Applying Guideline Recommendations Research Articles

Adherence to guideline recommendations for asthma care in community pharmacies: actual and needed performance

Pharmaceutical care guidelines aim to provide recommendations for pharmaceutical care, reduce unwanted pharmacy practice variation and ultimately improve the quality of healthcare. This study evaluated community pharmacists’ adherence to recommendations for the provision of care to asthma patients with first dispensing and follow-up refill encounters in The Netherlands. Data were pharmacists’ self-assessment of adherence to guideline recommendations, independent observations of dispensing encounters and a nationwide questionnaire on pharmacists’ views on the desirable (clinical) necessity of applying guideline recommendations to their patient population. The 21 pharmacists who performed self-assessment judged their adherence concerning inhalation instructions as high. The lowest scores were reported for recommendations to collect additional information on the type of lung disease and for asking patients’ expectations, wishes and concerns. Sixty-eight dispensing encounters were observed. In 83% of the 35 first dispensing observations, inhalation instruction was provided. This percentage was lower (62%) at refill dispensings. During all encounters, pharmacy staff seldom explored patients’ perceptions or responded to patients’ expectations, wishes and concerns. One hundred and four pharmacists completed the feasibility questionnaire. Pharmacists judged that all patients should receive inhalation instruction at first dispensing. They regarded it necessary to check on patients’ expectations, wishes and concerns regarding the treatment for only up to 70% of the patients. More efforts on guideline implementation are needed, especially on follow-up dispensings and on gaining relevant information from patients and other healthcare professionals. Pharmacists still have opportunities to grow in applying a patient-tailored approach and exploring patients’ individual needs, rather than providing practical information.

Secondary stroke prevention and guideline adherent antithrombotic treatment in patients with atrial fibrillation: Insights from the Gulf Survey of atrial fibrillation events (Gulf SAFE)

BackgroundAnticoagulation therapy in patients with atrial fibrillation (AF) is well established as effective thromboprophylaxis. However, AF patients with prior stroke are often treated with suboptimal antithrombotic treatment (ATT). In the present study, we investigated clinical characteristics and outcomes in AF patients with versus without prior stoke, in relation to guideline adherence in ATT. MethodsWe used data from the Gulf SAFE registry, which included patients with AF who presented to hospitals in Gulf countries of the Middle East. Adherence to guideline recommended ATT was assessed against the European Society of Cardiology guidelines. ResultsOf 1860 patients, 15.4% had a history of stroke (secondary stroke prevention). For secondary stroke prevention, 62.0% of patients were prescribed oral anticoagulants, while 27.9% were still prescribed antiplatelet therapy alone and 10.1% received no ATT. Overall, 49.0% were treated with guideline adherent ATT, 25.5% were undertreated, and 25.4% were overtreated. On multivariable logistic regression analysis, undertreatment (OR; 2.763, 95% CI; 1.426–5.352, p = 0.003) was significantly associated with an increased risk of 1-year stroke. On the other hand, overtreatment was significantly associated with an increased risk of 1-year bleeding (OR; 3.294, 95% CI; 1.517–7.152, p = 0.003). ConclusionsOnly half of the AF patients received optimal ATT for stroke prevention if we apply guideline recommendations. Guideline adherent ATT significantly reduced the risk of stroke and bleeding compared with non-guideline adherent ATT.

Including patient preferences and applying guideline recommendations: a conflict?

Background One perceived barrier to adherence to guidelines is the existence of patient preferences which may conflict with them. We examined whether patient preferences influence the prescription of antibiotics in general practice, and how this affects adherence to guidelines. We hypothesised that preferences play a greater role in prescribing antibiotics if the guideline allows for patient preferences to be taken into account, i.e. if prescribing antibiotics is an option which can be considered rather than a clear guideline recommendation to prescribe or not. We included three guidelines: acute cough, acute rhinosinusitis, and urinary tract infections. Methods Data from the NIVEL Primary Care Database (NIVEL PCD) were used to assess antibiotic indications and prescriptions. These data were combined with a questionnaire among members of NIVEL’s Dutch Health Care Consumer Panel in order to examine patient preferences. According to the NIVEL PCD, 286 of these members contacted their GP in 2015 for acute cough, acute rhinosinusitis or urinary tract infections. A logistic multilevel regression analysis was performed to test our hypothesis. Results Patient preferences do play a role in GPs’ prescribing of antibiotics but only in situations where in accordance with the guideline their use is an option which could be considered (interaction between indication and preference: p = 0.049). If patients ask for antibiotics themselves in such situations, then GPs prescribe antibiotics more often. Conclusions Patient preferences only play a role if the guideline provides room for these preferences to be taken into account. Therefore, our results do not suggest a conflict between applying guideline recommendations and including patient preferences. Further research is recommended to examine whether this conflict exists in other situations. Key messages •Patient preferences do play a role in GPs’ prescribing of antibiotics but only in situations where in accordance with the guideline their use is an option which could be considered. •Our results do not suggest a conflict between applying guideline recommendations and including patient preferences. Research is recommended to examine whether this conflict exists in other situations. (aut. ref.)

Simulation in Heart Failure: Improving the Use of Guideline-Directed Care

Introduction: Many physicians are not applying guideline recommendations to optimize treatment of patients with heart failure (HF). Due to a multitude of factors, including physician-associated barriers, HF is associated with a significant health burden, resulting in more than 1 million hospitalizations per year. Hypothesis: An online, simulation-based continuing medical education (CME) intervention could improve performance of cardiologists and primary care physicians (PCPs) in the management of patients with HF. Methods: The CME intervention consisted of two cases presented in a virtual patient simulation (VPS) platform that allowed learners to make clinical decisions on lab tests, diagnoses and treatments matching the scope and depth of actual practice. Clinical decisions made by the learners were analyzed using a sophisticated decision engine, and tailored clinical guidance (CG) was provided based on current evidence and expert recommendations. Learner decisions were collected post-CG and compared with each user's baseline (pre-CG) data using a 2-tailed paired T-test to determine statistical significance. The activity launched on May 25, 2016 and data were collected through August 15, 2016. Results: Significant absolute improvements were observed after clinical guidance:Case 1 (n = 431 cardiologists; n = 240 PCPs): • -39% improvement among cardiologists (3% pre-CG vs 42% post-CG; P < .001) and 15% improvement among PCPs (6% vs 52%; P < .001) in ability to accurately diagnose and stage HF • - 41% improvement among cardiologists (6% vs 47%; P < .0001) and -35% improvement among PCPs (13% vs 48%; P < .001) in appropriate orders to start a bioavailable loop diuretic • -15% improvement among cardiologists (53% vs 68%; P < .001) and -18% improvement among PCPs (48% vs 66%; P < .001) in orders for patient education and counseling Case 2 (n = 215 cardiologists; n = 167 PCPs): • -37% improvement among cardiologists (16% vs 53%; P < .001) and -45% improvement among PCPs (8% vs 53%; P < .001) in appropriate orders for ivabradine • -20% improvement among cardiologists (49% vs 69%; P < .001) and -17% improvement among PCPs (51% vs 71%; P < .001) in orders for weight management • -20% improvement among cardiologists (53% vs 73%; P < .001) and -20% improvement among PCPs (53% vs 73%; P < .001) in orders for coordination of care. Conclusion: This study demonstrates that CME utilizing VPS methodology that immerses and engages clinicians for an authentic, practical and consequence-free learning experience can improve evidence-based clinical decisions of specialists related to the management of HF. Clinical Implications: Using VPS-based CME to improve performance of cardiologists and PCPs has the potential to translate into improvements in clinical care and patient outcomes.

Developing 'high impact' guideline-based quality indicators for UK primary care: a multi-stage consensus process.

BackgroundQuality indicators (QIs) are an important tool for improving clinical practice and are increasingly being developed from evidence-based guideline recommendations. We aimed to identify, select and apply guideline recommendations to develop a set of QIs to measure the implementation of evidence-based practice using routinely recorded clinical data in United Kingdom (UK) primary care.MethodsWe reviewed existing national clinical guidelines and QIs and used a four-stage consensus development process to derive a set of ‘high impact’ QIs relevant to primary care based upon explicit prioritisation criteria. We then field tested the QIs using remotely extracted, anonymised patient records from 89 randomly sampled primary care practices in the Yorkshire region of England.ResultsOut of 2365 recommendations and QIs originally reviewed, we derived a set of 18 QIs (5 single, 13 composites – comprising 2–9 individual recommendations) for field testing. QIs predominantly addressed chronic disease management, in particular diabetes, cardiovascular and renal disease, and included both processes and outcomes of care. Field testing proved to be critical for further refinement and final selection.ConclusionsWe have demonstrated a rigorous and transparent methodology to develop a set of high impact, evidence-based QIs for primary care from clinical guideline recommendations. While the development process was successful in developing a limited set of QIs, it remains challenging to derive robust new QIs from clinical guidelines in the absence of established systems for routine, structured recording of clinical care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0350-6) contains supplementary material, which is available to authorized users.

Acute Coronary Syndromes. New Diagnostic Strategies and Treatment

Within its continuing education program, Revista Espanola de Cardiologia launches a new series of Update articles. In recent years, these series have dealt with a range of topics in cardiology. Now, we believe the time has come to update our knowledge of acute coronary syndromes (ACS). Recent changes in the field have led to the publication of new guidelines on both acute ST-segment elevation myocardial infarction and non–ST-segment elevation ACS. The present Update deals with those issues that have changed most, or aroused most controversy, in ACS. In the first article, we review the epidemiological data that are currently most relevant and sketch a view of the future. In the diagnosis and prognosis of ACS, various biomarkers have been studied but none—except troponin—has been introduced into clinical practice. In another article, we will analyze the value of the different troponin biomarkers, along with their potential future applications. The invasive strategy in non–ST-segment elevation ACS will be discussed in another paper, at a time when an invasive strategy with possible drawbacks in some subgroups of patients—particularly those with lower levels of risk—is systematically used. In Spain, regional primary angioplasty programs are being implemented but run into difficulties when faced with the problems of performing reperfusion within an adequate time window. In this context, we will study how to improve these programs and the potential role of fibrinolysis as a reperfusion strategy in acute myocardial infarction. Subsequently, we will look at the clinical reality of damage from reperfusion—much in evidence in experimental models but less so in clinical scenarios—and possible means of protecting the myocardium. New antithrombotic drugs have been introduced in the treatment of ACS. These drugs are more effective, but they are also more expensive and entail a greater bleeding risk. How to use these drugs safely and their cost-efficiency will be analyzed in another article. Clinical practice guidelines generally report recommendations derived from major randomized trials. However, in the ‘‘real world’’, we treat patients who would be excluded from these trials and yet we apply guideline recommendations to them. We will devote one article to ACS treatment in these ‘‘special’’ patients represented by populations of advanced age and/or with comorbidities. There have been significant developments in imaging tests

Predictors of Statin Adherence

Statin therapy plays a central role in decreasing the morbidity and mortality associated with cardiovascular disease. However, prescribed statins are only effective if they are taken by patients on a regular basis, known as medication adherence. The factors that influence patient adherence to statin therapy can be categorized into patient factors, physician factors, and health system factors, often with interactions between the categories. Patient factors include demographics, socioeconomic status, comorbidities, and side effects. Physician factors include the physician's own adherence to applying guideline recommendations, office visits, and their interactions with patients. Health system factors include issues such as cost and access to care. Physicians should be aware of the various elements that may influence a patient's likelihood to take statin medications to improve adherence and provide the best possible patient outcomes.

Evaluation of the dissemination and implementation of pressure ulcer guidelines in Dutch nursing homes

Annual national prevalence surveys have been conducted in the Netherlands over the past 10 years and have revealed high prevalence rates in Dutch nursing homes. Pressure ulcer guideline implementation is one of the factors that can influence prevalence rates. Previous research has shown that these guidelines are often only partly implemented in Dutch nursing homes. Reasons for this lack of pressure ulcer guideline implementation are not known. Therefore, the aim of this study is to investigate the current situation regarding pressure ulcer guideline dissemination and implementation in Dutch nursing homes. Semi-structured interviews were conducted in eight nursing homes in the Netherlands from January till December 2008. In each nursing home, interviews were held with eight persons. The implementation of pressure ulcer guidelines was lacking in some of the nursing homes. Risk assessment scales were often not used in practice, repositioning schemes were not always available and, when they were, they were often not used in practice. Knowledge about guideline recommendations was also lacking and pressure ulcer education was inadequate. Barriers to applying guideline recommendations in practice were mostly related to personnel and communication. The implementation of pressure ulcer guidelines does not seem to be successful in all nursing homes and needs more attention. Barriers mentioned by the interviewees in applying guideline recommendations need to be addressed. Providing adequate education for nursing home staff and increasing attention for pressure ulcer care can be the first steps in improving the implementation of pressure ulcer guidelines.

Antiplatelet Therapy in Older Adults with Non–ST-Segment Elevation Acute Coronary Syndrome: Considering Risks and Benefits

Antiplatelet agents play an important role in the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS), particularly for those at high risk, such as older adults (aged > or =75 years) where treatment may yield the greatest benefits. Paradoxically, older adults are also at higher risk from bleeding complications. Most randomized trials have enrolled few older persons, so data are sparse with which to guide clinical practice. In this review, we highlight the relevant trial evidence for antiplatelet therapy (aspirin, P2Y(12) inhibitors, and small molecule glycoprotein IIb/IIIa inhibitors) in NSTE ACS in relation to age, taking into consideration the risks and benefits, dose, concomitant therapy, and duration of use. Given greater potential benefits from primary and secondary prevention strategies in cardiovascular care, it is important to apply guideline recommendations in older adults. However, given their complexity, it is important to further consider the application of existing and new therapies and strategies of care in "real-world" settings.

Competing Norms: Canadian Rural Family Physicians’ Perceptions of Clinical Practice Guidelines and Shared Decisionmaking

Implementation of clinical practice guidelines (CPGs) and shared decision-making are both advocated in primary care. Some authors argue that CPGs can enhance informed decisions by patients and physicians, while others warn that a standardized implementation of CPGs could hinder patients' involvement in decision-making. Our objective was to explore rural family physicians' perception of the interaction between clinical practice guidelines and shared decision-making in medical practice. A qualitative study using a semi-structured focus group interview: with 17 family physicians and residents, in a Canadian rural town. Interviews were audio-taped and transcribed verbatim. Thematic content analysis was performed and validated by the constant comparative method, member checking and group debriefing. Two distinct conceptions of how clinical practice guidelines should assist decision-making emerged. On the one hand, guidelines were seen as helping clinicians to make decisions on behalf of their patient about the best course of action. For interventions with uncertain benefit or that carried significant trade-off for patients, guidelines were seen as a tool that should inform decision-making between physicians and patients, providing them with details about risks, benefits, costs and alternative treatments. The pressure to apply guideline recommendations was perceived as a potential barrier to patient participation in decision-making. In circumstances where physicians judge patient participation in decision-making to be important, physicians perceive a tension between the need to respect patients' preferences and the pressure to apply guidelines. CPGs should include information that supports shared decision-making, besides their current focus on influencing prescription patterns, costs and health outcomes.

Playing Cards on Asthma Management: A New Interactive Method for Knowledge Transfer to Primary Care Physicians

To describe an interactive playing card workshop in the communication of asthma guidelines recommendations, and to assess the initial evaluation of this educational tool by family physicians. Family physicians were invited to participate in the workshop by advertisements or personal contacts. Each physician completed a standardized questionnaire on his or her perception of the rules, content and properties of the card game. A university-based continuing medical education initiative. Primary care physicians. Physicians' evaluation of the rules, content and usefulness of the program. The game allowed the communication of relevant asthma-related content, as well as experimentation with a different learning format. It also stimulated interaction in a climate of friendly competition. Participating physicians considered the method to be an innovative tool that facilitated reflection, interaction and learning. It generated relevant discussions on how to apply guideline recommendations to current asthma care. This new, interactive, educational intervention, integrating play and scientific components, was well received by participants. This method may be of value to help integrate current guidelines into current practice, thus facilitating knowledge transfer to caregivers.