0 to 100.0% versus 27.7 to 40.0%) in diagnosis, (46.6 to 80.0% versus 52.3%) in case notifications, (73.2 to 100.0% versus 89.2 to 96.9%) in performing specific laboratory investigations and (7.9 to 100.0% versus 21.5%) in monitoring, for outpatient versus inpatient, respectively. Adherence trends were demonstrated to be higher in hospital settings compared to outpatient settings. Adherence to this Dengue CPG varies widely with overall good clinical outcomes observed.

A qualitative study of the determinants of HIV guidelines implementation in two south-eastern districts of Tanzania

Current HIV policies in Tanzania have adopted the three long-term impact results of zero new infections, zero HIV deaths and zero stigma and discrimination. Strategies to reach these results include scaling-up HIV Testing and Counselling (HTC); Preventing Mother-To-Child Transmission (PMTCT); and strengthening Care and Treatment Clinic (CTC) services. Previous studies showed that HIV policy and guideline recommendations were not always implemented in rural South Tanzania. This study aims to identify the determinants of HIV guideline implementation. A qualitative study of 23 semi-structured interviews with facility in-charges; healthcare workers; district, regional and national HIV coordinators was conducted. Five health facilities were purposively selected by level, ownership and proximity to district headquarters. Interviews were analysed according to Fleuren's five determinants of innovation uptake related to: strategies used in guideline development and dissemination; guideline characteristics; the guideline implementing organization; guideline users; and the socio-cultural and regulatory context. None of the facilities had the HTC national guideline document. Non-involvement of providers in revisions and weak planning for guideline dissemination impeded their implementation. Lengthy guidelines and those written in English were under-used, and activities perceived to be complicated, like WHO-staging, were avoided. Availability of staff and lack of supplies like test kits and medication impeded implementation. Collaboration between facilities enhanced implementation, as did peer-support among providers. Provider characteristics including education level, knowledge of, and commitment to the guideline influenced implementation. According to providers, determinants of clients' service use included gender norms, stigma, trust and perceived benefits. The regulatory context prohibited private hospitals from buying HIV supplies. Being tools for bringing policies to practice, national guidelines are crucial in the efforts towards the three zeros. Strategies to improve providers' adherence to guidelines should include development of clearer guideline dissemination plans, strengthening of the health system, and possibly addressing of provider-perceived patient-level barriers to utilizing HIV services.

Yusof MA, Ahmad Lutfi N, Thye SL, Ismail F, Mahmud M, Bakri R. Evaluation of awareness & utilisation of clinical practise guideline for management of adult Dengue infection among Malaysia doctors

Clinical Practice Guideline (CPG) provides evidence-based guidance for the management of Dengue Infection in adult patients. A cross sectional study was conducted to evaluate awareness and utilization of CPG among doctors in public or private hospitals and clinics in Malaysia. Doctors practicing only at hospital Medical and Emergency Departments were included, while private specialist clinics were excluded in this study. A multistage proportionate random sampling according to region (Central, Northern, Southern, Eastern, Sabah and Sarawak) was performed to select study participants. The overall response rate was 74% (84% for public hospitals, 82% for private hospitals, 70% for public clinics, and 64% for private clinics). The CPG Awareness and Utilization Feedback Form were used to determine the percentage in the study. The total numbers of respondent were 634 with response rate of 74%. The mean lengths of service of the respondent were 13.98 (11.55).A higher percentages of doctors from public facilities (99%) were aware of the CPG compared to those in private facilities (84%). The percentage of doctors utilising the CPG were also higher (98%) in public facilities compared to private facilities (86%). The percentage of Medical Officer in private facilities that utilizing the CPG were 84% compares to Medical Officer in public facilities 98%. The high percentage of doctors using the CPG in both public (97%) and private (94%) hospitals were also observed. However, only 69% of doctors in private clinics utilised the CPG compared to doctors in public clinics (98%). Doctors in both public and private facilities were aware of the dengue CPG. However, most doctors in private clinic were less likely to utilise the CPG. Therefore, there is a need to increase the level of CPG utilisation especially in private clinics.

Critical attitudes and beliefs towards guidelines amongst palliative care professionals - results from a national survey

BACKGROUND

Little is known about palliative care professionals' attitudes towards guidelines. In 2015, the German Association for Palliative Medicine (DGP) published an evidence based guideline for palliative care in adults with incurable cancer. Before publication we conducted a national survey among members of the DGP to detect possible barriers and facilitators for its implementation. The aim of the present publication was to evaluate critical attitudes and beliefs which could hinder the effective implementation of the new guideline and to evaluate differences within professional groups and medical specialisations.

METHODS

This web-based online survey was addressed to all members of the DGP in summer 2014. Twenty-one questions concerning attitudes and beliefs towards guidelines were a priori developed to represent the following topics: scepticism regarding the quality of guidelines, doubts about the implementation of guidelines, restrictions in treatment options through guidelines, discrepancy between palliative care values and guidelines. Differences within professions and specialisations were tested using Kruskal-Wallis tests.

RESULTS

All 4.786 members with known email address were invited, 1.181 followed the link, 1.138 began to answer the questionnaire and 1.031 completed the questionnaire. More than half of participating members were physicians and one third nurses. Scepticism regarding the quality of existing guidelines was high (range 12.8-73.2%). Doubts regarding practical aspects of guidelines were less prevalent but still high (range 21.8-57.6%). About one third (range 5.4-31.4%) think that guidelines restrict their treatment options. In addition, 38.8% believed that guidelines are a kind of cookbook and restrict the flexibility of individual patient care. The majority saw no or little discrepancy between palliative care values and guidelines (range 68.4-82.6%). There were relatively small but significant differences between professions and specialisations.

CONCLUSION

The person-centred and individual approach of palliative care does not seem to contradict the acceptance of guidelines. Main barriers were related to scepticism regarding the quality of guidelines and the implementation of guidelines in general.

What patients really think about asthma guidelines: barriers to guideline implementation from the patients' perspective

BACKGROUND

Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations.

METHODS

Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis.

RESULTS

Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition.

CONCLUSIONS

We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues should be addressed at the planning stage.

TRIAL REGISTRATION

DRKS00000562 (German Clinical Trials Registry).

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap

In this paper, we outline the relationship between the need to put existing applied health research knowledge into practice (the 'know-do gap') and the need to improve the evidence base (the 'know gap') with respect to the healthcare process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in CGA; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base that requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.

Impact of Asia-Pacific guidelines on gastric cancer and Helicobacter pylori infection on prevailing clinical practices

OBJECTIVE

To determine the impact of the Asia-Pacific guidelines on gastric cancer prevention and Helicobacter pylori (H. pylori) infection on clinical practice.

METHODS

An electronic survey was carried out among Asian Pacific Digestive Week (APDW) medical delegates in 2012. The survey questionnaire captured details such as participants' characteristics, their awareness of the guidelines and knowledge of the key guideline recommendations, the impact of the guidelines on individual practice and on national policies and the sources of medical information that the individual used to make clinical decisions. A total of 1372 APDW medical delegates were invited via email to participate in the electronic survey and 432 (31.5%) responded.

RESULTS

Among the respondents, 57.6% were familiar with at least one of the guidelines. Among those familiar with the guidelines, 85.9% believed that they influenced their clinical practice. More than half (64.9%) reported that the guidelines clarified treatment indications for them. In terms of knowledge content, 85.0% of the participants provided correct responses to at least four of the six questions on understanding. More than half (52.7%) of the participants felt that the guidelines had made an impact on national policies.

CONCLUSION

The Asia-Pacific guidelines on gastric cancer and H. pylori had a positive impact on individual clinical practice and national policies.

The development, implementation and evaluation of clinical practice guidelines in Gulf Cooperation Council (GCC) countries: a systematic review of literature

RATIONALE, AIMS AND OBJECTIVES

Our aim was to examine and describe the current situation in Gulf Cooperation Council (GCC) member countries regarding the development, implementation and evaluation of clinical practice guidelines (CPG). The objectives were to describe from where the studies originated, what the clinical focus was of each study and examine the methodology and the status of each study (i.e. development, dissemination, implementation and evaluation).

METHODS

Review of literature - two stages: stage 1: screening through an abstract review, followed by independent adjudicator; stage 2: detailed assessment and classification.

RESULTS

Considering the widespread acceptance that CPG's are useful and effective tools for quality improvement in health care, it is worth noting that relatively few studies have been conducted in the GCC region that examine CPG. Furthermore, the reviewers found that the quality of the research methods used could be improved. The majority of the studies that were conducted evaluated the effects of guidelines and focused on the 'lifestyle diseases', in particular diabetes and cardiovascular diseases. It is also worth noting that there has been a steady increase in the number of publications over the 10 years period.

CONCLUSIONS

More attention needs to be given to developing, disseminating, implementing and evaluating CPG's in the GCC region in order to improve the quality and safety of health care.

Adaptation and innovation: a grounded theory study of procedural variation in the academic surgical workplace

RATIONALE, AIMS AND OBJECTIVES

Surgical research struggles to describe the relationship between procedural variations in daily practice and traditional conceptualizations of evidence. The problem has resisted simple solutions, in part, because we lack a solid understanding of how surgeons conceptualize and interact around variation, adaptation, innovation, and evidence in daily practice. This grounded theory study aims to describe the social processes that influence how procedural variation is conceptualized in the surgical workplace.

METHOD

Using the constructivist grounded theory methodology, semi-structured interviews with surgeons (n = 19) from four North American academic centres were collected and analysed. Purposive sampling targeted surgeons with experiential knowledge of the role of variations in the workplace. Theoretical sampling was conducted until a theoretical framework representing key processes was conceptually saturated.

RESULTS

Surgical procedural variation was influenced by three key processes. Seeking improvement was shaped by having unsolved procedural problems, adapting in the moment, and pursuing personal opportunities. Orienting self and others to variations consisted of sharing stories of variations with others, taking stock of how a variation promoted personal interests, and placing trust in peers. Acting under cultural and material conditions was characterized by being wary, positioning personal image, showing the logic of a variation, and making use of academic resources to do so. Our findings include social processes that influence how adaptations are incubated in surgical practice and mature into innovations.

CONCLUSIONS

This study offers a language for conceptualizing the sociocultural influences on procedural variations in surgery. Interventions to change how surgeons interact with variations on a day-to-day basis should consider these social processes in their design.

Implementation of Pharmaceutical Practice Guidelines by a Project Model Based: Clinical and Economic Impact

All around the world a few studies have been found on the effect of guideline implementation on direct medications' expenditure. The goal of this study was to evaluate cost savings of guideline implementation among patients who had to receive 3 costly medications including albumin, enoxaparin, and pantoprazole in a tertiary hospital in Shiraz, Iran.An 8-month prospective study was performed in 2 groups; group 1 as an observational group (control group) in 4 months from June to September 2014 and group 2 as an interventional group from October 2014 to January 2015.For group 1 the pattern of costly medications usage was determined without any intervention. For group 2, after guideline implementation, the economic impact was evaluated by making comparisons between the data achieved from the 2 groups.A total of 12,680 patients were evaluated during this study (6470 in group 1; 6210 in group 2). The reduction in the total value of costly administered drugs was 56% after guideline implementation. Such reduction in inappropriate prescribing accounts for the saving of 85,625 United States dollars (USD) monthly and estimated 1,027,500 USD annually.Guideline implementation could improve the adherence of evidence-based drug utilization and resulted in significant cost savings in a major teaching medical center via a decrease in inappropriate prescribing of costly medications.

Implementation of a ward round pro-forma to improve adherence to best practice guidelines

Our aim was firstly to assess adherence to best practice guidelines for the prevention of healthcare associated causes of inpatient mortality and morbidity by junior doctors. Secondly, we wanted to measure the impact of a ward round checklist on rates of adherence. The rates of correct prescribing of antibiotics, venous thrombo-embolism prophylaxis, and oxygen (pro re nata) as well as correctly completed paperwork for peripheral venous cannulas were measured in a spot audit of all medical notes of patients on a medical assessment unit. This was repeated two weeks and two months after the introduction of a specifically designed ward round checklist for junior doctors. Initial audit of 40 patient notes confirmed generally poor compliance with best practice guidelines in the prescription of antibiotics (58% correctly prescribed) and oxygen (42%), and in the use cannula care plans (39%). Venous thrombo-embolism prophylaxis prescribing on the other hand was widespread (82%). The introduction and extensive use of the ward round checklist did not have a significant impact on these figures as shown in the two following stop audits (30 and 36 notes respectively). Checklists are helpful in providing a structured and systematic approach to complex tasks and have been shown to have a measurable impact in improving patient care. Their effectiveness is however limited by their uptake and regular correct use. Obstructing issues include poor understanding of the need for change in practice, lack of individual accountability and variable involvement of clinical leaders. These issues must be addressed together in order to effect a successful change in clinical practice.

Strategies for reducing regional variation in the use of surgery: a systematic review

OBJECTIVE

To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation.

BACKGROUND

The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain.

METHODS

Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science.

RESULTS

A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results.

CONCLUSIONS

Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

A survey of emergency department resources and strategies employed in the treatment of pediatric gastroenteritis

OBJECTIVES

Although leading organizations have developed gastroenteritis management guidelines, little is known about emergency department (ED) use of clinical tools to improve outcomes. Our objective was to describe pediatric gastroenteritis clinical decision tools employed in EDs in the province of Ontario and to determine if a greater number of clinical decision tools are employed in academic, high-volume institutions staffed primarily by emergency medicine (EM)-trained physicians.

METHODS

A cross-sectional, Internet-based survey was distributed in the summer of 2010 to medical directors and managers of Ontario EDs. Domains included patient population, general resources, and gastroenteritis-specific strategies. Copies were requested of all gastroenteritis-specific strategies to enable a content review.

RESULTS

A total of 133 (83%) of 160 eligible participants responded. Practice guidelines, pathways, or order sets; medical directives; and printed discharge instructions were reported to be in use at 38 of the 133 (29%), 69 of 133 (52%), and 105 of 133 (79%) of the responding institutions, respectively. Oral rehydration therapy (ORT) is routinely initiated at triage in only 51 of the 133 of the EDs (38%). High-volume institutions are more likely to have clinical practice guidelines, pathways, or order sets (p = 0.001) than low- and medium-volume EDs. Physician training in EM was associated with the presence of medical directives for nursing administration of antiemetics and antipyretics (p = 0.04). Review of clinical practice guidelines, pathways, and order sets showed that only six of 27 gastroenteritis-specific strategies reviewed were correctly classified, and 20 (74%) met prespecified quality criteria.

CONCLUSIONS

Clinical decision tools designed to improve pediatric gastroenteritis management are not commonly implemented. Such strategies are more common in high-volume EDs and those staffed primarily by physicians with EM training.

A method for developing standardised interactive education for complex clinical guidelines

BACKGROUND

Although systematic use of the Perinatal Society of Australia and New Zealand internationally endorsed Clinical Practice Guideline for Perinatal Mortality (PSANZ-CPG) improves health outcomes, implementation is inadequate. Its complexity is a feature known to be associated with non-compliance. Interactive education is effective as a guideline implementation strategy, but lacks an agreed definition. SCORPIO is an educational framework containing interactive and didactic teaching, but has not previously been used to implement guidelines. Our aim was to transform the PSANZ-CPG into an education workshop to develop quality standardised interactive education acceptable to participants for learning skills in collaborative interprofessional care.

METHODS

The workshop was developed using the construct of an educational framework (SCORPIO), the PSANZ-CPG, a transformation process and tutor training. After a pilot workshop with key target and stakeholder groups, modifications were made to this and subsequent workshops based on multisource written observations from interprofessional participants, tutors and an independent educator. This participatory action research process was used to monitor acceptability and educational standards. Standardised interactive education was defined as the attainment of content and teaching standards. Quantitative analysis of positive expressed as a percentage of total feedback was used to derive a total quality score.

RESULTS

Eight workshops were held with 181 participants and 15 different tutors. Five versions resulted from the action research methodology. Thematic analysis of multisource observations identified eight recurring education themes or quality domains used for standardisation. The two content domains were curriculum and alignment with the guideline and the six teaching domains; overload, timing, didacticism, relevance, reproducibility and participant engagement. Engagement was the most challenging theme to resolve. Tutors identified all themes for revision whilst participants identified a number of teaching but no content themes. From version 1 to 5, a significant increasing trend in total quality score was obtained; participants: 55%, p=0.0001; educator: 42%, p=0.0004; tutor peers: 57%, p=0.0001.

CONCLUSIONS

Complex clinical guidelines can be developed into a workshop acceptable to interprofessional participants. Eight quality domains provide a framework to standardise interactive teaching for complex clinical guidelines. Tutor peer review is important for content validity. This methodology may be useful for other guideline implementation.

The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient

The KDIGO guideline for glomerulonephritis is designed to assist health-care providers in treating patients with glomerular diseases. A guideline is not a set of rules but is intended to allow the practitioner to make an informed decision based on the available evidence. Due to its general nature and the variability of strength of the available studies, it is often difficult to directly apply a guideline to the care of an individual patient. This commonly relates to the limited generalizability of the evidence, i.e., does not cover every clinical scenario. To underscore this point, we have introduced within the context of the glomerulonephritis guideline cases with specific features to illustrate the constant need for clinical judgment. These vignettes are intended to demonstrate how the best treatment plans should be individualized and take into account patient preference and clinical acumen, as well as the best available evidence.

Summary of the KDIGO guideline on anemia and comment: reading between the (guide)line(s)

The kidney disease improving global outcomes (KDIGO) clinical practice guideline for anemia in chronic kidney disease (CKD) is designed to assist health-care providers in treating CKD patients with anemia. A guideline is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. It is intended to provide information and to allow the practitioner to make an informed decision, based on evidence and expert judgment. Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in any particular clinical situation. Owing to the general nature of a guideline, it is sometimes difficult to translate it to an individual patient's condition. As the primary goal is to improve patient care, we have decided to focus on practical clinical aspects of the KDIGO anemia guideline.

Development and implementation of clinical practice guidelines: current status in Korea

Documentation of unexplained geographic variations in medical practices and use of inappropriate interventions has led to the proliferation of clinical practice guidelines. With increased enthusiasm for guidelines, evidence exists that clinical practice guidelines often influence clinical practices or health outcomes. Their successful implementation may improve the quality of care by decreasing in appropriate variation and expediting the application of effective advances to healthcare practices. In Korea, physicians and healthcare professionals have begun to take interests in clinical practice guidelines. Currently, over 50 practice guidelines have been developed through professional academic organizations or via other routes; however, the quality of the guidelines is unsatisfactory, implementation in clinical settings is incomplete, and there is insufficient infrastructure to develop clinical practice guidelines. Korea must develop policies and invest resources to enhance the development and implementation of clinical practice guidelines.

Prospective systematic review registration: perspective from the Guidelines International Network (G-I-N)

Clinical practice and public health guidelines are important tools for translating research findings into practice with the aim of assisting health practitioners as well as patients and consumers in health behavior and healthcare decision-making. Numerous programs for guideline development exist around the world, with growing international collaboration to improve their quality. One of the key features in developing trustworthy guidelines is that recommendations should be based on high-quality systematic reviews of the best available evidence. The review process used by guideline developers to identify and grade relevant evidence for developing recommendations should be systematic, transparent and unbiased. In this paper, we provide an overview of current international developments in the field of practice guidelines and methods to develop guidelines, with a specific focus on the role of systematic reviews. The Guidelines International Network (G-I-N) aims to stimulate collaboration between guideline developers and systematic reviewers to optimize the use of available evidence in guideline development and to increase efficiency in the guideline development process. Considering the significant benefit of systematic reviews for the guideline community, the G-I-N Board of Trustees supports the international prospective register of systematic reviews (PROSPERO) initiative. G-I-N also recently launched a Data Extraction Resource (GINDER) to present and share data extracted from individual studies in a standardized template. PROSPERO and GINDER are complementary tools to enhance collaboration between guideline developers and systematic reviewers to allow for alignment of activities and a reduction in duplication of effort.

An investigation of West Sussex general dental practitioners' awareness, attitudes and adherence to NICE dental recall guidelines

AIMS

The overall aim of this study was to determine whether general dental practitioners (GDPs) in West Sussex were aware of and followed National Institute for Health and Clinical Excellence (NICE) guidelines on dental recalls. The study also aimed to identify factors in the GDPs' practice of dentistry that could affect their adherence to NICE guidelines and to gain some insight into their views on this topic and how these might affect their adherence.

METHODS

A postal questionnaire, which had previously been piloted, and an explanatory letter were sent to a random sample of 195 GDPs representing 50% of the GDPs contracted to the West Sussex Primary Care Trust. Those who did not respond were sent the questionnaire and letter for a second time. The questionnaire consisted of 50 questions that covered awareness of, attitudes towards and adherence to the NICE guidelines on dental recalls, risk factors, and the GDPs' practising profile. Resulting data were entered into a database and, where appropriate, statistically tested with the chi-square test, with the level of statistical probability set at P<0.5.

RESULTS

Data were obtained from the 50 questions in the questionnaires. Only key results are presented in this abstract. Ten of the 195 GDPs had either moved away from the area or were orthodontists. The final sample was therefore 185, of whom 117 returned questionnaires, a response rate of 63%. Seventy-three per cent of the respondents had qualified in United Kingdom. Sixty-five per cent were male. The mean age of respondents was 43 years. Seventy-one per cent worked as GDPs within the General Dental Services (GDS) or Personal Dental Services. Concerning NICE recall guidelines, 94% stated that they were aware of them, 61% said they agreed with them, and 64% that they adhered to them. Female GDPs were statistically far more likely to state that they followed NICE guidelines ( P =0.0043). Seventy per cent of GDPs reported that they still recalled their patients at six-month intervals and only 3% that they recalled their patients according to need. Eighty-five per cent reported taking radiographs at two-year intervals and/or according to patient need, and 68% that they gave oral hygiene advice six monthly or at every recall. Risk assessments were reported as being always carried out by 65% of responding GDPs for caries, 83% for periodontal disease, and 81% for oral cancer. Ninety per cent reported that they thought risk factors were relevant when setting the recall interval and 82% thought that six-monthly recalls allowed appropriate screening to take place.

CONCLUSIONS

Only 3% of responding GDPs recalled their patients according to patient need, in line with NICE recall guidelines, although the majority of GDPs agreed with the guidelines and stated that they adhered to them; however, this was in contrast to the 70% of GDPs who continued to recall at six-month intervals. The majority of GDPs thought that less frequent recalls would not allow for early caries, periodontal disease and oral malignancy diagnosis, and did not think that access to NHS dentistry would be improved. They also did not believe that excessive NHS money was spent on over-frequent dental examinations. There would appear to be significant obstacles to altering the recall habits of dentists because of the way that dentists practise.

The need for an Intersociety Consensus Guideline for venous ulcer

BACKGROUND

The management of venous leg ulcers (VLU) consumes considerable resources in healthcare systems and accounts for up to 1% of healthcare budgets in some industrialized countries. Best practice clinical guidelines incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved quality and less costly outcomes for many diseases. The objective of this study was to determine whether there are common elements in guidelines for VLU and their evidentiary strength.

METHODS

A systematic analysis of guidelines for VLU that were identified through http://clinicaltrials.gov, a government-sponsored Web site, and other Web sites. The proportion of guidelines proposing a recommendation as well as the strength of the guidelines were analyzed.

RESULTS

Fourteen guidelines were identified, of which 13 were evidence-based, with the majority using the grading of recommendations, assessment, development, and evaluation method. Five were sponsored by a government agency and nine by a medical or nursing society, while nine had been developed or updated within the last 5 years. Ankle/brachial index and venous duplex were recommended in 100% and 64%, respectively, of the guidelines. All recommended wound dressings and high compression, with both at the strongly recommended level of 75% and 77%, respectively. Debridement was suggested in 86%, but only one-third at the strong level. For adjunctive measures, 80% advocated pentoxifylline and approximately 50% physical therapy for improving ankle joint mobility. The majority emphasized the preventive value of compression stockings and surgical reduction of superficial venous hypertension, with a strong recommendation in 58% in the former and 73% in the latter.

CONCLUSIONS

While there are numerous evidence-based guidelines for VLU, there is consensus on strong recommendations for dressings and compression only among the various guidelines. A number of the guideline elements need further study and refinement. To improve patient care and reduce wasted resources, it is imperative for specialty societies to collaborate and develop this consensus document.

Cognitive decline and the default American lifestyle

OBJECTIVES

Upward trends in IQ, education, and mental work suggest that cognitive function among seniors should be rising strongly across cohorts. There is little sign of such improvement in recent decades, and some analyses find poorer function in the newer cohorts. This essay explores possible explanations of the anomaly.

METHODS

Major long-term trends that might increase cognitive impairment are reviewed, and their implications are considered.

RESULTS

Physical activity is declining, food is increasingly manufactured, body fat is increasing, diabetes and metabolic syndrome are on the rise, the number of prescription drugs per person is increasing, and the proportion of the population either old or obese is growing.

DISCUSSION

Technological and economic development may lower the cognitive function needed for survival. They also lower physical activity in daily life. Sedentary work, transportation, and leisure undermine the aerobic and metabolic fitness required for the brain to perform well. Some prescription drugs impair cognitive function, and others do so when taken for many years or in combination with others. The growing fraction of the population that is either old or obese may further lower physical activity norms and requirements and substitute medical intervention for health, accelerating a trend toward cognitive impairment.

Diabetic retinopathy management by Australian optometrists

BACKGROUND

To survey the current diabetic retinopathy screening and management practices of Australian optometrists following the release of the 1997 National Health Medical Research Council Diabetic Retinopathy Management Guidelines.

DESIGN

Cross-sectional national survey, primary care setting.

PARTICIPANTS

1000 Australian optometrists across different states.

METHODS

A self-administered questionnaire was sent to 1000 optometrists across all states during 2007/2008.

MAIN OUTCOME MEASURES

Use of retinal camera, screening practices/attitudes and behaviour in diabetic retinopathy management.

RESULTS

568 optometrists (57%) responded to the survey. Patients' unpreparedness to drive post dilation (51%) and the fear of angle closure glaucoma (13%) were the two main barriers to optometrists not performing dilated ophthalmoscopy. Those who had strong desire to screen for diabetic retinopathy were more likely to use a retinal camera (p<0.005). Use of a retinal camera was significantly associated with an increased confidence in detecting clinical signs of diabetic retinopathy including macular oedema (P<0.001). Optometrists who read the guidelines at least once were 2.5-times (P<0.001) more likely to have confidence in detecting macular oedema than those who had never read the guidelines. Although they may be confident in diagnosis, and may use retinal cameras for screening, nearly 60% of optometrists would not refer patients with macular oedema to an ophthalmologist.

CONCLUSIONS

Despite their self-reported desire for involvement in diabetic retinopathy, the management of macular oedema by Australian optometrists needs improvement. The use of retinal cameras and promotion of the 2008 NHMRC guidelines should be encouraged to improve overall optometric diabetic retinopathy management, particularly with macular oedema.

The Delphi and nominal group techniques in health services research

This review examines two methodologies that are being increasingly used in health services research (HSR): the Delphi and nominal group techniques. The Delphi is a survey technique for decision making among isolated respondents while the nominal group technique (NGT) is a highly controlled small group process for the generation of ideas. Typical applications of the techniques are for the development of consensus guidelines or standards in areas where research based evidence is absent or inconclusive. We discuss methodological issues associated with these techniques, namely, sample size and composition, response rates, anonymity, feedback and consensus, and reliability and validity. We also illustrate the range of applications of the techniques in HSR, including pharmacy practice. Although not widely used to date, both methodologies are potentially valuable additions to the practice researcher's toolbox.