Availability Of Clinical Guidelines Research Articles

State of affairs in use of steroids in diffuse intrinsic pontine glioma: an international survey and a review of the literature.

Children diagnosed with diffuse intrinsic pontine glioma (DIPG) face a dismal prognosis, with severe neurologic deterioration and inevitable death at a median of 9 months from diagnosis. Steroids are widely prescribed as supportive or palliative treatment although they are known to cause severe side effects that may reduce the quality of life. This study aims to review the current knowledge on, and use of, steroids in DIPG patients. A global questionnaire-study among health care professionals was performed to ascertain information on the current (multi-)institutional and (multi-)national use of steroids, the availability of clinical guidelines, and the need for improvements in prescribing steroids to DIPG patients. In addition, an extensive literature search was performed to review studies investigating steroids in pediatric brain tumor patients. From 150 responding health care professionals, only 7 % had clinical guidelines. The use of steroids was heterogeneous and over 85 % of respondents reported serious side effects. Fourteen articles, with low level of evidence, described the use of steroids in pediatric brain tumor patients. Clinical trials investigating optimal dose or regimen were lacking. This study is a first inventory of the availability of evidence-based information and clinical guidelines, and the current attitude towards the use of steroids in DIPG patients. To date, the risk–benefit ratio of steroids in this disease is yet to be determined. We emphasize the need for clinical trials resulting in guidelines on steroids, and possibly alternative drugs, to optimize the quality of care and quality of life of DIPG patients.Electronic supplementary materialThe online version of this article (doi:10.1007/s11060-016-2141-x) contains supplementary material, which is available to authorized users.

The Availability and the Adherence to Pediatric Guidelines for the Management of Syncope in the Emergency Department

To evaluate the impact of the 2009 Italian pediatric clinical guidelines on the management of syncope. A retrospective study of patients who presented to the Emergency Department (ED) of Bambino Gesù Children's Hospital with syncope during the 2 years before and then for 2 years after the establishment of the Italian pediatric clinical guidelines. Implementation of the clinical guidelines included educational seminars, additional training of health care workers, and the availability of clinical guidelines and its algorithms on ED examination rooms. We studied a population of 1073 patients (n = 470 vs n = 603). Most patients had neurocardiogenic syncope with a greater increase in postimplementation period (n = 241, 51.3% vs n = 454, 49.8%); we also noticed a parallel reduction of the number of patients with undefined syncope (30% vs 8.3%). We observed an increase in electrocardiogram (n = 328, 69.8% vs n = 512, 85.1%; P < .001), a reduction in electroencephalogram (n = 54, 11.5% vs n = 25, 4.1%; P < .001), and computed tomography scan/magnetic resonance imaging utilization (n = 26, 5.5% vs n = 8, 1.3%; P < .001). In addition, there was a significant reduction of hospital admission rates (n = 195; 41.5% vs n = 116, 19.2%; P < .001). The time period was significantly associated with improvements in all procedures at the multivariate analysis. Providing practitioners in the ED with age-oriented clinical guidelines increased the efficiency of clinical management of pediatric syncope. Our study demonstrated that the implementation of pediatric clinical guidelines on syncope improve diagnosis, reduce hospital admissions, and decrease the use of unnecessary diagnostic tests.

OPTIMAL PREVENTION OF HOSPITAL VENOUS THROMBOEMBOLISM WITH THE HELP OF MEDICAL INFORMATION SYSTEM

Deep vein thrombosis and pulmonary embolism are an important medical and social problem, contributing to the structure of morbidity and mortality in the developed countries. Despite the availability of clinical guidelines for the prevention of venous thromboembolic complications there is a gap between scientific knowledge and clinical practice. Clinical decision support systems (CDSS) are confirmed to be effective tool for the implementation of clinical guidelines in daily practice. CDSS should be based on national and international clinical guidelines; their effectiveness depends upon successful integration with other health information systems and care flow processes.

Abstract 47: ICONS: Identifying Continence OptioNs after Stroke: Findings From a Randomised Trial

Introduction: Urinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients. Methods: A cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services were randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation (using facilitation as a means of enabling and supporting staff to change their practice), or usual care. The trial aimed to recruit 500 participants in 12 stroke services (4 services per arm). The primary outcome was presence/absence of urinary incontinence. Secondary outcomes included frequency and severity of urinary incontinence, quality of life and cost-utility. Outcomes were measured at six weeks, twelve weeks and twelve months after stroke. Process data included rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation was conducted in order to describe implementation and assist in explaining potential mediators and modifiers of the process. Results: Recruitment ended on July 31 st 2012. In total 413 participants were recruited; 164 received the systematic voiding programme, 125 the systematic voiding programme plus supported implementation and 124 usual care. Findings from the six and twelve week primary and secondary effectiveness outcomes will be presented. Conclusion: Not yet available.

Insurance coverage policies for personalized medicine.

Adoption of personalized medicine in practice has been slow, in part due to the lack of evidence of clinical benefit provided by these technologies. Coverage by insurers is a critical step in achieving widespread adoption of personalized medicine. Insurers consider a variety of factors when formulating medical coverage policies for personalized medicine, including the overall strength of evidence for a test, availability of clinical guidelines and health technology assessments by independent organizations. In this study, we reviewed coverage policies of the largest U.S. insurers for genomic (disease-related) and pharmacogenetic (PGx) tests to determine the extent that these tests were covered and the evidence basis for the coverage decisions. We identified 41 coverage policies for 49 unique testing: 22 tests for disease diagnosis, prognosis and risk and 27 PGx tests. Fifty percent (or less) of the tests reviewed were covered by insurers. Lack of evidence of clinical utility appears to be a major factor in decisions of non-coverage. The inclusion of PGx information in drug package inserts appears to be a common theme of PGx tests that are covered. This analysis highlights the variability of coverage determinations and factors considered, suggesting that the adoption of personal medicine will affected by numerous factors, but will continue to be slowed due to lack of demonstrated clinical benefit.

The association of health workforce capacity and quality of pediatric care in Afghanistan

To examine the relationship between workforce capacity and quality of pediatric care in outpatient clinics in Afghanistan. Annual national performance assessments were conducted between 2005 and 2008 to determine quality of care through patient observations in >600 health facilities, selected by stratified random sampling each year. Other variables measured were health provider capacity, competency and adequacy of support systems. Primary care facilities in 29 provinces in Afghanistan. Pediatric patients and their caretakers greater than 2400 were selected at random each year. Index of observed quality of care for patient assessment and counseling based on WHO's Integrated Management of Childhood Illness (IMCI) clinical guidelines. Quality of care improved for all IMCI indices between 2005 and 2008 (IMCI index increased from 43.1 to 56.1; P < 0.001) and was significantly associated with the availability of doctors, IMCI training and knowledge and factors such as provider job satisfaction, availability of clinical guidelines, frequency of supervision and the presence of community councils. There was also a progressive increase in the index summarizing staffing capacity during the study period. Basic health centers increased from 75.6 to 85.5% (P < 0.001), comprehensive health centers increased from 27.9 to 37.9% (P < 0.03) and district hospitals increased from 34.1 to 37.2% (P > 0.05). Enhancing workforce capacity and competency and ensuring appropriate supervision and systems support mechanisms can contribute to improved quality of care. Although the results indicate sustained improvements over the study period, further research on the mixture of provider skills, competency and factors influencing provider motivation are essential to determine the optimal workforce capacity in Afghanistan.

Improving Live Donor Kidney Transplant Guidelines: More Evidence Required

The availability of clinical guidelines on living donor kidney transplantation has undoubtedly aided clinical decision-making in this area and hopefully helped to minimize adverse outcomes and unintended harm to living donors. Several countries, including the United Kingdom, the United States, Canada, Australia, and countries in continental Europe, have published guidelines that cover the screening and follow-up of living kidney donors. In addition, in 2005, the Transplantation Society produced an international consensus report from the Amsterdam Forum that includes medical guidelines for living donation. The intention of guidelines is to synthesize available evidence into recommendations for best practice. Where evidence is poor or lacking, it is replaced by aspiration or opinion, either of an individual or, more often, a group of clinicians with experience in the area in question. How do the various guidelines compare? In this issue of Transplantation, Tong et al. (1) report a carefully undertaken and comprehensive comparison of the scope, quality, and consistency of the published guidelines on the screening of potential living donors and donor follow-up. They evaluated nine published guidelines, including those from the Amsterdam Forum, using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (2). This appraisal instrument examines the quality of the guidelines, both in terms of the evidence used and the way it is reported, and provides a benchmark for producing high-quality guidelines. The quality of guidelines assessed was variable. Reassuringly, many of the recommendations made in the different published guidelines were consistent. However, in several areas, the guidelines differed in their recommendations, particularly with respect to the medical contraindications to donation. For example, the acceptable thresholds stated for hypertension, obesity, glucose metabolism, and cardiovascular disease were not consistent across the different guidelines, although some of these differences may reflect the different populations for which they were written. Tong et al. also make the important observation that although the published guidelines are consistent in emphasizing the importance of assessing the potential donors' psychological state, they failed to provide adequate guidance on how and with what tools psychological state should be assessed. Many of the recommendations made in the guidelines examined were based on limited evidence, and this reflects the relative lack of good long-term data on which to base such guidance. Given the lack of available high-quality evidence in many areas, it is not perhaps surprising that there should sometimes be a lack of consensus. This should serve, however, as a very timely reminder of the need to improve the evidence base for evaluating potential living donors. This requires much better long-term follow-up data than is currently available, and this need is particularly pressing in view of the trend toward accepting living donors which may in previous years have been declined on the basis of comorbid conditions. Living kidney donation is a major undertaking for donor and recipient. The donor agrees to undergo surgery in the belief that the risks are defined and are minimized. They have a right to understand fully the short- and long-term risks of donation that they are exposing themselves to, especially where comorbidity makes them less than ideal donors. There are many barriers to achieving long-term follow-up, in addition to the cost and workload involved. The donor may live some distance from the transplant unit, and may be ambivalent about participating in long-term follow-up, or may not wish to be reminded about their surgery and that there may be long-term sequelae. Similarly, long-term studies are not appealing to research funding bodies or researchers because the results by definition will be a long time coming and as such are not useful for career progression. Nevertheless, it is important that more effort is made by the medical community to follow-up, and when necessary give appropriate support to, living donors. Perhaps the most important message from the study of Tong et al. is that there is a need for more effort to be made in gathering long-term data on living donors. Their call for mandatory submission of registry data, along with improved long-term monitoring by healthcare providers, and appropriate education and support to maintain a healthy lifestyle should be supported. Tong et al. conclude that there is an urgent need to ensure that guidelines for living donation are consistent, evidence-based, and comprehensive to promote best outcome. Most transplant clinicians would agree, but the key to this is a better evidence base than is currently available. A major focus on improving the evidence base in living donor assessment and long-term outcome is required without delay. Other clinical practice guidelines should adopt the same rigorous approach recommended for living kidney donor guidelines if they are to be accurate, useful, and appropriate.

Metabolic Syndrome Associated with Schizophrenia and Atypical Antipsychotics

Patients with schizophrenia are at increased risk for developing the metabolic syndrome or its individual components due to their lifestyle, suspected genetic predisposition, and exposure to antipsychotic medications that can cause weight gain and other metabolic side effects. Despite the availability of clinical guidelines, screening for and monitoring of metabolic problems in this patient population continue to be suboptimal. We provide an overview specifically addressing 1) why patients with schizophrenia are at increased risk for metabolic problems; 2) how commonly used antipsychotic medications vary in terms of their metabolic liability; 3) how to effectively screen for and monitor metabolic problems in patients receiving antipsychotic medications; 4) what interventions can prevent, limit, or reverse the metabolic side effects of antipsychotic drug treatment; and 5) what are the barriers to the care of these patients.

Estrutura de maternidades do Sistema Único de Saúde do Rio de Janeiro: desafio à qualidade do cuidado à saúde

OBJETIVOS: avaliar a estrutura de maternidades pertencentes ao Sistema Único de Saúde (SUS) do Estado do Rio de Janeiro. MÉTODO: REalizou-se uma avaliação normativa, com corte transversal de maternidades selecionadas, vinculadas ao SUS no ano de 2005. Foram selecionadas 67 maternidades por amostragem de conveniência. Foram empregados um roteiro de observação e um de entrevistas com chefes de serviço e profissionais. Aspectos da estrutura destes serviços foram analisados, utilizando-se como referência a conformidade com as normas disponibilizadas pelo Ministério da Saúde e preconizadas na literatura. Esses aspectos foram: instalação, equipamentos, equipe de saúde, capacitação de profissionais e disponibilidade de diretrizes clínicas. RESULTADOS: a presença dos requisitos da estrutura avaliados difere entre os estratos de complexidade, sendo menos frequente nas maternidades de menor complexidade. Os aspectos da estrutura física, disponibilidade de diretrizes clínicas e a presença dos profissionais nos serviços foram mais adequados do que a capacitação oferecida pelos serviços. CONCLUSÕES: SÃo necessários investimentos na capacitação dos profissionais, ampliação da disponibilidade de diretrizes clínicas e melhoria da estrutura física, visando qualificar o cuidado perinatal e adequá-lo às regulamentações nacionais.

Is Endoscopic Ultrasound (EUS) Appropriate for the Diagnosis of Perianal Fistula in Crohn's Disease (CD)? A Survey of North American Inflammatory Bowel Disease (IBD) Experts

Background: Although few comparative studies exist in the literature, a growing body of evidence suggests that EUS is a sensitive modality for the diagnosis of perianal fistulas in CD. Despite the availability of clinical guidelines, it remains unclear how experts rate the appropriateness of EUS compared with other diagnostic modalities for perianal CD. We therefore performed a survey of IBD experts to elicit their opinion regarding the appropriateness of EUS for perianal CD. Methods: In collaboration with content and methods experts, we developed a survey comprised of 5 clinically relevant vignettes pertaining to the diagnosis and management of CD including one vignette describing a new presentation of perianal fistula in a patient with known CD.

A Randomized Controlled Trial of CQI Teams and Academic Detailing: Can They Alter Compliance with Guidelines?

The availability of clinical guidelines in isolation has generally failed to promote voluntary change in practice patterns. Accordingly, a randomized controlled trial was conducted to determine the effectiveness of academic detailing (AD) techniques and continuous quality improvement (CQI) teams in increasing compliance with national guidelines for the primary care of hypertension and depression. Fifteen small group practices at four Seattle primary care clinics were assigned to one of three study arms--AD alone, AD plus CQI teams, or usual care. The activity of 95 providers and 4,995 patients was monitored from August 1, 1993, through January 31, 1996. Twelve-month baseline and study periods were separated by a six-month "wash-in" period during which training sessions were held. Changes in hypertension prescribing, blood pressure control, depression recognition, use of older tricyclics, and scores on the Hopkins Symptom Checklist depression scale were examined. Clinics varied considerably in their implementation of both the AD and the CQI team interventions. Across all sites, AD was associated with change in a single process measure, a decline in the percentage of depressives prescribed first-generation tricyclics (-4.7 percentage points versus control, p = 0.04). No intervention effects were demonstrated for CQI teams across all sites for either disease condition. Within the clinic independently judged most successful at implementing both change strategies, the use of CQI teams and AD in combination did increase the percentage of hypertensives adequately controlled (17.3 percentage points versus control, p = 0.03). The AD techniques and the CQI teams evaluated were generally ineffective in improving guideline compliance and clinical outcomes regarding the primary care of hypertension and depression.