[Guideline compliance in hip fracture : Results of an external quality-assurance program in North Rhine Westphalia: 2003-2005.]

Unfallchirurg. 2008 Feb;111(2):65-70

Authors: Schulze Raestrup U, Grams A, Smektala R

BACKGROUND: Whereas the Scottish guidelines are audited annually, nobody evaluates guideline compliance in Germany. Thus, can external quality assurance data pursuant to section 137 of the German Social Code Book V be suitable for auditing guideline compliance? MATERIALS AND METHODS: From North Rhine Westphalia, a total of 48,831 cases of femoral fractures near the hip joint were evaluated. Compliance with the guidelines was determined based on preoperative hospital stay, thrombosis, and antibiotic prophylaxis. Guideline rationale was reviewed in terms of mortality and thromboembolism rate. RESULTS: Sixty-four percent of the interventions were performed in a timely manner. Thrombosis prophylaxis was given in 99% of cases. Antibiotics were given as a single shot. There was no connection between mortality and thromboembolism rates or time to surgery. CONCLUSION[UBERSCHRIFT]: Guideline compliance is similar in German and Scotland. The external quality assurance data are suitable for evaluating guideline compliance. The literature recommends a short time to surgery. Given the short observation period, it was not possible to demonstrate any improvement in outcomes.

PMID: 18239903 [PubMed - in process]

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Evaluation of current practice: compliance with osteoporosis clinical guidelines in an outpatient fracture clinic.

Aust Health Rev. 2008 Feb;32(1):34-43

Authors: Kimber CM, Grimmer-Somers KA

Better detection and management of osteoporosis will reduce unnecessary health expenditure. A number of high quality guidelines are available to support early detection and best practice management of osteoporosis in hospital settings. However, sustainable implementation of guidelines poses practical issues in terms of structure and processes in hospitals. This paper describes an investigation into guideline compliance in one large tertiary metropolitan hospital and discusses practical elements of guideline implementation. Given the evidence of poor practice across the two audit periods, we recommend that a coordinated clinical pathway be implemented in the fracture clinic, supported by a targeted and discipline-specific training program. Small steps towards improving awareness and management of osteoporosis in patients presenting for the first time with non-trauma wrist fracture may well produce large cost savings by future fracture prevention.

PMID: 18241147 [PubMed - in process]

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Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings.

BMC Health Serv Res. 2008 Feb 2;8(1):29

Authors: Davies B, Edwards N, Ploeg J, Virani T

ABSTRACT: BACKGROUND: Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings. METHODS: A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n=681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n=261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN’s, nurses and administrators to describe recommendations selected, strategies used and participants’ perceived facilitators and barriers to guideline implementation. RESULTS: While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance. CONCLUSIONS: Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.

PMID: 18241349 [PubMed - as supplied by publisher]

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Effect of standard treatment guidelines with or without prescription audit on prescribing for acute respiratory tract infection (ARI) and diarrhoea in some thana health complexes (THCs) of Bangladesh.

Bangladesh Med Res Counc Bull. 2007 Apr;33(1):21-30

Authors: Chowdhury AK, Khan OF, Matin MA, Begum K, Galib MA

Inappropriate prescribing for ARI and diarrhoea is a serious health problem in many developing countries including Bangladesh. A baseline retrospective prescribing survey for ARI and diarrhoea have been conducted in randomly selected 60 thana health complexes (THCs) of Dhaka division of Bangladesh. In the 38 of 60 THCs, the prescribers did not comply with the standard treatment guidelines (STG) for ARI. They are marked as ‘unsatisfactory performers’. In these THCs unnecessary antibiotics were prescribed in more than 50% of the encounters. The study further revealed that in 26 THCs, comprising 41.6% of the 38 THCs, the situation was even worse regarding the indiscriminate use of antibiotics. In these THCs antibiotics were prescribed in > or =72% of the encounters. For diarrhoea, only in 8.3% of the THCs antibiotics were prescribed in > or =50% of the encounters. Encouragingly, most of the prescribers prescribed ORS. So the diarrhoea cases were dropped from the intervention. The 24 out of 26 worse performing THCs for ARI management, were grouped into three groups: Group-I (implementing STG+ Audit), Group-II (STG) and Group-III (no intervention, control). The prescribers of the THCs belonging to Group-I and Group-II received STG+Audit and STG only respectively as intervention(s). On the contrary, the prescribers of the THCs of Group-III (control) did not receive any intervention. It was observed that after the implementation of interventions the use of the unnecessary antibiotics to treat ARI was significantly reduced (p

PMID: 18246731 [PubMed - indexed for MEDLINE]

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Perception towards asthma clinical practice guidelines and appropriateness of prescribing practices–a comparison between government and private doctors.

Med J Malaysia. 2007 Aug;62(3):210-3

Authors: Loh LC, Wong PS

A self-answered, anonymously completed, nationwide questionnaire survey was conducted between June 2002 and May 2003 among Malaysian doctors through post and at medical meetings. Findings based on 116 government and 110 private doctors who satisfactorily completed the forms (effective respondent rate: 30.1%) showed that more than 70% of government and private doctors claimed familiarity with asthma CPGs but proportionately more private doctors considered them “unworkable” and were reluctant to adopt them in their practice setting, quoting cost as the primary reason. Between those who frequently adopted the CPGs and those who did not, there was an equally high proportion of inappropriate prescribing. Despite the shortcomings of such a survey, our findings suggest that medicinal cost and practitioner’s prescribing practices are important in the acceptance and execution of asthma CPGs recommendations.

PMID: 18246909 [PubMed - in process]

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The use of unit watch or command interest profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional.

Mil Med. 2008 Jan;173(1):25-35

Authors: Payne SE, Hill JV, Johnson DE

Military mental health care professionals have, for decades, recommended that commanders implement a unit watch (now called a “command interest profile” at most Army posts) as a tool for enhancing the safety of personnel in the unit when a soldier presents with suicidal or homicidal ideation. Although these procedures are used extensively in garrison and in operational settings, there exists no specific body of literature or Army publication to offer either a rationale or a set of guidelines for their use. We have successfully used unit watch protocols for years both in the deployment setting and in garrison. This article provides both a rationale and a set of guidelines for their use based on fundamental military psychiatric principles, review of the relevant literature, and anecdotal experience with this intervention. Although further research is indicated, this article provides support for the use of unit watch in military settings.

PMID: 18251328 [PubMed - indexed for MEDLINE]

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Standardization of search methods for guideline development: an international survey of evidence-based guideline development groups.

Health Info Libr J. 2008 Mar;25(1):23-30

Authors: Deurenberg R, Vlayen J, Guillo S, Oliver TK, Fervers B, Burgers J,

Background: Effective literature searching is particularly important for clinical practice guideline development. Sophisticated searching and filtering mechanisms are needed to help ensure that all relevant research is reviewed. Purpose: To assess the methods used for the selection of evidence for guideline development by evidence-based guideline development organizations. Methods: A semistructured questionnaire assessing the databases, search filters and evaluation methods used for literature retrieval was distributed to eight major organizations involved in evidence-based guideline development. Results: All of the organizations used search filters as part of guideline development. The medline database was the primary source accessed for literature retrieval. The OVID or SilverPlatter interfaces were used in preference to the freely accessed PubMed interface. The Cochrane Library, embase, cinahl and psycinfo databases were also frequently used by the organizations. All organizations reported the intention to improve and validate their filters for finding literature specifically relevant for guidelines. Discussion: In the first international survey of its kind, eight major guideline development organizations indicated a strong interest in identifying, improving and standardizing search filters to improve guideline development. It is to be hoped that this will result in the standardization of, and open access to, search filters, an improvement in literature searching outcomes and greater collaboration among guideline development organizations.

PMID: 18251909 [PubMed - as supplied by publisher]

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Guidelines for good practice in PGD: programme requirements and laboratory quality assurance.

Reprod Biomed Online. 2008 Jan;16(1):134-47

Authors:

The Preimplantation Genetic Diagnosis International Society (PGDIS) was organized in October 2002, with the purpose of encouraging and co-ordinating research, education and training in this multidisciplinary field, requiring a close collaboration of obstetricians, fertility specialists, embryologists and human geneticists. One of the major tasks of PGDIS is to advance the safety and accuracy of PGD and to encourage its adoption into clinical practice for improvement of genetic practices and reproductive medicine. In this context, PGDIS published voluntary guidelines applicable for any centre offering PGD in 2004, and these guidelines are now being updated and extended based on the present extensive PGD experience. The application of these guidelines is intended to further benefit patients and provide guidance to the laboratory staff. As in previous guidelines, PGDIS presents this document being aware that differences in national regulations exist that can affect local PGD practice. The document contains recent consensus points of general application that promote quality biopsy procedures and laboratory practice, enabling PGD centres to offer an improved clinical outcome to their patients. A variety of aspects related to a safe working system have been taken into consideration, based on the assumption that a quality programme depends on the cooperation of the whole PGD team.

PMID: 18252060 [PubMed - in process]

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Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence.

Br J Gen Pract. 2007 Dec;57(545):948-52

Authors: Heneghan C, Perera R, Mant D, Glasziou P

BACKGROUND: GPs vary greatly in their clinical management of hypertension, for reasons that are poorly understood. AIM: To explore GPs’ awareness of current hypertension guidelines and their self-reported implementation of them in clinical practice. DESIGN OF STUDY: Questionnaire survey via the internet. SETTING: Primary care. METHOD: Survey of GPs (n = 401), based on the ‘awareness-to-adherence’ model of behavioural change. RESULTS: While awareness of recommendations was high, agreement and adoption were often less so. Almost all practitioners (99%) were aware of the guidance on statin therapy but fewer than half (43%; 95% confidence interval [CI] 38-48%) adhered to the recommendation in practice. Three-quarters (77%) were aware that blood pressure should initially be measured in both arms, but only 30% agreed with the recommendation (95% CI = 26 to 34%), and 13% (95% CI = 10 to 16%) adhered to it. Although the adoption of a recommendation was usually consequent on agreement with it, 19% of GPs (95% CI = 15 to 23%) reported adherence to financially incentivised guidance on statin therapy without either being aware of it or in agreement with it. No significant association was found among age, sex, year of graduation, or post held and level of awareness, agreement, or adoption. CONCLUSION: The specific barrier and action needed to promote application of hypertension guidelines varies with each clinical action. Lack of awareness is seldom the problem. Most GPs are unlikely to implement elements of guidance they disagree with even if given financial incentives. High adherence requires a reflective workforce that can respond to the scientific evidence underpinning the guidance.

PMID: 18252069 [PubMed - in process]

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Thou shalt versus thou shalt not: a meta-synthesis of GPs’ attitudes to clinical practice guidelines.

Br J Gen Pract. 2007 Dec;57(545):971-8

Authors: Carlsen B, Glenton C, Pope C

BACKGROUND: GPs’ adherence to clinical practice guidelines is variable. Barriers to guideline implementation have been identified but qualitative studies have not been synthesised to explore what underpins these attitudes. AIM: To explore and synthesise qualitative research on GPs’ attitudes to and experiences with clinical practice guidelines. DESIGN OF STUDY: Systematic review and meta-synthesis of qualitative studies. METHOD: PubMed, CINAHL, EMBASE, Social Science Citation Index, and Science Citation Index were used as data sources, and independent data extraction was carried out. Discrepancies were resolved by consensus. Initial thematic analysis was conducted, followed by interpretative synthesis. RESULTS: Seventeen studies met the inclusion criteria. Five were excluded following quality appraisal. Twelve papers were synthesised which reported research in the UK, US, Canada, and the Netherlands, and covered different clinical guideline topics. Six themes were identified: questioning the guidelines, GPs’ experience, preserving the doctor-patient relationship, professional responsibility, practical issues, and guideline format. Comparative analysis and synthesis revealed that GPs’ reasons for not following guidelines differed according to whether the guideline in question was prescriptive, in that it encouraged a certain type of behaviour or treatment, or proscriptive, in that it discouraged certain treatments or behaviours. CONCLUSION: Previous analyses of guidelines have focused on professional attitudes and organisational barriers to adherence. This synthesis suggests that the purpose of the guideline, whether its aims are prescriptive or proscriptive, may influence if and how guidelines are received and implemented.

PMID: 18252073 [PubMed - in process]

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