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Clinical practice must be evaluated for efficiency and effectiveness using a logical, step-by-step methodology. Problem-solving models can serve as a guide to help clinicians systematically evaluate and answer the question, "Do nursing interventions make a difference?" Ultimately, this type of clinical practice evaluation will contribute to improving quality patient care as well as the efficiency of nurses' time.
Through the use of three scenarios, this paper presents the challenges for clinical practice guidelines in the 21st century. Such challenges relate to technological developments to improve the efficiency and pace of the development process, to ensure that clinical practice guidelines are kept up to date, and to facilitate implementation of guidelines in the clinical setting. To improve and ensure the validity of the content of clinical practice guidelines, we need to address the important problem of publication bias, for which researchers, granting agencies, industry, and journal editors share responsibility. This means insisting on registration of trials at their inception, and incentives backed up by rules for funding and peer review publication that would promote behaviors to avoid publication bias. The more difficult challenges for clinical practice guidelines relate to what are referred to as attitudinal factors. To achieve optimal efficiencies in development and maintenance of clinical practice guidelines, we need to promote cooperation among various information resource providers internationally and to stress partnership over leadership. Finally, there need to be reconciliation of the different stakeholder perspectives of the value and purpose of clinical practice guidelines so that they are used appropriately as aids to decision making and are not abused as tools for controlling clinical practice.
This paper focuses on some issues in the assessment of clinical practice of particular interest to the author. The assessment of students of nursing in clinical practice is acknowledged as a long-standing and difficult problem. There is little consensus as to what is meant by the term competence when applied to clinical nursing practice, making the assessment of clinical practice a mainly subjective process. The English National Board (1989) has distinguished the term mentor as meaning counsellor and guide, nevertheless the roles of mentor and assessor are frequently confused. It is suggested that nurses are equally accountable for the accurate assessment of student nurses' clinical skills as they are for their own practice. The validity and reliability of tools used to assess clinical practice are difficult to establish, making objective assessment complex at best, and impossible at worst. The assessment of the reflective process has been suggested as one way out of the dilemma, but the ability to think and to write does not necessarily translate into competent clinical practice.
OBJECTIVE: Clinical practice guidelines are widely used as effective tools for improving the management of patients with cancer. However, there is increasing concern about variation in guideline quality. In this study we identified predictors for high-quality guidelines in oncology. DESIGN: The quality scores for 32 oncology guidelines from 13 countries were determined by four independent appraisers using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. MAIN MEASURE: : The contribution to the quality score of six characteristics of guidelines and three of guideline developing organizations was then assessed using analysis of variance and stepwise linear regression analysis. RESULTS: Some guideline and organizational characteristics were shown to be responsible for a large part of the variations in quality scores. The availability of background information was the strongest predictor of quality with an explained variance ranging from 17% ("Applicability") to 67% ("Rigour of development"). High-quality guidelines were more often produced by government-supported organizations and/or within a structured, coordinated programme. The other characteristics (publication year, type of guideline, format, level of care, and scope) were not independent predictors of quality. CONCLUSIONS: Guidelines should provide more explicit information about the context of their development and methods used in order to improve their quality and thus encourage their use in clinical practice.
PURPOSE: To compare physician referral practices and attitudes regarding hereditary breast cancer by clinical practice location. METHODS: A self-administered survey of 214 physicians in Ohio's tri-state region. RESULTS: Rural-practice physicians were less likely to have ever referred for an indication of hereditary breast cancer than urban- and suburban-practice physicians combined. Rural-practice physicians reported stronger barriers to referral, including distance, lack of awareness, lack of effective cancer risk reduction, and lack of patient interest. CONCLUSION: These findings demonstrate a need for increased clinical genetics outreach, physician education, and public awareness of genetic services for hereditary breast cancer in rural areas.
In Japan, the governmental report on health technology assessment in 1999 referred to the need to develop evidence-based clinical practice guidelines. The Ministry of Health and Welfare established priorities for the development of clinical practice guidelines, and started several projects. About 20 clinical practice guidelines are to be developed by 2004. However, what "guideline" means and how "guidelines" work are unclear because the word "guideline" is ambiguous in Japan. Although it is generally accepted that "directives are stronger than recommendations, which are stronger than guidelines" in the western countries, Japanese people do not usually recognize these distinctions and tend to regard guidelines as mandatory directives even in individual cases. Patients, consumers and legal professionals may overestimate the authority of clinical practice guidelines when they see them. What clinical practice guidelines are, or are not should be clarified appropriately. Autumn 2003, the Japan Council for Quality Health Care will open the information service that provides practice guidelines and related literature. This will be accessible to both healthcare professionals and the general public. Much remains to be done to bring other stakeholders to the table. All of Japanese society can, and needs to, participate in the process of developing a consensus on clinical practice guidelines.
An interdisciplinary forum to examine systems related to clinical practice strengthens collaboration and capitalizes on the collective knowledge base of all members. The success of the clinical practice committee is dependent primarily on the ability of the group to negotiate complex systems, as well as authorize changes in clinical practice. The nurse leader plays a critical role as facilitator and mentor in this process. This report describes the evolution of the clinical practice committees at Children's Hospital Boston, provides practical strategies for group development, includes methods to maximize the effectiveness of a diverse group, and presents examples of system improvements and outcomes that have emerged from this interdisciplinary team.
AIMS: Revascularization in patients with coronary artery disease changed over the last two decades, favouring the number of patients treated by means of percutaneous coronary interventions (PCI) when compared with coronary artery bypass grafting (CABG). Many randomized controlled trials (RCTs) have been performed to compare these two competing revascularization techniques. Because of the strict enrolment criteria of RCTs in which highly selected patients are recruited, the applicability of the results may be limited in clinical practice. The current study evaluates to what extent patients in clinical practice were similar to those who participated in RCTs comparing PCI with CABG. METHODS AND RESULTS: Clinical characteristics and 1-year outcome of 4713 patients enrolled in the Euro Heart Survey on Coronary Revascularization were compared with 8647 patients who participated in 14 major RCTs, comparing PCI with CABG. In addition, we analysed which proportion of survey patients would have disqualified for trial participation (n=3033, 64%), aiming at identifying differences between trial-eligible and trial-ineligible survey patients. In general, important differences were observed between trial participants and survey patients. Patients in clinical practice were older, more often had comorbid conditions, single-vessel disease, and left main stem stenosis when compared with trial participants. Almost identical differences were observed between trial-eligible and trial-ineligible survey patients. In clinical practice, PCI was the treatment of choice, even in patients who were trial-ineligible (46% PCI, 26% CABG, 28% medical). PCI remained the preferred treatment option in patients with multi-vessel disease (57% in trial-eligible and 40% in trial-ineligible patients, respectively, P<0.001); yet, the risk profile of patients treated by PCI was better than that for patients treated either by CABG or by medical therapy. In the RCTs, there was no mortality difference between PCI and CABG. In clinical practice, however, we observed 1-year unadjusted survival benefit for PCI vs. CABG (2.9 vs. 5.4%, P<0.001). Survival benefit was only observed in trial-ineligible patients (3.3 vs. 6.2%, P<0.001). CONCLUSION: Many patients in clinical practice were not represented in RCTs. Moreover, only 36% of these patients were considered eligible for participating in a trial comparing PCI with CABG. We demonstrated that RCTs included younger patients with a better cardiovascular risk profile when compared with patients in everyday clinical practice. This study highlights the disparity between patients in clinical practice and patients in whom the studies that provide the evidence for treatment guidelines are performed.
INTRODUCTION: Evaluation of clinical practice in pulmonary oncology aims to improve both the quality of care and the control of costs. REVIEW OF THE LITERATURE: A Medline search of the literature allowed analysis of the published studies of the evaluation of clinical practice. They showed that though 82-95% of patients with small cell bronchial carcinoma were treated with a combination of etoposide and cisplatin, less than half of the patients with non-small cell cancer received treatment. VIEWPOINT: Various factors such as age, comorbidity, race, socio-economic status and gender affect the treatment decisions. There is also a discrepancy between the trial data and clinical practice that could be explained by two factors. On one hand advances are not always adopted by doctors and on the other hand the patient populations treated may sometimes be different from those in the trials. CONCLUSION: Though the number of published studies is still low an increase is to be expected on account of the publication of new regulations concerning the evaluation of clinical practice and the appropriate use of drugs.
OBJECTIVE: To describe the complete range of factors which doctors recognise as changing their clinical practice and provide a measure of how often education is involved in change. DESIGN: Interviews using the critical incident technique. SETTING: Primary and secondary care. SUBJECTS: Random sample of 50 general practitioners and 50 consultants. MAIN OUTCOME MEASURES: Categories of reasons for change in clinical practice. RESULTS: Doctors described 361 changes in clinical practice, with an average of 3.0 reasons per change. The three most frequently mentioned reasons were organisational factors, education, and contact with professionals, together accounting for 47.9% of the total number of reasons for change. Education accounted for one sixth (16.9%) of the reasons for change and was involved in one third (37.1%) of the changes. Education was seldom mentioned as a reason for change in referral practice but was more often mentioned in management and prescribing changes. Consultants were influenced by medical journals and scientific conferences, while general practitioners were more influenced by medical newspapers and postgraduate meetings. CONCLUSIONS: Education is involved in about a third of changes in clinical practice. The wide range of other factors affecting changes in practice need to be taken into account in providing and evaluating education. The role of education in the numerous changes in clinical practice that currently have no educational component should also be considered.
Encouraging professionals in training and later to consider practice-related research findings when making important clinical decisions is an on-going concern. Evidenced-Based Medicine (EBM) and the Cochrane Collaboration (CC) provide a source of tools and ideas for doing so, as well as a roster of colleagues who share this interest. Evidenced-based medicine involves integrating clinical expertise with the best available external evidence from systematic research as well as considering the values and expectations of patients/clients. Advantage can be taken of educational formats developed in EBM, such as problem-based learning and critical-appraisal workshops in which participants learn how to ask key answerable questions related to important clinical practice questions (e.g., regarding effectiveness, accuracy of assessment measures, prediction, prevention, and quality of clinical practice guidelines) and to access and critically appraise related research. The Cochrane Collaboration is a world-wide network of centers that prepare, maintain, and disseminate high-quality systematic reviews on the efficacy of healthcare. These databases allow access to evidence related to clinical practice decisions. Forging reciprocal working relationships with those involved in EBM reciprocal and the CC should contribute to the pursuit of shared goals such as basing clinical decisions on the best-available evidence and involving clients as informed consumers.
BACKGROUND: Clinical practice guidelines are issued periodically by professional medical societies or committees to assist practitioners in clinical decision making. However, it is unclear whether such guidelines have any lasting impact on clinical practice. OBJECTIVE: The purpose of this study was to assess the impact of the American Society of Clinical Oncology (ASCO) guidelines regarding use of hematopoietic colony-stimulating factors (CSF) on cancer care in a university hospital in Paris. METHODS: The study was performed at Hĵpital Tenon, an 830-bed university hospital in Paris, in 1996 and 1997, both before and after the ASCO guidelines were implemented. The guidelines were first disseminated as a continuing medical education program and then actively implemented using a CSF prescription order form summarizing the guidelines. This form had to be used during the patient consultation and was sent to the Hĵpital Tenon pharmacy for CSF dispensation. Even if CSF use did not comply with the ASCO guidelines, the pharmacy filled the prescription. Seven other university hospitals in Paris, where the ASCO guidelines were not actively implemented, comprised the control group. The main outcome measure was the proportion of prescriptions in compliance with the 1996 update of the ASCO guidelines. Secondary outcome measures were the proportions of prescriptions in compliance with ASCO guidelines regarding primary prophylactic, secondary prophylactic, and therapeutic CSF administration. RESULTS: Before implementation of the ASCO guidelines, CSF use in compliance with the guidelines was 39% (41/105) at the study site and 31% (16/51) at the control sites (P > 0.05). Six months after dissemination and implementation of the guidelines, the proportion of CSF prescriptions complying with ASCO guidelines increased significantly versus baseline (P = 0.003) in the study group, to 61% (50/82). However, even after the guidelines were implemented, compliance with guidelines on primary prophylactic CSF administration did not change significantly versus before implementation in the study group (12% [5/41] before implementation vs 6% [2/33] after implementation; P > 0.05). CONCLUSIONS: The results suggest an association between the active implementation strategy (continuing medical education and CSF prescription reminder form) and physician compliance with the ASCO guidelines. Implementation of the ASCO guidelines appears to have had some impact on medical practice.
BACKGROUND: Recent studies reveal patients on protease inhibitor (PI)-based regimens achieve viral suppression less often in clinical practice than in clinical trials. Nonnucleoside reverse transcriptase inhibitors (NNRTIs) can provide an equally effective and more convenient alternative. PURPOSE: This retrospective chart review examines the effectiveness, tolerability, and convenience of a nevirapine (NVP), stavudine (d4T), and lamivudine (3TC)-containing regimen in an urban HIV clinical practice. METHOD: Chart review of patients from September 1996 to April 2000 yielded 73 patients on NVP+d4T+3TC; 83.6% were treatment experienced. RESULTS: By 16 weeks, 86.4% (57/66) had viral loads (VL) <400 in an as-treated (AT) analysis, while 78.1% (57/73) had VL <400 in an intent-to-treat (ITT) analysis. By 24 weeks, 84.6% (33/39) had VL <50 (AT). Beyond 48 weeks, 88.9% (16/18) had VL <50. The mean CD4 increase was 170 cells/mm(3). Rash was the most common adverse event (13.7%) in this review. CONCLUSION: Consistent with other studies, this NVP+d4T+3TC regimen appears effective in both treatment-experienced and -naive patients, regardless of baseline viral loads, in a clinical practice setting.
There is limited research on student perceptions of their clinical experiences particularly in different clinical courses and settings. The purpose of this study was to examine the degree of stress, challenge, and threat associated with clinical practice experiences among ADN and BSN nursing students enrolled in various clinical courses and settings. The Pagana Clinical Stress Questionnaire was used to assess the clinical experiences of 416 undergraduate nursing students from 10 randomly selected associate degree (ADN) and baccalaureate (BSN) programs in the midwest. Significant differences were found across clinical courses (F[5,399] = 9.58, p < .0001) and settings (F[2,386] = 4.63, p = .01) in terms of students' stress. Stress was highest for students enrolled in pediatric nursing courses. ANOVA indicated significant differences across clinical courses in the degree of challenge and threat experienced by students. There were no differences in any of the variables studied when students had faculty from the nursing program or preceptors from the clinical setting as their teachers.
OBJECTIVE: To identify primary care physicians' familiarity with the 2004 acute otitis media (AOM) clinical practice guideline and to compare their practices with its recommendations. DESIGN: Mail survey October through December 2004 to all active physician members of the Slone Center Office-based Research Network, a national, practice-based, pediatric research network. RESULTS: The response rate was 276 of 469 (58.8%). Overall, 90.5% had read the guideline or summaries of it. Pneumatic otoscopy was always used by 16.2%, used half the time or more by 23.1%, used less than half the time by 34.6% and never used by 26.2%. Observation is considered a reasonable option for some AOM cases by 88.0% and, over the previous 3 months, these physicians used observation a median of 10% of the time (25th and 75th percentiles, 5% and 25%, respectively). In terms of concern that the observation option may increase AOM complications, 75.6% were not at all or only slightly concerned; 24.4% were moderately or very concerned. In general, these physicians have altered their antibiotic prescribing practices for AOM towards the guideline's recommendations since its publication. However, antibiotic choices deviated most widely from the guideline in cases of AOM with severe illness, where only 17.9% follow the recommendation for high-dose amoxicillin-clavulanate, and in cases of children who fail treatment with amoxicillin-clavulanate, where only 27.7% favor the recommended intramuscular ceftriaxone. CONCLUSIONS: Most physicians in this survey are familiar with the AOM guideline, but many do not follow its diagnostic and antibiotic recommendations. Observation for selected cases is acceptable to most of these physicians and is currently used in a small proportion of cases.
Psoriasis treatment is highly individualized. Although a standardized assessment of psoriasis severity for clinical practice may be theoretically advantageous for the purposes of determining treatment, the relevance of currently available research tools in clinical practice is uncertain. Our objectives were to ascertain in workshop discussions and through a prospective survey the relevance of standard severity measures in clinical practice with regard to choice of treatment. Although there was agreement on the possible structure of an algorithm for the treatment-related definition of psoriasis severity, consensus on the cut-off levels for the PASI and %BSA that would indicate a switch in treatment mode could not be reached. The lack of agreement prompted a prospective survey of 112 patients with psoriasis from 10 countries. This survey used a formal questionnaire asking for the PASI and %BSA scores, the patient's self assessment score (VAS ranging from 0 to 10), location of the psoriatic lesions and disease phase. Severity scores from 20 patients pre-selected for inclusion in a trial of a biological agent were included for comparison. Severity scores were analysed in relation to the choice of treatment (topical or systemic, which included phototherapy and combination) suggested by the treating physician.PASI scores differed significantly between the treatment groups (topical vs systemic, p=0.009); however, there was large overlap in the range of PASI scores between the groups. The same was true for VAS scores (topical vs systemic, p=0.035). %BSA scores were not significantly different between treatment groups. There was a large overlap for both the topical and systemic treatment groups with the biologicals group for the range of both the PASI and %BSA scores. A standardized protocol for the evaluation of psoriasis severity based on established severity scores (PASI, %BSA) appears to be unrealistic in day-to-day clinical practice. In clinical practice, a host of factors must be evaluated alongside possible metric measures. This requires experience and the specialized medical education of those involved in the treatment of patients with psoriasis.
Not only are there large number of guides, protocols and other support tools available for the clinical decision-making process in the Spanish National Health System, but there is also a major degree of variability among them, reflecting inconsistencies and low quality of those documents. This study is aimed at conducting all inventory of the Clinical Practice Guideline assessment scales and clinical analysis tools and to propose a scale or set of criteria for assessing the quality of the Clinical Practice Guidelines put out in Spain. A systematic search of critical evaluation scales was conducted. The inclusion criteria and the concordance analysis of the items by three evaluators were independently applied. The discordances were resolved by explicit consensus. Ten suggested critical assessment scales and sets of criteria from eleven institutions were identified, eight of which consist of scales and tools proposed for assessing the quality of the Clinical Practice Guidelines, the other two being proposals for assessing the implementation and inclusion of the Clinical Practice Guidelines in a register. In the comparative analysis, the criteria most often repeated on the scales analysed were related to the areas included in the AGREE Instrument. The areas considered in most of the critical assessment scales were the same as those of the AGREE Instrument. Although this tool does not take in criteria for guide implementation assessment purposes, it is considered suitable for use in the assessment prior to inclusion to the national CPG register.
The purpose of this study was to evaluate the relevance of available practice guidelines to clinical quality improvement programs. A sample of 19 guidelines was evaluated in four prominent primary care areas. Two research assistants independently coded the clinical conditions and recommended/not recommended procedures abstracted from the guidelines (Cohen's kappa .67 and .50, respectively). An average of 35.1 (+/- 25.8) medical conditions and 48.4 (+/- 41.5) clinical procedures were defined by the guidelines. Most conditions were defined by using ICD-9-CM, age/sex group, or therapy, but 29% of definitions included symptoms which are not coded routinely. CPT codes alone were unable to identify most procedures. AHCPR guidelines mentioned significantly more procedures (p < .001) and fewer symptoms (p < .001) per clinical condition than other guidelines. The difficulty of finding codes for conditions and procedures, the high rate of non-codable items, and the lack of recommended measures limit the applicability of published clinical practice guidelines to continuous quality improvement programs.