Guidelines In Daily Practice Research Articles

Quality improvement in depression care in the Netherlands: the Depression Breakthrough Collaborative. A quality improvement report

Improving the healthcare for patients with depression is a priority health policy across the world. Roughly, two major problems can be identified in daily practice: (1) the content of care is often not completely consistent with recommendations in guidelines and (2) the organization of care is not always integrated and delivered by multidisciplinary teams. To describe the content and preliminary results of a quality improvement project in primary care, aiming at improving the uptake of clinical depression guidelines in daily practice as well as the collaboration between different mental health professionals. A Depression Breakthrough Collaborative was initiated from December 2006 until March 2008. The activities included the development and implementation of a stepped care depression model, a care pathway with two levels of treatment intensity: a first step treatment level for patients with non-severe depression (brief or mild depressive symptoms) and a second step level for patients with severe depression. Twelve months data were measured by the teams in terms of one outcome and several process indicators. Qualitative data were gathered by the national project team with a semi-structured questionnaire amongst the local team coordinators. Thirteen multidisciplinary teams participated in the project. In total 101 health professionals were involved, and 536 patients were diagnosed. Overall 356 patients (66%) were considered non-severely depressed and 180 (34%) patients showed severe symptoms. The mean percentage of non-severe patients treated according to the stepped care model was 78%, and 57% for the severely depressed patient group. The proportion of non-severely depressed patients receiving a first step treatment according to the stepped care model, improved during the project, this was not the case for the severely depressed patients. The teams were able to monitor depression symptoms to a reasonable extent during a period of 6 months. Within 3 months, 28% of monitored patients had recovered, meaning a Beck Depression Inventory (BDI) score of 10 and lower, and another 27% recovered between 3 and 6 months. A stepped care approach seems acceptable and feasible in primary care, introducing different levels of care for different patient groups. Future implementation projects should pay special attention to the quality of care for severely depressed patients. Although the Depression Breakthrough Collaborative introduced new treatment concepts in primary and specialty care, the change capacity of the method remains unclear. Thorough data gathering is needed to judge the real value of these intensive improvement projects.

Compliance to Consensus Recommendations, Surgeon's Experience, and Introduction of a Quality Assurance and Management Program

State-of-the-art surgical staging and adjuvant chemotherapy in early-stage ovarian carcinoma have an impact on patient's outcome, but compliance to guidelines and consensus recommendations is still poor. This article reports on our results before and after introduction of a quality assurance and management program in our clinic in 2001. Patients with ovarian carcinoma limited to the pelvis who underwent primary surgery in our hospital from 1997 to October 2007 were eligible for this study. Univariate and multivariate logistic regression analyses were performed to evaluate the impact of compliance with our management program and physician's experience in ovarian carcinoma surgery on achieving both standards of surgery and chemotherapy. In a total of 117 women, a significant impact on adherence to guideline-defined comprehensive surgical staging was found for poor Eastern Cooperative Oncology Group performance status (odds ratio [OR], 22.16; confidence interval [CI] 3.2-152.0; P = 0.002) and year of surgery before 2001 (OR, 47.60; CI, 9.20-245.22; P < 0.001). Tumor grading less than G3 (OR, 4.14; CI, 1.20-14.22; P = 0.02) was a statistically significant predictor for receiving standard adjuvant chemotherapy. Survival analyses showed a trend toward improved survival for patients having received guideline-adopted therapy, but event numbers were too low for adequate analyses. The introduction of a quality assurance program for treatment of ovarian carcinoma represents a major improvement of patient care. It led to a higher compliance with consensus recommendations and showed already a trend toward improved outcome. Further outcome research should focus on methods for implementation of guidelines in daily practice in institutions caring for patients with ovarian carcinoma.

Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries

The first and second EUROASPIRE surveys showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey was done in 2006-07 in 22 countries to see whether preventive cardiology had improved and if the Joint European Societies' recommendations on cardiovascular disease prevention are being followed in clinical practice. EUROASPIRE I, II, and III were designed as cross-sectional studies and included the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Consecutive patients (men and women </=70 years) were identified after coronary artery bypass graft or percutaneous coronary intervention, or a hospital admission with acute myocardial infarction or ischaemia, and were interviewed at least 6 months later. 3180 patients were interviewed in the first survey, 2975 in the second, and 2392 in the third. Overall, the proportion of patients who smoke has remained nearly the same (20.3% in EUROASPIRE I, 21.2% in II, and 18.2% in III; comparison of all surveys p=0.64), but the proportion of women smokers aged less than 50 years has increased. The frequency of obesity (body-mass index >/=30 kg/m(2)) increased from 25.0% in EUROASPIRE I, to 32.6% in II, and 38.0% in III (p=0.0006). The proportion of patients with raised blood pressure (>/=140/90 mm Hg in patients without diabetes or >/=130/80 mm Hg in patients with diabetes) was similar (58.1% in EUROASPIRE I, 58.3% in II, and 60.9% in III; p=0.49), whereas the proportion with raised total cholesterol (>/=4.5 mmol/L) decreased, from 94.5% in EUROASPIRE I to 76.7% in II, and 46.2% in III (p<0.0001). The frequency of self-reported diabetes mellitus increased, from 17.4%, to 20.1%, and 28.0% (p=0.004). These time trends show a compelling need for more effective lifestyle management of patients with coronary heart disease. Despite a substantial increase in antihypertensive and lipid-lowering drugs, blood pressure management remained unchanged, and almost half of all patients remain above the recommended lipid targets. To salvage the acutely ischaemic myocardium without addressing the underlying causes of the disease is futile; we need to invest in prevention.

Atopic eczema in children: clinical guidelines for daily practice

Atopic eczema in children: clinical guidelines for daily practice

Compliance to consensus recommendations, surgeon's experience and introduction of a quality assurance and management program. – Influence on therapy of early-stage ovarian carcinoma

State of the art surgical staging and adjuvant chemotherapy in early-stage ovarian carcinoma has an impact on patient's outcome, but compliance to guidelines and consensus recommendations is still poor. This study reports on our results before and after introduction of a quality assurance and management program in our clinic in 2001. Patients with ovarian carcinoma limited to the pelvis who underwent primary surgery in our hospital from 1997 to October 2007 were eligible for this study. Univariate and multivariate logistic regression analyses were performed to evaluate the impact of compliance with our management program and physician's experience in ovarian carcinoma surgery on achieving both standards of surgery and chemotherapy. In a total of 117 women a significant impact on adherence to guideline defined comprehensive surgical staging was found for poor ECOG performance status (OR 22.16; CI 3.2–152.0; p=0.002) and year of surgery before 2001 (OR 47.60; CI 9.20–245.22; p<0.001). Tumor grading < G3 (OR 4.14; CI: 1.20–14.22; p=0.02) was a statistically significant predictor for receiving standard adjuvant chemotherapy. Survival analyses showed a trend towards improved survival for patients having received guidelines adopted therapy, but event numbers were too low for adequate analyses. The introduction of a quality assurance program for treatment of ovarian carcinoma represents a major improvement of patient care. It led to a higher compliance with consensus recommendations and showed already a trend towards improved survival. Further outcome research should focus on methods for implementation of guidelines in daily practice in institutions caring for patients with ovarian carcinoma.

Metabolic monitoring in veterans with schizophrenia-related disorders and treated with second-generation antipsychotics: Findings from a Veterans Affairs–based population

ObjectivesTo describe the proportions of veterans living with schizophrenia-related disorders monitored for dyslipidemia and hyperglycemia and to investigate whether the likelihood of metabolic dysregulation monitoring was influenced by veterans’ sociodemographic characteristics, preswitch pharmacologic treatment, and monitoring before the switch from one second-generation antipsychotic (SGA) to another. DesignRetrospective, observational, descriptive study. SettingVeterans Affairs (VA) Healthcare System between October 1, 2001, and December 31, 2003. Patients1,826 veterans with schizophrenia-related disorders. InterventionVeterans who were dispensed two or more prescriptions for one of five SGAs (i.e., clozapine, olanzapine, quetiapine, risperidone, and ziprasidone) on the VA Healthcare System formulary were identified. Of these veterans, a subset that was switched from one SGA to another was identified. From this subset, veterans were identified who were on the first SGA continuously for at least 90 days before the index date and the new SGA for 180 or more days after. Finally, among these veterans, ICD-9 codes were used to identify veterans with a schizophrenia or schizoaffective disorder diagnosis (ICD-9 code 295.xx or 296). Main outcome measuresProportions of veterans with lipid (i.e., low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides) and blood glucose (i.e., fasting blood glucose [FBG], glycosylated hemoglobin [A1C]) laboratory results. ResultsNearly 39% of the veterans had at least one of three lipid fractions monitored 6 months or less before their SGA switch and 59% during the 12 months after. The corresponding proportions of veterans monitored were 57% and 80% for FBG and 19% and 31% for A1C. Pharmacologic agent for metabolic dysregulation, monitoring during the 6 months before the switch, and age 50 years or older were significant predictors of monitoring after the SGA switch for all three laboratory parameters. ConclusionThese findings serve as a benchmark for lipid and blood glucose monitoring among patients who switch SGA therapy. Veterans’ metabolic dysregulation was more likely to be monitored after SGA switch for those receiving pharmacologic treatment for metabolic dysregulation, monitored before the switch, and aged 50 years or older. Implementation of monitoring guidelines in daily practice is emphasized to ensure that individuals living with schizophrenia-related disorders and taking SGAs achieve optimal physical health.

Differences in nutritional care in pressure ulcer patients whether or not using nutritional guidelines

Objective Malnutrition, characterized by a loss of lean body mass, enhances the risk of pressure ulcers (PUs). Because the intrinsic risk factor nutritional status in PU development can be influenced by practitioners’ interventions, the use of clinical guidelines might be a satisfactory management approach. This study investigated the influence of using nutritional guidelines in daily practice on the actual nutritional care that PU (prone) patients receive, and barriers with regard to providing nutritional support were also explored. Methods A cross-sectional study was carried out in 1087 hospitals, nursing homes, and home care organizations in the Netherlands, Germany, and the United Kingdom. Because this study focused on comparing nutritional care in daily practice in PU (prone) patients using and not using nutritional guidelines, for the analyses two groups (health care organizations with and without guidelines) were identified. Differences between groups were tested using chi-square test and by analysis of variance. Results Respondents from 363 organizations participated in the study, of which 66.1% used nutritional guidelines for PU care in practice. Significant differences between organizations with nutritional guidelines versus organizations without guidelines were mostly on nutritional screening ( P = 0.001) and the extent of nutritional assessments that included significantly more weight history recalls, weight measurements, and body mass index measurements (all P < 0.05). The most important barrier to providing nutritional support for PU (prone) patients in both groups was knowledge and skills. Conclusion Using a nutritional guideline in PU care contributes to the amount of nutritional screening conducted in daily practice and to the content and extent of the assessment.

Treatment of chronic heart failure with carvedilol in daily practice: The SATELLITE survey experience

Background β-blockers are well established for treatment of chronic heart failure (CHF). However, the extent of implementation of trial results and guidelines in daily practice remains limited, and information regarding how patients feel is scarce. Methods In this prospective observational survey of 6 months duration, 531 physicians from 10 countries recruited 3748 β-blockers untreated patients with CHF. We assessed the efficacy, tolerability and achieved dosage of carvedilol. In addition, patients assessed their well-being 3 times: at baseline, after 3 and 6 months of treatment. Results Carvedilol was started in 3721 patients with CHF (median age 65 years, 60% men). NYHA class, clinical symptoms and signs, vital signs, 5-item well-being rating scale and visual analogue scale improved during the survey. Side effects, mostly fatigue, hypotension, and dizziness, were reported for 6.5% and 5% of patients at 3 and 6 months and carvedilol had to be discontinued in 63 patients. A total of 55 deaths (1.5%) and 520 hospitalisations in 466 patients (13%) were recorded. At 6 months the mean daily dose of carvedilol was 31 ± 11 mg; 25 mg/day was prescribed to 35% and 50 mg/day to 26% of patients. Conclusions Initiation and up-titration of carvedilol in ambulatory care patients with CHF is feasible and safe. Its efficacy and tolerability were at least as good as in clinical trials, while the amelioration of patients' well-being was significant despite sub-optimal dosing. An additional effort should be done by physicians to treat their patients with CHF in daily practice with the recommended β-blockers at optimal doses.

Guideline-based development of quality indicators for subfertility care

Internationally, several organizations have developed clinical guidelines for subfertility care to supply patients with the best possible care. However, to improve the implementation of such guidelines, we first need to gain insight into the application of clinical guidelines in daily practice. Valid quality indicators are necessary to estimate actual guideline adherence. However, none of the existing subfertility guideline programmes is accompanied by a satisfactory set of quality indicators. In this study, we develop a set of valid guideline-based quality indicators for subfertility care. A systematic RAND-modified Delphi method was used to develop a set of key recommendations based on 10 national Dutch subfertility guidelines, international literature and existing international indicators. Experts' opinions were used to appraise recommendations regarding specific criteria such as efficacy, level of health gain, applicability and potential for care improvement. A representative set of 39 key recommendations was selected from 303 initial recommendations. The recommendations covered two structural and 37 procedural aspects, the latter encompassing 'indications for treatment', 'diagnostic procedures', 'treatment procedures' and 'patient information'. This study describes the systematic, stepwise method used to develop 39 process and structure indicators that can be used to monitor subfertility care.

Impact of Hospital-Acquired Pneumonia (HAP) Guidelines on Outcome

In Brief Hospital-acquired pneumonia (HAP) associated with mechanical ventilation complicates the course of patients in the intensive care unit (ICU), prolongs hospital stay, and increases the risk of death. Despite extensive clinical experience with this disease, controversies still exist regarding epidemiologic patterns and optimal management strategies, including empiric antibiotic therapy. Empiric broad-spectrum treatment is commonly used based on the prevalence of local pathogens, their antibiotic sensitivity pattern, and on host factors. The seriousness of HAP and the varied and polymicrobial nature of the etiologic agents coupled with diagnostic problems led to the development of evidence-based guidelines for initial empiric treatment. Guidelines on HAP facilitates comprehension and the knowledge required for optimizing the management of this complex condition, allows the interpretation of the different recommendations included in the guidelines according to the level of evidence supporting each statement, offers homogeneous definitions of HAP and groups at risk, and favors decisions regarding adequate antimicrobial therapy. Protocolized treatment guidelines, however, should be adapted to local epidemiologic and microbiologic data, including markers of multiresistance, antimicrobial agents approved in each country, and antibiotics included in the protocols of individual hospitals or services. Implementation of guidelines on HAP in daily practice requires extensive institutional support, design of effective campaigns for the diffusion of guidelines to all professionals involved in the day-to-day care of these critically ill patients, and sufficient resources for the monitoring of adherence to guidelines and assessment of the impact of guidelines on indicators of the quality of care. This opinion paper presents the strengths and limitations of evidence-based guidelines for the management of hospital-acquired pneumonia (HAP) in critically ill patients. Results of a few studies in which the level of implementation of these recommendations has been assessed by comparing preguideline and postguideline data are evaluated. Some indicators that may be useful to quantify the impact of guidelines in daily practice are proposed.

Antithrombotic therapy for prevention of stroke in clinical practice in the ED

Objective The objective of this study was to analyze the emergency medicine department's practice of recommending anticoagulation medication for stroke prevention, its compliance with clinical guidelines, and the role of the emergency physician in recommending anticoagulation medication. We also determined the occurrence of thromboembolic events in patients with atrial fibrillation (AF) during a follow-up period of up to 8 months after their discharge from the ED. Materials and Methods Over a 6-month period, patients presenting to the ED with AF were registered using a predesigned 2-part questionnaire. The first part considered the management of the patients with AF at the ED; the second part evaluated data on patients who returned to the ED and their treatment follow-up, based on the drug supply registry. Results This study included 102 ED visits by patients with AF, of whom 38 were hospitalized and 64 were discharged. Thirty-six of the discharged patients required anticoagulation according to American College of Cardiology/American Heart Association Task Force on Practice Guidelines/European Society of Cardiology guidelines. Of these patients, 28 (78%) were recommended anticoagulation medication and 8 (25%) were not: 5 because of contraindications and 3 because of unknown reasons. No patient returned to the ED with a thromboembolic event during the 8-month follow-up period. Conclusion The prevalence of anticoagulation recommendation for stroke prevention and compliance with clinical guidelines were found to be greater than previously reported. Our data show that most of the patients with AF and risk factors for stroke were recommended anticoagulation medication. This study illustrates the importance of applying clinical guidelines in daily practice and integrating them into patients' medical files in the ED.

Osteoprotektive Medikation: sinnvolles Monitoring, wie lange therapieren?

The improved options for effective treatment of osteoporosis and the shift to treatment strategies based on each patient's absolute fracture risk raise new questions in daily clinical care. Which patient should have what osteoprotective therapy and when and for how long? What techniques can be used to assess the individual effects of novel therapeuties? Are the results yielded by these techniques affected by concomitant factors? What specific characteristics need to be taken account of in rheumatological clinics and how should we deal with these? What is the impact of patient compliance on the assessment of therapeutic effects? This review is intended to shed some light on these questions and on the new DVO guidelines in daily practice with reference to the ambulatory setting.

P-776: The search for an optimal stimulation protocol for intrauterine insemination (IUI): A Cochrane systematic review

Intrauterine insemination (IUI) combined with ovarian hyperstimulation (OH) has been proven an effective first-line treatment for subfertile couples but many different OH protocols using various drugs in various dosages have been compared with conflicting results, conclusions and guidelines for daily practice. For the first time all available evidence from randomized clinical trials (RCTs) comparing OH protocols for IUI has been collected and appraised following the guidelines of evidence based medicine as provided by the Cochrane collaboration. Cochrane systematic review using truly randomized clinical trials only. We performed an extensive search to detect all publications that described randomized trials comparing different OH protocols for IUI: We searched the Menstrual Disorders and Subfertility Group’s Central register of Controlled Trials (CENTRAL), the electronic databases of MEDLINE (1966 to present) and EMBASE (1980 to present). All trials were assessed by 2 independent reviewers for in-or exclusion and relevant data was extracted. Data was pooled into meta-analyses when appropriate. Pregnancy rate per couple was our primary outcome. Adverse outcomes such as multiple pregnancies and ovarian hyperstimulation syndrome (OHSS) were considered. 81 RCTs were found and 43 could be included in this review. Seven RCTs compared anti-estrogens with gonadotropins in an IUI program. After pooling a significant difference in favor of gonadotropins was found (OR 1.8, 95% CI 1.2 to 2.7). The number of multiple pregnancies per treatment modality did not differ significantly (OR 1.2 95% CI 0.3 to 5). Both the addition of a GnRH agonist (4 RCTs) as the addition of a GnRH antagonist (3 RCTs) did not show a significant difference in pregnancy rates compared to gonadotropins alone. However, GnRH antagonist showed a tendency to improve treatment outcome (OR 1.6 95% CI 0.9 to 2.8). The addition of a GnRH agonist resulted in significant higher multiple pregnancy rates (OR 4.5 95% CI 1.4 to 15). Furthermore, five RCTs compared aromatase-inhibitors with anti-estrogens. When pooling the results it showed no evidence of benefit using aromatase-inhibitors in IUI programs compared to anti-estrogens (OR 1.2 95% CI 0.6 to 2.1). Comparing 150 IU gonadotropins per day with 75 IU per day (2 RCTs) revealed no evidence of benefit using 150 IU gonadotropins per day (OR 1.2 95% CI 0.7 to 1.9). However, high dose gonadotropins resulted in significant more OHSS (OR 5.5 95% CI 1.9 to 17). Finally, 15 RCTs were included but did not provide the needed information about pregnancy rate per couple. This study demonstrates that gonadotropins are the most effective drugs for OH in IUI. Pregnancy rates with low dose gonadotropin protocols do not significantly differ from more aggressive stimulation protocols, but low dose gonadotropin protocols are associated with significantly fewer side effects. GnRH-agonists or aromatase-inhibitors do not improve treatment outcome. GnRH-antagonists show a tendency for higher pregnancy rates. In general, large cost-effectiveness trials using live birth rates as primary outcome are mandatory.

German ambulatory care physicians' perspectives on clinical guidelines – a national survey

BackgroundThere has been little systematic research about the extent to which German physicians accept or reject the concept and practice ofa) clinical practice guidelines (CPG) andb) evidence based medicine (EBM)The aim of this study was to investigate German office-based physicians' perspective on CPGs and EBM and their application in medical practice.MethodsStructured national telephone survey of ambulatory care physicians, four thematic blocks with 21 questions (5 point Likert scale). 511 office-based general practitioners and specialists. Main outcome measures were the application of Clinical Practice Guidelines in daily practice, preference for sources of guidelines and degree of knowledge and acceptance of EBM. In the data analysis Pearson's correlation coefficient was used for explorative analysis of correlations. The comparison of groups was performed by Student's t-test. Chi2 test was used to investigate distribution of two or more categorical variables.ResultsOf the total study population 55.3% of physicians reported already using guidelines in the treatment of patients. Physicians in group practices (GrP) as well as general practitioners (GP) agreed significantly more with the usefulness of guidelines as a basis for patient care than doctors in single practices (SP) or specialists (S) (Student's t-test mean GP 2.57, S 2.84, p < 0.01; mean GrP 2.55, SP 2.80, p < 0.05). 33.1% of the participants demonstrated a strong rejection to the application of guidelines in patient care. Acceptance of guidelines from a governmental institution was substantially lower than from physician networks or medical societies (36.2% vs. 53.4% vs. 62.0%). 73.8% of doctors interpret EBM as a combination of scientific research and individual medical knowledge; 80% regard EBM as the best basis for patient care.ConclusionDespite a majority of physicians accepting and applying CPGs a large group remains that is critical and opposed to the utilization of CPGs in daily practice and to the concept of EBM in general. Doctors in single practice and specialists appear to be more critical than physicians in group practices and GPs. Future research is needed to evaluate the willingness to acquire necessary knowledge and skills for the promotion and routine application of CPGs.

Urinary incontinence in the elderly: Attitudes and experiences of general practitioners

Objective. To assess general practitioners’ (GPs’) attitudes to urinary incontinence in elderly patients and their experiences in the application of the Dutch College of General Practitioners’ guideline in daily practice. Design. Two existed groups of six GPs working in villages and seven GPs working in urban practices. Method. Two focus-group discussions with recording of discussions and transcription. Transcripts were analysed by two independent researchers. Results. During the discussions three main themes of attitudes came forward: (1) therapeutic nihilism of GPs and low motivation of patients, (2): GPs experienced lack of time because of difficulties in explaining the therapy and because of impaired mobility of older patients, (3) because of the complexity of the problem and co-morbidity, GPs as well as patients were reluctant to treat the UI. The most remarkable findings in the application of the guideline were: (1) because of the barriers mentioned above, physical examination did not take place in spite of GPs’ conviction as to the benefit of it; (2) GPs’ knowledge of treatment options in the elderly with UI is substandard. Conclusion. Several patient (comorbidity, impaired mobility, low motivation, and acceptance of the problem) and GP factors (therapeutic nihilism, lack of time and knowledge) interfere with good management of UI in the elderly.

Ontwikkeling van richtlijnen

Guidelines are important in the policy of quality in health care. Since some decades scientific societies of family physicians, nursing home physicians and medical specialists are engaged in developing guidelines. At first development of guidelines was consensus-based and has been more and more evidence-based after the foundation of the Cochrane Collaboration. Patients and their representatives participate increasingly in development of guidelines. For appropriate use of guidelines in daily practice it is important to take into account expectable problems with implementation. Guidelines aren't strict dictates but they have juridical significance.

Physicians' liability in ophthalmology practice.

The aims of this paper are to point out the importance of coherence in established guidelines in daily practice, highlight the value of signed patient informed consent forms and stress the value of a good understanding of the law, while focusing on issues related to malpractice in ophthalmology. Search of the current relevant literature. The most common causes of medical litigation in ophthalmology are related to LASIK surgery, cataract surgery, glaucoma care, radial keratotomy for myopia reduction and failure to diagnose binocular vision anomalies in children and adults in a timely fashion. The litigation raised in most cases is driven by unfavourable outcomes and not by malpractice. Maintenance of high standards in daily practice, with continuous training and clear communication along with the appropriate documentation of any procedure carried out, may improve the professional safety of practising eye specialists in the event of medical litigation. Although the use of patient informed consent varies substantially among European countries, it may serve as useful evidence in the physician's defence.

Guideline adherence for the treatment of asthma in general practice is associated with a higher quality of life

Guidelines are intended to optimise the quality of patient care. While optimal therapy focuses on the patient, traditionally, assessment guidelines' effectiveness has focused on physicians. Little attention has been given to the effect of guidelines on patient outcomes such as mortality, morbidity or quality of life (QOL). In this study we compare QOL in asthma patients treated according to the 1997 NIH asthma guideline and those receiving non-guideline recommended treatment. We determined the asthma severity of 146 asthmatics during a clinical research appointment using a combination of symptom, lung function and medication use data. The appropriateness of each patient's medication regime was determined according to the NIH asthma guideline. QOL was assessed on a 7-point scale using the validated Asthma Quality of Life questionnaire (AQLQ). Patients treated according to the guideline had a higher QOL than patients with non-guideline treatment (5.7 vs. 5.3, p=0.019). After stratifying for asthma severity, a large clinically relevant difference in QOL (1.0) was observed for severity class 4 patients. Non-guideline treatment increased with asthma severity. We observed an association between non-guideline treatment and a lower QOL, particularly in the patients with severe asthma. QOL in severe patients was lower and these patients were less likely to be treated according to the guidelines than patients with mild or moderate asthma. Further studies are needed, especially among severe asthmatics, to determine if guideline recommended treatment is responsible for the observed increase in asthma related QOL observed in this work. For doctors, and other health care professionals this study emphasises the role of evidence-based guidelines in daily practice.

Implementing evidence in Finnish primary care. Use of electronic guidelines in daily practice

In Finland, electronic guidelines have provided general practitioners (GPs) with a source of up-to-date information at their fingertips since 1989. The Physician's Desk Reference and Database (PDRD) covers the majority of problems encountered in primary care with some 1000 articles. These are available in electronic format, updated every 4 months, and as a book published in a fully revised edition every 2 years. Physicians use these guidelines as a routine part of their daily work. They seek information for both common and rare health problems and use it to plan diagnostic strategies as well as treatment and follow-up. In nearly 90% of cases the doctor finds the information she needs from the guidelines. The electronic version is user friendly; typically the relevant article is found and read in 2 min. Patients find it reassuring when their doctor uses guidelines to select optimal treatment. Other Nordic countries are also producing several national guidelines, but Finland has so far the widest scope and longest experience in this area. An English version of the PDRD guidelines (Evidence-Based Medicine Guidelines) is available, and a Swedish-language version will be completed in 2002.

The Dutch consensus on the diabetic foot

In 1996 the Dutch Diabetes Federation installed a consensus committee to formulate practical guidelines for daily practice to prevent, diagnose and treat foot-related complications in patients with diabetes mellitus. A list of definitions was formulated. A new ulcer classification was introduced. Pathophysiology, diagnostic and therapeutic strategies were discussed with special attention for patients with a high risk foot and for prevention instruction. After several rounds of implementation the definite document was unanimously accepted in the fall of 1998.