Clinical Pharmacogenetics Implementation Consortium (CPIC) Guidelines for Codeine Therapy in the Context of Cytochrome P450 2D6 (CYP2D6) Genotype.

Clin Pharmacol Ther. 2012 Feb;91(2):321-6

Authors: Crews KR, Gaedigk A, Dunnenberger HM, Klein TE, Shen DD, Callaghan JT, Kharasch ED, Skaar TC

PMID: 22205192 [PubMed - in process]

Factors influencing the implementation of the guideline Triage in emergency departments: a qualitative study.

J Clin Nurs. 2012 Feb;21(3-4):437-447

Authors: Janssen MA, van Achterberg T, Adriaansen MJ, Kampshoff CS, Schalk DM, Mintjes-de Groot J

Abstract
Aims and objectives.? The objectives are: (1) to identify factors that influence the implementation of the guideline Triage in emergency departments [2004] in emergency departments in the Netherlands, and (2) to develop tailored implementation strategies for implementation of this guideline. Background.? Guideline dissemination is no guarantee for guideline implementation. In 2004 the guideline Triage in Emergency Departments was disseminated in Dutch hospitals. Guideline revision was scheduled in 2008. Prior to the revision, factors which influenced the implementation of the guideline [2004] were studied to be addressed at the implementation of the revised guideline. Methods.? This is an exploratory study using a qualitative design including: a questionnaire sent to all emergency departments in the Netherlands (n?=?108): four focus group interviews, including nurses and ward managers and in-depth interviews with ward managers and doctors. Based on the results, tailored implementation strategies and activities were suggested which target the identified influencing factors. Results.? Various factors at individual, social context and organisational level were identified as influencing the implementation of the 2004 version of the guideline, namely: level of knowledge; insight and skills; work preferences; motivation and/or commitment; support; informed doctors; preliminary work and arrangements for implementation; description of tasks and responsibilities; workload and resources. Ward managers, nurses and doctors mentioned similar as well as different factors. Consequently, tailored implementation strategies and activities related to education, maintenance of change, motivation and consensus-building, information, organisation and facilitation were suggested. Conclusion.? Nurses, ward managers and doctors broadly indicated similar influencing factors, although the importance of these factors differed for the different groups. For nurses, resistance and lack of resources are most important, ward managers mentioned culture and doctors the availability of doctors at the emergency department. Relevance to clinical practice.? Insight into the barriers for implementation and tailoring implementation strategies to these barriers improves the implementation.

PMID: 22171544 [PubMed - as supplied by publisher]

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]

Mapping evidence-based guidelines to standardized nursing terminologies.

Comput Inform Nurs. 2011 Dec;29(12):698-705

Authors: Dontje K, Coenen A

Abstract
The purpose of this study was to explore how evidence-based practice recommendations for adults with depression were represented in two standardized nursing terminologies. A qualitative concept analysis was used to answer the research question. Concepts were extracted from the recommendations and matched to two standardized nursing terminologies through lexical and semantic concept mapping techniques. Study findings included variability in the lexical mapping to the standardized terminologies. The ability to map semantically was greater than lexical mapping, but the majority of these were partial matches. Findings also raised concerns about the potential for ambiguity of data retrieved when using standardized terminology.

PMID: 21825974 [PubMed - in process]

Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing.

Eur J Anaesthesiol. 2011 Dec;28(12):867-73

Authors: Flamm M, Fritsch G, Seer J, Panisch S, Sönnichsen AC

Abstract
CONTEXT: Preoperative evaluation is aimed at prevention of complications and risk stratification. Routine testing should be abandoned in favour of selective ordering according to contemporary guidelines. This study was conducted to calculate the possible economic impact of a Web-based preoperative diagnostic guideline prior to its implementation in the state of Salzburg, Austria.
DESIGN: Prospective observational cohort study.
SETTING: The study was carried out in a secondary care hospital in Salzburg (Schwarzach). PARTICIPANTS AND MAIN OUTCOME MEASURES: Data from 1363 consecutive patients scheduled for elective surgery from 1 September to 30 November 2007 were collected: demographic data, medical history, surgical procedure, preoperative tests and findings. The data were entered into the preoperative diagnostic guideline software and the guideline-adherent recommendations were compared with the investigations performed, with special attention to duplicate examinations.
RESULTS: A total of 5879 tests were documented and analysed. In 65.6% of patients, guideline-adherent evaluation would have indicated only basic requirements, but 3380 additional tests were carried out. In all, 81.7% of tests were identified as nonadherent based on the preoperative diagnostic guideline software and 226 duplicate tests were performed. Possible savings per 1000 patients would be €26? 287 if preoperative diagnostic guideline recommendations were followed exactly and €1076 if duplicated tests were avoided. According to a generalised linear model (Gamma model), an increase of 1 year of age leads to an increase of costs by a factor of 1.020.
CONCLUSION: These data indicate a considerable potential for improvement in process quality and cost reduction by using structured preoperative assessment with computer-assisted implementation of a guideline.

PMID: 21968636 [PubMed - in process]

Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline.

Am J Ind Med. 2011 Dec 27;

Authors: Franklin GM, Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D

Abstract
BACKGROUND: Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers’ compensation system following implementation of a specific WA opioid dosing guideline in April, 2007. METHODS: Using detailed computerized billing data from WA workers’ compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (?120?mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period. RESULTS: Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses ?120?md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths. CONCLUSIONS: The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses ?120?mg MED per day, and number of opioid-related deaths among injured workers. Am. J. Ind. Med. © 2011 Wiley Periodicals, Inc.

PMID: 22213274 [PubMed - as supplied by publisher]

Evidence-based guideline: clinical evaluation and treatment of transverse myelitis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

Neurology. 2011 Dec 13;77(24):2128-34

Authors: Scott TF, Frohman EM, De Seze J, Gronseth GS, Weinshenker BG,

Abstract
OBJECTIVE: To assess the evidence for diagnostic tests and therapies for transverse myelitis (TM) and make evidence-based recommendations. METHODS: A review of the published literature from 1966 to March 2009 was performed, with evidence-based classification of relevant articles. Recommendations: Level B recommendations: neuromyelitis optica (NMO)-immunoglobulin G (IgG) antibodies should be considered useful to determine TM cause in patients presenting with clinical acute complete transverse myelitis (ACTM) features. The presence of NMO-IgG antibodies (aquaporin-4-specific antibodies) should be considered useful in determining increased TM recurrence risk. Level C recommendations: in suspected TM, distinction between ACTM or acute partial transverse myelitis may be considered useful to determine TM etiology and risk for relapse (more common with APTM). Age and gender may be considered useful to determine etiology in patients presenting with TM syndrome, with spinal infarcts seen more often in older patients and more female than male patients having TM due to multiple sclerosis (MS). Brain MRI characteristics consistent with those of MS may be considered useful to predict conversion to MS after a first partial TM episode. Longer spinal lesions extending over >3 vertebral segments may be considered useful in determining NMO vs MS. CSF examination for cells and oligoclonal bands may be considered useful to determine the cause of the TM syndrome. Plasma exchange may be considered in patients with TM who fail to improve after corticosteroid treatment. Rituximab may be considered in patients with TM due to NMO to decrease the number of relapses. Level U recommendations: there is insufficient evidence to support or refute the efficacy of other TM therapies or the usefulness of ethnicity to determine the cause of a subacute myelopathy.

PMID: 22156988 [PubMed - in process]

Bridging evidence and consensus methodology for inherited metabolic disorders: creating nutrition guidelines.

J Eval Clin Pract. 2011 Dec 13;

Authors: Singh RH, Rohr F, Splett PL

Abstract
Rationale, aims and objectives? The management of many inherited metabolic disorders (IMDs) is dependent on nutrition intervention, but few clinical management guidelines for these uncommon disorders exist. Clinicians are forced to make nutrition treatment decisions using limited data. This results in clinical variations in both service and cost. We describe a method for establishing management guidelines to help clinicians treat patients with IMDs. Methods? The Southeast Newborn Screening and Genetics Collaborative (Region 3) convened a group of nine national experts in metabolic nutrition to determine the pertinent issues in the development of nutrition management guidelines for IMDs. These experts were trained in evidence analysis and examined established consensus techniques for guideline development. Results? The workgroup developed a multi-step process for guideline development known as the Delphi-Nominal Group-Delphi-Field Testing methodology, which includes a review of scientific and grey (unpublished) literature, a Delphi survey of practice, a nominal group meeting to clarify discrepancies, a formulation of recommendations and a second Delphi round to assess the degree of consensus with the proposed recommendations. External review and field testing are also built into the process. Conclusion? The evidence- and consensus-based method suggested for the development of nutrition management guidelines for IMDs will result in the production of consistent and accessible guidelines that can be created in a timely and cost-effective manner and offer a validated methodology to develop management guidelines for this field to optimize outcomes.

PMID: 22168925 [PubMed - as supplied by publisher]

Implementation of intravenous to oral antibiotic switch therapy guidelines in the general medical wards of a tertiary-level hospital in South Africa.

J Antimicrob Chemother. 2011 Dec 13;

Authors: van Niekerk AC, Venter DJ, Boschmans SA

Abstract
OBJECTIVES: The design and implementation of an antibiotic intravenous (iv) to oral switch therapy (IVOST) guideline in a Third World health setting. METHODS: The guideline was developed and integrated into daily practice by a ward pharmacist over a period of 7 weeks. Patients were switched once they were deemed clinically stable according to IVOST criteria. The final decision to switch was left to the attending physician. One pre- and two post-implementation audits (150 patient medical records per audit) were compared. RESULTS: Implementation of the IVOST guideline was successful in increasing (P?< ?0.0005) the number of patients switched from 16% (19/119) pre-implementation to 43.9% (47/107) immediately after implementation; however, the change was not sustained 3 months after implementation (20.8%; 25/120). The intervention was also successful in decreasing the overall duration of iv therapy (P?< ?0.0005) from 7.2?±?3.5 days pre-implementation to 5.2?±?3.0 days immediately post-implementation. The change was not sustained 3 months after implementation (6.5?±?3.5 days). CONCLUSIONS: Despite the challenges encountered in a Third World environment, an antibiotic IVOST guideline can be successfully implemented. Continual, active integration of the guideline into daily practice by a ward pharmacist is essential if positive IVOST outcomes are to be maintained.

PMID: 22167244 [PubMed - as supplied by publisher]

Evaluation of safety monitoring guidelines based on MRI lesion activity in multiple sclerosis.

Neurology. 2011 Dec 13;77(24):2089-96

Authors: Riddell CA, Zhao Y, Li DK, Petkau AJ, Riddehough A, Cutter GR, Traboulsee A

Abstract
OBJECTIVE: We evaluate variants of a commonly used data safety monitoring guideline in clinical trials in multiple sclerosis (MS) that flags patients who, at a follow-up visit, have 5 or more contrast-enhancing lesions (CELs) above their baseline count.
METHODS: We apply the guideline to a relapsing cohort and a secondary progressive cohort. We assess the number of patients that meet the guideline and describe the characteristics of these patients; we also examine the value of the guideline in predicting relapse occurrence in the 28 days following that MRI. These analyses were repeated for thresholds varying from 1 to 10 CELs above baseline.
RESULTS: Between 4% and 6% of patients met the threshold of 5 in both cohorts; patients with higher baseline counts and higher T2 lesion burden were more apt to meet the threshold. After adjustment for other covariates, the odds ratio (OR) of relapse associated with meeting the threshold is significant (p < 0.05) or near significant (0.05 ? p < 0.10) for thresholds between 5 and 8 for the relapsing cohort, but not for the secondary progressive cohort. Across thresholds, the adjusted OR is consistently greater than 1, and there is an increasing trend as the threshold increases from 1 to 7.

CONCLUSIONS: A guideline based on crossing a threshold CEL count above baseline may be valuable in monitoring patient safety. Further study should be conducted using different datasets to assess the generalizability of these results.

PMID: 22094474 [PubMed - in process]