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PubMed2005

Barriers to effective implementation of guideline recommendations.

Cardiovascular disease (CVD) is the leading cause of death worldwide, and its prevention and treatment are important healthcare aims. Hypercholesterolemia is among the most important modifiable risk factors for CVD, and numerous guidelines exist for the treatment of this condition. Nevertheless, despite the existence of well-established and safe pharmacologic therapy for lowering cholesterol and preventing CVD, surveys in the United States and Europe have revealed that many patients have elevated cholesterol levels. There is a clear gap between what is known about treating CVD and the implementation of that knowledge. A survey assessing patients' knowledge about CVD observed that many patients are unaware of the disease prevalence and have little knowledge about the main risk factors, including the importance of cholesterol. Another survey demonstrated that many physicians overestimate patients' awareness of CVD and that physicians also overestimate the extent to which guidelines are implemented in clinical practice. Guideline implementation may be improved by narrowing the discrepancies between what patients and physicians believe and the reality. Many physicians claim that lack of time hinders guideline implementation and improvement of patient education. Physicians also appear to lack the motivation to implement lipid-lowering interventions. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment and prevention of CVD.

Cardiovascular Diseases↗
PubMed2001

Coronary care physician 1994-2000 adherence to 1993 National Cholesterol Education Program diet and lipid recommendations.

The 1993 NCEP recommended phase 2 diets and < or = 100 mg/dL LDL goals for all atherosclerotic patients. We reviewed Washington, DC physician 1994-2000 use of these recommendations for coronary care unit (CCU) patients. Questionnaires, chart reviews and interviews of cardiologists, residents and dietitians showed > 80% of CCU physicians ignored NCEP dietary recommendations. NCEP 1 diets were ordered for approximately 80% of patients. NCEP 2, AHA 3 or vegetarian diets were used for < 20%. Statins were reported for approximately 25% of patients in 1994-95 but were on < 20% of charts in 1996-7. This increased to approximately 58% by 2000. NCEP 2 diets lower cholesterol approximately 5%, rarely reaching LDL goals, and < 20% of CHD patients on anti-lipid therapy were at NCEP LDL goals by 1999. With 1-year post-myocardial infarction 34% mortality and 53% readmission rates, we need early and much more aggressive anti-lipid diets and drugs in treating these patients.

Arteriosclerosis↗
PubMed1999

Evidence of self-report bias in assessing adherence to guidelines.

OBJECTIVE: To assess trends in the use of self-report measures in research on adherence to practice guidelines since 1980, and to determine the impact of response bias on the validity of self-reports as measures of quality of care. METHODS: We conducted a MEDLINE search using defined search terms for the period 1980 to 1996. Included studies evaluated the adherence of clinicians to practice guidelines, official policies, or other evidence-based recommendations. Among studies containing both self-report (e.g. interviews) and objective measures of adherence (e.g. medical records), we compared self-reported and objective adherence rates (measured as per cent adherence). Evidence of response bias was defined as self-reported adherence significantly exceeding the objective measure at the 5% level. RESULTS: We identified 326 studies of guideline adherence. The use of self-report measures of adherence increased from 18% of studies in 1980 to 41% of studies in 1985. Of the 10 studies that used both self-report and objective measures, eight supported the existence of response bias in all self-reported measures. In 87% of 37 comparisons, self-reported adherence rates exceeded the objective rates, resulting in a median over-estimation of adherence of 27% (absolute difference). CONCLUSIONS: Although self-reports may provide information regarding clinicians' knowledge of guideline recommendations, they are subject to bias and should not be used as the sole measure of guideline adherence.

Bias↗
PubMed2002

Development of clinical practice guidelines for dentists: methods for topic selection.

OBJECTIVES: The aim of this study was to compare four methods for assessing the preferences of the dental profession for topics to be considered for the development of clinical practice guidelines. METHODS: The methods were: (1) a survey among dentists, (2) an analysis of topics discussed in dental peer groups, and (3) screening of dental journals. A fourth method was obtained from method number 3. The frequencies of the reported topics were calculated for each of the methods. For the fourth method, the number of publications per topic were plotted against the year of publication, and the slope of the linear regression line was used as an indicator. Within each of the four methods, the topics were ranked according to the frequency in which they were reported, and to the slope value. The reliability of the methods was tested by the "item-rest sum correlation", which is the correlation of the rank positions of one method with the sum of the rank positions obtained by the remaining three methods. RESULTS: In using all methods, a total of 1027 topics were obtained. Reclassification resulted in 34 topics. Moderate item-rest sum correlations ranging from 0.34 to 0.48 were found for all methods, indicating that the rank order of every method moderately predicts the sum of the rank orders obtained by all other methods. The topic 'prevention of cross-infection' had the highest overall rank position. CONCLUSION: It is concluded that the four applied methods appeared to provide a consistent ranking of potential topics. In view of the fact that the questionnaire method is generally applicable, this method should be preferred for assessing dentists' preferences for topics to be considered for the development of clinical practice guidelines.

Data Collection↗
PubMed2006

Rating the raters: assessing the quality of Hamilton rating scale for depression clinical interviews in two industry-sponsored clinical drug trials.

OBJECTIVE: The quality of clinical interviews conducted in industry-sponsored clinical drug trials is an important but frequently overlooked variable that may influence the outcome of a study. We evaluated the quality of Hamilton Rating Scale for Depression (HAM-D) clinical interviews performed at baseline in 2 similar multicenter, randomized, placebo-controlled depression trials sponsored by 2 pharmaceutical companies. METHODS: A total of 104 audiotaped HAM-D clinical interviews were evaluated by a blinded expert reviewer for interview quality using the Rater Applied Performance Scale (RAPS). The RAPS assesses adherence to a structured interview guide, clarification of and follow-up to patient responses, neutrality, rapport, and adequacy of information obtained. RESULTS: HAM-D interviews were brief and cursory and the quality of interviews was below what would be expected in a clinical drug trial. Thirty-nine percent of the interviews were conducted in 10 minutes or less, and most interviews were rated fair or unsatisfactory on most RAPS dimensions. CONCLUSIONS: Results from our small sample illustrate that the clinical interview skills of raters who administered the HAM-D were below what many would consider acceptable. Evaluation and training of clinical interview skills should be considered as part of a rater training program.

Antidepressive Agents↗
PubMed1998

Physician noncompliance with the 1993 National Cholesterol Education Program (NCEP-ATPII) guidelines.

BACKGROUND: We sought to determine the frequency with which physicians follow National Cholesterol Education Program (NCEP-ATPII) guidelines in screening for cardiovascular risk factors and treating hyperlipidemia. METHODS AND RESULTS: We conducted a retrospective chart review on randomly sampled charts of 225 patients admitted to the coronary care unit between January and June 1996. The main outcome measures were rates of physician screening for coronary heart disease risk factors; rates of counseling for cigarette cessation, diet, and exercise; and extent of use of NCEP algorithms for obtaining LDL cholesterol values and treating hypercholesterolemia. Screening rates for interns (who performed best) were: cigarette use (89%), known coronary heart disease (74%), hypertension (68%), hyperlipidemia (59%), family history (56%), diabetes (37%), postmenopausal hormone therapy (11%), and premature menopause (1%). Four percent of smokers were counseled to quit, 14% of patients were referred to dietitians, and 1% were encouraged to exercise. A full lipid panel was obtained in 50% of patients in whom it was indicated on the basis of NCEP criteria. Patients were more likely to receive lipid-lowering treatment if NCEP criteria indicated that they should, but 36% of hospitalized patients and 46% of patients who should have been treated on discharge were not. CONCLUSIONS: Physicians are poorly compliant with NCEP guidelines for risk factor assessment and counseling, even in patients at high risk for coronary heart disease. Physicians follow NCEP-ATPII algorithms for obtaining an LDL value, a key step in evaluating the need for treatment, only 50% of the time. NCEP criteria seem to influence the decision to initiate lipid-lowering therapy, but significant numbers of eligible patients remain untreated.

Aged↗
PubMed2005

[Reduced fetal movements--clinical management, recommendations and information].

BACKGROUND: We reviewed the Norwegian guidelines and clinical routines in delivery units and investigated whether guidelines for management of reduced fetal movements and information given to pregnant women were based upon evidence-based knowledge. MATERIAL AND METHODS: All Norwegian delivery units responded to a questionnaire about their management of pregnancies with reduced fetal movements. Literature for professionals and pregnant women was found in databases, books and journals. RESULTS: Clinical management varied significantly. All delivery units used a non-stress test when available, but few included ultrasound and Doppler examinations routinely. Five of 55 units advised women that absence of fetal movements up to 24 hours may be normal. National guidelines and university curricula recommend that distinct reduction of fetal movements require investigation. Formal kick counting was regarded as either useful, recommended or to be dissuaded. Information for pregnant women emphasises the importance of vigilance towards fetal movements, but have contradictory limits for normal fetal movements. INTERPRETATION: We have documented significant variation in clinical routines, which do not correlate with information given to pregnant women, the literature, or guidelines. This can lead to uncertainty for both pregnant women and health care professionals and may put patient safety at risk. There is a need for evidence-based guidelines.

Cardiotocography↗
PubMed2006

Sudden unexpected death in epilepsy (SUDEP): don't ask, don't tell?

BACKGROUND: The National Institute for Clinical Excellence in the UK has issued guidelines stating all individuals with epilepsy be given information about sudden unexpected death in epilepsy (SUDEP). METHODS: We conducted a survey of current practice among UK neurologists, using a questionnaire sent to all practising neurologists in the UK listed on the Association of British Neurologists database, asking under what circumstances they told patients about SUDEP. RESULTS: Of the validated respondents, 5% discussed SUDEP with all patients, 26% with a majority, 61% with a few, and 7.5% with none. The commonest reasons for SUDEP to be discussed were the patient asking about it and the neurologist counselling people with known risk factors for SUDEP. CONCLUSIONS: The variation we found, although not necessarily in tune with the guidelines, reflects the variation in patients' need for knowledge about their condition.

Adaptation, Psychological↗
PubMed2004

Quality assurance of the EORTC 26981/22981; NCIC CE3 intergroup trial on radiotherapy with or without temozolomide for newly-diagnosed glioblastoma multiforme: the individual case review.

The phase III randomised European Organisation for Research and Treatment of Cancer (EORTC) and National Cancer Institute of Canada Clinical Trail Group (NCIC) Intergroup trial (EORTC 26981/22981; CE3) compares irradiation alone with irradiation plus temozolomide for patients with glioblastoma multiforme (GBM). We evaluated the compliance to radiotherapy (RT) guidelines. All 85 recruiting centres were invited to participate in the individual case review. Fifty-four centres (64%) entering 71% of the patients provided data on one randomly selected patient. All participating centres used individual head immobilisation and computerised tomography (CT)-based treatment planning. Most (74%) performed three-dimensional conformal radiotherapy (3-D-CRT) including dose-volume histograms. Ninety-four percent performed portal imaging at least once. Planning target volume (PTV) and structures at risk were delineated in most of the centres (94%). Although the PTV received < 95% of the prescription dose (60 Gy in 2 Gy/fraction/day) in 39% of the centres; all except 2 centres delivered 50-60 Gy to the PTV. The maximum dose to the critical structures exceeded the protocol dose constraints in 39% of the reviewed patients, but in only 9% was this over the acceptable tolerance dose reported in the literature. We found a high rate of compliance with the protocol and general RT guidelines in the centres participating in this individual case review. In multicentre trials with a large of number of investigators from international and national groups, it is essential to confirm the interinstitutional consistency, qualitatively and quantitatively.

Antineoplastic Agents, Alkylating↗
PubMed1997

Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study.

OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians.

Abortion, Threatened↗
PubMed1998

Consensus guidelines in the treatment of major depressive disorder.

The number of available antidepressant medications has increased dramatically in the last 10 years. Furthermore, no single medication is a panacea for all depressed patients-a fact underscored by randomized, controlled trial evidence showing that when one medication fails, an alternative may succeed. Thus, a key issue in the treatment of depression is how to optimally orchestrate available medication options to maximally benefit the greatest number of patients most rapidly. One approach is the use of consensus guidelines or medication algorithms. This paper discusses the rationale for and critical issues in the development of medication algorithms, and the timely use of symptom measures to ensure proper implementation. Once developed, guidelines must be appropriately implemented by clinicians, adhered to by patients, and supported by administrators. These three stakeholder groups often need education, incentives, and ongoing support to implement such guidelines. Whether guidelines actually improve outcome is largely uninvestigated, although a recent study of depressed patients in primary care found that using guidelines did improve outcome but at an increased treatment cost. The clinical and economic impact of guideline-driven treatment for the severe and persistently depressed deserves study.

Algorithms↗
PubMed2005

[Screening for skin cancer in organ transplant recipients in Denmark].

INTRODUCTION: Non-melanoma skin cancer (NMSC) is a serious cause of morbidity and mortality in organ transplant recipients. The necessary immunosuppressive therapy is linked to an increased number of biologically more aggressive acting skin tumours. Preventing disease and providing early diagnosis and treatment is thus essential. This is done through repetitive patient education and regular examination of the skin performed by a trained specialist, i.e., a dermatologist. We investigated the routine level of monitoring for NMSC in organ transplant recipients in Denmark. MATERIALS AND METHODS: A questionnaire survey was conducted on how hospital departments educate patients in NMSC prevention, the frequency of full-body skin examination and where patients are treated when a tumour is found. The questionnaire was sent to 28 medical departments in Denmark that follow up organ transplant recipients. Twenty-five departments returned the questionnaire. RESULTS: A full-body skin examination was routinely done in six (24%) of the departments. Fifteen (60%) of the departments informed patients about the risk factors for developing skin cancer, but only five (20%) provided written information. DISCUSSION: There appears to be considerable scope for improvement in the follow-up of organ transplant recipients. Providing thorough and repeated information to organ transplant patients, in addition to early diagnosis and treatment carried out by trained specialists according to standard guidelines, can minimize the morbidity and mortality caused by non-melanoma skin cancer in these patients. We suggest that written guidelines be provided in order to improve these patients" treatment and prognosis. A corresponding survey done in the United Kingdom produced almost the same conclusions.

Follow-Up Studies↗