Relationships between American Urological Association symptom index, prostate volume, and disease-specific quality of life question in patients with benign prostatic hyperplasia

The American Urological Association (AUA) symptom index is both valid and reliable in identifying the need to treat patients with benign prostatic hyperplasia (BPH) and in monitoring their response to therapy. We evaluated the relationships between AUA symptom index, disease-specific quality of life question, and prostate volume in patients with BPH. A total of 100 patients who came to Kaohsiung Medical University Hospital, Taiwan, for help due to lower urinary tract symptoms (LUTS) and who were diagnosed with BPH between October 2002 and June 2003 were included in the study. All patients were evaluated using transrectal ultrasonography, AUA symptom index, and disease-specific quality of life question. The disease-specific quality of life question showed good correlation with AUA symptom score (r = 0.815, p < 0.01), but weak correlation with prostate volume (r = 0.225, p < 0.05) and age (r = 0.274, p < 0.05). Prostate volume had weak correlation with AUA symptom score (r = 0.251, p < 0.05) and age (r = 0.472, p < 0.01), but good correlation with prostate specific antigen (r = 0.638, p < 0.01). In addition to AUA symptom index, we suggest using the disease-specific quality of life question to evaluate the influence on quality of life and response to treatment in clinical practice. Moreover, we should assess the impact of BPH symptoms rather than the increase in prostate volume during the management of BPH.     

The role and scope of practice of nurses working in Canadian heart failure clinics

BACKGROUND: Nurses play an integral role in providing care in heart failure (HF) clinics and disease management programs that lead to improved outcomes for HF patients. OBJECTIVES: This pilot study explored how closely nurses in Canadian HF clinics follow consensus guideline recommendations and nursing interventions from published studies. METHODS: A total of 27 nurses from HF clinics across Canada completed a questionnaire about their role and scope of practice. RESULTS: The majority of nurses covered recommended topic areas for counseling and education with the exceptions of discussing advanced directives, teaching patients to titrate diuretics, and counseling on secondary prevention. Nurses with a postgraduate degree were more likely to independently titrate medications and order echocardiograms. Nurses affiliated with the Canadian Congestive HF Clinic Network were more likely to provide telephone management, titrate medications, and order echocardiograms and other diagnostic tests. CONCLUSION: Patients may not be experiencing the benefits that are reported in the literature for being followed up in a HF clinic because the role and scope of practice of nurses varies from one clinic to another. The role and scope of practice of nurses in HF clinics needs to be standardized.     

Guideline Alignment in Related Areas

Clinical practice guidelines serve an important role in the primary and secondary prevention of cardiovascular disease. There is variability among guideline groups in the methods used to assess and grade clinical evidence, resulting in discrepancies in various guidelines. Multiple guidelines focused on different aspects of cardiovascular care can lead to recommendations that are out of sync. Discrepancies between a practice recommendation from 2 different Canadian guideline groups can lead to confusion among clinicians and patients, reducing the likelihood that the practice recommendation will be carried out. Assisting cardiovascular-focused guideline groups to align, to harmonize, and to score highly on appraisal has been a main function of the Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE). Validated appraisal tools, harmonized guideline initiatives, and continuous evaluation of the impact of guidelines on quality indicators and practice outcomes are crucial for improving cardiovascular care for all Canadians.     

Addressing resource allocation issues in recommendations from clinical practice guideline panels: suggestions from an American College of Chest Physicians task force

Most panels that develop clinical practice guidelines are poorly equipped to address resource allocation or cost issues associated with management options. This risks neglect, arbitrariness, lack of transparency, and methodological flaws in consideration of resource allocation. We provide recommendations for guideline panels to promote greater transparency and rigor. We suggest focusing on resource allocation issues for only a limited number of recommendations and provide criteria for selecting those in which economic considerations are likely to influence the direction or strength of the recommendation. Panels should involve a health economist to assist with the systematic review and critical interpretation of relevant economic analyses. They should carefully define the intended audience and may consider issuing alternative recommendations when available resources vary widely across target clinical settings. Targeting a limited number of recommendations for the consideration of resource allocation issues, and ensuring methodologically high-quality review, will best serve guideline panels, and the health-care providers and patients they hope to assist.     

Diagnosis and Treatment of Benign Prostatic Hyperplasia: Practice Patterns of Primary Care Physicians

OBJECTIVE: To define primary care physicians' (PCPs) practices in managing patients with benign prostatic hyperplasia (BPH), and to compare these practices to portions of the Agency for Health Care Policy and Research BPH guideline and urologists' practices. DESIGN: Mail survey. PARTICIPANTS: Nationwide random sample of PCPs and urologists, selected from the American Medical Association Registry. METHODS: Initial mailing, postcard reminder, second mailing, telephone reminder, final mailing. MAIN RESULTS: Primary care physicians (n = 444, response = 51%) reported seeing a median of 35 patients with BPH over the preceding year, in contrast to 240 for urologists (n = 394, response = 68%). Regarding tests recommended by the guideline, two thirds of PCPs reported rarely or never using the American Urological Association (AUA) symptom index, nearly all reported routinely performing digital rectal examinations, and many (66%) reported routinely ordering tests to determine the serum creatinine level. Although considered "optional" by the guideline, more than 90% of PCPs reported routinely ordering a prostate-specific antigen test, while infrequently using other optional tests. Regarding "not recommended" studies, a substantial minority reported selectively or routinely ordering intravenous pyelography (34%) and renal ultrasound (33%), while two thirds reported rarely or never ordering these tests. Eighty-six percent of PCPs reported prescribing medications for BPH over the preceding year; α blockers to a median of 12 patients, and finasteride to a median of 2. Variation in urology referral thresholds was suggested in responses to two patient scenarios. CONCLUSIONS: Primary care physicians are actively managing patients with BPH. Some of their diagnostic evaluations vary from the recommendations of a national guideline and urologists' practices. Referral thresholds appear to vary considerably.     

Acute urinary retention and surgery for benign prostatic hyperplasia: the patient's perspective

It is now possible to reduce the risk of acute urinary retention (AUR) and prostate surgery in patients suffering from symptomatic benign prostatic hyperplasia (BPH) with medical therapy. The objective of this study was to determine the concern and perceived impact on quality of life (QoL) of these potential events in patients at risk. Seventy-four consecutive patients with a diagnosis of BPH, but no history of AUR or prostate surgery referred to a single urology practice completed an AUA/BPH symptom index (AUA-SI), AUA BPH impact index, QoL assessment, and a comprehensive questionnaire (before and after counseling). This questionnaire explored their concern and opinion regarding the perceived impact of AUR or surgery on their personal QoL. Sixty-two patients (mean age 69.5) with an average AUA BPH Symptom Index of 12.2 were eligible for analysis. Over half of the patients were significantly concerned about the prospect of AUR (57%) and two thirds of the patients (67%) were significantly concerned about the prospect of surgery. However, more patients considered the insertion of a catheter for acute urinary retention would be more detrimental to their quality of life than surgery (68% vsersus 45%). More patients believed that catheterization would be more of a problem in their life than surgery (69% versus 52%). Patients with BPH at risk for future acute urinary retention and surgery generally felt that the potential occurrence of these events were of a major concern and if they occurred would be an important event affecting their personal quality of life.     

Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which the ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the first of 2 that will provide guidance on the management of patients with chronic stable angina. This document will cover diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on history or on electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A future guideline will cover pharmacologic therapy and follow-up.     

Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers,children and adults

BACKGROUND:

In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.

METHODS:

Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta₂-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.

RESULTS:

The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.

CONCLUSIONS:

The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.     

The Canadian Hypertension Education Program--a unique Canadian initiative

While almost two-thirds of all strokes and one-half of all myocardial infarctions could be prevented if hypertensive individuals had their blood pressures optimally controlled, only a minority of hypertensive individuals (even in publicly funded health care systems with subsidization of medication costs) achieve target blood pressures. Traditional hypertension guidelines have had limited impact on hypertension management and control rates. As a result, the Canadian Hypertension Education Program was developed to address the perceived flaws in the traditional hypertension guideline approach. In the present article, the key features of the Canadian Hypertension Education Program methodology are reviewed, with attention to those factors thought to be critical to the successful translation of recommendations into practice.     

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative

IntroductionPostpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings.MethodsThe guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations.ResultsThe evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations.ConclusionThe guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.     

Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: The patient perspective

A series of clinical practice guidelines were recently developed by the Canadian Association of Gastroenterology (CAG) to provide clinicians with recommendations for the medical management of nonhospitalized ulcerative colitis (UC) patients. These guidelines were developed, reviewed and agreed on by expert clinicians and methodologists. Following the finalization of the guidelines, a group of patients with UC as well as several inflammatory bowel disease clinicians, were brought together for a half-day workshop to provide feedback from the patient perspective. At the workshop, the guideline development process was described and the guidelines were reviewed to ensure comprehension. Patients then had the opportunity to provide their insight to the relevance of the guideline development process and the content of the guidelines as it related to their personal experiences with UC. The patient group believed that, although the new guidelines will be a tremendous resource for the health care provider community, a more ‘lay-friendly’ version would better facilitate dialogue between patients and their health care practitioners. The importance of the patient/physician relationship is paramount when making decisions regarding treatment plans, in which patient preferences play a key role in determining the most appropriate therapy and dosing regimen, which, in turn, impact the likelihood of adherence to the treatment plan. It was also believed that quality of life issues were not fully addressed in the guidelines. Much could be learned from shared experiences and coping strategies that would empower patients to take charge of their health and become equal partners with their care providers.     

A sampling of Canadian practice in managing nonvariceal upper gastrointestinal bleeding before recent guideline publication: is there room for improvement?

BACKGROUND: There are few recent published consensus guidelines regarding nonvariceal upper gastrointestinal bleeding. In 2003, the Canadian Association of Gastroenterology sponsored a set of 20 recommendations. AIM: To compare current Canadian clinical practice patterns with these most recent guidelines. METHODS: Data obtained from the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), complemented by a questionnaire sent out to the 18 participating RUGBE sites, were used to compare present practice with all 20 guidelines. RESULTS: Only three RUGBE sites had an explicit written protocol for nonvariceal upper gastrointestinal bleeding, and only 40% of the sites had support staff available after hours. The Blatchford prognostic scale was not used routinely, and only one site used the Rockall score for risk stratification. Most patients classified as low-risk according to the literature had endoscopy within 24 h and a median length of stay of two days compared with high-risk patients who underwent endoscopy approximately 4 h earlier, had a median length of stay of 4.3 days and displayed a higher mortality. Nineteen per cent of all patients had a routine second-look endoscopy. Proton pump inhibitors were frequently used in the acute setting. Thirteen per cent of all patients rebled and only 34% of these received a second endoscopy. One-half of all patients were tested for Helicobacter pylori while in hospital, mostly by histology, and one-third of those who tested positive received H pylori eradication during their hospitalization. CONCLUSION: Compared with recommendations put forward in the new guidelines, clinical practice before guideline publication was variable. The future level of guideline adherence and patient outcome data should be quantified and monitored as the guidelines are disseminated.     

Periprocedural Anticoagulation for Cardioversion of Acute Onset Atrial Fibrillation and Flutter: Evidence Base for Current Guidelines

The practice of electrical or pharmacological cardioversion (CV) to restore sinus rhythm in patents with symptomatic atrial fibrillation (AF) or atrial flutter has been a part of clinical practice for more than 100 years. For almost as long as CV has been performed, it has been recognized that the act of restoring sinus rhythm is associated with an increased risk of stroke and systemic embolism, and that oral anticoagulant (OAC) therapy can be used to prevent peri-CV thromboembolism. Although it has been widely accepted that OAC therapy is necessary to prevent thromboembolism in patients with chronic AF/atrial flutter who undergo CV, previous clinical practice recommendations have suggested that OAC therapy may be omitted in patients at low risk of stroke. However, in recent years, evidence has emerged from several sources challenging these historical conventions. In 2018 the Canadian Cardiovascular Society AF guidelines updated the previous recommendations regarding CV of acute onset AF, and the use of peri-CV anticoagulation. In this article we present an extensive review of the evidence informing the previous recommendations, as well as the novel evidence that informed the change in recommendations. In addition, the current Canadian Cardiovascular Society AF guideline recommendations are examined within the context of contemporary international major society guidelines.     

Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers,children and adults: Executive summary

BACKGROUND:

In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.

METHODS:

Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta₂-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.

RESULTS:

The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.

CONCLUSIONS:

The present document is an executive summary of the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.     

Introducing the Canadian Thoracic Society Framework for Guideline Dissemination and Implementation,with Concurrent Evaluation

The Canadian Thoracic Society (CTS) is leveraging its strengths in guideline production to enable respiratory guideline implementation in Canada. The authors describe the new CTS Framework for Guideline Dissemination and Implementation, with Concurrent Evaluation, which has three spheres of action: guideline production, implementation infrastructure and knowledge translation (KT) methodological support. The Canadian Institutes of Health Research ‘Knowledge-to-Action’ process was adopted as the model of choice for conceptualizing KT interventions. Within the framework, new evidence for formatting guideline recommendations to enhance the intrinsic implementability of future guidelines were applied. Clinical assemblies will consider implementability early in the guideline production cycle when selecting clinical questions, and new practice guidelines will include a section dedicated to KT. The framework describes the development of a web-based repository and communication forum to inventory existing KT resources and to facilitate collaboration and communication among implementation stakeholders through an online discussion board. A national forum for presentation and peer-review of proposed KT projects is described. The framework outlines expert methodological support for KT planning, development and evaluation including a practical guide for implementers and a novel ‘Clinical Assembly – KT Action Team’, and in-kind logistical support and assistance in securing peer-reviewed funding.     

Treatment Recommendations for the Management of Axial Spondyloarthritis

Clinical practice guidelines aid clinicians in providing optimal care for their patients. Over the past decade, treatment guidelines have been published for ankylosing spondylitis (AS), but there are no evidence-based recommendations for the management of axial spondyloarthritis. In 2003, Canadian rheumatologists published treatment recommendations for AS, which have been subsequently updated. More recently, in 2011, the Assessment of SpondyloArthritis international Society and the European League Against Rheumatism published recommendations for the management of AS. SPondyloArthritis Research and Treatment Network proposes an American College of Rheumatology–led effort to develop treatment recommendations for axial spondyloarthritis.     

Misconceptions, challenges, uncertainty, and progress in guideline recommendations

Although the quality of clinical practice guidelines has improved over the last decade, current guideline systems have limitations that reduce their validity and limit their acceptance. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group, a worldwide collaboration of guideline developers, methodologists, and clinicians, has constructed a system for developing guidelines that addresses these shortcomings. The system includes a transparent and rigorous methodology for rating the quality of evidence, an explicit balancing of benefits and harms of healthcare interventions, an explicit acknowledgement of the values and preferences that underlie the recommendations, and whether the intervention represents a wise use of resources. These four elements determine whether a recommendation is strong or weak. A guideline panel offers strong recommendations when virtually all informed patients would choose the same management strategy. Weak recommendations imply that choices will differ across the range of patient values and preferences. The GRADE system has been tested in multiple practice settings and for a large spectrum of questions, refined and re-evaluated to ensure that it captures the complex issues involved in evidence assessment and grading recommendations while maintaining simplicity and practicality. Many guideline organizations and medical societies have endorsed the system and adopted it for their guideline processes.     

A novel process for updating recommendations for managing hypertension: rationale and methods

BACKGROUND: There are numerous hypertension consensus recommendations intended for practising physicians. However, recommendations in their current format have limited impact on improving hypertension control. MATERIALS AND METHODS: A group of national societies, headed by the Canadian Hypertension Society, the Heart and Stroke Foundation of Canada, the Canadian Coalition for High Blood Pressure Prevention and Control, and Health Canada has developed strategies to maintain annually updated recommendations for hypertension management and to provide greater opportunities for their implementation into clinical practice. The process is overseen by a steering committee. Subcommittees have been formed for each of a list of topics seen as important to the control of hypertension. The subcommittees, with the aid of a central librarian, conduct annual literature reviews in accordance with Cochrane Collaboration strategies. Modified existing and new recommendations are forwarded to a group with expertise in clinical epidemiology. Grades of evidence are assigned to each recommendation. Revised recommendations based on the above process will be presented annually at the conjoint Canadian Hypertension Society/Canadian Cardiovascular Congress meeting. Under the leadership of the Cardiovascular Disease Division of the Laboratory Centre for Disease Control, Health Canada, a committee has been charged with the implementation process. CONCLUSIONS: The improvements of the current process over previous national hypertension recommendations are four-fold. First, the recommendations will be updated annually. Second, the methodology has been improved. Third, the grading system can be used in the evaluation of complex study designs. Finally, the implementation process is extended. The authors are optimistic that these changes will contribute to the improvement of hypertension control in the Canadian population.     

Minimally Invasive Treatment of BPH: An Update

Objectives: Aim of this review is provide updated information regarding the current role of minimally invasive treatment (MIT) for lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO).Methods: We reviewed the literature and report on the statements of BPH guidelines released by the European Association of Urology (EAU) and the American Urological Association (AUA). We largely concentrate on randomised clinical trials (RCT) and long-term follow-up series (≥12 months).Results: When assessing the current role of MIT a number of parameters, such as the need for anaesthesia, intra- and postoperative complications, morbidity, short- and long-term outcome have to be considered. MIT can be divided into (i) thermal-based therapies, (ii) laser therapies, (iii) ablative therapies and (iv) other technologies. The currently most attractive MITs are high-energy TUMT, Holmium-laser enucleation and transurethral electrovaporisation.Conclusions: BPH guidelines such as those of the EAU and AUA give clear recommendations in this evolving field. MITs not considered established by BPH guidelines should not be used outside clinical trials.