Implementation Of Practice Guidelines Research Articles

First-line managers’ experience of guideline implementation in orthopaedic nursing and rehabilitation: a qualitative study

BackgroundFirst-line managers have a unique role and potential in encouraging the use of evidence-based clinical practice guidelines (CPGs) and thus serve the provision of safe patient care. In acute and planned hospital care, effective yet safeguarded nursing procedures are a necessity. Little is currently known about how first-line managers engage in supporting the adoption of evidence-based nursing care and about what barriers and enablers there are for implementation of CPGs in the orthopaedic care context.PurposeTo investigate first-line managers’ experience of clinical practice guideline implementation in orthopaedic care.MethodsThis qualitative interview study included 30 first-line nursing and rehabilitation managers in 17 orthopaedic units in Sweden. A deductive content analysis, with the Ottawa Model of Implementation Leadership as a guide, was employed.ResultsTo the first-line managers, any guideline implementation required them to balance contexts, including their outer context (signified by the upper-level management and decision-makers) and their inner context, including staff and patients in their unit(s). Acting in response to these contexts, the managers described navigating the organization and its terms and conditions; using relations-, change-, and task-oriented leadership, such as involving the staff; motivating the change by emphasizing the patient benefits; and procuring resources, such as time and training. Even though they knew from past experience what worked when implementing CPGs, the first-line managers often encountered barriers within the contexts that hampered successful implementation.ConclusionsAlthough first-line managers know how to effectively implement CPGs, an organization’s terms and conditions can limit their opportunities to fully do so. Organizational awareness of what supports and hinders first-line managers to offer implementation leadership can enhance opportunities to alter behaviours and conditions for the benefit of CPG implementation.Trial registrationThe study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021.

Implementation of the clinical practice guidelines among family medicine doctors at primary health care facilities in Khartoum and Gezira states of Sudan

IntroductionThe health system in Sudan faces several challenges, including increasing numbers of patients, shortages of health supplies, and disparities in the distribution of health services. Guidelines implementation improves patients’ outcomes and ensures efficient use of the resources in such a resource limited country. The study aimed to assess the implementation of the clinical practice guidelines among family medicine doctors working in the primary health care centers in Khartoum and Gezira states to provide baseline data about the current practice in Sudan.MethodsDescriptive cross-sectional facility-based survey, conducted from April to December 2021, on 373 of the practicing family-medicine doctors. A total of 101 Primary health care centers were surveyed (77 centers in Khartoum state and 24 in Gezira state). The questionnaire was pilot tested on a small group of physicians to improve clarity and reduce response bias. Descriptive statistics were used to summarize the data and analyzed by frequency tables. Chi square and logistic regression tests were used to determine the association between categorized variables. P value < 0.05 was considered statistically significant.ResultsMost of the practicing family-medicine doctors (98.4%) reported implementation of the guidelines. Moreover, (68.6%) of them received training programs which were organized and funded by the Sudan Ministry of Health. The local Sudanese guidelines were difficult to access and not regularly updated. Services unavailability and inaccessibility (87.1%), health insurance factors (83.9%), and patient factors (81.2%) were the most frequent barriers to guidelines implementation. Service cost (79.9%), lack of regular training programs (79.9%), absence of local guidelines (77.2%), lack of continuity in the comprehensive care process (63.0%), and lack of time (57.1%) were also reported as barriers to guidelines implementation.ConclusionGuidelines implementation is limited by unavailability and inaccessibility of the health services and the health insurance limited coverage. Expansion of the health insurance coverage, organization of continuous training programs, encouragement of regular auditing and issuing regulations to ensure the use of updated guidelines, dissemination of the updated national guidelines along with establishing clinical governance in Sudan can be useful tools for policymakers in the optimum allocation of public health resources.

Clinical cohort of nonalcoholic fatty liver disease in a primary care setting

ABSTRACT Background and Aims: Nonalcoholic fatty liver disease (NAFLD) is increasingly common, and primary care physicians (PCPs) are often the first to diagnose NAFLD. While guidelines on NAFLD management in primary care exist, there are limited data on clinical practice patterns. Approach: We gathered data from over 370,000 patients with at least one PCP visit between July 2016 and September 2023. Using ICD-10 codes to identify patients with a diagnosis of NAFLD or Nonalcoholic Steatohepatitis (NASH), we extracted demographics, comorbidities, laboratory results, prescriptions, imaging orders, and referrals to describe their care. Results: We identified 10,334 patients with a diagnosis code of NAFLD (93.1%) and/or NASH (16.7%) during a PCP visit. Just over half (54.8%) were female, mean age was 52.8 years, and mean BMI was 33.2 kg/m2 with 90% having overweight or obese. More than 50% had hypertension and hyperlipidemia, and 38% had diabetes. At the diagnosis visit, 2.7% had ultrasound elastography ordered, 2.7% liver biopsy, and less than 1% magnetic resonance elastography. During follow-up ranging from 0 to 7 years, patients had a mean of 15 encounters, during which 4% were diagnosed with fibrosis or cirrhosis. Only 24.2% of patients were referred to a nutritionist and 18% had an appointment, and only 0.7% were referred to hepatology and 3.8% saw a hepatologist. Conclusion: PCPs have not widely implemented clinical practice guidelines for NAFLD, resulting in suboptimal care including for the substantial minority with fibrosis or cirrhosis. Patients might benefit from targeted NAFLD education for PCPs and improved decision and management support.

Nurses’ experience of prehospital sepsis assessment: a qualitative study

Background Sepsis is a frequent cause of global deaths with time critical diagnosis and treatment impacting outcomes. Prehospital emergency nurses are pivotal in assessment that influences timely diagnosis. Aim To gain a deep understanding of nurse’s experiences when caring for those with suspected sepsis. Design and Methods A qualitative study using semi-structured interviews and inductive content analysis according to the Elo Kyngäs method. Findings Early identification of sepsis by prehospital emergency nurses (n = 13) was augmented through a combination of clinical experience and the implementation of practice guidelines. There were three key components to practice improvement a) clinical experience, b) continuous education and c) explicit guidelines. Conclusions Identification of sepsis in the prehospital environment can shorten the time to treatment for patients with sepsis. Early identification can be achieved by continuous education in the Emergency Medical Service (EMS), ensuring experienced personnel and including the EMS in medical guidelines.

Treatment of bipolar depression: clinical practice vs. adherence to guidelines-data from a Bavarian drug surveillance project.

Pharmacotherapy of bipolar depression (BPD) is confronted with major clinical challenges, like limited evidence-based treatment options, regular cases of treatment resistance, and risk of treatment-emergent affective switches. Medical guidelines can support practitioners to make decisions based on current scientific evidence. The objective of this study is to evaluate to what extent recommendations of the 2019 German S3 guidelines "Diagnosis and Treatment of Bipolar Disorders" are reflected in clinical practice in inpatient treatment. We conducted a descriptive analysis of prescription numbers in 2,627 patients with BPD in a naturalistic inpatient setting analyzing data from the ongoing Bavarian multicenter drug safety project Pharmaco-Epidemiology and Vigilance (Pharmako-EpiVig) from the years 2014-2022. Of the patients, 38% were not administered any drug explicitly recommended for treatment of BPD, that is, quetiapine, lamotrigine, carbamazepine, or olanzapine. Only 6% of the patients received monotherapy with one of those drugs. Of the patients, 34% were administered ≥4 psychotropic drugs simultaneously. Patients received 912 different therapy regimens of mono or combination therapy with mood stabilizers (MS), atypical antipsychotics (AAP), and antidepressants. Of the patients, 72% received an antidepressant and 6% without concomitant prescription of an AAP or MS. Prescription rates of venlafaxine (21% to 14%) and tricyclic antidepressants (9% to 6%) decreased significantly from the first (2014-2016) to the last (2020-2022) observed time period. Of the patients, 60% received an MS. Prescription rate of valproate (22% to 14%) decreased significantly, while lithium prescription increased significantly (29% to 35%). Of the patients, 71% were administered an AAP. Quetiapine was the most prescribed drug overall (43%). Only two patients were administered a combination of olanzapine and fluoxetine. Our results demonstrate a substantial gap between guideline recommendations and current clinical practice. The remarkable heterogeneity in treatment regimens, with no discernible dominant treatment approach, is in part a reflection of the complexity of bipolar disorder but also substantiates the need of comprehensive recommendations regarding combination therapies. Increase in lithium prescription is an encouraging development due to its unique efficacy in maintenance treatment. To improve the quality of clinical practice guideline implementation, more randomized controlled trials shouldbeconducted in the future to prospectively investigate different implementation strategies.

Obstacles to the Implementation of clinical practice guidelines at Mandau District General Hospital.

Highlights:1. Given the suboptimal implementation of clinical practice guidelines at Mandau District General Hospital, it is important to conduct research on potential obstacles to this problem.2. The findings of this study can encourage hospitals to develop and apply effective clinical practice guidelines while also addressing the obstacles to their implementation. Abstract Clinical practice guidelines are procedures followed by physicians to optimize healthcare services and achieve more effective outcomes. Conducted in October 2022, this study aimed to analyze the factors that hinder the implementation of clinical practice guidelines among physicians at Mandau District General Hospital, Bengkalis, Indonesia. This study used an analytical survey design and a cross-sectional approach. This study included all 85 individuals who were employed as general practitioners at the Mandau District General Hospital. The data were subjected to univariate, bivariate, and multivariate analyses. The independent t-test was used in the data analysis, with a value of p&lt;0.05 considered significant. The results showed that there was an association between the implementation of clinical practice guidelines and several variables, including the levels of ability in recognizing and explaining clinical pictures of diseases (p=0.008), diagnosing diseases (p=0.004), carrying out initial management (p=0.000), and carrying out independent and directed management (p=0.001). Upon conducting the follow-up analysis on logistic regression, it was found that the variables that were associated with the implementation of clinical practice guidelines were the ability to carry out initial management (p=0.000, OR=65.512, 95% CI=22.048–98.835). In conclusion, physicians' insufficient ability to perform initial management hinders the implementation of clinical practice guidelines. This study suggests incorporating the findings as input in the evaluation and development of training for physicians on the implementation of clinical practice guidelines.

Exploring the factors influencing evidence-based approaches to advanced chronic kidney disease: a qualitative study involving nurses and physicians

BackgroundAdvanced chronic kidney disease (ACKD) is associated with a high risk of adverse cardiovascular and renal events and has a significant impact on quality of life and life expectancy. Several studies have identified areas for improvement in their management in primary care. Some professional and environmental factors can act as key barriers to appropriate care.ObjectiveTo analyse attitudes, subjective norms, and perceived behavioural control among primary care professionals related to the implementation of an evidence-based approach for individuals with ACKD in primary care.MethodologyThis was a qualitative study using an interpretative phenomenological approach based on the theory of planned behaviour. Two aspects of the evidence-based approach were explored: the implementation of clinical practice guidelines and the utilisation of electronic kidney disease records within the scope of this study. Primary care nurses and physicians participated in a previous pilot interview and five focus groups. Subsequently, a thematic analysis of the gathered data was conducted.FindingsThirty-three primary care professionals participated. The emerging themes included: experiences in the management of ACKD (highlighting a distinct profile of older, frail patients with comorbidities masking CKD and a CKD follow-up primarily focused on analytical monitoring and drug adjustment); factors in the professional environment influencing the use of scientific evidence (such as time constraints, excessive electronic health records, and unfamiliar reference guidelines); attitudes towards the application of recommendations on ACKD (recognising limitations of computer systems despite considering them as guidance); and capacities to implement evidence-based recommendations (acknowledging formative needs and challenges in coordinating care with nephrology services).ConclusionsSeveral psychological elements identified through the TBP hinder the adequate implementation of an evidence-based approach for individuals with CKD. Attitudes have been identified as factors modulating the use of standardised electronic records. Instead, subjective norms (influences from the professional environment) and perceived behavioral control (perception of capabilities) acted as barriers to the proper application of clinical practice guidelines and standardised records.Implications for practiceStrategies aimed at optimising the management of people with ACKD should focus not only on training but also on improving attitudes, organisational structures, IT systems and coordination between primary care and nephrology.

PERCUTANEOUS CORONARY INTERVENTIONS IN PATIENTS TREATED WITH ORAL ANTICOAGULANT THERAPY: BASELINE CLINICAL CHARACTERISTICS OF THE PERSEO REGISTRY

Abstract Background International guidelines recommend a dual antithrombotic therapy (DAT) with direct oral anticoagulant (DOAC) for patients on chronic oral anticoagulant therapy (OAT) undergoing percutaneous coronary intervention with stent implantation (PCI–S). However, the implementation of practice Guidelines in the “real world” is often a complex exercise. Aim of the multicenter prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) registry was to evaluate the management of the different antithrombotic regimens strategies in patients with an indication for OAT undergoing PCI–S in a “real world” setting and its association with clinical outcomes. Methods The PERSEO registry has been designed to enrol patients requiring OAT and treated by PCI–S in 25 Italian Cardiology Centres. No exclusion criteria have been defined. The primary end–point was a combined measure of efficacy and safety outcome (NACE), including major bleeding events + major adverse cardiac and cerebral events at one year follow up in patients treated with DOAC compared to vitamin K antagonists. Results From February 2018 to February 2022, a total of 1233 patients were enrolled: mean age 74±9 years, 900 males and 333 females. The primary indication for OAT was atrial fibrillation (1066 patients, 87%) while an acute coronary syndrome was the leading reason for PCI–S (789 patients, 64%). Of those, 271 patients had an ST elevation myocardial infarction at admission. Mean CHA2DVAS2C score and HASBLED score were respectively 4±2 and 4±1. Six patients died during hospitalization and 1227 were discharged alive: 1027 on triple antithrombotic therapy (oral anticoagulant and dual antiplatelet therapy), 196 patients on DAT (oral anticoagulant and single antiplatelet therapy) and 4 patients on oral anticoagulant alone. The majority of patients enrolled were discharged on DOAC (1006 patients, 82%), whereas only a minority received vitamin K antagonists (221 patients, 18%). Conclusions The Italian PERSEO Registry is the largest prospective observational study comparing different antithrombotic strategies in patients with an indication for OAT undergoing PCI–S in a “real world” setting. Baseline characteristics, depicted a population at high thrombotic and haemorrhagic risk. In agreement with current guidelines the majority of patients were discharged on DOAC, yet the use of a DAT was still limited to a minority of the patients included.

Screening for Hypertension in adolescents living with HIV: Protocol for a cluster randomized trial to improve guideline adherence.

Although AIDS-related deaths have reduced with increased access to antiretroviral care, cardiovascular disease-related morbidities among persons living with HIV are rising. Contributing to this is the higher incidence of Hypertension among Persons Living with HIV. The duration of exposure to the virus and antiretroviral drugs plays a vital role in the pathogenesis, putting perinatally infected children and adolescents at higher risk than behaviorally-infected ones, supporting the calls for increased surveillance of Hypertension among them. Despite the availability of guidelines to support this surveillance, the blood pressure (BP) of adolescents living with HIV (ADLHIV) is not checked during clinical visits. This study aims to assess the effect of a theory-based intervention on healthcare workers' adherence to the guidelines for hypertension screening among adolescents. A multi-facility cluster-randomized study will be conducted. The clusters will be 20 antiretroviral therapy sites in the Greater Accra Region of Ghana with the highest adolescent caseload. Data will be extracted from the folders of adolescents (10-17 years) who received care in these facilities six months before the study. The ART staff of intervention facilities will receive a multicomponent theory of planned behaviour-based intervention. This will include orientation on hypertension risk among ADLHIV, provision of job aids and pediatric sphygmomanometers. Six months after the intervention, the outcome measure will be the change from baseline in the proportion of ADLHIV whose BP was checked during clinical visits. The calculated sample size is 400 folders. This study will generate evidence on the effectiveness of a multicomponent theory-based intervention for improving the implementation of clinical practice guidelines. PACTR202205641023383.

Management of inflammatory bowel disease in the emergency setting: the MIBODI international survey and evidence-based practices.

This study aimed to evaluate the impact of the WSES-AAST guidelines in clinical practice and to investigate the knowledge, attitudes, and practices of emergency surgeons in managing the complications of ulcerative colitis (UC) and Crohn's disease (CD). The MIBODI survey is a cross-sectional study among WSES members designed as an international web-based survey, according to the Checklist for Reporting Results of Internet E-Surveys, to collect data on emergency surgeons' knowledge, attitudes, and practices concerning the management of patients presenting with acute complications of CD and UC. The questionnaire was composed of 30 questions divided into five sections: (1) demographic data, (2) primary evaluation, (3) non-operative management, (4) operative management, and (5) perianal sepsis management. Two hundred and forty-two surgeons from 48 countries agreed to participate in the survey. The response rate was 24.2% (242/1000 members on WSES mail list). Emergency surgeons showed high adherence to recommendations for 6 of the 21 assessed items, with a "correct" response rate greater than or equal to 60%, according to WSES-AAST recommendations. Nine critical issues were highlighted, with correct answers at a rate of less than 50%. Inflammatory bowel disease is a complex disease that requires a multidisciplinary approach with close collaboration between gastroenterologists and surgeons. Emergency surgeons play a crucial role in managing complications related to IBD. One year after publication, the MIBODI study showed significant global implementation of the WSES-AAST guidelines in clinical practice, offering an imperative tool in the improved management of IBD in emergency and urgent settings.

Addressing cervical cancer prevention in Bhutan: A study on the use of loop electrosurgical excision procedures at the primary health care level

AbstractBackgroundCervical cancer is the top and fourth leading cause of death among women in Bhutan and worldwide, respectively. The cervical cancer elimination flagship program initiated by the Ministry of Health aims to achieve the 90–70–90 goals by 2030. To achieve this, detection and treatment of pre‐cancerous lesions of the cervix through colposcopy and loop electrosurgical excision procedure (LEEP) are being carried out through the outreach health camps.MethodsThis descriptive study aimed to assess the safety and tolerability of LEEP under local anesthesia and assess the margin status of high‐grade lesion (HGL). We analyzed 193 records of clients who underwent LEEP at Wangdue Phodrang Hospital from 26 September to 5 October 2022. The sociodemographic profile, intraoperative pain, complications, and histopathological reports were described using structured pro forma.ResultsThe mean age of clients was 40.9 ± 8.5 years (range 25–66 years). There were 3.1% who had intraoperative and 2.6% who had postoperative bleeding. There were 18.6% who had foul‐smelling vaginal discharge, and 8.3% had moderate‐to‐severe intraoperative pain. Histopathological assessment revealed 29.5% with chronic cervicitis, 34.2% with HGL, and 1.6% with microinvasive cervical carcinoma. The margin positivity for HGL was 36.4%.ConclusionGiven the safety profile of LEEP under local anesthesia in our setting, the scope of providing a complete cervical cancer screening and treatment package at the primary health care level looks promising. Based on the higher rate of overtreatment and margin positivity, we recommend the practical implementation of standard colposcopy guidelines.

Survival in systemic sclerosis associated pulmonary arterial hypertension in the current treatment era-results from a nationwide study.

Pulmonary arterial hypertension (PAH) is a leading cause of mortality in systemic sclerosis (SSc). This nationwide study aims to describe real world treatment characteristics and assess survival rates of patients with SSc-PAH. In this retrospective cohort study, patients with SSc-PAH were identified from Turkish Ministry of Health National Electronic Database (from January 2016 to September 2022), using ICD-10 codes. Data on demographics, treatment characteristics, and death was collected. Kaplan-Meier curves were used to calculate cumulative probabilities of survival at 1, 3, and 5years. Five hundred forty-seven patients (90.7% female) with SSc-PAH were identified. Median age at PAH diagnosis was 59.9 (50.0-67.4) years. During a median follow-up duration of 3.2 (1.5-4.8) years, 199 (36.4%) deaths occurred. Estimated survival rates at 1, 3, and 5years were 90.2%, 73.2%, and 56.6%, respectively. Survival was similar among patients with and without interstitial lung disease (p = 0.20). Patients who used immunosuppressives had better survival than those who did not (p < 0.001). No difference was observed in survival rates according to initial PAH-specific treatment regimen (monotherapy or combination) (p = 0.49). Compared to most of historical cohorts, higher survival rates for SSc-PAH were observed in this study. Early diagnosis of PAH may have contributed to these findings. The impact of immunosuppressive therapy on prognosis of SSc-PAH needs to be further investigated in prospective studies. Key Points • Early diagnosis is pivotal for better outcomes in SSc-PAH. • Implementation of PAH treatment guidelines in routine clinical practice is still poor and should be improved. • Effect of immunosuppressive therapies on disease course has to be defined in SSc-PAH.

366 Implementation of COPD Clinical Practice Guidelines with Use of Telehealth

OBJECTIVES/GOALS: Studies to improve uptake of Chronic Obstructive Pulmonary Disease Clinical Practice Guidelines (COPD CPG) have yielded inconsistent results. We hypothesized that using implementation science would facilitate rigorous site ‘diagnosis’, and promote effective contextual tailoring of COPD CPG, while piloting the use of telehealth for this. METHODS/STUDY POPULATION: The study was conducted in two Veterans Affairs primary care clinics located in a small sized city. A detailed formative evaluation was conducted using key informant interviews (with VA staff and veterans with COPD who received care at this location) and quantitative data. Multidisciplinary stakeholder group was engaged and strategies to address the determinants identified through the previous step were identified. Telehealth was strongly encouraged as the primary modality for implementing the COPD CPG and we are collecting pilot data on this. Tele-Facilitation, used as the meta-strategy was employed in conjunction with other strategies such as develop/distribute educational materials, tailor strategies, change record systems and revise professional roles. RESULTS/ANTICIPATED RESULTS: Primary Care at the VA is provided by Patient Aligned Care Teams (PACT-teams), where each team consists of multiple health professionals to provide collaborative care to the patient. Discussions with the multidisciplinary stakeholder team suggested that any implementation effort primarily focused on physician and nursing efforts was unlikely to succeed due to competing demands. A pharmacy-centric model that allowed for the PACT-team clinical pharmacist to address most of the COPD CPG (inhaler technique education/assessment, inhaler choice optimization, COPD-specific patient education, spirometry use, smoking and immunization) was developed and implemented with incorporation of telehealth (video visits and telephone). We will present pilot implementation outcomes using RE-AIM framework elements. DISCUSSION/SIGNIFICANCE: This use of implementation science to implement COPD CPG and novel use of telehealth has enormous potential for impact. Increasing reach/adoption by targeting primary care practices can help permeate quality care to the underserved population. This data will allow us to explore generalizability through wider scale implementation studies.

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.

You've (Not) Been Warned: Developer Best Practices for Content Warnings and Why Compassion Matters

Content warnings are an essential accessibility feature in games with distressing and traumatic content. With mixed research findings and even more mixed public opinion, there are very few resources available to support developers who want to have content warnings in their games. The following article provides a brief historical overview and current research on the use of content warnings, case examples games that have successfully utilized content warnings, and best practice guidelines for content warning language and implementation.

A Systematic Review of Diagnostic Modalities and Strategies for the Assessment of Complications in Adult Patients with Neurofibromatosis Type 1.

Neurofibromatosis Type 1 is an autosomal dominant tumour-predisposition condition commonly diagnosed in childhood and fully penetrant by adulthood. Long-term monitoring through imaging is inconsistent and varies between high- and low-income countries. Implementation of a clinical practice guideline through a multidisciplinary clinic is instrumental to the care of adult Neurofibromatosis Type 1 patients. We aim to systematically review international diagnostic modalities and strategies to evaluate any association between a country's socioeconomic status and diagnostic modalities or strategies used for Neurofibromatosis Type 1 patients. We searched PubMed, Embase, Web of Science, and Cochrane. Relevant clinical information on the surveillance of adult Neurofibromatosis Type 1 patients worldwide was reviewed, extracted, and synthesised. We identified 51 papers reporting on 7724 individuals. Multiple imaging modalities are actively employed in high-income and upper-middle-income countries for surveying adult Neurofibromatosis Type 1 patients. We did not find any relevant papers from low- and middle-income countries. This systematic review suggests that there is robust data on diagnostic modalities for adult Neurofibromatosis Type 1 patients in high-income countries, but not for low- and middle-income countries. There is a lack of data on consolidated diagnostic strategies from both high- and low-income countries. Efforts should be made to publish data on usual clinical practice in low- and middle-income countries to develop clinical practice guidelines describing best medical practice to fit a local context.

Development and validation of a questionnaire to identify barriers to the implementation of the Clinical Practice Guidelines for lower limb amputees in a middle‐income country

AbstractAimTo develop and validate a questionnaire to identify the perceived barriers in the implementation of the Clinical Practice Guidelines for the lower limb amputee (CPG‐AMP).Study Design and SettingThe study consisted of two stages: first, the development of the questionnaire based on a meta‐review of the literature and interviews with patients and health providers (mixed‐methods research). Second, the evaluation of its psychometric properties was performed. Participants included health providers from hospitals and clinics, prosthetic workshops and academic institutions in Colombia.ResultsA total of 90 items were obtained from the literature review and interviews. The validation of a preliminary 66‐item questionnaire was performed with 545 participants. After the factorial analysis, a 25‐item questionnaire with four domains was developed. Internal consistency was adequate in all domains, with Cronbach's α values between 0.76 and 0.83. Test–retest reliability in 58 participants yielded intraclass correlation coefficients between 0.51 and 0.59.ConclusionsA 25‐item questionnaire with four domains (health system, guideline, institutional and individual) was proposed to measure the perception of barriers to the CPG‐AMP. The conceptual framework and the questionnaire can be used to identify barriers of other CPGs and to help design strategies aimed at improving its implementation.

Implementation of World Health Organization Recommendations for Semen Analysis: A Survey of Laboratories in the United Kingdom

The standard method for identification of male fertility status is a semen analysis. This is performed in fertility and pathology laboratories accredited by different bodies in the UK such as the HFEA or UKAS, and is based on whether they perform licenced clinical treatment or diagnostic testing. The WHO laboratory semen analysis criteria provide the most comprehensive guidance for best practice, yet this is not strictly adhered to. Our objective was to determine any differences in semen analyses between laboratories in the UK, based on the regulatory body they are registered with. A cross-sectional survey was sent to NEQAS for andrology registrants (n = 184 laboratories), HFEA (n = 117 clinics), and individual ARCS members (n = 682). Most ARCS members are associated with NEQAS and/or the HFEA. A ∼50% laboratory response rate (n = 106 included responses) was found. Results were grouped based on accreditation: Group 1, UKAS accredited only (n = 38); Group 2, both UKAS accredited and HFEA licenced (n = 17); Group 3, HFEA licenced only (n = 42); and Group 4, no accreditation (n = 9). Over 85% of UKAS accredited laboratories (Groups 1 and 2) state they perform semen analysis according to WHO 2010 recommendations and adhere to best practice guidelines. A significantly fewer number of HFEA only laboratories (&lt;74% Group 3, p &lt;0.01) adhere to both guidelines. Non-HFEA laboratories (Groups 1 and 4) are almost all performing sperm counts according to WHO criteria, while &lt;60% HFEA clinics (Groups 2 and 3) perform counts according to regulation (Group 1 vs. Groups 2 and 3: Fixed sperm, p &lt;0.05; Neubauer chamber: p &lt;0.005). QC is implemented in most laboratories, however there is a significant difference (p &lt;0.01) between non-UKAS (Groups 3 and 4) and UKAS laboratories (Groups 1 and 2). There is a significant difference in semen analysis performance between UKAS and HFEA laboratories with regards to implementation of best practice guidelines and QC procedures. This may have a detrimental effect on result accuracy and consequently lead to patient misdiagnosis and mismanagement.

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.

Childhood obesity prevention in general practice: supporting implementation through co-ideation.

Childhood obesity is associated with physical and psychological complications thus the prevention of excess weight gain in childhood is an important health goal. Relevant to the prevention of childhood obesity, Australian general practice-specific, preventive care guidelines recommend General Practitioners (GPs) conduct growth monitoring and promote a number of healthy behaviours. However, challenges to providing preventive care in general practice may impact implementation. In October and November, 2022, a series of three workshops focusing on the prevention of childhood obesity were held with a group of Australian GPs and academics. The objective of the workshops was to determine practical ways that GPs can be supported to address barriers to the incorporation of obesity-related prevention activities into their clinical practice, for children with a healthy weight. This paper describes workshop proceedings, specifically the outcomes of co-ideation activities that included idea generation, expansion of the ideas to possible interventions, and the preliminary assessment of these concepts. The ecological levels of the individual, interpersonal, and organisation were considered. Possible opportunities to support childhood obesity prevention were identified at multiple ecological levels within the clinic. The preliminary list of proposed interventions to facilitate action included GP education and training, clinical audit facilitation, readily accessible clinical guidelines with linked resources, a repository of resources, and provision of adequate growth monitoring tools in general practice. Co-ideation with GPs resulted in a number of proposed interventions, informed by day-to-day practicalities, to support both guideline implementation and childhood obesity prevention in general practice.