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Quality assessment of clinical practice guidelines for the prevention and treatment of childhood overweight and obesity.

Eur J Pediatr. 2008 Sep 25;

Authors: Delgado-Noguera M, Tort S, Bonfill X, Gich I, Alonso-Coello P

BACKGROUND: The prevalence of childhood overweight and obesity is increasing at dramatic rates in children and adolescents worldwide. Clinical practice guidelines (CPGs) are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Their objective is to provide explicit recommendations for clinical practice based on current evidence for best practice in the management of diseases. MATERIALS AND METHODS: The aim of this study was to identify and assess the quality of CPGs for the prevention and treatment of obesity and overweight in childhood. We developed a search to identify CPGs published between January 1998 and August 2007. We considered for inclusion documents that provided recommendations for clinical practice referring to children and adolescents. Three independent appraisers assessed the quality of the1 CPGs using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument. We identified 376 references and selected 22 for further assessment. RESULTS: The overall agreement among reviewers using the intraclass correlation coefficient was 0.856 (95% confidence interval [CI] 0.731-0.932). Six of the 22 initial guidelines were recommended and a further eight were recommended with conditions or provisos. We concluded that the number of documents with recommendations on the prevention and treatment of childhood obesity published during the 10-year study period was considerable, but only a few of them could be considered as high quality. CPGs were deficient in areas such as applicability, editorial independence and rigor in development. CONCLUSION: Due to the increasing burden of obesity among children and the potential for long-term comorbidities, clinicians need to be critical in assessing the rigor of how these are developed and their appropriateness for use in the clinician’s own practice. There is a need to improve the methodology and the quality of CPGs on childhood obesity to help clinicians and other decision-makers to tackle this disease.

PMID: 18815809 [PubMed - as supplied by publisher]

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Guideline implementation for breast healthcare in low-income and middle-income countries : overview of the Breast Health Global Initiative Global Summit 2007.

Cancer. 2008 Sep 24;113(S8):2221-2243

Authors: Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, Carlson RW, Azavedo E, Harford J

Breast cancer outcomes in low- and middle-income countries (LMCs) correlate with the degree to which 1) cancers are detected at early stages, 2) newly detected cancers can be diagnosed correctly, and 3) appropriately selected multimodality treatment can be provided properly in a timely fashion. The Breast Health Global Initiative (BHGI) invited international experts to review and revise previously developed BHGI resource-stratified guideline tables for early detection, diagnosis, treatment, and healthcare systems. Focus groups addressed specific issues in breast pathology, radiation therapy, and management of locally advanced disease. Process metrics were developed based on the priorities established in the guideline stratification. The groups indicated that cancer prevention through health behavior modification could influence breast cancer incidence in LMCs. Diagnosing breast cancer at earlier stages will reduce breast cancer mortality. Programs to promote breast self-awareness and clinical breast examination and resource-adapted mammographic screening are important early detection steps. Breast imaging, initially with ultrasound and, at higher resource levels with diagnostic mammography, improves preoperative diagnostic assessment and permits image-guided needle sampling. Multimodality therapy includes surgery, radiation, and systemic therapies. Government intervention is needed to address drug-delivery problems relating to high cost and poor access. Guideline dissemination and implementation research plays a crucial role in improving care. Adaptation of technology is needed in LMCs, especially for breast imaging, pathology, radiation therapy, and systemic treatment. Curricula for education and training in LMCs should be developed, applied, and studied in LMC-based learning laboratories to aid information transfer of evidence-based BHGI guidelines. Cancer 2008;113(8 suppl):2221-43. Published 2008 by the American Cancer Society.

PMID: 18816619 [PubMed - as supplied by publisher]

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Are global nephrology guidelines feasible?

Nat Clin Pract Nephrol. 2008 Oct;4(10):521

Authors: Eknoyan G

PMID: 18818662 [PubMed - in process]

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Overactive Bladder and Continence Guidelines: implementation, inaction or frustration?

Int J Clin Pract. 2008 Oct;62(10):1588-93

Authors: Wagg A, Cardozo L, Chapple C, Diaz DC, de Ridder D, Espuna-Pons M, Haab F, Kelleher C, Kolbl H, Milsom I, Van Kerrebroeck P, Vierhout M, Kirby M

Guidelines for the management of continence and overactive bladder are generally available across Europe. For a majority of countries, these have been adopted by professional societies in either urology or gynaecology for local use. There has, however, been little monitoring of formal implementation of these guidelines and seldom any attempt to audit their operation. The state of continence care therefore remains largely unknown. This article reviews current guidelines and their status across Europe and examines what might be relevant from other disease areas to promote successful implementation.

PMID: 18822029 [PubMed - in process]

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[Guidelines for the management of uveitis in Internal Medicine.]

Rev Med Interne. 2008 Sep 26;

Authors: Abad S, Sève P, Dhote R, Brézin AP

In developed countries, uveitis is quite common and chronic course is associated with a poor visual prognosis. However, no guidelines for their management have been consensually proposed. Based on the experience of ophthalmologists and internists from tertiary care centers, this article describes the management of uveitis, including the diagnostic procedure, indications and types of anti-inflammatory treatments. We focus on the interest of an exhaustive ophthalmologic examination for the diagnosis of an underlying systemic disease such as sarcoidosis. In this way, a multidisciplinary staff could be useful for an optimal management of uveitis. We also reviewed the main current treatments for severe uveitis. Whatever the origin of ocular inflammation, corticosteroids are consensually used as first line treatment. However, the identification of an underlying systemic disease helps in the refinement of further therapeutic choices. In cases of refractory and sight threatening uveitis, the short-term use of infliximab, a chimeric anti-TNF-alpha antibody, has been shown to be effective and safe. These recommendations do not constitute treatment guidelines but aim at improving the uniformity of clinical practice for the management of uveitis, until higher levels of evidence are obtained.

PMID: 18824279 [PubMed - as supplied by publisher]

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Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit.

Crit Care Med. 2008 Sep 26;

Authors: Kumwilaisak K, Noto A, Schmidt UH, Beck CI, Crimi C, Lewandrowski K, Bigatello LM

OBJECTIVE:: Diagnostic testing is frequently overused in the intensive care unit. We devised guidelines to optimize blood tests utilization, and designed this study to quantify their efficacy over time, their safety, and their possible benefits. DESIGN:: Laboratory testing guidelines were created by consensus and implemented through repeated staff education. The guidelines included: a) the tests to be obtained daily: complete blood count, serum electrolytes, urea nitrogen, creatinine, and blood glucose concentration; b) the need to discuss laboratory testing at daily patient’s rounds; c) the need to provide a written order for all tests. The number of tests performed, corresponding physician orders, and various outcome measures were collected for two 6-months study periods, before and after the first day of implementation of the guidelines. SETTING:: Twenty-bed surgical intensive care unit in a tertiary care teaching hospital. PATIENTS:: All patients admitted during the two study periods. METHODS:: Laboratory tests and related physician orders, demographics, blood products transfusion, and outcomes were collected from hospital databases. In prospectively defined subgroups, additional outcome measures were obtained by ad-hoc chart review. RESULTS:: One thousand hundred seventeen patients were enrolled. After the institution of the guidelines, the number of laboratory tests decreased by 37% (from 64,305 to 40,877), and the number of respective physician orders increased by 38% (from 20,940 to 35,472; p < 0.001). These results were manifest within 1 month, sustained through the study period, and still present at 1 yr. No changes in outcomes or in the rates of selected complications were detected. Red blood cells utilization correlated linearly (r .47) with the number of blood tests performed in both study periods. CONCLUSIONS:: Guidelines designed to optimize laboratory tests use in an intensive care unit can produce rapid and long-lasting effects, can be safe and may affect the number of red blood cell units transfused.

PMID: 18824907 [PubMed - as supplied by publisher]

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[Quality assurance and guidelines in rehabilitation for musculoskeletal diseases.]

Z Rheumatol. 2008 Oct 1;

Authors: Glattacker M, Müller E, Jäckel WH

Diseases of the musculoskeletal system are among the most common and most costly diseases in Germany. They are also associated with a considerable burden for those affected. As a result these disorders also dominate the utilization statistics with respect to medical rehabilitation measures paid for by the statutory pension insurance. In the last 10 years, quality assurance programs have been developed for rehabilitation - initiated and financed by the rehabilitation sponsors - that are characterized by a comprehensive, perspective, pronounced scientific basis, region-wide implementation, and strong patient orientation. The development of guidelines for rehabilitation began later than for acute medicine. In addition to the formulation of guidelines for rehabilitation by medical organizations and professional associations, the German pension insurance has developed so-called process guidelines containing framework requirements for the treatment of defined indication groups rather than support for decision-making in the rehabilitation of individual patients. By planned control of adherence to the process guidelines in the quality assurance programs of the pension insurers prompt implementation of the guidelines can be anticipated.

PMID: 18825391 [PubMed - as supplied by publisher]

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Implementing arthritis clinical practice guidelines in primary care.

Med Teach. 2008 Sep 29;:1-8

Authors: Lineker SC, Bell MJ, Boyle J, Badley EM, Flakstad L, Fleming J, Lyddiatt A, Macdonald J, McCarthy J, Zummer M

Background: Multi-faceted interventions are among the strongest methods for changing provider behavior. Aims: This paper reports the design, implementation and process evaluation of an educational program to disseminate clinical practice guidelines (CPGs) on the management of rheumatoid arthritis (RA) and osteoarthritis (OA) in primary care. Methods: Organizations were invited to participate in inter-professional workshops on OA and RA followed by six months of activities to support the delivery of care in the community. Confidence in ability to manage arthritis was assessed at baseline using a 10 point numerical rating scale. Qualitative assessments were done immediately and 3-12 months post workshop. Results: 646 multidisciplinary providers from 216 organizations attended one of 30 workshops. Providers (n = 584) reported moderate confidence in managing arthritis: family physicians: mean: SD = 7.46(1.42), n = 145; nurse practitioners: 6.10(1.84), n = 73; other health care professionals: 5.23(2.83), n = 389. Participants identified team learning, the opportunity to network and the involvement of trained patient educators as strong features of the workshops. At follow-up, participants indicated the greatest impact of the program was on collaborative care (83%) and patient self-management (79%). Conclusions: Qualitative results suggest that inter-professional learning may be a successful strategy for improving the delivery of collaborative arthritis care and supporting patient self-management.

PMID: 18825571 [PubMed - as supplied by publisher]

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Evaluation of guidelines for community-acquired pneumonia: a story of confounders, surprises and challenges.

Eur Respir J. 2008 Oct;32(4):823-5

Authors: Ewig S, Welte T

PMID: 18827148 [PubMed - in process]

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An assessment of the new lipid screening guidelines.

Pediatrics. 2008 Oct;122(4):904-5; author reply 906-7

Authors: Steiner MJ, Brown WD, Liles E

PMID: 18829821 [PubMed - in process]

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