The challenges of automating a real-time clinical practice guideline.

OBJECTIVE: To elucidate the types of problems encountered during implementation of a World Wide Web-based clinical practice guideline to manage hyperbilirubinemia in newborn infants. DESIGN: Formative assessment of an automated clinical-practice guideline in a large-scale implementation. SETTING: Primary-care clinics and offices, inpatient clinics, and emergency department affiliated with an academic children's hospital. PARTICIPANTS: General pediatricians, neonatologists, pediatric nurses, and computer scientists. RESULTS: Existing guidelines for hyperbilirubinemia management could not be translated directly into web pages. Modifications of the original guidelines were required to represent the clinical intent of the guidelines accurately. In addition, the automated guideline was augmented to incorporate a mechanism for generating clinical encounter forms in order for the system to be accepted into the clinical work flow. Other clinical considerations that influenced the final form of the automated guideline included limitations of computer resources and time constraints during patient encounters. CONCLUSIONS: Many existing guidelines are not amenable to straightforward implementation in automated systems. Strategies to increase the efficacy of the automated guidelines included guideline modifications, as well as careful consideration of the flow of clinical work. Repeated cycles of development and pilot testing are needed to design methods to accommodate the constraints imposed by clinical use.     

Effect of a clinical practice guideline on physician compliance.

OBJECTIVES: To evaluate the effect of a clinical practice guideline for cesarean section due to dystocia on physician compliance, pregnancy outcome, and cesarean delivery rates, and to identify factors associated with physician non-compliance. DESIGN: A cross-sectional study. SETTING: A university hospital, Southern Thailand. STUDY PARTICIPANTS: All 719 medical records of women undergoing a cesarean section due to dystocia (failure to progress; cephalopelvic disproportion) before and after implementation of the guideline, from 1 January 1998 to 31 December 2000. INTERVENTION: A clinical practice guideline for cesarean section due to dystocia was implemented on 1 June 1999. MAIN OUTCOME MEASURES: Physician compliance, pregnancy outcomes, and cesarean section rates. Multivariate logistic regression was used to identify factors associated with physician non-compliance. Independent variables consisted of maternal age, height, parity, type of service, and birthweight. RESULTS: Physician compliance with the guideline was 89.2%. Maternal complications were less in the period after implementation of the guideline. Fetal outcomes were not different between the two periods. The cesarean section rates due to dystocia decreased after implementation of the guideline, from 10.7% in 1999 to 8.6% in 2002. Private practice, maternal short stature, and birthweight > or = 3500 g were significant predictors of physician non-compliance. CONCLUSIONS: Physician compliance was high. A clinical practice guideline can reduce the cesarean section rates due to dystocia without increasing adverse outcomes. Physician non-compliance was more common in women with well known risk for cephalopelvic disproportion, and private practice.     

健康体检颈动脉超声临床应用的评价

目的:讨论健康体检中颈动脉超声表现以及对其颈动脉粥样硬化、斑块形成的诊断意义.方法:对353例行超声检查双侧颈总动脉,颈内动脉管腔、内壁并用彩色多普勒血流情况.结果:双侧顼动脉均显示正常234例,余均有单侧或双侧不同程度的内膜改变.结论:高频超声及CDFI的应用,为临床能及早检测出颈动脉粥样硬化的发生、发展、斑块形成并确定其性质及位置,其方法灵活、无损害.     

Economic benefit from clinical practice guideline compliance in stroke patient management

BACKGROUND AND PURPOSE: In a previous study we showed that compliance with evidence-based guidelines improves the health outcome of stroke patients in terms of both survival and residual disability. In this analysis, we shall investigate the impact of such guidelines on healthcare costs during the acute/sub-acute hospitalisation phase. METHOD: we considered the direct costs from the hospital's point of view, where funding is provided by the National Healthcare System. We did not consider production loss or intangible costs related to the decreased quality of life. Data was collected on both costs and guideline compliance prospectively, and the relationship between them was studied through a multivariate statistical model. RESULTS: Patients treated according to guidelines result in lower costs; on average they have a shorter length of stay in hospital (10.8 versus 12.9 days), leading to a significant difference in the consumption of hospital resources. On a level of statistical analysis, guideline compliance is a significant independent indicator of cost, together with the patient's initial disability and neurological deficit.     

Adopting health behavior change theory throughout the clinical practice guideline process

Adopting a theoretical framework throughout the clinical practice guideline (CPG) process (development, dissemination, implementation, and evaluation) can be useful in systematically identifying, addressing, and explaining behavioral influences impacting CPG uptake and effectiveness. This article argues that using a theoretical framework should increase the utility and probably the implementation of a CPG. A hypothetical scenario is provided using the theory of planned behavior (TPB) to aid in our explanation. While other theories may be viable, the TPB is chosen because it accounts for a wide spectrum of behavioral factors known to influence physician behavior, and because its flexibility allows it to be used for different populations (e.g., specialists), behaviors, and contexts (e.g., hospital, private clinic). In addition, evidence has indicated that the TPB can influence physician behavior. Empirical research examining whether CPG utility can be significantly improved by appropriately selecting and implementing theory throughout the CPG process is warranted.     

The practice guideline 'vitiligo'

A working group of the Dutch Society for Dermatology and Venereology (NVDV), in collaboration with the Dutch Institute for Health Care Improvement (CBO), has written an evidence-based guideline for the treatment of vitiligo. A distinction is made between generalised or non-segmental vitiligo and localised, including segmental, vitiligo. In patients with generalised vitiligo phototherapy (especially narrow-band ultraviolet B) is the treatment of first choice while in localised vitiligo, this is surgery, particularly autologous skin transplantation (Thiersch grafting, the use of blister epidermis and cell suspensions). However, on the basis of the results of the treatments proposed in the guideline, the working group cannot advise dermatologists to propose a particular treatment to each vitiligo patient they see. On the other hand, the working group is of the opinion that, based on a proper medical examination and an assessment of the disease burden, well-considered advice--and in some cases therapy--should be given to every vitiligo patient who requests it. The benefit of the guideline is that it provides clarity to dermatologists, general practitioners and patients regarding the therapeutic possibilities and limitations.     

A comparison of two comorbidity instruments in arthritis

Comorbidity (CM) is a powerful predictor of health outcome and cost, as well as an important confounder in many epidemiologic studies. However, choosing the most appropriate CM measurement instrument is difficult because comparative data on how the available instruments perform in various disease settings are limited. We collected CM data (from the complete medical records) for two population-based prevalence cohorts with rheumatoid arthritis (RA) and osteoarthritis (OA) and a comparison cohort without arthritis (NA), using two different CM instruments: the Charlson CM index (Charl), which is based on 17 diagnoses each weighted by mortality risk, and the Index of Coexistent Diseases (ICED), which estimates the severity and frequency of 14 comorbid conditions and provides an assessment of the impairment or disability caused by each. Cox proportional hazards modeling was used to assess the impact of the two types of comorbidity scores (Charl and ICED) on survival after prevalence (index) date, adjusting for the age, sex, and disease status. There were 450, 441, and 889 individuals in the RA, OA, and NA groups, respectively, with a mean follow-up period of 10.6 years. During the follow-up, 293, 307, and 546 deaths occurred in the RA, OA, and NA groups, respectively. The mean age and percent females were: 63.3 years, 74%; 70.7 years, 74%; and 67.5 years, 75% for the RA, OA, and NA groups, respectively. Comorbidity was highest in RA, intermediate in OA, and lowest in NA by both Charl and ICED. Cox proportional hazards modeling demonstrated that both Charl and ICED were highly statistically significant predictors of mortality (P < 0.0001) after adjusting for age, sex, and disease state (RA, OA, or NA) and that ICED remained highly significant as a predictor of mortality, even after adjusting for Charl. We conclude that estimating CM from medical records using ICED, an instrument that incorporates an assessment of impairment and disability, is feasible and that such as assessment provides information that independently predicts mortality, even after adjusting for the results of traditional diagnosis-based CM measures, such as Charl.     

ActCPG framework to learn about information user requirements of a clinical practice guideline

A clinical practice guideline is a knowledge uptake instrument that supports evidence-based decision making by clinicians. It represents a model of a clinical process that describes the sequence of actions, decisions and their outcomes, and the interface with other processes beyond the scope of a guideline. In domains outside healthcare, the computerization of business processes via information systems follows a very rigorous design labeled as the system development life cycle. Our argument is that the computerization of a clinical practice guideline is the equivalent of building an information system for a clinical process and therefore should follow a similarly rigorous design method. One of the first and also one of the most important steps in the system development life cycle is learning about user information requirements. This paper is about a user requirements elicitation and definition process customized to clinical practice guideline. We propose the novel ActCPG conceptual framework for elicitation of basic user requirements for developing computer-interpreted guidelines. This framework relies on Activity Theory to structure and decompose information coming from a clinical practice guideline and associated narrative. We illustrate operation of the ActCPG framework with an example of a practice guideline for a management of clinically obese children enrolled in the Children's Hospital of Eastern Ontario obesity program.     

The practice guideline 'atopic dermatitis'

Since clear evidence is lacking that avoidance of exposure to inhalation or food allergens will have a favourable effect on the course of atopic dermatitis, allergological screening should be restricted to patients having acute allergic symptoms. Topical corticosteroids are the treatment of choice. The working group recommends starting with a class 2-3 corticosteroid daily followed by intermittent maintenance therapy with a corticosteroid of the same class or daily administration of a class 1 corticosteroid. When used in this way, corticosteroids are safe as far as local and systemic side effects are concerned; patients with severe atopic dermatitis have decreased serum-cortisol levels but this is due to the illness and not the corticosteroid. Serum-cortisol levels will usually return to normal following topical steroid therapy. Topical calcineurin inhibitors are a good second-line alternative for patients in whom corticosteroids are insufficiently effective or produce side effects. During such treatment, the skin should be protected against ultraviolet light. Non-sedating antihistamines have no place in the treatment of atopic dermatitis. Cyclosporin is the agent of choice for the systemic treatment of severe atopic dermatitis. The attending physician should also pay attention to psychosocial factors, since severe eczema in children, their parents and adults has a serious impact on the quality of life. Patients with severe atopic dermatitis should be discouraged from working in a wet environment. Patients with moderately active atopic dermatitis without eczema of the hands should avoid exposure to water and other irritating factors.     

A framework for assessing Health Economic Evaluation (HEE) quality appraisal instruments

ABSTRACT: BACKGROUND: Health economic evaluations support the health care decision-making process by providing information on costs and consequences of health interventions. The quality of such studies is assessed by health economic evaluation (HEE) quality appraisal instruments. At present, there is no instrument for measuring and improving the quality of such HEE quality appraisal instruments. Therefore, the objectives of this study are to establish a framework for assessing the quality of HEE quality appraisal instruments to support and improve their quality, and to apply this framework to those HEE quality appraisal instruments which have been subject to more scrutiny than others, in order to test the framework and to demonstrate the shortcomings of existing HEE quality appraisal instruments. METHODS: To develop the quality assessment framework for HEE quality appraisal instruments, the experiences of using appraisal tools for clinical guidelines are used. Based on a deductive iterative process, clinical guideline appraisal instruments identified through literature search are reviewed, consolidated, and adapted to produce the final quality assessment framework for HEE quality appraisal instruments. RESULTS: The final quality assessment framework for HEE quality appraisal instruments consists of 36 items organized within 7 dimensions, each of which captures a specific domain of quality. Applying the quality assessment framework to four existing HEE quality appraisal instruments, it is found that these four quality appraisal instruments are of variable quality. CONCLUSIONS: The framework described in this study should be regarded as a starting point for appraising the quality of HEE quality appraisal instruments. This framework can be used by HEE quality appraisal instrument producers to support and improve the quality and acceptance of existing and future HEE quality appraisal instruments. By applying this framework, users of HEE quality appraisal instruments can become aware of methodological deficiencies inherent in existing HEE quality appraisal instruments. These shortcomings of existing HEE quality appraisal instruments are illustrated by the pilot test.     

AuSPEN clinical practice guideline for home parenteral nutrition patients in Australia and New Zealand

OBJECTIVE: Evidence based guidelines for home parenteral nutrition (HPN) were commissioned by the Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) and developed by a multidisciplinary group. The guidelines make recommendations in four domains: patient selection, patient training, formulation and monitoring regimens, and preventing and managing complications. METHODS: The Appraisal of Guidelines Research and Evaluation guideline process was used to focus questions and identify evidence by systematic literature reviews of meta-analyses and randomized control trials in the Cochrane Library, Medline, Embase, and Cinahl to mid-2007. Where no randomized control trial evidence was found, the search was broadened to observational studies and expert opinion from related national and international guidelines as assessed by a validated appraisal process. RESULTS: Selection of patients must assess individual risk/benefit and medical ethics. Patient training should be undertaken within a structured framework. Access devices should be selected for lowest risk of complications, including occlusion, sepsis, and breakage and be managed by early diagnosis and treatment. HPN should be formulated according to individual patient requirements by professionals with relevant skills and training. Pumps and ancillary products should conform to quality standards. Other intravenous medications may be prescribed provided these are reviewed for compatibility and effects on metabolic status. CONCLUSION: Overall there is a lack of randomized control trials to provide high-quality evidence-based guidance but graded recommendations can be made. Multidisciplinary teams in centers with HPN management expertise are required for optimal care. This guideline should improve outcomes and quality of life for HPN patients in Australia and New Zealand.