Adherence to the u.s. Preventive services task force 2002 osteoporosis screening guidelines in academic primary care settings.

J Womens Health (Larchmt). 2012 Jan;21(1):50-3

Authors: Powell H, O’Connor K, Greenberg D

Abstract
Abstract Background: Osteoporosis is very common in older women in the United States. Osteoporotic fractures cause significant morbidity and mortality, as well as high healthcare costs. Since 2002, the United States Preventive Services Task Force (USPSTF) has recommended screening for osteoporosis of all women aged ?65. Our objective was to determine adherence to osteoporosis screening guidelines by primary care internists in a large academic medical center and to assess if adherence varies based on provider gender or practice location. Methods: This was a retrospective electronic medical record (EMR) review. All women aged ?65 who were seen in the General Internal Medicine Center (GIMC) or the Women’s Health Care Center (WHCC) at the University of Washington Medical Center by internal medicine attending physicians between January 1, 2006, and February 2, 2008, were included in the study. We determined if the patient had a dual energy x-ray absorptiometry (DEXA) study in the EMR database. We calculated the percentage of patients screened per provider and also compared the rate of screening for male vs. female providers and for GIMC vs. WHCC providers. Results: Of the 1363 women included in the study, 70% had documentation of a DEXA study. Adherence to screening recommendations for individual providers varied from 33% to 100%. Screening was more likely to occur in the WHCC than in the GIMC (79.2% vs. 66.7%, p<0.001). Although women providers were more likely to screen than their male counterparts (72.2% vs. 66.1%, p=0.023), this relationship did not hold true after excluding women providers from the WHCC. Conclusions: We found good adherence to the USPSTF 2002 guidelines for osteoporosis screening in women aged ?65 years by primary care physicians in a large urban academic medical center. The practice site and not gender of the provider resulted in significantly different screening rates.

PMID: 22150154 [PubMed - in process]

Will the implementation of the 2007 National Institute for Health and Clinical Excellence (NICE) guidelines on childhood urinary tract infection (UTI) in the UK miss significant urinary tract pathology?

BJU Int. 2011 Dec 7;

Authors: Deader R, Tiboni SG, Malone PS, Fairhurst J

Abstract
What’s known on the subject? and What does the study add? Most centres continue to investigate children extensively after a urinary tract infection. These investigations are invasive, time consuming and expensive and despite their widespread application they have not had a significant impact on the rates of chronic renal failure secondary to infection. Despite this evidence the National Institute for Health and Clinical Excellence (NICE) guidelines generated significant controversy that abnormalities would be missed, placing children at increased risk of renal injury, thus reducing their implementation. Significant underlying abnormalities of the urinary tract will not be missed if the NICE guidelines are followed. This will reduce the unpleasant investigations that children will be subjected to and it should lead to considerable cost savings. The NICE guidelines are safe and should be widely implemented. OBJECTIVE: •? To investigate whether the implementation of the August 2007 National Institute for Health and Clinical Excellence (NICE) guidelines would miss significant urinary tract pathology in children with urinary tract infection (UTI). PATIENTS AND METHODS: •? All ultrasound (US) performed in children aged >6 months, during the year 1 August 2006 to 31 July 2007 for UTI, were retrospectively studied. •? Each US scan in the study population of 346 was categorised dependent on whether it was appropriate or inappropriate to have been performed under the new guidelines and whether the US scan was normal or abnormal. •? The records of each patient with an inappropriate abnormal US scan were re-analysed to see if patient management was affected by the US scan. •? In 2011 patients with an original inappropriate abnormal US scan were re-evaluated to identify if any had presented with further urinary pathology. RESULTS: •? In accordance with the NICE guidelines patients were divided by age. •? Children aged 0.5-3 years: 78/95 (82%) US scans were inappropriate of which 12 (15%) were abnormal and four of these had a further documented UTI. After careful assessment of the US abnormalities it was judged that only one would have benefited from the initial US scan. •? Children aged >3 years: 146/251 (58%) US scans were inappropriate of which 21(14%) were abnormal and six of these (29%) had a further documented UTI. After careful assessment of the US abnormalities it was judged that only three of 21 (14%) would have benefited from the initial US scan. CONCLUSIONS: •? The vast majority of anomalies detected on the inappropriate US scans were of little clinical significance. •? It is difficult to identify any patient who would have been truly disadvantaged if the US scan had not been performed after the initial UTI. •? The NICE guidelines are safe to follow.

PMID: 22145915 [PubMed - as supplied by publisher]

Quality evaluation of guidelines on genetic screening, surveillance and management of hereditary colorectal cancer.

Eur J Public Health. 2011 Dec 2;

Authors: Simone B, De Feo E, Nicolotti N, Ricciardi W, Boccia S

Abstract
BACKGROUND: We examined the methodological quality of guidelines on colorectal cancer genetic susceptibility syndromes. METHODS: PubMed, EMBASE, and Google were searched up to July 2010. Adjourned guidelines in English were included. The Appraisal of Guidelines, Research and Evaluation (AGREE) instrument was used to assess their quality, and the reported evidence base of the guidelines was evaluated. RESULTS: The search yielded 17 eligible guidelines: 11 were developed by independent associations, while 6 had national\state endorsement. Only three guidelines performed satisfactorily, achieving a score >50% in all 6 AGREE domains. Mean standardized scores for the 6 AGREE domains were: ‘scope and purpose’, 83.9?±?22.5%; ‘stakeholder involvement’, 35.6?±?24.9%; ‘rigour of development’, 48.6?±?25.3%; ‘clarity and presentation’, 71.6?±?19.3%; ‘applicability’, 33.8?±?30.1%; ‘editorial independence’, 42.2?±?39.7%. Guidelines with national endorsement performed better in all the domains, with a statistically significant difference in three domains. Fifteen guidelines out of 17 were found to be based on research evidence. CONCLUSIONS: There is scope, in many areas, for improving the guidelines analysed, among which are the involvement of various professional figures and patients’ representatives, and policies for their application. The AGREE instrument is a useful tool and could also be used profitably by guideline developers to improve the quality of recommendations.

PMID: 22140249 [PubMed - as supplied by publisher]

The development of evidence based guidelines for clinical practice portfolios.

Nurse Educ Today. 2011 Nov;31(8):872-6

Authors: Sowter J, Cortis J, Clarke DJ

Abstract
AIMS: Although the use of portfolios is widespread within healthcare education, agreement on their purpose, content, assessment and value is still debated. The objective of this study was to achieve consensus on quality criteria for clinical practice portfolios that would act as guidance for students and lecturers.
METHODS: A Delphi survey was undertaken to seek consensus on the opinions of 23 ‘expert participants’ through a series of rounds of structured questionnaires. The Delphi tool was produced as an on-line survey questionnaire and panel experts were invited to score statements using a discrete 7 point visual analogue scale. The statements were written as quality criteria relating to portfolio development which had been identified from the literature and by the research team. The survey employed three rounds of feedback and consensus was measured as 80% agreement for each quality criteria scoring 5 and above.
RESULTS: Consensus was reached on 31 quality criteria which were categorised into 4 areas: structured collection of labelled evidence; nature of evidence; critical reflection; and assessment and judgement. Mean scores for the final wording of the quality criteria ranged from 5.3 to 6.8 with the standard deviation for all of the mean scores being below 1.5. There was consensus that these quality criteria were relevant to health and social care professionals involved in developing clinical practice portfolios.
CONCLUSIONS: The Delphi process facilitated exchange of ideas amongst panel ‘experts’ about the content and evaluation of clinical practice portfolios, with most debate relating to judgement of competence and rewarding originality and creativity. These issues illustrate the tensions between educational values and professional constraints. The Delphi process proved to be an effective method for achieving consensus on quality criteria for clinical practice portfolios and enabled the development of validated guidelines.

PMID: 21295382 [PubMed - in process]

Evaluation of nurses’ and doctors’ knowledge of basic & advanced life support resuscitation guidelines.

Nurse Educ Pract. 2011 Nov;11(6):365-9

Authors: Passali C, Pantazopoulos I, Dontas I, Patsaki A, Barouxis D, Troupis G, Xanthos T

Abstract
Lack of resuscitation skills of nurses and doctors in basic life support (BLS) and advanced life support (ALS) has been identified as a contributing factor to poor outcomes of cardiac arrest victims. Our hypothesis was that nurses’ and doctors’ knowledge of cardiopulmonary resuscitation guidelines would be related to their professional background as well as their resuscitation training. A secondary aim of this study was to assess and compare the theoretical knowledge on BLS and ALS in nurses and doctors. A total of 82 nurses and 134 doctors agreed to respond to a questionnaire containing demographic questions, resuscitation experience questions and 15 theoretical knowledge questions. Our study demonstrated that nurses and doctors working in Greece have knowledge gaps in current BLS and ALS guidelines. However, resuscitation training had a positive effect on theoretical CPR knowledge. Furthermore, nurses and doctors who worked in high-risk areas for cardiac arrest, scored significantly higher than those who worked in low-risk areas. Those who had encountered more than 5 cardiac arrests the previous year, scored significantly better. Finally the percentage of nurses who had attended the ALS course was quite low thus ALS training should be incorporated into the nursing curriculum.

PMID: 21474382 [PubMed - in process]

Impact of the 21-gene recurrence score assay compared with standard clinicopathologic guidelines in adjuvant therapy selection for node-negative, estrogen receptor-positive breast cancer.

Ann Surg Oncol. 2011 Nov;18(12):3399-406

Authors: Partin JF, Mamounas EP

Abstract
BACKGROUND: The development of multigene assays has proved useful in the clinical management of early-stage breast cancer. The 21-gene recurrence score (RS) assay has been shown to quantify risk of distant recurrence and predict chemotherapy benefit in node-negative and node-positive, estrogen-receptor (ER)-positive breast cancer patients. Small, single-institution series have shown that, compared with standard clinicopathologic criteria, use of RS significantly affects adjuvant chemotherapy recommendations.
METHODS: We performed a retrospective review of RS use and its effect on chemotherapy recommendations in node-negative, ER-positive breast cancer patients at a tertiary care teaching hospital. Patient and tumor characteristics and adjuvant treatment information were obtained on 183 patients with RS results between January 2004 and October 2009. Risk categories were assigned based on the RS and on standard clinicopathologic criteria according to guidelines from NCCN, St. Gallen, and Adjuvant!.
RESULTS: A total of 14 patients were excluded for negative ER status (n=2), insufficient data (n=4), inclusion in TAILORx trial (n=7), and recurrent breast cancer (n=1), leaving 169 patients in the cohort. RS use increased 3-fold over the study period (from 18% in 2004 to 50% in 2009). Tumor grade, ER status, and PR status were significantly correlated with RS category. Overall concordance between RS and NCCN, St. Gallen, and Adjuvant! was 10, 48, and 50%, respectively. Depending on the guideline used for comparison, adjuvant therapy recommendations changed with the addition of the RS in 27-74% of cases.
CONCLUSIONS: RS use is increasing, and the assay significantly reduced adjuvant chemotherapy utilization in node-negative, ER -positive breast cancer patients.

PMID: 21537874 [PubMed - in process]

The feasibility of automating audit and feedback for ART guideline adherence in Malawi.

J Am Med Inform Assoc. 2011 Nov-Dec;18(6):868-74

Authors: Landis Lewis Z, Mello-Thoms C, Gadabu OJ, Gillespie EM, Douglas GP, Crowley RS

Abstract
OBJECTIVE: To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.
MATERIALS AND METHODS: We evaluated recommendations from Malawi’s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure’s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.
RESULTS: We analyzed 423,831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi’s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.
DISCUSSION: It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs’ opportunities to reflect on their performance.
CONCLUSION: A moderate number of recommendations from Malawi’s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.

PMID: 21565857 [PubMed - in process]

The development of evidence-informed physical activity guidelines for adults with spinal cord injury.

Spinal Cord. 2011 Nov;49(11):1088-96

Authors: Ginis KA, Hicks AL, Latimer AE, Warburton DE, Bourne C, Ditor DS, Goodwin DL, Hayes KC, McCartney N, McIlraith A, Pomerleau P, Smith K, Stone JA, Wolfe DL

Abstract
Objectives:To systematically develop evidence-informed physical activity guidelines to improve physical fitness in people with spinal cord injury (SCI).Setting:This study was conducted in CanadaMethods:The Appraisal of Guidelines, Research and Evaluation II guideline development protocol was used to develop exercise guidelines to improve physical capacity and muscular strength. The evidence base for the guideline development process consisted of a systematic review and quality appraisal of research examining the effects of exercise on physical fitness among people with SCI. A multidisciplinary expert panel deliberated the evidence and generated the guidelines. Pilot testing led to refinement of the wording and presentation of the guidelines.Results:The expert panel generated the following guidelines: for important fitness benefits, adults with a SCI should engage in (a) at least 20?min of moderate to vigorous intensity aerobic activity two times per week and (b) strength training exercises two times per week, consisting of three sets of 8-10 repetitions of each exercise for each major muscle group.Conclusion:People with SCI, clinicians, researchers and fitness programmers are encouraged to adopt these rigorously developed guidelines.

PMID: 21647164 [PubMed - in process]

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes.

Diabet Med. 2011 Nov;28(11):1282-8

Authors: Dyson PA, Kelly T, Deakin T, Duncan A, Frost G, Harrison Z, Khatri D, Kunka D, McArdle P, Mellor D, Oliver L, Worth J,

Abstract
This article summarizes the Diabetes UK evidence-based guidelines for the prevention of Type 2 diabetes and nutritional management of diabetes. It describes the development of the recommendations and highlights the key changes from previous guidelines. The nutrition guidelines include a series of recommendations for the prevention of Type 2 diabetes, nutritional management of Type 1 and Type 2 diabetes, weight management, management of microvascular and macrovascular disease, hypoglycaemia management, and additional considerations such as nutrition support, end-of-life care, disorders of the pancreas, care of the older person with diabetes, nutrition provided by external agencies and fasting. The evidence-based recommendations were graded using the Scottish Intercollegiate Guidelines Network methodology and, in a small number of topic areas, where strong evidence was lacking, the recommendations were reached by consensus. The Diabetes UK 2011 guidelines place an emphasis on carbohydrate management and a more flexible approach to weight loss, unlike previous guidelines which were expressed in terms of recommendations for individual nutrient intakes. Additionally, the guidelines for alcohol have been aligned to national recommendations. The full evidence-based nutrition guidelines for the prevention and management of diabetes are available from: http://www.diabetes.org.uk/nutrition-guidelines.

PMID: 21699560 [PubMed - in process]

Computerization of workflows, guidelines, and care pathways: a review of implementation challenges for process-oriented health information systems.

J Am Med Inform Assoc. 2011 Nov-Dec;18(6):738-48

Authors: Gooch P, Roudsari A

Abstract
OBJECTIVE: There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways.
METHODS: A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes.
RESULTS: One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed.
DISCUSSION AND CONCLUSION: We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings.

PMID: 21724740 [PubMed - in process]