International Primary Care Respiratory Group (IPCRG) Guidelines: integrating diagnostic guidelines for managing chronic respiratory diseases in primary care.

This is the first of the IPCRG Guideline papers. The IPCRG took on the task of producing an integrated guideline for the management of chronic respiratory diseases in primary care. This included some original work aimed at developing questionnaires suitable for improving the diagnosis and recognition of respiratory diseases in the primary care setting. This paper provides the background evidence and rationale for the integrated diagnostic section of the IPCRG Guideline. It focuses on identifying the unique challenges in respiratory disease diagnosis in primary care, the use of epidemiology to build a co-ordinated diagnostic framework, and the development of tools to support guideline implementation.     

Cost‐effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: economic evaluation alongside a randomised trial

Objective To evaluate the cost‐effectiveness of an educational outreach intervention to improve primary respiratory care by South African nurses. Methods Cost‐effectiveness analysis alongside a pragmatic cluster randomised controlled trial, with individual patient data. The intervention, the Practical Approach to Lung Health in South Africa (PALSA), comprised educational outreach based on syndromic clinical practice guidelines for tuberculosis, asthma, chronic obstructive pulmonary disease, pneumonia and other respiratory diseases. The study included 1999 patients aged 15 or over with cough or difficult breathing, attending 40 primary care clinics staffed by nurses in the Free State province. They were interviewed at first presentation, and 1856 (93%) were interviewed 3 months later. Results The intervention increased the tuberculosis case detection rate by 2.2% and increased the proportion of patients appropriately managed (that is, diagnosed with tuberculosis or prescribed an inhaled corticosteroid for asthma or referred with indicators of severe disease) by 10%. It costs the health service $68 more for each extra patient diagnosed with tuberculosis and $15 more for every extra patient appropriately managed. Analyses were most sensitive to assumptions about how long training was effective for and to inclusion of household and tuberculosis treatment costs. Conclusion This educational outreach method was more effective and more costly than usual training in improving tuberculosis, asthma and urgent respiratory care. The extra cost of increasing tuberculosis case detection was comparable to current costs of passive case detection. The syndromic approach increased cost‐effectiveness by also improving care of other conditions. This educational intervention was sustainable, reaching thousands of health workers and hundreds of clinics since the trial.     

Developing multidisciplinary guidelines for the management of early rheumatoid arthritis

Objective: To develop an evidence based guideline, for the multidisciplinary management of early rheumatoid arthritis (RA). Methods: Recommendations were developed using both an evidence‐based approach and expert opinion. The scientific committee, composed of key members of the rheumatology multidisciplinary team used a Delphi approach to evaluate topics and standard statements, which formed the basis for developing recommendations for management of RA in the first 2 years of disease. Evidence taken from literature was used to support these recommendations. Results: 24 evidence based recommendations for the management of early RA, with a grade of recommendation from A to C, were developed. In addition an algorithm of care was designed to promote a clear multidisciplinary management pathway. A mechanism for audit was also identified. Conclusion: Involvement of the multidisciplinary rheumatology team has enabled a holistic guideline to be developed for the management of patients presenting with early RA. This guideline is based around best practice that is supported by published literature. Whilst most statements in the guideline are based on strong evidence, others have been formulated by expert consensus in the absence of data and should serve as an opportunity to improve current practice through future research and audit. The development and implementation of such a guideline should improve the care of patients with early RA. Copyright © 2007 John Wiley & Sons, Ltd.     

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement

OBJECTIVE: Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax. OPTIONS: Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging. OUTCOMES: Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence. EVIDENCE: Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel. VALUES: The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire. Benefits, harms, and costs: The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation. RECOMMENDATIONS: Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care. VALIDATION: Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee. IMPLEMENTATION: The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs. SPONSORS: The ACCP.     

Sexually transmitted infections in Estonia--syndromic management of urethritis in a European country?

Sexually transmitted infections (STIs) are considered a major public health problem, globally. In particular, increasing STI rates have been documented throughout eastern Europe and central Asia. The Russian Federation and adjacent countries have, traditionally, managed STIs on an aetiological basis. This approach is expensive in terms of laboratory costs and it may lead to delayed diagnosis and treatment. To overcome the limitations of the aetiological management of STIs, the World Health Organization (WHO) has placed an increased emphasis on integrated care using syndromic management at the primary care level, especially in developing countries. This article reviews the current aetiology of STIs in Estonia, an eastern European country bordering the Baltic Sea and formerly a part of the Soviet Union, with the aim of defining whether infection with Trichomonas vaginalis is common enough to include its management in a syndromic management protocol. The use of syndromic management, in general, is also discussed.     

International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care.

This Diagnosis paper constitutes the second of the IPCRG Guideline papers on the management of chronic respiratory diseases in primary care. Primary care health professionals are usually the first point of contact for patients who can present a wide range of initial symptoms which may or may not constitute their first presentation of a chronic disease such as asthma, COPD, or rhinitis. This paper is focussed upon the early identification and diagnosis of chronic respiratory diseases in primary care. It uses a symptom-based approach, and includes original questionnaires and diagnostic guides to help the primary care clinician proceed systematically through the diagnostic process.     

Magnitude and control of acute respiratory infections in children

Acute respiratory infections of viral or bacterial origin represent 1 of the 3 main causes of morbidity and mortality in children of developing countries, where they typically are responsible for 15-20% of deaths in children under 5. Mortality rates are higher in children under 1 year and decline with age. Fewer than 2% of children with pneumonia in developed countries die, vs. an estimated 10-20% in developing countries. Operational studies indicate that children dying of acute respiratory infections are those who do not receive health services or receive them too late, and those whose moderate infections are inadequately treated. Determining factors include inaccessibility of health services, socioeconomic problems, cultural factors limiting the frequency and acceptance of formal health services, and inadequate management of acute respiratory infections by the general health services. Immunizations, better case management and health education are 3 interventions for control of respirator infections that offer immediate potential benefits for primary health care in developing countries. Vaccinations against whooping cough, measles, and diphtheria are part of the Expanded Program of Immunization. Anti-pneumococcal vaccines and flu shots are not appropriate for use in children in developing countries. Health personnel should be trained to use antibiotics more rationally and efficiently and to make referrals to higher levels of care when needed. Oxygen treatment should be available in secondary and tertiary care centers. Health personnel should be trained to administer simple treatments for other possible complications of respiratory infections. Such measures have been applied sporadically in developing countries and data on their efficacy remain sparse. But mortality rates declined greatly in 1 rural community of India after introduction of the measures, and more proofs of their efficacy will become available as programs develop. It will be necessary to train health agents in differentiation of cases according to gravity, to recommend and apply treatment, to administer antimicrobial drugs, and to refer cases to hospitals. The main decision of the health agent concerns the gravity of the case and not the diagnosis of pneumonia or bronchitis. A classification based on the few most important signs and symptoms will facilitate the 2 principal decisions about treatment; whether to administer antimicrobial and whether to treat at home or refer to a higher level of care. A 3-part classification of acute respiratory infections if suggested for all outpatient care and community health agents: serious cases requiring hospitalization 2) moderate cases requiring antimicrobial but not hospitalization and 3) mild cases not requiring antimicrobial.     

Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome

BACKGROUND: Irritable bowel syndrome (IBS) presents a significant diagnostic and management challenge for primary care practitioners. Improving the accuracy and timeliness of diagnosis may result in improved quality and efficiency of care. OBJECTIVE: To systematically appraise the existing diagnostic criteria and combine the evidence with expert opinion to derive evidence- and consensus-based guidelines for a diagnostic approach to patients with suspected IBS. METHODS: We performed a systematic literature review (January 1966-April 2000) of computerized bibliographic databases. Articles meeting explicit inclusion criteria for diagnostic studies in IBS were subjected to critical appraisal, which formed the basis of guideline statements presented to an expert panel. To develop a diagnostic algorithm, an expert panel of specialists and primary care physicians was used to fill in gaps in the literature. Consensus was developed using a modified Delphi technique. RESULTS: The systematic literature review identified only 13 published studies regarding the effectiveness of competing diagnostic approaches for IBS, the accuracy of diagnostic tests, and the internal validity of current diagnostic symptom criteria. Few studies met accepted methodological criteria. While symptom criteria have been validated, the utility of endoscopic and other diagnostic interventions remains unknown. An analysis of the literature, combined with consensus from experienced clinicians, resulted in the development of a diagnostic algorithm relevant to primary care that emphasizes a symptom-based diagnostic approach, refers patients with alarm symptoms to subspecialists, and reserves radiographic, endoscopic, and other tests for referral cases. The resulting algorithm highlights the reliance on symptom criteria and comprises a primary module, 3 submodules based on the predominant symptom pattern (constipation, diarrhea, and pain) and severity level, and a subspecialist referral module. CONCLUSIONS: The dearth of available evidence highlights the need for more rigorous scientific validation to identify the most accurate methods of diagnosing IBS. Until such time, the diagnostic algorithm presented herein could inform decision making for a range of providers caring for primary care patients with abdominal discomfort or pain and altered bowel function suggestive of IBS.     

2008 update of the guideline: early detection of breast cancer in Germany

Introduction  The goal of the 2008 updated guideline: early detection of breast cancer in Germany is to support physicians as well as healthy and affected women in the decision-making process involved in the diagnostic chain for the early detection of breast cancer by providing them with evidence- and consensus-based recommendations. The updated guideline replaces the guideline issued in 2003. Materials and methods  The guideline forms the basis for developing an effective and efficient national early breast cancer detection program that meets the standards set by the Council of Europe and WHO for cancer control programs. The guideline presents the current, evidence- and consensus-based state of scientific knowledge in a multidisciplinary approach for the entire diagnostic chain, consisting of history taking and risk consultation, information on health behavior, clinical breast examination, diagnostic imaging, image-guided percutaneous tissue-acquisition techniques, open surgical excisional biopsy and pathomorphological tissue evaluation. The guideline recommends a set of quality indicators to assure resource availability, performance quality and outcomes enhancing total quality management for early breast cancer diagnosis. Conclusion   Currently, early detection of breast cancer offers the most promising possibility to optimize the diagnosis and treatment of breast cancer and, as a result, reduce breast cancer mortality and improve health related quality of life in women. The original German version of this paper has been published in Geburtsh Frauenheilk 2008; 68:251–261. Dedication: In memory of Klaus-Dieter Schulz, in highest respect for his contributions to improve breast health care, founder of the guideline task force Concerted Action Early Detection of Breast Cancer in Germany (“Konzertierte Aktion Brustkrebs-Früherkennung in Deutschland”) in 1999, who passed away on 29 September 2007.     

Perspektiven der Leitlinienentwicklung und -implementation aus der Sicht der AWMF

Guidelines are important tools for improving knowledge management, processes and outcomes in health care. They aim to assisst both the clinical and the patient decision-making process, particularly in those areas of health care where considerable variation or potential for improvement exist. However, guidelines are often subject to substantial criticism by practicing clinicians. A prerequisite to improving the acceptance of guidelines is a systematic and methodically sound approach in guideline development. The German instrument for methodological guideline appraisal, DELBI, is intended to assist both guideline developers and users. However, this alone is insufficient. Implementation is a process requiring multifaceted strategies to promote behavior change. These include the provision of assistance for local adaptation and well-defined quality indicators for monitoring guideline adherence and quality of care. Additionally, possible links to existing quality management activities should be taken into account to avoid duplication of efforts.     

The scope of cell phones in diabetes management in developing country health care settings

Diabetes has emerged as a major public health concern in developing nations. Health systems in most developing countries are yet to integrate effective prevention and control programs for diabetes into routine health care services. Given the inadequate human resources and underfunctioning health systems, we need novel and innovative approaches to combat diabetes in developing-country settings. In this regard, the tremendous advances in telecommunication technology, particularly cell phones, can be harnessed to improve diabetes care. Cell phones could serve as a tool for collecting information on surveillance, service delivery, evidence-based care, management, and supply systems pertaining to diabetes from primary care settings in addition to providing health messages as part of diabetes education. As a screening/diagnostic tool for diabetes, cell phones can aid the health workers in undertaking screening and diagnostic and follow-up care for diabetes in the community. Cell phones are also capable of acting as a vehicle for continuing medical education; a decision support system for evidence-based management; and a tool for patient education, self-management, and compliance. However, for widespread use, we need robust evaluations of cell phone applications in existing practices and appropriate interventions in diabetes.     

Syndromic approach to sexually transmitted infections in Tunisian women: bacteriological validation

The World Health Organization emphasizes an integrated primary care approach using syndromic management of sexually transmitted infections. The objective of our study was to evaluate the quality of care of the syndromic management of sexually transmitted disease in women in Rabta hospital in Tunisia. Algorithms have been developed for: cervicitis due to Neisseria gonorrhoeae or Chlamydia (algorithm 3a), vaginitis due to Trichomonas vaginalis or Chlamydia trachomatis (algorithm 3b) and vaginitis due to Candida (algorithm 3c). A total of 116 women were enrolled in the study during February 2003 to April 2004. The prevalence of each bacterium was Chlamydia (10%), N. gonorrhoeae (1%), Treponema pallidum (1%), T. vaginalis (5%) and Candida (21%). Algorithm '3a' had a sensitivity of 45%, a specificity of 42% and positive predictive value (PPV) of 11.9%. Algorithm '3b' had a sensitivity of 35.7%, a specificity of 68.9% and PPV of 20.8%. Algorithm '3c' had a sensitivity of 12%, a specificity of 88% and PPV of 33.3%. To improve the sensitivity of the syndromic approach, we suggest improving the quality of history taking.     

Geriatric assessment in family practice--results of concerted action by 7 European countries

General practitioners are faced with the complex medical care of an increasing number of older people. Traditional demand led care is not able to provide optimal management for this age group, since it has been shown that many important health problems remain unknown or not optimally treated. Preventive geriatric assessment offers primary health care providers new opportunities to focus their management on the particular health problems of older people. A European concerted action involving seven countries formed to develop a "standard assessment for elderly people in primary care (STEP)". The aim was threefold: 1) to identify important and preventable health problems in old age, 2) to supply health care planners and providers with scientific evidence of the corresponding preventive procedures, and 3) to initiate a practical assessment framework for use in European primary care practices. Using a strict methodological protocol, 33 health problems were identified that potentially improve health outcomes in preventive programs for older people. A summary of the evidence is given for each of the included health areas. Taking the best available evidence, patients' preferences, and practice conditions into account, a preventive assessment program was developed containing validated and accepted instruments. The approach is algorithmic with a simple problem identification level and a further diagnostic stage. All recommended procedures are harmonized for common European use. An evidence-based preventive assessment program is expected not only to prevent disease and minimize disability and handicap, but it also offers health care planners a European data set of older peoples' needs for optimized resource allocation.     

Educational and health service needs of Australian general practitioners in managing hepatitis C

BACKGROUND: There has been interest in recent years in the role of primary care practitioners in managing hepatitis C, but there has been minimal research to identify educational and health service needs. A national survey of Australian general practitioners (GPs) was therefore conducted to assess their needs and identify areas for service development. METHODS: A self-administered questionnaire was developed that included questions to assess caseload, confidence in patient management, educational needs and approaches to management and prevention. Questionnaires were sent to a random sample of Australian GPs. Returned questionnaires were coded, frequencies tabulated and significant associations identified. RESULTS: A 70% response rate was achieved from 658 eligible GPs. A total of 76% of respondents had managed one patient in the previous year with hepatitis C. While 69% reported feeling more confident about their management of hepatitis C than 5 years previously, 55% identified a high level of need for hospital-based clinics. Financial benefits for case conferences and chronic case management were not considered useful by most GPs. Topics identified for further skills development included therapeutics and diagnostic testing. Only 39% were highly likely to discuss psychosocial issues as part of initial patient management and 37% reported finding it difficult to play a central role in the medical and psychosocial care of patients with hepatitis C. CONCLUSION: These results have significant implications for policy and service development, as well as identifying areas where GPs need support. The findings invite further discussion between health authorities about the source and magnitude of funding for hospital-based services and further consideration of how to provide services to address patients' psychosocial needs.     

Guidelines for chronic obstructive pulmonary disease treatment and issues of implementation

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Treatment advances over the last decade, although limited, have precipitated the development of clinical practice guidelines, with the aim of improving the quality of care received by patients through fostering evidence-based decision making and accelerating the application of new advances to everyday practice. Of the COPD guidelines that have been developed, those developed through the Global Initiative for Chronic Obstructive Lung Disease (GOLD), initially a joint activity between the U.S. National Heart, Lung, and Blood Institute and the World Health Organization, and the National Institute of Clinical Excellence (NICE) in the United Kingdom have both published their methods for evaluation of evidence. These comprehensive guidelines cover all aspects of the disease, with the aim of providing the basis for local care pathways. The guideline development process includes evaluation of the evidence, development of the guideline, and dissemination of the findings. Efforts to enhance guideline effectiveness have focused on improving the methods and approaches to implementation, which requires an appreciation of the issues that stop translation of guideline definitions of best practice into improved patient care. A variety of questions remain unanswered in the clinical management of COPD, including the definition of outcome measures that move beyond lung function, the potential application of multidimensional grading systems that assess respiratory and systemic expressions of COPD and that could possibly better categorize and predict outcome in these patients, and the impact of new clinical trial findings. Large ongoing outcome studies may also have an effect on defining best practice within future guideline recommendations.     

Acute respiratory infections in children in the developing world.

The profound decline in death rates from respiratory infections in recent decades in the developed countries of the world is a complex phenomenon that probably results from a combination of socioeconomic and environmental change and modern medical care. Death rates from respiratory infections in the developing world are very variable, and there is evidence that they can decrease dramatically when effective health services are engrafted onto a social environment in which mothers are literate and trained to observe their children's health. A worldwide case management program aimed at making lifesaving antibiotics and oxygen available for treatment of children in deprived areas is currently being spearheaded by the World Health Organization and rests on simplified approaches to diagnosis that are widely disseminated to parents and primary health workers. These guidelines have been shown in field studies to contribute to changes in child mortality. The epidemiology of pneumonia in childhood seems similar worldwide. Most children suffer five to eight respiratory infections annually if they live in the cities and fewer if they live in rural areas but, in deprived circumstances, pneumonia complicates the infection much more often and the principal organisms are pneumococcus and Haemophilus influenzae. A vaccine approach to these two organisms is attractive and needs further field testing. Meanwhile, a case management approach, making antibiotics available on a rational basis worldwide, is capable of saving lives. Until mothers in the developing world have confidence in the survival of their children, they are unlikely to be attracted to control of their fertility.     

The global burden of respiratory infections in indigenous children and adults: A review

This review article focuses on common lower respiratory infections (LRIs) in indigenous populations in both developed and developing countries, where data is available. Indigenous populations across the world share some commonalities including poorer health and socio‐economic disadvantage compared with their non‐indigenous counterparts. Generally, acute and chronic respiratory infections are more frequent and more severe in both indigenous children and adults, often resulting in substantial consequences including higher rates of bronchiectasis and poorer outcomes for patients with chronic obstructive pulmonary disease (COPD). Risk factors for the development of respiratory infections require recognition and action. These risk factors include but are not limited to socio‐economic factors (e.g. education, household crowding and nutrition), environmental factors (e.g. smoke exposure and poor access to health care) and biological factors. Risk mitigation strategies should be delivered in a culturally appropriate manner and targeted to educate both individuals and communities at risk. Improving the morbidity and mortality of respiratory infections in indigenous people requires provision of best practice care and awareness of the scope of the problem by healthcare practitioners, governing bodies and policy makers.     

A chronic disease management programme can reduce days in hospital for patients with chronic obstructive pulmonary disease

BACKGROUND: A steady increase in chronic obstructive pulmonary disease (COPD) admissions was addressed by enhancing primary care to provide intensive chronic disease management. AIM: To compare the effect of a disease management programme, including a COPD management guideline, a patient-specific care plan and collaboration between patients, general practitioners, practice nurses, hospital physicians and nurse specialists with conventional care, on hospital admissions and quality of life. METHODS: One hundred and thirty-five patients with a clinical diagnosis of moderate to severe COPD were identified from hospital admission data and general practice records. General practices were randomized to either conventional care (CON), or the intervention (INT). Pre- and post-study assessment included spirometry, Shuttle Walk Test, Short Form-36, and the Chronic Respiratory Questionnaire (CRQ). Admission data were compared for 12 months prior to and during the trial. RESULTS: For respiratory conditions, mean hospital bed days per patient per year for the INT group were reduced from 2.8 to 1.1, whereas those for the CON group increased from 3.5 to 4.0 (group difference, P = 0.030) The INT group also showed an improvement for two dimensions of the CRQ, fatigue (P = 0.010) and mastery (P = 0.007). CONCLUSIONS: A chronic disease management programme for COPD patients that incorporated a variety of interventions, including pulmonary rehabilitation and implemented by primary care, reduced admissions and hospital bed days. Key elements were patient participation and information sharing among healthcare providers.