Review of guidelines for bone mineral density testing and treatment of osteoporosis

Clinical practice guidelines (CPGs) are systematically developed statements intended to influence the behavior of health care providers and improve patient care. There are many CPGs with recommendations for selection of patients for bone mineral density testing and pharmacologic treatment of osteoporosis. Health care provider adherence rates for these CPGs are low. The multiplicity of osteoporosis CPGs directed to the same health care providers may play a role in their limited utilization in clinical practice. Similarities, differences, and conflicts in osteoporosis CPGs with wide distribution in the United States were examined. The analysis showed similarities as well as substantial variation in the patient populations addressed, inconsistency of some recommendations, differences in clinical risk factors identified, and sometimes limitations in clinical applications. If the number and diversity of osteoporosis CPGs is adversely affecting their use in clinical practice, then collaboration of stakeholder organizations to develop more consistent CPGs, in combination with systems-based approaches for their implementation, may improve patient care and reduce the burden of osteoporotic fractures.     

Breast Cancer Guidelines in Canada: A Review of Development and Implementation

A series of specific clinical practice guidelines (CPGs) were published in Canada in 1998. A primary objective of these 'Clinical Practice Guidelines for the Care and Treatment of Breast Cancer' was to decrease the variation in breast cancer care across the country. Prior to this, researchers found moderate compliance with consensus recommendations for breast cancer therapies in several Canadian provinces. However, a recent study concluded that the publication of the Canadian CPGs did not reduce variations in surgical care for breast cancer. If guidelines are to achieve their intended objectives, they must be implemented in ways that support, encourage, and facilitate their use. Evidence strongly suggests the simple publication and passive dissemination of CPGs are usually ineffective in changing how physicians actually care for patients. CPG implementation, therefore, requires active knowledge translation processes to ensure that the evidence is relevant to all with a stake in bettering breast cancer care. For example, implementation strategies that use computerized CPGs can make evidence-based decision-making routine practice in the clinical setting. The breast cancer community can also work with the newly formed Canadian Partnership Against Cancer to find ways to more successfully support and facilitate guideline use considering the local context.     

New clinical practice guidelines for chronic kidney disease: a framework for K/DOQI

Chronic kidney disease affects millions of individuals in the United States, and millions more are at risk for the development of kidney disease. The National Kidney Foundation (NKF) has recently published 15 clinical practice guidelines (CPGs) for chronic kidney disease under the Kidney/Disease Outcomes Quality Initiative (K/DOQI). This initial set of guidelines creates a framework for additional interventional CPGs currently in development. Importantly, these guidelines define and classify CKD. In addition, recommendations for the clinical assessment of kidney disease are elaborated. In reviewing the guidelines, we find that they follow the basic principles of CPG development and incorporate the essential aspects of CPGs. The validity of the CPGs is limited in some areas because of the paucity of data. Despite their limitations, the current CPGs allow for the development of clinical performance measures and continuous quality improvement in the hopes of improving public health and reducing progression to end-stage renal disease (ESRD).     

Clinical practice guidelines to inform evidence-based clinical practice

Background  

With the volume of medical research currently published, any one practitioner cannot independently review the literature to determine best evidence-based medical care. Additionally, non-specialists usually do not have the experience to know best practice for all of the frequent clinical circumstances for which there is no good evidence. Clinical practice guidelines (CPGs) help clinicians to address these problems because they are systematically created documents that summarize knowledge and provide guidance to assist in delivering high-quality medicine. They aim to improve health care by identifying evidence that supports the best clinical care and making clear which practices appear to be ineffective.     

Clinical practice guidelines in end-stage renal disease: a strategy for implementation

Clinical practice guidelines (CPGs) for end-stage renal failure (ESRD) were recently published, and represent a comprehensive review of available literature and the considered judgment of experts in ESRD. To prioritize and implement these guidelines, the evidence underlying each guideline should be ranked and the attributes of each should be defined. Strategies to improve practice patterns should be tested. Focused information for each high priority guideline should be disseminated, including a synopsis and assessment of the underlying evidence, the evidence model used to develop that guideline, and suggested strategies for CPG implementation. Clinical performance measures should be developed and used to measure current practice, and the success of changing practice patterns on clinical outcomes. Individual practitioners and dialysis facilities should be encouraged to utilize continuous quality improvement techniques to put the guidelines into effect. Local implementation should proceed at the same time as a national project to convert high priority CPGs into clinical performance measures proceeds. Patients and patient care organizations should participate in this process, and professional organizations must make a strong commitment to educate clinicians in the methodology of CPG and performance measure development and the techniques of continuous quality improvement. Health care regulators should understand that CPGs are not standards, but are statements that assist practitioners and patients in making decisions.     

The quality of clinical practice guidelines in hand therapy.

Clinical practice guidelines (CPGs) should consist of treatment recommendations that assist hand therapists in providing high-quality cost-effective care to specific patients based on the highest level of available evidence. This requires CPGs to be developed using a rigorous process based on evidence, appraisal of both original studies and expert opinion, and a process for multiple reviewers to evaluate the draft CPG. This study identified CPGs relevant to hand therapy and then evaluated their quality using the AGREE quality assessment tool. The majority of guidelines were not evidence-based and were of extremely low quality. Two guidelines were produced using a rigorous process that emphasized comparative clinical trials. These were able to provide only a single treatment recommendation, that ultrasound is effective for calcific tendinitis of the shoulder. Hand therapists need to move away from opinion- or clinic-based protocols and toward more evidence-based treatment guidelines. However, the value of treatment guidelines must be tested, not assumed, regardless of the development process.     

The Use of Clinical Practice Guidelines (CPGs) to Evaluate Practice and Control Costs in Ventriculoperitoneal Shunt Management

Background

As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources.

Methods

The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation.

Results

CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant.

Conclusions

The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.     

Closing the loop between evidence-based medicine and care delivery: a possible role for clinical audits in spinal surgery

Background contextEvidence-based medicine (EBM) should be the ultimate force driving change in clinical practice. This process generally occurs through a trickle-down phenomenon by which practice recommendations are revised, modified, and/or changed based on the best published data. Recommendations are subsequently incorporated by individual physicians. The fundamental assumption that drives this paradigm is that adopting evidence-based recommendations and/or treatment guidelines will result in improved outcomes. Unfortunately, to date, the paradigm does not have an effective feedback loop that would then evaluate whether the changes did, in fact, improve outcomes.PurposeTo explore the process of clinical audits as a mechanism by which to provide a feedback loop to evaluate the results of spinal surgery on an individual basis and whether those results can be improved.Study designReview article, discussion.MethodsA literature review of the current data regarding clinical audits was performed, and a discussion of how they may apply to spinal surgery is offered.ResultsClinical audits have been used outside the United States, particularly in the United Kingdom, to fulfill this function. A clinical audit would allow a practicing spinal surgeon to examine his or her individual experience and determine if it is achieving the expected outcome based on published results. In the most important feature of a clinical audit, the reaudit, if an individual's results are found to be inconsistent with published results, it presents an opportunity to identify if there are reconcilable differences from which potential improvements can be made. Effectively, this “closes the loop” between EBM and actual clinical practice.ConclusionsDocumenting improved outcomes through the audit process can impact spinal care in several ways. Patients would receive a clear message that their doctors are interested in improving care. Hospitals will use the information to optimize treatment algorithms. Finally, insurers might make the audit process more tenable or attractive by indicating a physician's voluntary participation as a criterion to be a preferred provider.     

Federal guidelines for the management of urinary incontinence in the United States: Which patients should undergo urodynamic testing?

In 1992, the United States Agency for Health Care Policy and Research (AHCPR) proposed a guideline for the management of adults with urinary incontinence. The purpose of this study is to evaluate the criteria proposed by the AHCPR for the selective use of urodynamic testing in women complaining of stress incontinence. In order to examine the efficacy of these criteria, we retrospectively determined urodynamic diagnoses for 101 women presenting with the complaint of stress incontinence. These were then compared to the AHCPR recommendations for each subject's management. We found that the AHCPR algorithm would have recommended treatment without urodynamic testing for 65% of the population. If the AHCPR guideline had been followed, 32% of the overall population could have received inappropriate treatment. These results suggest that the implementation of the AHCPR guideline could result in inappropriate treatment for onethird of women presenting with symptoms of stress incontinence.Editorial Comment: The federal guidelines for the management of urinary incontinence in the United States emphasize medical management prior to any diagnostic urodynamic studies beyond those that can be obtained by a physical examination and prior to surgical management. The guidelines are not adequate to triage patients for the therapy of urinary incontinence, as is pointed out by this article. This has been recognized at a federal level as well, and new guidelines are being prepared. It is not anticipated that they will differ to any great degree with respect to the need for medical management prior to any definitive urodynamic testing or surgical therapy. Hopefully the new guidelines will be more useful in the triage of patients to earlier urodynamic testing in those cases where medical management will predictably fail, and more appropriate therapy for incontinence can be instituted from the beginning.     

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.     

Review article: The role of practice guidelines and evidence-based medicine in perioperative patient safety

Purpose

The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety.

Principal findings

The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue.

Conclusions

Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust.     

Quality assessment of clinical practice guidelines for adaptation in burn injury

Objectives

A number of clinical practice guidelines (CPGs) are available for managing burn injury patients but clinical practice is highly variable. We report the first steps to trans-contextual adaptation of international burn CPGs to local settings.

Methods

Key clinical topics and questions to be covered in the final guideline were defined and prioritized. Systematic search between 1990 and 2008 retrieved 546 citations, of which 24 were CPGs on the general and intensive care of burn patients. Assessment of the clinical content of CPGs was carried out. Methodological quality of CPGs was evaluated using the AGREE instrument.

Results

Of the 24 CPGs evaluated, 10 (42%) were evidence-based. All major burn topics were covered by at least one CPG, but no single CPG addressed all areas important in terms of outcomes. According to the AGREE criteria, 2 CPGs (8%) were strongly recommended, 14 with provisos or alterations (58%) and the rest were not recommended for adaptation.

Conclusions

Although existing CPGs for the management of burn may accurately reflect agreed clinical practice, most performed poorly when evaluated for methodological quality. Future CPG efforts addressing these methodological shortcomings would add substantially to the improved management of burned patients.     

Dutch guidelines for physiotherapy in patients with stress urinary incontinence: an update

Introduction and hypothesis

Stress urinary incontinence (SUI) is the most common form of incontinence impacting on quality of life (QOL) and is associated with high financial, social, and emotional costs. The purpose of this study was to provide an update existing Dutch evidence-based clinical practice guidelines (CPGs) for physiotherapy management of patients with stress urinary incontinence (SUI) in order to support physiotherapists in decision making and improving efficacy and uniformity of care.

Materials and methods

A computerized literature search of relevant databases was performed to search for information regarding etiology, prognosis, and physiotherapy assessment and management in patients with SUI. Where no evidence was available, recommendations were based on consensus. Clinical application of CPGs and feasibility were reviewed. The diagnostic process consists of systematic history taking and physical examination supported by reliable and valid assessment tools to determine physiological potential for recovery. Therapy is related to different problem categories. SUI treatment is generally based on pelvic floor muscle exercises combined with patient education and counseling. An important strategy is to reduce prevalent SUI by reducing influencing risk factors.

Results

Scientific evidence supporting assessment and management of SUI is strong.

Conclusions

The CPGs reflect the current state of knowledge of effective and tailor-made intervention in SUI patients.     

Development of Clinical Practice Guidelines: Surgical Perspective

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. The implications of this definition are that: the methodologic perspective and operations for systematic development must be specified, a strategy is needed to account for the patient's perspective in the CPG development process and the clinical decision, and a mechanism is required to determine how appropriateness ought to be conceptualized and defined. Addressing these issues, we review models of CPG development, outline challenges to evidence-based approaches to CPG development, address unique factors relevant to the development of guidelines for the surgical community, introduce an Ontario practice guidelines strategy that uses complementary methods of CPG development, and summarize the feedback provided by the surgical community regarding the practice guidelines produced in Ontario's cancer system.     

Management of rectal cancer in Canada: an evidence-based comparison of clinical practice guidelines

BackgroundRectal cancer requires a multidisciplinary and multimodality treatment approach. Clinical practice guidelines (CPGs) provide a framework for delivering consistent, evidence-based health care. We compared provincial/territorial CPGs across Canada to identify areas of variability and evaluate their quality.MethodsWe retrieved CPGs from Canadian organizations responsible for cancer care oversight and evaluated their quality and developmental methodology using the AGREE-II instrument. Recommendations for diagnostic and staging investigations, treatment by stage, and post-treatment surveillance of stage I–III rectal cancers were abstracted and compared.ResultsWe identified 7 sets of CPGs for analysis, varying in content, presentation, quality, and year last updated. Differences were noted in locoregional staging: 4 recommended magnetic resonance imaging over endorectal ultrasonography, 2 recommended either modality, and 3 specified scenarios for one over the other. Recommendations also varied for use of staging computed tomography of the chest versus chest radiography and for surgical management and indications for transanal excision. Recommendations for neoadjuvant therapy in stage II/III disease also differed: 3 guidelines recommended long-course chemoradiation over short-course radiation therapy alone, while 3 others recommended short-course radiation in specific clinical scenarios. Adjuvant chemotherapy for stage II/III disease was uniformly recommended, with variable protocols. The use of proctosigmoidoscopy and interval/duration of endoscopic post-treatment surveillance varied among guidelines.ConclusionCanadian CPGs vary in their recommendations for staging, treatment, and surveillance of rectal cancer. Some of these differences reflect areas with limited definitive evidence. Consistent guidelines with uniform implementation across provinces/territories may lead to more equitable care to patients.     

ABPI reporting and compression recommendations in global clinical practice guidelines on venous leg ulcer management: A scoping review

Clinical practice guidelines (CPGs) for venous leg ulcer (VLU) management recommend below‐knee compression to improve healing outcomes after calculating the ankle‐brachial pressure index (ABPI) to rule out significant arterial disease. This systematic scoping review aimed to complete a qualitative and quantitative content analysis of international CPGs for VLU management to determine if consensus existed in relation to recommendations for compression application based on an ABPI reading and clinical assessment. Our review shows that there is a lack of consensus across 13 VLU CPGs and a lack of clear guidance in relation to the specific ABPI range of compression therapy that can be safely applied. An area of uncertainty and disagreement exists in relation to an ABPI between 0.6 and 0.8, with some guidelines advocating that compression is contraindicated and others that there should be reduced compression. This has implications in clinical practice, including when it is safe to apply compression. In addition, the inconsistency in the levels of evidence and the grades of recommendation makes it difficult to compare across various guidelines.     

A Review of Osteoporosis Diagnosis and Treatment Options in New and Recently Updated Guidelines on Case Finding Around the World

Fracture rates are known to vary by more than an order of magnitude worldwide; therefore, a single approach cannot be universally applied to all countries. National considerations must reflect the burden of osteoporosis, available resources, the disease costs to the individual and society, and how these relate to competing health and other societal priorities. Recent developments in terms of diagnosis, fracture risk prediction, and therapeutic options have prompted many countries to review and update their clinical practice guidelines (CPGs) for the prevention and management of osteoporosis intended for use in primary care in the general adult population. This paper reviews recently updated CPGs from the following countries: Australia, Belgium, Canada, Germany, the United Kingdom, and the United States.     

The cycle of development, publication, and implementation of clinical practice guidelines for CKD

Implementation of clinical practice guidelines (CPGs) leads to better outcomes. The first K/DOQI guideline for chronic kidney disease (CKD) recommended the use of estimated glomerular filtration rate (eGFR) to assess kidney function, minimizing 24-h urine collections for the measurement of creatinine clearance. Kagoma et al. demonstrate that automatic reporting of eGFR with clinical decision support was required for implementation of this recommendation. The second cycle of development, publication, and implementation of CPGs for CKD is under way.