German Evidence-based Guidelines Research Articles

Multimedication in Family Doctor Practices: The German Evidence-Based Guidelines on Multimedication

Patients with multimorbidity and multimedication require special attention from their treating physicians, as the risks of drug interactions and negative effects on adherence increase with the number of drugs. Most guidelines aim for the treatment of a single disease and do not take potential problems due to multimedication into account. In 2021, updates and evidence-based upgrades of the first version (2012) of the German Guidelines on Multimedication were issued. The aim of the article is to introduce the framework of these evidence-based guidelines, which follows the medication process in six steps: (1) inventory and medication assessment; (2) coordination with the patient; (3) prescription proposal and communication; (4) dispensing of medicines; (5) medication application and self-management; and (6) monitoring. For each step, recommendations and practice tips are presented. The central feature is a structured medication review. The target group is patients with multimorbidity and the concurrent use of five or more drugs. The Medication Appropriateness Index has been modified, and the guiding questions are recommended as guidance for the structured medication review. Overuse and undertreatment are taken into account. The guidelines were consented to in a formal process with 15 medical societies, a patient representative, and experts, as well as piloted in general practices.

Post-operative follow-up of 150 patients with sentinel lymph node biopsy under tumescence local anesthesia.

Sentinel lymph node biopsy (SLNB) is useful for staging of patients with melanoma. Although SLNB is mostly performed under general anesthesia (GA), tumescence local anesthesia (TLA) can also be used. However, less data are available regarding feasibility of SLNB under TLA. Here we present a post-operative follow-up of 150 patients. We prospectively analyzed data from 150 patients with primary cutaneous malignant melanoma. We assessed pain, post-operative complications and patients' satisfaction after SLNB under TLA. 32% of the patients reported post-operative pain within the first 48h after SLNB. Seroma was the most frequent complication, as 29 seromas after SLNB were observed. Wound infection was observed in 3.3% of the patients. 98.7% of the patients were satisfied with SLNB under TLA. SLNB under TLA is a safe and feasible option and should be considered for patients with melanoma. Especially with multimorbid or elderly patients, the risks of GA can be avoided.

Was leisten Darmkrebszentren bei der Diagnostik und Therapie kolorektaler Lebermetastasen?

Successful resection of liver metastases increases overall survival and can even be a curative approach in patients with colorectal cancer (CRC) and isolated liver metastases. Resection of liver metastases has clearly changed the therapy of this group of patients and has become a standard procedure that is being used increasingly more. Accordingly, liver metastasis resection has been included in the German evidence-based guidelines and also in international guidelines on the treatment of CRC. The treatment of colorectal liver metastases requires a multidisciplinary team of experts in the disease, including experienced radiologists, medical oncologists, radiotherapists, pathologists and surgeons. The interdisciplinary approach to the treatment in specialized tumor boards staffed by qualified experts is a prerequisite for successful certification as a colorectal cancer center by the German Cancer Society. Regular audits ensure that these requirements and that defined quality indicators regarding the tumor board and primary and secondary liver metastasis resection, are fulfilled. The certification system of the colorectal cancer centers requires and promotes conditions that allow an optimal and guideline-oriented treatment of colorectal liver metastases both at the level of personnel and infrastructure of a given center. The high primary and secondary resection rates in these centers testify that the multidisciplinary teams are effective. A detailed analysis of the audit reports reveals the close collaboration of all partners within the certified networks. These networks also comprise external cooperation with highly specialized hospitals if and when necessary. However, the annual report of the certificated colorectal cancer centers also demonstrates areas for further improvements in multidisciplinary cooperation.

Malignant Melanoma S3‐Guideline “Diagnosis, Therapy and Follow‐up of Melanoma”

This first German evidence-based guideline for cutaneous melanoma was developed under the auspices of the German Dermatological Society (DDG) and the Dermatologic Cooperative Oncology Group (DeCOG) and funded by the German Guideline Program in Oncology. The recommendations are based on a systematic literature search, and on the consensus of 32 medical societies, working groups and patient representatives. This guideline contains recommendations concerning diagnosis, therapy and follow-up of melanoma. The diagnosis of primary melanoma based on clinical features and dermoscopic criteria. It is confirmed by histopathologic examination after complete excision with a small margin. For the staging of melanoma, the AJCC classification of 2009 is used. The definitive excision margins are 0.5 cm for in situ melanomas, 1 cm for melanomas with up to 2 mm tumor thickness and 2 cm for thicker melanomas, they are reached in a secondary excision. From 1 mm tumor thickness, sentinel lymph node biopsy is recommended. For stages II and III, adjuvant therapy with interferon-alpha should be considered after careful analysis of the benefits and possible risks. In the stage of locoregional metastasis surgical treatment with complete lymphadenectomy is the treatment of choice. In the presence of distant metastasis mutational screening should be performed for BRAF mutation, and eventually for CKIT and NRAS mutations. In the presence of mutations in case of inoperable metastases targeted therapies should be applied. Furthermore, in addition to standard chemotherapies, new immunotherapies such as the CTLA-4 antibody ipilimumab are available. Regular follow-up examinations are recommended for a period of 10 years, with an intensified schedule for the first three years.

OP0070 Update of the german evidence-based guideline on the management of fibromyalgia syndrome

BackgroundThe two evidence-based European guidelines available gave some divergent recommendations on first line therapies of fibromyalgia syndrome (FMS). Both guidelines did not consider risks and feasibility of therapies (1,2).ObjectivesTo update...

The German evidence-based guidelines for Hodgkin’s lymphoma

This report reviews aspects of the German evidence-based guidelines for Hodgkin's lymphoma relevant to radiation oncologists. Stage-adapted treatment is discussed with the focus on radiotherapy. Up-to-date literature citations provide an overview of current recommendations.

Critical Appraisal of Clinical Practice Guidelines for Adaptation in the Evidence-Based Guideline “Prevention of Skin Cancer”

During guideline development, it is essential to systematically review existing guidelines that may be suitable for adaptation; however, such review is laborious and may not always uncover useful guidelines. To identify existing clinical practice guidelines and assess their methodologic quality and suitability for adaptation in the German evidence-based guideline "Prevention of Skin Cancer." A systematic literature search was performed across a range of databases and homepages of guideline development institutions. The AGREE Instrument (Appraisal of Guidelines Research and Evaluation) was used to assess the methodologic quality of selected guidelines. A total of 480 citations were identified and screened. Of these, 12 guidelines were deemed suitable for potential adaptation. After comprehensive quality assessment, only 2 melanoma guidelines, one from Australia/New Zealand and the other from Scotland, were identified as being of high methodologic quality according to predefined selection criteria. Subsequent synopsis, however, revealed that neither of these guidelines was sufficiently comprehensive for full adaptation. It is surprising that most existing skin cancer guidelines that contain aspects on prevention are not appropriate for adaptation, with most lacking methodologic quality, particularly rigor applied during the development process. Of the 2 guidelines that met the predefined quality criteria, only a few aspects--limited to malignant melanoma--were adaptable. We conclude that, despite the labor-intensive search for existing guidelines, a de novo development, including systematic literature review, is indispensible for the development of the German evidence-based guideline Prevention of Skin Cancer.

S121– Quality indicators (QI) in German evidence-based guidelines

S121– Quality indicators (QI) in German evidence-based guidelines

German evidence-based guidelines for the treatment of psoriasis vulgaris (short version)

German evidence-based guidelines for the treatment of psoriasis vulgaris (short version)

German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version).

Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Despite the large variety of treatment options available, patient surveys have revealed insufficient satisfaction with the efficacy of available treatments and a high rate of medication non-compliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. The short version of the guidelines reported here consist of a series of therapeutic recommendations that are based on a systematic literature search and subsequent discussion with experts in the field; they have been approved by a team of dermatology experts. In addition to the therapeutic recommendations provided in this short version, the full version of the guidelines includes information on contraindications, adverse events, drug interactions, practicality, and costs as well as detailed information on how best to apply the treatments described (for full version, please see Nast et al., JDDG, Suppl 2:S1–S126, 2006; or http://www.psoriasis-leitlinie.de).

Introduction to the German Evidence-based Guidelines for Community Acquired Pneumonia

Introduction to the German Evidence-based Guidelines for Community Acquired Pneumonia

A METHOD FOR ASSESSING THE COST-EFFECTIVENESS AND THE BREAK-EVEN POINT OF CLINICAL PRACTICE GUIDELINES

Assessing the costs and benefits of developing a clinical practice guideline is important because investments in guidelines compete with investments in other clinical programs. Despite the considerable number of guidelines in many industrialized countries, little is known about their costs and cost-effectiveness. The authors have developed specific measures to determine the cost-effectiveness of guidelines, using a German evidence-based guideline on obesity for the diagnosis and treatment of obese patients as a model. The measures are: the number of people needed to cure, the number of people needed to prevent from developing the disease in question, and the number of people to treat in order to break even.