Clinical Practice Guidelines Compliance Research Articles

Effectiveness of implementing a locally-developed guideline for antibiotic treatment of lower urinary tract infection in adults in Thailand

Lower urinary tract infection (UTI) is still a major concern in clinical practice, but inappropriate antibiotics are commonly prescribed in Thailand. This study aimed to develop, implement, and evaluate the effectiveness of a clinical practice guideline (CPG) for antibiotic treatment of lower UTI in adults at Siriraj Hospital which is a university hospital in Thailand. This study comprised a retrospective cohort study development phase, and a prospective cohort study implementation phase. The outcomes of treatment were compared between phases. The development and implementation phases enrolled 220 and 151 patients, respectively. The CPG compliance rate was significantly increased from 17.3% during the development phase to 43.0% during the implementation phase (p = 0.001). The rates of fluoroquinolones and cotrimoxazole use were significantly lower during implementation than during development (p < 0.001 and p = 0.027, respectively). The rates of nitrofurantoin and fosfomycin use were significantly greater during implementation than during development (p = 0.009 and p = 0.005, respectively). The overall cure rate was not significantly different between the two study phases, but implementation group patients had significantly more unfavorable prognostic factors than development phase patients. CPG-compliance group patients had a significantly higher cure rate than CPG-non-compliance group patients (p = 0.011). The cost of the initial course of antibiotics per episode was significantly higher during the implementation phase because the cost of fosfomycin is more expensive and more fosfomycin was prescribed during implementation (p = 0.047). Implementation of the locally-developed CPG was found to be effective for increasing the appropriate use of empirical antibiotics and increasing the cure rate; however, measures to improve and reinforce CPG compliance are needed.

Vascular Quality Initiative assessment of compliance with Society for Vascular Surgery clinical practice guidelines on the management of extracranial cerebrovascular disease

ObjectivesCompliance with Society for Vascular Surgery (SVS) clinical practice guidelines (CPGs) is associated with improved outcomes for the treatment of abdominal aortic aneurysm, but this has not been assessed for carotid artery disease. The Vascular Quality Initiative (VQI) registry was used to examine compliance with the SVS CPGs for the management of extracranial cerebrovascular disease and its impact on outcomes. MethodsThe 2021 SVS extracranial cerebrovascular disease CPGs were reviewed for evaluation by VQI data. Compliance rates by the center and provider were calculated, and the impact of compliance on outcomes was assessed using logistic regression with inverse probability-weighted risk adjustment for each CPG recommendation, allowing for clustering by the center. Our primary outcome was a composite end point of in-hospital stroke/death. As a secondary analysis, compliance with the 2021 SVS carotid implementation document recommendations and associated outcomes were also assessed. ResultsOf the 11 carotid CPG recommendations, 4 (36%) could be evaluated using VQI registry data. Median center-specific CPG compliance ranged from 38% to 95%, and median provider-specific compliance ranged from 36% to 100%. After adjustment, compliance with 2 of the recommendations was associated with lower rates of in-hospital stroke/death: first, the use of best medical therapy (antiplatelet and statin therapy) in low/standard surgical risk patients undergoing carotid endarterectomy for >70% asymptomatic stenosis (event rate in compliant vs noncompliant cases 0.59% vs 1.3%; adjusted odds ratio: 0.44, 95% confidence interval: 0.29-0.66); and second, carotid endarterectomy over transfemoral carotid artery stenting in low/standard surgical risk patients with >50% symptomatic stenosis (1.9% vs 3.4%; adjusted odds ratio: 0.55, 95% confidence interval: 0.43-0.71). Of the 132 implementation document recommendations, only 10 (7.6%) could be assessed using VQI data, with median center- and provider-specific compliance rates ranging from 67% to 100%. The impact of compliance on outcomes could only be assessed for 6 (4.5%) of these recommendations, and compliance with all 6 recommendations was associated with lower stroke/death. ConclusionsFew SVS recommendations could be assessed in the VQI because of incongruity between the recommendations and the VQI data variables collected. Although guideline compliance was extremely variable among VQI centers and providers, compliance with most of these recommendations was associated with improved outcomes after carotid revascularization. This finding confirms the value of guideline compliance, which should be encouraged for centers and providers. Optimization of VQI data to promote evaluation of guideline compliance and distribution of these findings to VQI centers and providers will help facilitate quality improvement efforts in the care of vascular patients.

Evaluation of Posttraumatic Stress Disorder and Acute Stress Disorder VA/DoD Clinical Practice Guidelines Training.

This study evaluated the use of an online learning platform [Joint Knowledge Online (JKO)] for dissemination of the Veterans Affairs and Department of Defense Clinical Practice Guidelines for Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). User satisfaction with the training program was assessed, users were asked to estimate their knowledge base about PTSD and ASD, and users provided comments about how they might use the course material in their clinical practice. A total of 4,442 users took at least one of three courses offered via JKO related to the PTSD Clinical Practice Guidelines (CPG) between July 1, 2019 and June 25, 2020. A total of 1,663 users took the post-test after the JKO courses and 235 applied to a second website (J7) which granted Continuing Education (CE) credits. Data were gathered from the JKO post-course survey, as well as the J7 course survey, which also asked for respondents' written comments. User satisfaction was analyzed using the JKO survey Likert scale data for each course, and results found most users rated the courses as "good" or "great." Users were also asked to evaluate their knowledge about PTSD management before and after the course. Results from all three courses showed a statistically significant change in pre-post knowledge with a medium effect size. Thematic analysis was performed on the write-in comments from each course. Comments indicated participants found the assessment tools provided in the courses to be of particular value. The VA/DoD's online learning platform (JKO) was a user-friendly, effective tool for training users on PTSD and ASD clinical practice guidelines. Users were satisfied with their experience of the trainings on JKO and improved their knowledge base about the CPG. This study did not evaluate patient data for CPG compliance, but the future study may benefit from these outcomes to demonstrate provider adherence to the guidelines.

Even High-Quality CPGs Seldom Include Implementation Strategies.

Background: Implementation is a key step in ensuring that high-quality clinical practice guideline (CPG) recommendations are followed and have a positive impact. This step must be planned during CPG development. This study aims to inform professionals tasked with developing and implementing CPGs regarding implementation strategies and tools reported in high-quality CPGs for chronic non-communicable diseases (NCDs). Methods: NCD guidelines were selected based on Appraisal of Guideline Research and Evaluation (AGREE) II assessment. CPGs with a score of ≥60% in AGREE II domains 3 (rigor of development), 5 (applicability), and 6 (editorial independence), were considered high quality. The content related to implementation was extracted from CPG full texts and complementary materials. Implementation strategies and tools were assessed and classified using Mazza taxonomy. Results: Twenty high-quality CPGs were selected, most of which were developed by government institutions (16; 80%) with public funding (16; 80%); almost half (9; 45%) addressed the treatment of cardiovascular diseases. The countries with the most high-quality CPGs were the UK (6; 30%) and Colombia (5; 25%). These countries also had the highest average number of strategies, Colombia with 28 (SD = 1) distributed in all levels, and the UK with 15 (SD = 7), concentrating on professional and organizational levels. Although the content of the Colombian CPGs was similar regardless the disease, the CPGs from the UK were specific and contained data-based feedback reports and information on CPG compliance. Implementation strategies most frequently identified were at the professional level, such as distributing reference material (18; 80%) and educating groups of healthcare professionals (18; 80%). At the organizational level, the most frequent strategies involve changes in structure (15; 75%) and service delivery method (13; 65%). Conclusion: Countries with established CPG programs, such as the UK and Colombia, where identified as having the highest number of high-quality CPGs, although CPG implementation content had significant differences. Among high-quality CPGs, the most common implementation strategies were at the professional and organizational levels. There is still room for improvement regarding the implementation strategies report, even among high-quality CPGs, especially concerning monitoring of implementation outcomes and selection of strategies based on relevant implementation barriers.

An Education Program to Increase the Utilisation of Australian NSW Health Paediatric Clinical Practice Guidelines in Rural Emergency Departments

Clinical practice guidelines (CPGs) are evidence-based publications designed to provide direction and recommendations in the assessment and management of patients. They aim to reduce the level of inappropriate practice and improve safety for patients. However, CPG development does not guarantee their utilisation. A study directly investigated the barriers to utilisation in a population group within rural Australia. They found the most common reason for underutilisation were: a lack of awareness of the guideline, a lack of access to the guideline and the belief that there was inadequate education and training in the guidelines. This study evaluates the effectiveness of an evidence-based education program (EP) to increase the utilisation of New South Wales (NSW) Health paediatric CPGs in rural NSW within Australia. This study investigates the effectiveness of an evidence-based multifaceted EP, targeting pre-determined barriers to utilisation, which was subsequently delivered to ten rural emergency departments within the Murrumbidgee Local Health District. Following the intervention, a review of patient records over a three-month period was conducted to determine its effectiveness in change of utilisation. Compliance rates of CPG utilisation was found to significantly improve from 52.1% to 75.8% over 3 months. Furthermore, the evidence-based EP significantly increased CPG compliance, potentially improving the care of sick children in rural NSW Australia.

Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline.

Clinical practice guidelines (CPG) have been shown to decrease practice variation, reduce resource use, and improve patient outcomes. The purpose of this study was to audit compliance of a pediatric complicated appendicitis CPG to identify areas for continued improvement. A comprehensive complicated appendicitis CPG was implemented in a children's hospital system. Outcomes were compared for 48months pre- (01/2012 to 12/2015) and 28months post-implementation (01/2016 to 04/2018). A detailed compliance audit was nested within the post-implementation period in 60 consecutive patients from 11/2017 to 03/2018. Feedback was provided to care providers throughout the audit. Overall, 2370 children with complicated appendicitis were identified (1366 pre-CPG and 1004 post-CPG). The CPG resulted in decrease in mean length of stay from 5.3days to 4.5days (p = 0.751), postoperative returns to the system (13.0% to 10.1%, p = 0.030), and readmissions (5.3% to 4.3%, p = 0.237). Central line use decreased from 11.2% to 5.5% (p < 0.001) and antibiotic selection improved from 47.0% to 84.1% (p < 0.001). On audit, only 15% (9/60) had full CPG compliance and 49% (29/60) received recommended antibiotic durations. Compliance increased from 7% to 23% with audit-derived feedback. After stratifying by appendicitis severity, audits resulted in improved antibiotic duration compliance for patients with severe appendicitis (38.1% to 66.7%, p = 0.07) and postoperative ambulation for patients with lower grade disease (37.5% to 83.3%, p = 0.06). Audit cycles on a complicated appendicitis CPG and feedback to providers improved CPG compliance and more granular outcomes of interest.

Steroid Use for Sudden Sensorineural Hearing Loss: A CHEER Network Study.

The objective of this study was to describe patterns of corticosteroid treatment for sudden sensorineural hearing loss and to evaluate effectiveness based on delivery mode (oral vs intratympanic vs both). Cross-sectional repeated measures. Patients were recruited from practices within the Creating Healthcare Excellence through Education and Research (CHEER) Network. CHEER is a National Institutes of Health-funded nationwide network of 30 community and academic otolaryngology practice sites. A subset of 117 patients who had been treated with steroids for sudden sensorineural hearing loss were recruited from within a larger initial CHEER Network study on clinical practice guideline compliance. Outcomes included audiometric and speech scores and patient-perceived improvement. Descriptive analyses, Wilcoxon rank-sum tests, and Fisher exact tests were run. Two categories (oral and simultaneous oral + intratympanic) had adequate sample sizes to support statistical comparison of treatment results. Improvements were seen in both audiometry and speech testing scores; 57% of patients self-reported improvement perceived as either minor or major. There were no significant differences in degree of improvement between these treatment groups. We observed that a majority of steroid-treated patients demonstrated hearing improvement, but this improvement did not meet criteria for statistical significance. As in other studies on this topic, the relatively small sample size may have prevented differentiation of effectiveness among steroid treatments. We propose that the use of alternative approaches, such as pragmatic clinical trials and multidisciplinary electronic health record systems and megadatabases, may hold the most promise for an approach to best practice development.

Quality and compliance with Clinical Practice Guidelines of Chronic Noncommunicable Diseases in primary care

To assess the quality and compliance of clinical practice guidelines (CPG) applicable to chronic non-communicable diseases (CNCD) in primary healthcare (CS), and views of staff on the barriers, facilitators and their use. 18 valued CPG with AGREEII, 3 are selected to develop indicators and assess compliance using lot quality acceptance sample (LQAS, standard 75 / 95% threshold 40 / 75% respectively, α:0. 05, β:0. 10) on 5 CS. 70 professionals surveyed about knowledge and use of CPG. Average quality of the CPG was 57.2%; low rating in domains: "Applicability" (<25%), "Stakeholder involvement" (43.5%) and "Rigour of development" (55.0%). Compliance in CS ranges from 39 to 53.4%. Professionals show uneven knowledge of CPG; 44 to 45% (according to CPG), they declare that they are not used, they identify as main barriers the lack of training, and their difficult accessibility and management. The quality and implementation of evaluated CPG is deficient constituting an opportunity of improvement in health services.

Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone.

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among combat casualties and was later revised in 2011. We evaluated utilization of antimicrobials within 48 hours following injury in the combat zone over a 5-year period (June 2009 through May 2014) with regard to number of regimens, type of antimicrobial, and adherence to the 2011 CPG. The study population consisted of 5,196 wounded military personnel. Open fractures and skin and soft-tissue injuries were the most frequent injuries. Closed injuries had the highest overall compliance (83%), whereas open fractures and maxillofacial injuries had significant improvement in compliance from 2009-2010 (34 and 50%, respectively) to 2013-2014 (73 and 76%, respectively; p < 0.05). Part of the improvement with open fractures was a significant reduction of expanded Gram-negative coverage (61% received it in 2009-2010 compared to 7% in 2013-2014; p < 0.001). Use of Gram-negative coverage with maxillofacial injuries also significantly declined (37-12%; p = 0.001). Being injured during 2011-2014 compared to 2009-2010 was associated with CPG compliance (p < 0.001), while high injury severity scores (≥10) and admission to the intensive care unit in Germany were associated with noncompliance (p < 0.001). Our analysis demonstrates an increasing trend toward CPG compliance with significant reduction of expanded Gram-negative coverage.

Adherence to published antimicrobial prophylaxis guidelines for wounded service members in the ongoing conflicts in Southwest Asia.

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among military personnel with combat-related injuries. Our analysis expands on a prior 6-month evaluation and assesses CPG adherence with respect to antimicrobial prophylaxis for U.S. combat casualties medically evacuated to Landstuhl Regional Medical Center over a 1-year period (June 2009 through May 2010), with an eventual goal of continuously monitoring CPG adherence and measuring outcomes as a function of compliance. We classified adherence to the CPG as receipt of recommended antimicrobials within 48 hours of injury. A total of 1106 military personnel eligible for CPG assessment were identified and 74% received antimicrobial prophylaxis. Overall, CPG compliance within 48 hours of injury was 75%. Lack of antimicrobial prophylaxis contributed 2 to 22% to noncompliance varying by injury category, whereas receipt of antibiotics other than preferred was 11 to 30%. For extremity injuries, antimicrobial prophylaxis adherence was 60 to 83%, whereas it was 80% for closed injuries and 68% for penetrating abdominal injuries. Overall, the results of our analysis suggest an ongoing need to improve adherence, monitor CPG compliance, and assess effectiveness.

Prognosis role of clinical practice guidelines compliance in a chronic ischaemic heart disease primary care cohort. The BARIHD study

Purpose: Little is known about the prognosis role of clinical practice guidelines compliance (CPGC) in chronic ischaemic heart disease (CIHD). We assessed the role of CPGC as a prognosis factor for cardiovascular (CV) mortality during the follow up of CIHD cohort in a primary care physicians (PCP) setting Methods: BARIHD was a cross-sectional multicentric study made with the collaboration of 69 PCP. The PCP included during February 2007, patients (p) that fulfil the inclusion criteria: coronary artery disease (CAD) with at least 1 year of follow up since diagnosis, diagnosis clear established (stable angina, unstable angina or myocardial infarction-MI) in a discharge summary from cardiology department. Follow-up was done by clinical review or telephone contact and death or CV events were recorded, as well as the cause of death. We consider CPGC when the patient received antiplatelets, statins and betablockers together. Results: 1108p were included, we found CPGC in only 537p (48.5%), when CPGC was present the patients were younger (69 vs. 72 years; p<0.001) and with fewer time since CAD diagnosis (5 vs. 7 years; p<0.001), higher percentage of MI cases (65% vs. 45.8; p<0.001), coronary angioplasty (83.9% vs. 66; p<0.001) or CABG (20.4% vs. 15.1; p=0.021) also during follow-up more treadmill tests and angiography were made in this group. Less percentage of hypertension, atrial fibrillation, COPD, prior heart failure was found in the CPGC group, higher presence of physical exercise, and no differences for diabetes or renal failure,. The median of follow-up was 811 days, with 13p lost. CV death was lower in CPGC group (2.2% vs. 5.8%; p=0.003). The multivariate analysis for CV death is shown in the table. Multivariate analysis for CV mortality 95% CI, 95% Confidence interval; CPGC, Clinical practice guidelines compliance. Conclusions: We found that CPGC was an important protective factor for CV mortality in a contemporary CIHD cohort from a primary care setting

Systematic Review of Barriers and Facilitators to Venous Thromboembolism Clinical Practice Guideline Compliance by Healthcare Professionals in Acute Care

Aims: To examine compliance with Venous Thromboembolism clinical practice guidelines by health professionals and to identify barriers and facilitators in the acute healthcare setting. Background: Clinical practice guidelines for venous thromboembolism prevention are widely available, however not all patients with identifiable risk factors are receiving appropriate assessment or prophylaxis in the acute care setting. Design: Joanna Briggs Institute comprehensive systematic review methodology was utilised. Data Sources: A comprehensive, three-stage search strategy was conducted across six major databases. Review Methods: Retrieved papers were critically appraised by two independent reviewers prior to inclusion using standardised critical appraisal instruments. Results: Eighteen quantitative and two qualitative studies assessed compliance with venous thromboembolism clinical practice guidelines, and reported on facilitators and barriers to that compliance. Quantitative data was pooled using narrative summary due to heterogeneity of reporting. Qualitative data was aggregated using a process of meta-aggregation to generate synthesised findings based on similarity of meaning. Overall, nine barriers and nine facilitators were identified Conclusion: This systematic review has drawn together quantitative and qualitative data that highlights barriers to compliance and recommends that if an intervention is developed with these in mind they can improve compliance with clinical practice guidelines.

Reply to ‘Apropos “Evaluation of Serological Diagnostic Tests for Typhoid Fever in Papua New Guinea Using a Composite Reference Standard”’

We acknowledge the importance of quality control in the delivery of diagnostic services and in medical research. The PapuaNewGuineaInstituteofMedicalResearch(PNGIMR)conducts research in accordance with international standards where applicable (e.g., good clinical practice guideline compliance for intervention studies, World Health Organization National Influenza Centre, etc). In our typhoid diagnostics study (1), we planned and conducted the study in accordance with Standards for Reporting of Diagnostic Accuracy (STARD) guidelines (2). WhilethePNGIMRhasthecapacitytoconductresearchmeeting international standards, the delivery of health care and diagnostic services in Papua New Guinea (PNG) is poor by international standards. A recent survey found that only 15% of health care facilities had the capacity to diagnose malaria by either microscopy or rapid diagnostic tests (RDTs) (3). Conducting baseline surveys for Widal antibodies requires a level of laboratory capacity comparable to that needed for conducting malaria microscopy.Weagreewiththeauthorsoftheforegoingletterthatthe Widaltestrequirescollectionofbaselinedatatoenableaclinically relevant cutoff titer to be determined (4). In PNG, such surveillance would need to be conducted throughout the country on account of the differing levels of endemicity of typhoid fever and also at regular intervals (or ongoing) due to the temporal changes in endemicity (1, 5). However, in PNG, ongoing surveillance for quality control (QC) and local mean antibody titer is beyond the means of the already overburdened health care services. Duetotherequirementforlocallyrelevantbaselinedata,along with numerous other shortcomings (the reagents require coldchain delivery and storage, conducting the test requires more laboratory expertise than a rapid test, and interpretation of the test result is subjective), we believe further efforts should be invested in the development and evaluation of typhoid fever RDTs. The rollout of a typhoid RDT would need careful management and should include laboratory training and national uniformity of the RDT used. The global burden of typhoid fever is high, and it remains one of the most important causes of febrile illness globally on account of the severity of illness and the poor outcomes if untreated. Following the success of improved prevention, diagnosis, and treatment of malaria, the next step is to better diagnose and treat the other causes of fever. In countries such as PNG, QC should not be overlookedbutshouldnotburdenhealthcareservices.RDTstypically have some QC mechanisms incorporated, target antibodies specific to the pathogen causing the disease, and reduce (though donotnecessarilyalleviate)theneedformeanantibodytiterdata.

Health Care Professionals’ Attitudes and Compliance to Clinical Practice Guidelines to Prevent Falls and Fall Injuries

Clinical practice guidelines (CPGs) aimed at preventing falls and fall injuries have been shown to be effective in acute care hospitals. However, although CPGs are systematically developed and evidence-based tools, there has been a problem with their implementation in clinical practice. To describe influences on health care professionals' attitudes to CPGs for preventing falls and fall injuries. A qualitative approach was chosen and five focus group discussions were conducted, which included physicians, nurses, physiotherapists, and occupational therapists. The transcribed texts were analyzed using manifest and latent content analysis. Two main categories emerged: experiencing a course of events and influence of social factors. Experiencing a course of event included incidence of falls and fall injuries followed by negative consequences, which revealed benefits of using a CPG. Influence of social factors for implementation and compliance with the CPG was described as community obligations and organizational and individual resources. The findings confirm the complex process of implementation and compliance of CPGs for fall prevention. A relation between experiences of high incidence of falls with negative consequences and a positive attitude and compliance to CPGs appeared. To assure compliance and a positive attitude requires an obvious benefit of the CPG in reducing falls. Factors to overcome barriers to implementation and compliance seem to be a supportive leadership, systematic evaluations of the CPG outcome, and the facilitator role.

An Observational Study Using a National Administrative Database to Determine the Impact of Hospital Volume on Compliance With Clinical Practice Guidelines

Little information is available on the relationship between hospital volume and compliance with clinical practice guidelines (CPGs). To investigate the relationship between hospital volume and compliance with CPGs using a Japanese administrative database. This was an observational study that included 60,842 patients with acute cholangitis from 829 hospitals in Japan. Hospital volume was categorized into the following 3 groups based on the number of cases of acute cholangitis during the study period: low-volume hospitals (LVHs; n = 20,869), medium-volume hospitals (MVHs; n = 18,387), and high-volume hospitals (HVHs; n = 21,586). We further collected patient data with regard to CPGs for acute cholangitis, and counted the number of recommendations that had been complied with for each patient. CPGs compliance score was defined as the rate of compliance with these recommendations for each patient (range, 0-10). Aggregated CPGs compliance score was measured according to hospital volume. Mean CPGs compliance score in HVHs was significantly higher than that in MVHs and LVHs (6.8 ± 1.6 vs. 5.6 ± 1.5 vs. 3.9 ± 1.4, respectively; P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with CPGs compliance score. The standardized coefficient for CPGs compliance score in HVHs was 0.689, whereas that of MVHs was 0.366 (P < 0.001). This study demonstrated that hospital volume was significantly associated with compliance with CPGs and that the Japanese administrative database was a viable tool for the monitoring of compliance with CPGs.

Descontaminación: un tratamiento sin indicaciones

The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown.

Impact of clinical practice guidelines on the management for carcinomas of unknown primary site: a controlled "before-after" study.

In 2002, the French Federation of Comprehensive Cancer Centers published clinical practice guidelines (CPGs) for the management of carcinomas of unknown primary (CUP). A controlled "before-after" study at two centers (experimental in Lyon, France and control in Edmonton, Canada) to assess the impact of CPGs on CUP management. Fifty-CUP patients treated in 2000-2001, i.e. before CPG publication, and 50 patients treated in 2003-2004, were analyzed for both centers. In both groups, compliance for diagnostic workup was the same before or after CPGs publication. Non-adenocarcinoma histology and performance status (PS) < 2 were independent factors for CPGs compliance. In the experimental group, 75% of patients underwent inappropriate investigations. The proportion of patients from this group with unfavourable clinicopathologic entity and PS < or = 1, who received cisplatin-based chemotherapy did not significantly change (2000-2001: 27% vs. 2003-2004: 37.5%; P = 0.45). However, most patients treated in the pre period received organ-specific regimens, while most patients treated in the post period received taxane or gemcitabine-based regimens. Patients from the control group generally received taxane/carboplatin. Our study show that simply distributing CUP CPGs did not change practice and underline the necessity to disseminate and implement CPGs, both to oncologists and organ-specialist physicians.

Critical Care Nurse Practitioners Improve Compliance With Clinical Practice Guidelines in “Semiclosed” Surgical Intensive Care Unit

This prospective study examined whether the integration of acute care nurse practitioners (ACNP) in a "semiclosed" surgical intensive care unit (SICU) model increased compliance with clinical practice guidelines (CPG). Patients were admitted to critical care services with a (a) "semiclosed"/ACNP team or (b) "mandatory consultation"/non-ACNP team. CPG compliance was significantly higher (P < .05) on the "semiclosed"/ACNP team for all 3 CPGs examined in the study.

Good Clinical Practice Research Guidelines Reviewed, Emphasis Given to Responsibilities of Investigators: Second Article in a Series

Investigators should be aware of the importance of Good Clinical Practice guideline compliance.

Context, automated decision support, and clinical practice guidelines: Does the literature apply to the United States practice environment?

Background Context – the combined effect of factors such as physician type, clinical setting, and guideline characteristics – influences the ability of automated decision support (ADS) to improve physician compliance with clinical practice guidelines (CPGs). Our goal was to determine whether research about the utility of ADS for promoting CPG compliance is contextually applicable to United States physicians. Methods We extracted information about physicians, settings, and guidelines from all articles published in the last 10 years that describe original research about the use of ADS to promote CPG compliance. The extracted information was compared to the range of practice contexts seen in the United States. Results Nearly two-thirds (65.3%) of papers described studies conducted in an academic setting, but only 11% of physicians report academic affiliations ( p < 0.0001). Physician reimbursement structure is often not reported. Salaried physicians were explicitly included as subjects in 14% of articles, but make up 45% of US physicians ( p < 0.0001). There are little data about the generalizability of ADS research to emergency care settings (6% of articles), and nursing home or skilled nursing facilities (10% of articles). Finally, ADS has not been studied at all in several epidemiologically important disease categories. Conclusion The literature does not adequately address some physician, setting, and guideline contexts. Before making policy or spending decisions based on the effectiveness of ADS, additional research is needed to determine whether ADS research can be generalized to under-represented contexts.