Evaluation of Trauma Care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care.

World J Surg. 2006 Jun;30(6):946-56

Authors: Mock C, Nguyen S, Quansah R, Arreola-Risa C, Viradia R, Joshipura M

BACKGROUND: We sought to identify affordable and sustainable methods to strengthen trauma care capabilities globally, especially in developing countries, using the Guidelines for Essential Trauma Care. These guidelines were created by the World Health Organization (WHO) and the International Society of Surgery and provide recommendations on elements of trauma care that should be in place at the range of health facilities globally. METHODS: The guidelines were used as a basis for needs assessments in 4 countries selected to represent the world’s range of geographic and economic conditions: Mexico (middle income; Latin America); Vietnam (low income; east Asia); India (low income; south Asia); and Ghana (low income; Africa). One hundred sites were assessed, including rural clinics (n=51), small hospitals (n=34), and large hospitals (n=15). Site visits utilized direct inspection and interviews with administrative and clinical staff. RESULTS: Resources were partly adequate or adequate at most large hospitals, but there were gaps that could be improved, especially in low-income settings, such as shortages of airway equipment, chest tubes, and trauma-related medications; and prolonged periods where critical equipment (e.g., X-ray, laboratory) were unavailable while awaiting repairs. Rural clinics everywhere had difficulties with basic supplies for resuscitation even though some received significant trauma volumes. In all settings, there was a dearth of administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and regular in-service training. CONCLUSIONS: This study identified several low-cost ways in which to strengthen trauma care globally. It also has demonstrated the usefulness of the Guidelines for Essential Trauma Care in providing an internationally applicable, standardized template by which to assess trauma care capabilities.

PMID: 16736320 [PubMed - in process]

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Economics methods in the Clinical Outcomes Utilizing percutaneous coronary Revascularization and Aggressive Guideline-driven drug Evaluation (COURAGE) trial.

Am Heart J. 2006 Jun;151(6):1180-5

Authors: Weintraub WS, Barnett P, Chen S, Hartigan P, Casperson P, O’Rourke R, Boden WE, Lewis C, Veledar E, Becker E, Culler S, Kolm P, Mahoney EM, Dunbar SB, Deaton C, O’Brien B, Goeree R, Blackhouse G, Nease R, Spertus J, Kaufman S, Teo K

Percutaneous coronary intervention (PCI) remains a major therapeutic option for the treatment of chronic coronary artery disease. In the COURAGE trial, 2287 patients with chronic coronary disease were randomized between PCI with medical management and medical management alone. Embedded within the COURAGE trial is a detailed economic analysis being conducted in three health care systems: the US Veterans Administration (VA), Canada, and the US non-VA. Resource use and costs are being collected for each system and overall. Survival is assessed internally in the trial with mean follow-up of 4.5 years. Long-term mean survival will be estimated by projecting survival beyond the trial period by extrapolating the in-trial hazard rates. Utility is being assessed at baseline and at 1, 3, and 6 months and annually thereafter, using a computer-administered standard gamble. Quality-adjusted life years are calculated by multiplying survival by utility. The incremental cost-effectiveness ratio of PCI will be defined as the additional cost of PCI divided by the gain in life years and quality-adjusted life years. The 95% confidence regions of efficacy and costs will be determined by bootstrap over a range of acceptability thresholds, which will then be displayed in the cost-effectiveness plane and as a cost-effectiveness acceptability curve. A multilevel regression model will assess cost-effectiveness from a net benefit perspective. These approaches should provide the most detailed assessment available of the cost-effectiveness of PCI for coronary artery disease.

PMID: 16781215 [PubMed - indexed for MEDLINE]

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The influence of risk status on guideline adherence for patients with non-ST-segment elevation acute coronary syndromes.

Am Heart J. 2006 Jun;151(6):1205-13

Authors: Roe MT, Peterson ED, Newby LK, Chen AY, Pollack CV, Brindis RG, Harrington RA, Christenson RH, Smith SC, Califf RM, Braunwald E, Gibler WB, Ohman EM

BACKGROUND: Practice guidelines for patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) recommend targeting evidence-based therapies for the highest-risk patients. We characterized guideline adherence for NSTE ACS by risk status. METHODS: We analyzed inhospital treatments and outcomes for 77760 patients with NSTE ACS (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE initiative from January 2001 to September 2003 at 457 US hospitals. Compliance with the American College of Cardiology/American Heart Association Class guideline recommendations for NSTE ACS was evaluated in subgroups of eligible patients without listed contraindications at increased risk for mortality and among risk categories designated by an adapted version of the PURSUIT risk model designed to predict inhospital mortality. RESULTS: Inhospital mortality was increased in patients with diabetes mellitus (5.8% vs 4.3%), renal insufficiency (10.0% vs 3.9%), signs of congestive heart failure on presentation (10.6% vs 3.1%), and age > or = 75 years (8.6% vs 2.7%), compared with patients without these features. Use of guideline-recommended acute medications, invasive cardiac procedures, and discharge medications and interventions was significantly lower in patients with these high-risk features. Patients designated as high-risk for inhospital mortality were less likely to be treated with guideline-recommended therapies compared with low-risk and moderate-risk patients. CONCLUSIONS: Patients with NSTE ACS with the highest risk of mortality are less likely to receive guideline-recommended therapies and interventions. These findings highlight the need to clarify guideline recommendations for high-risk patients and to develop novel quality improvement approaches that target undertreated subgroups of patients with NSTE ACS.

PMID: 16781220 [PubMed - indexed for MEDLINE]

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Current challenges in adherence to clinical guidelines for antibiotic prophylaxis in surgery.

J Coll Physicians Surg Pak. 2006 Jun;16(6):435-7

Authors: Khan SA, Rodrigues G, Kumar P, Rao PG

To study the impact of guidelines on surgical antibiotic prophylaxis in clinical practice, barriers involved in adherence to guidelines and how to overcome the same. METHODS: Literature pertaining to prophylactic antibiotic usage was searched. Medscape, Medline, Cochrane, Surgical Infection Prevention (SIP) project databases were reviewed. Recent articles from relevant journals, texts, and standard guidelines were also studied. RESULTS: Local guidelines seem more likely to be accepted and followed than those developed nationally. Major barriers involved in adherence to guidelines include lack of awareness about the guidelines, general perception of guideline as a bureaucratic rather than educational tool. Some practitioners perceive guidelines as “cookbook medicine” that does not permit them to make their own medical decisions. Other barriers are complex, multi-step systems that create confusion, decrease accountability. Methods for guideline adherence include surveillance and data analysis, new systems to facilitate documentation and improving workflow, education regarding current evidence-based guidelines and promoting the development of local guidelines or protocol, development and implementation of reminders to facilitate adherence to the local guidelines. CONCLUSION: A multidisciplinary steering team of surgeons, infectious disease specialists, pharmacists, anesthesiologists, microbiologists and nurses should develop local guidelines suitable to their institution and methods for adherence to prevent the surgical site infections. The gap between evidence-based guidelines and practice must be addressed in order to achieve optimal practice in this domain.

PMID: 16787628 [PubMed - indexed for MEDLINE]

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Guideline: Hip dysplasia screening has insufficient evidence.

J Fam Pract. 2006 Jun;55(6):484

Authors:

PMID: 16795939 [PubMed]

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[Medical assessment of psychosomatic illnesses in the field of short-term disability compensation insurance: advantages of a multidimensional structured guideline]

Versicherungsmedizin. 2006 Jun 1;58(2):73-80

Authors: Svitak M, Müller-Svitak S, Rauh E

The aim of the medical report in the area of short-term disability claims caused by psychological and psychosomatic disorders is to make a valid prognosis on the further development of absenteeism and/or to estimate the return-to-work probability of the claimant. An analysis of the current practice of determining the validity of claims caused by psychosomatic illnesses shows that it is inadequate and unsatisfactory, mainly as a result of its reliance on a cross-sectional based judgement. The authors present a structured guideline (Multi-Axial-Psychodiagnostic for short-term disability claims, MAP-KTG), which supports, via a multi-dimensional diagnosis process, the validation of the psychological and psychosomatic symptoms of the claimant. It is also used to assess the amount of functional disability with a higher degree of accuracy. The determination of the prognosis, with regard to future work prospects, can be obtained by applying a list of empirically generated variables proven to be associated with the return-to-work probability.

PMID: 16800144 [PubMed - indexed for MEDLINE]

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The adherence to practice guidelines in the assessment of bone health in women with chemotherapy-induced menopause.

J Support Oncol. 2006 Jun;4(6):295-8, 304

Authors: Tham YL, Sexton K, Weiss HL, Elledge RM, Friedman LC, Kramer RM

Premenopausal women are diagnosed with 25% of all invasive breast cancers;adjuvant chemotherapy given to many of this population may induce menopause and increase the risk of osteoporosis development. Guidelines issued by the American Society of Clinical Oncology recommend regular assessment of bone health in such women. To assess appropriate attention to bone health, we performed a retrospective, cross-sectional survey of young women at high risk of osteoporosis secondary to chemotherapy-induced premature menopause. In all, 102 women with chemotherapy-induced menopause, 75% of whom were 40 years of age or younger, were asked whether they underwent screening and preventive measures for osteoporosis. Only 56% had discussed bone health with their healthcare providers; age at diagnosis, race, and use of tamoxifen were not linked to the likelihood of such discussions. Regular exercise was recommended to 73% of the women, calcium supplementation to 56%, and bone mineral density (BMD) testing to 40%. Approximately one half of the women regularly exercised and took a calcium supplement; however, over 37% of those using a supplement took less calcium than that recommended to prevent osteoporosis. Further, 32% reported having had BMD testing;women 40 years of age or younger were less likely to have had such tests (27%) than were older women (48%;P = 0.05). More emphasis must be given to educating breast cancer survivors with chemotherapy-induced menopause about bone health and its maintenance. Approved therapies to prevent osteoporosis probably are underused in this population.

PMID: 16805332 [PubMed - in process]

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Italian Stroke Guidelines (SPREAD): evidence and clinical practice.

Neurol Sci. 2006 Jun;27 Suppl 3:S225-7

Authors: Inzitari D, Carlucci G

Evidence-based medicine’s aims are to retrieve, screen and compound the best external evidence with the experience of the physician, and to best respond to the specific medical need of each individual patient. Clinical questions are better answered when good systematic reviews of randomised trials or good randomised clinical trials are available. On the other hand, in a clinical scenario, difficulties in applying the evidence may be amplified due to variability of disease conditions, feasibility of intervention and patient’s preferences. Guidelines are recommendations, based as much as possible on evidence, aimed at supporting clinical judgement/diagnostic skills/treatment decisions in everyday practice. Guidelines may improve the quality of care received by the patient and may contribute towards better consistency of care in a definite geographical area. However, guidelines risk reducing physician skills to critically appraising the evidence. In a clinical scenario, guidelines do not always provide substantial help, especially when no conclusive evidence supports them. The Italian Stroke Guidelines (SPREAD) have contributed towards more evidence-based and better harmonised stroke care in Italy. However, the number of high grade recommendations in SPREAD is still limited. Professionals should not forget that clinical decisions often reflect several issues, not only scientific ones, including personal experience, applicability of intervention and patient’s preferences.

PMID: 16752053 [PubMed - indexed for MEDLINE]

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Strategies for dissemination and implementation of guidelines.

Neurol Sci. 2006 Jun;27 Suppl 3:S231-4

Authors: Barosi G

Interventions designed to effectively implement and disseminate clinical practice guidelines (CPG) fall into different categories. A systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies was recently undertaken by the Health Technology Assessment (HTA) Programme in UK. Overall, the majority of comparisons reporting dichotomous process data observed improvement in care. However, there was considerable variation in the observed effects both within and across interventions. Evaluation studies provided evidence that adherence of physicians to CPG is a strong predictor of the stroke outcome. Cochrane Collaboration performed a systematic review including studies published up to 2004 that compared integrated clinical pathways (ICP) for stroke care with standard medical care. They found no significant difference between ICP and control groups in terms of death or discharge destination. Patients managed with a care pathway were more dependent at discharge, less likely to suffer a urinary tract infection, less likely to be readmitted and more likely to have neuroimaging. A positive effect was reported from a validation study of a multifaceted strategy for stroke care ICP implementation in Italy.

PMID: 16752055 [PubMed - indexed for MEDLINE]

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Workflow management systems for guideline implementation.

Neurol Sci. 2006 Jun;27 Suppl 3:S245-9

Authors: Panzarasa S, Stefanelli M

The activities of care providers need to be coordinated within a process properly designed on the basis of available best practice medical knowledge. It requires a rethinking of the management of care processes within health-care organisations. The current workflow technology seems to offer the most convenient solution to build such cooperative systems. However, some of its present weaknesses still require an intense research effort to find solutions allowing its exploitation in real medical practice. This paper presents an approach to design and build evidence-based workflow management systems (WfMS). They can be viewed as components of a knowledge management infrastructure each health care organisation should be provided with, to increase its performance in delivering high-quality care, by efficiently exploiting the available knowledge resources. On the basis of a general methodology, we describe a WfMS implementation in the area of Stroke management; such a system, after intensive testing in our research laboratory, is now in the process of being transferred in a real working setting (a stroke unit) and integrated with an existing electronic patient record.

PMID: 16752059 [PubMed - indexed for MEDLINE]

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