Impact Of Clinical Guidelines Research Articles

Impact of Clinical Guidelines on Hospital Utilization in Children With Croup.

To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission. Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year. Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant. Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.

What is the impact of clinical guidelines on imaging costs?

Inappropriate and irrational use of numerous advanced diagnostic imaging technologies has recently been highlighted in many countries and has gathered the attention of policymakers. This matter has not only increased health costs in countries but also resulted in adverse health results. Various factors are involved in the inappropriate or unnecessary use of advanced medical imaging techniques including patient-related, physician-related, technological, and ultimately radiologist-related factors. This calls for the provision of new guidelines by policymakers to encourage all service providers to make appropriate use of such techniques. One of the main approaches in this regard is the application of clinical guidelines and decision support systems. The present study was a systematized review that conducted in January 2019, and the articles related to palliative care requirements on databases of Web of Science, PubMed, Scopus, ScienceDirect, Ovid, ProQuest, Wiley, and Google Scholar from January 1, 2009, to January 20, 2019, were searched. Strategy for searching and selecting the articles was Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Overview of the studies shows that various reasons for the overuse of diagnostic imaging technologies and effects of applying clinical guidelines on reducing diagnostic costs of treatment are investigated in this article with respect to various aspects and viewpoints. Clinical guidelines can be significantly effective in evaluating suitability and quality of referrals for diagnostic imaging, if only adapted properly.

Seizure Prophylaxis Following Moderate to Severe Traumatic Brain Injury: Retrospective Investigation of Clinical Practice and the Impact of Clinical Guidelines.

BackgroundPost-traumatic seizure (PTS) is a major complication of traumatic brain injury (TBI). However, there has been controversy in the literature regarding whether anticonvulsants should be used prophylactically to prevent it, and there is significant variability in practice. The objective of this study is to describe seizure prophylaxis practices after moderate to severe TBI and to determine whether the use of seizure prophylaxis increased following the recommendations of the Quebec Institut National d'Excellence en Santé et Services Sociaux and the Ontario Neurotrauma Foundation (INESSS-ONF) guidelines. This study will also compare the characteristics of patients who receive the recommended prophylaxis and those who do not.MethodsAll adult patients admitted to a level-1 trauma centre for moderate to severe TBI were eligible for this study (n = 96). Medical records including patient age, sex, Glasgow Coma Scale (GCS) score, mechanism of injury, and occurrence of PTS were reviewed in a retrospective manner regarding the administration of recommended seizure prophylaxis.ResultsThe proportion of patients receiving the recommended seizure prophylaxis was 8%. There was no significant increase after the release of the INESSS-ONF guidelines (p: 0.38). There were no significant differences in demographics, injury characteristics, or rates of early PTS between patients receiving the recommended prophylaxis and those not receiving it (p: >0.05).ConclusionThe results indicate that the use of the recommended seizure prophylaxis after moderate to severe TBI is low and that the release of the INESSS-ONF guidelines did not increase its use. Patient and injury factors do not appear to influence the use of seizure prophylaxis. These results highlight variability in seizure prophylaxis practices and the importance of understanding local practice patterns. Implementation strategies should be identified to increase adherence to the recommendations and improve patient care.

Impact of guidelines for the management of minor head injury on the utilization and diagnostic yield of CT over two decades, using natural language processing in a large dataset

ObjectivesWe investigated the impact of clinical guidelines for the management of minor head injury on utilization and diagnostic yield of head CT over two decades.MethodsRetrospective before-after study using multiple electronic health record data sources. Natural language processing algorithms were developed to rapidly extract indication, Glasgow Coma Scale, and CT outcome from clinical records, creating two datasets: one based on all head injury CTs from 1997 to 2009 (n = 9109), for which diagnostic yield of intracranial traumatic findings was calculated. The second dataset (2009–2014) used both CT reports and clinical notes from the emergency department, enabling selection of minor head injury patients (n = 4554) and calculation of both CT utilization and diagnostic yield. Additionally, we tested for significant changes in utilization and yield after guideline implementation in 2011, using chi-square statistics and logistic regression.ResultsThe yield was initially nearly 60%, but in a decreasing trend dropped below 20% when CT became routinely used for head trauma. Between 2009 and 2014, of 4554 minor head injury patients overall, 85.4% underwent head CT. After guideline implementation in 2011, CT utilization significantly increased from 81.6 to 87.6% (p = 7 × 10−7), while yield significantly decreased from 12.2 to 9.6% (p = 0.029).ConclusionsThe number of CTs performed for head trauma gradually increased over two decades, while the yield decreased. In 2011, despite implementation of a guideline aiming to improve selective use of CT in minor head injury, utilization significantly increased.Key Points• Over two decades, the number of head CTs performed for minor, moderate, and severe head injury gradually increased, while the diagnostic yield for intracranial findings showed a decreasing trend.• Despite the implementation of a guideline in 2011, aiming to improve selective use of CT in minor head injury, utilization significantly increased, while diagnostic yield significantly decreased.• Natural language processing is a valuable tool to monitor the utilization and diagnostic yield of imaging as a potential quality-of-care indicator.

Impact of Clinical Guidelines on Revisits After Ambulatory Pediatric Adenotonsillectomy.

Pediatric adenotonsillectomies are common and carry known risks of potentially severe complications. Complications that require a revisit, to either the emergency department or hospital readmission, increase costs and may be tied to lower reimbursements by federal programs. In 2011 and 2012, recommendations by pediatric and surgical organizations regarding selection of candidates for ambulatory procedures were issued. We hypothesized that guideline-associated changes in practice patterns would lower the odds of revisits. The primary objective of this study was to assess whether the odds of a complication-related revisit decreased after publication of guidelines after accounting for preintervention temporal trends and levels. The secondary objective was to determine whether temporal associations existed between guideline publication and characteristics of the ambulatory surgical population. This study employs an interrupted time series design to evaluate the longitudinal effects of clinical guidelines on revisits. The outcome was defined as revisits after ambulatory tonsillectomy for privately insured patients. Data were sourced from the Truven Health Analytics MarketScan database, 2008-2015. Revisits were defined by the most prevalent complication types: hemorrhage, dehydration, pain, nausea, respiratory problem, infection, and fever. Time periods were defined by surgeries before, between, and after guidelines publication. Unadjusted odds ratios estimated associations between revisits and clinical covariates. Multivariable logistic regression was used to estimate the impact of guidelines on revisits. Differences in revisit trends among pre-, peri-, and postguideline periods were tested using the Wald test. Results were statistically significant at P < .005. A total of 326,993 surgeries met study criteria. The absolute revisit rate increased over time, from 5.9% (95% confidence interval [CI], 5.8-6.0) to 6.7% (95% CI, 6.6-6.9). The proportion of young children declined slightly, from 6.4% to 5.9% (P < .001). The proportion of patients having a tonsillectomy in an ambulatory surgery center increased (16.5%-31%; P < .001), as did the prevalence of obstructive sleep apnea (7.0%-14.0%; P < .001) and sleep-disordered breathing (20.6%-35.0%; P < .001). In a multivariable logistic regression model adjusted for age, sex, comorbidities, and surgical location, odds of a revisit increased during the preguideline period (0.4% increase per month; 95% CI, 0.24%-0.54%; P < .001). This monthly increase did not continue after guidelines (P = .002). While odds of a postoperative revisit did not decline after guideline publication, there was a significant difference in trend between the pre- and postguideline periods. Changes in the ambulatory surgery population also suggest at least partial adherence to guidelines.

The impact of scientific evidence and price level of hypertension drug therapies on their market performance – A Europe based analysis

This study aims to investigate how much the market performance of drug therapies is influenced by their scientific evidence and price level. Compared to the seemingly simple objective, performing the analysis in the pharmaceutical industry makes the evaluation very complex. Examining the purchase decision process in the prescription drug market, besides the patient as the final consumer, the prescribing physician has the largest decision potential. In addition, the authors cannot ignore the healthcare system financing the therapy either, not to mention the interlacements of regulations, manufacturer interests, their marketing potential and marketing activities. This complexity makes it impossible to describe the pharmaceutical industry in uniform terms. The literature search also confirms that the mentioned complexity makes it hard to draw unambiguous conclusions. In spite of that –with a positivistic approach- the authors live with the assumption that scientific evidence (better efficacy and safety profile) should be awarded on the market on the aggregate level. It is inevitable to clarify at the very beginning that the authors investigate active pharmaceutical ingredients (APIs) and not brands in the recent study. With all this in mind, their intention is to introduce a novel approach for the evaluation of the relationship between the product characteristics (clinical evidence of APIs) and their market performance. In order to examine the relationship the authors involved APIs that belong to the same indication group, having the same mechanism of action and which have been in the generic competition for years after their patent have expired. As a model they perform the analysis with antihypertensive drug therapies. The authors consider that it is possible to rank the active ingredients of drug therapies on the basis of their efficacy and safety, based on relevant clinical literature. The result of ranking serves as the starting point of the analysis. Unequivocally, the authors do not forget about the additional factors that significantly influence the market performance of APIs, but deliberately do not involve these factors in the recent analysis. These factors are the different reimbursement and funding policies, marketing activity of the manufacturers, country-of-origin effect, the impact of clinical guidelines and clinical literature, and their effect on each other. There is one exception, since the article partially deals with the influence of price level on the market performance. In contrast with the majority of the available literature, this study aims to explore the identifiable patterns by investigating the European pharmaceutical market on system-level.

The Impact of Clinical Guidelines on Prostate Cancer Screening Practices in a Population-Based Setting, 2000–2013

Background/Aims: Controversial clinical guidelines have recommended against widespread prostate-specific antigen (PSA) testing, despite evidence suggesting a benefit in certain populations. This study evaluates the impact of the publication of prostate cancer screening trial results in 2009 and changes to the U.S. Preventive Services Task Force (USPSTF) guidelines in 2012 on temporal trends in the use of PSA tests among men 40–80 years old, with follow-up through 2013.

Rehabilitation of Lower Limb Amputees in the VA Acute Setting: Impact of Clinical Guidelines

Rehabilitation of Lower Limb Amputees in the VA Acute Setting: Impact of Clinical Guidelines

Introduction to the supplement

Introduction to the supplement

232 Impact of clinical guidelines in France

Context and Objectives Clinical practice guidelines (CPGs) covering the perinatal period are published regularly by French College of Gynaecologists and Obstetricians as well as by the National Authority for Health. Nonetheless, assessment of the impact of these guidelines is not routinely considered in France. The objective of this work is to describe the trends in practices before and after CPGs are issued in France. Programme Between 1994 and 2005, Audipog received data from 209 public and private maternity units for a database covering 247 807 pregnancies. We constructed a random subsample for each year by including only the births occurring during a single month for each maternity ward. Our study analyzes therefore 103 141 pregnancies and 104 454 births. Because of the voluntary nature of participation in Audipog, its distribution of maternity units according to legal status and region differed from that of France as a whole, a difference that must be taken into account in the analysis. Eight sets of national CPGs were analysed in this study. Results The 1998 CPG had little impact, for the rate of infants weighing Discussion and Conclusion Practices were modified very little by CPGs, except for those concerning antenatal corticosteroid therapy, but practices often changed before the issuance of the guidelines. Research to determine how to optimise the dissemination of CPGs would be desirable. Contextes, objectifs Des recommandations de pratiques cliniques (RPC) sont regulierement publiees par le College des Gynecologues Obstetriciens Francais ainsi que par la Haute Autorite de Sante en perinatalite. Pour autant, l9etude de l9impact de ces recommandations n9est pas systematiquement envisage, en France. L9objectif de ce travail est de decrire l9evolution des pratiques avant et/ou apres la mise en place de RPC, en France. Porgramme L9Audipog a recu, entre 1994-2005, des donnees de 209 maternites publiques ou privees, conduisant a un fichier de 247807 grossesses. Nous avons constitue pour chaque annee, un sous echantillon, par tirage au sort, ne comprenant que 1es naissances survenues pendant un mois par maternite. Notre etude porte donc sur 103141 grossesses et sur 104454 naissances. La participation au Reseau etant volontaire, la distribution des maternites selon leur statut juridique et leur region differe de celle de la France entiere, ce qui necessite d9en tenir compte dans l9analyse. 8 RPC nationales ont ete retenues pour l9etude. Resultats La RPC de 1998, a eu peu d9impact puisque le taux des Discussion, conclusion Les pratiques ont ete peu modifiees par les RPC, en dehors de celle portant sur la corticotherapie antenatale, mais elles se modifient souvent avant celles-ci. Des recherches pour chercher a optimiser la diffusion des RPC sont souhaitables.

160 Impact of clinical guidelines on the reduction of episiotomies

160 Impact of clinical guidelines on the reduction of episiotomies

A decision-tree model to estimate the impact on cost-effectiveness of a venous thromboembolism prophylaxis guideline

Background and objective:The impact of clinical guidelines (GL) on venous thromboembolism (VTE) prophylaxis was evaluated in a large Italian hospital with a before/after study. GL were effective in increasing the...

Factors affecting the uptake of new medicines in secondary care a literature review

The rate of uptake of new medicines in the UK is slower than in many other OECD countries. The majority of new medicines are introduced initially in secondary care and prescribed by specialists. However, the reasons for relatively low precribing levels are poorly understood. This review explores the determinants of uptake of new medicines in secondary care. Nine electronic databases were searched covering the period 1992-2006. Once the searches had been run, records were downloaded and those which evaluated uptake of new medicines in secondary care were identified. UK studies were of primary interest, although research conducted in other countries was also reviewed if relevant. With the exception of 'think pieces', eligibility was not limited by study design. Studies published in languages other than English were excluded from the review. Determinants of uptake in secondary care were classified using Bonair and Persson's typology for determinants of the diffusion of innovation. Almost 1400 records were screened for eligibility, and 29 studies were included in the review. Prescribing of new medicines in secondary care was found to be subject to a number of interacting influences. The support structures which exist within secondary care facilitate access to other colleagues and shape prescribing practices. Clinical trial investigators and physicians who sit on decision-making bodies such as Drug and Therapeutic Committees (DTCs) appear to have a special influence due to their proximity to their research and understanding of evidence base. Pharmaceutical representatives may also influence prescribing decisions through funding of meetings and academic detailing, but clinicians are wary of potential bias. Little evidence on the influence of patients upon prescribing decisions was identified. The impact of clinical guidelines has been variable. Some guidelines have significantly increased the uptake of new medicines, but others have had little discernible impact despite extensive dissemination. However given the increasing influence of the National Institute for Health and Clinical Excellence, guidelines may become more important. The impact of financial prescribing incentives on secondary care prescribing is unclear. Although cost and budget may influence hospital prescribing of new drugs, they are of secondary importance to the safety and effectiveness profile of the medicine. If a drug has a novel mechanism of action, or belongs to a class with few alternatives, clinicians are more likely to consider it favourably as a prescribing option. Although price does not appear to be a primary factor behind prescribing decision-making, in secondary care there has long been a historical need for formal purchasing decisions through the DTC, which differentiates it from primary care. This, in addition to increasing pressures for cost-effectiveness within the NHS means that cost will appear more frequently on clinician consciousness. As a result, guidelines are more likely to be implemented using the strong professional networks in existence within secondary care, and although the influence of patients has not been addressed by the literature, they are likely to have an increasing input into the prescribing decision, given the importance of patient involvement in current UK policy.

Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia

Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia

Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia

To asses the impact of locally developed antimicrobial treatment guidelines in the initial empiric treatment of ICU patients with severe hospital-acquired pneumonia (HAP). Observational cohort study with pre-guideline and post-guideline data collection. A total of 48 pre-guideline patients with 56 episodes of severe HAP defined by the National Nosocomial Infections Surveillance (NNIS) compared with 58 guideline-treated (GUIDE) patients with 61 episodes of severe HAP. The two groups were similar in terms of mean (+/- SD) age (NNIS group, 67.7 +/- 9.6 years; GUIDE group, 68.0 +/- 11.5 years) and simplified acute physiology score (NNIS group, 12.9 +/- 3.9; GUIDE group, 12.6 +/- 3.1) at the HAP diagnosis, and the proportion of the most frequent isolates (ie, Pseudomonas and methicillin-resistant Staphylococcus aureus). There was wide variation in initial antibiotic use in NNIS-treated patients, with cefotaxime, ceftazidime, and piperacillin being the most common agents compared with all of the GUIDE patients who received an imipenem-cilastin-based regimen. Vancomycin use was similar in both groups. The GUIDE patients had a higher percentage of adequately treated patients (81% vs 46%, respectively; p < 0.01) with a lower mortality rate at 14 days (8% vs 23%, respectively; p = 0.03). A lower mortality rate was also noted at the end of 30 days and the end of hospitalization but was not statistically significant. Appropriate imipenem use (as defined by the guidelines) occurred in 74% of the cases, and there was no increase in the number of imipenem-resistant organisms isolated during the course of the study. These guidelines represent a successful implementation of a "deescalation" approach, because the recommended empiric therapy with broad-spectrum antibiotics was switched to therapy with narrower spectrum agents after 3 days. Based on our experience, this approach improves the adequacy of antibiotic treatment, with improvement in short-term survival and without increasing the emergence of resistant organisms.

How to increase the impact of clinical guidelines on medical practice

Clinical guidelines are not implemented in a simple linear way, their integration in clinical practice is an evolving process influenced by the doctor, the patient and society. Methodologically, it is not easy to evaluate definitively the impact of guidelines. The overall appraisal yields a pessimistic conclusion: in most cases, guidelines do not translate well enough into action (effect on physician behaviour) and are believed to express motivation rather than optimum care. To avoid an academic mirage, recommendations must be disseminated in ways that provide incentives for such action. Those to whom guidelines are directed must be remarkably receptive to, and already prepared to act on the message. There are some indications that the most successful strategy to change the behaviour of clinicians and general practitioners operates at a more local level, and with more careful targeting, than is feasible with a national or regional consensus exercise. In addition, a more forceful action plan and multi-pronged approach (e.g. including continuous medical education) is required.

The Impact of Clinical Guidelines on Oncology Care

The Impact of Clinical Guidelines on Oncology Care

General practitioners' management of low back pain: impact of clinical guidelines in a non-English-speaking country.

Cross-sectional. To evaluate the assessment of patients with low back pain by general practitioners (GPs) in a non-English-speaking country and to compare their behavior with AHCPR and CSAG clinical guidelines. The diffusion of clinical guidelines (and their everyday application by health care professionals) is a significant problem. Because most guidelines are developed in English, concerns over their diffusion are obviously greater in non-English-speaking countries. A questionnaire was sent to all the GPs in the province of Mantua, Italy (n = 318). The authors evaluated what examinations are routinely performed and what danger symptoms and signs prompt referral of patients. GPs indicated the frequency of their prescription of radiographs, computed tomography scans, magnetic resonance imaging, laboratory tests, and consultations. The findings were compared with a "gold standard": the AHCPR and CSAG clinical guidelines. The response rate was 68.2%. Only 28.0% of GPs perform all the tests considered important by the clinical guidelines, and 33.0% were aware of all the red flags. Correspondence with the clinical guideline recommendations ranged from 14.6% to 89.4%. There is a clear tendency to overprescribe examinations in acute cases, whereas in chronic cases underprescription is sometimes seen. In a non-English-speaking country the evaluation of low back pain by GPs does not reflect current recommendations, and the situation is seen to be worse than in English-speaking countries. Concerns over the diffusion of guidelines must therefore be considered greater in non-English-speaking countries, where thorough presentation to GPs of the existing "evidence-based" guidelines is to be recommended.

A national audit to monitor and promote the uptake of clinical guidelines on the management of diabetes in pregnancy.

Seeks to assess maternity care for women with Type 1 diabetes in relation to recommendations in a national clinical guideline using a criterion-based clinical audit. The audit covered all 22 consultant-led maternity units in Scotland, focusing on 268 completed pregnancies in women with Type 1 diabetes. Results are presented and discussed. Concludes that a national audit to monitor the impact of clinical guidelines proved feasible. Antenatal care is organised in line with guideline recommendations but there is lower provision of formal prepregnancy care. Pregnancy planning and periconceptual care fall short of recommendations but care during pregnancy is meticulous. Adverse pregnancy outcomes remain commoner than in non-diabetic pregnancies.

A review of research in the United Kingdom to evaluate the implementation of clinical guidelines in general practice.

An advisory group for the NHS research and development (R&D) programme recommended in 1993 that the impact of clinical guidelines at the interface between primary and secondary care should be a research priority area. In 1994, a systematic review of 91 published evaluations of implementing clinical guidelines identified only seven UK general practice studies. In this inquiry we aimed to determine the number of randomized studies of clinical guideline implementation in primary care being conducted in the UK in 1996 and to review the research designs. A national health research register was interrogated for all projects relating to clinical guidelines. The investigators were contacted to establish the nature of their project and to identify implementation studies that they knew to be going on elsewhere. Copies of protocols or briefing documents were obtained from the project teams for the identified studies. Thirteen randomized studies in general medical practice and one in general dental practice were identified. Guidelines were being introduced to aid diagnostic decision-making, prescribing practice or referral to hospital-based services. Eight strategies for promoting guideline adherence were being evaluated. Six studies proposed to conduct economic evaluations of the intervention packages. Twelve of the 14 studies were funded by the NHS R&D programme. Since there will be a considerable time delay before all 14 studies and a number of newer studies are fully reported, it seems imperative that information of the sort collected in this inquiry be made available, preferably in the National Research Register.