Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury

BACKGROUND/OBJECTIVES: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine METHODS: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention. RESULTS: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1. CONCLUSIONS: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.     

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).     

Provider Adherence to Implementation of Clinical Practice Guidelines for Neurogenic Bowel in Adults With Spinal Cord Injury

Abstract

Background/Objectives: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the " Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine

Methods: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1 ), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention.

Results: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1.

Conclusions: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.     

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.     

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.     

A reporting quality evaluation of the clinical practice guidelines for bladder cancer based on the RIGHT checklist

BackgroundThe Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist was developed to improve the reporting quality in clinical practice guidelines (CPGs). CPGs could provide the recommendations for key clinical issues with alternative care options and adherence to them could improve the outcomes. And, high reporting quality CPGs can assist health workers to incorporate the best evidence into the individual practice. There is no evaluation study on the reporting quality of CPGs in bladder cancer (BLCA). This study assessed the reporting quality of CPGs on BLCA and provided new insights for the development of CPGs in this disease.MethodsWe conducted a systematic search in multiple literature databases, including PubMed, Wanfang, China National Knowledge Infrastructure (CNKI) and China Biology Medicine (CBM) as well as the medical associations and websites of guideline development organizations. Relevant CPGs published between January 2017 and December 2021 were identified. Four trained investigators independently screened the extracted documents to include all eligible CPGs and evaluated whether the items in the RIGHT checklist were reported in each CPG. Subsequently, the reporting rate of each CPG and item, as well as the mean reporting rate of each domain in the RIGHT checklist was calculated.ResultsA total of 23 CPGs related to BLCA were finally included, of which, 22 guidelines were written in English and 1 was published in Chinese. The mean reporting rate of the included CPGs was approximately 65%. The reporting rates of the items in each RIGHT domain were 77% for basic information domain, 75% for recommendations domain, 72% for evidence domain, 69% for background domain, 43% for funding and declaration and management of interest domain, 35% for review and quality assurance domain, and 41% for other information domain. The reporting rate was determined as the mean value in Office Excel 2019.ConclusionsThe reporting quality of BLCA CPGs related to the domains of funding and declaration and management of interest domain, review and quality assurance domain, and other information domain is poor and warrants improvement in the future.     

Utilization of incontinence clinical practice guidelines.

Clinical practice guidelines (CPGs) are evidence-based recommendations for best practice and have been developed with the assumption they will be embraced by practitioners; a further assumption is that clinical practice guidelines will improve the delivery of care. In this article, we provide a working definition of evidence-based practice, discuss the strengths and limitations of CPGs, describe the implementation of CPGs in the context of urinary incontinence, and consider the steps that the WOCN has taken to initiate evidence-based practice. Current issues are presented along with initiatives that have resulted in clinical practice guidelines on incontinence from the United States, United Kingdom, and Canada. On the basis of the current literature, it is concluded that clinical practice guidelines can play an important role in WOCN practice and that the implementation of guidelines may improve clinical practice. However, guidelines are only as valid as the evidence on which they are based and may not take into account gender or cultural differences or the effect that comorbid conditions can have on treatment outcomes. Finally, guidelines must follow a comprehensive approach that involves management and staff and includes education, facilitation, evaluation, feedback, and an understanding of change strategies.     

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.     

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.     

Canadian Association of General Surgeons evidence based reviews in surgery. 11. Evidence-based guidelines for children with isolated spleen or liver injury.

Objective: To determine the impact of clinical practice guidelines (CPGs) on the management of trauma to the pediatric spleen and liver. Data sources: The CPGs were formulated by the American Pediatric Surgery Association (APSA) based on evidence from multiple sources including published non-randomized trials, historical controls and expert clinical experience and consensus, along with a retrospective review of 856 children with isolated spleen or liver injuries treated at 32 centres of pediatric surgery from June 1995 to July 1997. CPG implementation: The CPGs were applied prospectively in 312 children treated nonoperatively at 16 centres between 1998 and 2000. Compliance was analyzed for age, gender, the organ injured and its grade by computed tomography. All patients underwent follow-up for 4 months. Outcomes: Hospital stay, follow-up imaging and interval of activity restriction. Main results: Compared with the 832 patients previously studied, the 312 patients who had prospective application of the proposed guidelines had significant reductions in intensive-care-unit (ICU) and hospital stay (both p < 0.0006), follow-up imaging (p < 0.0001) and interval of rest from physical activity (p < 0.05) at each grade of injury. Conclusion: Application of specific CPGs based on injury severity has resulted in conformity in patient management, improved utilization of resources and validation of guideline safety.     

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.     

Understanding factors influencing venous leg ulcer guideline implementation in Australian primary care

The aim of this study was to gain a better understanding of the venous leg ulcer (VLU) management in primary health care settings located in Melbourne metropolitan and rural Victoria, Australia. We explored health professionals' perspective on the use of the Australian and New Zealand Venous Leg Ulcer Clinical Practice Guideline (VLU CPG) to identify the main challenges of VLU CPG uptake in clinical practice. We conducted semi‐structured interviews with 15 general practitioners (GPs) and 20 practice nurses (PNs), including two Aboriginal health nurses. The Theoretical Domains Framework guided data collection and analysis. Data were analysed using a theory‐driven analysis. We found a lack of awareness of the VLU CPGs, which resulted in suboptimal knowledge and limited adherence to evidence‐based recommendations. Environmental factors, such as busy nature of clinical environment and absence of handheld Doppler ultrasound, as well as social and professional identity factors, such as reliance on previous experience and colleague's advice, influenced the uptake of the VLU CPGs in primary care. Findings of this study will inform development of interventions to increase the uptake of the VLU CPG in primary care settings and to reduce the evidence‐practice gap in VLU management by health professionals.     

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.     

Cost of applying the K/DOQI guidelines for bone metabolism and disease to a cohort of chronic hemodialysis patients

Hyperphosphatemia is a common feature of advanced chronic kidney disease (CKD) and is treated routinely with oral calcium-based phosphate binders. In 2003, the National Kidney Foundation Kidney Disease Outcomes and Quality Initiative (K/DOQI) published Clinical Practice Guidelines (CPGs) for the treatment of Bone Metabolism and Disease in CKD. These advocate broad usage of expensive non-calcium-based phosphate binders such as sevelamer. This study was designed to determine the cost of implementation of the K/DOQI CPGs as they pertain to phosphate binding in a large Canadian hemodialysis (HD) unit. Laboratory and medication data for all chronic HD patients at the Ottawa Hospital were reviewed (n=416). Patients meeting each of the relevant K/DOQI guidelines were identified. Where guidelines would recommend a switch to non-calcium binders, equivalent sevelamer doses were estimated. The cost of implementing each guideline was then calculated individually and an estimate total cost of implementing all the guidelines was derived. Overall, 53% (222) patients fulfilled at least one criterion for sevelamer use. The yearly cost of implementation of the K/DOQI guidelines at this center was estimated at 500,605 dollars (American dollars). Given the significant cost, widespread adoption of the K/DOQI CPGs for Bone Metabolism and Disease should await the publication of compelling data demonstrating significant improved outcomes in patients treated with sevelamer.     

Comparison of Guidelines for the Use of Interleukin-17 Inhibitors for Psoriasis in the United States,Britain, and Europe: A Critical Appraisal and Comprehensive Review

BackgroundInterleukin (IL)-17 inhibitors are a newer class of biologic used to treat patients with moderate-to-severe plaque psoriasis and psoriatic arthritis.ObjectiveWe compared evidence-based clinical practice guidelines (CPGs) from leading dermatological organizations for the use of IL-17 inhibitors in psoriasis.MethodsGuidelines from the Joint American Academy of Dermatology-National Psoriasis Foundation (AAD-NFP) Guidelines, British Association of Dermatologists guidelines (BAD), and European S3 group (ES3) were all reviewed and compared.ResultsThis analysis revealed significant overlap in the recommendations made by experts from each CPG. However, our review highlights differences in routine laboratory recommendations and the relative and absolute contraindications to use with IL-17 inhibitors.ConclusionIL-17 inhibitors are an effective treatment option for psoriasis. This analysis and review of guidelines for IL-17 inhibitor use highlights the consensus in treatment protocols and areas of disagreement between CPGs.     

麻醉专业医务人员临床实践指南实施现状调查与研究

目的： 调查甘肃省麻醉专业医务人员对临床实践指南的认知、需求和使用情况,探究指南在实施过程中的促进和阻碍因素。
方法： 对麻醉专业医务人员对临床实践指南的认知、需求和使用情况以及指南实施过程中的促进和阻碍因素开展问卷调查,并对结果进行统计分析。
结果： 共发放问卷339份,均为有效问卷。96.8%的被调查者知晓指南,且多数被调查者（86.4%）在临床实践中遇到问题时会查阅指南。指南使用缺乏便捷性（70.2%）、缺乏指南获取途径（64.3%）或缺乏指南访问权限（56.9%）、缺乏培训（31.3%）、语言障碍（21.5%）是阻碍指南使用最主要的因素。多种形式辅助指南使用、开放指南获取权限被认为是促进指南实施的重要方式。
结论： 甘肃省麻醉专业医务人员对指南的知晓率和依从性均较好。目前国内使用指南的主要障碍因素来自于指南本身或指南获取困难。建议未来建立国家指南数据库、提供指南实施工具、增强对医务人员的培训,将有利于指南的推广和应用。     

Implementing nursing practice guidelines: a complex undertaking.

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.     

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.     

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.