Mapping evidence-based guidelines to standardized nursing terminologies.

Comput Inform Nurs. 2011 Dec;29(12):698-705

Authors: Dontje K, Coenen A

Abstract
The purpose of this study was to explore how evidence-based practice recommendations for adults with depression were represented in two standardized nursing terminologies. A qualitative concept analysis was used to answer the research question. Concepts were extracted from the recommendations and matched to two standardized nursing terminologies through lexical and semantic concept mapping techniques. Study findings included variability in the lexical mapping to the standardized terminologies. The ability to map semantically was greater than lexical mapping, but the majority of these were partial matches. Findings also raised concerns about the potential for ambiguity of data retrieved when using standardized terminology.

PMID: 21825974 [PubMed - in process]

Non-adherence to guidelines for preoperative testing in a secondary care hospital in Austria: the economic impact of unnecessary and double testing.

Eur J Anaesthesiol. 2011 Dec;28(12):867-73

Authors: Flamm M, Fritsch G, Seer J, Panisch S, Sönnichsen AC

Abstract
CONTEXT: Preoperative evaluation is aimed at prevention of complications and risk stratification. Routine testing should be abandoned in favour of selective ordering according to contemporary guidelines. This study was conducted to calculate the possible economic impact of a Web-based preoperative diagnostic guideline prior to its implementation in the state of Salzburg, Austria.
DESIGN: Prospective observational cohort study.
SETTING: The study was carried out in a secondary care hospital in Salzburg (Schwarzach). PARTICIPANTS AND MAIN OUTCOME MEASURES: Data from 1363 consecutive patients scheduled for elective surgery from 1 September to 30 November 2007 were collected: demographic data, medical history, surgical procedure, preoperative tests and findings. The data were entered into the preoperative diagnostic guideline software and the guideline-adherent recommendations were compared with the investigations performed, with special attention to duplicate examinations.
RESULTS: A total of 5879 tests were documented and analysed. In 65.6% of patients, guideline-adherent evaluation would have indicated only basic requirements, but 3380 additional tests were carried out. In all, 81.7% of tests were identified as nonadherent based on the preoperative diagnostic guideline software and 226 duplicate tests were performed. Possible savings per 1000 patients would be €26? 287 if preoperative diagnostic guideline recommendations were followed exactly and €1076 if duplicated tests were avoided. According to a generalised linear model (Gamma model), an increase of 1 year of age leads to an increase of costs by a factor of 1.020.
CONCLUSION: These data indicate a considerable potential for improvement in process quality and cost reduction by using structured preoperative assessment with computer-assisted implementation of a guideline.

PMID: 21968636 [PubMed - in process]

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Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: A study protocol.Implement Sci. 2011 Dec 28;6(1):133Authors: Scott SD, Grimshaw J, Klassen TP, Nettel-Aguirre A, Johnson DWAbstractABSTRACT: BACKGROUND: Canada is among the most prosperous nations in the world, yet the health and wellness outcomes of Canadian children are surprisingly poor. There is some evidence to suggest that these poor health outcomes are partly due to clinical practice variation, which can stem from failure to apply the best available research evidence in clinical practice, otherwise known as knowledge translation (KT). Surprisingly, clinical practice variation, even for common acute paediatric conditions, is pervasive. Clinical practice variation results in unnecessary medical treatments, increased suffering, and increased health care costs. This study focuses on improving health outcomes for common paediatric acute health concerns by evaluating strategies that improve knowledge translation and reduce clinical practice variation. Design/Methods: Using a multiple case study design, qualitative and quantitative data will be collected from four Emergency Departments in western Canada. Data sources will include: 1) pre- and post-implementation focus group data from multidisciplinary health care professionals, 2) individual interviews with the local champions, KT intervention providers and unit/site leaders/managers, 3) Alberta Context Tool (ACT) survey data, and 4) aggregated patient outcome data. Qualitative and quantitative data will be systematically triangulated and matrices will be built to do cross-case comparison. Explanations will be built about the success or lack of success of the CPG/CPs uptake based upon the cross-case comparisons. Significance: This study will generate new knowledge about the potential causal mechanisms and factors which shape implementation. Future studies will track the impact of the CPG/CPs implementation on children's health outcome, and healthcare costs.PMID: 22204440 [PubMed - as supplied by publisher]]]>

Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline.

Am J Ind Med. 2011 Dec 27;

Authors: Franklin GM, Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D

Abstract
BACKGROUND: Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers’ compensation system following implementation of a specific WA opioid dosing guideline in April, 2007. METHODS: Using detailed computerized billing data from WA workers’ compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (?120?mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period. RESULTS: Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses ?120?md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths. CONCLUSIONS: The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses ?120?mg MED per day, and number of opioid-related deaths among injured workers. Am. J. Ind. Med. © 2011 Wiley Periodicals, Inc.

PMID: 22213274 [PubMed - as supplied by publisher]

Evidence-based guideline: clinical evaluation and treatment of transverse myelitis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

Neurology. 2011 Dec 13;77(24):2128-34

Authors: Scott TF, Frohman EM, De Seze J, Gronseth GS, Weinshenker BG,

Abstract
OBJECTIVE: To assess the evidence for diagnostic tests and therapies for transverse myelitis (TM) and make evidence-based recommendations. METHODS: A review of the published literature from 1966 to March 2009 was performed, with evidence-based classification of relevant articles. Recommendations: Level B recommendations: neuromyelitis optica (NMO)-immunoglobulin G (IgG) antibodies should be considered useful to determine TM cause in patients presenting with clinical acute complete transverse myelitis (ACTM) features. The presence of NMO-IgG antibodies (aquaporin-4-specific antibodies) should be considered useful in determining increased TM recurrence risk. Level C recommendations: in suspected TM, distinction between ACTM or acute partial transverse myelitis may be considered useful to determine TM etiology and risk for relapse (more common with APTM). Age and gender may be considered useful to determine etiology in patients presenting with TM syndrome, with spinal infarcts seen more often in older patients and more female than male patients having TM due to multiple sclerosis (MS). Brain MRI characteristics consistent with those of MS may be considered useful to predict conversion to MS after a first partial TM episode. Longer spinal lesions extending over >3 vertebral segments may be considered useful in determining NMO vs MS. CSF examination for cells and oligoclonal bands may be considered useful to determine the cause of the TM syndrome. Plasma exchange may be considered in patients with TM who fail to improve after corticosteroid treatment. Rituximab may be considered in patients with TM due to NMO to decrease the number of relapses. Level U recommendations: there is insufficient evidence to support or refute the efficacy of other TM therapies or the usefulness of ethnicity to determine the cause of a subacute myelopathy.

PMID: 22156988 [PubMed - in process]

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RE: Letter to the Editor regarding 'The effect of applying NICE guidelines for the investigation of stable chest pain on out-patient cardiac services in the UK'QJM. 2011 Dec 15;Authors: Patterson C, Nicol E, Bryan L, Woodcock T, Collinson J, Padley S, Bell DPMID: 22179103 [PubMed - as supplied by publisher]]]>

Evaluation of safety monitoring guidelines based on MRI lesion activity in multiple sclerosis.

Neurology. 2011 Dec 13;77(24):2089-96

Authors: Riddell CA, Zhao Y, Li DK, Petkau AJ, Riddehough A, Cutter GR, Traboulsee A

Abstract
OBJECTIVE: We evaluate variants of a commonly used data safety monitoring guideline in clinical trials in multiple sclerosis (MS) that flags patients who, at a follow-up visit, have 5 or more contrast-enhancing lesions (CELs) above their baseline count.
METHODS: We apply the guideline to a relapsing cohort and a secondary progressive cohort. We assess the number of patients that meet the guideline and describe the characteristics of these patients; we also examine the value of the guideline in predicting relapse occurrence in the 28 days following that MRI. These analyses were repeated for thresholds varying from 1 to 10 CELs above baseline.
RESULTS: Between 4% and 6% of patients met the threshold of 5 in both cohorts; patients with higher baseline counts and higher T2 lesion burden were more apt to meet the threshold. After adjustment for other covariates, the odds ratio (OR) of relapse associated with meeting the threshold is significant (p < 0.05) or near significant (0.05 ? p < 0.10) for thresholds between 5 and 8 for the relapsing cohort, but not for the secondary progressive cohort. Across thresholds, the adjusted OR is consistently greater than 1, and there is an increasing trend as the threshold increases from 1 to 7.

CONCLUSIONS: A guideline based on crossing a threshold CEL count above baseline may be valuable in monitoring patient safety. Further study should be conducted using different datasets to assess the generalizability of these results.

PMID: 22094474 [PubMed - in process]

Implementation of intravenous to oral antibiotic switch therapy guidelines in the general medical wards of a tertiary-level hospital in South Africa.

J Antimicrob Chemother. 2011 Dec 13;

Authors: van Niekerk AC, Venter DJ, Boschmans SA

Abstract
OBJECTIVES: The design and implementation of an antibiotic intravenous (iv) to oral switch therapy (IVOST) guideline in a Third World health setting. METHODS: The guideline was developed and integrated into daily practice by a ward pharmacist over a period of 7 weeks. Patients were switched once they were deemed clinically stable according to IVOST criteria. The final decision to switch was left to the attending physician. One pre- and two post-implementation audits (150 patient medical records per audit) were compared. RESULTS: Implementation of the IVOST guideline was successful in increasing (P?< ?0.0005) the number of patients switched from 16% (19/119) pre-implementation to 43.9% (47/107) immediately after implementation; however, the change was not sustained 3 months after implementation (20.8%; 25/120). The intervention was also successful in decreasing the overall duration of iv therapy (P?< ?0.0005) from 7.2?±?3.5 days pre-implementation to 5.2?±?3.0 days immediately post-implementation. The change was not sustained 3 months after implementation (6.5?±?3.5 days). CONCLUSIONS: Despite the challenges encountered in a Third World environment, an antibiotic IVOST guideline can be successfully implemented. Continual, active integration of the guideline into daily practice by a ward pharmacist is essential if positive IVOST outcomes are to be maintained.

PMID: 22167244 [PubMed - as supplied by publisher]

Bridging evidence and consensus methodology for inherited metabolic disorders: creating nutrition guidelines.

J Eval Clin Pract. 2011 Dec 13;

Authors: Singh RH, Rohr F, Splett PL

Abstract
Rationale, aims and objectives? The management of many inherited metabolic disorders (IMDs) is dependent on nutrition intervention, but few clinical management guidelines for these uncommon disorders exist. Clinicians are forced to make nutrition treatment decisions using limited data. This results in clinical variations in both service and cost. We describe a method for establishing management guidelines to help clinicians treat patients with IMDs. Methods? The Southeast Newborn Screening and Genetics Collaborative (Region 3) convened a group of nine national experts in metabolic nutrition to determine the pertinent issues in the development of nutrition management guidelines for IMDs. These experts were trained in evidence analysis and examined established consensus techniques for guideline development. Results? The workgroup developed a multi-step process for guideline development known as the Delphi-Nominal Group-Delphi-Field Testing methodology, which includes a review of scientific and grey (unpublished) literature, a Delphi survey of practice, a nominal group meeting to clarify discrepancies, a formulation of recommendations and a second Delphi round to assess the degree of consensus with the proposed recommendations. External review and field testing are also built into the process. Conclusion? The evidence- and consensus-based method suggested for the development of nutrition management guidelines for IMDs will result in the production of consistent and accessible guidelines that can be created in a timely and cost-effective manner and offer a validated methodology to develop management guidelines for this field to optimize outcomes.

PMID: 22168925 [PubMed - as supplied by publisher]

Management of chronic spontaneous urticaria in real life – in accordance with the guidelines? A cross-sectional physician-based survey study.

J Eur Acad Dermatol Venereol. 2011 Dec 8;

Authors: Weller K, Viehmann K, Bräutigam M, Krause K, Siebenhaar F, Zuberbier T, Maurer M

Abstract
Background? Recently, the updated EAACI/GA(2) LEN/EDF/WAO guidelines for urticaria have been published. Objective? To examine how chronic spontaneous urticaria (csU) patients in Germany are diagnosed and treated, and to compare the outcome to the guideline recommendations. Methods? During this cross-sectional survey study, most dermatologists, paediatricians and 5149 general practitioners in private practice in Germany were asked to participate. All physicians who agreed were requested to complete a standardized questionnaire about their diagnostic and therapeutic management of csU. Results? A total of 776 questionnaires were available for analysis. Most physicians (82%) were attempting to identify underlying causes in their csU patients, but with only limited success. More than 70% reported to check for total serum IgE and to do skin prick testing (not suggested in first line by guideline). In contrast, only 10% applied the autologous serum skin test. The most common first-line treatments were non-sedating antihistamines in standard or higher doses (as recommended). However, many physicians reported still using first generation sedating antihistamines (23%) (not recommended) or systemic steroids (18%). Experience with alternative options was low. Less than one-third of the participants reported to be familiar with the guidelines. Those who did, were found to be more likely to check for underlying causes, to be more experienced with antihistamine updosing and to be more reluctant to use sedating antihistamines or systemic steroids. Conclusion? The diagnostic and therapeutic management of csU by private practice physicians does not sufficiently comply with the guidelines. Awareness of the guidelines can lead to improved care.

PMID: 22150693 [PubMed - as supplied by publisher]