Guideline-adherent Management Research Articles

The 2024 European Society of Cardiology Guidelines for Diagnosis and Management of Atrial Fibrillation: A Viewpoint from a Practicing Clinician's Perspective.

Atrial fibrillation (AF) is a complex disease requiring a multidomain and (usually) long-term management, thus posing a significant burden to patients with AF, practitioners, and health care system. Unlike cardiovascular conditions with a narrow referral pathway (e.g., acute coronary syndrome), AF may be first detected by a wide range of specialties (often noncardiology) or a general practitioner. Since timely initiated optimal management is essential for the prevention of AF-related complications, a concise and simple guidance is essential for practitioners managing AF patients, regardless of their specialty. Guideline-adherent management of patients with AF has been shown to translate to improved patient outcomes compared with guideline-nonadherent treatment. To facilitate guideline implementation in routine clinical practice, a good guideline document on AF should introduce only evidence-based new recommendations, while avoiding arbitrary changes, which may be confusing to practitioners. Herein, we discuss the main changes in the 2024 European Society of Cardiology (ESC) AF Guidelines relative to the previous 2020 ESC document. Whether the updates and new recommendations issued by the new guidelines will translate in high adherence in clinical practice (and hence improved prognosis of patients with AF) will need to be addressed in upcoming years.

A cross-sectional survey examining clinician characteristics, practices, and attitudes associated with adoption of the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines.

The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) risk-based management consensus guidelines are the most recent national guidelines for the management of abnormal cervical cancer screening tests. These guidelines benefit patients by concentrating testing and treatment in those at highest cervical cancer risk. Adoption of guidelines often occurs slowly, with few studies examining the factors associated with guideline-adherent management of abnormal results. To elucidate the factors associated with the use of the 2019 ASCCP guidelines among clinicians who perform cervical cancer screening, physicians and advanced practice professionals who perform cervical cancer screening were cross-sectionally surveyed. Clinicians responded to screening vignettes with differing recommendations for management between the 2019 and prior management guidelines. Screening vignette 1 involved reduction of invasive testing on a low-risk patient; screening vignette 2 involved increased surveillance testing on a high-risk patient. Binomial logistic regression models determined the factors associated with the use of the 2019 guidelines. A total of 1251 clinicians participated from across the United States. For screening vignettes 1 and 2, guideline-adherent responses were given by 28% and 36% of participants, respectively. Management recommendations differed by specialty and were incorrect in different situations: there was inappropriate invasive testing by obstetrics and gynecology physicians (vignette 1) and inappropriate discontinuation of screening by family and internal medicine physicians (vignette 2). Regardless of their chosen response, over half erroneously believed they were guideline adherent. Many clinicians who believe they are following appropriate guidelines may not realize their management strategy is inconsistent with the 2019 guidelines. Education initiatives tailored to clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms. The 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines are the most recent national guidelines for abnormal cervical cancer screening test management. We surveyed over 1200 obstetrics and gynecology (OB/GYN), family medicine, and internal medicine physicians and advanced practice providers about their screening and abnormal results follow-up practices in relation to guidelines. Few clinicians are following the 2019 guidelines. Management recommendations differed by clinician specialty and were incorrect in different situations: there was inappropriate invasive testing by OB/GYN physicians and inappropriate screening discontinuation by family and internal medicine physicians. Education tailored by clinician specialty could address the understanding of current guidelines, encourage the use of updated guidelines, maximize patient benefits, and minimize harms.

Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study

ABSTRACT Introduction The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization. Objective The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students’ adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach. Methods A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management. Results The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management. Conclusion DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.

Reclassification of risk of malignancy with Percepta Genomic Sequencing Classifier following nondiagnostic bronchoscopy

IntroductionBronchoscopic sampling of pulmonary lesions suspicious for lung cancer is frequently nondiagnostic. A genomic sequencing classifier utilizing bronchial brushings obtained at the time of the bronchoscopy has been shown to provide an accurate reclassification of the risk of malignancy (ROM) based on pre-procedure risk. Our objectives for this study were to determine the frequency with which the classifier up- or down-classifies risk in regular clinical practice and to model the potential clinical utility of that reclassification. MethodsThis observational study retrospectively assessed data from four clinical sites that regularly use the genomic classifier in the bronchoscopic evaluation of indeterminate lesions. Demographics and pre-bronchoscopy ROM were recorded. The frequency of up- and down-classification was calculated. Modeling based on reclassification rates and the performance characteristics of the classifier was performed to demonstrate the potential clinical utility of the result. Results86 patients who underwent classifier testing following a nondiagnostic bronchoscopy were included. 45% of patients with high ROM prior to bronchoscopy were reclassified very high-risk. 38% of patients with intermediate ROM were up-or down-classified. 56% of patients with low ROM were reclassified to very low-risk. Overall, 42% of patients had a change in classification. 35% of the study cohort could potentially have avoided additional unnecessary procedures with subsequent guideline-adherent management. ConclusionsThe classifier can guide decision-making following a nondiagnostic bronchoscopy, reclassifying risk in a significant percentage of cases. Use of the classifier should allow more patients with early-stage cancer to proceed directly to curative therapy while helping more patients with benign disease avoid further unnecessary procedures.

Abstract 11346: Overcoming Barriers to Complete and Early Extraction for CIED Infection: A Narrative Review of the Epidemiological, Clinical and Economic Evidence

Background: As the number of patients with cardiac implantable electronic devices (CIEDs) grows, they are likely to present with issues to diverse groups of physicians. Clinical guidelines have Class I recommendations for complete CIED extraction for infection. Guideline-adherent management is associated with improved prognosis in patients with CIED infection. However, this is insufficiently implemented in practice and there is limited discussion on barriers and solutions to optimizing treatment. Purpose: The objective is to provide a comprehensive overview of CIED infections with respect to (1) current guidelines for treatment of CIED infection (2) awareness of those guidelines in clinical practice, and (3) overcoming barriers to the guideline adherence. Methods: This review assessed the current literature landscape from January 1, 2005 to October 21, 2020 on the burden of CIED infection, clinical outcomes for CIED extraction, and guideline recommendations pertaining to CIED extraction. Results: Fifty-seven publications were included for this review. Five clinical practice guidelines reported a Class I indication for complete device and lead removal in all patients with defined CIED infection (systemic, local, bacteremia, or infection endocarditis). CIED infection rates ranged between 0.8% to 4.2% globally and such infections were found to be associated with substantial clinical and economic burden. Clinical studies assessing CIED extraction for infection consistently reported high procedural success (~95%), low major procedural complication rates (0% to 4.8%) and very low procedural mortality rates (0% to 2.4%). Furthermore, several studies reported that complete and early extraction has significant clinical and economic benefit compared with no extraction or late extraction. However, a large physician survey reported poor compliance with recommendations globally. Conclusions: The research indicates that barriers to optimal treatment may include challenges with infection diagnosis and patient referral to extraction centers, as well as misconceptions regarding extraction procedures. To help address these barriers, a multiprong quality initiative to optimize patient care pathways and increase awareness is necessary.

Association between Maternal Obesity Class, Adherence to Labor Guidelines, and Perinatal Outcomes.

Background Data are limited concerning rates of perinatal complications in women with a body mass index (BMI) ≥40 kg/m2 compared to women with other BMI classes when guidelines for the safe prevention of the primary cesarean delivery are applied. Objective The aim of the study is to evaluate labor guideline adherence by BMI class and to compare perinatal outcomes across BMI classes with guideline adherent management. Study Design This retrospective study included low-risk women admitted for delivery between April 2014 and April 2017 after the labor guidelines were implemented. BMI closest to delivery was used for analysis. Women with cesarean for nonreassuring fetal status were excluded. Results Guideline adherence decreased with increasing BMI, with 93% adherence among women of normal weight compared to 81% for class III obese women ( p < 0.0001). Among women who had guideline-adherent management, there was increased rates of cesarean among class III versus other obesity classes; however, there were no differences in rates of infectious morbidity ( p = 0.98) or hemorrhage ( p = 0.93). Although newborns of women with class III obesity had higher rates of meconium at birth, neonatal outcomes were not different with increasing maternal BMI ( p = 0.65). Conclusion There were no differences in adverse perinatal outcomes with increasing BMI.

Validation of the EQUAL Aspergillosis Score by analysing guideline-adherent management of invasive pulmonary aspergillosis.

To investigate the diagnosis and treatment standards at the University Hospital of Cologne, Germany, by applying the EQUAL Aspergillosis Score to invasive pulmonary aspergillosis (IPA) patients. The charts of 103 patients with probable or proven IPA at the University Hospital of Cologne were reviewed and the score retrospectively applied to all patients. Patients were stratified into two groups according to the underlying disease: a haematology group (n = 76, 73.8%) and a non-haematology group (n = 27, 26.2%). While the haematology group attained 67.8% of achievable score points (median: 15; IQR: 13-18; range: 8-25), the non-haematology group reached 48.4% (median: 12 points; IQR: 9-14; range: 4-18) (P < 0.001). Regarding diagnostics, haematological patients achieved 81.3% of achievable points (median: 7; IQR: 8-10; range: 3-13) and non-haematological 56.3% (median: 7; IQR: 5-9; range: 3-11). Concerning treatment, haematological patients gained 86.3% (median: 5; IQR: 5-5; range: 0-5) and non-haematological 68.1% (median: 5; IQR: 0-5; range: 0-5) of achievable points. Among the haematological patients with versus those without mould-active prophylaxis, 90 day mortality was 46.0% and 59.3% (P = 0.004), respectively. Guideline adherent management of IPA was observed in 31.1% of cases (39.5% in haematological patients and 7.4% in non-haematological). The EQUAL Aspergillosis Score is more suitable for evaluation of management of haematological patients compared with those without such underlying disease. In both groups there was no correlation between score points and survival. Larger prospective studies may be suitable to correlate outcome and score. A revision of the score should be considered based on the data presented.

Abstract 14379: Implementation of Pharmacist-led Antithrombotic Medication Management for Elective Endoscopic Procedures

Introduction: Mismanagement of antithrombotic medications often leads to cancelled elective procedures. Pharmacist-led anticoagulation management prior to elective procedures is not well studied. Methods: We implemented a best practice advisory (BPA) that offered referral to a pharmacist-led medication management service prior to elective outpatient gastrointestinal endoscopies. Eligible patients were taking warfarin, a direct oral anticoagulant, and/or a P2Y12 inhibitor for management of atrial fibrillation (AF), venous thromboembolism (VTE), coronary artery disease (CAD), peripheral arterial disease (PAD), and/or mechanical heart valve. Patients referred to the antithrombotic service were compared to those managed by the ordering provider. Outcomes assessed included documentation of a medication management plan, guideline-appropriateness of drug cessation prior to endoscopy, and guideline-appropriate rates of enoxaparin bridging for high risk warfarin patients. Results: Seventy-four percent of patients (448/645) were referred to the antithrombotic service. These patients were more likely to have had VTE (33.0% vs. 18.2%), less likely to have CAD (31.9% vs. 40.9%; p=0.009 for indication category), and more likely to be prescribed warfarin (32.8% vs 20.9%, p&lt;0.001). After adjusting for baseline differences, patients referred to the antithrombotic service were more likely to have had pre-procedure medication plan documentation (98.7% vs 56.1%, p &lt;0.001), and pre-procedure antithrombotic management was more likely to follow guidelines (97.5% vs. 91.5%, p=0.024). Guideline-appropriate use of bridging enoxaparin for warfarin patients was not different (10/16 [62.5%] vs. 2/6 [33.3%], p=0.221). Conclusion: Pre-procedural antithrombotic medication management by a pharmacist-led team for elective endoscopies was associated with more guideline-adherent management and better documentation of the medication plans.

Knowledge gaps, lack of confidence, and system barriers to guideline implementation among European physicians managing patients with CIED lead or infection complications: a European Heart Rhythm Association/European Society of Cardiology educational needs assessment survey.

As the number of patients with cardiac implantable electronic devices (CIEDs) grows, they are likely to present with issues to diverse groups of physicians. Guideline-adherent management is associated with improved prognosis in patients with CIED infection or lead problems but is insufficiently implemented in practice. The European Heart Rhythm Association (EHRA) with the support of the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery, performed a multinational educational needs assessment study in ESC member countries, directed at physicians who might be confronted with CIED patients with complications. A total of 336 physicians from 43 countries, reached through the ESC mailing list, participated. They included a mix of electrophysiologists, cardiologists general physicians and cardiac surgeons .One hundred and twenty-nine (38%) of the respondents performed lead extraction. The survey included eight clinical cases and a self-evaluation question of knowledge and skills to apply that knowledge. The survey looked at 14 areas of care across five stages of the patient journey. Of the non-extracting physicians over 50% felt they lacked the knowledge and skills to make the diagnosis and refer for lead extraction and over 75% felt they lacked knowledge and skills to manage aspects of extraction and post-extraction care. Barriers to correct referral were logistic and attitudinal. Extracting physicians reported significantly higher rates of adequate skills and knowledge across all five stages of the patient journey (P < 0.05). We identified major gaps in physicians' knowledge and skills across all stages of CIED care. These gaps should be addressed by targeted educational activities and streamlining referral pathways.

Clinical Decision Support for Recognition and Management of Hypertension: A Randomized Trial.

Although blood pressure (BP) is routinely measured in outpatient visits, elevated BP and hypertension are often not recognized. We evaluated whether an electronic health record-linked clinical decision support (CDS) tool could improve the recognition and management of hypertension in adolescents. We randomly assigned 20 primary care clinics within an integrated care system to CDS or usual care. At intervention sites, the CDS displayed BPs and percentiles, identified incident hypertension on the basis of current or previous BPs, and offered tailored order sets. The recognition of hypertension was identified by an automated review of diagnoses and problem lists and a manual review of clinical notes, antihypertensive medication prescriptions, and diagnostic testing. Generalized linear mixed models were used to test the effect of the intervention. Among 31 579 patients 10 to 17 years old with a clinic visit over a 2-year period, 522 (1.7%) had incident hypertension. Within 6 months of meeting criteria, providers recognized hypertension in 54.9% of patients in CDS clinics and 21.3% of patients in usual care (P ≤ .001). Clinical recognition was most often achieved through visit diagnoses or documentation in the clinical note. Within 6 months of developing incident hypertension, 17.1% of CDS subjects were referred to dieticians or weight loss or exercise programs, and 9.4% had additional hypertension workup versus 3.9% and 4.2%, respectively (P = .001 and .046, respectively). Only 1% of patients were prescribed an antihypertensive medication within 6 months of developing hypertension. The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.

Successful Assessment and Educational Intervention of Guideline-based Approaches for the Management of Multiple Myeloma

The management of myeloma has evolved rapidly, resulting in the need to integrate guideline-adherent management approaches to improve the quality of care for patients with multiple myeloma (MM).

The efficacy and safety of high dose melpharan plus bortezomib followed by auto PBSCT in elderly multiple myeloma patients

Introduction/Background: The management of myeloma has evolved rapidly, resulting in the need to integrate guideline-adherent management approaches to improve the quality of care for patients with multiple myeloma (MM). Materials and Methods: Responses from hematologist/oncologists (hem/onc) who participated in a case-based online educational intervention designed to address gaps in MM were analyzed. Clinical decision questions from 2 case vignettes provided consequences related to the specific answer selected and an effect size was calculated to show the strength of the consequence-based learning method. Learners who did not make the correct decision on the first attempt were allowed a second decision opportunity. Knowledge assessment questions preand post-intervention were included with a paired 2-tailed t-test to assess changes. McNemar’s 2-statistic was used to measure changes in responses. Results: Between January 16 and February 16, 2015, 213 hem/onc data was collected. Compared with the baseline assessment, a large effect size was noted (1.408, P<.05) and significant improvements were observed, specifically:

Novel oral anticoagulants for stroke prevention in atrial fibrillation: results of the European Heart Rhythm Association survey

The purpose of this European Heart Rhythm Association (EHRA) survey was to assess clinical practice in relation to stroke prevention in atrial fibrillation (AF), particularly into the use of novel oral anticoagulants (NOACs) for stroke prevention, among members of the EHRA electrophysiology (EP) research network. In this EP Wire survey, we have provided some insights into current practice in Europe for the use of NOACs for stroke prevention in AF. There were clear practice differences evident, and also the need for greater adherence to the guidelines, especially since guideline adherent management results in better outcomes in AF.

Cost-effectiveness of a specialized atrial fibrillation clinic vs. usual care in patients with atrial fibrillation

A recent randomized controlled trial demonstrated significant reductions in cardiovascular hospitalizations and deaths with a nurse-led integrated chronic care approach in patients with atrial fibrillation (AF) compared with usual care. The aim of the present study is to assess cost-effectiveness of this nurse-led care programme vs. usual care. A cost-effectiveness analysis was undertaken alongside the randomized controlled trial in which 712 patients were included at the Maastricht University Medical Centre, The Netherlands, and allocated to nurse-led care or usual care. Nurse-led care implied guideline-adherent management, steered by dedicated software, supervised by cardiologists. Usual care was regular outpatient care performed by cardiologists. A cost per life-year and a cost per quality-adjusted life-year (QALY) analysis was performed, both from a hospital perspective. The nurse-led care programme was associated with slightly more life-years and QALYs at a lower cost. Specifically, the nurse-led programme contributed to 0.009 QALY gains with a reduced cost of €1109 per patient and a gain of 0.02 life-years with a reduced cost of €735 per patient. Therefore, the nurse-led programme would be considered dominant. In fact, for all the possible values of willingness to pay for a QALY the nurse-led programme is considered to be more likely cost-effective than the care as usual. The cost-effectiveness analysis in the present study demonstrated that a nurse-led integrated care approach will save costs and improve survival and quality of life, and is therefore a cost-effective management strategy for patients with AF.

Assessing clinicians' management of first episode schizophrenia using clinical case vignettes

Patients with first episode schizophrenia may present in a variety of clinical settings to providers who have a range of knowledge and skills. A thoughtful workup of patients with new-onset psychosis is critical, and the treatment of first episode schizophrenia differs from that of chronic psychotic disorders. Clinical case vignettes with free-form responses can be used to carefully assess whether front line practitioners provide guideline-adherent management of first episode psychosis. A clinical case vignette, presenting a patient with first episode schizophrenia, was created and administered to the attendees of a continuing medical education programme. Free-form responses to questions regarding differential diagnosis, workup, treatment and treatment duration were scored based on published practice guidelines. Response frequencies were tabulated and performance was compared among professional disciplines. Sixty-two attendees completed the vignette. Though the attendees typically considered a broad differential diagnosis and appropriately initiated treatment with antipsychotics, the respondents' proposed medical workup was limited, and they prescribed antipsychotics at higher doses and for a shorter duration than recommended in the literature. The prescribers outperformed the non-prescribers on treatment questions (P = 0.006), but the two groups' performance did not significantly differ on the assessment questions (P = 0.08). The front line clinicians who encounter patients with first episode schizophrenia may have significant practice gaps in the initial and follow-up care of these patients. Given the preliminary nature of this study and the debate about the optimal care for first episode psychosis, further study is needed. If such gaps are confirmed, additional educational interventions are required to align clinical management with published practice guidelines.