Development of a South African integrated syndromic respiratory disease guideline for primary care

AIMS: The Practical Approach to Lung Health in South Africa (PALSA) initiative aimed to develop an integrated symptom- and sign-based (syndromic) respiratory disease guideline for nurse care practitioners working in primary care in a developing country. METHODS: A multidisciplinary team developed the guideline after reviewing local barriers to respiratory health care provision, relevant health care policies, existing respiratory guidelines, and literature. Guideline drafts were evaluated by means of focus group discussions. Existing evidence-based guideline development methodologies were tailored for development of the guideline. RESULTS: A locally-applicable guideline based on syndromic diagnostic algorithms was developed for the management of patients 15 years and older who presented to primary care facilities with cough or difficulty breathing. CONCLUSIONS: PALSA has developed a guideline that integrates and presents diagnostic and management recommendations for priority respiratory diseases in adults using a symptom- and sign-based algorithmic guideline for nurses in developing countries.     

Disease‐specific knowledge and clinical skills required by community‐based physiotherapists to co‐manage patients with rheumatoid arthritis

Objective

While strong evidence supports the role of physiotherapy in the co‐management of patients with rheumatoid arthritis (RA), it remains unclear what constitutes the essential disease‐specific knowledge and clinical skills required by community‐based physiotherapists to effectively and safely deliver recommended care. This study aimed to identify essential disease‐specific knowledge and skills, link these with evidence from clinical guidelines, and broadly determine the professional development (PD) needs and confidence related to the management of RA among physiotherapists.

Methods

An international Delphi panel of rheumatologists, physiotherapists, and consumers (n = 27) identified essential disease‐specific knowledge and clinical skills over 3 rounds. Physiotherapy‐relevant recommendations from high‐quality, contemporary clinical guidelines were linked to Delphi responses. Finally, an e‐survey of PD needs among registered physiotherapists (n = 285) was undertaken.

Results

Overarching themes identified by the Delphi panel across the RA disease stages included the need for excellent communication, the importance of a multidisciplinary team and early referral, adoption of chronic disease management principles, and disease monitoring. Of the essential Delphi themes, 86.7% aligned with clinical guideline recommendations. Up to 77.5% of physiotherapists reported not being confident in managing patients with RA. Across the range of essential knowledge and skills themes, 45.1–93.5% and 71.1–95.2% of respondents, respectively, indicated they would benefit from or definitely need PD.

Conclusion

To effectively manage RA, community‐based physiotherapists require excellent communication skills and disease‐specific knowledge, including understanding the role of the multidisciplinary team and the principles of early referral, chronic disease management, and monitoring. Physiotherapists identified a need for PD to develop these skills.     

Consensus recommendations on managing the selected comorbidities including cardiovascular disease,osteoporosis, and interstitial lung disease in rheumatoid arthritis

Background:Rheumatoid arthritis (RA)-related comorbidities, including cardiovascular disease (CVD), osteoporosis (OP), and interstitial lung disease (ILD), are sub-optimally managed. RA-related comorbidities affect disease control and lead to impairment in quality of life. We aimed to develop consensus recommendations for managing RA-related comorbidities.Methods:The consensus statements were formulated based on emerging evidence during a face-to-face meeting of Taiwan rheumatology experts and modified through three-round Delphi exercises. The quality of evidence and strength of recommendation of each statement were graded after a literature review, followed by voting for agreement. Through a review of English-language literature, we focused on the existing evidence of management of RA-related comorbidities.Results:Based on experts’ consensus, eleven recommendations were developed. CVD risk should be assessed in patients at RA diagnosis, once every 5 years, and at changes in DMARDs therapy. Considering the detrimental effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids on CVD risks, we recommend using the lowest possible dose of corticosteroids and prescribing NSAIDs cautiously. The OP/fragility fracture risk assessment includes dual-energy X-ray absorptiometry and fracture risk assessment (FRAX) in RA. The FRAX-based approach with intervention threshold is a useful strategy for managing OP. RA-ILD assessment includes risk factors, pulmonary function tests, HRCT imaging and a multidisciplinary decision approach to determine RA-ILD severity. A treat-to-target strategy would limit RA-related comorbidities.Conclusions:These consensus statements emphasize that adequate control of disease activity and the risk factors are needed for managing RA-related comorbidities, and may provide useful recommendations for rheumatologists on managing RA-related comorbidities.     

EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE: To formulate EULAR recommendations for the management of early arthritis. METHODS: In accordance with EULAR's "standardised operating procedures", the task force pursued an evidence based approach and an approach based on expert opinion. A steering group comprised of 14 rheumatologists representing 10 European countries. The group defined the focus of the process, the target population, and formulated an operational definition of "management". Each participant was invited to propose issues of interest regarding the management of early arthritis or early rheumatoid arthritis. Fifteen issues for further research were selected by use of a modified Delphi technique. A systematic literature search was carried out. Evidence was categorised according to usual guidelines. A set of draft recommendations was proposed on the basis of the research questions and the results of the literature search.. The strength of the recommendations was based on the category of evidence and expert opinion. RESULTS: 15 research questions, covering the entire spectrum of "management of early arthritis", were formulated for further research; and 284 studies were identified and evaluated. Twelve recommendations for the management of early arthritis were selected and presented with short sentences. The selected statements included recognition of arthritis, referral, diagnosis, prognosis, classification, and treatment of early arthritis (information, education, non-pharmacological interventions, pharmacological treatments, and monitoring of the disease process). On the basis of expert opinion, 11 items were identified as being important for future research. CONCLUSIONS: 12 key recommendations for the management of early arthritis or early rheumatoid arthritis were developed, based on evidence in the literature and expert consensus.     

The development of a multidisciplinary,evidence-based guideline for “HIV and employment”

The objective of this study was to develop a multidisciplinary guideline that supports the care and vocational rehabilitation of HIV-infected people with employment-related problems. The guideline was developed according to the “evidence-based guideline development” method developed by the Dutch Institute for Health Care Improvement. This method consists of the following steps: forming a multidisciplinary core group and an expert panel, formulating key questions, searching and appraising the available literature, formulating considerations and recommendations, peer reviewing the draft guideline, and authorizing the final guideline. All relevant professional associations were represented in the core group that was assembled to develop the guideline, i.e., HIV doctors, HIV nurses, general practitioners, occupational health physicians, psychologists, social workers, occupational health nurses, vocational experts, and insurance physicians. Five key questions for the guideline were formulated with the following themes: determinants of employment, disclosure and stigma, self-management, interventions, and the organization of care. In the literature review on these topics, 45 studies met the inclusion criteria. The methodological quality of the included articles was poor. Factors such as patient preferences and medical/ethical issues were considered. The recommendations in the guideline are a weighting of the scientific evidence and the considerations of the core group. The guideline, as well as its summary for daily practice, clarifies the most important barriers and facilitators to people with HIV either staying at work or returning to work, and it constitutes a clinical, easy-to-use guideline for health-care providers and how they can support people with HIV who want to work.     

Pregnancy after bariatric surgery: Consensus recommendations for periconception,antenatal and postnatal care

The objective of the study is to provide evidence‐based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow‐up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print‐friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high‐quality evidence and warrant further research. These areas are highlighted in the paper.     

Orthogeriatric care for the elderly with hip fractures: where are we?

Hip fracture (HF) is a major health care problem in the Western world, associated with significant morbidity, mortality and loss of function. Its incidence is expected to increase as the population ages. The authors discuss the role of a coordinated multidisciplinary team in the management of patients during hospital stay, at discharge and during rehabilitation. Orthogeriatric care should not just be viewed as a multidisciplinary activity, but as a radical alternative to the traditional model of care, an alternative based on all those strategies in which evidence shows an improvement in outcomes in the fractured elderly. Therefore, key points of the care are early surgery, immediate mobilization, prevention and management of delirium, pain and malnutrition, as well as an integrated and multidisciplinary approach. Comprehensive geriatric assessment is useful in identifying frail elderly and in providing information that is essential in formulating clinical recommendations and making care plans. In each hospital, the orthogeriatric unit should represent a center of excellence for treating elderly patients with major fractures. However, when an orthogeriatric project is implemented, it is essential that detailed data about the case-mix of patients, process of care and outcomes are collected, to compare the results with historical data and to be able to participate in audit processes.     

Current topics on models of care in the management of inflammatory arthritis

While there is strong evidence supporting a multidisciplinary team approach in arthritis management, access and use are hindered by limited human and financial resources. To safeguard the provision of comprehensive care throughout the disease trajectory, alternative care models are being developed. Three promising arthritis care models include the use of information technology and telemedicine, patient initiated care, and extended roles of health professionals. Future research projects should focus on: (1) the cost-effectiveness of information technology for exchange of patient-based data and education and management support; (2) the characteristics and needs of patients who can versus those who cannot self-manage; (3) strategies to improve access to care for patients with early arthritis, such as extending roles of health professionals to include triage; and (4) further structuring and standardizing rheumatology training of nursing and allied health professionals.     

Does everybody need a team?

Multidisciplinary team care, defined as care provided by a group of health professionals from various disciplines, has been widely used in arthritis management since the 1950s. Its effectiveness in comparison with regular outpatient care has mainly been established in patients with rheumatoid arthritis (RA). Recent studies have shown that similar outcomes can be achieved in patients with RA at lower costs using care provided by a clinical nurse specialist. These latter findings suggest that the active components of the multidisciplinary team care model may not be related to the number or professional backgrounds of the health professionals involved, nor with their physical proximity, but rather to the provider's skills in rheumatology and the coordination of services. Because many patients with arthritis have healthcare needs that are not met through treatment by the rheumatologist alone and since traditional multidisciplinary team care in many countries is unavailable or may be undesirable in specific situations, the development and evaluation of alternative, comprehensive models of care delivery is recommended.     

Clinical guidelines: a must for rheumatology?

Clinical guidelines are sets of recommendations, backed by medical evidence, to aid physicians in patient-care decisions. There has been a proliferation of practice guideline development in all fields of medicine, including rheumatology. This chapter will discuss the need for guidelines in rheumatology, the methodology of guideline development, validation and implementation, the various guidelines published in rheumatology, and the role of the rheumatologist in guideline development. Clinical guidelines can serve to inform practitioners of the latest medical evidence and minimize harmful practice variation. Guidelines must rely on good evidence to be credible to the medical community, yet there are still many barriers to guideline acceptance by practitioners. The theories behind guideline development and validation are well described, although not always practised. Guideline dissemination and implementation methods are still being explored. It remains unclear how best to implement guidelines and convince physicians to accept and incorporate evidence-based recommendations into their practice.     

Use of basal insulin in the management of adults with type 2 diabetes: An Asia-Pacific evidence-based clinical practice guideline

The objective of this study was to provide recommendations regarding effectiveness, safety, optimal starting dose, optimal maintenance dose range, and target fasting plasma glucose of five basal insulins (glargine U-300, degludec U-100, glargine U-100, detemir, and insulin protamine Hagedorn) in insulin-naïve adult patients with type 2 diabetes in the Asia-Pacific region. Based on evidence from a systematic review, we developed an Asia-Pacific clinical practice guideline through comprehensive internal review and external review processes. We set up and used clinical thresholds of trivial, small, moderate, and large effects for different critical and important outcomes in the overall certainty of evidence assessment and balancing the magnitude of intervention effects when making recommendations, following GRADE methods (Grading of Recommendations, Assessment, Development, and Evaluation). The AGREE (Appraisal of Guidelines, Research and Evaluation) and RIGHT (Reporting Items for practice Guidelines in HealThcare) guideline reporting checklists were complied with. After the second-round vote by the working group members, all the recommendations and qualifying statements reached over 75% agreement rates. Among 44 contacted external reviewers, we received 33 clinicians' and one patient's comments. The overall response rate was 77%. To solve the four research questions, we made two strong recommendations, six conditional recommendations, and two qualifying statements. Although the intended users of this guideline focused on clinicians in the Asia-Pacific region, the eligible evidence was based on recent English publications. We believe that the recommendations and the clinical thresholds set up in the guideline can be references for clinicians who take care of patients with type 2 diabetes worldwide.     

Executive summary of evidence and consensus-based Clinical Practice Guidelines for management of obesity and overweight in midlife women: An AIIMS-DST initiative

Background and aimsWeight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women.MethodsThe key clinical questions specific to weight management in midlife women were finalised with the help of a multidisciplinary team of experts in the guideline development group (GDG). Phase I included a systematic and/or narrative review to gather evidence, grading of evidence and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method and GRADE approach.Results-The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the healthcare provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviours. Before initiating the management, a comprehensive assessment of clinical and lifestylerelated parameters should be completed. A personalised behavioural lifestyle modification program addressing the midlife specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife specific barriers for sustenance of healthy weight.ConclusionThese recommendations will be useful in opportunistic screening and management of obesity in midlife women across healthcare settings.     

EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE: To develop evidence based recommendations for the management of hip osteoarthritis (OA). METHODS: The multidisciplinary guideline development group comprised 18 rheumatologists, 4 orthopaedic surgeons, and 1 epidemiologist, representing 14 European countries. Each participant contributed up to 10 propositions describing key clinical aspects of hip OA management. Ten final recommendations were agreed using a Delphi consensus approach. Medline, Embase, CINAHL, Cochrane Library, and HTA reports were searched systematically to obtain research evidence for each proposition. Where possible, outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. Effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the traditional A-D grading scale and a visual analogue scale. RESULTS: Ten key treatment propositions were generated through three Delphi rounds. They included 21 interventions, such as paracetamol, NSAIDs, symptomatic slow acting disease modifying drugs, opioids, intra-articular steroids, non-pharmacological treatment, total hip replacement, osteotomy, and two general propositions. 461 studies were identified from the literature search for the proposed interventions of efficacy, side effects, and cost effectiveness. Research evidence supported 15 interventions in the treatment of hip OA. Evidence specific for the hip was strikingly lacking. Strength of recommendation varied according to category of research evidence and expert opinion. CONCLUSION: Ten key recommendations for the treatment of hip OA were developed based on research evidence and expert consensus. The effectiveness and cost effectiveness of these recommendations were evaluated and the strength of recommendation was scored.     

Commissioning guidance for weight assessment and management in adults and children with severe complex obesity

The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non‐surgical) weight management services. We have undertaken a systematic review of ‘what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?’ using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.     

The new 2012 German recommendations for treating rheumatoid arthritis

The German Society for Rheumatology recently published guidelines for the sequential therapy of rheumatoid arthritis (RA). These recommendations were developed as a transition from the 2010 EULAR (EUropean League Against Rheumatism) recommendations to the national clinical practice and are based on an updated systematic literature research and expert discussion. While most EULAR recommendations have remained unchanged, some were modified based on new evidence from randomized, controlled trials, current clinical practice, or national drug approval status. The guidelines also include a treatment algorithm for sequential therapy of RA with disease-modifying agents including biologics.     

Management of overweight and obesity in primary care—A systematic overview of international evidence‐based guidelines

Overweight and obesity are increasing worldwide. In general practice, different approaches exist to treat people with weight problems. To provide the foundation for the development of a structured clinical pathway for overweight and obesity management in primary care, we performed a systematic overview of international evidence‐based guidelines. We searched in PubMed and major guideline databases for all guidelines published in World Health Organization (WHO) “Stratum A” nations that dealt with adults with overweight or obesity. Nineteen guidelines including 711 relevant recommendations were identified. Most of them concluded that a multidisciplinary team should treat overweight and obesity as a chronic disease. Body mass index (BMI) should be used as a routine measure for diagnosis, and weight‐related complications should be taken into account. A multifactorial, comprehensive lifestyle programme that includes reduced calorie intake, increased physical activity, and measures to support behavioural change for at least 6 to 12 months is recommended. After weight reduction, long‐term measures for weight maintenance are necessary. Bariatric surgery can be offered to people with a BMI greater than or equal to 35 kg/m² when all non‐surgical interventions have failed. In conclusion, there was considerable agreement in international, evidence‐based guidelines on how multidisciplinary management of overweight and obesity in primary care should be performed.     

Multidisciplinary patient care in rheumatoid arthritis: evolving concepts in nursing practice

Multidisciplinary patient care is essential in the management of rheumatoid arthritis (RA), a chronic potentially disabling, multisystem disease. Concepts of multidisciplinary care continue to evolve. While all team members can make valuable contributions to patient care, this chapter focuses in particular on continuing and changing aspects of team management. Of the many disciplines associated with rheumatology, nursing has undergone the most radical change in recent years. New roles have been defined and the nursing profession is now emerging with additional skills to support patients and their families. Concepts of patient education also continue to evolve. As the beneficial effects of education are demonstrated, a patient education programme should be seen as essential to the management of rheumatoid arthritis. Finally, the importance of counselling skills is emphasised.     

Management of hepatocellular carcinoma: Report of Consensus Meeting in the 45th Annual Meeting of the Japan Society of Hepatology (2009)

Hepatocellular carcinoma (HCC) is responsible for approximately 600 000–700 000 deaths worldwide. It is highly prevalent in the Asia–Pacific region and Africa, and is increasing in Western countries. The evidence‐based guideline for HCC in Japan was published in 2005 and revised in 2009. Apart from this guideline, a consensus‐based practice manual proposed by the HCC expert panel of the Japan Society of Hepatology (JSH), which reflects widely accepted daily practice in Japan, was published in 2007. At the occasion of the 45th Annual meeting of the JSH in Kobe 4–5 June 2009, a consensus meeting of HCC was held. Consensus statements were createdbased on 67% agreement of 200 expert members.This article describes the up‐to‐date consensus statements which largely reflect the real world HCC practice in Japan. We believe readers of this article will gain the newest knowledge and deep insight on the management of HCC proposed by consensus of the HCC expert members of JSH.     

Guidelines for endoscopic diagnosis of early gastric cancer

The Japan Gastroenterological Endoscopy Society developed the Guideline for Endoscopic Diagnosis of Early Gastric Cancer based on scientific methods. Endoscopy for the diagnosis of early gastric cancer has been acknowledged as a useful and highly precise examination, and its use has become increasingly more common in recent years. However, the level of evidence in this field is low, and it is often necessary to determine recommendations based on expert consensus only. This clinical practice guideline consists of the following sections to provide the current guideline: [I] Risk stratification of gastric cancer before endoscopic examination, [II] Detection of early gastric cancer, [III] Qualitative diagnosis of early gastric cancer, [IV] Diagnosis to choose the therapeutic strategy for gastric cancer, [V] Risk stratification after endoscopic examination, and [VI] Surveillance of early gastric cancer.