The effect of professional-led guideline workshops on clinical practice for the management of patent ductus arteriosus in preterm neonates in Japan: a controlled before-and-after study.

Tetsuya Isayama,Masanori Fujimura,Katsuaki Toyoshima,Satoshi Kusuda,Xiang Y Ye,Rintaro Mori,Hironobu Tokumasu,Hideko Mitsuhashi,Hiroo Chiba,Sadequa Shahrook

doi:10.1186/s13012-015-0258-5

Abstract

BackgroundClinical guidelines assist physicians to make decisions about suitable healthcare. We conducted a controlled before-and-after study to investigate the impact of professional-led guideline workshops for patent ductus arteriosus (PDA) management on physicians’ clinical practices, discharge mortality, and associated morbid conditions among preterm neonates.MethodsWe recruited physicians practicing at two neonatal intensive care units (NICUs) in Japan and used the data of all neonates weighing less than or equal to 1,500 g admitted to 90 NICUs (2 intervention NICUs and 88 control NICUs) in the Neonatal Research Network of Japan from April 2008 to March 2010. We held 1-day workshops for physicians on PDA clinical practice guidelines at the two intervention NICUs. Physicians’ skills assessed by confidence rating (CR) scores and the Sheffield Peer Review Assessment Tool (SPRAT) were compared between pre- and post-workshop month at the intervention NICUs using Wilcoxon signed-rank tests. Neonatal discharge mortality and morbidity were compared between pre- and post-workshop year at both the intervention and control NICUs using multivariable regression analyses adjusting for potential confounders.ResultsFifteen physicians were included in the study. Physicians’ CR scores (2.14 vs. 2.47, p = 0.02) and SPRAT (4.14 vs. 4.50, p = 0.05) in PDA management improved after the workshops. The analyses of neonatal outcomes included 294 and 6,234 neonates in the intervention and control NICUs, respectively. Neonates’ discharge mortality declined sharply at the intervention NICUs (from 15/146 to 5/148, relative risk reduction −0.67; adjusted odds ratio 0.30, 95% confidence interval 0.10 to 0.89) during the post-workshop period. The mortality reduction was much greater than that in the control NICUs (from 207/3,322 to 147/2,912, relative risk reduction −0.19; adjusted odds ratio 0.75, 95% confidence interval 0.59 to 0.95), although the difference between the intervention and control NICUs were not statistically significant.ConclusionsOverall, physicians’ confidence in PDA management improved after attending guideline workshops. Face-to-face workshops by guideline developers can be a useful strategy to improve physicians’ PDA management skills and, thereby, might reduce PDA-associated mortality in preterm neonates.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0258-5) contains supplementary material, which is available to authorized users.

Highlights

Clinical guidelines assist physicians to make decisions about suitable healthcare
patent ductus arteriosus (PDA) is a cardiac condition that might be associated with infant mortality [3,4] and morbidity such as bronchopulmonary dysplasia (BPD) [5,6], intraventricular hemorrhage (IVH) [7], and necrotizing enterocolitis (NEC) [8,9]
Physicians’ PDA management skills Fifteen physicians participated in the workshops and questionnaire (100% response rate; no missing data)

Summary

Introduction

We conducted a controlled before-and-after study to investigate the impact of professional-led guideline workshops for patent ductus arteriosus (PDA) management on physicians’ clinical practices, discharge mortality, and associated morbid conditions among preterm neonates. PDA management has been constrained by complex uncertainties in diagnosis, allocation of clinical priority, treatment identification, and preferred management modality [14] that have led to gaps between evidence and routine practice. In Japan, wide variations are reported in indomethacin use, enteral feeding adjustment, fluid management, and ventilation strategies, diagnosis criteria between institutions do not vary [18]. These inconsistencies have resulted in confusion and uncertainty in the medical community and raise questions about treatment ethics. Standard PDA treatment should follow ‘risks versus benefits’ rationale quantified by robust evidence tailored to the conditions of individual neonates [10,11]

Methods

Results

Discussion

Conclusion