Practice Guideline Adherence Research Articles

A Multifaceted Assessment of Benign Prostatic Hyperplasia Practice and AUA Guideline Adherence.

Guidelines for benign prostatic hyperplasia (BPH) were initially formulated by the AUA to provide evidence-based reasoning for the management and care of men suffering from lower urinary tract symptoms due to BPH. Recommendations for a urinalysis and validated symptom questionnaire (AUA Symptom Score [AUASS]/International Prostate Symptom Score [IPSS]) have been long standing, making these data points a metric for examining guidelines adherence. A survey assessed providers' awareness of AUA BPH guidelines and practice patterns, and was sent to a randomly selected portion of the AUA membership. The AUA Quality (AQUA) Registry was queried to assess testing and practice patterns. Of 4884 invitations sent, 404 responses were received. Most survey respondents (91.8%) indicate they intend to get a urinalysis at initial evaluation. AQUA data found urinalysis was obtained in only 22.8% of patients. Symptom questionnaire use increased with increasing guideline familiarity, with 95.7% of those who are "extremely familiar" routinely using AUASS/IPSS compared to only 69.4% who are "somewhat familiar" (P < .005). Utilization increased by a factor of 2.7 (P < .005) for each increment in familiarity. The lowest use of AUASS/IPSS was in the group within 5 years of finishing training (P = .069). Discrepancies are noted between our practice survey and AQUA data. The AUASS/IPSS is less commonly used by providers with less guideline familiarity and in providers with the least clinical experience. The intent to obtain urinalysis is high; however, actual testing is unfortunately infrequent. These findings could point toward the need for increasing education of providers with regard to clinical guidelines.

Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association.

The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial. STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022-23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers. The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care. Clinicaltrials.gov, NCT04396418.

Barriers to osteoporosis management and adherence to Clinical Practice Guideline: a comparative study between tertiary East Coast hospitals and a Fracture Liaison Services (FLS)-accredited hospital in Malaysia.

Osteoporosis management poses a substantial healthcare challenge, necessitating effective strategies and Clinical Practice Guidelines (CPG) adherence. The study employed a self-administered online questionnaire via Google Forms. Orthopedic clinicians from all study sites were invited to participate via messaging platforms. A total of 135 participants completed the questionnaire and the data was proceeded to statistical analyses. The study identified significant barriers, including inadequate knowledge of current osteoporosis guidelines and medications (p = 0.014), limited choice of anti-osteoporosis medication (p < 0.001), insufficient post-fracture care staff (p < 0.001), patients' financial constraints due to socioeconomic status (p = 0.027), and lack of doctor-patient time (p = 0.042). FLS demonstrated superior performance in CPG adherence in areas such as clinical diagnosis of osteoporosis without BMD assessment (p = 0.046), timely treatment initiation (p < 0.001), treatment monitoring using BMD (p = 0.004), reassessment treatment after 3-5years of bisphosphonate therapy (p = 0.034) and considering anabolic agents in very high-risk patients (p = 0.018). The findings highlight an essential opportunity for improvement and emphasize the necessity for robust strategies and strict adherence to Clinical Practice Guidelines (CPG), especially within tertiary East Coast hospitals. The exemplary efficacy demonstrated by the FLS model strongly advocates for its broader integration across multiple hospitals, promising substantial advancements in osteoporotic patient care outcomes throughout Malaysia.

Improving Equitable Postpartum Care in an Urban Private Clinic with Predominantly Black Patients.

Maternal health disparities based on race, ethnicity, and socioeconomic factors exist in the United States, with Black women experiencing significantly worse outcomes. With much of perinatal morbidity and mortality attributed to the postpartum period, attention to equitable postpartum care is necessary for addressing this disparity. A rapid-cycle quality improvement initiative was implemented in an urban clinic serving predominantly Black, Medicaid-insured clients. Although baseline data indicated 95% of clients experienced comorbidities, only 65% attended a comprehensive postpartum visit (PPV). The project's goal was to improve equitable postpartum care by increasing PPV attendance and quality of postpartum care to 90% in 8 weeks. The clinical team was engaged throughout to promote organizational change within the clinic. A provider checklist was implemented to improve PPV care metrics, and shared decision-making was initiated surrounding contraception and mood disorders. A care log tracked clinical practice guideline adherence with regular feedback informing the change process. Postpartum care improved across a variety of factors studied over 8 weeks. The provider checklist prompted a 78% documentation rate of PPV care metrics, and care log tracking reflected an ending PPV attendance rate of 93%. Client satisfaction with postpartum care education was measured using a Likert scale of 1 to 5 (1 = dissatisfied and 5 = satisfied) with a noted improvement from a baseline score of 4.3 to an overall mean of 4.8. This quality initiative addressed a key factor in health equity for a predominantly Black, Medicaid-insured population in an urban clinic by raising PPV attendance rates above national standards of 90% and improving client satisfaction and the quality of care received during these visits. The project was low cost and created sustainable systems for maintaining evidence-based equitable care. Limitations included the coronavirus disease 19 pandemic, clinic staff turnover, and staff and client biases. Continued innovative research targeted at improving health equity is needed.

Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training

BackgroundHealth care routinely fails Indigenous peoples and anti-Indigenous racism is common in clinical encounters. Clinical training programs aimed to enhance Indigenous cultural safety (ICS) rely on learner reported impact assessment even though clinician self-assessment is poorly correlated with observational or patient outcome reporting. We aimed to compare the clinical impacts of intensive and brief ICS training to control, and to assess the feasibility of ICS training evaluation tools, including unannounced Indigenous standardized patient (UISP) visits.MethodUsing a prospective parallel group three-arm randomized controlled trial design and masked standardized patients, we compared the clinical impacts of the intensive interactive, professionally facilitated, 8- to10-h Sanyas ICS training; a brief 1-h anti-bias training adapted to address anti-Indigenous bias; and control continuing medical education time-attention matched to the intensive training. Participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners from family practice clinics, and one emergency department across four teaching hospitals in Toronto, Canada. Main outcome measures were the quality of care provided during UISP visits including adjusted odds that clinician would be recommended by the UISP to a friend or family member; mean item scores on patient experience of care measure; and clinical practice guideline adherence for NSAID renewal and pain assessment.ResultsClinicians in the intensive or brief ICS groups had higher adjusted odds of being highly recommended to friends and family by standardized patients (OR 6.88, 95% CI 1.17 to 40.45 and OR 7.78, 95% CI 1.05 to 58.03, respectively). Adjusted mean item patient experience scores were 46% (95% CI 12% to 80%) and 40% (95% CI 2% to 78%) higher for clinicians enrolled in the intensive and brief training programs, respectively, compared to control. Small sample size precluded detection of training impacts on clinical practice guideline adherence; 100% of UISP visits were undetected by participating clinicians.ConclusionsPatient-oriented evaluation design and tools including UISPs were demonstrated as feasible and effective. Results show potential impact of cultural safety training on patient recommendation of clinician and improved patient experience. A larger trial to further ascertain impact on clinical practice is needed.Trial registrationClinicaltrials.org NCT05890144. Retrospectively registered on June 5, 2023.

NURSES’ KNOWLEDGE AND ADHERENCE TO CLINICAL PRACTICE GUIDELINE TO PREVENT EXTRAVASATION OF CHEMOTHERAPY IN ERBIL CITY

BackgroundKnowledge is the cornerstone of providing safe nursing care. However, to do so, they require access to the most recent clinical information and guidance.&#x0D; ObjectivesThis study aimed to determine the nurses’ knowledge and adherence to clinical practice guidelines to prevent chemotherapy-related extravasation&#x0D; Materials and MethodsDescriptive cross-sectional design was used, 70 oncology nurses who administer chemotherapeutic drugs were selected in both Rizgary Teaching Hospital and Nanakaly Hospital for blood disease in Erbil City, from June 2022 to May 2023, data was collected through a structured interview questionnaire consisting of demographic data of nurses, knowledge about extravasation of chemotherapy, adherence to clinical practical guideline and barrier adherence to clinical practical guideline, data analyzed by using mean, standard deviation, frequency, percentage, Chi-square and binary logistic regression were used to find out the result of the study, and, a p-value less than 0.05 is considered significant.&#x0D; ResultsConcerning the overall level of knowledge of oncology nurses 55.7% had inadequate knowledge, 61.4% of them had low adherence to clinical practice guidelines, and the factors associated with low adherence to clinical practice guidelines was lower level of education (P-value=0.007, OR= 0.63), inadequate knowledge, (P-value= 0.041, OR=6.48), and high perceived barrier (P-value=0.004, OR= 9.87), the most commonly reported barriers was lack of continuing education to update nursing information and poor applicability of clinical practice guideline in real-world practice.&#x0D; ConclusionThe clinical practice guideline adherence rate of nurses concerning chemotherapy administration was low because most oncology nurses had inadequate knowledge and high perceived barriers consequently the study highlighted the significance of continuing education to maintain oncology nursing staff with the updated evidence-based guidelines.

A novel method for continuous measurements of clinical practice guideline adherence.

Clinical practice guidelines (hereafter 'guidelines') are crucial in providing evidence-based recommendations for physicians and multidisciplinary teams to make informed decisions regarding diagnostics and treatment in various diseases, including cancer. While guideline implementation has been shown to reduce (unwanted) variability and improve outcome of care, monitoring of adherence to guidelines remains challenging. Real-world data collected from cancer registries can provide a continuous source for monitoring adherence levels. In this work, we describe a novel structured approach to guideline evaluation using real-world data that enables continuous monitoring. This method was applied to endometrial cancer patients in the Netherlands and implemented through a prototype web-based dashboard that enables interactive usage and supports various analyses. The guideline under study was parsed into clinical decision trees (CDTs) and an information standard was drawn up. A dataset from the Netherlands Cancer Registry (NCR) was used and data items from both instruments were mapped. By comparing guideline recommendations with real-world data an adherence classification was determined. The developed prototype can be used to identify and prioritize potential topics for guideline updates. CDTs revealed 68 data items for recording in an information standard. Thirty-two data items from the NCR were mapped onto information standard data items. Four CDTs could sufficiently be populated with NCR data. The developed methodology can evaluate a guideline to identify potential improvements in recommendations and the success of the implementation strategy. In addition, it is able to identify patient and disease characteristics that influence decision-making in clinical practice. The method supports a cyclical process of developing, implementing and evaluating guidelines and can be scaled to other diseases and settings. It contributes to a learning healthcare cycle that integrates real-world data with external knowledge.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia.

The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers. The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127). Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body. Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Which strategies support the effective use of clinical practice guidelines and clinical quality registry data to inform health service delivery? A systematic review

BackgroundEmpirical evidence suggests data and insights from the clinical practice guidelines and clinical quality registries are not being fully utilised, leaving health service managers, clinicians and providers without clear guidance on how best to improve healthcare delivery. This lack of uptake of existing research knowledge represents low value to the healthcare system and needs to change.MethodsFive electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews) were systematically searched. Included studies were published between 2000 and 2020 reporting on the attributes, evidence usage and impact of clinical practice guidelines and clinical quality registries on health service delivery.ResultsTwenty-six articles including one randomised controlled trial, eight before-and-after studies, eight case studies/reviews, five surveys and four interview studies, covering a wide range of medical conditions and conducted in the USA, Australia and Europe, were identified. Five complementary strategies were derived to maximise the likelihood of best practice health service delivery: (1) feedback and transparency, (2) intervention sustainability, (3) clinical practice guideline adherence, (4) productive partnerships and (5) whole-of-team approach.ConclusionThese five strategies, used in context-relevant combinations, are most likely to support the application of existing high-quality data, adding value to health service delivery. The review highlighted the limitations of study design in opportunistic registry studies that do not produce clear, usable evidence to guide changes to health service implementation practices. Recommendations include exploration of innovative methodologies, improved coordination of national registries and the use of incentives to encourage guideline adherence and wider dissemination of strategies used by successful registries.

US physical therapist practice patterns evaluating concussion and clinical practice guideline adherence

ObjectivesTo assess the influence of contemporary physical therapy clinical practice guidelines (CPG) on concussion evaluation practice patterns and barriers/facilitators for CPG adherence. DesignElectronic cross-sectional survey. SettingOnline survey platform. ParticipantsUS licensed physical therapists that manage concussion. Main outcome measures1) practice patterns 2) knowledge/use of CPG 3) barriers/facilitations to CPG adherence. ResultsKnowledge/use of CPG categories significantly predicted the model (χ2(1) = 10.966, p < .001) of total vignette scores/practice patterns with a statistically significant effect. A Kruskal-Wallis test indicated significant differences in total vignette score means based on knowledge/use between “not aware of the concussion CPG” and “integrated concussion CPG into practice” groups (p < .001, ES = .21). Knowledge/use of the CPG predicted the perceived barriers/facilitators model for three questions: investment in specialized concussion training (χ2(1) = 39.52, p < .001), necessary equipment to complete concussion evaluation (χ2(1) = 16.01, p < .001), and confidence around concussion evaluation knowledge (χ2(1) = 27.46, p < .001) with a significant effect. ConclusionThe results of this study provide support for guiding documents like the CPG to positively influence concussion practice patterns and insight into facilitators for guideline adherence.

Increase in Direct-to-Consumer Telemedicine in Urology.

Purpose of ReviewDirect-to-consumer telemedicine has vastly expanded in recent years, and urologic conditions are a common target for these companies. We aim to identify the urologic conditions being treated by direct-to-consumer telemedicine platforms and review the feasibility of adherence to evidence-based practice guidelines via this relatively new healthcare model.Recent FindingsErectile dysfunction, premature ejaculation, testosterone deficiency, and male infertility are being treated with direct-to-consumer telemedicine. Such platforms treating erectile dysfunction perform modestly in practice guideline adherence. Guidelines-based treatment of other urologic conditions via telemedicine is feasible, however, the treatment of these conditions through popular direct-to-consumer telemedicine platforms is largely unstudied.SummaryThe impact of direct-to-consumer telemedicine on the field of urology is vast and likely to continue to grow. Future studies should inspect direct-to-consumer telemedicine companies’ practice patterns and treatment outcomes to ensure the field’s standards of care are being met. Guidelines specific to the treatment of various urologic conditions via telemedicine are needed.

Risk factors management in coronary artery disease patients

Background and Aims : SURF II was developed as a simple audit tool during routine clinic visits aimed to assess risk factors and guideline adherence in daily practice. Our country was an active participant in this survey Aim: The purpose of this study was to evaluate risk factors in patients with coronary artery disease undergoing secondary prevention and to assess their adherence to treatment and guideline recommendations.

Evaluation of the Quality of Online Information on Sudden Sensorineural Hearing Loss.

To evaluate the quality of leading Internet resources of information on sudden sensorineural hearing loss (SSNHL). Cross-sectional descriptive design. An online search by means of the Google search engine. An online search was conducted using terms related to SSNHL. We defined "quality" according to scaled readability measures (Flesch Reading Ease [FRE] and Flesch-Kincaid Grade-Level [FKGL]), as well as "understandability" and "actionability" (Patient Education Materials Assessment Tool), and Clinical Practice Guideline (CPG) adherence. Scoring was performed by two independent physicians. The 10 most frequently encountered patient education websites were analyzed. The average FRE score was "fairly difficult" (mean 57.28, median 55.55, range 46.4-71.8) and the average FKGL score was "standard" (mean 9th grade, median 9th grade, range 5th-10th grade). Nine websites were understandable (mean 83%, median 84%, range 69-100%), and seven had good actionability scores (mean 73%, median 75%, range 50-100%). Most websites conformed with the CPG for patient education at a reasonable level (mean 5.6, median 5.5, range 3-7). Notably, all websites encouraged seeking medical help. Internet resources for patient education on SSNHL vary in quality and are generally understandable to the average layman. There is still much room for better, more comprehensive and easier-to-read information to improve patients' medical knowledge about their condition.Level of Evidence: 1.

Online Dysnatremia Correction Calculators: Consistency and Practice Guideline Adherence

Online Dysnatremia Correction Calculators: Consistency and Practice Guideline Adherence

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study

We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.

Clinical practice guidelines adherence, knowledge and awareness in rare and complex connective tissue diseases across Europe: results from the first ERN ReCONNET survey

IntroductionThe European Reference Network (ERN) ReCONNET is the ERN aimed at improving the management of rare and complex connective tissue and musculoskeletal diseases (rCTDs) across the European Union (EU). In...

Instant Gratification as a Method to Promote Physician Practice Guideline Adherence: A Systematic Review.

Inadequate adherence to best practice guidelines may have a negative impact on the processes of critical care and patient outcomes. Instant gratification has been used to modify human behavior in industries such as gaming, lottery, and social media. We hypothesize that, if properly and purposefully utilized, IG can become a successful tool for encouraging best practice guideline adherence among critical care providers. Four major databases were searched with a medial librarian. Covidence application was used to identify studies pertaining to the instant gratification being used to improve provider adherence with best practice guidelines. A total of 712 studies were identified, and, through duplicates removal, title and abstract screening, and full-text screening, a total of 13 studies were included in the final review. The exclusion criteria used included the following: no provider gratification, wrong focus/intervention, wrong study design, patient-focused intervention, not generalizable, and no conclusion. There is a knowledge gap regarding instant gratification utilization to influence practice guideline adherence among providers. The intervention functions of the Behavior Change Wheel (BCW) were evident, especially ‘persuasion’ and ‘incentivization’, which are most pertinent to our field. The restorative process that promotes positive reinforcement can be a potential solution for alleviating inadequacies in guideline adherence. Examining interventions based on functions of the BCW has shown that an instant gratification process may have the potential in altering critical care providers’ behavior and improving guideline adherence. This review is the first step towards creating smart algorithms to instantly alert providers for their actions compliant with best practices. Developing, testing, and validating the algorithms will be the next several steps.

Impact of adherence to board-certified surgeon systems and clinical practice guidelines on colon cancer surgical outcomes in Japan: A questionnaire survey of the National Clinical Database.

AimTo investigate the effectiveness of the institutional medical structure and of the implemented clinical practice guidelines for improving colon cancer surgical outcomes.MethodsWe conducted a web‐based questionnaire survey among departments registered at the National Clinical Database in Japan from October 2014 to January 2015 to assess the association between quality indicators (QIs), including structure and process indicators (clinical practice guideline adherence), and the risk‐adjusted odds ratio for operative mortality (AOR) after right hemicolectomy for colorectal cancer during the study period.ResultsAmong the 2064 departments registering at least one colorectal surgery during the study period, we obtained responses from 814 departments (39.4%). Our analysis on data from 22 816 patients with right hemicolectomy demonstrated that three structural QIs (certification of training hospitals by the Japanese Society of Gastroenterological Surgery and the presences of board‐certified gastroenterological and colorectal surgeons) were associated with significantly lower AOR (P < .001, P = .02, and P = .05, respectively). The “performed at the doctor's discretion” answer was associated with poorer short‐term outcomes in six process QIs than other answers.ConclusionThe board certification system for gastroenterological and colorectal surgeons and the adherence to the clinical guidelines improve the operative mortality after right hemicolectomy. It is desired to clarify the most suitable QIs to reduce the operative mortality after colorectal surgery.

A Survey of Venous Thromboembolism (VTE) Prophylaxis in Obstetrics Patients in Iran

Objective: The purpose of the present study was a survey of venous thromboembolism (VTE) prophylaxis in obstetrics patients in Iran. Materials and methods: A national, multicenter, non-interventional, prospective study was performed on 1000 women at 11 different parts of Iran. Primary outcome was to assess the situation of VTE prophylaxis in pregnant and postpartum women and the secondary outcome was risk stratification in obstetrics patients and to evaluate the guideline adherence in physician's practice of VTE prophylaxis. Results: 1,036 women entered the final analysis. The three main VTE risk factors before hospitalization were BMI > 30 kg/m2, history of oral contraceptive (OCP) use, and the age over 35.VTE risk factors upon enrollment were detected in 780 (75.28%) patients. 219 women (28.07%) were deemed eligible for drug prophylaxis, however, only 37 women (17%) received it. A total of 113 (10.9%) patients received VTE prophylaxis, of which 76 (67.25%) women had no clear indications. Concordance between theory and practice was detected with a Cohen's Kappa coefficient to be 0.74 (p < 0.001), which fell within "good agreement". Multivariate analysis for association between VTE prophylaxis and VTE risk factors showed that history of VTE [OR = 9.06 (CI 95% 1.16 - 70.8) p = 0.036] was the most frequent risk factor for receiving VTE prophylaxis followed by obesity (BMI > 30 Kg/m2); [OR = 3.74 (CI 95% 1.79 - 5.69), p = <0.001], multiple pregnancy [OR= 2.81 (CI 95% 1.70 - 4.64), p = < 0.001] and age > 35 years; [OR =1.09 (CI 95% 0.82 - 1.21), p = 0.026]. Varicose Veins [OR= 0.22 (CI 95% 0.56 - 0.87), p = 0.031], PROM / PPROM [OR= 0.33 (CI 95% 0.12 - 0.91), p = 0.032] and history of using OCP [OR= 0.36 (CI 95% 0.24 - 0.53), p = < 0.001] were the most missed risk factors for receiving VTE prophylaxis respectively. Conclusion: History of VTE, obesity, multiple pregnancy and age > 35 years were the most frequent risk factors for receiving VTE prophylaxis and varicose veins, PROM / PPROM and history of using OCP were the most missed risk factors for receiving VTE prophylaxis.

Job satisfaction and guideline adherence among physicians: Moderating effects of perceived autonomy support and job control

Value-based purchasing of physician services aims to incentivize greater adherence to clinical practice guidelines. By increasing job demands, new reimbursement models could adversely affect job satisfaction and, indirectly, clinical performance. Studies of satisfaction-performance associations among healthcare practitioners have yielded inconsistent findings. We investigated whether physicians' perceptions of autonomy support and job control significantly moderate the relationship between practice satisfaction and guideline adherence in a pay-for-performance context. We performed secondary analysis of a study dataset created by merging prospective information on clinical services provided by Rochester (NY)-based primary physicians (N = 156) during the years 2001–2004 with census data on specific characteristics of their ambulatory-care populations, claims-sourced information on attributes of their primary care practices, and survey data on their work-related attitudes. Greater job satisfaction had a significant multivariate association with lower adherence (β = −0.139; p=<.0001) among physicians that perceived low autonomy support from the market-dominant payer organization. For physicians experiencing high autonomy support, a positive satisfaction-adherence association existed (β = 0.105; p=<.0001). Low job control was a negative moderator (β = −0.103; p=<.0001), and high control a positive moderator (β = 0.071; p=<.0001), of the influence of job satisfaction on guideline adherence. Given the limitations of this study, such as the cross-sectional survey data and potential for unmeasured confounding variables, the validity of our findings should be tested by future research. We conclude that payers attempting to over-direct partner physicians can demotivate the satisfied physicians from achieving top-level guideline adherence, thereby squandering opportunities for intrinsic satisfaction to improve guideline adherence. To optimize the potential for job satisfaction to motivate greater guideline adherence, it may be important for payers to be perceptibly more supportive of physicians’ autonomy and sense of job control.