[Outpatient management of COPD in Germany according to national or international guidelines]

Dtsch Med Wochenschr. 2006 May 26;131(21):1203-8

Authors: Glaab T, Banik N, Singer C, Wencker M

BACKGROUND AND OBJECTIVE: Primary care physicians (PCPs) are the ones mainly responsible for the initial diagnosis and outpatient care of patients with COPD. The aim of the present survey was to investigate their initial management of COPD in Germany based on current guidelines and to identify any deviations. METHODS: A prospective cross-sectional survey was conducted as a multiple-choice questionnaire sent out to 1836 PCPs in seven Federal States of Germany (one large town and surrounding country in each). The product-neutral questions focused on the key aspects of current national and international (GLOBAL) COPD guidelines. RESULTS: 486 physicians participated in the study (response rate 26.5%). 66.5% of the physicians used the German COPD guidelines, 20.8% used GOLD guidelines, and only 11.7% observed no guidelines. The physicians were aware of the epidemiological and public health significance of COPD. 76.5% saw spirometry as the diagnostic standard: it was available in 90.1% of the practices. However, only 60-65% were able to cite the correct spirometric criteria for classifying severity of the disease. Educational measures to help patients quit smoking and the teaching and monitoring of patients’ inhalation technique were inadequately implemented. The two most important therapeutic goals cited were to improve quality of life (69.1%) and prevent exacerbations (53.1%). Except for the criteria for the use of steroids and the implementation of pulmonary rehabilitation measures, treatment of COPD based on severity class was largely in compliance with the guidelines. However, a significant percentage of the physicians incorrectly assessed the evidence-based clinical benefits of various therapeutic measures. CONCLUSION: The study shows that, despite the high regard in which COPD guidelines are held, deficiencies exist with regard to the diagnosis and treatment of COPD and the practical implementation of educational measures.

PMID: 16721708 [PubMed - in process]

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Related ArticlesHow evidence based are recruitment strategies to randomized controlled trials in primary care? Experience from seven studies.

Fam Pract. 2003 Feb;20(1):83-92

Authors: Foy R, Parry J, Duggan A, Delaney B, Wilson S, Lewin-Van Den Broek NT, Lassen A, Vickers L, Myres P

BACKGROUND: Failure to recruit adequate numbers of participants represents a major barrier to the completion of randomized controlled trials in primary care and is associated with substantial opportunity costs. However, uncertainty exists regarding the relative effectiveness of different methods to promote recruitment. OBJECTIVES: The purpose of this study was to estimate the proportion of strategies used to promote patient recruitment to randomized controlled trials in primary care that are evidence based. METHODS: Investigators from seven primary care-based clinical trials of dyspepsia management aiming to recruit a total of 6070 patients participated. Following a survey of trial organization, a Delphi technique was used to reach consensus on levels of evidence on the effectiveness of interventions or organizational characteristics in influencing recruitment. The main outcome measures were the proportions of interventions or organizational characteristics for influencing patient recruitment that are based upon randomized controlled trials, on convincing non-experimental evidence or meeting neither of these criteria. RESULTS: Out of a total of 56 interventions used across the trials, 35 (63%) were judged as evidence based. Out of a total of 29 organizational characteristics possessed by the trials, five (17%) were judged as evidence based. Across the seven dyspepsia trials, the presence of ‘favourable’ organizational characteristics appeared to be important contributors towards successful recruitment. CONCLUSIONS: A wide range of interventions and organizational characteristics with the potential to promote recruitment were used or possessed by seven primary care trials. Many were not evidence based. Our experience suggests that organizational characteristics could be more influential in trial recruitment than the use of specific interventions. Given the costs of primary care-based trials, researchers need more rigorous evidence to inform recruitment strategies.

PMID: 12509377 [PubMed - indexed for MEDLINE]

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Related ArticlesMinimizing errors of omission: behavioural reenforcement of heparin to avert venous emboli: the BEHAVE study.

Crit Care Med. 2006 Mar;34(3):694-9

Authors: McMullin J, Cook D, Griffith L, McDonald E, Clarke F, Guyatt G, Gibson J, Crowther M

OBJECTIVE: To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation. DESIGN: Prospective longitudinal observational study. SETTING: Medical-surgical intensive care unit. PARTICIPANTS: Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit. INTERVENTIONS: Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period. MEASUREMENTS AND MAIN RESULTS: Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p

PMID: 16505655 [PubMed - indexed for MEDLINE]

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Kommentar:
Praktisches Beispiel der erfolgreichen Verbindung der Bereiche Evidenzbasierte Medizin, Leitlinien, Patientensicherheit und Qualitätsmanagement. An dem Beispiel wird deutlich wie essentiell die konkrete und zielgerichtete Umsetzung von Leitlinienempfehlungen in den eigenen “Behandlungsalltag” ist.

• BEHAVE Studie
  (Behavioural rEnforcement of Heparin to Avert Venous Emboli)
  Es handelt sich um eine Beobachtungsstudie (Vorher-Nachher Vergleich), welche auf einer chirurgischen Intensivstation die Einführung einer Anleitung zur Thromboseprophylaxe untersucht. Ausgangspunkt sind Daten, die Hinweise geben, dass keine ausreichende Prophylaxe durchgeführt wird und damit vermeidbare Komplikationen auftreten.
  In einer ersten 3-monatigen Phase wird die gehandhabte Thromboseprophylaxe dokumentiert. In einer zweiten Phase wird zunächst eine evidenzbasierte Handlungsanleitung entwickelt, in welcher insbesondere die Indikationen zur Thromboseprophylaxe genau festgelegt werden (Grundlage sind LL-Empfehlungen). In einem nächsten Schritt wird die Handlungsanleitung mit Hilfe verschiedener Maßnahmen implementiert:
  - interaktive Schulung, insbesondere für Assistenzärzte
  - mündliche Erinnerungen bei den morgendlichen Visiten
  - Dokumentation der Thromboseprophylaxe in den elektronischen Krankenakten
  - Rückmeldung zum jeweiligen Grad der Übereinstimmung mit den Vorgaben an die einzelnen behandelnden Ärzte
  - Rückmeldung zum Grad der Übereinstimmung auf der gesamten Station (öffentlich).
  10 Monate nach Ende der Implementierungsphase (lediglich die Dokumentation in der Krankenakte wurde beibehalten) wurde erneut die Thromboseprophylaxe dokumentiert, ohne dass das Team über die erneute Erfassung informiert war.
  Vor der Intervention war an 60% aller Behandlungstage eine angemessene Thromboseprophylaxe erfolgt, nach Erstellung und Implementierung der Handlungsanleitung an 100% aller Tage (bestehende Kontraindikationen wurden in der Auswertung berücksichtigt).
  Aus Sicht der Autoren, welche die möglichen Limitationen der Aussagekraft von Beobachtungsstudien diskutieren, zeigt die Studie, mit welch einfachen Mitteln, sich eine nachhaltige Änderung des Verordnungsverhaltens erreichen lässt.