A parallel guideline development and formalization strategy to improve the quality of clinical practice guidelines

Purpose

Clinical practice guidelines often contain ambiguities, inconsistencies, and logical errors that hamper implementation of these guidelines in practice. As guideline formalization is useful to verify the logical structure, consistency, and completeness of guidelines, several authors have argued that the formalization of guidelines concurrent with their development may improve their quality. However, experiences with such a parallel guideline development and formalization approach have not yet been reported. The goal of this study was to develop such a strategy and evaluate its application in practice.

Methods

Existing methodologies for guideline development and guideline formalization were analyzed and used as a basis to develop a strategy in which guideline formalization is performed concurrently with guideline development. The developed strategy was applied in the development of a clinical practice guideline for cardiac rehabilitation.

Results

A parallel guideline development and formalization strategy was developed that intertwines the processes of guideline development and guideline formalization. Central assets are early involvement of guideline formalization specialists and formalization tools, cooperation between guideline authors and guideline formalization specialists in the development of clinical algorithms, access to domain knowledge when formalization identifies inconsistencies or omissions, and formal verification of the guideline model prior to guideline dissemination. This strategy was applied in the development of a guideline for cardiac rehabilitation and helped to identify several vague and inconsistent recommendations and impracticabilities in the narrative guidelines that could be resolved before publication. In addition, the strategy ensured consistency between the narrative and formalized guideline.

Conclusions

Based on our experience, formalizing a guideline concurrent with its development is feasible in practice and we recommend applying such a strategy as it can be beneficial to the quality of and consistency between the guideline's narrative and formalized version.     

Clinical practice guidelines for the treatment of schizophrenia: from theory to practice

INTRODUCTION: Based on the concept of evidence-based medicine (EBM), the clinical practice guidelines (CPG) occupy an increasingly important place in the field of the treatment of schizophrenia. Although CPGs have been elaborated in a rigorous way, few of them provide the readers with tools for their use in practice. The clinician must therefore create his own method of application. This problem was encountered within the framework of a retrospective study carried out in a rehabilitation unit, where we sought to answer the question concerning the use of the CPG approach in the pharmacological treatment of schizophrenia: "to what degree do doctors, with only indirect knowledge, respect these CPGs?" METHOD: The comparative study between CPG and practical current clinic implied: (1) the choice of a pertinent CPG for the clinical framework studied, (2) the selection of measuring instruments, which allow the quantification of obvious clinical problems approached in the CPG, and (3) the development of a standardized system of comparison to determine the degree of respect of the recommendations. The Expert Consensus Guideline for the treatment of schizophrenia (ECGTS) was selected as the reference. A method of application of the ECGTS is depicted: use of standardized clinical scales; translation of the results of the clinical examination in terms of clinical problems to which the recommendations of the guideline refers; and determination of the degree of respect of the recommendations. RESULTS: In the group of 20 patients included in this study, the recommendations of the ECGTS were totally respected in 65% of the patients, and partially respected in 10%, while in 25% of the patients, they were not respected. COMMENTS: These observations suggest that the clinical approach has to be improved, mainly with regard to the treatment of psychotic and depressive symptoms. This work also showed the limits of the CPG: for example, over half of the patients presented side effects on clinical evaluation, whereas the regulation of their medication respected the recommendations of the ECGTS. CONCLUSION: The future certainly belongs to CPG, which proposes, in addition to the clinical recommendations themselves, a method to check their application in clinical practice.     

Management issues for women with epilepsy—Focus on pregnancy (an evidence-based review): I. Obstetrical complications and change in seizure frequency

A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. The committee evaluated the available evidence according to a structured literature review and classification of relevant articles. For WWE who are taking antiepileptic drugs (AEDs), there is probably no substantially increased risk (>2 times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (>1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. WWE should be counseled that seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84–92%) of remaining seizure-free during pregnancy. WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery.     

美国NIOSH《危险化学品职业安全与卫生指南》之一百○五——一氧化碳

笔者在系统研究美国一系列有关化学物质的职业安全卫生专著、文件和我国的职业卫生标准的基础上,针对我国急性一氧化碳中毒高发的特点,详细描述了我国一氧化碳相关职业卫生标准以及《危险化学品职业卫生指南》中苯的指南卡内容,旨在为我国制定苯的综合职业卫生防护指南提供技术参考,同时也供职业卫生工作者在实际工作中预防控制一氧化碳危害借鉴使用。     

Determinants of adherence to oral hygiene prophylaxis guidelines in patients with previous infective endocarditis

BackgroundInfective endocarditis (IE) is characterized by low incidence but high mortality. Patients with a history of IE are at highest risk. Adherence to prophylaxis recommendations is poor. We sought to identify determinants of adherence to oral hygiene guidelines on IE prophylaxis in patients with a history of IE.MethodsUsing data from the cross-sectional, single-centre POST-IMAGE study, we analysed demographic, medical and psychosocial factors. We defined patients as adherent to prophylaxis if they declared going to the dentist at least annually and brushing their teeth at least twice a day. Depression, cognitive status and quality of life were assessed using validated scales.ResultsOf 100 patients enrolled, 98 completed the self-questionnaires. Among these, 40 (40.8%) were categorized as adherent to prophylaxis guidelines, and were less likely to be smokers (5.1% vs. 25.0%; P = 0.02) or have symptoms of depression (36.6% vs. 70.8%; P < 0.01) or cognitive decline (0% vs. 15.5%; P = 0.05). Conversely, they had higher rates of: valvular surgery since the index IE episode (17.5% vs. 3.4%; P = 0.04), searching for information on IE (61.1% vs. 46.3%, P = 0.05), and considering themselves as adherent to IE prophylaxis (58.3% vs. 32.1%; P = 0.03). Tooth brushing, dental visits and antibiotic prophylaxis were correctly identified as measures to prevent IE recurrence in 87.7%, 90.8% and 92.8% of patients, respectively, and did not differ according to adherence to oral hygiene guidelines.ConclusionsSelf-reported adherence to secondary oral hygiene guidelines on IE prophylaxis is low. Adherence is unrelated to most patient characteristics, but to depression and cognitive impairment. Poor adherence appears related more to a lack of implementation rather than insufficient knowledge. Assessment of depression may be considered in patients with IE.     

Do neurosurgeons subscribe to the guideline lumbosacral radicular syndrome?

Background: This study presents a survey of the opinion of neurosurgeons on the multidisciplinary clinical guideline ‘lumbosacral radicular syndrome’. The aim was to describe to what extent neurosurgeons in the Netherlands endorse the content of this guideline. The guideline was issued in 1996 by the Netherlands Institute of Quality Health Care and this is the first attempt to evaluate the implementation of this guideline. Methods: All active neurosurgeons (n=92) in the Netherlands were invited to complete a questionnaire investigating to what extent they agree with the 26 recommendations in the guideline ‘lumbosacral radicular syndrome’. The results are represented in frequencies (%) in order to express the magnitude of their consent or dissent with the recommendations. Results: Overall, 75% of the neurosurgeons responded and, of these, 94% agreed (at least partially) with the content of the guideline. Of the 26 recommendations in the guideline, seven were not fully endorsed by the neurosurgeons. Three of these seven recommendations may need revision based on newly published data. Conclusion: This survey shows that almost all neurosurgeons subscribed (at least partially) to the multidisciplinary LRS guideline. Therefore, one important aspect of the implementation process has been fulfilled, i.e. acceptance of the content of the guideline.     

Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients

Purpose

The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs).

Materials and Methods

We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN ÷ energy prescribed by the dietitian × 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy.

Results

The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs.

Conclusions

Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence.     

Systematic review of adherence to infection control guidelines in dentistry

OBJECTIVES: The purpose of this study was to determine the knowledge and attitudes of dental health care workers (DHCWs) towards infection control procedures, to examine DHCWs' practising behaviour in respect of infection control, and to determine whether a relationship exists between knowledge, attitudes and behaviour. METHODS: Within this systematic review, study quality was assessed in line with selection criteria relating to study design, participants, interventions and outcome measures. Following data extraction, the heterogeneity of study design, targeted participants, sample size and outcome measures precluded a quantitative analysis. Qualitative data synthesis followed. RESULTS: Overall, the quality of the studies reviewed was poor. Only 71 studies meeting the selection criteria were identified. Data indicated that over the period of the review there have been substantial improvements with compliance in some areas of infection control in dentistry, for example glove wearing. However, other aspects, such as the effective management of needlestick injuries, remain problematic. CONCLUSIONS: More rigorously designed studies are required to assess accurately dental team members' adherence to infection control guidelines.     

The trend and outcome of postsurgical therapy for high-risk early-stage cervical cancer with lymph node metastasis in Japan: a report from the Japan Society of Gynecologic Oncology (JSGO) guidelines evaluation committee

ObjectiveThe Japan Society of Gynecologic Oncology published the first guidelines for the treatment of cervical cancer in 2007. The aim of this research was to evaluate the influence of the introduction of the first guideline on clinical trends and outcomes of patients with early-stage cervical cancer who underwent surgery.MethodsThis analysis included 9,756 patients who were diagnosed based on the pathological Tumor-Node-Metastasis (pTNM) classification (i.e., pT1b1, pT1b2, pT2b and pN0, pN1, pNX) and received surgery as a primary treatment between 2004 and 2009. Data of these patients were retrospectively reviewed, and clinicopathological trends were assessed. The influence of the introduction of the guideline on survival was determined by using a competing risk model.ResultsFor surgery cases, the estimated subdistribution hazard ratio (HR) by the competing risk model for the influence of the guideline adjusted for age, year of registration, pT classification, pN classification, histological type, and treatment methods was 1.024 (p=0.864). Following the introduction of the first guideline in 2007, for patients with lymph node metastasis, the use of chemotherapy (CT) as a postsurgical therapy increased, whereas that of concurrent chemoradiotherapy (CCRT)/radiotherapy (RT) decreased (p<0.010). For pN1 cases, the estimated subdistribution HR by the competing risk model for the influence of the guideline was 1.094 (p=0.634). There was no significance in the postsurgical therapy between CT and CCRT/RT (p=0.078).ConclusionsSurvival of surgical cases was not improved by the introduction of the guidelines. It is necessary to consider more effective postsurgical therapy for high-risk early-stage cervical cancer.