Guideline Nonadherence Research Articles

Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines

The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

Physician Awareness and Adherence to Clinical Practice Guidelines in the Diagnosis of Vaginitis Patients: A Retrospective Chart Review.

Vaginitis is one of the main causes of primary care and gynecological visits in the United States. The most common infectious causes are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis. A physician survey was conducted to measure awareness of vaginitis clinical guidelines and availability of in-office point-of-care (POC) diagnostic tools. Participants were asked to perform a chart review to evaluate diagnostic practices for their symptomatic vaginitis patients. A total of 333 physicians and 984 patient charts were included. Physicians were most familiar with VVC and BV diagnostic guidelines; fewer than half were aware of current trichomoniasis guidelines. Although access to POC tools used to evaluate and diagnose vaginitis varied by practice, there was limited access to all 3 tools (microscope, pH test strips, potassium hydroxide solution) required to perform a full Amsel workup for BV (47% obstetricians/gynecologists vs. 32% primary care physicians, P < .05). Based on guidelines, 66% of patients evaluated for VVC, 45% of patients evaluated for BV, and 17% evaluated for trichomoniasis received an optimal workup. Among trichomoniasis positive patients, 75% received chlamydia/gonorrhea testing, 42% were tested for HIV, partner therapy was noted in 59% of cases, and 47% returned to be retested within 3 months. Limited awareness of recommended diagnostic practices and lack of access to POC tools contributed to broad guideline nonadherence. This study demonstrates that clinicians commonly fall short of current guidelines and suggests the need for lab-based assessments and appropriate insurance coverage to fill the present diagnostic void.

Guideline Adherence in Antibiotic Prescribing to Patients with Respiratory Diseases in Primary Care: Prevalence and Practice Variation.

Respiratory tract infections (RTIs) account for a large part of antibiotic prescriptions in primary care. However, guidelines advise restrictive antibiotic prescribing for RTIs. Only in certain circumstances, depending on, e.g., comorbidity, are antibiotics indicated. Most studies on guideline adherence do not account for this. We aimed to assess guideline adherence for antibiotic prescribing for RTIs as well as its variation between general practices (GPs), accounting for patient characteristics. We used data from electronic health records of GPs in the Netherlands. We selected patients who consulted their GP for acute cough, rhinitis, rhinosinusitis or sore throat in 2014. For each disease episode we assessed whether, according to the GP guideline, there was an indication for antibiotics, using the patient’s sociodemographic characteristics, comorbidity and co-medication. We assessed antibiotic prescribing for episodes with no or an unsure indication according to the guidelines. We analysed 248,896 episodes. Diagnoses with high rates of antibiotic prescribing when there was no indication include acute tonsillitis (57%), strep throat (56%), acute bronchitis (51%) and acute sinusitis (48%). Prescribing rates vary greatly between diagnoses and practices. Reduction of inappropriate antibiotic prescribing remains a key target to tackle antimicrobial resistance. Insight into reasons for guideline non-adherence may guide successful implementation of the variety of interventions already available for GPs and patients.

Clinical Practice Guideline Nonadherence and Patient Outcomes in Pediatric Appendicitis

BackgroundClinical practice guidelines (CPGs) have been associated with improved patient outcomes. We aimed to evaluate institutional CPG adherence and hypothesized that adherence would be associated with fewer complications in pediatric appendicitis. MethodsA retrospective review was conducted of pediatric (<18 y) appendicitis patients who underwent appendectomy (6/1/2017-5/30/2018). Patients were managed using an institutional pediatric appendicitis CPG. The primary outcome was CPG adherence, defined as receipt of preoperative antibiotics at diagnosis, surgical prophylaxis before incision, and, in perforated/gangrenous appendicitis, continued postoperative antibiotics, and prescription for discharge antibiotics. Univariate and multivariate analyzes were performed. ResultsAmong 399 patients, the baseline characteristics were similar between CPG-adherent and nonadherent patients. Overall CPG adherence was low at 55% (n = 221). Only 58% of patients received preoperative antibiotics per protocol (n = 233). Patients with simple appendicitis were more likely to proceed to surgery without receiving any preoperative antibiotics (35% vs. 21%, P = 0.004). Surgical prophylaxis compliance was high at 97% (n = 389). CPG violation was associated with reoperation (n = 5 versus 0, P = 0.02). After adjusting for age and admission white blood cell count, the association between CPG adherence and postoperative surgical site infection or intra-abdominal abscess remained nonsignificant (OR: 1.2, 95% CI: 0.5-2.5). ConclusionsDespite a long-standing pediatric appendicitis CPG, adherence with antibiotic components of the CPG was poor. CPG violation was significantly associated with reoperation, but was not associated with other postoperative complications. Regular audits of CPG adherence are necessary to ascertain reasons for noncompliance and identify ways to improve adherence.

Real-World Experience with AGA Guidelines in the Management of Crohn's Disease following Ileocolonic Resection: A Retrospective Cohort Study.

Background Postoperative endoscopic recurrence (PER) is common in patients with Crohn's disease (CD) after surgery. The impact of the American Gastroenterological Association (AGA) guideline adherence on PER in real life remains unclear. Methods The postoperative management of CD patients undergoing ileocolonic resection with anastomosis from 2017 to 2018 was conducted based on the AGA guidelines. Colonoscopies were performed within one year after surgery. Clinical data and risk factors for endoscopic recurrence were analyzed focusing on postoperative pharmacological prophylaxis. Results All patients were at a high risk of postoperative recurrence according to the AGA guidelines. PER occurred in 29 (28.7%) of these patients. The overall PER rate was 39.2% at one year. The PER rate in patients treated with nitroimidazole, thiopurines, infliximab, or a combination of thiopurines and infliximab for postoperative prophylaxis was 88.1%, 34.1%, 20.5%, and 0%, respectively. Cox regression showed that smoking at the time of surgery and AGA guideline adherence were independent factors associated with PER (HR: 3.75, 95% CI: 1.36-10.33, P = 0.01; HR: 0.36, 95% CI: 0.15-0.86, P = 0.02). In addition, further investigation revealed that educational background was the main factor related to patients' nonadherence to AGA guidelines. Conclusions The majority of CD patients who undergo surgery in clinical practice may be at a high risk of disease recurrence. Thiopurines and infliximab are effective in preventing endoscopic recurrence. Guideline nonadherence is associated with PER at one year, thus indicating that there is room for improvement in adherence to the AGA guidelines.

Epidemiology, Disposition, and Treatment of Ambulatory Veterans With Skin and Soft Tissue Infections.

Most skin and soft tissue infections (SSTIs) are managed in the outpatient setting, but data are lacking on treatment patterns outside the emergency department (ED). Available data suggest that there is poor adherence to SSTI treatment guidelines. We conducted a retrospective cohort study of Veterans diagnosed with SSTIs in the ED or outpatient clinics from 1 January 2005 through 30 June 2018. The incidence of SSTIs over time was modeled using Poisson regression using robust standard errors. Antibiotic selection and incision and drainage (I&D) were described and compared between ambulatory settings. Anti-methicillin-resistant Staphylococcus aureus (MRSA) antibiotic use was compared to SSTI treatment guidelines. There were 1 740 992 incident SSTIs in 1 156 725 patients during the study period. The incidence of SSTIs significantly decreased from 4.58 per 1000 patient-years in 2005 to 3.27 per 1000 patient-years in 2018 (P < .001). There were lower rates of β-lactam prescribing (32.5% vs 51.7%) in the ED compared to primary care (PC), and higher rates of anti-MRSA therapy (51.4% vs 35.1%) in the ED compared to PC. The I&D rate in the ED was 8.1% compared to 2.6% in PC. Antibiotic regimens without MRSA activity were prescribed in 24.9% of purulent SSTIs. Anti-MRSA antibiotics were prescribed in 40.1% of nonpurulent SSTIs. We found a decrease in the incidence of SSTIs in the outpatient setting over time. Treatment of SSTIs varied depending on the presenting ambulatory location. There is poor adherence to guidelines in regard to use of anti-MRSA therapies. Further study is needed to understand the impact of guideline nonadherence on patient outcomes.

Shockwave Lithotripsy Use in the State of Michigan: American Urological Association Guideline Adherence and Clinical Implications

To understand how treatment of patients with urinary stones by shockwave lithotripsy (SWL) aligns with current published practice guidelines. We used the Michigan Urologic Surgery Improvement Collaborative Reducing Operative Complications for Kidney Stones registry to understand SWL use in the state of Michigan. This prospectively maintained clinical registry includes data from community and academic urology practices and contains clinical and operative data for patients undergoing SWL and ureteroscopy (URS). We identified patients undergoing SWL from 2016 to 2019. In accordance with AUA guidelines, we evaluated practice patterns in relation to recommendations for treatment selection for SWL as well as clinical implications of guideline nonadherence. Four thousand, two hundred and nine SWL procedures performed across 34 practices were analyzed. Perioperative antibiotics were administered to 61.3% of patients undergoing SWL. A ureteral stent was placed at the time of SWL in 2.7% of patients. For lower pole renal stones >1 cm or large (>2 cm) renal stones in the registry, 32.2% and 58.9% of patients, respectively, underwent SWL, while the remainder were treated with URS. In these instances, SWL was associated with inferior stone-free rate (SFR) relative to URS. In patients with residual stones after SWL, 34.6% were treated with repeat SWL with lower SFR than those treated with subsequent URS. Postoperatively, 42.1% of patients were prescribed alpha-blockers with no benefit seen in terms of SFR. Substantial variation exists among urology practices with regard to SWL use. These data serve to inform quality improvement efforts regarding appropriateness criteria for SWL in Michigan.

63 The Incidence and Downstream Effect of Guideline Non-Adherence: The HEART Score in the Community Hospital Emergency Department Setting

Overutilization of hospital resources in low risk chest pain patients (LOWCPs) is a serious issue that has been addressed in multiple previous studies. It has been found that the implementation of accelerated diagnostic protocols for chest pain have shown substantial improvement in the utilization of health care resources. The development and subsequent validation of the history, electrocardiogram, age, risk factors, and troponin (HEART) score to identify ED chest pain patients who can safely be discharged without emergent provocative testing represents a potential breakthrough in the management of LOWCPs.

Adherence to guidelines for baseline staging in newly diagnosed localized breast cancer

Rationale, aims, and objectivesDifferent health agencies in Canada including Cancer Care Ontario (CCO) have developed guidelines for the baseline staging of newly diagnosed breast cancer patients but adherence to them is unknown. We sought to investigate adherence to CCO staging guidelines in a single cancer center in addition to the factors that influence this adherence. MethodA retrospective chart review was conducted on 212 newly diagnosed breast cancer patients between 2015 and 2017. Baseline patient demographic and disease characteristics as well as radiologic staging studies and subsequent treatments were recorded. The group of patients in whom the guidelines were observed was compared to the group of patients in whom the guidelines were not followed. ResultsStaging guidelines were not followed in 46.7% of the patients in the cohort (99 of 212 patients). In most cases, deviations from the guidelines consisted of performing more than the recommended baseline screening, most commonly in the form of a computerized tomography (CT) scan or a bone scan and chest x-ray (CXR)/ ultrasound (US) of the liver. Less commonly, a recommended staging evaluation was omitted or the suggested timing of the staging procedure (i.e., pre-operatively versus post-operatively) was not followed. Higher stage and grade of the disease and subsequent chemotherapy administration were associated with higher guideline non-adherence. ConclusionsLow adherence to staging guidelines for newly diagnosed breast cancer according to CCO is shown in a community cancer center. Incorporation of arising prognostic factors to staging procedure determination may increase acceptance and adherence to guidelines in the future.

Guideline Adherence and the Factors Associated with Better Care for Type 2 Diabetes Mellitus Patients in Lithuanian PHC: Diabetes Mellitus Guideline Adherence in Lithuania PHC

Background: Type 2 diabetes mellitus is one of the most common chronic conditions, which requires appropriate management and care at PHC level, which is described in guidelines. However, guideline adherence at the international arena is insufficient and little is known about the reasons for guideline non-adherence. Objective: The aim of the survey was to analyse to what extent the Lithuanian family practitioners adhere to diabetes guidelines in order to compare to international data and to discover the factors associated with better diabetes care. Methods: The present study is a part of EUPRIMECARE Project, which sets out to develop a framework aiming at the analysis of PHC across Europe. The sample strategy was based on an unequal probability sampling design. An audit of 4 public and 6 private PHC medical records of the year 2011 was carried out in Kaunas region, clinical records of 382 diabetes type 2 patients were reviewed. Demography, diseases and diabetes performance indicators data were collected using a uniform template. Binary and multivariable logistic regression analyses were used in the investigation of the factors related to better diabetes guideline adherence. Results: Three guideline adherence levels were identified: high performance (performed in more than 90% cases) - BP measurement and HbA1c exam; good performance (performed in more than 50% cases) - ECG examination and serum creatinine check; insufficient performance (performed in less than 50% of cases) - annual endocrinologist consultation, eye fundus and foot examinations, LDL check and BMI calculation. Insufficient glycaemic control was positive associated with increased endocrinologist consultation and foot exam rates, elevated BP demonstrated the positive effect to creatinine check rate, multimorbidity had positive association to the annual eye, ECG, creatinine check rates; frequent FP attendance showed no positive effect on process indicators. Rural patients have a negative association to foot and ECG exam rates compared to urban patients. In a stepwise logistic regression model, 3 dependent variables had statistically significant impact on overall diabetes care indicator performance: negative - rural location of patients (OR 0.4, 95% CI 0.2-0.8), elevated mean BP (OR 0.6, 95% CI 0.4-0.9); positive - multimorbidity (OR 2.0, 95% CI 1.2-3.4). Conclusion: Guideline adherence for T2DM is not optimal in Lithuanian PHC. The best are BP and HbA1c checks. Suboptimal are BMI and LDL annual checks. The situation with these is almost the same as in other European countries. The better guideline adherence has been observed in urban (foot exam, ECG exam), multimorbidity (eye, ECG, creatinine exams), controlled by means of BP patients (serum creatinine test).

Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors

Surgical management of appendiceal carcinoid tumors is heavily debated, despite National Comprehensive Cancer Network guidelines recommending aggressive resection of tumors >2 cm. We investigated national practice patterns and the predictors and impact of guideline non-adherence. The National Cancer Database was queried for cases of appendiceal carcinoids diagnosed from 2004 to 2015 treated with either appendectomy or hemicolectomy. Multivariable logistic regression, adjusted for demographic and clinical factors, identified associations with the procedure type among patients stratified by tumor size ≤2 cm and >2 cm. Cox Proportional Hazards then identified associations with overall survival among stratified patient groups. Of 3,198 cases of appendiceal carcinoids, 1,893 appendectomies and 1,305 hemicolectomies were identified. Contrary to National Comprehensive Cancer Network guidelines, 32.4% of tumors ≤2 cm were treated with hemicolectomy and 31.3% of tumors >2 cm were treated with definitive appendectomy. Hemicolectomy for small tumors was associated with age 65 years and older (odds ratio [OR] 2.4; 95% CI 1.7 to 3.3; reference group age 18 to 39 years), history of malignancy (OR 2.0; 95% CI 1.6 to 2.6), tumor size 1.1 to 2 cm (OR 2.8; 95% CI 2.3 to 3.4; reference group size ≤1 cm), and lymphovascular invasion (OR 2.2; 95% CI 1.6 to 3.2); appendectomy for large tumors was associated with age 65 years and older only (OR 2.2; 95% CI 1.1 to 4.2). Procedure type was not associated with survival for small or large tumors (hazard ratio 1.0; 95% CI 0.7 to 1.4 and hazard ratio 1.1; 95% CI 0.6 to 2.0, respectively). Despite well-known size-based treatment guidelines for appendiceal carcinoids, one-third of patients in the US undergo hemicolectomy for small tumors and appendectomy for large tumors. Guideline non-adherence, however, is not associated with overall survival. Reasons for these practice patterns should be explored, and guidelines revisited.

Variation in Guideline Implementation and Adherence Regarding Severe Traumatic Brain Injury Treatment: A CENTER-TBI Survey Study in Europe

Guidelines may reduce practice variation and optimize patient care. We aimed to study differences in guideline use in the management of traumatic brain injury (TBI) patients and analyze reasons for guideline non-adherence. As part of a prospective, observational, multicenter European cohort study, participants from 68 centers in 20 countries were asked to complete 72-item questionnaires regarding their management of severe TBI. Six questions with multiple sub-questions focused on guideline use and implementation. Questionnaires were completed by 65 centers. Of these, 49 (75%) reported use of the Brain Trauma Foundation guidelines for the medical management of TBI or related institutional protocols, 11 (17%) used no guidelines, and 5 used other guidelines (8%). Of 54 centers reporting use of any guidelines, 41 (75%) relied on written guidelines. Four centers of the 54 (7%) reported no formal implementation efforts. Structural attention to the guidelines during daily clinical rounds was reported by 21 centers (38%). The most often reported reasons for non-adherence were "every patient is unique" and the presence of extracranial injuries, both for centers that did and did not report the use of guidelines. There is substantial variability in the use and implementation of guidelines in neurotrauma centers in Europe. Further research is needed to strengthen the evidence underlying guidelines and to overcome implementation barriers.

Why do clinicians withhold anticoagulation in patients with atrial fibrillation and CHA2DS2-VASc score ≥ 2?

Current guidelines recommend oral anticoagulant (OAC) to prevent stroke and systemic embolism for atrial fibrillation (AF) patients at high thromboembolic (TE) risk (CHA2DS2-VASc score ≥ 2). Approximately 40% of eligible patients do not receive recommended OAC. The reasons for guideline non-adherence are unclear. To identify patient characteristics associated with non-use of OAC for AF despite CHA2DS2-VASc score ≥ 2. Patient characteristics associated with OAC in the GARFIELD-AF registry were assessed using logistic regression analysis [OR (95%)]. The rate of annual all-cause mortality, ischemic stroke or systemic embolism (SSE), and major bleeding (%/y) were compared between patients with and without OAC with a log-rank test. P -values < 0.05 were considered significant. Subsequently, a sample of European physicians was questioned through a web-based survey to identify factors that may influence their decision-making. Among 52,014 patients enrolled in GARFIELD-AF, 42471 (83%) had a CHA2DS2-VASc score ≥ 2 and 12,884 (30%) of them did not receive OAC. Use of antiplatelet therapy [OR = 15.0(14.1–15.8)] and a history of bleeding [OR = 2.5(2.2–3.0)] were the strongest predictors of withholding OAC, followed by no hypercholesterolemia [OR = 1.4(1.3–1.5)] and no vascular disease [OR = 1.5(1.4–1.6)]. Compared to patients with OAC, those without OAC had an increased annual all-cause mortality (5.3 vs 3.9%, P < 0.001) and SSE (1.6 vs 1.1%, P < 0.001), and a decreased in major bleeding (0.5 vs. 0.8%, P < <0.001). Table 1 shows the most frequently reported characteristics leading to a preference to withhold OAC among 266 survey respondents. Antiplatelet therapy and history of bleeding were the strongest predictors of OAC non-use in AF patients with high TE risk in GARFIELD-AF registry. Major/critical site bleeding and cirrhosis may also influence non-use of OAC by some physicians. Guideline-based treatment with OAC was associated with better outcomes.

Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors

Practice Patterns and Guideline Non-Adherence in Surgical Management of Appendiceal Carcinoid Tumors

Diagnostic test guidelines based on high-quality evidence had greater rates of adherence: a meta-epidemiological study

ObjectivesTo determine the association between the quality of guidelines for diagnostic tests (both the quality and reporting and the quality of the evidence underpinning recommendations) and nonadherence. Study Design and SettingWe conducted a meta-epidemiological study. We previously published a systematic review that quantified the percentage of test use that was nonadherent with guidelines. For the present study, we assessed these guidelines using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. We then assessed the quality of evidence underpinning recommendations within these guidelines using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Linear models were then constructed to determine the association between guideline nonadherence and (1) AGREE II score and (2) GRADE score. ResultsThere was no significant association between AGREE II score and nonadherent testing (P = 0.09). There was a significant association between GRADE score and nonadherence: recommendations based on low-quality and very low–quality evidence had 38% (P < 0.01) and 24% (P = 0.02) more nonadherent testing, compared with recommendations based on high-quality evidence. ConclusionDiagnostic test guideline recommendations based on high-quality evidence are adhered to more frequently.

Adherence to a COPD treatment guideline among patients in Hong Kong.

BackgroundThis study aimed to assess the adherence rate of pharmacological treatment to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline published in 2011 and the prevalence of comorbidities among patients with COPD in Hong Kong (HK).MethodsPatients were recruited from five tertiary respiratory centers and followed up for 12 months. Data on baseline physiological, spirometric parameters, use of COPD medications and coexisting comorbidities were collected. The relationship between guideline adherence rate and subsequent COPD exacerbations was assessed.ResultsAltogether, 450 patients were recruited. The mean age was 73.7±8.5 years, and 92.2% of them were males. Approximately 95% of them were ever-smokers, and the mean post-bronchodilator (BD) forced expiratory volume in 1 second was 50.8%±21.7% predicted. The mean COPD Assessment Test and modified Medical Research Council Dyspnea Scale were 13.2±8.1 and 2.1±1.0, respectively. In all, five (1.1%), 164 (36.4%), eight (1.8%) and 273 (60.7%) patients belonged to COPD groups A, B, C and D, respectively. The guideline adherence rate for pharmacological treatment ranged from 47.7% to 58.1% in the three clinic visits over 12 months, with overprescription of inhaled corticosteroids (ICS) and underutilization of long-acting BDs in group B COPD patients. Guideline nonadherence was not associated with increased risk of exacerbation after adjustment of confounding variables. However, this study was not powered to assess a difference in exacerbations. In all, 80.9% of patients had at least one comorbidity.ConclusionA suboptimal adherence to GOLD guideline 2011, with overprescription of ICS, was identified. The commonly found comorbidities also aligned with the trend observed in other observational cohorts.

A Retrospective Study of Patient Factors That Indicate Provider Nonadherence to an Institutional Clostridium difficile Treatment Guideline

Background: Clostridium difficile infection (CDI) is treated most often with metronidazole or vancomycin. Both have been effective in treatment of mild to moderate infection. In more severe cases, vancomycin may be more effective. Objectives: The primary objectives were to quantify the severity of CDI and to describe overall adherence to the institutional CDI guideline. Secondary objectives were to assess factors associated with adherence to the guidelines. Methods: Retrospective analysis of the electronic medical record was used to evaluate adherence to institutional guidelines. Data collected included demographics and other factors potentially contributing to adherence: Charlson comorbidity index, severity of infection, recurrence, intensive care unit (ICU) admission, infectious diseases (ID) consult, total duration and number of antibiotics, alternative therapies, and acid suppression. Descriptive statistics and bivariate analyses were used to describe and compare factors associated with guideline adherence; multivariate logistic regression assessed independent predictors of adherence. Results: A total of 387 patients met the inclusion criteria. CDI severity was 55.8% mild/moderate cases, 42.4% severe, 0.5% fulminant, and 1.3% prophylaxis. Overall, institutional guideline adherence was 51.9%. In bivariate analyses, 5 factors were associated with nonadherence to guidelines: older age, ICU admission, duration of antibiotics, mild/moderate and severe infection (all P < .05). In the logistic regression model, severe infection (P < .001) and longer duration of antibiotics (P < .05) were independently associated with guideline nonadherence. Conclusion: In this study, 42.4% of the patients met criteria for severe infection. Providers for patients with severe infection and longer duration of antibiotic therapy were less likely to adhere to the institutional guideline.

Effectiveness and usage of a decision support system to improve stroke prevention in general practice: A cluster randomized controlled trial.

BackgroundAdherence to guidelines pertaining to stroke prevention in patients with atrial fibrillation is poor. Decision support systems have shown promise in increasing guideline adherence.AimsTo improve guideline adherence with a non-obtrusive clinical decision support system integrated in the workflow. Secondly, we seek to capture reasons for guideline non-adherence.Design and settingA cluster randomized controlled trial in Dutch general practices.MethodA decision support system was developed that implemented properties positively associated with effectiveness: real-time, non-interruptive and based on data from electronic health records. Recommendations were based on the Dutch general practitioners guideline for atrial fibrillation that uses the CHA2DS2-VAsc for stroke risk stratification. Usage data and responses to the recommendations were logged. Effectiveness was measured as adherence to the guideline. We used a chi square to test for group differences and a mixed effects model to correct for clustering and baseline adherence.ResultsOur analyses included 781 patients. Usage of the system was low (5%) and declined over time. In total, 76 notifications received a response: 58% dismissal and 42% acceptance. At the end of the study, both groups had improved, by 8% and 5% respectively. There was no statistically significant difference between groups (Control: 50%, Intervention: 55% P = 0.23). Clustered analysis revealed similar results. Only one usable reasons for non-adherence was captured.ConclusionOur study could not demonstrate the effectiveness of a decision support system in general practice, which was likely due to lack of use. Our findings should be used to develop next generation decision support systems that are effective in the challenging setting of general practice.

Intravenous Immune Globulin Stewardship Program at a Tertiary Academic Medical Center.

In October 2010, a pharmacist-driven stewardship program was implemented at the Brigham and Women's Hospital to ensure continued adherence to the prescribing guideline, focusing on indications for intravenous immune globulin (IVIG) use and dosing per ideal body weight. The primary objective was to describe an IVIG stewardship program at a tertiary academic medical center. This was a prospective, observational study from January 2013 through December 2014. All patients ordered to receive IVIG during the defined study period were included. The intervention assessed describes a pharmacist-driven IVIG stewardship program for medication approval. The primary end point was guideline compliance based on indication, dose, dosing weight, and frequency. Secondary end points included the number of patients receiving IVIG, indications, orders discontinued as a result of guideline nonadherence, and total amount dispensed. A total of 418 patients were identified during the study time frame. The top indications were: hypogammaglobulinemia in bone marrow transplantation and hematological malignancy (50.7%), acute solid organ rejection (11.8%), and immune thrombocytopenia with bleeding (10.1%). In all, 12 patients (2.9%) received IVIG for an indication nonadherent with the IVIG prescribing guideline; 9 patients (2.2%) and 2 patients (0.5%), respectively, received a different dose or frequency per the prescribed indication; and 12 orders (2.9%) for indications nonadherent to the guideline were discontinued. A total of 26 033 g of IVIG were dispensed during the study period. An IVIG stewardship program, including an institution-specific prescribing guideline and a pharmacist-driven stewardship program, may ensure guideline compliance for appropriateness of indication and dose at an academic medical center.

PWE-120 Stricter Adherence to Surveillance Colonoscopy Guidelines for Colorectal Adenomas Could Result in Reduced Burden on Endoscopy Services

Introduction International guidelines recommend repeating surveillance colonoscopy in patients with colonic adenomas. We aimed to study local adherence to such guidelines. Methods Patients diagnosed with colonic adenomas between March and August 2008 were enrolled. Surveillance colonoscopy following adenoma removal was audited against the British Society of Gastroenterology guidelines: repeat in 5 years or no follow-up in low risk patients, repeat in 3 years in intermediate risk patients and repeat in 1 year in high risk patients. Results 165 patients (61.8% males; mean age 62.1) were risk stratified as per guidelines. 95 patients (57.6%) were low risk, 61 (37%) intermediate risk, and 9 (5.4%) high risk. In the low risk group, 43 patients (45%) had surveillance either ≥5 years or never and 52 (55%) had a shorter follow up. In the intermediate risk group, 9 (14.8%) patients had surveillance at 3 years, 28 (45.9%) patients before 3 years, 8 (13.1%) patients after 3 years and 16 (26.2%) patients had no follow up colonoscopy. In the high risk group, 5 (55.6%) patients had surveillance at 1 year, 1 (11.1%) patient before 1 year, 2 (22.2%) patients after 1 year and 1 (11.1%) patient had no follow up colonoscopy. 2 patients (1.2%) were diagnosed with interval colon cancer in the same year as the index colonoscopy. Conclusion Guideline non-adherence was noted in 65.5%, mainly due to too aggressive surveillance (49.1% early colonoscopies), increasing burden on endoscopy services. Late colonoscopies (6.1%) or no follow up colonoscopies (10.3%) were not the cause for interval cancers. Disclosure of Interest None Declared