Clinical Practice Guidelines In Primary Care Research Articles

Primary Care Clinical Practice Guidelines and Referral Pathways for Oral and Dental Diseases in Pakistan

Primary Care Clinical Practice Guidelines and Referral Pathways for Oral and Dental Diseases in Pakistan

Sustainability of healthcare professionals\u2019 adherence to clinical practice guidelines in primary care

BackgroundSustainability of adherence to clinical practice guidelines (CPGs) represents an important indicator of the successful implementation in the primary care setting.AimTo explore the sustainability of primary care providers’ adherence to CPGs after receiving planned guideline implementation strategies, activities, or programmes.MethodsCochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); EMBase; Joanna Briggs Institute; Journals@Ovid; Medline; PsycoINFO; PubMed, and Web of Science were searched from January 2000 through May 2021 to identify relevant studies. Studies evaluating the sustainability of primary care providers’ (PCPs’) adherence to CPGs in primary care after any planned guideline implementation strategies, activities, or programmes were included. Two reviewers extracted data from the included studies and assessed methodological quality independently. Narrative synthesis of the findings was conducted.ResultsEleven studies were included. These studies evaluated the sustainability of adherence to CPGs related to drug prescribing, disease management, cancer screening, and hand hygiene in primary care. Educational outreach visits, teaching sessions, reminders, audit and feedback, and printed materials were utilized in the included studies as guideline implementation strategies. None of the included studies utilized purpose-designed measurements to evaluate the extent of sustainability. Three studies showed positive sustainability results, three studies showed mixed sustainability results, and four studies reported no significant changes in the sustainability of adherence to CPGs. Overall, it was difficult to quantify the extent to which CPG-based healthcare behaviours were fully sustained based on the variety of results reported in the included studies.ConclusionCurrent guideline implementation strategies may potentially improve the sustainability of PCPs’ adherence to CPGs. However, the literature reveals a limited body of evidence for any given guideline implementation strategy. Further research, including the development of a validated purpose-designed sustainability tool, is required to address this important clinical issue.Trial registrationThe study protocol has been registered at PROSPERO (No. CRD42021259748).

Antibiotic treatment of gastroenteritis in primary care.

Gastroenteritis (GE) is a frequent reason for consultating a general practitioner. Yet little is known about antibiotic prescribing in primary care patients with GE. In this study, we quantified empirical and targeted antibiotic treatment of GE, compliance with recommendations from primary care clinical practice guidelines (CPGs) and the degree of antimicrobial resistance in patients receiving diagnostic faeces testing (DFT). We performed a cohort study using routine care data of 160 general practitioners, including electronic patient records from 2013 to 2014. GE episodes were extracted and linked to microbiological laboratory records to retrieve results of DFT. For each episode, data on patient characteristics, DFT results including antimicrobial resistance testing, and antibiotic prescriptions were collected. We identified 13217 GE episodes. Antibiotic treatment was prescribed in 1163 (8.8%) episodes, most frequently with metronidazole (n = 646, 4.9%), azithromycin (n = 254, 1.9%) or ciprofloxacin (n = 184, 1.4%). Treatment was empirical for 641 (5%) GE episodes, of which 30% (n = 191) followed the CPG-recommended antibiotic choice. Targeted treatment following DFT results was prescribed for 537 GE episodes (4%), of which 99% (n = 529) followed CPG recommendations. Non-susceptibility to first- or second-choice antibiotics was demonstrated in three Salmonella isolates (9%-13% of all isolates) and one Campylobacter isolate (1%). Antibiotic treatment of GE in primary care is relatively infrequent, with 1 in 11 episodes treated. Empirical treatment was more frequent compared with targeted treatment and mostly with non-CPG-recommended antibiotics. However, treatment based upon DFT results followed CPG recommendations.

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders

BackgroundClinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa’s health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level.MethodsWe used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data.ResultsWe conducted 37 in-depth interviews from June 2014–July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process.ConclusionsOur findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Series: Clinical Epidemiology in South Africa. Paper 2: Quality and reporting standards of South African primary care clinical practice guidelines

ObjectivesClinical practice guidelines (CPGs) development has evolved over the past decade, with greater emphasis now being placed on transparency, rigor of development, and reporting standards. Our evaluation assesses the quality of the guideline development processes and reporting of selected South African primary care (PC) CPGs. Study Design and SettingCPGs were iteratively identified by two authors, seeking CPGs reflecting common conditions with which patients present in South African PC settings. CPGs could address diagnosis, treatment, or clinical management. Each CPG was independently appraised by two reviewers using the AGREE II (Appraisal of Guideline REsearch and Evaluation) quality checklist, and the weighted scoring algorithm to calculate scores for the six domains. ResultsWe included 16 CPGs from the National Department of Health and clinical professional associations. Overall, the domains of rigor of development, editorial independence, and applicability had the lowest median scores (0, 4%, and 13%, respectively). Clarity of presentation reported the highest median score (69%), with seven CPGs scoring above 70%. ConclusionsThe methodological quality of the selected South African PC CPGs was generally poor to moderate. Concerted efforts should be made to ensure that transparent, rigorous, and up-to-date evidence assessments are conducted and well reported by CPG developers.

Comparing Resident Self-Report to Chart Audits for Quality Improvement Projects: Accurate Reflection or Cherry-Picking?

Resident engagement in quality improvement is a requirement for graduate medical education, but the optimal means of instruction and evaluation of resident progress remain unknown. To determine the accuracy of self-reported chart audits in measuring resident adherence to primary care clinical practice guidelines. During the 2010-2011 academic year, second- and third-year internal medicine residents at a single, university hospital-based program performed chart audits on 10 patients from their primary care clinic to determine adherence to 16 US Preventive Services Task Force primary care guidelines. We compared residents' responses to independent audits of randomly selected patient charts by a single external reviewer. Self-reported data were collected by 18 second-year and 15 third-year residents for 330 patients. Independently, 70 patient charts were randomly selected for review by an external auditor. Overall guideline compliance was significantly higher on self-reported audits compared to external audits (82% versus 68%, P < .001). Of 16 guidelines, external audits found significantly lower rates of adherence for 5 (tetanus vaccination, osteoporosis screening, colon cancer screening, cholesterol screening, and obesity screening). Chlamydia screening was more common in audited charts than in self-reported data. Although third-year residents self-reported higher guideline adherence than second-year residents (86% versus 78%, P < .001), external audits for third-year residents found lower overall adherence (64% versus 72%, P = .040). Residents' self-reported chart audits may significantly overestimate guideline adherence. Increased supervision and independent review appear necessary to accurately evaluate resident performance.

Educational Interventions for Implementation of Arthritis Clinical Practice Guidelines in Primary Care: Effects on Health Professional Behavior

The dissemination and adoption of clinical practice guidelines (CPG) has been suggested as one method for improving arthritis care delivery. This article provides a review and synthesis of studies evaluating the influence of educational programs designed to implement CPG for osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care. A systematic literature search was conducted to identify relevant educational interventions that reported behavioral outcomes that ensured actual knowledge utilization in primary care. A standardized approach was used to assess the quality of the individual studies and a modified version of the Philadelphia Panel methodology allowed for grading of studies based on strength of design, clinical relevance, and statistical significance. The search identified 485 articles; 7 studies were selected for review. In OA, peer facilitated workshops with nurse case-management support for patients decreased the number of referrals to orthopedics by 23%, and educational outreach by trained physicians improved prescribing of analgesics. Interprofessional peer facilitated workshops were successful in increasing referrals to rehabilitation services for people with OA and RA. There was sparse literature on educational programs for the implementation of arthritis CPG in the primary care environment. Future studies are needed to evaluate which specific organizational, provider, patient, and system level factors influence the uptake of arthritis CPG in primary care.

Análisis de calidad de las guías de práctica clínica sobre riesgos cardiovasculares en el País Vasco y propuesta para su evaluación

To find the implantation and quality of clinical practice guidelines (CPG) to manage the major cardiovascular risks: tobacco dependency, hypertension, hyperlipaemia and diabetes mellitus. To work out a model to evaluate the quality of the CPG in primary care. Cross-sectional descriptive study. The primary care centres of the Basque Country. 170 CPG used at present to manage the four mentioned cardiovascular risks. Information was requested on the use of CPG and copies of their guidelines were requested from those in charge of 103 ranked centres. 77 centres replied (76%), of which 66 said they used one of them. A total of 170 CPG were received. On the basis of non-specific prior proposals for primary care, 21 quality criteria for the CPG, grouped in 6 blocks, were drawn up. Top quality was found in the block for clarity of clinical procedure with 63% compliance with the CPG, followed by general description (54%), and evaluation and measurement of impact (30%). The blocks with worst compliance were identification of people involved in their design (23%), evidence of their recommendations (19%) and conditions of application (4%). A model was proposed to evaluate the quality of the CPG. Major deficiencies in quality were found. These were most marked in key aspects such as bibliographic support for their recommendations, envisaging of conditions for application and identification of authors and reviewers.