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

Practice determinants for adherence to the Guide for the Comprehensive Clinical Care of Dengue Patients, Urabá (Colombia). A multifaceted approach to implementation research

INTRODUCTION

Dengue is a significant public health issue in the Urabá region, accounting for 37.5% of morbidity and 41.7% of mortality resulting from dengue in the department of Antioquia (Colombia) in 2018. Clinical Practice Guidelines (CPGs) are tools based on Evidence-Based Medicine, intended for medical personnel to bridge the gap between proven intervention efficacy and clinical decision-making. This study aims to identify barriers and facilitators in the implementation of CPGs for dengue patient care by healthcare officials in the municipalities of the banana axis in the Urabá region.

METHODOLOGY

From a multifaceted approach to implementation research, a mixed method study that combines qualitative and quantitative approaches, was conducted during the years 2020 and 2021, using combined instruments to identify determinants (Guide Indicative Factors, Individual factors of health professionals, Patient factors, Professional interactions, Incentives and resources, Capacity for organizational change, and lastly Social, political, and legal factors) affecting adherence to the Comprehensive Clinical Care Guide for Patients with Dengue (GACIPD). Semi-structured interviews and focus groups with healthcare workers were conducted to assess determinants based on clinical experience. Questionnaires on determinants of GACIPD adherence, using an adapted version of the Chronic Disease Implementation Checklist (TICD), were also employed. Qualitative analysis of the interviews and focus groups used a concept-based coding framework. The questionnaire responses were analyzed using Likert scaling and frequency counts of determinants within and across domains. Participants included general practitioners, other health professionals, researchers, academics, and administrators.

RESULTS

There was a total of 103 participants in focus groups, 7 in semi-structured interviews, and 136 participants through questionnaires. Among the domains studied, the identification of barriers and facilitators emphasized institutional factors and individual factors. Organizational change capacity was identified as a major barrier, with only 3.6% of respondents indicating that their institution adjusted the prioritization of adequate care according to the guideline. The GACIPD domain received the highest facilitator rating, with 66.7% acceptance due to its practicality, simplicity, clarity, documentation, and ease of implementation, despite this, only 10% of professionals completely agree that their work is in accordance with the GACIPD. The determinant of patient factors was significant in the negative perception of adherence to GACIPD.

CONCLUSIONS

Although barriers outweighed facilitators for GACIPD adherence, determinants for its use were generally positive, as most participants reported it as being a complete, documented, and easy-to-implement guide. The lack of knowledge of the guidelines impacting health professional's decision making was identified as a potentially modifiable barrier, and educational strategies could be implemented to overcome it. The region requires greater emphasis on the management of chronic health conditions, comorbidities, and coinfections of dengue with other endemic diseases.

Using clinical practice guidelines to manage dengue: a qualitative study in a Malaysian hospital

Background

Malaysia has rising dengue incidence. World Health Organization clinical practice guidelines for managing dengue have been adapted by the Ministry of Health in Malaysia, with evidence of good awareness by clinicians. However, dengue mortality has not reduced. This study aimed to explore the challenges of dengue management for Medical Officers, with a particular focus on use of clinical practice guidelines.

Methods

Qualitative study using six focus groups and 14 semi-structured interviews with doctors responsible for dengue management at a large tertiary hospital in Malaysia.

Results

Dengue was recognised as difficult to diagnose and manage. Wide awareness and use of both WHO and Ministry of Health guidelines was reported, but several limitations noted in their coverage of particular patient groups. However, the phrase ‘guidelines’ also referred to local algorithms for fluid management, which were less clinically evidence-based. Where Medical Officers were well trained in the appropriate use of evidence-based guidelines, barriers to use included: the potential for ‘following the algorithm’ to undermine junior clinicians’ claims to clinical expertise; inability to recognise the pattern of clinical progress; and lack of clinical experience. Other reported barriers to improved case management were resource constraints, poor referral practices, and insufficient awareness of the need for timely help seeking.

Conclusions

Awareness of clinical practice guidelines is a necessary, but not sufficient, condition for optimal dengue management. In high prevalence settings, all clinical staff would benefit from regular dengue management training which should include diagnosis, practice in monitoring disease progression and the use of clinical practice guidelines in a range of clinical contexts.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3680-5) contains supplementary material, which is available to authorized users.

Dengue in Malaysia: Factors Associated with Dengue Mortality from a National Registry

BACKGROUND

The increasing incidence and geographical distribution of dengue has had significant impact on global healthcare services and resources. This study aimed to determine the factors associated with dengue-related mortality in a cohort of Malaysian patients.

METHODS

This was a retrospective cohort study of patients in the Malaysian National Dengue Registry of 2013. The outcome measure was dengue-related mortality. Associations between sociodemographic and clinical variables with the outcome were analysed using multivariate analysis.

RESULTS

There were 43 347 cases of which 13081 were serologically confirmed. The mean age was 30.0 years (SD 15.7); 60.2% were male. The incidence of dengue increased towards the later part of the calendar year. There were 92 probable dengue mortalities, of which 41 were serologically confirmed. Multivariate analysis in those with positive serology showed that increasing age (OR 1.03; CI:1.01-1.05), persistent vomiting (OR 13.34; CI: 1.92-92.95), bleeding (OR 5.84; CI 2.17-15.70) and severe plasma leakage (OR 66.68; CI: 9.13-487.23) were associated with mortality. Factors associated with probable dengue mortality were increasing age (OR 1.04; CI:1.03-1.06), female gender (OR 1.53; CI:1.01-2.33), nausea and/or vomiting (OR 1.80; CI:1.17-2.77), bleeding (OR 3.01; CI:1.29-7.04), lethargy and/or restlessness (OR 5.97; CI:2.26-15.78), severe plasma leakage (OR 14.72; CI:1.54-140.70), and shock (OR 1805.37; CI:125.44-25982.98), in the overall study population.

CONCLUSIONS

Older persons and those with persistent vomiting, bleeding or severe plasma leakage, which were associated with mortality, at notification should be monitored closely and referred early if indicated. Doctors and primary care practitioners need to detect patients with dengue early before they develop these severe signs and symptoms.