Evidence-based clinical guidelines for immigrants and refugees.

CMAJ. 2011 Sep 6;183(12):E824-925

Authors: Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, Narasiah L, Kirmayer LJ, Ueffing E, Macdonald NE, Hassan G, McNally M, Khan K, Buhrmann R, Dunn S, Dominic A, McCarthy AE, Gagnon AJ, Rousseau C, Tugwell P,

PMID: 20530168 [PubMed - in process]

Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada.

CMAJ. 2011 Sep 6;183(12):E933-E938

Authors: Tugwell P, Pottie K, Welch V, Ueffing E, Chambers A, Feightner J,

Abstract
BACKGROUND: This article describes the evidence review and guideline development method developed for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada by the Canadian Collaboration for Immigrant and Refugee Health Guideline Committee. METHODS: The Appraisal of Guidelines for Research and Evaluation (AGREE) best-practice framework was combined with the recently developed Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to produce evidence-based clinical guidelines for immigrants and refugees in Canada. RESULTS: A systematic approach was designed to produce the evidence reviews and apply the GRADE approach, including building on evidence from previous systematic reviews, searching for and comparing evidence between general and specific immigrant populations, and applying the GRADE criteria for making recommendations. This method was used for priority health conditions that had been selected by practitioners caring for immigrants and refugees in Canada. INTERPRETATION: This article outlines the 14-step method that was defined to standardize the guideline development process for each priority health condition.

PMID: 20573711 [PubMed - as supplied by publisher]

Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline.

Int J Radiat Oncol Biol Phys. 2011 Sep 1;81(1):59-68

Authors: Smith BD, Bentzen SM, Correa CR, Hahn CA, Hardenbergh PH, Ibbott GS, McCormick B, McQueen JR, Pierce LJ, Powell SN, Recht A, Taghian AG, Vicini FA, White JR, Haffty BG

Abstract
PURPOSE: In patients with early-stage breast cancer treated with breast-conserving surgery, randomized trials have found little difference in local control and survival outcomes between patients treated with conventionally fractionated (CF-) whole breast irradiation (WBI) and those receiving hypofractionated (HF)-WBI. However, it remains controversial whether these results apply to all subgroups of patients. We therefore developed an evidence-based guideline to provide direction for clinical practice.
METHODS AND MATERIALS: A task force authorized by the American Society for Radiation Oncology weighed evidence from a systematic literature review and produced the recommendations contained herein.
RESULTS: The majority of patients in randomized trials were aged 50 years or older, had disease Stage pT1-2 pN0, did not receive chemotherapy, and were treated with a radiation dose homogeneity within ±7% in the central axis plane. Such patients experienced equivalent outcomes with either HF-WBI or CF-WBI. Patients not meeting these criteria were relatively underrepresented, and few of the trials reported subgroup analyses. For patients not receiving a radiation boost, the task force favored a dose schedule of 42.5 Gy in 16 fractions when HF-WBI is planned. The task force also recommended that the heart should be excluded from the primary treatment fields (when HF-WBI is used) due to lingering uncertainty regarding late effects of HF-WBI on cardiac function. The task force could not agree on the appropriateness of a tumor bed boost in patients treated with HF-WBI.
CONCLUSION: Data were sufficient to support the use of HF-WBI for patients with early-stage breast cancer who met all the aforementioned criteria. For other patients, the task force could not reach agreement either for or against the use of HF-WBI, which nevertheless should not be interpreted as a contraindication to its use.

PMID: 20638191 [PubMed - indexed for MEDLINE]

An evaluation of the UK National Pandemic Flu Service swine flu algorithm in hospitalised children, and comparison with the UK National Institute for Health and Clinical Excellence fever guideline.

Emerg Med J. 2011 Sep;28(9):761-3

Authors: Mann C, Wood D, Davies P

Abstract
Aim To evaluate the efficacy of the UK swine flu algorithm as a screening tool in unwell children, and to compare the management advice given with the National Institute for Health and Clinical Excellence (NICE) feverish illness guideline advice. Method All paediatric medical admissions to the unit, with a fever and over the age of 1 year, during 2 weeks in November were analysed, and their histories were put through both the swine flu algorithm and the NICE fever guidance for the under 5s. Results Of 72 patients, 71 would have had a diagnosis of swine flu had their symptoms been put through the algorithm. Two patients had confirmed swine flu on testing, and 32 patients definitely did not have swine flu. The positive predictive value of the algorithm is between 2.8% and 56.3% in this population. 39% would have been advised to have a face-to-face consultation by the NICE guidance, but would not have been advised to have an urgent consultation by the swine flu guidance. At least 79% of patients had treatments only available in hospitals. Conclusions The swine flu algorithm is of little use in differentiating unwell children, and advice given does not correlate well with that of the NICE guidance. There is a significant risk of harm with false-positive diagnoses and potential delays in appropriate treatment. The authors were unable to obtain the data and rationale behind the algorithm, and believe that this should be published. Face-to-face consultations may be the only way to ensure patient safety.

PMID: 20817663 [PubMed - in process]

Guidelines for conducting and reporting economic evaluation of fall prevention strategies.

Osteoporos Int. 2011 Sep;22(9):2449-59

Authors: Davis JC, Robertson MC, Comans T, Scuffham PA

Abstract
UNLABELLED: Falls in older people result in substantial health burden. Compelling evidence indicates that falls can be prevented. We developed comprehensive guidelines for economic evaluations of fall prevention interventions to facilitate publication of high-quality economic evaluations of the effective strategies and aid decision making.
INTRODUCTION: The importance of economics applied to falls and fall prevention in older people has largely been overlooked. The use of different methodologies to assess the costs and health benefits of the interventions and their comparators and the inconsistent reporting in the studies limits the usefulness of these economic evaluations for decision making. We developed guidelines to encourage and facilitate completion of high-quality economic evaluations of effective fall prevention strategies.
METHODS: We used a generic checklist for economic evaluations as a platform to develop comprehensive guidelines for conducting and reporting economic evaluations of fall prevention strategies. We considered the many challenges involved, particularly in identifying, measuring, and valuing the relevant cost items.
RESULTS: We recommend researchers include cost outcomes and report incremental cost-effectiveness ratios in terms of falls prevented and quality adjusted life years in all clinical trials of fall prevention interventions. Studies should include the following cost categories: (1) implementing the intervention, (2) delivering the comparator group intervention, (3) total health care costs, (4) costs of fall-related health care resource use, and (5) personal and informal carer opportunity costs.
CONCLUSIONS: This paper provides a timely benchmark to promote comparability and consistency for conducting and reporting economic evaluations of fall prevention strategies.

PMID: 21104231 [PubMed - in process]

Emergency Department Triage Nurses’ Self-reported Adherence With American College of Cardiology/American Heart Association Myocardial Infarction Guidelines.

J Cardiovasc Nurs. 2011 Sep-Oct;26(5):408-13

Authors: Arslanian-Engoren C, Eagle KA, Hagerty B, Reits S

Abstract
BACKGROUND AND OBJECTIVE: : Mortality from acute coronary syndromes has decreased. This achievement is based on the rapid recognition of possible acute coronary syndrome, obtaining an electrocardiogram for diagnosis, and the prompt initiation of therapy, including aspirin, oxygen, thrombolytics, and cardiac catheterization. The importance of rapid diagnosis and therapy is emphasized by American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines. However, these goals are not always met, and their failure leads to increased mortality. The purpose of this study was to determine the frequency emergency department nurses report guideline-related activities when triaging patients for complaints suggestive of myocardial infarction.
SUBJECTS AND METHODS: : As part of a larger study examining nurses’ cardiac triage decisions, 158 emergency department nurses who belonged to the Emergency Nurses Association responded to a mailed questionnaire, which asked how frequently certain nursing practice activities were performed that would facilitate the attainment of ACC/AHA myocardial infarction guidelines and goals. Responses were measured on a 5-point Likert-type scale from “none of the time” to “all of the time.”
RESULTS: : Not a single one of the 9 goals was met “all of the time” by all of the nurse participants. “All of the time” ranged from 52% for giving analgesics to 87% asking about chest pain. Only 81% of participants had a goal of obtaining electrocardiogram within 10 minutes of arrival, and only 27% of participants met all 9 goals “all of the time.” The likelihood of nurses meeting goals was not associated with their age, experience, educational level, or certification status.
CONCLUSIONS: : We recommend tailored educational interventions be developed to improve nurses awareness of the importance of complying with the ACC/AHA standard of care practice goals and the necessity of achieving these goals all of the time as a path to improving patient outcome.

PMID: 21263336 [PubMed - in process]

Quality varies across clinical practice guidelines for mammography screening in women aged 40-49 years as assessed by AGREE and AMSTAR instruments.

J Clin Epidemiol. 2011 Sep;64(9):968-76

Authors: Burda BU, Norris SL, Holmer HK, Ogden LA, Smith ME

Abstract
OBJECTIVE: To assess the quality of clinical practice guidelines providing recommendations on the frequency of mammography screening in asymptomatic, average-risk women 40-49 years of age.
STUDY DESIGN AND SETTING: We searched the National Guideline Clearinghouse and MEDLINE for guidelines published from 2005 to 2010. Five independent assessors rated the quality of each guideline and its underlying evidence review using the Appraisal of Guidelines for Research and Evaluation (AGREE) and Assessment of Multiple Systematic Reviews (AMSTAR) instruments, respectively.
RESULTS: Eleven guidelines were appraised. Ten referenced an underlying evidence review; two referenced the same review. Three reviews were rated good, one was moderate, and five were rated poor quality. On overall assessment of the quality of the guidelines, two were strongly recommended, two were recommended with provisos, and seven were either not recommended or the assessors were unsure whether to recommend it. Most guidelines clearly presented their recommendations, but the rigor of development, applicability, and stakeholder involvement varied. Seven guidelines recommended mammography screening as part of a periodic health examination and four recommended individualized screening in the target population. The latter four guidelines were based on good-quality reviews and three were recommended by the assessors.
CONCLUSION: Guideline users need to be aware of the variability in quality and identify the high-quality guidelines that meet their needs.

PMID: 21420280 [PubMed - in process]

A descriptive study evaluating the circumstances of medical treatment for acute pancreatitis before publication of the new JPN guidelines based on the Japanese administrative database associated with the Diagnosis Procedure Combination system.

J Hepatobiliary Pancreat Sci. 2011 Sep;18(5):678-83

Authors: Murata A, Matsuda S, Mayumi T, Yokoe M, Kuwabara K, Ichimiya Y, Fujino Y, Kubo T, Fujimori K, Horiguchi H

Abstract
PURPOSE: To examine the circumstances of medical treatment for acute pancreatitis before publication of the new Japanese (JPN) guidelines using the Japanese administrative database associated with the Diagnosis Procedure Combination system.
METHODS: We collected data from 7,193 patients with acute pancreatitis in 2008 and examined the recommended medical treatment in the new JPN guidelines [from recommendations B (considered to be recommended treatments) to D (considered to be unacceptable treatments)] according to severity of acute pancreatitis. Patients were divided into two groups: mild cases (n = 6,520) and severe cases (n = 673).
RESULTS: Enteral nutrition for severe cases without ileus (recommendation B) was uncommon (13.5%). In contrast, prophylactic antibiotics were administered in a large number (80.4%) of mild cases without acute cholangitis (recommendation D). Furthermore, administration of H(2) receptor antagonists, except for cases of upper gastrointestinal bleeding (recommendation D), were performed in many patients with both mild and severe cases (66.8 vs. 78.6%).
CONCLUSIONS: This study demonstrated a discrepancy between actual medical treatment performed and the new JPN guidelines with regard to some of the medical treatments. Future studies are required after publication of the new JPN guidelines to determine how they affect medical treatments.

PMID: 21431888 [PubMed - in process]

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia.

J Am Med Dir Assoc. 2011 Sep;12(7):499-507

Authors: Hutt E, Ruscin JM, Linnebur SA, Fish DN, Oman KS, Fink RM, Radcliff TA, Van Dorsten B, Liebrecht D, Fish R, McNulty MC

Abstract
OBJECTIVE: Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates.
DESIGN: Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial.
SETTING: Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007.
PARTICIPANTS: Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible.
INTERVENTION: Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education.
MEASUREMENTS: Subjects’ NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding.
RESULTS: Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections.
CONCLUSIONS: Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

PMID: 21450174 [PubMed - in process]

A strategy for patient involvement in clinical practice guidelines: methodological approaches.

BMJ Qual Saf. 2011 Sep;20(9):779-84

Authors: Díaz Del Campo P, Gracia J, Blasco JA, Andradas E

Abstract
Background An increasing number of initiatives involve patients in the development of Clinical Practice Guidelines (CPGs). However, the method used for patient involvement is fundamental to achieving a quality patient-oriented CPG. The objective is to present a strategy for patient involvement that includes both robust patient consultation and participation. This strategy is based on the authors’ experience in the development of four CPGs included in the Spanish National CPG Development Program, which deemed it a valuable nation-wide patient involvement initiative. Methods Patient consultation in the CPG preparation phase combines quantitative and qualitative primary research techniques as well as a systematic review of patient-perspective studies. Participation relies on patients and patient representatives as members of the guideline development groups in all development phases at the same level as professionals. NVivo 8 software was used to analyse discourses of qualitative data. Results Patients and patient representatives provided relevant information on their perspectives, experiences with the illness, social circumstances, habits, values and preferences. They collaborated in different CPG development phases, including setting the scope and objectives, defining key research questions, writing and reviewing recommendations, developing patients’ versions and the dissemination of CPGs. Conclusions The authors’ strategy allows for patient-oriented CPG development, but it requires appropriate training and knowledge of qualitative research techniques (primary research and systematic review of qualitative evidence) for developers. It is also crucial to have specific support for patients, previously selected with eligibility criteria, to facilitate an effective engagement, providing clear guidance on their roles and ensuring opportunities to attend training events.

PMID: 21460393 [PubMed - in process]