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Ugwu CV, Jergel A, Murray B, Rees CA, Jain S. Clinical Practice Guideline Development in Pediatric Emergency Medicine Departments Across the United States: A Cross-sectional Study. Pediatr Emerg Care 2024:00006565-990000000-00487. [PMID: 38950408 DOI: 10.1097/pec.0000000000003230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
OBJECTIVE This cross-sectional study aimed to assess the process of clinical practice guideline (CPG) development in pediatric emergency medicine departments (PEDs) across the United States, with a focus on identifying areas for improvement to enhance the quality of CPGs. METHODS An electronic survey was distributed to PEDs with pediatric emergency medicine fellowship programs. Respondents were asked about their CPG development processes (ie, guideline committee composition, consideration of conflicts of interest, grading recommendations, guideline training opportunities) based on the Appraisal of Guidelines, Research, and Evaluation (AGREE II) tool as well as implementation and monitoring. Univariate analysis was used to assess associations between the number of AGREE II elements adhered to and annual patient volume. RESULTS Of the 84 PEDs surveyed, 44 (52.4%) responded, representing institutions from 28 states. Most PEDs (97.7%, n = 43) reported developing their own guidelines, citing the need to improve care quality and standardize patient care as primary reasons. Although most guideline committees included multidisciplinary team members (74.4%, n = 32), routine patient involvement in committees was rare (11.6%, n = 5), and barriers such as time and resource constraints hindered their inclusion. Formal training for committee members in guideline development was uncommon (18.6%, n = 8). There was an association between higher annual patient volume and the number of AGREE II elements adhered to (P = 0.03). Few PEDs considered potential conflicts of interest among committee members (13.6%, n = 6). Over half of surveyed PEDs (54.5%, n = 24) lacked a systematic approach to grading recommendations. Educational materials and workshops were the most common guideline implementation strategies. CONCLUSIONS Our findings highlight need for improvement in the CPG development process in PEDs. Including patients in committees, providing formal training for committee members, and adopting a rigorous approach to grading recommendations are crucial steps toward enhancing guideline quality. Emphasizing these improvements has the potential to improve the quality of CPGs for pediatric emergency care.
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Affiliation(s)
| | - Andrew Jergel
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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Kocken PL, van Kesteren NMC, van Zoonen R, Reijneveld SA. Availability and implementation of guidelines in European child primary health care: how can we improve? Eur J Public Health 2022; 32:670-676. [PMID: 36006035 PMCID: PMC9527973 DOI: 10.1093/eurpub/ckac114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical guidelines are important for providing high-quality child primary health care. We aimed to assess the availability, use and achieved delivery of guidelines in the European Union (EU). METHODS We used a case study design to ascertain expert views on guidelines in six countries representing the EU. The experts completed an online questionnaire (response 49%), asking about their perception of guideline availability and implementation regarding three topics that represent prevention and care, i.e. vaccination, assessment of mental health and asthma care. RESULTS According to the respondents all countries had guidelines available for asthma care. For vaccination and mental health assessment respondents agreed to a lesser degree that guidelines were available. Implementation of guidelines for vaccination was mostly perceived as intended, but implementation of the guidelines for mental health assessment and asthma care was limited. Notable barriers were complexity of performance, and lack of training of professionals and of financial resources. Important facilitators for guideline implementation were the fit with routine practice, knowledge and skills of professionals and policy support. We found no clear relationship of guideline availability and implementation with type of child primary health care system of countries, but strong governance and sufficient financial resources seemed important for guideline availability. CONCLUSIONS Availability and implementation of clinical guidelines in child primary health care vary between EU countries. Implementation conditions can be strongly improved by adequate training of professionals, stronger governance and sufficient financial resources as facilitating factors. This can yield major gains in child health across Europe.
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Affiliation(s)
- Paul L Kocken
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Sijmen A Reijneveld
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Zhang S, Wu L, Wang Y, Zhou Q, Luo X, Mathew JL, Wang Q, Song Y, Chen Y. Methodological and reporting quality of pediatric clinical practice guidelines: a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1258. [PMID: 34532395 PMCID: PMC8421971 DOI: 10.21037/atm-21-2686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/20/2021] [Indexed: 11/25/2022]
Abstract
Background Pediatric clinical practice guidelines (CPGs) can provide systematically developed clinical recommendations to guide pediatric clinicians and patients making decisions. This study aims to assess the methodological and reporting quality of pediatric CPGs. Methods We performed a systematic literature search of MEDLINE from 1 January 1990 to 2 April 2020 to identify pediatric CPGs published in the ten highest-impact pediatric journals and four highest-impact general medical journals. Two researchers evaluated the methodological and reporting quality of pediatric CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II instrument and Reporting Items for Practice Guidelines in Health care (RIGHT) checklist. We calculated the mean AGREE II scores and compliance to RIGHT overall, and for each domain of the respective tools. We compared the methodological and reporting quality by different time periods and calculated the correlation between the AGREE II score and compliance to RIGHT. Results A total of 159 pediatric CPGs were identified. The mean (± standard deviation) scores for the six domains of the AGREE II instrument were as follows: scope and purpose 74.5%±14.2%, stakeholder involvement 42.7%±16.2%, rigour of development 18.7%±14.2%, clarity of presentation 56.5%±17.0%, applicability 8.9%±12.7% and editorial independence 25.2%±34.6%. The overall assessment score was 37.8%±12.4%. The mean compliance to RIGHT items in the seven domains of the checklist were: basic information 73.6%±14.9%, background 67.1%±16.4%, evidence 32.7%±27.2%, recommendations 32.4%±22.5%, review and quality assurance 22.9%±40.4%, funding and declaration and management of interests 24.1%±36.3%, and other information 45.3%±30.1%. The overall reporting rate for RIGHT was 46.4%±16.6%. Both the AGREE II scores and RIGHT reporting rates increased over time. We found a high positive correlation between AGREE II scores and RIGHT reporting compliance (r=0.645, P<0.001). Discussion The methodological and reporting quality of pediatric CPGs have improved over time, but remain still suboptimal and needs to be further improved. An international database of pediatric guidelines is urgently needed to identify and promote high-quality guidelines and guide clinical practice in pediatrics.
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Affiliation(s)
- Shu Zhang
- Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Lei Wu
- Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yang Wang
- Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Qi Zhou
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Xufei Luo
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Joseph L Mathew
- Advanced Pediatrics Centre, PGIMER Chandigarh, Chandigarh, India
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster Health Forum, McMaster University, Hamilton, Canada
| | - Yang Song
- Iberoamerica Cochrane Centre, Research Institute, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Yaolong Chen
- National Clinical Research Center for Child Health and Disorders, Evidence-Based Medicine Center, Basic Medical Sciences, Lanzhou University, Lanzhou, China
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Abstract
BACKGROUND There is a lack of a comprehensive evaluation for pediatric clinical practice guidelines (CPGs) published in recent years. Here, we assessed the quality of pediatric CPGs, considering factors that might affect their quality. The aim of the study is to promote a more coherent development and application of CPGs. METHODS Pediatric CPGs published in PubMed, MedLive, Guidelines International Network, National Institute for Health and Care Excellence, and World Health Organization between 2017 and 2019 were searched and collected. Paired researchers conducted screening, data extraction, and quality assessment using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Linear regression analysis determined the factors affecting CPGs' quality. RESULTS The study included a total of 216 CPGs, which achieved a mean score of 4.26 out of 7 points (60.86%) in the AGREE II assessment. Only 6.48% of the CPGs reached the "recommend" level. The remaining 69.91% should have been modified before recommendation, while the other 23.61% did not reach the recommended level at all. The overall quality of recent pediatric CPGs was higher than previously, and the proportion of CPGs with low-quality decreased over time. However, there were still too few CPGs that reached a high-quality level. The "applicability" and "rigor of development" domains had generally low scores. CPGs formulated by developing countries or regions, those that are not under an organizations or groups responsibility, and those that used non-evidence-based methods were found to be associated with poorer quality in different domains as independent or combinational factors. CONCLUSIONS The quality of pediatric CPGs still needs to be improved. Specifically, a quality control before applying new CPGs should be essential to ensure their quality and applicability.
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Sun Y, Chen J, Shi SZ, Ge L, Bu YX, Xi JB, Tian JH. Are paediatric clinical practice guidelines trustworthy? J Paediatr Child Health 2019; 55:1044-1055. [PMID: 31350939 DOI: 10.1111/jpc.14567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 11/28/2022]
Abstract
AIM To assess the methodological and reporting quality of paediatric clinical practice guidelines (CPGs) in National Guideline Clearinghouse (NGC) using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and Reporting Items for Practice Guidelines in Healthcare (RIGHT) standard. METHODS We identified all published CPGs through the NGC, and search records were screened in duplicate for inclusion. Two researchers evaluated the methodological and reporting quality of paediatric CPGs using the AGREE II instrument and RIGHT standard. STATA version 12.0 and SPSS version 22.0 software were used to analyse the related data. RESULTS A total of 50 paediatric CPGs were included. The scores for all six domains by AGREE II instrument were presented as follows: scope and purpose (85.6 ± 9.59), stakeholder involvement (69.15 ± 19.32), rigour of development (73.19 ± 17.18), clarity of presentation (78.51 ± 14.36), applicability (54.61 ± 22.63) and editorial independence (68.42 ± 13.06). In the seven domains of the RIGHT standard, the reporting rate of the recommendation domain was the lowest (52.86%).The highest reporting rate was the other information domain, which was 68%.There was a high correlation between reporting the completeness of CPGs using the AGREE II instrument and RIGHT standard (r = 0.77, P < 0.001). CONCLUSIONS The paediatric CPGs from NGC have good quality. There was a high correlation in the completeness of reporting for paediatric CPGs using the AGREE II instrument and RIGHT standard. It could be concluded that the CPGs of good methodological quality have good reporting quality. Maybe the researcher should effectively combine the AGREE II instrument and RIGHT standard in the development process of CPGs.
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Affiliation(s)
- Yue Sun
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
| | - Ji Chen
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
| | - Shu-Zhen Shi
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
| | - Long Ge
- WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.,The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - You-Xiang Bu
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
| | - Jiang-Bo Xi
- School of Geological Engineering and Geomatics, Chang'an University, Xi'an, China
| | - Jin-Hui Tian
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, China.,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
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Maraña Pérez AI, Rius Peris JM, Rivas Juesas C, Torrecilla Cañas J, Hernández Muelas S, de la Osa Langreo A. Multimodal implementation of clinical practice guidelines on bronchiolitis: Ending the overuse of diagnostic resources. An Pediatr (Barc) 2018. [DOI: 10.1016/j.anpede.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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7
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Implementación multimodal de una guía de práctica clínica en bronquiolitis: acabando con el uso excesivo de recursos diagnósticos. An Pediatr (Barc) 2018; 89:352-360. [DOI: 10.1016/j.anpedi.2018.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 11/23/2022] Open
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Beckett RD, Linn DD, Tellor KB, Sheehan AH, Montagano KJ, Vonada B. Systematic evaluation of the methodological quality of clinical practice guidelines intended for pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Robert D. Beckett
- Department of Pharmacy Practice; Manchester University; Fort Wayne Indiana
| | - Dustin D. Linn
- Department of Pharmacy Practice; Manchester University; Fort Wayne Indiana
| | - Katie B. Tellor
- Department of Pharmacy Practice, Division of Acute Care Pharmacy; St. Louis College of Pharmacy; St. Louis Missouri
| | - Amy H. Sheehan
- Department of Pharmacy Practice; Purdue University; West Lafayette Indiana
| | - Kaitlin J. Montagano
- Division of Drug Information, Center for Drug Evaluation and Research, U.S. Food and Drug Administration
| | - Brooke Vonada
- Department of Pharmacy Services, University of Toledo Medical Center
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Beckett RD, Kisor DF, Smith T, Vonada B. Systematic evaluation of clinical practice guidelines for pharmacogenomics. Pharmacogenomics 2018; 19:693-700. [DOI: 10.2217/pgs-2018-0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To systematically assess methodological quality of pharmacogenomics clinical practice guidelines. Methods: Guidelines published through 2017 were reviewed by at least three independent reviewers using the AGREE II instrument, which consists of 23 items grouped into 6 domains and 2 items representing an overall assessment. Items were assessed on a seven-point rating scale, and aggregate quality scores were calculated. Results: 31 articles were included. All guidelines were published as peer-reviewed articles and 90% (n = 28) were endorsed by professional organizations. Mean AGREE II domain scores (maximum score 100%) ranged from 46.6 ± 11.5% (‘applicability’) to 78.9 ± 11.4% (‘clarity of presentation’). Median overall quality score was 72.2% (IQR: 61.1–77.8%). Conclusion: Quality of pharmacogenomics guidelines was generally high, but variable, for most AGREE II domains.
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Affiliation(s)
- Robert D Beckett
- Manchester University Doctor of Pharmacy Program, Department of Pharmacy Practice, 10627 Diebold Rd, Fort Wayne, IN 46845, USA
| | - David F Kisor
- Manchester University Doctor of Pharmacy & Master of Science in Pharmacogenomics Programs, Department of Pharmaceutical Sciences, 10627 Diebold Rd, Fort Wayne, IN 46845, USA
| | - Thomas Smith
- Manchester University Doctor of Pharmacy & Master of Science in Pharmacogenomics Programs, Department of Pharmacy Practice, 10627 Diebold Rd, Fort Wayne, IN 46845, USA
| | - Brooke Vonada
- Manchester University Doctor of Pharmacy Program, 10627 Diebold Rd, Fort Wayne, IN 46845, USA
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Richter Sundberg L, Garvare R, Nyström ME. Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare. BMC Health Serv Res 2017; 17:344. [PMID: 28490325 PMCID: PMC5426017 DOI: 10.1186/s12913-017-2277-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/27/2017] [Indexed: 11/23/2022] Open
Abstract
Background The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease. Methods A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data. Results The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: ‘clinical knowledge and experience’, ‘potential guideline consequences’ and ‘needs of vulnerable groups’. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals’ relative influence on group discussions. Conclusions The study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.
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Affiliation(s)
- Linda Richter Sundberg
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE 901 87, Umeå, Sweden. .,Department of Clinical Science, Child and Adolescent Psychiatry, Umeå University, SE 901 87, Umeå, Sweden.
| | - Rickard Garvare
- Department of Business Administration, Technology and Social Sciences, Luleå University of Technology, SE 971 87, Luleå, Sweden
| | - Monica Elisabeth Nyström
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE 901 87, Umeå, Sweden.,Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden
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Lucendo AJ, Arias Á, Redondo-González O, Molina-Infante J. Quality assessment of clinical practice guidelines for eosinophilic esophagitis using the AGREE II instrument. Expert Rev Gastroenterol Hepatol 2017; 11:383-390. [PMID: 28117605 DOI: 10.1080/17474124.2017.1285696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND High-quality evidence-based clinical practice guidelines can guide diagnosis and treatment to optimize outcomes. We aimed to systematically review the quality of international guidelines on eosinophilic esophagitis (EoE). METHODS MEDLINE and Scopus databases were searched for appropriate guidelines up to 2016. Two gastroenterologists and two methodologists independently evaluated the documents using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. RESULTS Amongst the 25 records initially retrieved, four guidelines developed by recognized scientific organizations met inclusion criteria. AGREE II results varied widely across domains, but none achieved an overall assessment score of over 60%. Scope and purpose (61.82 ± 19.24%), clarity of presentation (57.13 ± 40.56%) and editorial independence (93.75 ± 1.69%) showed the highest mean rating, whereas stakeholder involvement (28.82 ± 11.19%), rigor of development (32.29 ± 12.02%) and applicability (21.62 ± 7.14%) did not reach quality thresholds. Intraclass correlation coefficients for agreement was excellent among appraisers (0.903), between gastroenterologists and methodologists (0.878) and for each individual guideline (0.838 to 0.955). CONCLUSION Clinical practice guidelines for EoE vary significantly in quality, are invariably limited and currently, none can be 'strongly recommended'.
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Affiliation(s)
- Alfredo J Lucendo
- a Department of Gastroenterology , Hospital General de Tomelloso , Tomelloso , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Ángel Arias
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Research Support Unit , Hospital General La Mancha-Centro , Alcázar de San Juan , Spain
| | - Olga Redondo-González
- c Research Support Unit , Hospital General La Mancha-Centro , Alcázar de San Juan , Spain
| | - Javier Molina-Infante
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,d Department of Gastroenterology , Hospital San Pedro de Alcántara , Cáceres , Spain
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Zhang X, Zhao K, Bai Z, Yu J, Bai F. Clinical Practice Guidelines for Hypertension: Evaluation of Quality Using the AGREE II Instrument. Am J Cardiovasc Drugs 2016; 16:439-451. [PMID: 27580999 DOI: 10.1007/s40256-016-0183-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hypertension is an important public health challenge. The purpose of clinical practice guidelines (CPGs) is to provide explicit recommendations for clinical practice, reduce inadequate variations, optimize results, minimize risks, and promote cost-effective practice. Therefore, a highly methodological quality development process for CPGs is more likely to yield a CPG that contains relevant and appropriate recommendations. METHOD To assess the quality of CPGs for the prevention and treatment of hypertension, a systematic search was performed using the following literature databases: PubMed, Excerpta Medica Database (EMBASE), Web of Science, the National Guideline Clearinghouse (NGC), Chinese National Knowledge Infrastructure (CNKI), Wan fang Data, VIP, and Chinese Biomedical Literature Database (CBM). Then the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was used to assess the quality of the CPGs. RESULTS Forty-one CPGs were identified (ten CPGs in Chinese and 31 CPGs in English). The results for the overall recommendation were as follows: strongly recommended (15 %), recommended (29 %), weakly recommended (51 %), and not recommended (5 %). The scores for all domains (mean ± standard deviations) were "scope and purpose" (58.65 ± 12.67 %), "stakeholder involvement" (48.07 ± 11.41 %), "rigor of development" (27.31 ± 12.29 %), "clarity of presentation" (53.89 ± 11.09 %), "applicability" (40.10 ± 13.33 %), and "editorial independence" (38.75 ± 16.43 %). All differences were statistically insignificant for all domains (P > 0.05) according to publication time. CPGs using an evidence-based (EB) method were of a higher quality than non-EBs for all domains, but the differences were significant for the following domains: "Scope and Purpose," "Rigor of Development," "Applicability," and "Editorial Independence" (P < 0.05). The scores for the CPGs developed based on associations and society appeared slightly higher than those developed by individuals. However, the differences were insignificant for all domains (P > 0.05). CONCLUSION A more systematic approach for the development and report of these guidelines is recommended. The AGREE II instrument can be a useful tool to improve the quality of guidelines.
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Affiliation(s)
- Xiaowei Zhang
- Section of Hypertension, Hospital of Cardiology, Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Kun Zhao
- The Second Clinic School of Lanzhou University, Lanzhou, 730030, China
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730030, China
| | - Zhenggang Bai
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730030, China
| | - Jing Yu
- Section of Hypertension, Hospital of Cardiology, Lanzhou University Second Hospital, Lanzhou, 730030, China.
| | - Feng Bai
- Section of Hypertension, Hospital of Cardiology, Lanzhou University Second Hospital, Lanzhou, 730030, China
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13
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Font-Gonzalez A, Mulder RL, Loeffen EAH, Byrne J, van Dulmen-den Broeder E, van den Heuvel-Eibrink MM, Hudson MM, Kenney LB, Levine JM, Tissing WJE, van de Wetering MD, Kremer LCM. Fertility preservation in children, adolescents, and young adults with cancer: Quality of clinical practice guidelines and variations in recommendations. Cancer 2016; 122:2216-23. [PMID: 27175973 DOI: 10.1002/cncr.30047] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/24/2016] [Accepted: 03/17/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fertility preservation care for children, adolescents, and young adults (CAYAs) with cancer is not uniform among practitioners. To ensure high-quality care, evidence-based clinical practice guidelines (CPGs) are essential. The authors identified existing CPGs for fertility preservation in CAYAs with cancer, evaluated their quality, and explored differences in recommendations. METHODS A systematic search in PubMed (January 2000-October 2014); guideline databases; and Web sites of oncology, pediatric, and fertility organizations was performed. Two reviewers evaluated the quality of the identified CPGs using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II). From high-quality CPGs, the authors evaluated concordant and discordant areas among the recommendations. RESULTS A total of 25 CPGs regarding fertility preservation were identified. The average AGREE II domain scores (scale of 0%-100%) varied from 15% on applicability to 100% on clarity of presentation. The authors considered 8 CPGs (32%) to be of high quality, which was defined as scores ≥60% in any 4 domains. Large variations in the recommendations of the high-quality CPGs were observed, with 87.2% and 88.6%, respectively, of discordant guideline areas among the fertility preservation recommendations for female and male patients with cancer. CONCLUSIONS Only approximately one-third of the identified CPGs were found to be of sufficient quality. Of these CPGs, the fertility preservation recommendations varied substantially, which can be a reflection of inadequate evidence for specific recommendations, thereby hindering the ability of providers to deliver high-quality care. CPGs including a transparent decision process for fertility preservation can help health care providers to deliver optimal and uniform care, thus improving the quality of life of CAYAs with cancer and cancer survivors. Cancer 2016;122:2216-23. © 2016 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.
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Affiliation(s)
- Anna Font-Gonzalez
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Renée L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Erik A H Loeffen
- Department of Pediatric Oncology/Hematology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | | | - Melissa M Hudson
- Department of Pediatric Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Lisa B Kenney
- Department of Pediatric Oncology, Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jennifer M Levine
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York, New York
| | - Wim J E Tissing
- Department of Pediatric Oncology/Hematology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marianne D van de Wetering
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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Jiang M, Liao LY, Liu XQ, He WQ, Guan WJ, Chen H, Li YM. Quality Assessment of Clinical Practice Guidelines for Respiratory Diseases in China: A Systematic Appraisal. Chest 2015; 148:759-766. [PMID: 25950752 DOI: 10.1378/chest.14-3201] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There has been a significant increase in the publication of clinical practice guidelines (CPGs) for respiratory diseases in China. However, little is known about the quality and potential impacts of these CPGs. Our objective was to critically evaluate the quality of Chinese CPGs for respiratory diseases that were published in peer-reviewed medical journals. METHODS A systematic search of scientific literature published between 1979 and 2013 was undertaken to identify and select CPGs that were related to respiratory diseases. Four Chinese databases (the Chinese Biomedical Literature database [CBM], the China National Knowledge Infrastructure [CNKI], the VIP database, and the WANFANG database) were used. The quality of eligible guidelines was assessed independently by four reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The overall agreement among reviewers was evaluated using an intraclass correlation coefficient. RESULTS A total of 109 guidelines published in 27 medical journals from 1979 to 2013 were evaluated. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.838; 95% CI, 0.812-0.862). The scores of the six AGREE domains were low: 57.3% for scope and purpose (range, 4.2%-80.5%), 23.8% for stakeholder involvement (range, 2.8%-54.2%), 7.7% for rigor of development (range, 0%-27.1%), 59.8% for clarity and presentation (range, 22.2%-80.6%), 10.9% for applicability (range, 0%-22.9%), and 0.6% for editorial independence (range, 0%-16.7%). Scores for all guidelines were below 60%, and only three guidelines (2.8%) were recommended for clinical practice with modifications. CONCLUSIONS The quality of the guidelines was low, and stakeholder involvement, rigor of development, applicability, and editorial independence should be considered in the future development of CPGs for respiratory diseases in China.
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Affiliation(s)
- Mei Jiang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Li-Yue Liao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou; State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Xiao-Qing Liu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Wei-Qun He
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Wei-Jie Guan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Hao Chen
- Second Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Yi-Min Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou.
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Ronsoni RDM, Pereira CCDA, Stein AT, Osanai MH, Machado CJ. [Evaluation of eight Clinical Protocols and Therapeutic Guidelines under the Brazilian Ministry of Health using the AGREE II instrument: a pilot study]. CAD SAUDE PUBLICA 2015. [PMID: 26200364 DOI: 10.1590/0102-311x00118814] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The number of clinical guidelines is increasing worldwide, while there are concerns regarding their quality. In 2000, the Brazilian Ministry of Health began its process of creating clinical guidelines, called Clinical Protocols and Therapeutic Guidelines (PCDT). The goal of this study was to assess the quality of Brazilian guidelines approved since 2009 using the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation). We identified 59 PCDT from 2009 to 2012, of which eight were randomly selected and evaluated by three independent evaluators. For the item "recommends the guidelines", two evaluators recommended the use of all eight, but with modifications, and one did not recommend any to the guidelines. Regarding the item "global quality of the guidelines" (varying from 1 to 7), the mean was 4.25 (SD = 0.46). The results showed the need for adjustments in the PCDT in relation to AGREE II domains. However, due to the instrument's limitations, further studies are needed, including the quality of evidence used in the PCDT.
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Affiliation(s)
| | | | | | | | - Carla Jorge Machado
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
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16
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Hester G, Nelson K, Mahant S, Eresuma E, Keren R, Srivastava R. Methodological quality of national guidelines for pediatric inpatient conditions. J Hosp Med 2014; 9:384-90. [PMID: 24677729 PMCID: PMC4043870 DOI: 10.1002/jhm.2187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/11/2014] [Accepted: 02/28/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children's hospitals. The methodological quality of guidelines for priority conditions is unknown. OBJECTIVE To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions. DESIGN We searched sources including PubMed for national guidelines published from 2002 to 2012. Guidelines specific to 1 organism, test or treatment, or institution were excluded. Guidelines were rated by 2 raters using a validated tool (Appraisal of Guidelines for Research and Evaluation) with an overall rating on a 7-point scale (7 = the highest). Inter-rater reliability was measured with a weighted kappa coefficient. RESULTS Seventeen guidelines met inclusion criteria for 13 conditions; 7 conditions yielded no relevant national guidelines. The highest methodological-quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5, and 6.5, respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3, respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78-0.87). CONCLUSIONS We identified a group of moderate to high methodological-quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives.
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Affiliation(s)
| | | | - Sanjay Mahant
- Department of Pediatrics, SickKids, University of Toronto
- For the Pediatric Research in Inpatient Settings (PRIS) Network
| | | | - Ron Keren
- Department of Pediatrics, Children's Hospital of Philadelphia
- For the Pediatric Research in Inpatient Settings (PRIS) Network
| | - Rajendu Srivastava
- Department of Pediatrics, University of Utah
- For the Pediatric Research in Inpatient Settings (PRIS) Network
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Abstract
BACKGROUND AND OBJECTIVES Evidence-based practice guidelines for bronchiolitis management published by the American Academy of Pediatrics in 2006 recommend supportive care with limited diagnostic testing and treatment. We sought to determine the impact of these guidelines on the treatment of hospitalized children. METHODS We analyzed data on inpatients with bronchiolitis aged 1 to 24 months from the Pediatric Health Information System, an administrative billing database, from November 1, 2004 to March 31, 2012. We compared trends in use of diagnostic and treatment resources before and after the publication of the guidelines by using segmented time series. RESULTS A total of 41 pediatric hospitals contributed data to yield 130,262 patients; 58% were male, and 59% were publicly insured. Median age was 4.0 months (interquartile range, 2-9). Unadjusted analysis showed improvement in utilization rates before and after guidelines for diagnostic tests and for medications; however, there was no decreased use of antibiotics. A segmented regression analysis also demonstrated differences in rates of change before and after guidelines, with significant improvement for chest radiography, steroids, and bronchodilators (P < .0001). CONCLUSIONS In a nationally representative cohort of pediatric hospitals, publication of the 2006 American Academy of Pediatrics bronchiolitis guidelines was associated with significant reductions in the use of diagnostic and therapeutic resources.
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Affiliation(s)
- Kavita Parikh
- Division of Hospitalist Medicine, 111 Michigan Ave NW, Washington, DC 20010.
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Schoenmaker NJ, Tromp WF, van der Lee JH, Offringa M, Craig JC, Groothoff JW. Quality and consistency of clinical practice guidelines for the management of children on chronic dialysis. Nephrol Dial Transplant 2013; 28:3052-61. [PMID: 24097802 DOI: 10.1093/ndt/gft303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical practice guidelines aim to improve the quality of care, yet for users of guidelines it is often not clear how these guidelines were developed and whether the recommendations are robust. We aimed to identify all current published guidelines for the management of children on chronic dialysis, assess the quality of their development and evaluate consistency among their recommendations. METHODS We searched Medline (1948 to January 2012), and relevant websites of guideline development programmes. Three reviewers appraised all 17 identified guidelines with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS The guidelines were developed by five different professional associations. The overall mean AGREE II score from seven Kidney Disease Outcomes Quality Initiatives (KDOQI) guidelines was considered sufficient (mean scores 64-75%), and from all other 10 guidelines poor (29-44%). Five out of seven KDOQI guidelines scored weak on applicability. We found important inconsistencies between recommendations concerning initiation of renal replacement therapy, management of haemoglobin level and the use of mupirocin to prevent exit-site infections. CONCLUSIONS While the recently developed KDOQI guidelines meet the modern quality standards, advice for implementation of these recommendations is lacking. There is an urgent need for international collaboration and coordination to ensure that the management of children on chronic dialysis is informed by relevant and high-quality evidence.
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Affiliation(s)
- Nikki J Schoenmaker
- Department of Paediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, The Netherlands
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, USA.
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20
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Isaac A, Saginur M, Hartling L, Robinson JL. Quality of reporting and evidence in American Academy of Pediatrics guidelines. Pediatrics 2013; 131:732-8. [PMID: 23530180 DOI: 10.1542/peds.2012-2027] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The primary objectives were to evaluate the quality of development and reporting of American Academy of Pediatrics (AAP) guidelines and to determine the level of evidence underlying the recommendations. METHODS Two reviewers scored each guideline by using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument and determined the level of evidence for each recommendation in each guideline. Subgroup analyses compared AAP guidelines published before and after key changes in AAP guideline development policy and compared internal with endorsed guidelines. RESULTS For the 28 current guidelines, the highest average scores on AGREE-II were in scope and purpose (75%) and clarity of presentation (73%). The lowest average scores were in editorial independence (17%) and applicability (30%). The only domain that improved after AAP policy updates was editorial independence (P = .01). Of the 190 treatment recommendations, 43% were based on experimental studies, 30% on observational studies, and 27% on expert opinion or no reference. Compared with early guidelines, late guidelines included a higher proportion of treatment recommendations based on experimental studies (P = .05). CONCLUSIONS There was no clear improvement in the quality of development and reporting of AAP clinical practice guidelines over time. Routine application of AGREE-II to guideline development could enhance guideline quality. The proportion of guideline recommendations based on experimental evidence has increased slightly over time. Pediatric research agendas should be matched to vital gaps in the evidence underlying pediatric guidelines.
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Affiliation(s)
- Andre Isaac
- Department of Pediatrics and Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
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21
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Zhang ZW, Liu XW, Xu BC, Wang SY, Li L, Kang YY, Guo YF. Analysis of quality of clinical practice guidelines for otorhinolaryngology in China. PLoS One 2013; 8:e53566. [PMID: 23349719 PMCID: PMC3548820 DOI: 10.1371/journal.pone.0053566] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 11/29/2012] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the quality of clinical practice guidelines (CPGs) for otorhinolaryngology in China. Materials and Methods A systematic search of relevant literature databases (CBM, WANFANG, VIP, CNKI, China Guideline Clearinghouse) published between 1978 and March 2012 was undertaken to identify and select CPGs related to otorhinolaryngology. Four independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Their degree of agreement was evaluated using the intraclass correlation coefficient (ICC). Result From 170 citations, 21 relevant guidelines were included. The overall agreement among reviewers was moderate (ICC = 0.87; 95% confidence interval [CI], 0.78–0.91). The scores for each of the AGREE domains were the following: “scope and purpose” (mean ± standard error [SE] = 45.4±4.4; ICC = 0.92), “stakeholder involvement” (mean ± SE = 30.4±3.1; ICC = 0.81), “rigor of development” (mean ± SE = 20.9±2.8; ICC = 0.87), “clarity of presentation” (mean ± SE = 48.8±3.7; ICC = 0.80), “applicability” (mean ± SE = 12.6±1.7; ICC = 0.72), and “editorial independence” (mean ± SE = 6.2±0.8; ICC = 0.76). Three guidelines (14%) mentioned updates, and the average update frequency was 7 years. None used the GRADE system. Conclusion The quality of otorhinolaryngology guidelines in China is low. Greater efforts are needed to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision-making in this field.
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Affiliation(s)
- Zhe-wen Zhang
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiao-wen Liu
- Department of Otolaryngology-Head and Neck Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Bai-cheng Xu
- Department of Otolaryngology-Head and Neck Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Su-yang Wang
- Department of Otolaryngology-Head and Neck Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Li Li
- Department of Otolaryngology-Head and Neck Surgery, The Gan Su Provincial Hospital, China
| | - Ying-ying Kang
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yu-fen Guo
- Department of Otolaryngology-Head and Neck Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
- Ministry of Health, Gansu province, Lanzhou, China
- * E-mail:
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Barclay CA, Vonderhaar KJ, Clark EA. The development of evidence-based care recommendations to improve the safe use of anticoagulants in children. J Pediatr Pharmacol Ther 2012; 17:155-8. [PMID: 23118667 DOI: 10.5863/1551-6776-17.2.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Evidence-based care recommendations and standardized protocols improve outcomes. In addition, anticoagulant management has been recognized by The Joint Commission (TJC) as an opportunity for improving patient safety. A National Patient Safety Goal requiring a standardized process for patients receiving anticoagulants was established by TJC. This requirement provided an opportunity to apply evidence-based care recommendations to the issue of safe anticoagulant use. To meet TJC requirement, the following searchable clinical question was drafted: "In children receiving anticoagulation therapy, what are the appropriate dosing, laboratory monitoring, timing, and dosing adjustments for warfarin, unfractionated heparin, and low-molecular-weight heparin to prevent coagulation-related complications?" The team used the Appraisal of Guidelines Research and Evaluation Collaboration (AGREE) instrument to evaluate the quality and relevance of identified guidelines in answering the clinical question. Best Evidence Statements (BESts) were developed for each of the medications (warfarin, low-molecular-weight heparin, and unfractionated heparin). BESts provide the format for the presentation of recommendations, discussion, and methods for point-of-care providers seeking synthesized evidence to guide care decisions. The primary goal of developing and implementing these statements was to standardize the use of anticoagulants and to prevent unsafe practices. A secondary goal was to ensure accessibility of the BESts throughout our organization, including the electronic medical record, various internal division home pages, and our organization's external website. The anticoagulant BESts developed at our organization show how an interprofessional approach to patient care results in the development of evidence-based care recommendations. The BESts were developed to standardize care associated with the use of anticoagulants and to provide dosing and monitoring parameters to ensure safe care to all patients receiving these medications. The development of evidence-based care recommendations can be accomplished with a focused interprofessional team dedicated to providing the safest possible care to patients.
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Affiliation(s)
- Cynthia A Barclay
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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23
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Systematic review of the methodological quality of clinical guideline development for the management of chronic disease in Europe. Health Policy 2012; 107:157-67. [DOI: 10.1016/j.healthpol.2012.06.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 06/06/2012] [Accepted: 06/07/2012] [Indexed: 11/19/2022]
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Legido-Quigley H, Panteli D, Brusamento S, Knai C, Saliba V, Turk E, Solé M, Augustin U, Car J, McKee M, Busse R. Clinical guidelines in the European Union: mapping the regulatory basis, development, quality control, implementation and evaluation across member states. Health Policy 2012; 107:146-56. [PMID: 22939646 DOI: 10.1016/j.healthpol.2012.08.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 06/05/2012] [Accepted: 08/07/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Clinical guidelines are advocated to improve the quality of care, especially for chronic diseases. However, the regulatory basis of clinical guidelines, their development, quality control, implementation and use as well as evaluation within countries across the European Union is not systematically known. METHODS Using information collected from key informants in each country by means of a structured questionnaire, this mapping exercise illustrates the varied status of guideline production in European Union countries. RESULTS Most European Union countries have an established national, regional or local clinical guideline programme, and a substantial proportion have developed guidelines on the prevention and management of chronic diseases. Several countries have mechanisms in place to ensure the quality of scientific evidence used for the development of guidelines is high and that the process is consistent and transparent. Others are only now taking an interest in guideline development and are taking the first steps towards establishing ways of implementing them. The majority of countries have no legal basis for the development of guidelines and those that have well established systems mostly implement them on a voluntary basis. The process of guideline development varies in its degrees of decentralisation across countries with many different types of organisations taking on this responsibility. There is general acceptance of the value of the instrument developed by the AGREE collaboration for evaluating the methodological robustness of guidelines. However, the extent to which guidelines are implemented in Europe is unknown, as there is no systematic data collection and, in most countries, no structure to enable it. There are few examples of formal evaluations of the development, quality, implementation and use of guidelines. CONCLUSIONS Our findings call for renewed efforts to respond to the severe lack of standardized guideline terminology and accessibility as well as rigorous studies to evaluate the relationship between different ways to develop guidelines and their methodological quality, between their quality and the actual implementation and usage, and finally between implementation and health outcomes.
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Affiliation(s)
- Helena Legido-Quigley
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Harstall C, Taenzer P, Angus DK, Moga C, Schuller T, Scott NA. Creating a multidisciplinary low back pain guideline: anatomy of a guideline adaptation process. J Eval Clin Pract 2011; 17:693-704. [PMID: 20846284 DOI: 10.1111/j.1365-2753.2010.01420.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES A collaborative, multidisciplinary guideline adaptation process was developed to construct a single overarching, evidence-based clinical practice guideline (CPG) for all primary care practitioners responsible for the management of low back pain (LBP) to curb the use of ineffective treatments and improve patient outcomes. METHODS The adaptation strategy, which involved multiple committees and partnerships, leveraged existing knowledge transfer connections to recruit guideline development group (GDG) members and ensure that all stakeholders had a voice in the guideline development process. Videoconferencing was used to coordinate the large, geographically dispersed GDG. Information services and health technology assessment experts were used throughout the process to lighten the GDG's workload. RESULTS The GDG reviewed seven seed guidelines and drafted an Alberta-specific guideline during 10 half-day meetings over a 12-month period. The use of ad hoc subcommittees to resolve uncertainties or disagreements regarding evidence interpretation expedited the process. Challenges were encountered in dealing with subjectivity, guideline appraisal tools, evidence source limitations and inconsistencies, and the lack of sophisticated evidence analysis inherent in guideline adaptation. Strategies for overcoming these difficulties are discussed. CONCLUSION Guideline adaptation is useful when resources are limited and good-quality seed CPGs exist. The Ambassador Program successfully utilized existing stakeholder interest to create an overarching guideline that aligned guidance for LBP management across multiple primary care disciplines. Unforeseen challenges in guideline adaptation can be overcome with credible seed guidelines, a consistently applied and transparent methodology, and clear documentation of the subjective contextualization process. Multidisciplinary stakeholder input and an open, trusting relationship among all contributors will ensure that the end product is clinically meaningful.
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Affiliation(s)
- Christa Harstall
- Health Technology Assessment Unit, Institute of Health Economics, Edmonton, Alberta, Canada
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Clinical practice guidelines: what they are, why we need them and how they should be developed through rigorous evaluation. Eur J Pediatr 2011; 170:831-6. [PMID: 21132571 DOI: 10.1007/s00431-010-1344-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 11/03/2010] [Indexed: 10/18/2022]
Abstract
The number of available clinical practice guidelines has grown enormously in the recent years, therefore requiring a correct approach and use of them. We present a revision of what guidelines are and serve, how to correctly develop and find them, and how to develop and evaluate them through rigorous scientific methods. Limits and benefits of guidelines are also discussed. An overview about the use of paediatrics' guidelines is finally reported.
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Polyzos NP, Mauri D, Ioannidis JPA. Guidelines on chemotherapy in advanced stage gynecological malignancies: an evaluation of 224 professional societies and organizations. PLoS One 2011; 6:e20106. [PMID: 21611154 PMCID: PMC3096663 DOI: 10.1371/journal.pone.0020106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Accepted: 04/25/2011] [Indexed: 12/04/2022] Open
Abstract
Background Clinical practice guidelines are important for guiding practice, but it is unclear if they are commensurate with the available evidence. Methods We examined guidelines produced by cancer and gynecological societies and organizations and evaluated their coverage of and stance towards chemotherapy for advanced stage disease among 4 gynecological malignancies (breast, ovarian, cervical, endometrial cancer) where the evidence for the use of chemotherapy is very different (substantial and conclusive for breast and ovarian cancer, limited and suggesting no major benefit for cervical and endometrial cancer). Eligible societies and organizations were identified through systematic internet searches (last update June 2009). Pertinent websites were scrutinized for presence of clinical practice guidelines, and relative guidelines were analyzed. Results Among 224 identified eligible societies and organizations, 69 (31%) provided any sort of guidelines, while recommendations for chemotherapy on advanced stage gynecological malignancies were available in 20 of them. Only 14 had developed their own guideline, and only 5 had developed guidelines for all 4 malignancies. Use of levels of evidence and grades of recommendations, and aspects of the production, implementation, and timeliness of the guidelines did not differ significantly across malignancies. Guidelines on breast and ovarian cancer utilized significantly more randomized trials and meta-analyses. Guidelines differed across malignancies on their coverage of disease-free survival (p = 0.033), response rates (p = 0.024), symptoms relief (p = 0.005), quality of life (p = 0.001) and toxicity (p = 0.039), with breast and ovarian cancer guidelines typically covering more frequently these outcomes. All guidelines explicitly or implicitly endorsed the use of chemotherapy. Conclusions Clinical practice guidelines are provided by the minority of professional societies and organizations. Available guidelines tend to recommend chemotherapy even for diseases where the effect of chemotherapy is controversial and recommendations are based on scant evidence.
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Affiliation(s)
- Nikolaos P. Polyzos
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Davide Mauri
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Department of Medical Oncology, General Hospital of Lamia, Lamia, Greece
| | - John P. A. Ioannidis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Medicine, Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
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Fiks AG. Designing computerized decision support that works for clinicians and families. Curr Probl Pediatr Adolesc Health Care 2011; 41:60-88. [PMID: 21315295 PMCID: PMC3373310 DOI: 10.1016/j.cppeds.2010.10.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Evidence-based decision-making is central to the practice of pediatrics. Clinical trials and other biomedical research provide a foundation for this process, and practice guidelines, drawing from their results, inform the optimal management of an increasing number of childhood health problems. However, many clinicians fail to adhere to guidelines. Clinical decision support delivered using health information technology, often in the form of electronic health records, provides a tool to deliver evidence-based information to the point of care and has the potential to overcome barriers to evidence-based practice. An increasing literature now informs how these systems should be designed and implemented to most effectively improve outcomes in pediatrics. Through the examples of computerized physician order entry, as well as the impact of alerts at the point of care on immunization rates, the delivery of evidence-based asthma care, and the follow-up of children with attention deficit hyperactivity disorder, the following review addresses strategies for success in using these tools. The following review argues that, as decision support evolves, the clinician should no longer be the sole target of information and alerts. Through the Internet and other technologies, families are increasingly seeking health information and gathering input to guide health decisions. By enlisting clinical decision support systems to deliver evidence-based information to both clinicians and families, help families express their preferences and goals, and connect families to the medical home, clinical decision support may ultimately be most effective in improving outcomes.
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Affiliation(s)
- Alexander G Fiks
- Pediatric Research Consortium, Center for Biomedical Informatics, Policylab, Division of General Pediatrics at the Children’s Hospital of Philadelphia, Department of Pediatrics at the University of Pennsylvania School of Medicine, Philadelphia, USA
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Evaluation of the quality of guidelines for acute gastroenteritis in children with the AGREE instrument. J Pediatr Gastroenterol Nutr 2011; 52:183-9. [PMID: 20808248 PMCID: PMC3713480 DOI: 10.1097/mpg.0b013e3181e233ac] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
AIM The aim of the study was to assess the quality of clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument, a validated international tool. MATERIALS AND METHODS CPGs were identified by searching MEDLINE (1966-January 2009) and Embase (1988-January 2009), CPG databases, and relevant Web sites of agencies and organizations that produce and/or endorse guidelines. Included in the study were CPGs in English that addressed the management of acute gastroenteritis in children. Retrieved CPGs were evaluated with the AGREE instrument for quality assessment by 6 independent reviewers. AGREE consists of 6 domains for a total of 23 items. RESULTS Nine CPGs were identified. Four were evidence based (EB) and 2 of these included tables of evidence. Eight CPGs (88%) scored <50% for "applicability," 7 (77%) for "stakeholder involvement," and 6 (66%) for "editorial independence." Compared with non-EB CPGs, EB CPGs had higher quality scores for all AGREE domains, with a better score for "rigor of development" (P < 0.001), "stakeholder involvement" and "clarity of presentation" (P < 0.01), and applicability (P < 0.05). Over time, the quality of guidelines tended to improve. The main recommendations of CPGs were similar. However, there were differences in the treatment of diarrhea, namely based on the settings and circumstances in which CPGs were produced. CONCLUSIONS The overall quality of CPGs on acute gastroenteritis management in children is fair. Aims, target population, synthesis of evidence, formulation of recommendations, and clarity of presentation are points of strength. Weak issues are applicability, including identification of organizational barriers and adherence parameters, and cost/efficacy analysis.
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Turner T, Harris C, Green S. A pragmatic model for evidence‐based guideline development in hospitals. ACTA ACUST UNITED AC 2010. [DOI: 10.1108/14777271011084019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Powers RJ, Wirtschafter DW. Decreasing central line associated bloodstream infection in neonatal intensive care. Clin Perinatol 2010; 37:247-72. [PMID: 20363458 DOI: 10.1016/j.clp.2010.01.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.
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Affiliation(s)
- Richard J Powers
- Good Samaritan Hospital, Newborn Intensive Care Unit, Pediatrix Neonatology Medical Group of San Jose, 3880 South Bascom Avenue, Suite 208, San Jose, CA 95124, USA.
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Turner TJ. Developing evidence-based clinical practice guidelines in hospitals in Australia, Indonesia, Malaysia, the Philippines and Thailand: values, requirements and barriers. BMC Health Serv Res 2009; 9:235. [PMID: 20003536 PMCID: PMC2800111 DOI: 10.1186/1472-6963-9-235] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 12/15/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence-based clinical practice guidelines support clinical decision-making by making recommendations to guide clinical practice. These recommendations are developed by integrating the expertise of a multidisciplinary group of clinicians with the perspectives of consumers and the best available research evidence. However studies have raised concerns about the quality of guideline development, and particularly the link between research and recommendations. The reasons why guideline developers are not following the established development methods are not clear.We aimed to explore the barriers to developing evidence-based guidelines in eleven hospitals in Australia, Indonesia, Malaysia, the Philippines and Thailand, so as to better understand how evidence-based guideline development could be facilitated in these settings. The research aimed to identify the value clinicians place on guidelines, what clinicians want in guidelines developed in hospital settings and what factors limit rigorous evidence-based guideline development in these settings. METHODS Semi-structured, face-to-face interviews were undertaken with senior and junior healthcare providers (nurses, midwives, doctors, allied health) from the maternal and neonatal services of the eleven participating hospitals. Interviews were audio-recorded, transcribed and a thematic analysis undertaken. RESULTS Ninety-three individual, 25 pair and eleven group interviews were conducted. Participants were clear that they want guidelines that are based on evidence and updated regularly. They were also clear that there are major barriers to this. Most of the barriers were shared across countries, and included lack of time, lack of skills in finding, appraising and interpreting evidence, lack of access to relevant evidence and difficulty arranging meetings and achieving consensus.Barriers that were primarily identified in Australian hospitals include cumbersome organisational processes and a feeling that guidelines are being developed for bureaucratic ends. Barriers that were primarily identified in South East Asian hospitals include difficulty accessing evidence due to limited resources available for computers, internet and journal subscriptions and limited skills in computing and English. CONCLUSIONS The clinicians in these eleven very different hospitals want evidence-based guidelines. However they are frustrated by guideline development processes that are enormously time, skill and resource intensive. They feel strongly that "there's got to be a better way".The fact that the great majority of the identified barriers were shared across settings may provide an opportunity to develop a more pragmatic way of developing guidelines that can be applied in many contexts.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Monash Medical Centre, Clayton, Victoria, Australia.
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Scott NA, Moga C, Harstall C. Making the AGREE tool more user-friendly: the feasibility of a user guide based on Boolean operators. J Eval Clin Pract 2009; 15:1061-73. [PMID: 20367706 DOI: 10.1111/j.1365-2753.2009.01265.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Rationale, aims and objectives The Appraisal of Guidelines Research and Evaluation (AGREE) instrument is a generic tool for assessing guideline quality. This feasibility study aimed to reduce the ambiguity and subjectivity associated with AGREE item scoring, and to augment the tool's capacity to differentiate between good- and poor-quality guidelines. Methods A literature review was conducted to ascertain what AGREE instrument adjustments had been reported to date. The AGREE User Guide was then modified by: 1 constructing a detailed set of instructions, or dictionary, using Boolean operators, and 2 overlaying seven criteria to categorize guideline quality. The feasibility of the Boolean-based dictionary was tested by three appraisers using three randomly selected guidelines on low back pain management. The dictionary was then revised and re-tested. Results Of the 52 published studies identified, 14% had modified the instrument by adding or deleting items and 35% had adopted strategies, such as using a consensus approach, to overcome inconsistencies and ensure identical item scoring among appraisers. For the feasibility test, Pearson correlation coefficients ranged from 0.27 to 0.81. Revision and re-testing of the dictionary increased the level of agreement (range 0.41 to 0.94). Application of the revised dictionary not only decreased the variability of the domain scores, but also reduced the tool's reliability among inexperienced appraisers. Conclusion Appraisers found the Boolean-based AGREE User Guide easier to use than the original, which improved their confidence in the tool. Good reliability was achieved in the feasibility test, but the reliability and validity of some of the changes will require further evaluation.
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Affiliation(s)
- N Ann Scott
- Health Technology Assessment Unit, Institute of Health Economics, Edmonton, AB, Canada
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de Boer WE, Bruinvels DJ, Rijkenberg AM, Donceel P, Anema JR. Evidence-based guidelines in the evaluation of work disability: an international survey and a comparison of quality of development. BMC Public Health 2009; 9:349. [PMID: 19765295 PMCID: PMC2754463 DOI: 10.1186/1471-2458-9-349] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Accepted: 09/18/2009] [Indexed: 11/10/2022] Open
Abstract
Background In social insurance, the evaluation of work disability is becoming stricter as priority is given to the resumption of work, which calls for a guarantee of quality for these evaluations. Evidence-based guidelines have become a major instrument in the quality control of health care, and the quality of these guidelines' development can be assessed using the AGREE instrument. In social insurance medicine, such guidelines are relatively new. We were interested to know what guidelines have been developed to support the medical evaluation of work disability and the quality of these guidelines. Methods Five European countries that were reported to use guidelines were approached, using a recent inventory of evaluations of work disability in Europe. We focused on guidelines that are disease-oriented and formally prescribed in social insurance medicine. Using the AGREE instrument, these guidelines were appraised by two researchers. We asked two experts involved in guideline development to indicate if they agreed with our results and to provide explanations for insufficient scores. Results We found six German and sixteen Dutch sets of disease-oriented guidelines in official use. The AGREE instrument was applicable, requiring minor adaptations. The appraisers reached consensus on all items. Each guideline scored well on 'scope and purpose' and 'clarity and presentation'. The guidelines scored moderately on 'stakeholder involvement' in the Netherlands, but insufficiently in Germany, due mainly to the limited involvement of patients' representatives in this country. All guidelines had low scores on 'rigour of development', which was due partly to a lack of documentation and of existing evidence. 'Editorial independence' and 'applicability' had low scores in both countries as a result of how the production was organised. Conclusion Disease-oriented guidelines in social insurance medicine for the evaluation of work disability are a recent phenomenon, so far restricted to Germany and the Netherlands. The AGREE instrument is suitably applicable to assess the quality of guideline development in social insurance medicine, but some of the scoring rules need to be adapted to the context of social insurance. Existing guidelines do not meet the AGREE criteria to a sufficient level. The way patients' representatives can be involved needs further discussion. The guidelines would profit from more specific recommendations and, for providing evidence, more research is needed on the functional capacity of people with disabilities.
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Affiliation(s)
- Wout El de Boer
- Department of Quality of Life, TNO, Hoofddorp, the Netherlands.
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Delgado-Noguera M, Tort S, Bonfill X, Gich I, Alonso-Coello P. Quality assessment of clinical practice guidelines for the prevention and treatment of childhood overweight and obesity. Eur J Pediatr 2009; 168:789-99. [PMID: 18815809 DOI: 10.1007/s00431-008-0836-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 09/04/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of childhood overweight and obesity is increasing at dramatic rates in children and adolescents worldwide. Clinical practice guidelines (CPGs) are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." Their objective is to provide explicit recommendations for clinical practice based on current evidence for best practice in the management of diseases. MATERIALS AND METHODS The aim of this study was to identify and assess the quality of CPGs for the prevention and treatment of obesity and overweight in childhood. We developed a search to identify CPGs published between January 1998 and August 2007. We considered for inclusion documents that provided recommendations for clinical practice referring to children and adolescents. Three independent appraisers assessed the quality of the1 CPGs using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument. We identified 376 references and selected 22 for further assessment. RESULTS The overall agreement among reviewers using the intraclass correlation coefficient was 0.856 (95% confidence interval [CI] 0.731-0.932). Six of the 22 initial guidelines were recommended and a further eight were recommended with conditions or provisos. We concluded that the number of documents with recommendations on the prevention and treatment of childhood obesity published during the 10-year study period was considerable, but only a few of them could be considered as high quality. CPGs were deficient in areas such as applicability, editorial independence and rigor in development. CONCLUSION Due to the increasing burden of obesity among children and the potential for long-term comorbidities, clinicians need to be critical in assessing the rigor of how these are developed and their appropriateness for use in the clinician's own practice. There is a need to improve the methodology and the quality of CPGs on childhood obesity to help clinicians and other decision-makers to tackle this disease.
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Spooner SA, Classen DC. Data standards and improvement of quality and safety in child health care. Pediatrics 2009; 123 Suppl 2:S74-9. [PMID: 19088233 DOI: 10.1542/peds.2008-1755e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Progress in using information technology to achieve the goal of high-quality health care is hindered by the lack of coordinated data standards. To accelerate quality improvement in pediatrics, child health providers must participate actively in the creation of health care data standards. To do so will require far greater understanding on the part of pediatricians and other pediatric providers regarding the scope and role of data standards in advancing health information systems for children, as well as how data standards could improve quality in child health, what kinds of data standards hold the most promise for quality improvement in child health, and how child health professionals can engage in the work of creating data standards. Child health professionals in organized and academic medicine should participate in standards development organizations, to present the pediatric point of view as data standards emerge. They also should support efforts to certify electronic health record systems that include pediatric functionality. A major challenge to academic pediatrics is to prove that data standards can lead to improved health outcomes for children; this is only a compelling conjecture as of this writing.
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Affiliation(s)
- S Andrew Spooner
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2007, Cincinnati, OH 45229, USA.
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Vitry AI, Zhang Y. Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions. Med J Aust 2008; 190:459. [PMID: 18837677 DOI: 10.5694/j.1326-5377.2008.tb02079.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 01/14/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the quality of Australian clinical guidelines for chronic diseases and their relevance to older people with multiple comorbid conditions. DESIGN Selection and assessment of national clinical guidelines for chronic conditions listed as National Health Priority Areas: cardiovascular health, diabetes mellitus, mental health, asthma, arthritis and musculoskeletal conditions, and cancer. MAIN OUTCOME MEASURES Standardised mean scores obtained with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (criteria grouped into six domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence). Relevance of guidelines for older people with multiple comorbid conditions. RESULTS 17 guidelines were included in the study. Guidelines approved by the National Health and Medical Research Council (NHMRC) scored significantly better than those not approved by the NHMRC in all domains except for editorial independence and clarity and presentation. The mean quality of guidelines not approved by the NHMRC was below 50% in all domains except clarity and presentation. Half of the guidelines addressed treatment for older patients or for patients with one comorbid condition, but only one addressed treatment for older patients with multiple comorbid conditions. CONCLUSIONS Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements. Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions.
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Affiliation(s)
- Agnes I Vitry
- Quality Use of Medicines and Pharmacy Practice Research Centre, Sansom Institute, University of South Australia, Adelaide, SA.
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Turner T, Misso M, Harris C, Green S. Development of evidence-based clinical practice guidelines (CPGs): comparing approaches. Implement Sci 2008; 3:45. [PMID: 18954465 PMCID: PMC2584093 DOI: 10.1186/1748-5908-3-45] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 10/27/2008] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND While the potential of clinical practice guidelines (CPGs) to support implementation of evidence has been demonstrated, it is not currently being achieved. CPGs are both poorly developed and ineffectively implemented. To improve clinical practice and health outcomes, both well-developed CPGs and effective methods of CPG implementation are needed. We sought to establish whether there is agreement on the fundamental characteristics of an evidence-based CPG development process and to explore whether the level of guidance provided in CPG development handbooks is sufficient for people using these handbooks to be able to apply it. METHODS CPG development handbooks were identified through a broad search of published and grey literature. Documents published in English produced by national or international organisations purporting to support development of evidence-based CPGs were included. A list of 14 key elements of a CPG development process was developed. Two authors read each handbook. For each handbook a judgement was made as to how it addressed each element; assigned as: 'mentioned and clear guidance provided', 'mentioned but limited practical detail provided ', or 'not mentioned'. RESULTS Six CPG development handbooks were included. These were produced by the Council of Europe, the National Health and Medical Research Council of Australia, the National Institute for Health and Clinical Excellence in the UK, the New Zealand Guidelines Group, the Scottish Intercollegiate Guideline Network, and the World Health Organization (WHO).There was strong concordance between the handbooks on the key elements of an evidence-based CPG development process. All six of the handbooks require and provide guidance on establishment of a multidisciplinary guideline development group, involvement of consumers, identification of clinical questions or problems, systematic searches for and appraisal of research evidence, a process for drafting recommendations, consultation with others beyond the guideline development group, and ongoing review and updating of the CPG. CONCLUSION The key elements of an evidence-based CPG development process are addressed with strong concordance by existing CPG development handbooks. Further research is required to determine why these key elements are often not addressed by CPG developers.
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Affiliation(s)
- Tari Turner
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton, Victoria, 3168, Australia.
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Valderas JM, Ferrer M, Mendívil J, Garin O, Rajmil L, Herdman M, Alonso J. Development of EMPRO: a tool for the standardized assessment of patient-reported outcome measures. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:700-708. [PMID: 18194398 DOI: 10.1111/j.1524-4733.2007.00309.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE This study was aimed to develop a tool for the standardized assessment of patient-reported outcomes (PROs) to assist the choice of instruments. METHODS An expert panel adapted the eight attributes proposed by the Medical Outcomes Trust as evaluation review criteria, created items to evaluate them, and included a response scale for each item. A pilot test was designed to test the new tool's feasibility and to obtain preliminary information concerning its psychometric properties. The Spanish versions of five measures were selected for assessment: the SF-36 Health Survey, the Nottingham Health Profile, the COOP-WONCA charts, the EuroQol-5D, and the Quality of Life Questionnaire EORTC-QLQ-C30. We assessed the new tool's reliability (Cronbach's alpha and intraclass correlation coefficient [ICC]) and construct validity. RESULTS The new EMPRO (Evaluating the Measurement of Patient-Reported Outcomes) tool has 39 items covering eight key attributes: conceptual and measurement model, reliability, validity, responsiveness, interpretability, burden, alternative modes of administration, and cross-cultural and linguistic adaptations. Internal consistency was high (alpha = 0.95) as was interrater concordance (ICC: 0.87-0.94). Positive associations consistent with a priori hypotheses were observed between EMPRO attribute scores and the number of articles identified for the measures, the years elapsed since the publication of the first article, and the number of citations. CONCLUSION A new tool for the standardized assessment of PRO measures is available. It has shown good preliminary reliability and validity and should be a useful aid to investigators who need to choose between alternative measures. Further assessment of the tool is necessary.
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Affiliation(s)
- Jose M Valderas
- National Primary Care Research and Development Center, University of Manchester, Manchester, UK
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Ramstrand N, Brodtkorb TH. Considerations for developing an evidenced-based practice in orthotics and prosthetics. Prosthet Orthot Int 2008; 32:93-102. [PMID: 18330808 DOI: 10.1080/03093640701838190] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Evidence-based practice has become somewhat of a catchphrase over the past ten years. In this paper evidence-based practice is defined and its importance for the development of the prosthetics and orthotics profession is highlighted. The authors suggest that evidence-based practice needs to be prioritized within the profession and that a cultural change needs to be initiated which supports clinicians in incorporating research findings into their daily practice. In addition, the authors highlight the need for prosthetists/orthotists to become more active in generating research rather than relying on other professional groups to contribute to their professional body of knowledge.
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Affiliation(s)
- N Ramstrand
- Department of Rehabilitation, School of Health Sciences, Jönköping University, Jönköping, Sweden.
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de Haas ERM, de Vijlder HC, van Reesema WS, van Everdingen JJE, Neumann HAM. Quality of clinical practice guidelines in dermatological oncology. J Eur Acad Dermatol Venereol 2008; 21:1193-8. [PMID: 17894704 DOI: 10.1111/j.1468-3083.2007.02216.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical practice guidelines are increasingly used. To determine the quality of guidelines the Appraisal of Guidelines and Research and Evaluation (AGREE) instrument was developed and introduced in 2001. The AGREE instrument consists of 23 criteria, grouped in six domains. OBJECTIVE Assessment of quality of evidence-based guidelines in dermatological oncological care according to the AGREE instrument. METHODS We searched MEDLINE, PubMed, EMBASE and Cochrane literature and relevant websites of guidelines development programmes and the national dermatological society to identify evidence-based dermatological guidelines especially in the treatment of to basal cell carcinoma, squamous cell carcinoma and melanoma. Twenty guidelines, published between 1990 and 2005, were appraised according to the AGREE instrument by three authors. Standardized domain scores were calculated as advised by AGREE. We compared guidelines published before 2002 with those published later. RESULTS Domain scores in the domains Scope & Purpose and Clarity were scored best. Applicability and Editorial Independence were scored worst (see Table 1). In time a weak trend towards better guidelines was seen. This trend can be attributed to better scores in the domains Search Strategy and Level of Evidence which are closely related to evidence-based medicine. The increase in score is due to more explicitly mentioning the search strategy, possible conflict of interest and involvement of different specialties in development of the guideline. Using the Mann-Whitney test to compare guidelines published before the AGREE and afterwards only a statistically significant better score was found for the domain Clarity (P < 0.05; Table 2). CONCLUSIONS Guidelines in dermatological oncological care are of reasonable quality according to the AGREE instrument. The domains in the AGREE instrument concern especially the methods of development of guidelines. The score according to AGREE can be improved by explicitly mentioning the different items. As clinical guidelines are regarded to be an important instrument to improve quality of care, improvements are needed.
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Affiliation(s)
- E R M de Haas
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands.
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March JS, Szatmari P, Bukstein O, Chrisman A, Kondo D, Hamilton JD, Kremer CME, Kratochvil CJ. AACAP 2005 Research Forum: speeding the adoption of evidence-based practice in pediatric psychiatry. J Am Acad Child Adolesc Psychiatry 2007; 46:1098-1110. [PMID: 17712233 DOI: 10.1097/chi.0b013e318074eb48] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES At the 2005 Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), the Academy's Workgroup on Research conducted a Research Forum entitled "Increasing Research Literacy Through the Adoption of Evidence-Based Practice (EBP) in Pediatric Psychiatry." METHOD Forum participants focused on speeding the adoption of EBP across five areas: EBP as the preferred heuristic for teaching research literacy, use of EBP in training programs, dissemination of EBP in clinical practice, EBP in partnership with industry, and EBP as a framework for developing practice guidelines. RESULTS EBP provides an easy-to-understand method for accessing and evaluating the research literature and then applying this information to decisions about patient care. Although EBP has been gaining greater visibility in pediatric psychiatry, it is far from the preferred heuristic. To move the field toward fully embracing EBP will require greater understanding of what EBP is (and is not), educating mental health professionals in EBP skills, access to EBP resources, and a commitment to apply EBP to the conceptualization and design of research protocols and practice guidelines. CONCLUSIONS Pediatric psychiatry would benefit from a principled commitment to follow other areas of medicine in adopting EBP.
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Affiliation(s)
- John S March
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha..
| | - Peter Szatmari
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Oscar Bukstein
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Allan Chrisman
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Douglas Kondo
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - John D Hamilton
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Charlotte M E Kremer
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
| | - Christopher J Kratochvil
- Drs. March, Chrisman, and Kondo are with the Department of Psychiatry, Duke University Medical Center, Durham, NC; Dr. Szatmari is with the Department of Psychiatry at McMaster University, Hamilton, Ontario; Canada; Dr. Bukstein is with Western Psychiatric Institute and Clinic, University of Pittsburgh; Dr. Hamilton is with The Permanente Medical Group of California; Dr. Kremer is with Pfizer, Inc.; Dr. Kratochvil is with the Department of Psychiatry, University of Nebraska Medical Center, Omaha
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Préparations pour nourrissons et préparations de suite: pour une commercialisation et une communication basées sur les preuves. Arch Pediatr 2007; 14:319-21. [PMID: 17321726 DOI: 10.1016/j.arcped.2007.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2006] [Accepted: 01/05/2007] [Indexed: 11/22/2022]
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[Evidence-based dietetics: what has to be kept in mind for the prescription of infant formulae and follow-on formulae in 2007th?]. Arch Pediatr 2007; 14:370-5. [PMID: 17321116 DOI: 10.1016/j.arcped.2007.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Revised: 12/18/2006] [Accepted: 01/17/2007] [Indexed: 11/19/2022]
Abstract
All infant and follow-on formulae available on the market are of high quality. Nevertheless, they are not identical. Several formulae recently launched are characterized by innovations that may have interesting functional effects in some infants. The rising number of formulae and the uncertainty on the validity of the claims presented to justify these innovations make more and more difficult the prescription of a formula that has to be individually tailored for each child. A rational prescription should only be approached on the principle of evidence-based dietetics. Infant formulae satisfy by themselves the nutritional needs of infants up to 6 months of age whereas follow-on formulae should only be used after 6 months when complementary feeding has been introduced into the diet. None of these formulae can claim any nutritional superiority, in particular over breast feeding, which is the reference mode of feeding during the first 6 months of life. The nature of the protein source is the main criteria for choosing an infant formula. In the absence of breast feeding, cow's milk protein infant and follow-on formulae represent the first choice, with the exception of infants at risk for allergy, who should be exclusively fed a hypoallergenic formula during the first 6 months of life. The main interest of soy protein infant and follow-on formulae is feeding infants in vegan families. A functional benefit has only been shown for anti regurgitation formulae as well as for formulae that have the potential to soften stools. Except for the prevention of allergic disease in at-risk families with the use of hypoallergenic infant (and not follow-on) formulae, there is no convincing evidence supporting the prescription of specific formulae in a preventive approach.
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Watine J, Friedberg B, Nagy E, Onody R, Oosterhuis W, Bunting PS, Charet JC, Horvath AR. Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners. Clin Chem 2006; 52:65-72. [PMID: 16391328 DOI: 10.1373/clinchem.2005.056952] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND It is not clear if good methodologic quality in current practice guidelines necessarily leads to more valid recommendations, i.e., those that are supported with consistent research evidence or, when evidence is conflicting or lacking, with sufficient consensus among the guideline development team. To help clarify this issue, we assessed whether there is a link between methodologic quality and recommendation validity in practice guidelines for the use of laboratory tests in the management of patients with non-small cell lung cancer (NSCLC). METHODS We conducted a systematic review of data on laboratory tests in NSCLC published in English or in French within the last 10 years and retrieved 11 practice guidelines for the use of these tests. The guidelines were critically appraised and scored for methodologic quality and recommendation validity based on the Appraisal of Guidelines Research and Evaluation (AGREE) criteria and on the systematic review. RESULTS Overall, these 11 guidelines had considerable shortcomings in methodologic quality and, to a lesser extent, in recommendation validity. Practice guidelines with the best methodologic quality were not necessarily the most valid in their recommendations, and conversely. CONCLUSIONS Poor methodologic quality and lack of recommendation validity in laboratory medicine call for methodologic standards of guideline development and for international collaboration of guideline development agencies. We advise readers of guidelines to critically evaluate the methods used as well as the content of the recommendations before adopting them for use in practice.
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Affiliation(s)
- Joseph Watine
- Laboratoire de Biologie Polyvalente, Centre Hospitalier Général de Rodez, Rodez, France.
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Guala A, Guarino R, Zaffaroni M, Martano C, Fabris C, Pastore G, Bona G. The impact of national and international guidelines on newborn care in the nurseries of Piedmont and Aosta Valley, Italy. BMC Pediatr 2005; 5:45. [PMID: 16329760 PMCID: PMC1315318 DOI: 10.1186/1471-2431-5-45] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2004] [Accepted: 12/05/2005] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Care procedures for preventing neonatal diseases are carried out according to nurseries' traditions and may be not consistent with the evidence based medicine issues. METHODS A multi-centric survey was conducted in 2 Regions located in NW Italy (Piedmont and Aosta Valley) in order to collect information on some healthy newborn care procedures. During 2001, a questionnaire was sent to the chief pediatrician in charge to the all 33 nurseries of the region asking the methods used during 2000 as prevention of ophthalmia neonatorum, early and late hemorrhagic disease of newborn, umbilical cord care and recommendations of vitamin D administration. Thereafter, during 2004 the same questionnaire was sent to the 34 chief pediatrician of nurseries to evaluate if the procedures were changed during 2003 according to guidelines. The nurseries care for 32,516 newborns in 2000 and 37,414 in 2003. RESULTS Aminoglycoside eyes drops as prevention of ophthalmia neonatorum were the first choice in both periods (23 out 33 nurseries in 2000 and 24 out 34 in 2003 p > 0.05; the corresponding figures for newborns were 18,984 out 32,516 newborns vs. 28,180 out of 37,414 p < 0.05). The umbilical cord care was carried out with alcohol in 12/33 centers (13,248 newborns) and dry gauze in 3/33 centers (2,130 newborns) in 2000, the corresponding figures in 2003 were 6/34 centers (p > 0.05), (6,380 newborns, p < 0.05) and 12/34 centers (p < 0.05), (18,123 newborns, p < 0.05). The percentage of newborns receiving of i.m. vitamin K. at birth increased during the study period (15,923/32,104 in 2000 vs. 19,684/37,414 in 2003, p < 0.01), but not the number of nurseries (16 in 2000 and 17 in 2003 p > 0.05). The numbers of parents of newborns who receive the recommendations of oral vitamin K during the first months life decreased from 2000 (25,516/30,606) to 2003 (29,808/37,414, p < 0.01) as well as for Vitamin D recommendation (14,582/30,616 in 2000 vs. 11,051/37,414 in 2003, p < 0.01). Oral vitamin K during the first months of life was recommended by 25 nurseries in 2000 and 27 in 2003 (p > 0.05), the corresponding figures for Vitamin D were 15 and 14 (p > 0.05). CONCLUSION In the present study a large variability of procedures among the nurseries was observed. During the study periods, guidelines and evidence based medicine issues have only partially modified the neonatal care procedures In Piedmont and Aosta Valley nurseries. These observations suggest to implement local forum/consensus conference to standardized procedures as much as possible.
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Affiliation(s)
- Andrea Guala
- S.O.C. di Pediatria, Ospedale SS Pietro e Paolo, ASL 11, Borgosesia, Italy
| | - Roberta Guarino
- S.O.C. di Pediatria, Ospedale SS Pietro e Paolo, ASL 11, Borgosesia, Italy
| | - Mauro Zaffaroni
- Clinica Pediatrica, Dipartimento di Scienze Mediche, Università del Piemonte Orientale, Novara, Italy
| | - Claudio Martano
- Cattedra di Neonatologia, Dipartimento Materno-Infantile, Università di Torino, Torino, Italy
| | - Claudio Fabris
- Cattedra di Neonatologia, Dipartimento Materno-Infantile, Università di Torino, Torino, Italy
| | - Guido Pastore
- Clinica Pediatrica, Dipartimento di Scienze Mediche, Università del Piemonte Orientale, Novara, Italy
| | - Gianni Bona
- Clinica Pediatrica, Dipartimento di Scienze Mediche, Università del Piemonte Orientale, Novara, Italy
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