Adherence to guidelines in the clinical care for adults with congenital heart disease: the Euro Heart Survey on adult congenital heart disease.

AIMS: To investigate the role of guidelines in structuring the clinical care for adult patients with congenital heart disease (CHD), and to assess adherence to the guidelines in Europe. METHODS AND RESULTS: A selected number of current guidelines were chosen pertaining to operative procedures, investigations, and the use of medication ('interventions'). The source for this analysis was the database of the Euro Heart Survey on adult CHD, which contains retrospectively collected data on 4110 patients followed-up for a median of 5.1 years. For each guideline investigated, patients were selected from the database for whom the particular guideline was relevant. The selected cases were classified according to two criteria: was there an indication for the particular intervention and did the intervention take place? In this manner, cases of 'undue treatment' and 'insufficient treatment' were identified. Adherence to guidelines was found to be good in the case of operative procedures and prophylactic drug treatment. However, regarding diagnostic procedures there had been adherence to guidelines in only slightly more than half of the cases. CONCLUSION: Guidelines have an important role in the actual clinical care of adults with CHD. However, large outcome studies are needed to develop more precise guidelines.     

Guidelines in pulmonary medicine: a 25-year profile.

OBJECTIVE: We attempted to identify clinical practice guideline and pathway articles in the area of pulmonary medicine published in peer-reviewed journals since 1974. DESIGN: Review. DATA SOURCES: MEDLINE, the Cochrane Database, Best Evidence, and Abstracts of Clinical Care Guidelines from January 1974 to December 1998. STUDY SELECTION: All articles contained relevant search terms for pulmonary topics and were included irrespective of setting (primary or specialty, inpatient or outpatient). Controlled and uncontrolled trials as well as observational studies and consensus opinion/statements were all identified. The articles were stratified by design as well as by pulmonary topic. DATA EXTRACTION: Limited data on study type, study focus, year of publication, and results of study were abstracted. RESULTS: Our criteria yielded 271 articles, including 115 consensus statements and expert opinion guidelines; 30 controlled studies, meta-analyses, or systematic reviews; and 126 uncontrolled trials and observational studies. Of these, 82 articles (30.3%) related to asthma, 46 articles (17.0%) related to COPD, and 36 articles (13.3%) related to pneumonia. In addition, we tracked the increasing publication of all guideline-related pulmonary articles; randomized, controlled trials (RCTs); systematic reviews; and consensus statements by year for the past 25 years. CONCLUSION: Pulmonary guidelines are increasingly published in peer-reviewed journals, but few are tested clinically in RCTs. There is continued reliance on consensus statements and expert opinion. Pulmonary guideline publications have continued to dramatically increase in number and in importance since 1974, both on the local level and internationally.     

Perspektiven der Leitlinienentwicklung und -implementation aus der Sicht der AWMF

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

Adherence to pressure ulcer prevention guidelines: implications for nursing home quality

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs. DESIGN: Review of NH medical records. SETTING: A geographically diverse sample of 35 Veterans Health Administration NHs. PARTICIPANTS: A nested random sample of 834 residents free of PU on admission. MEASUREMENTS: Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical. RESULTS: Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P <.001) and from 24% to 75% across the six key recommendations (P <.001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated. CONCLUSIONS: NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.     

Methodological appraisal of guidelines. The AGREE instrument.

The increasingly important role of clinical practice guidelines as a support tool for clinical decision-making is shown by a growing number of publications in the literature. In fact, it is almost impossible to open a medical journal without coming across one or more guidelines on various subjects. Guidelines serve several objectives: 1) improvement in health care (increasing good and decreasing bad practices); 2) greater availability of and access to medical knowledge; and 3) promotion of cost-effective strategies. The recommended methodology for guideline design and development requires that the recommendations should be evidence-based, i.e., based on selected and critically appraised data, with the final inclusion of evidence that is valid, important and applicable, based on explicit pre-defined criteria. The methodological quality of guidelines varies substantially, raising credibility issues, with subsequent lack of results (in terms of changing medical practice). This has given rise to a series of recent publications on methodological rules for the design and writing of guidelines. This paper presents the first international instrument that can be used as a quality assurance tool for evidence-based clinical guidelines: the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.     

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.     

An international environmental scan of quality indicators for cardiovascular care

Quality indicators (QIs) are increasingly being used to measure and improve the quality of cardiac care. We conducted an international environmental scan to identify and critically appraise published QI development initiatives addressing cardiovascular disease (CVD). A review of the peer-reviewed and grey English-language literature was conducted to identify published CVD QI development initiatives. The quality of identified studies was assessed using a modified version of the Appraisal of Guidelines for Research and Evaluation (AGREE) II QI tool-an instrument originally developed for the assessment of the quality of clinical practice guidelines. An initial literature search identified 2314 potentially relevant abstracts of peer-reviewed articles. After a review of the abstracts, 120 full text articles were retrieved and reviewed. Of these, 20 articles and 1 peer-reviewed monograph were selected for critical appraisal (n = 21). Most of the initiatives were conducted in North America (76%) and were published after 2005 (62%). The majority (5 of 6) of the AGREE II QI domain scores were skewed toward higher values, including the median score for the 'overall quality' rating (83.3%). Of the CVD categories addressed within the 21 initiatives, heart failure was the most common (n = 10 QI indicator sets), followed by acute coronary syndromes (n = 8). Considerable variation was observed in the methods utilized and the degree of scientific rigour applied in the published international CVD QI development initiatives. Adoption of standardized methods could help improve the quality of QI development initiatives.     

The German guideline clearing-project on bronchial asthma - part 2: recommendations and key topics for a national guideline on bronchial asthma

BACKGROUND: In order to promote the quality of asthma management in Germany, a national asthma guidelines clearing project was initiated in 2000 by the German Guidelines Clearinghouse (Sponsors: German Medical Association (GMA), National Association of the Statutory Health Insurance Physicians (NASHIP), German Hospital Federation, Federal Association of the Statutory Sickness Funds. This Part shows the key topics which should be dealt with in a German guideline on bronchial asthma. SUMMARY POINTS: For quality promotion of bronchial asthma management in Germany, the development of a national evidence-based guideline, using the internationally accepted quality criteria for clinical practice guidelines, was recommended by an expert group of the German Guideline Clearinghouse. The experts identified and peer-reviewed 16 out of 54 guidelines, which might be useful as benchmarks and examples for a German asthma guideline. From the peer review results, the expert group identified 18 key topics for a national asthma guideline.     

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.     

Diabetes UK evidence‐based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence‐based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes‐related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non‐nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted ‘GRADE’ methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines .     

Balancing vision with pragmatism: The geriatric emergency department guidelines-realistic expectations from emergency medicine and geriatric medicine

In 2014 the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterize the complex needs of the older emergency department (ED) patient and current best practices with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and the vast majority of EDs then and now do not have either the resources nor hospital administrative support to provide this additional service. At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency medicine physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline recommended care in EDs, this article will explore three high impact GED clinical conditions to highlight guideline recommendations, challenges and opportunities, and discuss realistically achievable expectations for non-Geriatric ED accredited institutions. In 2014 the Geriatric Emergency Department Guidelines were published describing the current best practices for geriatric ED patients. Unfortunately, the vast majority of EDs worldwide do not provide the level of service recommended by the GED guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.     

Diabetes care practices in primary care: results from two samples and three measurement sets

PURPOSE: There has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings. METHODS: We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes. RESULTS: In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities. CONCLUSIONS: Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.     

Quality of colonoscopy reporting: a process of care study

OBJECTIVE: Several groups have developed guidelines for specific content necessary in endoscopic procedure reports. Little information is available assessing adherence to reporting recommendations, and little is known about common reporting errors. The aim of this study was to assess the quality of colonoscopy reporting and to identify possible areas of improvement. METHODS: Using the 1997 American Society for GI Endoscopy guidelines for endoscopy reporting, we created operational definitions for adherence to each guideline. We then created 31 specific process of care criteria to assess adherence to each of these operational definitions. We subdivided the 31 specific process of care criteria into six domains: demographic information, patient history, sedation procedure, adequacy of preparation/visibility, lesion identification/removal, and procedure interpretation. Reports obtained from 122 separate endoscopy centers were reviewed for adherence to the guidelines. Adequate performance for any criterion was defined as 70% or better compliance. RESULTS: Performance varied widely across the domains. Clinicians demonstrated adequate performance on sedation procedure (75%) and lesion identification/removal (84%). Clinicians scored poorly on demographic data (69%), patient history (57%), procedure quality (40%), and procedure interpretation (58%). CONCLUSIONS: Clinicians' colonoscopy reporting practices are widely variable and often suboptimal. There is an opportunity to improve the quality of care in colonoscopy reporting by improving physicians' adherence to established standards.     

An International Study of Adherence to Guidelines for Patients Hospitalised with a COPD Exacerbation

Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.     

Effect of local standards on the implementation of national guidelines for asthma

OBJECTIVE: To assess the level of modification by local primary care doctors of key aspects of the National Asthma Education Program (NAEP) Guidelines for the Diagnosis and Management of Asthma. DESIGN: A random sample of primary care physicians participating in local asthma guideline development. SETTING: Two hospital systems, one based in an urban environment, and a second in a community and rural environment. PARTICIPANTS: Primary care physicians. INTERVENTION: Design of consensus-based local asthma guidelines using a modified Delphi approach. MEASUREMENTS AND MAIN RESULTS: A total of 42 physicians participated in the local guideline development. With few exceptions, the primary care physicians modified in major ways the NAEP Guidelines regarding the role of pulmonary function testing and spirometry. Specifically, the local guidelines did not require peak flow and spirometry measurements as the basis for initiating inhaled steroids as did the national guidelines. All 42 physicians emphasized a clinical diagnosis versus one based on a pulmonary function. Peak flow monitoring was recommended by 35 (83%) of physicians in selected patients only, in contrast to the national guidelines, which emphasized monitoring for all patients routinely and during exacerbations. There was strong agreement with the national guidelines on the role and importance of patient education, and on the indications for the use of inhaled steroids. CONCLUSIONS: Disagreement by primary care doctors with parts of the NAEP guideline is a potential cause for poor compliance and lack of influence on patient care. Recognizing the need to modify or customize guidelines through field testing with local primary care physicians will improve acceptance of national guidelines.     

Swedish guidelines for type 1 diabetes and pregnancy outcomes: A nationwide descriptive study of consensus and adherence

AimsType 1 diabetes (DM1) during pregnancy and labor is associated with an increased risk of maternal and fetal complications. Evidence-based care is therefore provided in accordance with guidelines.In this study, we aimed to compare all the Swedish guidelines for DM1 during pregnancy and labor in terms of the variables emphasized in the national guidelines from the US and from England and Wales. The second aim was to measure adherence to local guidelines at the four hospitals in Stockholm that cared for pregnant women with DM1 during 2016 and to describe the pregnancy and labor outcomes.MethodsAll the Swedish guidelines for DM1 during pregnancy and labor were reviewed on 31 variables. The medical records of 114 women were reviewed according to whether ≥70% of 22 variables in the guidelines were followed.ResultsNo consensus was found in the Swedish guidelines for any of the 31 variables. Some guidelines were contradictory. The pregnancy guidelines were followed in 17.5% of the medical records, 18.4% followed the labor guidelines, and 5.3% followed both guidelines. The onset of labor, mode of delivery and HbA1c in the third trimester varied significantly, depending on the adherence to guidelines.ConclusionsThe Swedish guidelines for DM1 during pregnancy and labor lack both consensus and adherence. A national guideline on DM1 during pregnancy and childbirth with high adherence could improve care for pregnant Swedish women with DM1 and their fetuses.     

Clinician awareness of adherence to hypertension guidelines

PURPOSE: Little is known about how well clinicians are aware of their own adherence to clinical guidelines, an important indicator of quality. We compared clinicians' beliefs about their adherence to hypertension guidelines with data on their actual performance. METHODS: We surveyed 139 primary care clinicians at three Veterans Affairs medical centers, asking them to assess their own adherence to hypertension guidelines. We then extracted data from the centers' clinical databases on guideline-concordant medication use and blood pressure control for patients cared for by these providers during a 6-month period. Data were collected for patients with hypertension and diabetes, hypertension and coronary disease, or hypertension with neither of these comorbid conditions. RESULTS: Eighty-six clinicians (62%) completed the survey. Each clinician saw a median of 94 patients with hypertension (mean age, 65 years). Patients were treated with an average of 1.6 antihypertensive medications. Overall, clinicians overestimated the proportion of their patients who were prescribed guideline-concordant medications (75% perceived vs. 67% actual, P <0.001) and who had blood pressure levels <140/90 mm Hg on their last visit (68% perceived vs. 43% actual, P <0.001). Among individual clinicians, there were no significant correlations between perceived and actual guideline adherence (r = 0.18 for medications, r = 0.14 for blood pressure control; P > or =0.10 for both). Clinicians with relatively low actual guideline performance were most likely to overestimate their adherence to medication recommendations and blood pressure targets. CONCLUSION: Clinicians appear to overestimate their adherence to hypertension guidelines, particularly with regards to the proportion of their patients with controlled blood pressure. This limited awareness may represent a barrier to successful implementation of guidelines, and could be addressed through the use of provider profiles and point-of-service feedback to clinicians.     

The Diabetes Initiative of South Carolina and the 18th Annual Diabetes Fall Symposium for Health Care Professionals

The Diabetes Initiative of South Carolina (DSC) is charged with the development of guidelines for the management of diabetes and supporting adherence to evidence-based standards for education and care. The DSC is committed to lowering the burden of diabetes in the state through translation of evidence-based standards of clinical practice, and patient and community education centered on blood glucose control, blood pressure control, healthy eating, physical activity, and foot care. The DSC has developed many programs for the education of a variety of health professionals about diabetes and its complications. DSC has sponsored 18^th Annual Diabetes Fall Symposia for primary health care professionals featuring education on all aspects of diabetes mellitus. The intent of the program is to enhance the lifelong learning process of physicians, nurses, pharmacists, dietitians and other health care professionals by providing educational opportunities and to advance the quality and safety of patient care.