Active Guideline Implementation Research Articles

A study protocol for implementing Canadian Practice Guidelines for Treating Children and Adolescents with Eating Disorders

BackgroundEating disorders have one of the highest mortality rates among psychiatric illnesses. Timely intervention is crucial for effective treatment, as eating disorders tend to be chronic and difficult to manage if left untreated. Clinical practice guidelines play a vital role in improving healthcare delivery, aiming to minimize variations in care and bridge the gap between research and practice. However, research indicates an active guideline implementation approach is crucial to effective uptake.MethodsMixed methods will be used to inform and evaluate our guideline implementation approach. Semi-structured focus groups will be conducted in each of the eight provinces in Canada. Each focus group will comprise 8–10 key stakeholders, including clinicians, program administrators, and individuals with lived experience or caregivers. Qualitative data will be analyzed using conventional content analysis and the constant comparison technique and the results will be used to inform our implementation strategy. The study will then evaluate the effectiveness of our implementation approach through pre- and post-surveys, comparing changes in awareness, use, and impact of the guidelines in various stakeholder groups.DiscussionThrough a multifaceted implementation strategy, involving the co-creation of educational materials, tailored training, and context-specific strategies, this study intends to enhance guideline uptake and promote adherence to evidence-based practices. Our study will also contribute valuable information on the impact of our implementation strategies.

Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period.

BackgroundAn ever-increasing technological development in the field of radiology urges a need for guidelines to provide predictable and just health services. A musculoskeletal guideline was developed in Norway in 2014, without active implementation.PurposeTo investigate the impact of active guideline implementation on the use of musculoskeletal diagnostic imaging most frequently encountered in general practice (pain in the neck, shoulders, lower back, and knees).Material and MethodsThe total number of outpatient radiological examinations across modalities registered at the Norwegian Health Economics Administration between January 2013 and February 2019 was assessed using an interrupted time series design.ResultsA 12% reduction in the total examination of Magnetic Resonance Imaging shoulder and knee, and x-ray lower back and shoulder was found at a significant level (p = 0.05). Stratified analysis (Magnetic Resonance Imaging examination as one group and x-ray examinations as the other) showed that this reduction mainly was due to the reduction in the use of Magnetic Resonance Imaging examinations (shoulder and knee) which was reduced by 24% at a significant level (p = 0.002), while x-ray examinations had no significant level change (p = 0.71). No other statistically significant changes were found.ConclusionThe impact of the implementation on the use of imaging of the neck, shoulder, lower back, and knee is uncertain. Significant reductions were demonstrated in the use of some examinations in the intervention county, but similar effects were not seen when including a control group in the analysis. This indicates a diffusion of the implementation, or other interventions or events that affected both counties and occurred in the intervention period.

Prevention of overuse: A view on upper gastrointestinal endoscopy.

Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed Helicobacter pylori test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.

Justification and active guideline implementation for spine radiography referrals in primary care.

Background Spinal disorders are a major public health problem. Appropriate diagnostic imaging is an essential part in the management of back complaints. Nevertheless, inappropriate imaging increases population collective dose and health costs without improving outcome. Purpose To determine the effects of active implementation of referral guidelines on the number and justification of spine radiography in primary care in one city. Material and Methods Specified guidelines for spine radiography were distributed to referring practitioners altogether three times during the study period. Educational lectures were provided before the guidelines were taken into use. The guidelines were also made available via the intranet. The number of spine radiography referrals during similar 6-month periods in the year preceding the interventions and the following 2 years was analyzed. Justification of 448 spine radiographs was assessed similarly. Results After interventions, the total number of spine radiography examinations decreased by 48% (P < 0.001) and that of cervical spine radiography by 46% ( P < 0.001), thoracic spine by 53% ( P < 0.001), and lumbar spine by 47% ( P < 0.001). The results persisted after 1-year follow-up. Before interventions, 24% of the cervical, 46% of the thoracic, and 32% of the lumbar spine radiography referrals were justified. After interventions, only justification of lumbar spine radiography improved significantly, 64% being justified ( P = 0.005). Conclusion Spine radiography in primary care can be reduced significantly by active referral guideline implementation. The proportion of inappropriate radiography was unexpectedly high. Thus, further education and studies concerning the appropriate use of spinal radiography seems to be needed.

The Canadian Critical Care Nutrition Guidelines in 2013

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances, and are designed to minimize practice variation, improve costs, and improve clinical outcomes. The Canadian Critical Care Practice Guidelines (CCPGs) were first published in 2003 and most recently updated in 2013. A total of 68 new randomized controlled trials were identified since the last version in 2009, 50 of them published between 2009 and 2013. The remaining articles were trials published before 2009 but were not identified in previous iterations of the CCPGs. For clinical practice guidelines to be useful to practitioners, they need to be up-to-date and be reflective of the current body of evidence. Herein we describe the process by which the CCPGs were updated. This process resulted in 10 new sections or clinical topics. Of the old clinical topics, 3 recommendations were upgraded, 4 were downgraded, and 27 remained the same. To influence decision making at the bedside, these updated guidelines need to be accompanied by active guideline implementation strategies. Optimal implementation strategies should be guided by local contextual factors including barriers and facilitators to best practice recommendations. Moreover, evaluating and monitoring performance, such as participating in the International Nutrition Survey of practice, should be part of any intensive care unit's performance improvement strategy. The active implementation of the updated CCPGs may lead to better nutrition care and improved patient outcomes in the critical care setting.

Implementation of guidelines for sequential therapy with fluoroquinolones in a Belgian hospital

This study measured the impact of three interventions for physicians, in order to implement guidelines for sequential therapy (intravenous to oral conversion) with fluoroquinolones. A Belgian university hospital with 1,065 beds. Method The first intervention consisted of the hospital-wide publication of guidelines in the local drug letter towards all prescribers. The consumption of fluoroquinolones was measured by means of an interrupted time-series (ITS) analysis 21 months before (period A) and 24 months after publication (period B). The second intervention was an educational interactive session, by infectious disease specialists, to the medical staff of orthopaedics and endocrinology. The third intervention comprised a proactive conversion programme on the abdominal surgery, gastro-enterology and plastic surgery wards, where pharmacists attached a pre-printed note with a suggestion to switch to an oral treatment every time a patient met the criteria for switching. The second and third intervention took place 6 months after the first intervention. Fluoroquinolone treatments were evaluated during a 2 month period before (group 1) and after the introduction of the second (group 2) and third (group 3) intervention. The monthly ratio of intravenous versus total fluoroquinolone consumption (daily defined doses per 1,000 bed days) was measured to assess the impact of the first intervention. The impact of the second and third intervention was measured in relation to the number of days that intravenous therapy continued beyond the day that the patient fulfilled the criteria for sequential therapy and the antibiotic cost. The ITS demonstrated a reduction of 3.3% in the ratio of intravenous versus total consumption after the publication of the guidelines (P = 0.011). In group 1, patients were treated intravenously for 4.1 days longer than necessary. This parameter decreased in group 2 to 3.5 days and in group 3 to 1.0 day (P = 0.006). The mean additional cost for longer intravenous treatment decreased from 188.0 euro in group 1, to 103.0 euro in group 2 and 44.0 euro in group 3 (P = 0.037). This study demonstrated that active implementation of guidelines is necessary. A proactive conversion programme by a pharmacist resulted in a reduction in the duration of the intravenous treatment, and the treatment cost.

Implementation of an evidence-based guideline on fluid resuscitation: lessons learnt for future guidelines

IntroductionThere is little experience with the nationwide implementation of an evidence-based pediatric guideline on first-choice fluid for resuscitation in hypovolemia.MethodsWe investigated fluid prescribing behavior at (1) guideline development, (2) after guideline development, and (3) after active implementation and identified potential barriers and facilitators for guideline implementation. In order to minimize costs and to optimize implementation effect, we continuously developed and adjusted implementation strategies according to identified barriers. Implementation success was evaluated using questionnaires, pharmaceutical data, and data from medical records.DiscussionThe most remarkable change occurred after guideline development and dissemination: Normal saline use by neonatologists increased from 22–89% to 100% and by pediatric intensivists from 43–71% to 88–100%, and synthetic colloid use by pediatric intensivists declined from 29–43% to 0–13% with a reduction in albumin use by neonatologists from 11–44% to 0%. After active guideline implementation, most of specialist’s management behavior was according to the guideline.ConclusionStakeholders involved in the developmental process are of great importance in disseminating recommendations before active implementation. Therefore, to successfully implement guidelines and reduce costs of active implementation, any guideline development should consider implementation right from the beginning. Implementation strategies should target identified barriers and will therefore always be guideline specific.

Efficacy of clinical guideline implementation to improve the appropriateness of chest physiotherapy prescription among inpatients with community-acquired pneumonia

Although there is no strong evidence of benefit, chest physiotherapy (CP) seems to be commonly used in simple pneumonia. CP requires equipment and frequently involves the assistance of a respiratory therapist, engendering a significant medical workload and cost. To measure and compare the efficacy of two modalities of chest physiotherapy (CP) guideline implementation on the appropriateness of CP prescription among patients hospitalised for community-acquired pneumonia (CAP). We measured the CP prescription rate and duration in all consecutive CAP inpatients admitted in a division of general internal medicine at an urban teaching community hospital during three consecutive one-year time periods: (1) before any guideline implementation; (2) after a passive implementation by medical grand rounds and guideline diffusion through mailing; (3) after adding a one-page reminder in the CAP patient's medical chart highlighting our recommendations. Death and recurrent hospitalisation rates within one year after hospitalisation were recorded to assess whether CP prescription reduction, if any, impaired patient outcomes. During the three successive phases, 127, 157, and 147 patients with similar characteristics were included. Among all CAP inpatients, the CP prescription rate decreased from 68% (86/127) to 51% (80/157), and to 48% (71/147), respectively (P for trend <0.01 for trend). A significant reduction in CP duration was observed after the active guideline implementation (12.0, 11.0, 7.0days, respectively) and persisted after adjustment for length of stay. Reductions in CP prescription rate and duration were also observed among CAP patients with COPD CP prescription rate: 97% (30/31), 67% (24/36), 75% (35/47), respectively (P<0.01 for trend). The mean cost of CP per patient was reduced by 56%, from $709 to $481, and to $309, respectively. Neither the in-hospital deaths, the one-year overall recurrent hospitalisation nor the one-year CAP-specific recurrent hospitalisation significantly differed between the three phases. Both passive and active implementation of guidelines appear to improve the appropriateness of CP prescription among inpatients with CAP without impairing their outcomes. Restricting CP use to patients who benefit from this treatment might be an opportunity to decrease CAP medical cost and workload.

Commentary on “Influence of Industry on Renal Guideline Development”

On behalf of CARI (Caring for Australasians with Renal Impairment; www.cari.org.au), the national kidney guidelines group of Australia-New Zealand, we would like to respond to the recent series of articles in CJASN on the role of industry in renal guideline development. CARI is funded through unrestricted educational grants from the pharmaceutical industry and the Australian government through a National Health and Medical Research Council Centre of Clinical Research Excellence grant. Unlike the Kidney Disease Outcomes Quality Initiative, individual guidelines are not funded; rather all funding provides core infrastructure to support all guideline activities. The annual budget of AU$300,000 has been adequate to fund development of two new major guidelines each year, update old guidelines (published for more than three years), and commence active guideline implementation projects. The evidence threshold we use for guideline statements is high. …

Management of Women with Epilepsy: Are Guidelines Being Followed? Results from Case‐note Reviews and a Patient Questionnaire

Several international guidelines for the management of women with epilepsy (WWE) have been developed since 1989. We aimed to determine whether guidelines for the management of WWE are followed and whether active implementation of such guidelines makes a difference to clinical practice. The study covered a 2-year period of "passive dissemination" of guidelines followed by a 2-year period of "active implementation." Documentation reflecting adherence to the guidelines was abstracted retrospectively from electronic medical records on 215 WWE aged 16-42 years. Data abstracted from case notes included counselling on contraception and pregnancy-related issues; follow-up during pregnancy; advice on supplementation of folic acid, calcium, and vitamin D; and serum folate measurements. A questionnaire assessing the knowledge of WWE issues was completed by 112 (71%) of 157 patients. Documentation that WWE issues had been addressed was found in approximately one third of medical case records with no measurable effect of active implementation. Only the follow-up during pregnancy seemed to have improved. Serum folate measurements in 51 women treated with enzyme-inducing antiepileptic drugs (AEDs) revealed folate deficiency in 11 (22%). Respondents to the questionnaire recalled having received information from their neurologists on the interaction between AEDs and oral contraceptives (46%), need to plan pregnancy (63%), and folic acid requirement (56%). Judged by a review of documentation in case notes, active implementation of guidelines had no measurable effect on clinical practice. However, the follow-up during pregnancy seemed to have improved. Patients' knowledge of WWE issues compared favorably with published studies. Better strategies are needed to secure successful implementation of guidelines.