[Recommendations concerning the use of serial tumor markers in management of primary bronchial cancers. Society of French Pneumology. Synthesis and recommendations].
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Biomarkers, Tumor↗
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Syphilis: recommended treatment schedules, 1976. Recommendations established by the Venereal Disease Control Advisory Committee.
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Administration, Oral↗
Syphilis - CDC recommended treatment schedules, 1976: the following recommendations were established by the Veneral Disease Control Advisory Committe after deliberation with therapy experts.
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Adult↗
[Works and recommendations of commissions of the French Society of Clinical Biology. Nomenclature in clinical chemistry and hematology. Recommendations concerning sizes and units and laboratory results (document B, stage 3)].
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Chemistry, Clinical↗
Exploration of physicians' recommendations for activities in chronic low back pain.
STUDY DESIGN: A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients. OBJECTIVES: To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations. SUMMARY OF BACKGROUND DATA: Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations. METHODS: Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders. RESULTS: Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms. CONCLUSIONS: Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.
Activities of Daily Living↗
The role of physicians' recommendations in medical treatment decisions.
BACKGROUND: A shift away from the medical paternalism of the past has occurred, and today, the law and ethics advocate that physicians share decision-making responsibility with their patients. It is unclear, however, what the appropriate role of physicians' recommendations ought to be in this new shared decision-making paradigm. One way to approach this question is to assess the influence of physicians' recommendations. OBJECTIVE: In this study, the authors examine the influence of physicians' recommendations on hypothetical treatment decisions. Do physicians' recommendations influence treatment decisions in scenarios where the decision that maximizes health is obvious and apparent to subjects? Do recommendations pull subjects away from the treatment choice that they otherwise prefer (based on their decision when unaware of the physicians' recommendation)? DESIGN: An experimental web questionnaire presented hypothetical medical treatment scenarios in which the treatment choice that maximized health was obvious. Across scenarios, the authors varied physicians' recommendations in 3 ways: (1) physicians' recommendations supporting what maximized health, (2) physicians' recommendations that went against what maximized health, and (3) no physicians' recommendation. The participants were 102 volunteers. RESULTS: Hypothetical treatment decisions were significantly influenced by physicians'recommendations (P < 0.0001), and physicians'recommendations against the decision that maximized health pulled subjects away from the treatment decision that they made when no recommendation was given (P < 0.0001). CONCLUSION: Physicians' recommendations can lead people to make decisions that go against what is best and against what they would otherwise prefer. Physicians must take care in making recommendations and should incorporate patient preferences into their recommendations.
Adult↗
Improving the use of research evidence in guideline development: 9. Grading evidence and recommendations.
BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the ninth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on grading evidence and recommendations in guidelines. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct a full systematic review ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: Should WHO grade the quality of evidence and the strength of recommendations? Users of recommendations need to know how much confidence they can place in the underlying evidence and the recommendations. The degree of confidence depends on a number of factors and requires complex judgments. These judgments should be made explicitly in WHO recommendations. A systematic and explicit approach to making judgments about the quality of evidence and the strength of recommendations can help to prevent errors, facilitate critical appraisal of these judgments, and can help to improve communication of this information. What criteria should be used to grade evidence and recommendations? Both the quality of evidence and the strength of recommendations should be graded. The criteria used to grade the strength of recommendations should include the quality of the underlying evidence, but should not be limited to that. The approach to grading should be one that has wide international support and is suitable for a wide range of different types of recommendations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which is currently suggested in the Guidelines for WHO Guidelines, is being used by an increasing number of other organizations internationally. It should be used more consistently by WHO. Further developments of this approach should ensure its wide applicability. Should WHO use the same grading system for all of its recommendations? Although there are arguments for and against using the same grading system across a wide range of different types of recommendations, WHO should use a uniform grading system to prevent confusion for developers and users of recommendations.
Journal Article↗
Enhancing pharmacists' recommendation process in an internal medicine resident clinic.
OBJECTIVE: To determine the number and type of recommendations made by pharmacists in an internal medicine residency clinic, the percentage of recommendations that were addressed and acted upon by the residents, whether changes needed to be made to the recommendation process, and areas in which pharmacy services could be improved. SETTING: Outpatient, urban, internal medicine clinic. PRACTICE DESCRIPTION: The clinic operates Monday through Thursday afternoons. Each of these afternoons, six to eight medical residents evaluate patients. Pharmacists provide services on Monday and Thursdays. The pharmacists spend the mornings before patients' visits reviewing charts and making recommendations for more appropriate medication use. Originally, pharmacists' recommendations were listed on a form that was attached to the front of each patient's chart but did not become a part of the medical record. At times, pharmacists made recommendations while a medical resident presented the patient's case to the attending physician. PRACTICE INNOVATION: Data for calendar year 2002 were analyzed retrospectively to identify a recommendation acceptance rate, areas of potential improvement, and actions that might enhance pharmacists' effectiveness. MAIN OUTCOME MEASURES: Number of recommendations made, number of each type of recommendation made, percentage of overall recommendations addressed and acted upon by the residents, and percentage of each type of recommendation addressed and acted upon by the resident physician. RESULTS: For 61 patients, 135 recommendations were made by pharmacists during 2002. Of these, 72 (53.3%) were therapeutic interventions and 63 (46.7%) were recommendations for laboratory monitoring. Overall, 66 (49.0%) recommendations were addressed and acted upon by the residents, while 69 (51.1%) were not addressed by the residents. Because of deficiencies identified in the communication process, a new form was developed that includes spaces for pharmacists' recommendations and residents' responses. Other potential future enhancements include providing more education for residents and implementing a pharmacist-run disease clinic. CONCLUSION: This retrospective analysis showed that pharmacists were able to identify many therapeutic and laboratory interventions, thus serving a useful role in patient care and physician education in an internal medicine residency clinic.
Ambulatory Care Facilities↗
Public health and clinical recommendations for physical activity and physical fitness: special focus on overweight youth.
Numerous physical activity and physical fitness recommendations exist for youth. To date, however, no investigator has systematically reviewed these public health and clinical guidelines to determine whether the recommendations address overweight youth. This review examines youth-oriented physical activity and physical fitness recommendations for both the public health community and the clinical community, and assesses how overweight youth are specifically targeted by each of these two groups. Our review determined the extent to which the recommendations assessed four components of physical activity (i.e. frequency, intensity, duration and type) and four components of physical fitness (i.e. cardiorespiratory capacity, strength, flexibility and body composition). We further reviewed clinical recommendations to determine how they included two facets of the physician-patient encounter: assessment and counselling. After identifying all current physical activity and physical fitness recommendations for youth, we evaluated whether public health (n = 13) and clinical recommendations (n = 12) addressed physical activity and physical fitness for overweight youth. Findings revealed inconsistent, yet explicit, recommendations for the public health community where most organisations (12 of 13, 92%) included > or =3 physical activity components. In addition, organisations encouraged volumes of daily moderate- to vigorous-intensity physical activity for youth ranging from 30-60 or more minutes. Recommendations for the clinical community generally did not provide explicit physical activity and fitness recommendations to advise physicians on the assessment and counselling of patients and their families. Overweight youth were addressed within some recommendations (6 of 12, 50%) for the clinical community, but within few recommendations (2 of 13, 15%) for the public health community. To best inform public health and clinical communities, organisations developing future recommendations should include information fully documenting the decision-making processes used to develop the recommendations. In cases where mutual goals exist, public health and clinical communities should consider collaborating across agencies to develop joint recommendations.
Adolescent↗
[Treatment recommendations in psychosomatic rehabilitation -- empirical analyses based on the pension insurers' standardized discharge report].
BACKGROUND: The recommendations for aftercare listed in discharge reports represent a core component of communication between inpatient psychosomatic rehabilitation and ambulatory follow-up care. The standardized discharge report used by the pension insurance institutes makes use of a generic category system for systematization and simplification of recommendations for aftercare. Neither the practice of making recommendations for aftercare as observed by therapists and physicians responsible for treatment in the inpatient setting nor the appropriateness and differentiation of the category system has previously been systematically examined. A randomized sample of discharge reports was analyzed for this purpose. METHODS: A sample of 500 discharge reports from an inpatient-oriented psychosomatic rehabilitation setting were analyzed regarding the categories of recommended aftercare measures and their relationship with socio-demographic variables, clinical diagnosis and sociomedical variables. RESULTS: Outpatient psychotherapy represents the most frequently recommended aftercare treatment, being suggested in nearly 70% of the patients. Further substantial percentages were found in recommendations for areas including occupational rehabilitation, somatic-medical recommendations, and recommendations for health behaviour and self-help groups. In approximately one quarter of the patients, recommendations for aftercare were given that were coded under the category of "other suggestions". In younger and socio-medically burdened patients, recommendations for the fields of occupational rehabilitation and psychotherapy were more frequently given. In patients with a somatic illness or a somatoform disorder as the primary diagnosis, recommendations within the field of outpatient psychotherapy were found less frequently, while recommendations in the somatic-medical area were more commonly found. DISCUSSION: The results give some support for the clinical validity of the form of recommendations given for aftercare measures in an inpatient psychosomatic rehabilitation setting. At the same time, the analyses indicate excessive as well as insufficient differentiation in the generic category system for follow-up treatment recommendations, which could lead to a loss of valuable information at the interface between inpatient and outpatient treatments.
Adult↗
The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support.
This publication contains the pediatric and neonatal sections of the 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (COSTR). The consensus process that produced this document was sponsored by the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1993 and consists of representatives of resuscitation councils from all over the world. Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and to generate consensus on treatment recommendations. ECC includes all responses necessary to treat life-threatening cardiovascular and respiratory events. The COSTR document presents international consensus statements on the science of resuscitation. ILCOR member organizations are each publishing resuscitation guidelines that are consistent with the science in this consensus document, but they also take into consideration geographic, economic, and system differences in practice and the regional availability of medical devices and drugs. The American Heart Association (AHA) pediatric and the American Academy of Pediatrics/AHA neonatal sections of the resuscitation guidelines are reprinted in this issue of Pediatrics (see pages e978-e988). The 2005 evidence evaluation process began shortly after publication of the 2000 International Guidelines for CPR and ECC. The process included topic identification, expert topic review, discussion and debate at 6 international meetings, further review, and debate within ILCOR member organizations and ultimate approval by the member organizations, an Editorial Board, and peer reviewers. The complete COSTR document was published simultaneously in Circulation (International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2005;112(suppl):73-90) and Resuscitation (International Liaison Committee on Resuscitation. 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2005;67:271-291). Readers are encouraged to review the 2005 COSTR document in its entirety. It can be accessed through the CPR and ECC link at the AHA Web site: www.americanheart.org. The complete publication represents the largest evaluation of resuscitation literature ever published and contains electronic links to more detailed information about the international collaborative process. To organize the evidence evaluation, ILCOR representatives established 6 task forces: basic life support, advanced life support, acute coronary syndromes, pediatric life support, neonatal life support, and an interdisciplinary task force to consider overlapping topics such as educational issues. The AHA established additional task forces on stroke and, in collaboration with the American Red Cross, a task force on first aid. Each task force identified topics requiring evaluation and appointed international experts to review them. A detailed worksheet template was created to help the experts document their literature review, evaluate studies, determine levels of evidence, develop treatment recommendations, and disclose conflicts of interest. Two evidence evaluation experts reviewed all worksheets and assisted the worksheet reviewers to ensure that the worksheets met a consistently high standard. A total of 281 experts completed 403 worksheets on 275 topics, reviewing more than 22000 published studies. In December 2004 the evidence review and summary portions of the evidence evaluation worksheets, with worksheet author conflict of interest statements, were posted on the Internet at www.C2005.org, where readers can continue to access them. Journal advertisements and e-mails invited public comment. Two hundred forty-nine worksheet authors (141 from the United States and 108 from 17 other countries) and additional invited experts and reviewers attended the 2005 International Consensus Conference for presentation, discussion, and debate of the evidence. All 380 participants at the conference received electronic copies of the worksheets. Internet access was available to all conference participants during the conference to facilitate real-time verification of the literature. Expert reviewers presented topics in plenary, concurrent, and poster conference sessions with strict adherence to a novel and rigorous conflict of interest process. Presenters and participants then debated the evidence, conclusions, and draft summary statements. Wording of science statements and treatment recommendations was refined after further review by ILCOR member organizations and the international editorial board. This format ensured that the final document represented a truly international consensus process. The COSTR manuscript was ultimately approved by all ILCOR member organizations and by an international editorial board. The AHA Science Advisory and Coordinating Committee and the editor of Circulation obtained peer reviews of this document before it was accepted for publication. The most important changes in recommendations for pediatric resuscitation since the last ILCOR review in 2000 include: Increased emphasis on performing high quality CPR: "Push hard, push fast, minimize interruptions of chest compression; allow full chest recoil, and don't provide excessive ventilation" Recommended chest compression-ventilation ratio: For lone rescuers with victims of all ages: 30:2 For health care providers performing 2-rescuer CPR for infants and children: 15:2 (except 3:1 for neonates) Either a 2- or 1-hand technique is acceptable for chest compressions in children Use of 1 shock followed by immediate CPR is recommended for each defibrillation attempt, instead of 3 stacked shocks Biphasic shocks with an automated external defibrillator (AED) are acceptable for children 1 year of age. Attenuated shocks using child cables or activation of a key or switch are recommended in children <8 years old. Routine use of high-dose intravenous (IV) epinephrine is no longer recommended. Intravascular (IV and intraosseous) route of drug administration is preferred to the endotracheal route. Cuffed endotracheal tubes can be used in infants and children provided correct tube size and cuff inflation pressure are used. Exhaled CO2 detection is recommended for confirmation of endotracheal tube placement. Consider induced hypothermia for 12 to 24 hours in patients who remain comatose following resuscitation. Some of the most important changes in recommendations for neonatal resuscitation since the last ILCOR review in 2000 include less emphasis on using 100% oxygen when initiating resuscitation, de-emphasis of the need for routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid, proven value of occlusive wrapping of very low birth weight infants <28 weeks' gestation to reduce heat loss, preference for the IV versus the endotracheal route for epinephrine, and an increased emphasis on parental autonomy at the threshold of viability. The scientific evidence supporting these recommendations is summarized in the neonatal document (see pages e978-e988).
Child↗
Lifestyle modifications to prevent and control hypertension. 6. Recommendations on potassium, magnesium and calcium. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada.
OBJECTIVE: To provide updated, evidence-based recommendations on the consumption, through diet, and supplementation of the cations potassium, magnesium and calcium for the prevention and treatment of hypertension in otherwise healthy adults (except pregnant women). OPTIONS: Dietary supplementation with cations has been suggested as an alternative or adjunctive therapy to antihypertensive medications. Other options include other nonpharmacologic treatments for hypertension. OUTCOMES: The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered. EVIDENCE: A MEDLINE search was conducted for the period 1966-1996 with the terms hypertension and potassium, magnesium and calcium. Reports of trials, meta-analyses and review articles were obtained. Other relevant evidence was obtained from the reference lists of articles identified, from the personal files of the authors and through contacts with experts. The articles were reviewed, classified according to study design, and graded according to the level of evidence. VALUES: A high value was placed on the avoidance of cardiovascular morbidity and premature death caused by untreated hypertension. BENEFITS, HARMS AND COSTS: The weight of the evidence from randomized controlled trials indicates that increasing intake of or supplementing the diet with potassium, magnesium or calcium is not associated with prevention of hypertension, nor is it effective in reducing high blood pressure. Potassium supplementation may be effective in reducing blood pressure in patients with hypokalemia during diuretic therapy. RECOMMENDATIONS: For the prevention of hypertension, the following recommendations are made: (1) The daily dietary intake of potassium should be 60 mmol or more, because this level of intake has been associated with a reduced risk of stroke-related mortality. (2) For normotensive people obtaining on average 60 mmol of potassium daily through dietary intake, potassium supplementation is not recommended as a means of preventing an increase in blood pressure. (3) For normotensive people, magnesium supplementation is not recommended as a means of preventing an increase in blood pressure. (4) For normotensive people, calcium supplementation above the recommended daily intake is not recommended as a means of preventing an increase in blood pressure. For the treatment of hypertension, the following recommendations are made. (5) Potassium supplementation above the recommended daily dietary intake of 60 mmol is not recommended as a treatment for hypertension. (6) Magnesium supplementation is not recommended as a treatment for hypertension. (7) Calcium supplementation above the recommended daily dietary intake is not recommended as a treatment for hypertension. VALIDATION: These guidelines are consistent with the results of meta-analyses and recommendations made by other organizations. They have not been clinically tested. SPONSORS: The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada.
Adult↗
The 2004 Canadian recommendations for the management of hypertension: Part II--Therapy.
OBJECTIVE: To provide updated, evidence-based recommendations for the management of hypertension in adults. OPTIONS AND OUTCOMES: For patients who require pharmacological therapy for hypertension, a number of antihypertensive agents may be used. Randomized trials evaluating first-line therapy with diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), alpha-blockers, centrally acting agents or angiotensin receptor antagonists were reviewed. Also, randomized trials evaluating other agents, such as statins or acetylsalicylic acid, in patients with hypertension were reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. In addition, other relevant outcomes such as development of end-stage renal disease or changes in blood pressure were examined where appropriate. EVIDENCE: MEDLINE searches were conducted from November 2001 to October 2003 to update the 2001 Recommendations for the management of hypertension. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently, using prespecified levels of evidence by content and methodology experts. RECOMMENDATIONS: This document contains detailed recommendations and supporting evidence on treatment thresholds, target blood pressures and choice of agents for hypertensive patients with or without comorbidities. Lifestyle modifications are a key component of any antiatherosclerotic management strategy and detailed recommendations are contained in a separate document. Key recommendations for pharmacotherapy include the following: treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbidities, with particular attention to systolic blood pressure; blood pressure should be lowered to 140/90 mmHg or less in all patients, and 130/80 mmHg or less in those with diabetes mellitus or renal disease (125/75 mmHg or less in those with nondiabetic renal disease and more than 1 g of proteinuria per day); most adults with hypertension require more than one agent to achieve target blood pressures; for adults without compelling indications for other agents, initial therapy should include thiazide diuretics; other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), ACE inhibitors (in non-Blacks), long-acting dihydropyridine CCBs or angiotensin receptor antagonists; other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine CCBs or angiotensin receptor antagonists; certain comorbidities provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or thiazides in patients with diabetes mellitus without albuminuria) are appropriate first-line therapies; and in patients with mild to moderate nondiabetic renal disease, ACE inhibitors are recommended; all hypertensive patients should have their fasting lipids screened and those with dyslipidemia should be treated using the thresholds, targets and agents as per the Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease; and selected patients with hypertension should also receive statin and/or acetylsalicylic acid therapy. VALIDATION: All recommendations were graded according to the strength of the evidence and voted on by the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. Individuals with irreconcilable competing interests (declared by all members, compiled and circulated before the meeting) relative to any specific recommendation were excluded from voting on that recommendation. Only recommendations achieving at least 70% consensus are reported here. These guidelines will continue to be updated annually.
Adult↗
Applying the grades of recommendation for antithrombotic and thrombolytic therapy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
This article about the grades of recommendation for antithrombotic and thrombolytic therapy is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Clinicians need to know whether a recommendation is strong or weak, and about the methodological quality of the evidence underlying that recommendation. We determine the strength of a recommendation by considering the trade-off between the benefits of a treatment, on the one hand, and the risks, burdens, and costs on the other. Here, as elsewhere, we assume that a recommended treatment will increase costs (we recognize this is not always the case, but for simplicity we will continue to make this assumption). If the benefits outweigh the risks, burdens, and costs, we recommend that clinicians offer a treatment to typical patients. The uncertainty associated with the trade-off between the benefits and the risks, burdens, and costs will determine the strength of the recommendations. If we are very certain that the benefits do, or do not, outweigh the risks, burdens, and costs, we make a strong recommendation (in our formulation, Grade 1). If we are less certain of the magnitude of the benefits and the risks, burdens, and costs, and thus of their relative impact, we make a weaker Grade 2 recommendation. We grade the methodological quality of a recommendation according to the following criteria. Randomized clinical trials (RCTs) with consistent results provide evidence with a low likelihood of bias, which we classify as Grade A recommendations. RCTs with inconsistent results, or with major methodological weaknesses, warrant Grade B recommendations. Grade C recommendations come from observational studies or from a generalization from one group of patients included in randomized trials to a different, but somewhat similar, group of patients who did not participate in those trials. When we find the generalization from RCTs to be secure, or the data from observational studies overwhelmingly compelling, we choose a Grade C+. When that is not the case, we designate methodological quality as Grade C.
Bias↗
Primary care physician recommendations for colorectal cancer screening. Patient and practitioner factors.
BACKGROUND: Current guidelines for colorectal cancer screening do not specify the role of age or comorbidity in patient selection. Reported screening practices may thus be influenced by patient, as well as physician, characteristics. METHODS: A questionnaire was sent to primary care physicians in 10 states to determine recommendations for fecal occult blood testing (FOBT) and sigmoidoscopy in 4 pairs of clinical vignettes that varied by patient age (65 or 75 years) and comorbidity (none, mild, moderate, and terminal). RESULTS: Among the 884 respondents (50%), most physicians recommended FOBT in all vignettes except those with a terminal illness and fewer than half recommended sigmoidoscopy in any vignette. Physician recommendations were influenced by comorbidity, but one third still recommended FOBT for terminally ill patients and less than 50% recommended sigmoidoscopy for patients with no comorbidity. Differences in recommended screening between vignettes that differed only in patient age were small. Among all subgroups of physicians, at least 30% recommended FOBT in terminally ill patients and no more than 60% recommended sigmoidoscopy in healthy patients. CONCLUSIONS: Primary care physicians were much more likely to recommend screening with FOBT than sigmoidoscopy, regardless of patient and practitioner factors. Although physician recommendations were influenced by patient comorbidity and age, they frequently recommended FOBT in clinically inappropriate settings and failed to recommend sigmoidoscopy when appropriate. Broad-based interventions to improve appropriate screening practices may be needed.
Aged↗
Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment.
BACKGROUND: We evaluated depression severity, health-related quality of life (HRQL), and medical cost outcomes of primary care patients receiving recommended and less-than-recommended levels of antidepressant treatment. METHODS: We performed a secondary analysis of clinical trial data from primary care clinics in a staff-model managed care organization. The trial included patients with Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depression who were starting antidepressant treatment. The primary outcomes measures used were the 17-item Hamilton Depression Rating Scale (HDRS), Hopkins Symptom Checklist depression scores, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) mental and physical component summary scores, and the total outpatient and inpatient medical costs. RESULTS: Of 358 patients starting antidepressant treatment, 195 (54.5%) received doses recommended by the Agency for Health Care Policy and Research for 90 days or more. Mean HDRS score decreased from 14.1 to 8.8 in patients receiving less-than-recommended treatment and decreased from 13.8 to 8.9 in patients with minimum recommended treatment (P = .761). No significant differences in improvement of HRQL outcomes during 6 months were observed between patients receiving recommended or less-than-recommended antidepressant therapy. Mean total medical costs over 6 months for patients taking the recommended levels of antidepressant treatment were $1872 +/- 140 compared with $2622 +/- 413 for patients taking less-than-recommended treatment (P = .032). The differences in total medical costs were attributable to significantly lower nonmental health-related inpatient costs in the recommended antidepressant treatment group ($104 vs $785, P = .004). CONCLUSIONS: Patients receiving minimum recommended levels of antidepressant therapy for 3 months showed improvement in depression severity and HRQL comparable with patients receiving less-than-recommended treatment. Patients receiving minimum recommended treatment had lower total costs and nonmental health-related inpatient costs. Antidepressant treatment in primary care patients may have the greatest impact on the frequency of health care visits and on costs for medical conditions and impairments.
Adult↗
What influences physician practice behavior? An interview study of physicians who received consultative geriatric assessment recommendations.
BACKGROUND: Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation. OBJECTIVE: To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved. METHODS: A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions. RESULTS: Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01). CONCLUSIONS: Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.
Ambulatory Care↗
[Effects of recommendations and patient seminars on effectivity of outpatient treatment for headache].
BACKGROUND: Treatment of patients suffering from migraine and/or tension-type headache in primary care needs to be improved. To this purpose we tested two strategies for implementation of evidence-based recommendations for treatment of headaches: first, communication of recommendations to the primary care physicians and, second, standardized communication and discussion of these recommendations with patients in combination with exercising of progressive muscle relaxation during patient seminars. METHODS: Patients with at least 2 migraine attacks/month or 8 days of tension-type headache/month were included in the study. Evidence-based pharmacological and non-pharmacological recommendations of the Medicines Committee of the German Medical Profession for treatment of migraine and tension-type headache have been offered to primary care physicians by printed material and during conferences. Patient seminars at 10 days for 2 hours were organized by the outpatient pain facility of the neurological department of the university of Erlangen. During seminars the patients were informed about these recommendations and learned progressive muscle relaxation. Agreed therapy between physician and patient was documented by physicians and patients during a 6 months treatment interval and compared with the recommended therapy. Effectivity of treatment was assessed by pre-post changes of days of headache/month, attack frequency/month, headache intensity (visual analogue scale), pain related impairment (German version of the Brief Pain Inventory), and health related quality of life (German Version of the SF-36). 51 patients were documented by 24 primary care physicians after communication of recommendations and 46 patients completed the patient seminar. Data of both groups were compared with those of 80 patients from primary care physicians before interventions. RESULTS: Communication of recommendations for headache therapy to primary care physicians did not improve conformity of the agreed therapy with the recommended. Contrary conformity of the agreed therapy for pharmacological treatment of migraine attacks and interval therapy of migraine by progressive muscle relaxation with the recommended therapy improved significantly. However, interventions did not significantly improve the outcome quality of outpatient treatment as compared to the therapy of primary care physicians before interventions. CONCLUSION: Effectivity of headache treatment in primary health care could not be improved by communication of evidence-based recommended therapy to primary care physicians nor by direct information of patients about these recommendations in combination with provided availability to learn progressive muscle relaxation.
Adult↗