Dissemination of the Agency for Health Care Policy and Research guideline

The Saudi Guidelines for the Diagnosis and Management of COPD

The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

Dissemination of the AHCPR clinical practice guideline in community health centres

OBJECTIVE

To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres.

DESIGN

Pre- and post-trial.

SETTING

Fourteen community health centres in Rhode Island.

SUBJECTS

Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up.

INTERVENTIONS

Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building.

OUTCOME MEASURES

Chart documentation of four A's (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit.

RESULTS

While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points.

CONCLUSIONS

This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.

Smoking cessation interventions among hospitalized patients: what have we learned?

BACKGROUND

We conducted a structured review of controlled studies on inpatient hospital-based smoking cessation interventions.

METHODS

Electronic searches were conducted with two different search engines, and reference sections of articles located were also reviewed. The RE-AIM framework was used to organize the review around the issues of reach, efficacy, adoption, implementation, and maintenance of interventions.

RESULTS

Thirty-one intervention articles were located, 20 of which included a comparison condition and were included in the review. Overall, a moderate number of studies (13/20) reported on reach, which was highly variable and limited (30-50% in most studies), while few reported on implementation (7/20). Longer term cessation results produced relative risk ratios of 0.9-2.3, with a median of 1.5. Increases in quit rates above the control condition ranged from -1 to 10% (median 4%) among general admission patients and from 7 to 36% (median 15%) among cardiac admission patients. Studies with a dedicated smoking cessation counselor and 3-5 months of relapse prevention had a significant impact on cessation rates. Study settings (adoption) were limited to university, Veterans affairs, and HMO hospitals. Maintenance at the individual level was variable and related to the presence of a relatively intensive initial intervention and a sustained relapse prevention intervention.

CONCLUSIONS

Efficacious inpatient smoking programs have been developed and validated. The challenge now is to translate these interventions more widely into practice, given changing hospitalization patterns.