Implementation Of Clinical Practice Guidelines Research Articles

Abstract 2233: Limited adherence to clinical practice guidelines on fertility preservation for patients with early-onset cancer

Abstract Background: ASCO Clinical Practice Guidelines on fertility preservation (FP) recommend that healthcare providers discuss the possibility of infertility—including FP options—for cancer patients of reproductive-age as early as possible before treatment initiation. However, the evaluation of patient perceptions on provider adherence to these FP guidelines is largely undetermined. We sought to assess patient-reported provider adherence to FP guidelines for adults ages 18 to 49 years when diagnosed with a first primary cancer (early-onset). Patients and Methods: The Reproductive Health After Cancer Diagnosis and Treatment (REACT) Study is a patient-partnered study in cooperation with 23 community partners and patient advocates. Adults with a first primary early-onset cancer were recruited over an 8-week period (October to December 2021). Patient-reported provider adherence to FP guidelines, reproductive health history, sociodemographic, cancer and cancer impact questions were prospectively collected via patient questionnaire using a secure, web-based application. To examine the association of provider non-adherence with patient-level factors, logistic regression models were fitted to estimate odds ratios (OR) and 95% CI. Results: Among 647 patients diagnosed with early-onset cancer between 2006 and 2021 (mean [SD] age, 36.8 [7.8] years), a total of 376 (58.1%) reported that a healthcare professional involved in their cancer care did not discuss FP options before starting cancer treatment. Patients with thyroid, lung, ovarian and colorectal cancers reported the highest rates of provider non-adherence to FP guidelines (all ≥63% non-adherence). Females with cervical (OR 2.87, 95% CI: 1.11-7.41), colorectal (OR 2.05, 95% CI: 1.15-3.68), lung (OR 15.79, 95% CI:5.66-44.1) and ovarian (OR 10.90, 95% CI: 3.19-37.3) cancers, Hodgkin (OR 4.00, 95% CI: 1.15-13.98) and non-Hodgkin lymphoma (OR 4.65, 95% CI: 1.11-19.47) were more likely to report provider non-adherence to FP guidelines compared to breast cancer patients in models adjusted for diagnosis age and year, self-reported race/ethnicity, marital status and insurance coverage at cancer diagnosis. Similar patterns were observed for male patients with early-onset colorectal and lung cancers compared with testicular cancer patients. No overall or sex-specific associations were observed between patient-reported provider non-adherence and race/ethnicity, insurance coverage or diagnosis year. Conclusions: Nearly six of every 10 early-onset cancer patients reported that a healthcare professional involved in their cancer care did not discuss FP options prior to cancer treatment. The development of tailored, effective strategies for implementation of clinical practice guidelines on FP and delivery of concordant reproductive healthcare to a growing population of reproductive-age individuals with cancer is needed. Citation Format: Samantha R. Keller, Mark A. Lewis, Allison Rosen, Hyo K. Park, Rebecca Babyak, Jill Feldmann, Fei Ye, Rajiv Agarwal, Kristen K. Ciombor, Timothy M. Geiger, Cathy Eng, Michelle K. Roach, Digna R. Velez Edwards, Michele L. Cote, Richard Viskochil, Andreana N. Holowatyj. Limited adherence to clinical practice guidelines on fertility preservation for patients with early-onset cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2233.

The Outcomes, Barriers, and Facilitators of Implementing Clinical Practice Guidelines in Iran: A Comprehensive Review.

Clinical practice guideline (CPGs) are highly valuable in enhancing healthcare efficiency as they lead to the selection of the best medical methods and reduction of their costs. Nevertheless, implementing CPGs in practice can be quite challenging, as they require alterations at individual, organizational, and health system levels. Therefore, we aimed to identify the outcomes, barriers, and facilitators associated with CPG implementation. We conducted an extensive search using Web of Science, PubMed, Scopus, Embase, and various non-English databases to gather quantitative, qualitative, and review studies on the implementation of CPGs from Jan 1, 1990, to Dec 26, 2022. Our analysis focused on the outcomes, barriers, and facilitators of CPG implementation, which categorized into four groups: policy-making, health system and hospitals, professional experts, and clinical guidelines. After conducting a thorough review of 37 studies, the most significant outcomes were found to be reduced costs and enhanced quality of care. However, certain challenges, such as inadequate support, insufficient education, high work pressure, tight schedules, and a lack of unified and clear guidelines, hindered these improvements. To overcome these barriers, it is essential to prioritize effective leadership, improve work conditions, allocate necessary resources, create a structured framework for the guidelines, and simplify their content to fit the clinical circumstances. It is crucial to identify the outcomes and barriers associated with implementing CPGs to enhance professional performance, elevate the quality of care, and foster patient satisfaction. Developing effective strategies hinges on this awareness.

Using a theory-based, customized video game as an educational tool to improve physicians’ trauma triage decisions: study protocol for a randomized cluster trial

Background Transfer of severely injured patients to trauma centers, either directly from the field or after evaluation at non-trauma centers, reduces preventable morbidity and mortality. Failure to transfer these patients appropriately (i.e., under-triage) remains common, and occurs in part because physicians at non-trauma centers make diagnostic errors when evaluating the severity of patients’ injuries. We developed Night Shift, a theory-based adventure video game, to recalibrate physician heuristics (intuitive judgments) in trauma triage and established its efficacy in the laboratory. We plan a type 1 hybrid effectiveness-implementation trial to determine whether the game changes physician triage decisions in real-life and hypothesize that it will reduce the proportion of patients under-triaged.MethodsWe will recruit 800 physicians who work in the emergency departments (EDs) of non-trauma centers in the US and will randomize them to the game (intervention) or to usual education and training (control). We will ask those in the intervention group to play Night Shift for 2 h within 2 weeks of enrollment and again for 20 min at quarterly intervals. Those in the control group will receive only usual education (i.e., nothing supplemental). We will then assess physicians’ triage practices for older, severely injured adults in the 1-year following enrollment, using Medicare claims, and will compare under-triage (primary outcome), 30-day mortality and re-admissions, functional independence, and over-triage between the two groups. We will evaluate contextual factors influencing reach, adoption, implementation, and maintenance with interviews of a subset of trial participants (n = 20) and of other key decision makers (e.g., patients, first responders, administrators [n = 100]).DiscussionThe results of the trial will inform future efforts to improve the implementation of clinical practice guidelines in trauma triage and will provide deeper understanding of effective strategies to reduce diagnostic errors during time-sensitive decision making.Trial registrationClinicalTrials.gov; NCT06063434. Registered 26 September 2023.

Anti-NMDAR Encephalitis Clinical Practice Guideline: Improving Time to Diagnosis, Treatment, and Hospital Length of Stay.

A clinical practice guideline (CPG) was created to standardize evaluation and treatment for patients with suspected anti-methyl-d-aspartate receptor (NMDAR) autoimmune encephalitis (AE), the most common AE in children. The objective of this study was to evaluate the CPG effect on time to diagnosis, treatment, and hospital length of stay (LOS). Patients with an inpatient consult to pediatric rheumatology for AE during a 4-year period (period 2) after CPG implementation were identified. Data were extracted and compared with data over the preceding 4-year period (period 1). During period 1, fewer patients underwent diagnostic testing than during period 2 (34 vs 80). Number of patients diagnosed with AE did not differ from period 1 to that from period 2 (NMDAR AE 9 vs 8; seronegative AE 4 vs 5). The average time to diagnostic evaluation with lumbar puncture decreased from 5.4 to 1.5 days (p = 0.0082), and time to treatment decreased from 7.6 to 3.9 days (p = 0.018). LOS showed a trend toward improvement (40.4-29.2 days (p = 0.23)). Creation of a CPG for patients with suspected AE was associated with an improved time to diagnostic evaluation and treatment. With the CPG, more patients underwent AE testing, though total diagnoses remained the same.

Mortality in hypotensive combat casualties who require emergent laparotomy in the forward deployed environment

IntroductionMortality rates among hypotensive civilian patients requiring emergent laparotomy exceed 40%. Damage control (DCR) principles were incorporated into the military's Clinical Practice Guidelines (CPG) in 2008. We examined combat casualties requiring emergent laparotomy to characterize how mortality rates compare to hypotensive civilian trauma patients. MethodsThe DoD Trauma Registry (2004–2020) was queried for adults who underwent combat laparotomy. Patients who were hypotensive were compared to normotensive patients. Mortality was the outcome of interest. Mortality rates before (2004–2007) and after (2009–2020) DCR CPG implementation were analyzed. Results1051 patients were studied. Overall mortality was 6.5% for normotensive casualties and 28.7% for hypotensive casualties. Mortality decreased in normotensive patients but remained unchanged in hypotensive patients following the implementation of the DCR CPG. ConclusionHypotensive combat casualties undergoing emergent laparotomy demonstrated a mortality rate of 29.5%. Despite many advances, mortality rates remain high in hypotensive patients requiring emergent laparotomy.

Pilot testing implementation of the pain management clinical practice guideline in nursing homes

Pain is a common symptom for older adults living with dementia in nursing homes. Unfortunately, there are many challenges to pain assessment, diagnosis and management for these individuals. The purpose of this study was to pilot test the implementation of the newly published Pain Management Clinical Practice Guideline from AMDA: The Society of Post Acute and Long-Term Care using our theoretically based Pain-CPG-EIT approach. Implementation was provided by a research nurse facilitator and included four components: Component I: Establishing and working with a stakeholder team monthly; Component II: Education of the staff; Component III: Mentoring and motivating the staff; and Component IV: Ongoing monitoring of pain assessment, diagnosis and management for residents. Findings provide some preliminary support for the feasibility and effectiveness of our implementation approach.

The Application of Computer Technology to Clinical Practice Guideline Implementation: A Scoping Review.

Implementation of clinical practice guidelines (CPG) is a complex and challenging task. Computer technology, including artificial intelligence (AI), has been explored to promote the CPG implementation. This study has reviewed the main domains where computer technology and AI has been applied to CPG implementation. PubMed, Embase, Web of science, the Cochrane Library, China National Knowledge Infrastructure database, WanFang DATA, VIP database, and China Biology Medicine disc database were searched from inception to December 2021. Studies involving the utilization of computer technology and AI to promote the implementation of CPGs were eligible for review. A total of 10429 published articles were identified, 117 met the inclusion criteria. 21 (17.9%) focused on the utilization of AI techniques to classify or extract the relative content of CPGs, such as recommendation sentence, condition-action sentences. 47 (40.2%) focused on the utilization of computer technology to represent guideline knowledge to make it understandable by computer. 15 (12.8%) focused on the utilization of AI techniques to verify the relative content of CPGs, such as conciliation of multiple single-disease guidelines for comorbid patients. 34 (29.1%) focused on the utilization of AI techniques to integrate guideline knowledge into different resources, such as clinical decision support systems. We conclude that the application of computer technology and AI to CPG implementation mainly concentrated on the guideline content classification and extraction, guideline knowledge representation, guideline knowledge verification, and guideline knowledge integration. The AI methods used for guideline content classification and extraction were pattern-based algorithm and machine learning. In guideline knowledge representation, guideline knowledge verification, and guideline knowledge integration, computer techniques of knowledge representation were the most used.

Obstetric Violence: What Do Midwifery Students Know?

The aim of this study is to determine the diagnosis levels and experiences of obstetric violence, which negatively affects women, of midwife candidates. The sample of the descriptive study consisted of 203 students studying in the Midwifery department of a public university who volunteered to participate in the research (Participation rate: 56%). Data were collected with the "Personal Information Form", "Obstetric Violence Diagnosis Form". Descriptive statistics were used to evaluate the data. The mean age of the students who contributed to the research was determined as 21.20±2.18. While it was determined that 59.1% of the students participating in the study had knowledge about obstetric violence, it was determined that the most common source of information was the internet (27.6%) and the immediate environment (13.8%), respectively. It was determined that 33.5% of the students witnessed obstetric violence. In addition, 23.2% of the students stated that obstetric violence is common in health institutions. In the light of the study findings, it was determined that the knowledge level of midwifery students about diagnosing obstetric violence should be improved. Therefore, raising awareness through improved educational models, standardizing care through the implementation of clinical practice guidelines, establishing protocols for respectful care, establishing the preventive legal basis, and promoting the humanization of childbirth will be key to eradicating obstetric violence.

Neonatal Hyperbilirubinemia Admissions Following Clinical Practice Guideline Implementation.

Treatment of neonatal hyperbilirubinemia remains one of the most common reasons for readmission following delivery. Revised clinical practice guidelines (CPGs) for the treatment of neonatal hyperbilirubinemia were published on August 5, 2022. This report describes the preliminary outcomes following implementation of the new CPGs at Tripler Army Medical Center. A retrospective chart review was performed for the 12 months prior to implementation and the 5 months post implementation. Bilirubin admissions decreased from 15.6% of total admissions during the 12 months prior to the new guidelines (69/441) to 4.1% of admissions (8/194) during the 5 months after implementation of the new guidelines (P < 0.001). This corresponds to a 74% reduction (risk ratio = 0.26, 95% confidence interval [CI] 0.13 to 0.54). The decrease in admissions was found to correlate to greater than $140,000 in annual savings. Adhering to the revised CPGs has the potential to increase resource availability at a time when nursing shortages and financial instability are impacting health care systems nationwide. No short-term adverse events were noted; however, long-term follow up will be needed.

Infographic summaries for clinical practice guidelines: results from user testing of the BMJ Rapid Recommendations in primary care

ObjectivesInfographics have the potential to enhance knowledge translation and implementation of clinical practice guidelines at the point of care. They can provide a synoptic view of recommendations, their rationale and...

Optimizing resource utilization: palliative care consultations in critically ill pediatric trauma patients

ObjectivesThe American College of Surgeons Trauma Quality Improvement Program (TQIP) and Committee on Trauma released a best practice guideline for palliative care in trauma patients in 2017. Utilization of pediatric...

The burden of the knowledge-to-action gap in acute appendicitis

BackgroundThe burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance.MethodsData were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG.ResultsFrom 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%).Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units.ConclusionsWe confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.

Effectiveness of implementing a locally-developed guideline for antibiotic treatment of lower urinary tract infection in adults in Thailand

Lower urinary tract infection (UTI) is still a major concern in clinical practice, but inappropriate antibiotics are commonly prescribed in Thailand. This study aimed to develop, implement, and evaluate the effectiveness of a clinical practice guideline (CPG) for antibiotic treatment of lower UTI in adults at Siriraj Hospital which is a university hospital in Thailand. This study comprised a retrospective cohort study development phase, and a prospective cohort study implementation phase. The outcomes of treatment were compared between phases. The development and implementation phases enrolled 220 and 151 patients, respectively. The CPG compliance rate was significantly increased from 17.3% during the development phase to 43.0% during the implementation phase (p = 0.001). The rates of fluoroquinolones and cotrimoxazole use were significantly lower during implementation than during development (p < 0.001 and p = 0.027, respectively). The rates of nitrofurantoin and fosfomycin use were significantly greater during implementation than during development (p = 0.009 and p = 0.005, respectively). The overall cure rate was not significantly different between the two study phases, but implementation group patients had significantly more unfavorable prognostic factors than development phase patients. CPG-compliance group patients had a significantly higher cure rate than CPG-non-compliance group patients (p = 0.011). The cost of the initial course of antibiotics per episode was significantly higher during the implementation phase because the cost of fosfomycin is more expensive and more fosfomycin was prescribed during implementation (p = 0.047). Implementation of the locally-developed CPG was found to be effective for increasing the appropriate use of empirical antibiotics and increasing the cure rate; however, measures to improve and reinforce CPG compliance are needed.

The perspectives of participants with traumatic brain injury on prospective memory rehabilitation incorporating compensatory and metacognitive skills training

ObjectivePatient feedback is rarely gathered systematically in cognitive rehabilitation research. This study examined the perceptions and experiences of people with traumatic brain injury (TBI) who participated in a trial of a 6-session educational program for the rehabilitation of prospective memory (PM) impairment. MethodsA mixed methods design was used with 47 participants with TBI who completed a compensatory strategy training program (COMP) or COMP plus metacognitive strategy training program (COMP-MST) delivered by an occupational therapist. Data were collected via a participant survey, extracts from progress notes, and audiotaped discussions about learnings from the program during the final session. ResultsParticipants from both programs were highly satisfied and perceived improvements in everyday PM performance post-intervention. Elements that were highly valued include setting individualised client-centred goals, repetitive training of strategy use, establishing habits and routines, and receiving experiential, verbal, and written feedback.Changes including more therapy sessions were recommended. ConclusionsBoth the COMP and COMP-MST programs were perceived as effective by participants with TBI in improving their PM performance in everyday life using compensatory strategies such as assistive technology. Practice implicationsRoutine collection of patient feedback on cognitive rehabilitation can provide valuable information to support person-centred implementation of clinical practice guidelines.

Barriers and facilitators to implementation of APTA's breast cancer-related lymphedema diagnosis and intervention clinical practice guidelines.

The purpose of this study was to identify barriers and facilitators influencing implementation ofthe diagnosis and intervention clinical practice guidelines (CPGs) related to the management of patients with breast cancer-related lymphedema (BCRL). A descriptive, cross-sectional web-based survey was conducted. Participants included physical therapists and assistants who were members of the APTA's Academy of Oncologic Physical Therapy and Lymphology Association of North America. Desriptive statisitcs were computed for all demographic and barriers and facilitators data. Individual exploratory factor analyses (EFA) were performed on survey items for both CPGs to identify themes of barriers and facilitators to implementation. A total of 180 respondents completed the survey. 34.9%of respondents read the diagnosis CPG and 22.4% read the intervention CPG. A total of 77.8% reported that they did not have issues in changing their clinical routines and 69.5% did not have resistance working according to CPGs. The EFA resulted in 3 themes for each CPG, accounting for 46% of the variance for the diagnostic CPG and 54% of the variance for the intervention CPG. The 3 themes, clinician characteristics, patient demographics, therapist practice setting and beliefs/values, were weighted differently for each EFA. Most respondents did not read either CPG, however, report a willingness to make changes to clinical practice and utilization of CPGs. For those who have attempted to implement the CPGs, this study was the first to identify the barriers and facilitators impacting the implementation of the CPGs related to the management of BCRL. The results will inform the development of targeted implementation strategies to improve access to and adherence to recommendations from the CPGs ultimately improving the efficiency and efficacy of care delivery to patients.

Improving the quality of clinical practice guidelines in China: A call to action for editors of medical journals

High-quality clinical practice guidelines (CPGs) have the potential to standardize medical practice and improve patient outcomes. However, in China, the quality of CPGs is generally lower than the global average, particularly in terms of methodological and reporting quality. This hinders the dissemination and implementation of CPGs in healthcare practice. To enhance the scientific rigor and authority of CPGs, their development should adhere to reporting guidelines. As medical journals serve as the platform for CPG publication, editors of medical journals have a significant responsibility for the quality control of publishing CPGs. We call on editors of medical journals to be equipped with the CPG reporting guidelines, implement them in their journal practice, and actively participate in the development of CPGs. Additionally, editors of medical journals can also promote CPG quality awareness among medical professionals and journal editors. These efforts will contribute to the high-quality development of CPGs in China.

Are There Any Developments in the Attitudes and Practices of Oncologists Regarding Fertility Preservation in Saudi Arabia After 12 Years?

The current practice of offering fertility preservation (FP) counseling and treatment has become one of the focal points in patient care throughout cancer treatment. The turning point was the approval of the Council of Senior Religious Scholars four years ago to freeze tissues from the ovarian membrane, the entire ovary, and the eggs for later use in reproduction to preserve the offspring. Thus, we aimed to assess any development in oncologists' knowledge, attitude, and referral practices regarding FP in Saudi Arabia. This is a cross-sectional survey using a self-administered questionnaire. We assessed oncologists' opinions on the importance of FP, their perception of the patient's preferences, and factors to consider when discussing the subject. Then, we assessed the knowledge and referral practices, including the timing of referral before starting cancer treatment. Most oncologists showed good knowledge and positive attitudes toward FP; however, their referral practices could be better. Most were familiar with FP options. The most significant factors influencing the oncologist-patient FP discussion were the number of existing children, marital status, cost, and type of cancer (96.6%, 76.7%, 65.7%, and 58.9%, respectively). There is a significant improvement in the knowledge and attitude of oncologists toward FP. However, patients' counseling and referral to fertility services still need to be improved. There is a shortfall in the clinical practice guidelines for FP in cancer patients in Saudi Arabia. The implementation of clinical practice guidelines would enhance FP. However, patients' counseling and referral to fertility services still need to be improved. The lack of proper guidelines on FP is affecting oncologists' practice.

Patient mobilization in the intensive care unit: Assessing practice behavior – A multi-center point prevalence study

ObjectivesTo describe intensive care unit mobility clinical practice behaviors and the factors associated with these behaviors that could explain the theory–practice gap. MethodologyA multi-center, descriptive, retrospective, one-day point prevalence study. Settingintensive care patients hospitalized for a minimum of 24 hours, in 20 Israeli Adult Intensive Care Units, from six medical centers. Main outcome measuresMaximum patient mobility level during the 24 hours prior to the prevalence study collection day and 48 hours from patient admission; mobility clinical practice behaviors and their inhibiting factors. ResultsThe study included 210 patients from a relatively even distribution of admission diagnoses. About half (46%) were intubated and 31% were hemodynamically unstable. Position change was most frequently reported as the maximum mobility level. The use of intubation, ventilation, tracheostomy, and inotropes was positively correlated with the level of mobility. Charlson Comorbidity Index and body mass index were not related to the level of mobility.A multiple regression model including these variables found that only intubation was a significant predictor of mobility level (R2 = 0.52, p < 0.001). ConclusionThere is a gap between clinical practice guidelines and actual intensive care mobility practice behaviors. The association between mobility level and common therapies suggests subjective norms or common practices that could serve as a barrier to guideline implementation and partially explain the gap between clinical practice guidelines and clinical practice behavior. Implications for clinical practiceBehaviors and their subjective norms can be barriers to the implementation of clinical practice guidelines. Promoting increased provider awareness and policies of proactive mobilization could potentially improve patient outcomes.

Assessing Barriers and Facilitators for Implementing Clinical Practice Guidelines in Middle Eastern and North African Region: Delphi Study.

Clinical practice guidelines (CPGs) improve clinical decision making and patient outcomes, but CPG implementation is poor. The success of CPGs is influenced by several factors related to barriers and facilitators. For this reason, it can be extremely useful to explore key barriers and facilitators of CPG implementation in the Middle East and North Africa (MENA). A three-round Delphi study was performed using the input of 30 experts involved in the clinical practice guidelines. In the first two rounds, participants were asked to score each statement relevant to barriers or facilitators for CPG implementation on a five-point Likert scale. These statements were identified from existing systematic reviews and expert input. In round three, participants ranked the most important barriers and facilitators identified from rounds one and two. A descriptive analysis was conducted on the barrier and facilitators statements using frequencies, percentages, and medians to summarize the variables collected. We identified 10 unique barriers and 13 unique facilitators to CPG implementation within the MENA region. The two highest-ranked barriers related to communications and available research and skills. The most important facilitator was the availability of training courses for healthcare professionals. Key barriers and facilitators to the implementation of clinical practice guidelines seem to exist in professional, organizational, and external contexts, which should all be taken into account in order to increase implementation success within MENA region. The results of this study are useful in the design of future implementation strategies aimed at overcoming the barriers and leveraging the facilitators.

Organic Integration of Traditional Chinese and Western Medicines-Future of Clinical Practice Guidelines of Integrated Traditional Chinese and Western Medicines.

The transformation and implementation of clinical practice guidelines for integrated traditional Chinese medicine (TCM) and Western medicine (WM) is crucial to the adoption of medical science and technological findings and is an important way for TCM to be made available to the world. First, clinical practice guidelines (CPGs) of TCM and WM integration in recent years was analyzed to clarify the current situation and problems in the existing guidelines according to the following four perspectives: (1) perspective of TCM and WM integration in guidelines, (2) diagnosis Using integrated TCM and WM, (3) integration of TCM and WM treatment, (4) promoting TCM and WM integration. Secondly, the information and quality evaluation of CPGs for integrated Chinese and Western medicine in 2020-2022 were analyzed to explore the degree and methods of integration of Chinese and Western medicine guidelines. And last this study aimed to lay a foundation for the further establishment of Chinese characteristic, repeatable, and calculable clinical practice guidelines of TCM and WM integration.