Impact Of National Guidelines Research Articles

The impact of national guidelines on the diagnostics of sore throat in children

BackgroundThe Finnish treatment guidelines for sore throat were updated in June 2020. The aim of this study was to determine how the publication of these guidelines affected the treatment of pediatric patients, particularly through the use of the Centor criteria, C-reactive protein tests, and microbiological testing in the diagnosis of Group A β-hemolytic streptococci tonsillitis.MethodsWe conducted a retrospective single-center before-and-after cohort study in Finland from 2019 to 2022. We included all patients who visited the pediatric emergency department and were diagnosed with tonsillitis or pharyngitis.ResultsWe included 246 patients who were admitted before the guidelines were updated and 219 patients after. Only two patients in the after group had a Centor score reported in their patient records. Rapid antigen tests were administered to 231 patients (93.9%) before the update and 202 patients (92.2%) after (proportion difference of 1.7%, CI -3.0–6.6%). C-reactive protein was taken from 193 patients (78.5%) before the update and 189 patients (86.3%) after (proportion difference of 7.8%, CI 0.1–14.7%).ConclusionsCentor scores were not used as recommended in the guidelines and did not impact the use of microbiological or C-reactive protein testing. More education and examining the preconceptions of health care personnel is required to implement the updated treatment guidelines in clinical practice.

LIFECYCLE MAINTENANCE PRACTICES OF VERTICAL GREENERY SYSTEMS IN TROPICAL CLIMATES: A CASE STUDY OF KUALA LUMPUR

ABSTRACT A vertical green system (VGS) proposes numerous benefits, expanding from the principles of sustainable social, environmental and economic development, such as aesthetics, health and ecology. While extensive research exists on VGS in terms of benefits, application, plant selection and design, limited attention has been given to the operational and long-term lifecycle maintenance of VGS, particularly in tropical climates such as Malaysia. Therefore, this paper aims to explore current VGS maintenance practices and issues in the tropical climate of Malaysia. Qualitative analysis was employed to study maintenance practices in commercial and institutional buildings in Malaysia. The qualitative data was then compared with international green wall guidelines to benchmark with current maintenance practices in Malaysia. The study revealed that the absence of a green wall guideline in Malaysia has resulted in a reliance on a limited number of competent experts on green walls, potentially contributing to higher installation and maintenance costs. These findings provide valuable insights into the impact of national guidelines on green wall maintenance practices in Malaysia, assisting building managers and policymakers in formulating appropriate maintenance practices and guidelines.

The Evolving Pediatric HIV Epidemic in Rural Southern Zambia: The Beneficial Impact of Advances in Prevention and Treatment at a District Hospital From 2007 to 2019.

Remarkable progress has been made in expanding access to services addressing the pediatric HIV epidemic, including programs to prevent mother-to-child transmission, early diagnosis and treatment for children living with HIV. Few long-term data are available from rural sub-Saharan Africa to assess implementation and impact of national guidelines. Results from 3 cross-sectional studies and 1 cohort study conducted at Macha Hospital in Southern Province, Zambia from 2007 to 2019 were summarized. For infant diagnosis, maternal antiretroviral treatment, infant test results and turnaround times for results were evaluated by year. For pediatric HIV care, the number and age of children initiating care and treatment, and treatment outcomes within 12 months were evaluated by year. Receipt of maternal combination antiretroviral treatment increased from 51.6% in 2010-2012 to 93.4% in 2019, and the proportion of infants testing positive decreased from 12.4% to 4.0%. Turnaround times for results returning to clinic varied but were shorter when labs consistently used a text messaging system. The proportion of mothers receiving results was higher when a text message intervention was piloted. The number of children living with HIV enrolled into care and the proportion initiating treatment with severe immunosuppression and dying within 12 months decreased over time. These studies demonstrate the long-term beneficial impact of implementing a strong HIV prevention and treatment program. While expansion and decentralization brought challenges, the program succeeded in decreasing the rate of mother-to-child transmission and ensuring that children living with HIV benefit from access to life-saving treatment.

Impact of national guidelines on use of BRCA1/2 germline testing, risk management advice given to women with pathogenic BRCA1/2 variants and uptake of advice

BackgroundThis nationwide study assessed the impact of nationally agreed cancer genetics guidelines on use of BRCA1/2 germline testing, risk management advice given by health professionals to women with pathogenic BRCA1/2 variants and uptake of such advice by patients.MethodsClinic files of 883 women who had initial proband screens for BRCA1/2 pathogenic variants at 12 familial cancer clinics between July 2008–July 2009 (i.e. before guideline release), July 2010–July 2011 and July 2012–July 2013 (both after guideline release) were audited to determine reason given for genetic testing. Separately, the clinic files of 599 female carriers without a personal history of breast/ovarian cancer who underwent BRCA1/2 predictive genetic testing and received their results pre- and post-guideline were audited to ascertain the risk management advice given by health professionals. Carriers included in this audit were invited to participate in a telephone interview to assess uptake of advice, and 329 agreed to participate.ResultsThere were no significant changes in the percentages of tested patients meeting at least one published indication for genetic testing - 79, 77 and 78% of files met criteria before guideline, and two-, and four-years post-guideline, respectively (χ = 0.25, p = 0.88). Rates of documentation of post-test risk management advice as per guidelines increased significantly from pre- to post-guideline for 6/9 risk management strategies. The strategies with the highest compliance amongst carriers or awareness post-release of guidelines were annual magnetic resonance imaging plus mammography in women 30–50 years (97%) and annual mammography in women > 50 years (92%). Of women aged over 40 years, 41% had a risk-reducing bilateral mastectomy. Amongst women aged > 40 years, 75% had a risk-reducing salpingo-oophorectomy. Amongst women who had not had a risk-reducing bilateral mastectomy, only 6% took risk-reducing medication. Fear of side-effects was cited as the main reasons for not taking these medicines by 73% of women.ConclusionsGuidelines did not change the percentages of tested patients meeting genetic testing criteria but improved documentation of risk management advice by health professionals. Effective approaches to enhance compliance with guidelines are needed to improve risk management and quality of care.

Impact of national guidelines on the cesarean delivery rate in France: A 2010–2016 comparison using the Robson classification

ObjectiveFrench national guidelines on indications of pre-labor cesarean delivery and management of women with a previous cesarean delivery (CD) were published in 2012. Our aim was to assess if these guidelines have impacted the global CD rate in France and the CD rate in specific groups according to the Robson classification, using the national perinatal population-based surveys of 2010 and 2016. MethodsWomen included in the French National Perinatal Surveys in 2010 and 2016 were classified using maternal characteristics and obstetrical history in 12 groups according to Robson’s classification (N = 14176 in 2010 and N = 13057 in 2016). We estimated relative size, CD rate and contribution of each group to the global CD rate in 2010 and 2016. Then, we compared the 2 survey years. We analyzed the population characteristics, timing and indications of CD in the groups with significant changes between the two survey years. ResultsThe global CD rate was 20.5 % in 2010 and 19.5 % in 2016 (p = 0.027), with a lower pre-labor CD rate (10.9 % versus 9.2 %, p < 0.001). Despite an increasing of maternal age in 2016, we observed a decrease of the relative size of group 2b (nulliparous, singleton, cephalic, term, pre-labor CD): 1.1 % in 2010 versus 0.8 % in 2016 (p = 0.008). Group 5 (previous CD, singleton, cephalic, ≥37 weeks) was the higher contributor to the global CD rate in both 2010 and 2016 (contribution: 5.8 % of the 20.5 % CD rate and 5.4 % of the 19.5 % CD rate, respectively). Despite an increase of BMI in this group, its CD rate significantly decreased between the two years (61.2 % in 2010 versus 55.1 % in 2016, p = 0.001). ConclusionIn France, CD rates have decreased between 2010 and 2016, among women having a pre-labor CD and women with a previous CD, in accordance with national guidelines. National guidelines can help mode of delivery decision-making of physicians and impact the national CD rates.

The impact of national guidelines on EBM implementation in clinical practice: a comparison between the practices in two countries

Objective: To determine if the application of guidelines for obstetrical anal sphincter injuries (OASIS) management adopted by professional society in a country improves healthcare compared to a country where the guidelines are not adopted. Materials and Methods: In 2008 and 2016, a questionnaire was sent to every maternity ward in the Czech and Slovak Republics. In 2011, the guidelines for OASIS management were published in the Czech Republic. The authors compared the changes in the management of OASIS in both countries and evaluated the effect of the guidelines on healthcare improvement. Results: In 2008, the current Royal College of Obstetricians and Gynaecologists (RCOG) classification of OASIS was not used by any hospital in both countries. In 2016, the classification was used by 48.8% of hospitals in the Czech Republic and by 11.5% of hospitals in the Slovak Republic. The percentage of hospitals in the Czech Republic which used antibiotic prophylaxis while treating OASIS increased from 87.3% in 2008 to 100% in 2016. In the Slovak Republic, the percentage decreased from 85.7% to 73.1%. Active follow-up increased in the Czech Republic from 40% to 70.8%. In the Slovak Republic, it increased from 33.3% to 38.5%. In 2008, the management according to EBM was not performed by any of centres participating in the survey. In 2016, this percentage increased to 34.1% in the Czech Republic and to 3.8% in the Slovak Republic. Conclusion: The introduction of guidelines improved healthcare more significantly compared to the country where guidelines are not yet adopted.

The impact of national guidelines covering moving and handling of people on injury rates and related costs.

Objective National guidelines for moving and handling of people (MHP) were introduced in New Zealand in 2012 to reduce MHP-related injuries in the healthcare sector. This study assessed the effectiveness of this on MHP-related injury claims. Methods MHP-related injury claims were identified from the national injury claims database, which included 118 755 accepted claims for 2005-2016 across 14 industries. Interrupted time-series analysis was used to assess temporal changes in MHP-related claims rates, costs, and causes for the period before (2005-2012) and following (2013-2016) the introduction of the national guidelines. Results Prior to the introduction of the guidelines, MHP-related claims were estimated to be 39 209 (33.0% of all accepted injury claims), with claims rates and associated costs for the 14 industries decreasing by 0.4 [95% confidence interval (CI) -0.5‒ -0.2, P<0.001] and NZ$ 230 per claim (95% CI -324‒ -136, P=0.001) respectively. In the year following the introduction of the guidelines, there were no overall changes in claim rates or costs. However, significant increases in claim rates [ranging from 1.27-1.99 (P=0.004-0.010)] and claim costs [ranging from NZ$ 724-987 per claim (P=0.032-0.045)] were found 2-4 years later. More than 65% of all MHP-related claims were caused by lifting/carrying/strain, and there was a significant increase in claim numbers due to this cause, ranging from 431.7-594.0 (P=0.001-0.008) in the four years following the introduction of the guidelines. Conclusions The introduction of national MHP-guidelines in 2012 in New Zealand did not reduce MHP-related injury rates and costs. On the contrary, there were statistically significant increases 2-4 years after introduction of the guidelines.

NATIONAL TRENDS IN ADMISSIONS AND IN-HOSPITAL MORTALITY IN HEART FAILURE PATIENTS AND IMPACT OF THE ACC/AHA MANAGEMENT GUIDELINES: INSIGHT FROM THE NATIONAL INPATIENT SAMPLE (NIS)

Background: We sought to investigate the impact of national guidelines on outcomes among patients hospitalized with heart failure (HF). Methods: Age- and gender-standardized annual national estimates in HF admissions were calculated using data from the National Inpatient Sample and the U.S. Census

The impact of national guidelines on venom immunotherapy practice in the United Kingdom.

Venom immunotherapy (VIT) is the only effective treatment for prevention of further anaphylactic reactions to bee and wasp stings in allergic individuals. A previous national survey carried out in 2006/2007 revealed significant heterogeneity in UK practice 1. The British Society for Allergy and Clinical Immunology (BSACI) guidelines for the diagnosis and management of hymenoptera venom (HV) allergy were subsequently published in 2011 2 (Table 1). Table 1 Results of the VIT UK national surveys This repeat survey was carried out to assess whether publication of BSACI guidelines helped improve the diagnosis and management of HV allergy in the UK National Health Service (NHS).

Improvement of medical care in a cohort of newborns with sickle-cell disease in North Paris: impact of national guidelines.

We conducted a retrospective study on newborns with sickle-cell disease (SCD), born 1995-2009, followed in a multicentre hospital-based network. We assessed patient outcomes, medical care and compliance with the national guidelines published in December 2005. Data from 1033 patients (742 SS/Sβ°-thalassaemia) with 6776 patient-years of follow-up were analysed (mean age 7·1±3·9years). SCD-related deaths (n=13) occurred only in SS-genotype patients at a median age of 23·1months, mainly due to acute anaemia (n=5, including 2 acute splenic sequestrations) and infection (n=3). Treatment non-compliance was associated with a 10-fold higher risk of SCD-related death (P=0·01). Therapeutic intensification was provided for all stroke patients (n=12), almost all patients with abnormal transcranial Doppler (TCD) (n=76) or with >1acute chest syndrome/lifetime (n=64) and/or ≥3 severe vaso-occlusive crises/year (n=100). Only 2/3 of patients with baseline haemoglobin <70g/l received intensification, mainly for other severity criteria. Overall, hydroxycarbamide was under-prescribed, given to 2/3 of severe vaso-occlusive patients and 1/3 of severely anaemic patients. Nevertheless, introduction of the on-line guidelines was concomitant with an improvement in medical care in the 2006-2009 cohort with a trend towards increased survival at 5years, from 98·3% to 99·2%, significantly increased TCD coverage (P=0·004) and earlier initiation of intensification of therapy (P≤0·01).

Tu1064 Insurance Approval Patterns for IFN-Free Regimens in HCV: Impact of National Guidelines

Introduction: Patients infected with the hepatitis C virus (HCV) have long been awaiting interferon-free regimens. The possibility of using two Direct Acting Antivirals (DAAs) became a possibility in clinical practice in December 2013, albeit at a significant financial cost. Guidelines were released in part by the AASLD on January 30th, 2014 with specific treatment recommendations in various patient populations. Included in these recommendations was that patients who have received a liver transplant should be treated with 12 or 24 weeks of daily sofosbuvir and simeprevir. We examined approval patterns for DAAs and factors affecting patient access. Methods: This was an IRB approved retrospective review. Two hundred and forty-five consecutive patients whose prescriptions for IFN-free regiments submitted by the University of Miami Hepatology Faculty were included and 82 pending prescriptions were not included. Most patients (96%) were genotype 1a or 1b, and 66 were post-transplant. 86% of prescriptions were for 12 weeks of sofosbuvir and simeprevir, and the remainder was for sofosbuvir and ribavirin. Type of insurance was noted. Those who required foundation assistance were excluded from the analysis. Statistical analysis with parametric, non-parametric or multivariate analysis was performed using JMP SAS software. Results: 71% of prescriptions were filled at an estimated cost of $26,090,000. A prior authorization was submitted to every insurance company on each case. There was a significant change in the approval pattern after the release of the AASLD guidelines (80 vs. 64%, p= 0.0057). After this date, post-liver transplant patients were also significantly more likely to have an IFN-free regimen approved (90 vs. 69%, p=0.04). There was also significant variation by medical insurance company. Patients with Medicare or Medicaid were most likely to have their drug approved compared with private insurance (85 vs. 68%, p=0.01). Conclusions: National guidelines appear to affect insurance company approval process. Approval rates in liver transplant patients significantly increased after AASLD guidelines indicated that they should be treated with interferon-free regimens. Those with public insurance were most likely to be approved compared to private insurance. National societies need to continue to make specific recommendation for the benefit of patient care.

Impact of national guidelines on brachytherapy monotherapy practice patterns for prostate cancer

In 1999 and 2000, 2 national guidelines recommended brachytherapy monotherapy (BT) primarily for treatment of low-risk prostate cancer but not high-risk prostate cancer. This study examined rates of BT use before and after publication of these guidelines, as compared with 4 other treatment options. From 1990 to 2011, 8128 men with localized prostate cancer (≤ T3cN0M0) were treated definitively within the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry with 1 of 5 primary treatments: BT, external beam radiotherapy (EBRT), EBRT with androgen deprivation therapy, EBRT+BT, or radical prostatectomy. Men were categorized into low-, intermediate-, and high-risk groups based on the guidelines' risk-group definitions. Within each risk group, logistic regression was used to estimate odds ratios (OR) comparing BT with other treatment options between the 1990-1998 and 1999-2011 periods, adjusting for age, disease characteristics, and clinic type. In total, 1117 men received BT alone for low- (n = 658), intermediate- (n = 244), or high-risk disease (n = 215). BT comprised 6.1% of all treatments in 1990-1998 versus 16.6% in 1999-2011 (P < .01). The odds of BT use remained increased after adjusting for potential confounders (OR = 3.06; P < .001) and was seen among low- (OR = 4.52; P < .001), intermediate- (OR = 2.67; P < .001), and even high-risk groups (OR = 2.11; P < .001). National guidelines did not appear to influence practice patterns, as BT monotherapy use increased relative to other treatments from the 1990-1998 to 1999-2011 periods in unfavorable risk groups including men with high-risk prostate cancer.

Impact of national guidelines on reporting anaphylaxis during anaesthesia - an outcome audit

Anaphylaxis during anaesthesia is a rare and potentially fatal event. Adequate reporting and investigation of anaphylaxis associated with anaesthesia results in improved patient safety and outcomes. Guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) designed to improve this process were first issued in 1990 and updated in 1995, 2003 and 2008. In a setting where no formal guideline was previously in place, we compared the reporting and investigation of anaphylaxis in a large hospital before and after the introduction of the 2008 guideline. A retrospective outcome audit was conducted to compare data from 12 patients referred from April 2006 to May 2008 prior to release of the 2008 AAGBI guidance, with 53 patients referred from 2008 until April 2011. Data were collected using the AAGBI Anaphylaxis Referral Form. There was an increase in the number of referrals for suspected anaphylaxis following implementation of the AAGBI guidance. The clinical features observed in patients were consistent with previous studies. There was improved documentation of referral to local and national databases. Most cases resulted in cancellation of surgery, and there were no patient deaths. A substantial increase in the number of patients with amoxicillin allergy was noted in the second time period, which was linked to a change in the local perioperative antibiotic policy. Implementation of the AAGBI guidelines locally in a large hospital in 2008 resulted in an improved awareness of the importance of reporting and investigation of suspected anaphylaxis under anaesthesia. This tool was implemented coincidentally with the change in hospital antibiotic prophylaxis and enabled the cases detected to be accurately recorded and investigated. This led to a change in the hospital antibiotic policy for surgical prophylaxis. Implementation of structured guidance from a national anaesthesia organisation enhances recognition of the clinical features of anaphylaxis, increases number and completeness of referrals and more thorough immunological investigation, leading to improved patient safety during anaesthesia.

Impact of national guidelines on family history breast cancer surveillance

The breast cancer risk of women already under family history surveillance was accurately assessed according to national guidelines in an attempt to rationalize the service. Women attending two breast units in Glasgow between November 2003 and February 2005 were included. One thousand and five women under annual surveillance were assessed and had their relatives diagnoses verified. Four hundred and ninety-seven women were at significantly increased risk and eligible for follow-up. Five hundred and eight (50%) women attending were not eligible for family history surveillance, and 498 (98%) of these women accepted discharge. In conclusion, national guidelines have helped to more clearly define women who should undergo surveillance. This avoids unnecessary and potentially harmful routine investigations, and the service has been improved.

The impact of national guidelines on the waiting list for colonoscopy: a quantitative clinical audit

To assess the compliance of the surveillance colonoscopy waiting list with ACPGBI/BSG guidelines for colonoscopy follow-up and to measure the impact of adjusting referrals to be inline with the guidelines. This is a quantitative five-stage clinical audit cycle involving a large patient cohort from the Kent and Medway Cancer Network, which includes seven hospitals across four NHS Hospital Trusts and an estimated population of 1.8 million. 3020 patients were waiting for a surveillance colonoscopy. Their notes were reviewed and the indications for colonoscopy were compared with the ACPGBI/BSG 2002 guidelines. Those patients whose referral to the surveillance colonoscopy waiting list was not found to be compliant were adjusted to be inline with the guidelines. The impact of adjusting the surveillance colonoscopy waiting list on the diagnostic colonoscopy service was assessed by measuring the average waiting times for a colonoscopy before and after the intervention. Around 22% (n = 664) of surveillance colonoscopy referrals were inline with the guidelines, 51% (n = 1540) could be cancelled from the list and 27% (n = 816) could be given a new date. Implementing these recommendations reduced the average wait for a diagnostic colonoscopy from 76.8 to 56.0 days (P = 0.0022). Following guidelines for surveillance colonoscopy can reduce waiting times for diagnostic colonoscopy. This allows a faster patient journey for diagnostic colonoscopy and a uniform plan for duration and frequency of surveillance colonoscopy. However, this action promoted serious debate on the social, moral and ethical issues.

The impact of national guidelines for the prophylaxis of venous thromboembolism on the complications of arthroplasty of the lower limb

Sir, I read with interest the paper by Jameson et al[1][1] in the January 2010 issue entitled, ‘The impact of national guidelines for the prophylaxis of venous thromboembolism on the complications of arthroplasty of the lower limb’. In order to understand the political hot potato that is

Preoperative β-blocker use: impact of national guidelines on clinical practice

Study Objective To determine if recommendations regarding perioperative β-blocker therapy were followed by an increase in the number of eligible presurgical patients receiving β-blockers and the number achieving the recommended heart rate (HR <60 beats per minute [bpm]). Design Retrospective, observational study. Setting Tertiary-care teaching hospital. Measurements The records of all 718 patients who underwent elective vascular surgery or coronary artery bypass grafting between January 2001 and March 2002 (pre-guideline) and those who did so between April 2002 and September 2003 (post-guideline) were reviewed. Percentage of eligible patients who received β-blockers preoperatively and the target HR achieved in pre-guideline versus post-guideline patients were recorded. Differences were assessed using the unpaired t test and χ 2 analysis. A P value of less than 0.05 is reported. Main Results Fifty percent of the post-guideline patients in the vascular surgery group were receiving β-blockers at the time of preanesthetic evaluation versus 48% of pre-guideline patients ( P = nonsignificant [NS]). Mean HR in the vascular surgery post-guideline β-blocker group (70 ± 14 bpm) was higher than in the pre-guideline β-blocker group (65 ± 11 bpm) ( P < 0.01). Only 22% of those vascular surgery patients in the post-guideline group who were taking β-blockers achieved the target HR of less than 60 bpm versus 29% of the vascular surgery patients taking β-blockers in the pre-guideline group ( P = NS). In the coronary artery bypass grafting group, 80% of post-guideline patients received β-blocker before anesthesia assessment versus 75% of pre-guideline patients ( P = NS). Mean HR in the post-guideline β-blocker group (67 ± 15 bpm) was similar to the pre-guideline β-blocker group (64 ± 13 bpm) ( P = NS). Only 28% of the post-guideline patients who were receiving β-blockers achieved the target HR of less than 60 bpm, which was not significantly different from the 17% achieved in the pre-guideline group ( P = NS). Conclusion At our institution, preoperative β-blocker use was not significantly changed by publication of the recommendations.

Charting the possible impact of national guidelines on the management of rheumatoid arthritis

Objective: To identify temporal trends in the prescription of disease‐modifying antirheumatic drugs (DMARDs) in patients with early rheumatoid arthritis (RA).Methods: Using data from the Swedish RA register (n = 2584), we analysed the proportion of RA patients prescribed DMARDs at their first consultation between 1997 and 2001. Statistical process control (SPC) was used to chart and analyse major changes in prescription behaviour, while more traditional time series analysis methods (i.e. regression) were used to corroborate the nature of any trend.Results: The SPC method identified an upward shift in the prescription of DMARDs in July 1998 and a change in the process by October 1998. Time series analysis confirmed an increasing trend in DMARD prescription over the period as a whole and the trend was statistically significant (p⩽0.0001). Further analysis showed that the trend was driven by a single shift in the data in July 1998 (p⩽0.0095), and once this shift was accounted for, no remaining trends within the periods (i.e. before and after the jump) could be detected (p = 0.5934 and 0.7497, respectively).Conclusion: The formulation and promulgation of Swedish guidelines in 1998 may have influenced the prescription of DMARDs for this patient group. Prospectively analysing data derived from clinical registers in real time using SPC shows promise as a means to evaluate interventions designed to have an impact on a national level.

The impact of national guidelines on the assessment and management of acute paediatric asthma presenting at a tertiary children??s emergency department

Recent Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines have highlighted best practice for asthma management. This study examines asthma management in a paediatric emergency setting before and after the publication of these guidelines. To assess the impact of Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines on asthma management. Retrospective review of patient notes over two equivalent 2-month periods in 2002 and 2003. Main outcomes were documentation of clinical history, examination, investigation, treatment and discharge; and also the use of various treatment modalities in each case. One hundred and sixty-four children presented with asthma, 100 in 2002 and 64 in 2003. Documentation was adequate throughout, though better when nursing staff were responsible. Completeness of documentation was not related to seniority or discipline of medical staff. Measurement of peak flow was poor in both years. The 'doubling up' of inhaled steroid dose for acute episodes was the only aspect of management affected by publication of the guidelines, with significantly fewer patients receiving this in 2003 (P<0.0001). Documentation within the centre is good but has potential for improvement. Guidelines have not impacted on this except when explicit statements are made regarding treatment.

Impact of national guidelines about the management of colorectal cancer on Australian surgeons' awareness of evidence: a pre/post survey

To evaluate the immediate impact of national evidence-based guidelines about colorectal cancer on Australian surgeons' self-reported practice and their deficits in awareness of scientific evidence underpinning clinical management practices. Pre/post evaluation, comprising preguidelines survey (November 1998) and postguidelines survey (February 2001). One hundred and fourteen Australian surgeons returned postguidelines surveys, of whom 103 (90%) agreed to matching of their pre- and postguidelines responses. National distribution of the CRC guidelines occurred in November 1999. Over the ensuing year, dissemination strategies included seminars, presentations at conferences and journal articles. The main outcome measures used were changes in awareness of evidence for each of 23 clinical recommendations, changes in overall awareness score (maximum possible 23), changes in subscore for nine items for which evidence was compelling and predictors of change. Of those surgeons followed up, 95% were aware of the guidelines and 32% had read them in detail. Only 47% recalled the consumer version. The three most highly rated topics in the guidelines were: high-risk familial syndromes (45%); screening based on family history of colorectal cancer (40%); population screening for colorectal cancer (25%). Compared with baseline, there was a modest improvement in the mean overall awareness score (P = 0.02). Paired analyses of awareness of the evidence for each of 23 individual topics revealed significant improvement only in five. For two, awareness significantly decreased. Our pre/post findings are not inconsistent with the expectation that dissemination of the CRC guidelines has had some short-term impact. However, definitive evidence acquired through more rigorously designed controlled trials will be needed to determine first, whether surgical practice has changed and, second, whether implementation of the CRC guidelines or some other secular event caused such change.