Feasibility and cost efficiency of a diagnostic guideline for chronic polyneuropathy: a prospective implementation study.

J Neurol Neurosurg Psychiatry. 2006 Mar;77(3):397-401

Authors: Vrancken AF, Kalmijn S, Buskens E, Franssen H, Vermeulen M, Wokke JH, Notermans NC

BACKGROUND: Extensive investigations are often performed to reveal the cause of chronic polyneuropathy. It is not known whether a restrictive diagnostic guideline improves cost efficiency without loss of diagnostic reliability. METHODS: In a prospective multicentre study, a comparison was made between the workup in patients with chronic polyneuropathy before and after guideline implementation. RESULTS: Three hundred and ten patients were included: 173 before and 137 after guideline implementation. In all patients, the diagnosis would remain the same if the workup was limited to the investigations in the guideline. After guideline implementation, the time to reach a diagnosis decreased by two weeks. There was a reduction of 33% in the number and costs of routine laboratory investigations/patient, and a reduction of 27% in the total number of laboratory tests/patient, despite low guideline adherence. CONCLUSION: The implementation of a diagnostic guideline for chronic polyneuropathy can reduce diagnostic delay and the number and costs of investigations for each patient without loss of diagnostic reliability. Continuous evaluation strategies after guideline implementation may improve guideline adherence and cost efficiency.

PMID: 16484653 [PubMed - indexed for MEDLINE]

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The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices.

Eval Health Prof. 2006 Mar;29(1):65-88

Authors: Feifer C, Ornstein SM, Jenkins RG, Wessell A, Corley ST, Nemeth LS, Roylance L, Nietert PJ, Liszka H

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

PMID: 16510880 [PubMed - indexed for MEDLINE]

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Evidence-based implementation of evidence-based guidelines.

Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(1):32-41

Authors: Doherty S

PURPOSE: There is evidence that some strategies for guideline implementation are more successful than others. This paper aims to describe the process of developing an evidence-based guideline implementation strategy for use in rural emergency departments. DESIGN/METHODOLOGY/APPROACH: Participation in a nationally funded, research fellowship program involved attendance at workshops run by internationally renowned experts in the field of knowledge translation. Attendance at these workshops, associated reading and a literature review allowed those implementation strategies with the most supportive evidence of effectiveness to be determined. FINDINGS: A multi-faceted implementation strategy was developed. This strategy involved the use of an implementation team as well as addressing issues surrounding individual clinicians, the “emergency department team”, the physical structure and processes of the ED and the culture of the department as a whole. Reminders, audit and feedback, education, the use of opinion leaders, and evidence-based formatting of guidelines were all integral to the process. PRACTICAL IMPLICATIONS: It is postulated that an evidence-based implementation strategy will lead to greater changes in clinician behaviour than other strategies used in quality improvement projects. ORIGINALITY/VALUE: This is an important article as it describes the concept and development of evidence-based interventions, which, if tailored to the individual hospital (as evidence-based medicine is tailored to the individual patient), has the potential to improve compliance with clinical guidelines beyond that achieved with most QI projects.

PMID: 16548397 [PubMed - indexed for MEDLINE]

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Related ArticlesThe price of guidelines: revising the national guidelines for managing Australian women with abnormal pap smears.

Sex Health. 2006 Mar;3(1):53-5

Authors: Mitchell H

Australia utilises nationally approved guidelines for managing women with abnormal Pap smears. The guidelines were recently revised using the process designated by the National Health and Medical Research Council. Revising the guidelines was protracted and controversial. This paper explores the reasons for the difficulties encountered and queries the cost of undertaking such work.

PMID: 16607975 [PubMed - in process]

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Related ArticlesUse of an ‘evidence-based implementation’ strategy to implement evidence-based care of asthma into rural district hospital emergency departments.

Rural Remote Health. 2006 Jan-Mar;6(1):529

Authors: Doherty SR, Jones PD

INTRODUCTION: To determine if an evidence-based implementation (EBI) could lead to the successful implementation of evidence based care for adult asthma in small rural district hospitals. METHODS: A controlled trial involving eight small rural hospitals (four each in the study and control groups) was conducted. Retrospective pre-intervention audits were conducted at all eight hospitals for 7 months (1 January 2004 to 31 July 2004) and evidence-practice gaps identified. An EBI was then used to implement established guidelines for the management of asthma in the study hospitals. Post-intervention audits were then performed over a period of 7 months (1 October 2004 to 31 April 2005). RESULTS: There were 52 presentations of asthma in the study hospitals in the pre-implementation phase and 47 post-implementation. The corresponding numbers for the control hospitals were 46 and 42 respectively. There were no statistically significant differences in the severity between the groups. Following the EBI there were significant improvements at the study hospitals for the documentation of severity (8% to 62%, p

PMID: 16569189 [PubMed - in process]

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Related ArticlesIs there evidence for the evidence-based guidelines for cardiovascular disease prevention in women?

Gend Med. 2006 Mar;3(1):5-12

Authors: Roberts BH, Thompson PD

PMID: 16638596 [PubMed - in process]

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Related ArticlesWhen implementation fails: the case of a nursing guideline for fall prevention.

Jt Comm J Qual Patient Saf. 2006 Mar;32(3):152-60

Authors: van der Helm J, Goossens A, Bossuyt P

BACKGROUND: Implementing guidelines can be very difficult. No magic bullet or step-by-step implementation plan is available, neither is any single implementation strategy superior. At the Academic Medical Center (AMC) in Amsterdam, a nursing guideline was developed in 1993 on prevention of patient falls. Falls decreased by 30% on six wards, yet an effort to implement the guideline into daily practice throughout the hospital failed. A renewed effort was made to implement the guideline in two wards (neurology and internal medicine) in 1999. IMPLEMENTING THE GUIDELINE: Preparations were made for implementation in the two wards. Barriers to change were identified and solutions were translated into day-to-day activities in the wards. The intervention period covered 18 months (January 2000-June 2001). A mix of implementation strategies was used, including a local consensus process, educational activities, and active support and feedback to management and staff. RESULTS: In the internal medicine ward, the target incidence of 6% was met for four of the 18 months in the intervention period. In the neurology ward, the incidence target of 11% was met in five months. DISCUSSION: Barriers to change and enabling factors may only become apparent during the implementation process itself. A strongly perceived need to change daily practice, a simple guideline, the hospital board’s support, an understanding of local barriers, monitoring of outcomes, a locally tailored multifaceted implementation strategy, and voluntarily cooperating nurses are no guarantees for success.

PMID: 16617946 [PubMed - in process]

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