Colorectal cancer screening: recommendations and guideline adherence by physicians from digestive endoscopy centers in the Lazio region, Italy.

Prev Med. 2006 Sep;43(3):183-6

Authors: Federici A, Valle S, Giorgi Rossi P, Grassi A, Borgia P, Guasticchi G

INTRODUCTION: Endoscopy plays a key role in colorectal cancer screening; at the beginning of a mass screening campaign, it is important for public health officials to assess physicians’ attitudes and adherence to guidelines regarding colorectal cancer screening. METHODS: In April 2004, a questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of the Italian Society of Digestive Endoscopy. The results were compared to those from a similar survey of general practitioners (GPs). RESULTS: Seventy-one centers (89%) returned the questionnaire. Only 3% of physicians said they did not recommend any colorectal cancer screening test. Colonoscopy was perceived as the most effective screening test and was the most recommended (80%). Fecal occult blood test was recommended by 61% of physicians and flexosigmoidoscopy by 11%. Endoscopy centers’ physicians recommend screening more than GPs (96.9% vs. 78.3%), while they have a similar level of over-recommending (50.8% vs. 47.2%). Almost 95% of endoscopy physicians properly recommended colonoscopy after positive FOBT. CONCLUSIONS: Neither physicians at endoscopy centers nor GPs tend to follow screening guidelines. Screening programmes should not rely on a single medical specialist, but on interdisciplinary management of the disease to strengthen adherence to existing guidelines.

PMID: 16777203 [PubMed - in process]

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Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO).

Kidney Int. 2006 Sep 27;

Authors: Uhlig K, Macleod A, Craig J, Lau J, Levey AS, Levin A, Moist L, Steinberg E, Walker R, Wanner C, Lameire N, Eknoyan G

Considerable variation in grading systems used to rate the strength of guideline recommendations and the quality of the supporting evidence in Nephrology highlights the need for a uniform, internationally accepted, rigorous system. In 2004, Kidney Disease: Improving Global Outcomes (KDIGO) commissioned a methods expert group to recommend an approach for grading in future nephrology guidelines. This position statement by KDIGO recommends adopting the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for the grading of evidence and guidelines on interventions. The GRADE approach appraises systematic reviews of the benefits and harms of an intervention to determine its net health benefit. The system considers the design, quality, and quantity of studies as well as the consistency and directness of findings when grading the quality of evidence. The strength of the recommendation builds on the quality of the evidence and additional considerations including costs. Adaptations of the GRADE approach are presented to address some issues pertinent to the field of nephrology, including (1) the need to extrapolate from studies performed predominantly in patients without kidney disease, and (2) the need to use qualitative summaries of effects when it is not feasible to quantitatively summarize them. Further refinement of the system will be required for grading of evidence on questions other than those related to intervention effects, such as diagnostic accuracy and prognosis.Kidney International advance online publication, 27 September 2006; doi:10.1038/sj.ki.5001875.

PMID: 17003817 [PubMed - as supplied by publisher]

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Economic evaluation of adherence to treatment guidelines in non-intensive care pneumonia.

Eur Respir J. 2006 Sep 27;

Authors: Menéndez R, Reyes S, Martínez R, de la Cuadra P, Manuel Vallés J, Vallterra J

Guidelines have been developed to improve the treatment of community acquired pneumonia (CAP), but information regarding their influence on costs is lacking. Our objective was to conduct a cost-effectiveness analysis, from the hospital perspective, of CAP treatment when adhering to Spanish guidelines.A prospective cohort study was performed in 271 patients with CAP, admitted to a tertiary-care hospital, not needing intensive care. Collected data included patients’ characteristics, co-morbidity, initial risk class, resource use (medication, blood and microbiological analyses, and radiology) and economic data. Antimicrobial treatment was recorded as adherent or not to Spanish guidelines. Outcome measures were mortality and re-admission at 30 days.The median cost for adherent treatment was 1665.5 versus 1710.5 euros for non-adherent treatment. Mortality and re-admission were 10% and 2.1% for adherent treatment versus 13.6% and 6.2% for non-adherent treatment. The cost-effectiveness ratio was 2,277euros /expected cure for the patients treated according to the guidelines and 2,552euros /expected cure for the non-adherence group. The incremental cost-effectiveness ratio showed that adherence to treatment guidelines saved 1,121euros /patient cured compared to non-adherence. The sensitivity analysis demonstrated that the findings were robust.An antimicrobial treatment according to guidelines is the dominant alternative because of its cost-effectiveness.

PMID: 17005580 [PubMed - as supplied by publisher]

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Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative.

Circulation. 2006 Sep 26;114(13):1380-7

Authors: Alexander KP, Chen AY, Newby LK, Schwartz JB, Redberg RF, Hochman JS, Roe MT, Gibler WB, Ohman EM, Peterson ED,

BACKGROUND: Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS); their safe use in women, however, remains a concern. The contribution of dosing to the observed sex-related differences in bleeding is unknown. METHODS AND RESULTS: We explored the relationship between patient sex, GP IIb/IIIa inhibitor use, dose, and bleeding in 32 601 patients with NSTE ACS across 400 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) hospitals, of whom 18 436 were treated. GP IIb/IIIa inhibitor dose was defined as excessive if not reduced when creatinine clearance was or = 0.12, need for transfusion, or intracranial bleeding. Major bleeding was adjusted for clinical factors and antithrombotic dose. The risk for bleeding attributable to excess GP IIb/IIIa dose was determined by sex using prevalence and adjusted odds ratios (ORs). Women had higher rates of major bleeding than men among those treated with GP IIb/IIIa inhibitors (15.7% versus 7.3%, P

PMID: 16982940 [PubMed - indexed for MEDLINE]

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Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis.

Med J Aust. 2006 Sep 18;185(6):310-4

Authors: Irving MJ, Craig JC, Gallagher M, McDonald S, Polkinghorne KR, Walker RG, Roger SD

OBJECTIVE: To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), using iron management in patients having dialysis as an example. DESIGN AND SETTING: On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients’ iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry. PARTICIPANTS: Patients with chronic kidney disease who were dependent on dialysis. MAIN OUTCOME MEASURES: Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines. RESULTS: There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%-32% of patients achieving haemoglobin targets of 110-120 g/L, 30%-68% achieving ferritin targets of 300-800 microg/L, and 65%-73% achieving transferrin saturation targets of 20%-50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer nephrologists per dialysis unit, and a “proactive” (actively keeping iron levels within target range) rather than “reactive” (only reacting if iron levels are out of the range) protocol. CONCLUSIONS: Variability in achievement of iron targets, despite the availability of a clinical practice guideline, may be explained by variability in processes of care for achieving and maintaining adequate iron parameters.

PMID: 16999671 [PubMed - in process]

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Implementation of the NICE guideline – Recommendations from the British Fertility Society for national criteria for NHS funding of assisted conception.

Hum Fertil (Camb). 2006 Sep;9(3):181-9

Authors: Kennedy R, Kingsland C, Rutherford A, Hamilton M, Ledger W

Assisted conception providers in England were surveyed to establish the uptake of NICE guideline for infertility particularly in respect of assisted conception and the criteria used to accept patients for NHS funded treatment. Detailed information on selection criteria was obtained from a group of commissioning consortia at an advanced stage in their arrangements. While there was an overall increase in the number of NHS IVF cycles purchased in England, implementation is stalled at one fresh cycle in the vast majority of Primary Care Trusts (PCTs). There is little consensus about the criteria used for acceptance into an NHS programme. This is particularly so in respect of social criteria which are often arbitrary and used as a rationing tool. This information complements that provided by the survey of Primary Care Trusts performed in March 2005 by the All Party Parliamentary Group on Infertility (APPGI) in partnership with the National Infertility Awareness Campaign (NIAC) which together provide a basis for recommendations for NHS funding. The recommendations presented should be applied across England and Wales to ensure consistency, fairness and equity of access.

PMID: 17008271 [PubMed - in process]

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