The development of evidence based guidelines for clinical practice portfolios.

Nurse Educ Today. 2011 Nov;31(8):872-6

Authors: Sowter J, Cortis J, Clarke DJ

Abstract
AIMS: Although the use of portfolios is widespread within healthcare education, agreement on their purpose, content, assessment and value is still debated. The objective of this study was to achieve consensus on quality criteria for clinical practice portfolios that would act as guidance for students and lecturers.
METHODS: A Delphi survey was undertaken to seek consensus on the opinions of 23 ‘expert participants’ through a series of rounds of structured questionnaires. The Delphi tool was produced as an on-line survey questionnaire and panel experts were invited to score statements using a discrete 7 point visual analogue scale. The statements were written as quality criteria relating to portfolio development which had been identified from the literature and by the research team. The survey employed three rounds of feedback and consensus was measured as 80% agreement for each quality criteria scoring 5 and above.
RESULTS: Consensus was reached on 31 quality criteria which were categorised into 4 areas: structured collection of labelled evidence; nature of evidence; critical reflection; and assessment and judgement. Mean scores for the final wording of the quality criteria ranged from 5.3 to 6.8 with the standard deviation for all of the mean scores being below 1.5. There was consensus that these quality criteria were relevant to health and social care professionals involved in developing clinical practice portfolios.
CONCLUSIONS: The Delphi process facilitated exchange of ideas amongst panel ‘experts’ about the content and evaluation of clinical practice portfolios, with most debate relating to judgement of competence and rewarding originality and creativity. These issues illustrate the tensions between educational values and professional constraints. The Delphi process proved to be an effective method for achieving consensus on quality criteria for clinical practice portfolios and enabled the development of validated guidelines.

PMID: 21295382 [PubMed - in process]

Evaluation of nurses’ and doctors’ knowledge of basic & advanced life support resuscitation guidelines.

Nurse Educ Pract. 2011 Nov;11(6):365-9

Authors: Passali C, Pantazopoulos I, Dontas I, Patsaki A, Barouxis D, Troupis G, Xanthos T

Abstract
Lack of resuscitation skills of nurses and doctors in basic life support (BLS) and advanced life support (ALS) has been identified as a contributing factor to poor outcomes of cardiac arrest victims. Our hypothesis was that nurses’ and doctors’ knowledge of cardiopulmonary resuscitation guidelines would be related to their professional background as well as their resuscitation training. A secondary aim of this study was to assess and compare the theoretical knowledge on BLS and ALS in nurses and doctors. A total of 82 nurses and 134 doctors agreed to respond to a questionnaire containing demographic questions, resuscitation experience questions and 15 theoretical knowledge questions. Our study demonstrated that nurses and doctors working in Greece have knowledge gaps in current BLS and ALS guidelines. However, resuscitation training had a positive effect on theoretical CPR knowledge. Furthermore, nurses and doctors who worked in high-risk areas for cardiac arrest, scored significantly higher than those who worked in low-risk areas. Those who had encountered more than 5 cardiac arrests the previous year, scored significantly better. Finally the percentage of nurses who had attended the ALS course was quite low thus ALS training should be incorporated into the nursing curriculum.

PMID: 21474382 [PubMed - in process]

Impact of the 21-gene recurrence score assay compared with standard clinicopathologic guidelines in adjuvant therapy selection for node-negative, estrogen receptor-positive breast cancer.

Ann Surg Oncol. 2011 Nov;18(12):3399-406

Authors: Partin JF, Mamounas EP

Abstract
BACKGROUND: The development of multigene assays has proved useful in the clinical management of early-stage breast cancer. The 21-gene recurrence score (RS) assay has been shown to quantify risk of distant recurrence and predict chemotherapy benefit in node-negative and node-positive, estrogen-receptor (ER)-positive breast cancer patients. Small, single-institution series have shown that, compared with standard clinicopathologic criteria, use of RS significantly affects adjuvant chemotherapy recommendations.
METHODS: We performed a retrospective review of RS use and its effect on chemotherapy recommendations in node-negative, ER-positive breast cancer patients at a tertiary care teaching hospital. Patient and tumor characteristics and adjuvant treatment information were obtained on 183 patients with RS results between January 2004 and October 2009. Risk categories were assigned based on the RS and on standard clinicopathologic criteria according to guidelines from NCCN, St. Gallen, and Adjuvant!.
RESULTS: A total of 14 patients were excluded for negative ER status (n=2), insufficient data (n=4), inclusion in TAILORx trial (n=7), and recurrent breast cancer (n=1), leaving 169 patients in the cohort. RS use increased 3-fold over the study period (from 18% in 2004 to 50% in 2009). Tumor grade, ER status, and PR status were significantly correlated with RS category. Overall concordance between RS and NCCN, St. Gallen, and Adjuvant! was 10, 48, and 50%, respectively. Depending on the guideline used for comparison, adjuvant therapy recommendations changed with the addition of the RS in 27-74% of cases.
CONCLUSIONS: RS use is increasing, and the assay significantly reduced adjuvant chemotherapy utilization in node-negative, ER -positive breast cancer patients.

PMID: 21537874 [PubMed - in process]

The feasibility of automating audit and feedback for ART guideline adherence in Malawi.

J Am Med Inform Assoc. 2011 Nov-Dec;18(6):868-74

Authors: Landis Lewis Z, Mello-Thoms C, Gadabu OJ, Gillespie EM, Douglas GP, Crowley RS

Abstract
OBJECTIVE: To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.
MATERIALS AND METHODS: We evaluated recommendations from Malawi’s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure’s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.
RESULTS: We analyzed 423,831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi’s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.
DISCUSSION: It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs’ opportunities to reflect on their performance.
CONCLUSION: A moderate number of recommendations from Malawi’s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.

PMID: 21565857 [PubMed - in process]

The development of evidence-informed physical activity guidelines for adults with spinal cord injury.

Spinal Cord. 2011 Nov;49(11):1088-96

Authors: Ginis KA, Hicks AL, Latimer AE, Warburton DE, Bourne C, Ditor DS, Goodwin DL, Hayes KC, McCartney N, McIlraith A, Pomerleau P, Smith K, Stone JA, Wolfe DL

Abstract
Objectives:To systematically develop evidence-informed physical activity guidelines to improve physical fitness in people with spinal cord injury (SCI).Setting:This study was conducted in CanadaMethods:The Appraisal of Guidelines, Research and Evaluation II guideline development protocol was used to develop exercise guidelines to improve physical capacity and muscular strength. The evidence base for the guideline development process consisted of a systematic review and quality appraisal of research examining the effects of exercise on physical fitness among people with SCI. A multidisciplinary expert panel deliberated the evidence and generated the guidelines. Pilot testing led to refinement of the wording and presentation of the guidelines.Results:The expert panel generated the following guidelines: for important fitness benefits, adults with a SCI should engage in (a) at least 20?min of moderate to vigorous intensity aerobic activity two times per week and (b) strength training exercises two times per week, consisting of three sets of 8-10 repetitions of each exercise for each major muscle group.Conclusion:People with SCI, clinicians, researchers and fitness programmers are encouraged to adopt these rigorously developed guidelines.

PMID: 21647164 [PubMed - in process]

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes.

Diabet Med. 2011 Nov;28(11):1282-8

Authors: Dyson PA, Kelly T, Deakin T, Duncan A, Frost G, Harrison Z, Khatri D, Kunka D, McArdle P, Mellor D, Oliver L, Worth J,

Abstract
This article summarizes the Diabetes UK evidence-based guidelines for the prevention of Type 2 diabetes and nutritional management of diabetes. It describes the development of the recommendations and highlights the key changes from previous guidelines. The nutrition guidelines include a series of recommendations for the prevention of Type 2 diabetes, nutritional management of Type 1 and Type 2 diabetes, weight management, management of microvascular and macrovascular disease, hypoglycaemia management, and additional considerations such as nutrition support, end-of-life care, disorders of the pancreas, care of the older person with diabetes, nutrition provided by external agencies and fasting. The evidence-based recommendations were graded using the Scottish Intercollegiate Guidelines Network methodology and, in a small number of topic areas, where strong evidence was lacking, the recommendations were reached by consensus. The Diabetes UK 2011 guidelines place an emphasis on carbohydrate management and a more flexible approach to weight loss, unlike previous guidelines which were expressed in terms of recommendations for individual nutrient intakes. Additionally, the guidelines for alcohol have been aligned to national recommendations. The full evidence-based nutrition guidelines for the prevention and management of diabetes are available from: http://www.diabetes.org.uk/nutrition-guidelines.

PMID: 21699560 [PubMed - in process]

Computerization of workflows, guidelines, and care pathways: a review of implementation challenges for process-oriented health information systems.

J Am Med Inform Assoc. 2011 Nov-Dec;18(6):738-48

Authors: Gooch P, Roudsari A

Abstract
OBJECTIVE: There is a need to integrate the various theoretical frameworks and formalisms for modeling clinical guidelines, workflows, and pathways, in order to move beyond providing support for individual clinical decisions and toward the provision of process-oriented, patient-centered, health information systems (HIS). In this review, we analyze the challenges in developing process-oriented HIS that formally model guidelines, workflows, and care pathways.
METHODS: A qualitative meta-synthesis was performed on studies published in English between 1995 and 2010 that addressed the modeling process and reported the exposition of a new methodology, model, system implementation, or system architecture. Thematic analysis, principal component analysis (PCA) and data visualisation techniques were used to identify and cluster the underlying implementation ‘challenge’ themes.
RESULTS: One hundred and eight relevant studies were selected for review. Twenty-five underlying ‘challenge’ themes were identified. These were clustered into 10 distinct groups, from which a conceptual model of the implementation process was developed.
DISCUSSION AND CONCLUSION: We found that the development of systems supporting individual clinical decisions is evolving toward the implementation of adaptable care pathways on the semantic web, incorporating formal, clinical, and organizational ontologies, and the use of workflow management systems. These architectures now need to be implemented and evaluated on a wider scale within clinical settings.

PMID: 21724740 [PubMed - in process]

Evidence-based (S3) guideline on topical corticosteroids in pregnancy.

Br J Dermatol. 2011 Nov;165(5):943-952

Authors: Chi CC, Kirtschig G, Aberer W, Gabbud JP, Lipozen?i? J, Kárpáti S, Haustein UF, Zuberbier T, Wojnarowska F

Abstract
Women with skin conditions may need topical corticosteroids during pregnancy. However, little is known about the effects of topical corticosteroids on the fetus. A guideline subcommittee of the European Dermatology Forum was organized to develop an evidence-based guideline on the use of topical corticosteroids in pregnancy (http://www.euroderm.org/edf/images/stories/guidelines/EDF-Guideline-on-Steroids-in-Pregnancy.pdf). The evidence from a Cochrane Review suggested that the major possible adverse effects on the fetus of topical corticosteroids were orofacial clefts when used preconceptionally and in the first trimester of pregnancy, and fetal growth restriction when very potent topical corticosteroids were used during pregnancy. To obtain robust evidence, a large population-based cohort study (on 84?133 pregnant women from the U.K. General Practice Research Database) was performed, which found a significant association of fetal growth restriction with maternal exposure to potent/very potent topical corticosteroids, but not with mild/moderate topical corticosteroids. No associations of maternal exposure to topical corticosteroids of any potency with orofacial cleft, preterm delivery and fetal death were found. Moreover, another recent Danish cohort study did not support a causal association between topical corticosteroid and orofacial cleft. The current best evidence suggests that mild/moderate topical corticosteroids are preferred to potent/very potent ones in pregnancy, because of the associated risk of fetal growth restriction with the latter.

PMID: 21729030 [PubMed - as supplied by publisher]

The use of clinical guidelines for referral of patients with lesions suspicious for oral cancer may ease early diagnosis and improve education of healthcare professionals.

Med Oral Patol Oral Cir Bucal. 2011;16(7):e864-9

Authors: Seoane J, Corral-Lizana C, González-Mosquera A, Cerero R, Esparza G, Sanz-Cuesta T, Varela-Centelles P

Abstract
Early diagnosis and referral of oral cancer is essential. Successful implementation of clinical guidelines must include current practitioners and students. Objective: To evaluate the diagnostic accuracy of students at oral cancer screening and to assess the effectiveness of clinical referral guidelines. Study Design: Fifth year dental students were randomly allocated to either control (n=19) or experimental groups (n=18). Both received the customary training in oral diagnosis. The experimental group underwent a 2 hour workshop where the guidelines for the referral of suspicious lesions were discussed. Three months later, a set of 51 clinical cases including benign, malignant, and precancerous conditions/lesions were used to assess the screening ability of each subject. Results: All 37 students entered the study. Sensitivity (control group) ranged from 16.7% to 66.7%; the experimental group scored from 16.7% to 83.3%. Fifty percent of the experimental students reached sensitivity values ?62.5% (p=0.01). Diagnostic specificity (control group) spanned from 80% to 93.3% (median=50%); amongst experimental group it ranged from 82.2% to 97.8% (median=92.8%); (p=0.003). Concordance -control group- was X=82.5 (SD=3.2), and X=88.2 (SD=4.3) for the experimental, (p>0.001). Cohen’s kappa test was poor (K<0.40) for the controls and moderate for the experimental group. The experimental group referred more oral cancers urgently (p=0.002) and left less unreferred cancers (0.04). This group also referred more precancerous lesions/conditions urgently (p=0.02). Conclusions: The implementation of a clinical referral guideline at undergraduate level has proved valuable, under experimental conditions, to significantly increase diagnostic abilities of the examiners and thus to improve screening for oral cancer.

PMID: 21743432 [PubMed - in process]

EAU Guidelines on Prostate Cancer. Part II: Treatment of Advanced, Relapsing, and Castration-Resistant Prostate Cancer.

Actas Urol Esp. 2011 Nov;35(10):565-579

Authors: Mottet N, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Schmid HP, van der Kwast T, Wiegel T, Zattoni F, Heidenreich A

Abstract
OBJECTIVES: Our aim is to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC). METHODS: The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and the levels of evidence (LEs) and/or grades of recommendation (GR) were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews. RESULTS: Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). Although LHRH antagonists decrease testosterone without any testosterone surge, their clinical benefit remains to be determined. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation (IAD) results in equivalent oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values > 0.2 ng/ml following radical prostatectomy (RP) and > 2 ng/ml above the nadir after radiation therapy (RT). Therapy for PSA relapse after RP includes salvage RT at PSA levels < 0.5 ng/ml and salvage RP or cryosurgical ablation of the prostate in radiation failures. Endorectal magnetic resonance imaging and 11C-choline positron emission tomography/computed tomography (CT) are of limited importance if the PSA is < 2.5 ng/ml; bone scans and CT can be omitted unless PSA is >20 ng/ml. Follow-up after ADT should include screening for the metabolic syndrome and an analysis of PSA and testosterone levels. Treatment of castration-resistant prostate cancer (CRPC) includes second-line hormonal therapy, novel agents, and chemotherapy with docetaxel at 75mg/m(2) every 3 wk. Cabazitaxel as a second-line therapy for relapse after docetaxel might become a future option. Zoledronic acid and denusomab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications. CONCLUSION: The knowledge in the field of advanced, metastatic, and CRPC is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice. A full version is available at the EAU office or online at www.uroweb.org.

PMID: 21757258 [PubMed - as supplied by publisher]