Impact Of Clinical Practice Guidelines Research Articles

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments.

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

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

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

The Impact of Clinical Practice Guidelines on Preoperative Antibiotic Administration for Carpal Tunnel Release.

Background: In 2015, the American Association of Plastic Surgeons (AAPS) published a consensus statement against the routine use of preoperative antibiotic prophylaxis to prevent surgical site infection in clean hand surgery. The American Academy of Orthopaedic Surgeons (AAOS) similarly cited "insufficient evidence" in its Appropriate Use Criteria guidelines to support the use of antibiotics in carpal tunnel surgery. Nonetheless, its administration remains a common practice during clean hand surgery. We sought to evaluate the impact of the above guidelines on preoperative antibiotic administration. Methods: An institutional review board-approved retrospective chart review of consecutive patients with carpal tunnel syndrome treated with open carpal tunnel release (CTR) at our institution was performed in the 2 years before and after publication of AAPS/AAOS guidelines. Patient demographics and surgical outcomes were reviewed. Incidence of antibiotic administration, patient demographics, and surgeon factors were collected. Results: A total of 770 primary open CTR procedures were performed in the studied years. In 2013 and 2014, 83.9% of patients received preoperative antibiotics. In 2017 and 2018, 48.2% of patients received preoperative antibiotics. Of the variables analyzed, immunosuppression, history of diabetes, and poorly controlled diabetes (A1c > 7) were found to be statistically significant in its positive correlation to prophylactic preoperative antibiotic use. Diabetes was not associated with surgical site infections. Conclusion: Patients were more likely to receive preoperative antibiotics before the publication of the AAPS/AAOS clinical practice guidelines. Patients with diabetes regardless of their glycemic control are more likely to receive preoperative antibiotics.

Measuring the impact of clinical practice guidelines on infantile hemangioma referrals.

High-risk infantile hemangiomas may be associated with significant patient comorbidity. The American Academy of Pediatrics published clinical practice guidelines with recommendations to refer high-risk hemangiomas early. The results of this study suggest that these guidelines may have resulted in an earlier referral age of patients with high-risk IH to hemangioma specialists.

Systematic review and appraisal of clinical practice guidelines on pelvic organ prolapse using the AGREE II tool.

To systematically evaluate the content and quality of national and international clinical guidelines on pelvic organ prolapse (POP). We searched medical databases and organizations websites, to identify national and international guidelines on diagnosis and management of POP. Five authors independently assessed guidelines using the validated AGREE II tool. Its six domains include (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence. Eight guidelines met the inclusion criteria. Three hundred and thirteen different recommendations were identified. One hundred and ninety-nine recommendations were comparable across guidelines. Thirty-one recommendations were not supported by research evidence. Assessment by history and physical examination using the POP quantification system and consideration of imaging were recommendations featuring in all guidelines. Conservative treatment recommendations namely pelvic floor muscle training and vaginal pessaries were also found in all guidelines. Regarding surgical management, patient counseling, treating only symptomatic POP, consideration of apical fixation during surgical treatment, and use of biological or synthetic implants in recurrent cases were recommendations in all guidelines. Overall, the highest median scores were in the domains "scope and purpose" and "rigor of development". The lowest median score was for applicability (28.3%). Although the median score of "editorial independence" was high (85.4%), variability was also substantial (interquartile range: 12.5-100). We identified variations in quality and deficiencies in certain areas, especially "applicability" and "editorial independence." Improvements in these key domains may enhance the quality and clinical impact of clinical practice guidelines.

Impact of Clinical Practice Guidelines on Blood Glucose Test Strip Prescription Rates in Manitoba and Saskatchewan (Canada): An Interrupted Time-Series Analysis

ObjectivesOur aim in this study was to assess the impact of the Diabetes Canada Dissemination & Implementation strategy on population-level prescription rates of blood glucose test strips. MethodsWe extracted all diabetes-related drugs and test strip claims in Manitoba and Saskatchewan between January 1, 2000 and September 30, 2015 from the Canadian Institute for Health Information’s National Prescription Drug Utilization Information System. The primary outcome was the proportion of the cohort in each quarter who had been dispensed strips in accordance with the Diabetes Canada 2013 guidelines. We conducted an interrupted time-series analysis examining prescribing trends overall and by drug groups. ResultsThe overall average sample size per quarter was 57,576 (standard deviation [SD]=12,320) and 49,533 (SD=10,206) individuals; the average age was 62.1 (SD=0.3) and 63.8 (SD=0.3) years, and the average proportion of total beneficiaries in the sample was 12.7% (SD=1.9%) and 12.6% (SD=1.7%) for Manitoba and Saskatchewan, respectively. On average preintervention, 27.9% (SD=0.68%, Manitoba) and 31.9% (SD=0.73%, Saskatchewan) of the sampled patients used strips according to the guidelines. On average postintervention, 26.5% (SD=0.29%, Manitoba) and 30.6% (SD=0.53%, Saskatchewan) of the patients used strips according to the guidelines. None of the interrupted time-series models reached statistical significance (p values ranging from 0.44 to 0.98 for Manitoba and 0.13 to 0.81 for Saskatchewan, depending on drug group). ConclusionsThe guideline and its Dissemination & Implementation strategy did not change strip prescribing. Potential reasons include complexity of the recommendations, lack of penetrance to primary care physicians and/or disagreement with recommendations.

Impact of clinical practice guidelines for vacuum-assisted delivery on maternal and neonatal outcomes in Japan: A single-center observational study.

Practice guidelines for vacuum-assisted delivery in Japan were revised in 2014 to improve clinical safety. We aimed to determine the success rates of vacuum delivery before and after the release of the revised guidelines. This retrospective observational study included singleton deliveries at term gestation. Success rate of vacuum delivery, duration of extraction, number of tractions and maternal and neonatal injuries were compared between 2011-2014 and 2015-2019. Vacuum extraction was attempted in 249 (15%) of 1657 deliveries. Duration of extraction was shorter in 2015-2019 (median, 3.0 min; interquartile range [IQR], 1.0-5.8 min) than in 2011-2014 (median, 4.0 min; IQR, 2.0-6.5 min; P = 0.0045). No significant differences were seen in success of vacuum extraction (98%), prolonged (>20 min) duration of extraction (1.5%) and repeated (>5 pulls) tractions (3.1%) in vacuum deliveries during 2011-2014, compared to success of vacuum extraction (94%), prolonged duration of extraction (1.6%) and repeated tractions (1.1%) in those during 2015-2019. Likewise, no significant differences were identified in maternal or neonatal injuries. Successful vacuum-assisted deliveries and shortened duration of extraction were still confirmed after guideline revision. However, because of consistent safe practice with vacuum delivery from before the revision, improvements in maternal and neonatal injuries were not observed.

A Bibliometric Analysis of Neurosurgical Practice Guidelines.

In the last 20 yr, the rate of neurosurgical guideline publication has increased. However, despite the higher volume and increasing emphasis on quality there remains no reliable means of measuring the overall impact of clinical practice guidelines (CPGs). To utilize citation analysis to evaluate the dispersion of neurosurgical CPGs. A list of neurosurgical guidelines was compiled by performing electronic searches using the Scopus (Elsevier, Amsterdam, Netherlands) and National Guideline Clearinghouse databases. The Scopus database was queried to obtain current publication and citation data for all included documents and categorized based upon recognized neurosurgical specialties. The h-index, R-index, h2-index, i10-index, and dissemination index (D-Index) were manually calculated for each subspecialty. After applying screening criteria the search yielded 372 neurosurgical CPGs, which were included for bibliometric analysis. The overall calculated h-index for neurosurgery was 56. When broken down by subspecialty trauma/critical care had the highest value at 35, followed by spine and peripheral nerve at 30, cerebrovascular at 28, tumor at 16, pediatrics at 14, miscellaneous at 11, and functional/stereotactic/pain at 6. Cerebrovascular neurosurgery was noted to have the highest D-Index at 3.4. A comprehensive framework is useful for guideline impact analysis. Bibliometric data provides a novel and adequate means of evaluating the successful dissemination of neurosurgical guidelines. There remains a paucity of data regarding implementation and clinical outcomes of individual guidelines.

Clinical guidelines and patient related outcomes: summary of evidence and recommendations

Purpose Good medical practice, evidence-based medicine (EBM) and clinical practice guidelines (CPG) have been recurring subjects in the scientific literature. EBM advocates argue that good medical practice should be guided by evidence-based CPG. On the other hand, critical authors of EBM methodology argue that various interests undermine the quality of evidence and reliability of CPG recommendations. The purpose of this paper is to evaluate patient related outcomes of CPG implementation, in light of EBM critics. Design/methodology/approach The authors opted for a rapid literature review. Findings There are few studies evaluating the effectiveness of CPG in patient-related outcomes. The systematic reviews found are not conclusive, although they suggest a positive impact of CPGs in relevant outcomes. Research limitations/implications This work was not a systematic review of literature, which is its main limitation. On the other hand, arguments from EBM and CPG critics were considered, and thus it can enlighten health institutions to recognize the caveats and to establish policies toward care improvement. Originality/value The paper is the first of its kind to discuss, based on the published literature, next steps toward better health practice, while acknowledging the caveats of this process.

1309. The Impact of Clinical Practice Guideline Using Educational Intervention for Improvement of Diabetic Foot Infections Treatment Outcomes

BackgroundDiabetic foot infections (DFIs) are important cause of lower-extremity amputation. The inappropriate empirical antimicrobial therapy for DFI was associated with amputation. We created the Clinical Practice Guideline (CPG) of empirical antimicrobial (ATB) therapy for in-patients with DFIs. The primary outcome of present study was to evaluate the intervention using educate and training the surgeons to adhere with CPG. The secondary outcome was the decreasing of unfavorable outcome (amputations).MethodsA prospective study of CPG implementation for treatment in adult in-patients who had DFIs was conducted at surgical and orthopedics wards. The CPG was developed by the investigator team based on the data from our previous study (submitted to publish). CPG was presented monthly to train the orthopedic and vascular surgeons for 1 year. The empirical ATB regimens were prescribed by the responsible surgeon who was trained to use CPG. Demographics data, wound characteristics, microbiological data, ATB therapy, and clinical outcome were recorded. The appropriate empirical ATB treatment was determined by investigators weather CPG matched or microbiological matched. The adherence to CPG, the appropriate empirical ATB, and the unfavorable outcome were analyzed. All data were reported by descriptive and inferential statistics.ResultsA total of 85 DFIs patients were enrolled. The patients received the appropriate empirical ATB matched to CPG and matched to microbiological data, were 87% and 67%, respectively. The unfavorable outcome was 26% while previously was 72.4% (submitted to publish data) before CPG implementation. The independent factors associated with unfavorable outcomes were (1) an inappropriate ATB and (2) infections with drug-resistant pathogens (adjusted relative ratio; aRR 2.98; 95% CI: 1.36–6.55, P = 0.007 and aRR 1.90; 95% CI: 1.05–3.43, P = 0.034, respectively).ConclusionThe current study demonstrated that mothly training of CPG resulting in the high adherence (87%) of CPG use and resulting in high rate of appropriate empirical ATB. Educational intervention insisted the responsible physician for administration the appropriate ATB with the improvement of unfavorable outcome in DFIs.Disclosures All authors: No reported disclosures.

The use and impact of clinical practice guidelines in interventional cardiology.

The use and impact of clinical practice guidelines in interventional cardiology.

OP144 Health Economics In Clinical Practice Guidelines: The Know-Do Gap

Introduction:Clinical practice guidelines (CPGs) are an ideal implementation mechanism for promoting effective clinical practice, but without due consideration of costs they may do more harm than good and become a source of inefficiency. The Alberta Guideline Adaptation Program sought current best practice for incorporating economic information into CPGs to better leverage health technology assessment (HTA) and health economic expertise in its guideline development program.Methods:A comprehensive, systematic review of published and grey literature was undertaken to: (i) catalogue theoretical frameworks and practical methods for incorporating economic information into CPGs and forecasting the post-implementation economic impact of CPGs; (ii) summarize current methods for evaluating the economic impact of CPGs; and, (iii) identify barriers and facilitators to incorporating economic information into CPGs.Results:Rigorous economic analyses were infrequently incorporated in CPG development. While a selection of guidance documents and CPG manuals published between 2001 and 2017 by leading CPG developers emphasized the health economist's role and the importance of incorporating economic evidence into CPGs, few provided adequate guidance on the best way to do this. There is no agreement on how best to monitor the economic impact of CPGs. Analysis of a sample of over 100 studies published between 2005 and 2013 identified the three main methods currently used to assess the post-implementation economic impact of CPGs: pre-test/post-test cost analyses, mapping studies, and modelled cost-effectiveness studies. The key elements of each study type were summarized and compared.Conclusions:The review highlighted the under-recognized know-do gap among developers with respect to using health economics information and expertise in CPG development. It identified the advantages and potential limitations of applying health economics to CPG development, as well as areas where developers can better utilize HTA researchers and health economists to improve the quality of guidelines and better document the resource implications and feasibility of the interventions they recommend.

An audit of referral and treatment patterns of high-risk prostate cancer patients in Alberta.

We aimed to determine the impact of clinical practice guidelines (CPG) on rates of radiation oncologist (RO) referral, androgen-deprivation therapy (ADT), radiation therapy (RT), and radical prostatectomy (RP) in patients with high-risk prostate cancer (HR-PCa). All men >18 years, diagnosed with PCa in 2005 and 2012 were identified from the Alberta Cancer Registry. Patient age, aggregated clinical risk group (ACRG) score, Gleason score (GS), pre-treatment prostate-specific antigen (PSA), RO referral, and treatment received were extracted from electronic medical records. Logistic regression modelling was used to examine associations between RO referral rates and relevant factors. HR-PCa was diagnosed in 261 of 1792 patients in 2005 and 435 of 2148 in 2012. Median age and ACRG scores were similar in both years (p>0.05). The rate of patients with PSA >20 were 67% and 57% in 2005 and 2012, respectively (p=0.004). GS ≤6 was found in 13% vs. 5% of patients, GS 7 in 27% vs. 24%, and GS ≥8 in 59% vs. 71% in 2005 and 2012, respectively (p<0.001). In 2005, RO referral rate was 68% compared to 56% in 2012 (p=0.001), use of RT + ADT was 53% compared to 32% (p<0.001), and RP rate was 9% vs. 17% (p=0.002). On regression analysis, older age, 2012 year of diagnosis and higher PSA were associated with decreased RO referral rates (odds ratios [OR] 0.49, 95% confidence interval [CI] 0.39-0.61; OR 0.51, 95% CI 0.34-0.76; and OR 0.64, 95% CI 0.39-0.61), respectively [p<0.001]). Since CPG creation in 2005, RO referral rates and ADT + RT use declined and RP rates increased, which demonstrates a need to improve adherence to CPG in the HR-PCa population.

Impact of the Centers for Disease Control's HIV Preexposure Prophylaxis Guidelines for Men Who Have Sex With Men in the United States.

Preexposure prophylaxis (PrEP) is effective for preventing human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) within trial settings. Population impact will depend on clinical indications for PrEP initiation, coverage levels, and drug adherence. No modeling studies have estimated the impact of clinical practice guidelines for PrEP issued by the Centers for Disease Control and Prevention (CDC). Mathematical models of HIV transmission among MSM were used to estimate the percentage of infections averted (PIA) and the number needed to treat (NNT) under behavioral indications of the CDC's PrEP guidelines. We modeled the contribution of these indications while varying treatment coverage and adherence. At 40% coverage of indicated MSM over the next decade, application of CDC guidelines would avert 1162 infections per 100 000 person-years, 33.0% of expected infections. The predicted NNT for the guidelines would be 25. Increasing coverage and adherence jointly raise the PIA, but reductions to the NNT were associated with better adherence only. Implementation of CDC PrEP guidelines would result in strong and sustained reductions in HIV incidence among MSM in the United States. The guidelines strike a good balance between epidemiological impact (PIA) and efficiency (NNT) at plausible scale-up levels. Adherence counseling could maximize public health investment in PrEP by decreasing the NNT.

Impact of Clinical Practice Guideline on the Treatment of Pediatric Femoral Fractures in a Pediatric Hospital.

Clinical practice guidelines are being developed for a number of topics in medicine to decrease practice variability and to improve evidenced-based care. Within orthopaedic surgery, the American Academy of Orthopaedic Surgeons (AAOS) has a dedicated committee that produces these clinical practice guidelines on a variety of issues. One such issue was the treatment of pediatric diaphyseal femoral fractures, with the clinical practice guideline being published in 2009. We performed a retrospective review of the treatment of pediatric diaphyseal femoral fractures at a single institution from 2007 to 2012 to assess the clinical impact of this clinical practice guideline on the treatment of this condition. A retrospective review of all patients treated at a single pediatric hospital between 2007 and 2012 for a pediatric diaphyseal femoral fracture was conducted. The 2009 AAOS clinical practice guideline on the treatment of this condition was assessed and each patient record was analyzed to determine if the clinical practice guideline was followed, based on the age-specific recommendations. The percentage of treatment rendered adhering to the clinical practice guideline recommendations was compared in the pre-guideline group (prior to June 2009) and the post-guideline group (after June 2009). A total of 361 patients were treated for a diaphyseal femoral fracture during this time frame and were included in this study. Overall, little change in treatment was found following the publication of this clinical practice guideline. The only significant change noted over this time period was a decrease (p = 0.03) in the percentage of patients between the ages of five and eleven years who were treated with flexible nails, at odds with this specific clinical practice guideline recommendation. We found little direct clinical impact of the recently published AAOS clinical practice guideline on the treatment of pediatric diaphyseal femoral fractures. This analysis suggests an important role for clinical assessment after guideline publication to identify areas of potentially important future clinical research and to assess the utility of this guideline.

Impact of Clinical Practice Guideline'S on Medical Practice and Survival for Head and Neck Cancer Management in Fisrt Line Treatment (N = 1121 Patients)

Impact of Clinical Practice Guideline'S on Medical Practice and Survival for Head and Neck Cancer Management in Fisrt Line Treatment (N = 1121 Patients)

Snapshots of Diabetes Care in Canada

Snapshots of Diabetes Care in Canada

The Strategic Impact of Clinical Practice Guidelines in Nursing on the Managerial Function of Supervision

Clinical practice guidelines in nursing (CPG-N) are tools that allow the necessary knowledge that frequently remains specialist-internalised to be made explicit. These tools are a complement to risk adjustment systems (RAS), reinforcing their effectiveness and permitting a rationalisation of healthcare costs. This theoretical study defends the importance of building and using CPG-Ns as instruments to support the figure of the nursing supervisor in order to optimise the implementation of R&D and hospital quality strategies, enabling clinical excellence in nursing processes and cost-efficient reallocation of economic resources through their linear integration with SARs.

Inconsistencies in the development of the ESC Clinical Practice Guidelines for Heart Failure

The publication of the European Society of Cardiology (ESC) guidelines for the management of heart failure, in 2012 represented the latest and arguably the most comprehensive document to date summarising recommended treatment and diagnostic options for the care of heart failure patients. The impact of clinical practice guidelines is now so great that it is important to review the processes that underlie guideline development. The ESC guideline process is compared and contrasted to those of other guideline bodies. The ESC uses its own internal experts inclined to review source clinical trial data rather than published or commissioned meta-analyses and systematic reviews. Uncertainties exist in several areas, such as how are the scope of potential treatments to be reviewed chosen, if there is no call for proposals or external consultation?, Two illustrative discrepancies are highlighted i) the non-surgical MitraClip device for reducing mitral regurgitation is given the verbal equivalent of a Class IIb recommendation on the basis of 107 patients in an uncontrolled registry, whereas no drug is reviewed based on such data, and another device, the subject of 3 prospective randomised controlled trials, was not reviewed at all and ii) for Ivabradine the whole trial population was included in the recommendation, despite a subgroup not benefitting, whereas for CRT the sub-group not thought to benefit was excluded from the recommendation. We propose that more interaction is needed between ESC and stakeholders so each can better understand the processes for producing guidelines to improve some of these aspects.

Impact d’un protocole de soins sur l’incidence des infections liées aux cathéters veineux épicutanéocaves chez le prématuré

In our neonatal intensive care unit, the incidence density of infections related to central catheters, assessed retrospectively over 2 years, exceeded that described in the literature. To reduce this incidence density, clinical practice guidelines were implemented for the insertion and maintenance of central lines. The purpose of this study was to evaluate the impact of the protocol on the incidence density and the incidence rate of nosocomial bloodborne infections. This was a prospective study in a neonatal intensive care unit of the Fort-de-France University Hospital over 17 months, which included all premature infants with a central line. We studied the adherence to the protocol, possible complications related to the protocol, the characteristics of the population, the incidence rate, and the density of specific central catheter-related infections. There were 111 children, 122 catheters, and 2575 catheter days during period 1 and 101 children, 125 catheters, and 1631 catheter days during period 2. Gestational age and birth weight were significantly lower in period 2 (29.6±2.3 GW vs 27.3±1.9, P=0.001; 1239±379g vs 915±175g, P<0.001) and the catheterization duration differed between the 2 periods (20±11 days vs 13±6 days, P<0.0001). A trend for a lower incidence density of infection was observed in the second period (16 per 1000 catheter days vs 10 per 1000 catheter days, P=0.06). Although the 2 groups' baseline characteristics were different, this study suggests a positive impact of clinical practice guidelines for the insertion and maintenance of central venous catheters on the incidence of nosocomial infections related to central catheters.