Clinician assessment of guidelines that support common dental procedures.

J Evid Based Dent Pract. 2008 Mar;8(1):1-7

Authors: Faggion CM

Many common clinical dental procedures do not have high-quality clinical guidelines available. Clinical guidelines are considered an important tool for applying the evidence-based concept to dental practice. The main objective of this study was to assess if current clinical guidelines that are easily available to dental practitioners in electronic databases support common dental procedures. In addition, a useful model for the assessment of the quality of the guidelines is presented. The results of a literature search demonstrated a lack in both the number and quality of clinical dental guidelines that support common dental procedures. Nine selected guidelines were assessed using the Appraisal of Guidelines, Research, and Evaluation instrument (AGREE). Following the AGREE recommendation, only one guideline could be considered for use in dental practice. Four guidelines were also considered for use in practice, but they would need some alteration in their contents. The last four guidelines did not achieve a good score and therefore could not be considered for use in dental practice. In conclusion, more high-quality dental guidelines should be developed to support common dental procedures using standardized quality criteria in order to appropriately implement the evidence-based process into dental practice. Furthermore, the AGREE instrument may help dental practitioners objectively assess the quality of clinical guidelines.

PMID: 18346691 [PubMed - indexed for MEDLINE]

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Guidelines for surveillance intervals after polypectomy: coping with the evidence.

Ann Intern Med. 2008 Mar 18;148(6):477-9

Authors: Imperiale TF, Sox HC

PMID: 18347353 [PubMed - indexed for MEDLINE]

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Guidelines for the prevention of infection after combat-related injuries.

J Trauma. 2008 Mar;64(3 Suppl):S211-20

Authors: Hospenthal DR, Murray CK, Andersen RC, Blice JP, Calhoun JH, Cancio LC, Chung KK, Conger NG, Crouch HK, D’Avignon LC, Dunne JR, Ficke JR, Hale RG, Hayes DK, Hirsch EF, Hsu JR, Jenkins DH, Keeling JJ, Martin RR, Moores LE, Petersen K, Saffle JR, Solomkin JS, Tasker SA, Valadka AB, Wiesen AR, Wortmann GW, Holcomb JB

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

PMID: 18316965 [PubMed - indexed for MEDLINE]

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How are the experiences and needs of families of individuals with mental illness reflected in medical education guidelines?

Acad Psychiatry. 2008 Mar-Apr;32(2):119-26

Authors: Riebschleger J, Scheid J, Luz C, Mickus M, Liszewski C, Eaton M

OBJECTIVE: This descriptive study explored the extent that medical education curriculum guidelines contained content about the experiences and needs of family members of people with serious mental illness. METHODS: Key family-focused-literature themes about the experiences and needs of families of individuals with mental illness were drawn from a review of over 6,000 sources in the mental health practice literature that were identified within a systematic search and thematic development process. The study identified the extent and nature of family-focused key literature themes as reflected in medical education curriculum guidelines for psychiatry and primary care practice specialties of family practice, internal medicine, and pediatrics. An iterative process was used to retrieve and analyze text data drawn from the curriculum guidelines of national accrediting organizations for undergraduate, graduate, and continuing medical education. RESULTS: The key family-focused themes, as drawn from the mental health practice research literature, were: mental illness stigma; family caregiver burden; information exchange and referral; family stress, coping, and adaptation; family support; crisis response; and family psychoeducation. Two of these seven themes appeared in medical education curriculum guidelines: information exchange and caregiver burden. The most frequently appearing family-focused key literature theme was information exchange. Psychiatry and undergraduate medical education reflected the most family content. CONCLUSION: It appears that medical education curriculum guidelines have insufficient content about families of people with mental illness. The educational experiences of psychiatrists and primary care physicians may not adequately prepare them for working with family members of their patients. It is recommended that medical education curriculum guidelines incorporate information about family stigma; family/caregiver burden; information exchange; family stress, coping, and adaptation; family support; crisis response; and multiple family group psychoeducation.

PMID: 18349331 [PubMed - in process]

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Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part I: introduction and general considerations.

Pain Physician. 2008 Mar;11(2):161-86

Authors: Manchikanti L

Evidence-based medicine, systematic reviews, and guidelines are part of modern interventional pain management. As in other specialties in the United States, evidence-based medicine appears to motivate the search for answers to numerous questions related to costs and quality of health care as well as access to care. Scientific, relevant evidence is essential in clinical care, policy-making, dispute resolution, and law. Consequently, evidence based practice brings together pertinent, trustworthy information by systematically acquiring, analyzing, and transferring research findings into clinical, management, and policy arenas. In the United States, researchers, clinicians, professional organizations, and government are looking for a sensible approach to health care with practical evidence-based medicine. All modes of evidence-based practice, either in the form of evidence-based medicine, systematic reviews, meta-analysis, or guidelines, evolve through a methodological, rational accumulation, analysis, and understanding of the evidentiary knowledge that can be applied in clinical settings. Historically, evidence-based medicine is traceable to the 1700s, even though it was not explicitly defined and advanced until the late 1970s and early 1980s. Evidence-based medicine was initially called “critical appraisal” to describe the application of basic rules of evidence as they evolve into application in daily practices. Evidence-based medicine is defined as a conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Evidence-based practice is defined based on 4 basic and important contingencies, which include recognition of the patient’s problem and construction of a structured clinical question, thorough search of medical literature to retrieve the best available evidence to answer the question, critical appraisal of all available evidence, and integration of the evidence with all aspects and contexts of the clinical circumstances. Systematic reviews provide the application of scientific strategies that limit bias by the systematic assembly, critical appraisal, and synthesis of all relevant studies on a specific topic. While systematic reviews are close to meta-analysis, they are vastly different from narrative reviews and health technology assessments. Clinical practice guidelines are systematically developed statements that aim to help physicians and patients reach the best health care decisions. Appropriately developed guidelines incorporate validity, reliability, reproducibility, clinical applicability and flexibility, clarity, development through a multidisciplinary process, scheduled reviews, and documentation. Thus, evidence-based clinical practice guidelines represent statements developed to improve the quality of care, patient access, treatment outcomes, appropriateness of care, efficiency and effectiveness and achieve cost containment by improving the cost benefit ratio. Part 1 of this series in evidence-based medicine, systematic reviews, and guidelines in interventional pain management provides an introduction and general considerations of these 3 aspects in interventional pain management.

PMID: 18354710 [PubMed - in process]

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Evolution of costs of care for cystic fibrosis patients after clinical guidelines implementation in a French network.

J Cyst Fibros. 2008 Mar 19;

Authors: Huot L, Durieu I, Bourdy S, Ganne C, Bellon G, Colin C, Touzet S,

OBJECTIVES: The aim of this study was to evaluate how advances in CF management in France between 2000 and 2003 impacted CF-related costs. METHODS: The analysis of direct medical costs was done in 2000 and 2003 from the perspective of the French national healthcare insurance system. The patients, 65 in 2000 and 64 in 2003, were followed-up in one pediatric and one adult CF reference center (CFRC). We quantified and valued CF-related home and hospital care costs. RESULTS: We found an average cost of euro16474/patient/year in 2000, and euro22725 in 2003 (based on the 2003 euro value). Hospital care increased from 15% of the total cost in 2000 to 22% in 2003. Medications accounted for 45% of the total cost for the two periods, with an average cost of euro7229/patient/year in 2000 and euro10336 in 2003. Home intravenous antibiotic therapy accounted for 20% of the total cost for the two periods. CONCLUSIONS: We highlighted an increase in CF care costs between 2000 and 2003, which might be related to the changes in practice patterns that followed guidelines implementation, such as the use of new medications (dornase alpha and tobramycin) and more frequent follow-up in the CFRC.

PMID: 18358793 [PubMed - as supplied by publisher]

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Ventilator-associated pneumonia: Improving outcomes through guideline implementation.

J Crit Care. 2008 Mar;23(1):118-125

Authors: Sinuff T, Muscedere J, Cook D, Dodek P, Heyland D,

Ventilator-associated pneumonia (VAP) is associated with increased duration of mechanical ventilation and increased risk of death for critically ill patients. Although scientific advances have the potential to improve the outcomes of critically ill patients who are at risk of or who have VAP, the translation of research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied in practice in the intensive care unit. Knowledge about VAP may be used more effectively at the bedside by a systematic process of knowledge translation through implementation of clinical practice guidelines. Unfortunately, there remain large gaps in our understanding of guideline implementation in the intensive care unit, specifically as it applies to guidelines for the prevention, diagnosis, and treatment of VAP.

PMID: 18359429 [PubMed - as supplied by publisher]

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Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention.

J Crit Care. 2008 Mar;23(1):126-137

Authors: Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D,

BACKGROUND: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. PURPOSE: To develop evidence-based guidelines for the prevention of VAP. DATA SOURCES: MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials. STUDY SELECTION: The authors systematically searched for all relevant randomized, controlled trials and systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to October 1, 2006. DATA EXTRACTION: Independently and in duplicate, the panel scored the internal validity of each trial. Effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of the guideline panel. LEVELS OF EVIDENCE: The following statements were used: recommend, consider, do not recommend, and no recommendation due to insufficient or conflicting evidence. DATA SYNTHESIS: To prevent VAP: CONCLUSION: There are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection.

PMID: 18359430 [PubMed - as supplied by publisher]

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Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment.

J Crit Care. 2008 Mar;23(1):138-147

Authors: Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D,

BACKGROUND: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Despite a large amount of research evidence, the optimal diagnostic and treatment strategies for VAP remain controversial. PURPOSE: The aim of this study was to develop evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. Data sources include Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials. STUDY SELECTION: The authors systematically searched for all relevant randomized controlled trials and systematic reviews on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1, 2006. DATA EXTRACTION: Independently and in duplicate, the panel critically appraised each published trial. The effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. The full guideline development panel arrived at a consensus for scores on safety, feasibility, and economic issues. LEVELS OF EVIDENCE: Based on the scores for each topic, the following statements of recommendation were used: recommend, consider, do not recommend, and no recommendation because of insufficient or conflicting evidence. DATA SYNTHESIS: For the diagnosis of VAP in immunocompetent patients, we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy. When there is a suspicion of VAP, we recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP. Choice of antibiotics should be based on patient factors and local resistance patterns. We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP. For patients who receive adequate initial antibiotic therapy, we recommend 8 days of antibiotic therapy. We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP. CONCLUSION: We present evidence-based recommendations for the diagnosis and treatment of VAP. Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP.

PMID: 18359431 [PubMed - as supplied by publisher]

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Clinical impact of adherence to guidelines on the outcome of chronic heart failure in Japan.

Int Heart J. 2008 Jan;49(1):59-73

Authors: Ohsaka T, Inomata T, Naruke T, Shinagawa H, Koitabashi T, Nishii M, Takeuchi I, Takehana H, Izumi T

The impact of guideline adherence on clinical outcomes in the management of chronic heart failure (CHF) has never been evaluated in Japan. We investigated outcomes in 92 consecutive CHF patients admitted to Kitasato University Hospital in 2004-2006 for HF exacerbation with a left ventricular ejection fraction

PMID: 18360065 [PubMed - in process]

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