American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate‐to‐high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.     

Review of the NICE guidelines for multiple myeloma

In February 2016, the National Institute for Health and Care Excellence (NICE) published guidelines on multiple myeloma. NICE have published numerous guidelines relating to haematology, but this was the first guideline focusing on a single haematological malignancy. The purpose of this review was to highlight the recommendations made in the guideline and the implications for the management of patients in the UK and also internationally. In addition, we review the NICE process and highlight issues around current guideline development.     

Routine screening during prenatal care: a systematic comparison of the do not do recommendations of the National Institute for Health and Care Excellence with North American evidence-based guidelines

BackgroundPopulation-wide screening measures during pregnancy might cause more harm than good in terms of health benefits. Therefore, the National Institute for Health and Care Excellence (NICE) formulated 14 do not do recommendations relating to 18 screening measures during pregnancy in the antenatal care guideline published in 2008. We aimed to compare do not do recommendations with evidence-based guidelines from developed countries other than the UK.MethodsWe systematically searched for corresponding recommendations in the guideline databases Guidelines International Network and National Guideline Clearinghouse applying a broad search strategy by using the keyword “screening”. Additionally, we searched websites of guideline development groups using disease-specific keywords. We included evidence-based guidelines published in English from Jan 1, 2007, to Dec 31, 2012, that dealt with routine screening during pregnancy. Guidelines had to fulfil predefined methodological quality criteria (ie, they needed to be based on a systematic literature search in at least two databases and needed to formulate recommendations explicitly linked to the underlying evidence).FindingsWe identified 13 relevant clinical practice guidelines from the USA and Canada covering 13 out of 18 do not do recommendations. The systematic guideline comparison showed that for seven screening measures recommendations were consistent. Differences across countries were observed for six screening measures: two of these screening measures not routinely recommended by NICE are explicitly recommended by North American clinical practice guidelines (chlamydia and streptococcus group B). Four of the six screening recommendations differed in terms of screening methods or the timing. For the remaining five of the 18 screening measures, we did not identify recommendations from the USA or Canada.InterpretationSeven of 18 prenatal screening recommendations from North American guidelines are in line with NICE do not do recommendations. The differences in six screening recommendations might be explained by specific contextual factors related to national health-care systems such as organisational aspects or disease prevalence. The comparison of international evidence-based guidelines can facilitate the re-evaluation of national public health programmes and can be a starting point for the appraisal of interventions in the national context.FundingThe Ludwig Boltzmann Institute for Health Technology Assessment is funded by national research funds (The Ludwig Boltzmann Gesellschaft) and by partner institutions (eg, the Federation of Austrian Social Insurance Institutions and the Austrian Ministry of Health). This in-depth comparison of screening recommendations was carried out within a larger project aiming at the reorientation of the Austrian parent-child preventive care programme on behalf of the Austrian Ministry of Health.     

Diagnosis and management of pancreatic cancer in adults: A summary of guidelines from the UK National Institute for Health and Care Excellence

To enable standardisation of care of pancreatic cancer patients and facilitate improvement in outcome, the United Kingdom's National Institute for Health and Care Excellence (NICE) developed a clinical guideline for the diagnosis and management of pancreatic cancer in adults. Systematic literature searches, systematic review and meta-analyses were undertaken. Recommendations were drafted on the basis of the group's interpretation of the best available evidence of clinical and cost effectiveness. There was patient involvement and public consultation. Recommendations were made on: diagnosis; staging; monitoring of inherited high risk; psychological support; pain; nutrition management; and the specific management of people with resectable-, borderline-resectable- and unresectable-pancreatic cancer. The guideline committee also made recommendations for future research into neoadjuvant therapy, cachexia interventions, minimally invasive pancreatectomy, pain management and psychological support needs. These NICE guidelines aim to promote best current practice and support and stimulate research and innovation in pancreatic cancer.     

Clinical practice guidelines for the management of delirium in older people in Australia

Delirium is a common and serious condition which is often overlooked or misdiagnosed in older people. In 2006, the first set of national clinical practice guidelines for the management of delirium in older people were developed. This paper provides an abbreviated version of the guideline document which includes recommendations for the detection of delirium (diagnosis and screening), assessment and prediction of risk factors for delirium, prevention of delirium and interventions to manage people with delirium. The guidelines reflect the available evidence base and highlight the limited high level research in delirium care, particularly in the areas of symptom management and screening for delirium.     

Secondary prevention for patients following a myocardial infarction: summary of NICE guidance

Mortality from coronary heart disease has been falling in the UK since the 1970s, but remains higher than in most other Western countries. Most patients receive some treatment for secondary prevention after myocardial infarction, but not all patients are offered the most effective secondary prevention package. The recently published NICE guideline for secondary prevention in patients after myocardial infarction, summarised in this article, makes clear recommendations for management of patients after myocardial infarction, based on best available evidence. The guidelines update the 2001 NICE guideline, and have expanded and emphasised the recommendations for physical activity, dietary and other lifestyle changes, and cardiac rehabilitation, and updated the recommendations for drug therapy.     

中国2型糖尿病防治指南（2013年版）更新要点的解读

近日,由中华医学会糖尿病学分会制定的《中国2型糖尿病防治指南（2013年版）》（下称“新版指南”）正式发布.该指南是继2010年版指南之后的新版指南,其内容强调需符合我国国情和疾病变迁特征,反映了我国糖尿病相关研究和防治策略的进展.新版指南在汇集国内证据和参考国外证据的基础上编撰而成,并对前一版指南的内容进行了丰富,更加关注T2DM防治的临床和应用.本文着重从T2DM的更新要点进行解读,并与国外指南及循证证据进行对比.     

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.     

Guidelines International Network: toward international standards for clinical practice guidelines

Guideline development processes vary substantially, and many guidelines do not meet basic quality criteria. Standards for guideline development can help organizations ensure that recommendations are evidence-based and can help users identify high-quality guidelines. Such organizations as the U.S. Institute of Medicine and the United Kingdom's National Institute for Health and Clinical Excellence have developed recommendations to define trustworthy guidelines within their locales. Many groups charged with guideline development find the lengthy list of standards developed by such organizations to be aspirational but infeasible to follow in entirety. Founded in 2002, the Guidelines International Network (G-I-N) is a network of guideline developers that includes 93 organizations and 89 individual members representing 46 countries. The G-I-N board of trustees recognized the importance of guideline development processes that are both rigorous and feasible even for modestly funded groups to implement and initiated an effort toward consensus about minimum standards for high-quality guidelines. In contrast to other existing standards for guideline development at national or local levels, the key components proposed by G-I-N will represent the consensus of an international, multidisciplinary group of active guideline developers. This article presents G-I-N's proposed set of key components for guideline development. These key components address panel composition, decision-making process, conflicts of interest, guideline objective, development methods, evidence review, basis of recommendations, ratings of evidence and recommendations, guideline review, updating processes, and funding. It is hoped that this article promotes discussion and eventual agreement on a set of international standards for guideline development.     

National Clinical Guideline Centre cost-effectiveness assessment for the National Institute for Health and Clinical Excellence

The National Clinical Guideline Centre (NCGC) develops evidence-based clinical guidelines on behalf of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom. The U.K. Department of Health has commissioned NICE to make recommendations on the basis of both clinical effectiveness and cost-effectiveness. This article describes how cost-effectiveness is evaluated and accounted for in NCGC guidelines. Six recent case studies are presented, in which consideration of cost-effectiveness has informed recommendations in various ways for clinical guidelines on alcohol use disorders, chronic obstructive pulmonary disease, glaucoma, lower urinary tract symptoms, non-ST-segment elevation myocardial infarction and unstable angina, and venous thromboembolism prophylaxis. Some of the challenges faced in trying to account for cost-effectiveness in clinical guidelines are outlined, as well as some of the difficulties in adapting cost-effectiveness guidelines for other settings.     

Sustainability and scalability of the hospital elder life program at a community hospital

The Hospital Elder Life Program (HELP), an effective intervention to prevent delirium in older hospitalized adults, has been successfully replicated in a community teaching hospital as a quality improvement project. This article reports on successfully sustaining the program over 7 years and expanding its scale from one to six inpatient units at the same hospital. The program currently serves more than 7,000 older patients annually and is accepted as the standard of care throughout the hospital. Innovations that enhanced scalability and widespread implementation included ensuring dedicated staffing for the program, local adaptations to streamline protocols, continuous recruitment of volunteers, and more-efficient data collection. Outcomes include a lower rate of incident delirium; shorter length of stay (LOS); greater satisfaction of patients, families, and nursing staff; and significantly lower costs for the hospital. The financial return of the program, estimated at more than $7.3 million per year during 2008, comprises cost savings from delirium prevention and revenue generated from freeing up hospital beds (shorter LOS of HELP patients with and without delirium). Delirium poses a major challenge for hospital quality of care, patient safety, Medicare no-pay conditions, and costs of hospital care for older persons. Faced with rising numbers of elderly patients, hospitals can use HELP to improve the quality and cost-effectiveness of care.     

Worldwide guidelines for chronic obstructive pulmonary disease: a comparison of diagnosis and treatment recommendations

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is a leading cause of worldwide burden of disease, but is underdiagnosed and undertreated. We performed a systematic review of worldwide COPD clinical practice guidelines (CPG) to determine the degree of international consensus on major guideline recommendations. METHODS: The COPD CPG were identified from the medical literature and through contact with respiratory experts and organizations. An abstraction form was developed to collect information related to COPD diagnosis and management. RESULTS: Locally developed COPD CPG are based upon expert consensus, but do not explicitly rate the strength of the evidence for recommendations. The detail and clarity of the 41 CPG varied regarding the diagnosis and management of COPD. Key differences included the lung function parameters that define a diagnosis and severity assignment of COPD. The use of anticholinergics, alone or in combination, was listed as a consideration for first-line therapy for persistent COPD in all 41 CPG. There was consensus regarding reserving corticosteroids for selected patients. CONCLUSIONS: There is variation and ambiguity within COPD CPG regarding specific recommendations that can be applied by clinicians at a patient-specific level. The variation in CPG for COPD may contribute to the underdiagnosis and suboptimal treatment of COPD. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop report may help resolve some of the variation surrounding COPD diagnosis and treatment. However, local guideline implementation efforts must assist physicians in applying guideline recommendations to support patient-specific management.     

Hospital Elder Life Program in the Real World: The Many Uses of the Hospital Elder Life Program Website

The Hospital Elder Life Program (HELP) can prevent delirium, a common condition in older hospitalized adults associated with substantial morbidity, mortality, and healthcare costs. In 2011, HELP transitioned to a web‐based dissemination model to provide accessible resources, including implementation materials; information for healthcare professionals, patients, and families; and a searchable reference database. It was hypothesized that, although intended to assist sites to establish HELP, the resources that the HELP website offer might have broader applications. An e‐mail was sent to all HELP website registrants from September 10, 2012, to March 15, 2013, requesting participation in an online survey to examine uses of the resources on the website and to evaluate knowledge diffusion related to these resources. Of 102 responding sites, 73 (72%) completed the survey. Thirty‐nine (53%) had implemented and maintained an active HELP model. Twenty‐six (35%) sites had used the HELP website resources to plan for implementation of the HELP model and 35 (50%) sites to implement and support the program during and after launch. Sites also used the resources for the development of non‐HELP delirium prevention programs and guidelines. Forty‐five sites (61%) used the website resources for educational purposes, targeting healthcare professionals, patients, families, or volunteers. The results demonstrated that HELP resources were used for implementation of HELP and other delirium prevention programs and were also disseminated broadly in innovative educational efforts across the professional and lay communities.     

Canadian Society of Clinical Chemists Harmonized Clinical Laboratory Lipid Reporting Recommendations on the Basis of the 2021 Canadian Cardiovascular Society Lipid Guidelines

There is limited guidance on laboratory reporting and interpretation of lipids and lipoproteins used in cardiovascular risk stratification. This contributes to inconsistencies in lipid reporting across clinical laboratories. Recently, the Canadian Cardiovascular Society (CCS) published the 2021 CCS guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. A subcommittee of the Working Group on Reference Interval Harmonization of the Canadian Society of Clinical Chemists has developed harmonized lipid reporting recommendations that are aligned with the 2021 CCS guidelines, to improve the standardization of lipid assessment and clinical decision-making. The proposed harmonized lipid reporting recommendations were critically reviewed by a broad range of laboratory and clinical experts across Canada. Feedback from approximately 30 expert reviewers was reviewed by the Working Group on Reference Interval Harmonization lipid subcommittee, and consensus decisions were incorporated into the 2021 harmonized lipid reporting recommendations. In this position statement, we provide 6 recommendations for laboratory reporting of lipid parameters. These recommendations include implementing the new National Institutes of Health equation to replace the Friedewald equation for calculating low-density lipoprotein cholesterol, offering lipoprotein (a), either as an in-house or send-out test, and using assays that report lipoprotein (a) in molar units (nmol/L). We also developed a harmonized lipid reporting format with interpretive comments that includes flagging results based on screening patients using treatment decision thresholds in a primary prevention setting. Overall, harmonized lipid reporting will help bridge the gap between clinical guideline recommendations and clinical laboratory reporting and interpretation, and will improve cardiovascular risk assessment across Canada.     

Interdisciplinary S2k guideline on the diagnosis and treatment of cervical carcinoma

The first treatment recommendations on the diagnosis and treatment of cervical carcinoma were published by experts in the DKG’s Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) in 1999 (S1 guideline). The purpose of the guidelines is to explicitly present current knowledge regarding specific medical care problems, evaluate them from methodological and clinical viewpoints, clarify contradictory positions, and define the current procedure of choice after weighing up advantages and disadvantages. It is therefore necessary for guidelines to have their validity continually checked and updated. Interdisciplinary collaboration is an indispensable principle for high-quality care in the field of oncology. This should be borne in mind when establishing recommendations for care. The first updating of the guideline was accordingly carried out in May 2004, with a structured consensus process being carried out by an interdisciplinary group of experts representative of the group of users (S2 guideline). The S2 guideline “Diagnosis and Treatment of Cervical Carcinoma” has now been revised again between October 2007 and January 2008 by the AGO’s Uterus Commission.     

Standards for the development and methodology of the 2019 International Working Group on the Diabetic Foot guidelines

Diabetic foot disease is a source of major patient suffering and societal costs. Investing in evidence‐based international guidelines on diabetic foot disease is likely among the most cost‐effective forms of health care expenditure, provided the guidelines are outcome focused, evidence based, and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2019 updates are based on formulating relevant clinical questions and outcomes, rigorous systematic reviews of the literature, and recommendations that are specific, and unambiguous along with their transparent rationale, all using the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework. We herein describe the development of the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease, which consists of six chapters, each prepared by a separate working group of international experts. These documents provide guidelines related to diabetic foot disease on prevention; offloading; peripheral artery disease; infection; wound healing interventions; and classification of diabetic foot ulcers. Based on these six chapters, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. We believe that adoption and implementation of the 2019 IWGDF guidelines by health care providers, public health agencies, and policymakers will result in improved prevention and management of diabetic foot disease and a subsequent worldwide reduction in the patient and societal burden this disease causes.     

Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention,Diagnosis, Risk Assessment,and Treatment of Hypertension in Adults and Children

Hypertension Canada’s 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.     

Two Decades of Overuse and Underuse of Interventions for Primary and Secondary Prevention of Cardiovascular Diseases: A Systematic Review

Quality use of anti-hypertensive and cholesterol-lowering medications is crucial for successful cardiovascular disease management. This systematic review aimed to estimate levels of over and underuse of services for primary and secondary prevention of cardiovascular diseases from 2000 to 2020: overprescribing/underprescribing, overtesting/undertesting and overutilization/ underutilization of procedures compared to clinical practice guideline recommendations. Thirteen studies from USA, Europe, Asia and Australia were included. Wide practice variation was identified. Six studies reported overuse (eg, perioperative cardiac consultations, anti-hypertensive overprescribing for normotensive or pre-hypertensive people); and ten studies reported underuse (eg, under-prescribing of statins when indicated and under-screening for familial hypercholesterolemia). Lifestyle recommendations for cardiovascular disease prevention were largely underused. In summary, lack of adherence to published guidelines was prevalent over the past 2 decades for both primary and secondary prevention across settings. Further investigation of potentially justifiable deviations from guidelines are warranted to verify the estimates and identify points for intervention.     

The use of plain radiography in diagnosing osteoarthritis: A systematic review and time trend analysis

Introduction

The National Institute for Health and Care Excellence (NICE) suggest there is no role for routine radiography in the diagnosis of osteoarthritis (OA). It is not known how consistent this recommendation is across international guidelines, or the impact of UK guidance on domestic OA X-ray request rates.

Methods

A systematic search identified guideline recommendations on the role of radiography in OA diagnosis. Full texts underwent dual screening and appraisal using the AGREE II tool. A narrative synthesis was performed. Consultation data were extracted from a UK primary care database: the Consultations in Primary Care Archives (CiPCA). The annual proportion of X-ray requests per 100 OA consulters from 2000 to 2012 were calculated. Joinpoint regression analysis examined if there were changes in the trend of X-ray request rates and compared these with the publication dates of UK guidelines.

Results

Eighteen evidence-based OA guidelines were included in the review. Eleven recommended a clinical diagnosis of OA without radiographic confirmation. Seven recommended routine radiography; these guidelines were predominantly for radiologists. A mean of 17.3 X-rays per 100 patients were requested in patients consulting for OA per year between 2000 and 2012. A statistically significant reduction in X-ray request rates was seen in 2003.

Conclusion

Recommendations on the role of radiography in OA vary between medical specialty and countries. UK guidelines appear to have had a limited impact on X-ray request rates in OA.