Application Of National Guidelines Research Articles

Optimal extent of lymph node dissection in gastric cancer.

Gastric cancer still remains a major cause of cancer-related deaths globally. Stage-adapted, individualized treatment is crucial to achieving optimal oncological outcomes. Postoperative morbidity and accurate nodal staging are heavily influenced by the extent of lymph node dissection. On one hand, insufficient lymphadenectomy may result in understaging and undertreatment of a patient, on the other hand, unnecessary lymph node dissection may result in a higher rate of postoperative complications. Approximately one-third of patients with gastric cancer undergoes an avoidable lymph node dissection. Many of the recent treatment updates in the management of gastric cancer have a major influence on both surgical and oncological approaches. Currently, a wide range of endoscopic, minimally invasive, and hybrid surgical techniques are available. The concept of sentinel node biopsy and utilization of the Maruyama Computer Program are significant components of stage-adapted gastric cancer surgery. Likewise, centralization and application of national guidelines, widespread use of neoadjuvant therapy, and the stage migration phenomenon are serious concerns to be discussed. Our goal is to review the available surgical strategies for gastric cancer, with a primary focus on lymphadenectomy.

Assessing service providers’ satisfaction with the chronic diseases package provided through the National Health Insurance Fund in Sudan

Background: The prevalence and burden of chronic diseases is growing significantly with direct impact on health and financial security of population. In Sudan, there is a continuous effort to improve access for good and integrated health services but still the utilization of these services is low. Therefore, there is an urgent need to assess the availability and integration of benefit package to ensure better and effective coverage of services.Aim: This is a descriptive cross sectional based study aimed to assess the opinion of service providers about the chronic diseases package provided through the national health insurance fund.Methods: Form390 participating, data was collected via closed ended standardized questionnaires. Pre testing was done to ensure quality survey instruments and fieldwork procedures were conducted. A structured questionnaire with closed-ended questions was developed based on literature and previous studies. The questionnaire made up of 30 questions and organized in the following sections: background characteristics, medical characteristics, health professionals’ knowledge and practice related to NHIF ’chronic diseases package and perception about NHIF ‘chronic diseases package.Results: Our results showed that despite the existence of a number of issues, the National Health Insurance Fund is rather accepted amongst our respondents. Issues manifested were in regards to health education and supply issues of drugs. Conclusion: Our study concluded that, there is an obvious weakness in both training of providers and implementation of national protocols for chronic diseases. Moreover, despite the challenges of drug availability, 70% of our participants expressed positivity when questioned about the presentation of the drug package, bearing in mind the importance of reviewing the list to ensure its inclusion of new items. There is a need for training medical providers about chronic diseases with more focusing on health promotion and application of national guidelines. Additionally, integration of chronic diseases services in necessary for achieving universal health coverage.
 Keywords: national protocols for chronic diseases, national health insurance fund, health promotion

Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence

BackgroundPeople who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England.MethodsWe requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research.ResultsEighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with ‘drugs used in substance dependence’ collectively categorised as posing low risk if delayed and moderate risk if omitted.ConclusionsMany hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the ‘low-risk’ categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.

Risk Factors Related to the Neonatal Mortality in Kurdistan Province, Iran: A Population-Based Case-Control Study

Background: Neonatal mortality rate (NMR) is one of the most important health indicators in the world. Objectives: The current study aimed at determining the factors influencing neonatal mortality in Kurdistan province, Northwest of Iran. Methods: The current population-based case-control study was conducted in 2013. Cases were neonates who passed away within their first 28 days of life, in Kurdistan. The controls were selected among neonates who were born in the closest time and place to the case group. Data were collected using a questionnaire through interviews by a trained questioner. Chi-square, Fisher exact test, and logistic regression were used to analyze the data. All analyses were conducted by SPSS version 19. Results: A significant difference was observed between the neonatal mortality and the place of residence, maternal education level, maternal passive smoking, age, neonate birth weight, type of delivery, and nutrition. Maternal passive smoking during the previous year, pregnancy interval of less than 3 years, placental abruption, age, birth weight, malformations, and asphyxia were the most important factors associated with neonatal mortality. Conclusions: To reduce the NMR, in addition to follow-up and application of national guidelines, other necessary factors including the regionalization of the maternal and neonatal cares, planning, and development of programs with the focus on the causes and risk factors of neonatal mortality in Kurdistan province should be considered.

Clinical significance of lymphadenectomy in patients with gastric cancer.

Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections, it was found that there is a significant difference in morbidity, favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy, and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However, the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized, stage-adapted gastric cancer surgery the Maruyama computer program (MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival, than D-level guided surgery. For these reasons, the preoperative application of MCP is recommended routinely, with an aim to perform "low Maruyama Index surgery". The sentinel lymph node biopsy (SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate (93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.

Meeting international standards of secondary fracture prevention: a survey on Fracture Liaison Services in the Netherlands.

The Fracture Liaison Service (FLS) is advocated to be effective for the prevention of secondary fractures, but implementation is variable. A questionnaire based on the International Osteoporosis Foundation (IOF) Capture the Fracture® FLS standards was used in the current study. The results showed high compliancy with the IOF standards in the Dutch responding hospitals. The FLS is advocated for the prevention of secondary fractures, but its implementation varies between hospitals and countries. The present survey applied the standards proposed by the IOF to evaluate the implementation of FLSs in non-university hospitals in the Netherlands. A questionnaire based on the IOF FLS standards was used in this study, requesting the selection, evaluation and treatment data of patients older than 50 years with a recent fracture. Of 90 invited hospitals, 24 (27 %) fully responded, providing data of 24,468 consecutive patients, corresponding with 25 % of fracture patients in the Netherlands in the year 2012. After excluding skull and toe fractures and patients exceeding the upper age limits applied by individual hospitals, 11,983 patient data were available for analysis. The data showed high compliance (>90 %) for fracture patient identification, invitation for FLS, timing of assessment, identification of vertebral fractures, application of national guidelines, evaluation of secondary osteoporosis, drug initiation when indicated, communication with the general practitioner and application of follow-up strategy and 70 % for fall prevention. The response rate was on average (49 %). The available data also showed that patients attending the FLSs were evaluated, treated and followed in high compliancy with the IOF standards. Some standards are open to different interpretations and may need further specification. The major shortcoming in FLS practice was that patients invited to attend the FLSs showed a low response rate. None of the hospitals achieved the IOF standard patient response rate of over 90 %.

A needs assessment of national hypertension organizations for hypertension prevention and control programs.

A needs assessment of national hypertension organizations for hypertension prevention and control programs.

Abstract A105: Application of national guidelines diminishes racial disparities in end-of-life cancer care

Abstract Introduction: There are known racial disparities in cancer mortality among African American (AA) patients with shorter median survival rates compared to white patients. Utilizing evidence based clinical guidelines allows for equitable treatment of all patients and may eliminate disparities. The goal of this study was to determine whether AA patients were referred to hospice earlier in their treatment course at a tertiary academic cancer center that routinely utilizes nationally recognized treatment guidelines (i.e. – National Comprehensive Cancer Center Network, NCCN). Methods: We retrospectively analyzed 315 charts of patients referred for hospice during 2008–2009. Subjects identified as either AA or Caucasian were analyzed by race, age and socioeconomic category. Subjects residing in geographic neighborhoods corresponding to postal zip codes with median incomes of either > or ≤ $50,000 were used as a surrogate for socioeconomic status. Charts were reviewed to determine how many lines of chemotherapy were administered before hospice referral. Patients were excluded if they were referred to hospice without receiving chemotherapy. Age, number of chemotherapy regimens and socioeconomic status were compared using Wilcoxon rank-sum test within each race. The overall number of lines of chemotherapy stratified by race was compared using Van Elteren's Test. All categorical variables were summarized by year and race and compared using Fisher's exact test. Results: Patient characteristics and outcomes are as listed in the table below. There was no significant difference between the average number of lines of chemotherapy administered to AA or Caucasian patients, respectively (2.92 vs 2.62; p=0.026), and no racial difference in the percentage of patients referred for hospice discussion prior to hospice transfer [AA (92.2%) Caucasian (83.3%); p=0.36). Similarly, adherence to NCCN treatment guidelines was similar between races [AA (89.1%) Caucasian (93.1%); p=0.36]. AA patients were more likely to reside in a zip code with a lower median income (p<0.001). Interestingly, lower income Caucasian patients were statistically found to have been treated with more lines of chemotherapy prior to hospice, (2.81 compared to 2.39; p=0.04). Conclusions: In this retrospective single institution analysis, there was no evidence that AA patients or patients from lower median incomes were referred to hospice earlier than white patients or patients with higher median incomes. These results are encouraging and may be partially attributable to the use of evidence based NCCN treatment guidelines, suggesting that applying such guidelines to all patients help to eliminate racial bias and disparities in cancer care. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A105.

Evaluation of Swiss Guidelines for the Indication for Hysterectomy in Relation to Patient Outcome

Background:The application of national guidelines which specify the appropriateness for hysterectomy is believed to lead to improved patient outcomes. However, there was no evidence to support this assumption by outcome data. Goals: To evaluate adherence to guidelines and the validity of the 1997 Swiss guidelines for the appropriateness of hysterectomy based on changes in patients’ functional and psychosocial status. Method: Multicentre study of 370 consecutive cases from 18 public hospitals assessing data on appropriateness and changes in patient status following hysterectomy. Data on appropriateness were obtained before the procedure (n = 286). Changes in patient status following hysterectomy were assessed using an adapted and weighted score. Baseline data were collected up to 8 weeks prior to hysterectomy. Outcome data were obtained 16–32 weeks after surgery (n = 237). Patients for whom appropriateness data were available (n = 286) were categorized into three groups: (1) 214 patients (74.82%) with an indication for hysterectomy, (2) 36 patients (12.58%) classified as having an indication with regard to their preference, and (3) 36 patients (12.58%) classified as not being appropriate for surgery according to national guidelines. Results: In 87% the indication for hysterectomy was judged as appropriate according to the guidelines. The status of all three groups of patients after hysterectomy was found to be significantly improved compared to baseline levels. Patients with an appropriate indication tended to profit more from hysterectomy. Conclusion: The appropriateness rating found may be interpreted as an example of justified use of medical procedural intervention. There was a positive correlation between appropriateness and outcome. The 1997 guidelines still seem to be valid.

Field and laboratory preparedness: challenges to rolling out new multidrug-resistant tuberculosis diagnostics

In a pilot implementation project of the microscopic-observation drug-susceptibility methodology, we conducted a process evaluation to identify health system and logistic challenges that need to be addressed in order to harness the benefits of rolling out promising new diagnostic tools for multidrug-resistant tuberculosis (MDRTB). Regional data relating to health system practices and performance related to the MDRTB diagnostic algorithm were collected at health center, local, and regional laboratories. Parallel implementation of a new test and an existing method creates demands on funds, personnel, sample transport, and information systems in addition to new test startup costs. Obviating the need for primary culture at intermediate laboratories through direct drug susceptibility testing (DST) at the regional reference laboratory significantly reduces delay. Field application of well-defined national guidelines for DST is patchy. If fidelity to national guidelines were perfect, DST requests would increase more than 50-fold, with important implications for laboratory capacity. Implementing a new MDRTB diagnostic presents challenges to the laboratory environment, the existing DST process, and the application of national guidelines in peripheral clinics. Assessing each element can maximize efficient use of a new tool. Specifically, strengthening systems for transferring samples to the laboratory and delivering results to the requesting clinic in addition to investing in personnel and laboratory resources are integral to harnessing the benefits of high-performance new diagnostic tests and can bring added value to other programs in the health care system.

Cardiovascular Disease

Cardiovascular disease is the leading cause of death among men and women in the United States. Silent myocardial ischemia, defined as documentation of ischemia in the absence of angina or anginal equivalents, affects up to 4 million Americans and carries a poor prognosis. The assessment of the presence of subclinical coronary atherosclerosis affords an opportunity to identify patients who may be at risk for coronary artery disease over the long term. In addition to traditional risk factors (such as lipid parameters, diabetes, hypertension, smoking, and age), a variety of novel factors (such as lipoprotein[a], homocysteine, and C-reactive protein) may enhance assessment of risk in specific populations. Risk modification should be aimed at achieving recommended levels of lipids and blood pressure, reducing obesity, facilitating optimal management of diabetes and the metabolic syndrome, and encouraging smoking cessation and physical activity. Clinicians should be knowledgeable regarding the application of national guidelines for the reduction of cardiovascular risk so as to maximize the prospects for both the primary and secondary prevention of coronary artery disease and associated adverse outcomes.

Undertreatment of hyperlipidemia in a cohort of United States kidney dialysis patients.

Application of national guidelines regarding cardiovascular disease risk reduction to kidney dialysis patients is complicated by the conflicting observations that dialysis patients have a high risk of atherosclerotic cardiovascular disease (ASCVD), but dialysis patients with higher serum cholesterol have lower mortality rates. Actual treatment patterns of hyperlipidemia are not well studied. We assessed the prevalence, treatment and control of hyperlipidemia in this high-risk patient population from 1995 - 1998. We measured low-density lipoprotein cholesterol, treatment with a lipid-lowering agent, and prevalence of hyperlipidemia as defined by the National Cholesterol Education Program (NCEP), Adult Treatment Panel (ATP) II guidelines in 812 incident hemodialysis (HD), and peritoneal dialysis (PD) patients from dialysis clinics in 19 states throughout the United States. Hyperlipidemia was present in 40% of HD and 62% of PD patients. Among subjects with hyperlipidemia, 67% of HD and 63% of PD patients were untreated and only 22% of HD and 14% of PD patients were treated and controlled. Those who entered the study in 1997 or 1998, those with diabetes, males and Caucasians were more likely to be treated and controlled, whereas subjects on PD and those with ASCVD were less likely to be treated and controlled. These data suggest that high rates of undertreatment exist in the United States ESRD dialysis population. Whether improved rates of treatment will result in decreased cardiovascular disease events needs to be tested in randomized clinical trials.