Utility Of Clinical Practice Guidelines Research Articles

HR+/HER2- early breast cancer with a high risk of recurrence: The impact of online education on clinician knowledge, competence, and confidence in utilization of clinical practice guidelines to enhance patient care.

e12515 Background: Clinical practice guidelines drive treatment decision making in HR-positive, HER2-negative early breast cancer with a high risk of recurrence. Understanding is necessary to incorporate the guidelines into practice and improve patient care. To address this gap, two global educational activities were developed that consisted of a 1-hour live streaming virtual meeting with a 45-minute online enduring activity and a 30-minute panel discussion. The objective of this study was to assess the educational impact of the online educational activities. Methods: To assess educational impact a repeated-pairs pre-/post-assessment study design using 6 knowledge/competence questions, in which everyone served as their own control. A paired samples t-test assessed mean differences in the average number of correct responses to the matched pre-/post-assessment questions, and a McNemar’s test assessed significance of improvement across core learning topics from pre- to post-assessment. P values <.05 are statistically significant. Confidence was also assessed using a pre/post confidence question. The activities launched in March 2023 and data was collected till January 2024. Results: 385 oncologists from the US and outside of the US who answered all the pre-/post-assessment questions were included in the analysis. Each assessment question was mapped to an activity learning objective. The learning objectives were grouped into three core topics. All core topics showed a significant improvement in education. Conclusions: These online activities resulted in a significant improvement of oncologists’ knowledge and competence related to the utilization of clinical practice guidelines. Confidence in understanding the implications of the latest guidelines also showed a statistically significant improvement. However, there is still a need for education in a significant percentage of oncologists on this topic. [Table: see text]

Determining the future role of clinical practice guidelines: The experience of Australia and New Zealand.

There has been recent discussion in Australia and New Zealand concerning the utility of Clinical Practice Guidelines (CPGs) and the role of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in their development. The College Board therefore established a Steering Group (SG) to oversee an exploration of options and produce recommendations about contemporary approaches to the development of high-quality evidence-based clinical practice guidance for psychiatry. This paper outlines the SG's conclusions and recommendations, as well as the underlying methods and reasoning. In particular, we discuss best practice and recent developments in the synthesis of research evidence. Account has been taken of the opportunities offered by digital technologies, the proliferation of clinical evidence and awareness of the gains to be made by increased inclusion of lived-experience perspectives. It is recommended that the broader concept of best practice resources (BPRs) as now emphasised in so many fields of service is the most appropriate starting point for the College's role in this area especially as the expertise of the College and its fellows lends itself to the development of a range of BPRs. In conclusion, contemporary guidance needs to be tailored to the requirements of the practitioners seeking it, to articulate the real-world needs and experiences of patients, and to be delivered in a contemporary format that is responsive to rapidly emerging evidence. The experience in Australia and New Zealand may have implications elsewhere for the development of CPGs and BPRs more broadly.

Utilization of clinical practice guidelines for cancer care in routine practice and during the coronavirus disease 2019 pandemic in India.

The coronavirus disease 2019 (COVID-19) pandemic affected cancer service delivery and the feasibility of following the standard treatment guidelines. The present paper describes the use of clinical care guidelines for cancer management in routine practice and the approach adopted towards cancer care during the COVID-19 pandemic in India. A web-based survey was done in 107 hospitals (including public and private health facilities) that hosted Hospital-Based Cancer Registries under the National Cancer Registry Programme. The participants comprised Principal Investigators of these registries, who were also medical, surgical, and radiation oncology clinicians. The survey was done between May 1, 2021, and July 31, 2021. Participants were provided with a web link for the survey questionnaire, confidential login, and password. The study found high utilization of Clinical Practice Guidelines (CPGs) during practice, with eight out of ten physicians constantly to referring them. The study reported lack of knowledge, skills, and training to administer the treatment based on the guidelines followed by organizational infrastructure and affordability of treatment by the patients as the factors hampering utilization. International clinical guidelines were preferred when compared to national guidelines. The COVID-19 pandemic decreased the use of CPGs, wherein six out of ten clinicians reported their use. Stakeholders who formulate clinical guidelines must consider the practical aspects and feasibility of implementing such guidelines during a pandemic and similar situations. This should be coupled with adequate changes in care practice to ensure optimal care delivery and a continuum of cancer care in routine and pandemic-imposed situations.

Management of Dyslipidemia and Hypertension – Journey Mapping in the Philippines

Literature was reviewed semi-systematically with the purpose of generating Philippines-specific data for the patient journey stages for dyslipidemia and hypertension, namely, awareness, screening, diagnosis, treatment, adherence, and control. A structured search was conducted on EMBASE and MEDLINE databases for studies published in English in the last 10 years, whose full text was available. An unstructured search was conducted on Google, and websites of health ministries and international organizations, without any limits. The last search was run for dyslipidemia on 12.11.2019 and for hypertension on 28.07.2020. For dyslipidemia, six records out of 590 records were retrieved, and for hypertension, seven records and one unpublished conference presentation out of 160 records retrieved, were included in the final synthesis. The review estimated that in the Philippines, the prevalence of dyslipidemia was 38.8%, while 59.0% of patients were undergoing treatment, with 44.2% of patients achieving control. Prevalence of hypertension was 27.5% and estimated rates at different stages of patient journey were- awareness- 61.5%, screening- 3.2%, diagnosis- 39.7%, treatment- 65.4%, adherence- 57%, and control- 57.6%. Potential contributory factors for low assessment rates and suboptimal management include low doctor-to-population ratio, inadequate time for screening and counseling, absence of locally validated tools for cardiovascular screening, low awareness and utilization of clinical practice guidelines, and some misperceptions of current treatment recommendations. Effective training of physicians, patient education initiatives, and multi-sectoral coordination are some of the recommendations to improve the status of management of dyslipidemia and hypertension in the Philippines.

Physicians’ perception of the reform of the review and assessment system of national health insurance reimbursement claims

Background: The Korean government has been promoting the reform of the review and assessment system of national health insurance reimbursement claims. The aim of this study was to find out physicians’ perception and evaluation of the health insurance review and assessment system and present the direction for the government’s reform plan.Methods: The 2020 Korean Physician Survey questionnaire was sent to 57,714 members of the Korean Medical Association from November 19, 2020 to January 10, 2021. A total of 6,507 physicians (11.5%) responded; of these, the responses of 4,454, including the self-employed and employed, professors, and fellows, were included for analysis. The respondents’ perception of the current health insurance review system and of the government’s reform plan were analyzed.Results: It was found that 84.2% of the respondents evaluated the current health insurance review system negatively—particularly in terms of medical autonomy, transparency of the review standards, the standard development and application process, and the post-review adjustment process. Furthermore, only 0.7% of the respondents evaluated the government’s reform plan positively—particularly, the utilization of clinical practice guidelines for review standards, introduction of the professional review committee, and expansion of the link between the review and assessment system.Conclusion: Policymakers should understand physicians’ perception and evaluation of the health insurance review system. In addition, the reform plan should be thoroughly communicated to physicians.

Implementation of the cardiovascular assessment screening program (CASP) by nurse practitioners-it's time to focus on early identification of cardiovascular risk

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Newfoundland and Labrador Support for Patient-Oriented Research (NL SUPPORT) Background There is inconsistent utilization of clinical practice guidelines (CPGs) for cardiovascular disease (CVD) screening and management by advanced practice nurses/nurses practitioners (NPs) to identify CVD risk factors early and to intervene using current recommendations. To address this clinical practice issue and increase utilization of Canadian CPGs, an exploratory multiphase sequential mixed methods study was conducted and the Cardiovascular Assessment Screening Program (CASP) was developed, implemented, and evaluated. Objective Phase 2 of the mixed methods study, a cluster randomized controlled trial (cRCT), evaluated the implementation of CASP by NPs with individuals aged 40-74 years, without established CVD or vascular disease (VD), in order to identify CVD risk factors early, to determine the level of risk for a CV event, to calculate the Heart Age, and to set heart health priorities and management, according to current CPGs in Canada. Methods In a cRCT, block randomization randomly divided ten NPs into the intervention group clusters (IGCs) and the control group clusters (CGCs). In turn, eight NPs recruited 166 patients in their own communities; the four NP IGCs recruited patients (n=67) and the four NP CGCs recruited patients (n=99). The web-based CASP intervention was implemented with patients in the IGCs, and the CGCs received standard care. The CASP intervention consisted of four components: an electronic CVD Database, an NP toolkit, an educational resource for NPs and patients, and a website containing CPGs. The data on CVD risk factors, Framingham Risk Score (FRS), Heart Age, and priorities for heart health were recorded in the CVD Database utilized by the NP IGCs. Results Utilizing the CVD database, CVD risk factors were consistently identified in patients by NPs in the IGCs compared to the NP CGCs. The patients in the IGCs had a high number of risk factors for CVD documented by NPs, including family history of CVD, hypertension, diabetes, obesity, renal dysfunction, and dyslipidemia, and found that 62 patients (91%) were at moderate to high risk for having a CV event in the next 10 years using the FRS. In comparison, NPs in the CGCs did minimal documentation of risk factors; the level of CVD risk was largely unknown (96%) for control group patients as the FRS was only documented on 7 patients (4%). The Heart Age was calculated in the IGCs (92%); in the CGCs, the Heart Age was not calculated. The recommendations made by IGC NPs matched their patients’ priorities 94% of the time; 75% of the intervention group patients developed personalised goals that matched their top priorities for improving heart health. Conclusion The key benefit of the CASP implementation by NPs was the identification of CVD risk factors earlier in individuals without established CVD or VD. Engaging individuals to participate in screening to learn about their CVD risk encourages priority setting for heart health using a patient-focused approach.

Utilization of clinical practice guideline on antimicrobial in China: an exploratory survey on multilevel determinants

BackgroundNowadays, irrational use of antimicrobials has threatened public health. It’s necessary to expand the use of clinical practice guideline (CPG) on antimicrobial for facilitating the proper use of antimicrobial. However, the utilization status of CPG on antimicrobial and the influencing factors, especially the ones at the organizational level, remain largely unknown.MethodsA cross-sectional questionnaire survey was conducted on a sample among physicians from 16 public hospitals in the eastern, central and western parts of China. A multilevel regression model was employed to examine factors associated with physicians’ utilization of CPG on antimicrobial.ResultsA total of 815 physicians were included in this study. About 80% of the surveyed physicians reported their adherence to the CPG on antimicrobial. Dimensions of “subjective norm”, “perceived risk” and “behavioral intention” from the domain of physician belief, a dimension of “ease of use” from the domain of CPG traits, and dimensions of “top management support” and “organization & implementation” from the domain of hospital practice were significantly associated with physicians’ utilization of CPG on antimicrobial. And except for working department, most demographics characteristics of the physician were not found to be significantly related to the CPG use. In addition, it also showed that region is a significant factor affecting physicians’ CPG use.ConclusionsThis study depicted the current status of CPG on antimicrobial and comprehensively identified its potential determinants not only from the three domains at the individual level, such as physician belief, but also from the location region at the organizational level. The results will provide a direct reference for the implementation of CPG on antimicrobial.

The Life and Career of Matthew O. Howard

The Life and Career of Matthew O. Howard

Malpractice in Emergency Medicine—A Review of Risk and Mitigation Practices for the Emergency Medicine Provider

BackgroundMalpractice in emergency medicine is of high concern for medical providers, the fear of which continues to drive decision-making. The body of evidence evaluating risk specific to emergency physicians is disjointed, and thus it remains difficult to derive cohesive themes and strategies for risk minimization. ObjectiveThis review evaluates the state of malpractice in emergency medicine and summarizes a concise approach for the emergency physician to minimize risk. DiscussionThe environment of the emergency department (ED) represents moderate overall malpractice risk and yields a heavy burden in finance and time. Key areas of relatively high litigation occurrence include missed acute myocardial infarction, missed fractures/foreign bodies, abdominal pain/appendicitis, wounds, intracranial bleeding, aortic aneurysm, and pediatric meningitis. Mitigation of risk is best accomplished through constructive communication, intelligent documentation, utilization of clinical practice guidelines and generalizable diagnoses, careful management of discharge against medical advice, and establishing follow-up for diagnostic studies ordered while in the ED (especially x-ray studies). Communication breakdown seems to be more predictive of malpractice litigation than injury experienced. ConclusionsThere are consistent diagnoses that are associated with increased litigation incidence. A combination of mitigation approaches may assist providers in mitigation of malpractice risk.

Attitudes, knowledge and behavior of Japanese physical therapists with regard to evidence-based practice and clinical practice guidelines: a cross-sectional mail survey

[Purpose] This study aimed to investigate Japanese physical therapists’ attitudes of evidence-based practice and clinical practice guidelines. [Subjects and Methods] In 2014, a cross-sectional postal mail survey using a self-administered questionnaire was conducted. Of 2,982 physical therapists belonging to the Chiba Prefecture Physical Therapist Association, 1,000 were randomly selected. The questionnaire comprised 42 items pertaining to the attitudes of and behavior toward evidence-based practice and clinical practice guidelines. It was investigated to reveal the relationship between clinical practice guidelines/evidence-based practice and therapist characteristics. [Results] The response rate was 39.6%, and 384 questionnaires were available. The main results were as follows: 83.3% participants agreed to the importance of evidence-based practice, 77.1% agree to that evidence-based practice supports clinical decision of physical therapists, and about 11% agreed to have been educated about evidence-based practice. Then, 29.2% used, 54.9% agreed to the importance of, and 13.3% agreed to the utility of clinical practice guidelines. An important factor related mostly to a positive attitude, knowledge and behavior of evidence-based practice and clinical practice guidelines was participating in research activities. [Conclusion] Many of physical therapists do not use and understand the importance of clinical practice guidelines. Participating in research activities may partially contribute to improving these conditions.

Utilization of clinical practice guidelines: a survey of Canadian pediatric physicians

Background: It is not clear how physicians currently use clinical practice guidelines (CPGs).Objectives: The objective was to describe how Canadian pediatric residents and pediatricians use CPGs and to identify barriers to CPG use.Methods: Pediatric emergency physicians and general pediatricians in Edmonton and Ottawa and all Canadian pediatric residents were surveyed regarding patterns of use for CPGs and barriers to use. Results: Response rate was 178/847 (21%). The majority of responding residents (62%), emergency physicians (54%) and general pediatricians teaching more than 6 weeks annually on a clinical teaching unit (CTU) use CPGs at least monthly (55%) with less frequent use by pediatricians who teach 1 to 6 weeks on CTU (14%) or rarely/never teach on CTU (21%) (p<0.001). Canadian physicians are more likely to read Canadian Paediatric Society guidelines when they are published versus referring to them later when dealing with clinical problems while the opposite appears to be true for American Academy of Pediatrics guidelines. The most common barrier to use of guidelines is forgetting that a guideline exists for a specific problem. The majority of physicians access CPGs electronically and support development of web based tools to improve accessibility.Conclusions: Almost all pediatric residents, pediatric emergency physicians and general pediatricians sometimes refer to CPGs. General pediatricians teaching less than 6 weeks per year on CTUs are an important target population, as most use CPGs infrequently. Prompts that CPGs exist and accessible online summaries of CPGs appear to have potential for overcoming the barriers to use.

176: Utilization of Clinical Practice Guidelines: A Survey of Canadian Pediatric Physicians

176: Utilization of Clinical Practice Guidelines: A Survey of Canadian Pediatric Physicians

Survey on Clinical Practice Guidelines Use among Latin American Cardiologists.

Background There is a broad consensus about the benefits of applying Clinical Practice Guidelines (CPGs) as a standard of care and most countries, even in Latin America; however, the applicability of CPGs to medical practice is lower than expected. The failure in the implementation of CPGs is due to several factors, including physicians’ lack of adherence. Objectives To estimate the utilization rate of CPGs and to know the objections of Latin American cardiologists against them. Material and Methods We conducted an anonymous email survey among 10% of the Spanish-speaking members of the Interamerican Society of Cardiology that were randomly selected. The questions included demographic data, use of CPGs and objections to use them. We assumed that most of the respondents would make a positive answer when asked about the use CPGs; yet, we also assumed that they would criticize and comment the limitations of CPGs if they were induced to do so. Results The survey was responded by 952 of the 1197 cardiologists selected. The utilization rate of CPGs was 91.5%; 75.8% (660/871) used foreign and local guidelines, while 24.2% only used local CPGs. 58.2% of survey respondents had at least one objection to the quality or usefulness of CPGs. The most common complaints were that the guidelines proposed the use of resources that were not always available (11.5%), recommended impractical strategies due to lack of medical coverage (9.2%) and did not represent the patients in real practice (7.7%). Among those who did not use CPGs, 22.2% did not know the last guidelines published. Conclusions Although the utilization of CPGs is high, the objections about their usefulness constitute a barrier to improve the adherence of cardiologists to use them. These data should be considered to improve the production, diffusion and implementation of CPGs in Latin America.

A Study on Participation in Clinical Decision Making by Home Healthcare Nurses

This study was done to identify participation by home healthcare nurses in clinical decision making and factors influencing clinical decision making. A descriptive survey was used to collect data from 68 home healthcare nurses in 22 hospital-based home healthcare services in Korea. To investigate participation, the researcher developed 3 scenarios through interviews with 5 home healthcare nurses. A self-report questionnaire composed of tools for characteristics, factors of clinical decision making, and participation was used. Participation was relatively high, but significantly lower in the design phase (F=3.51, p=.032). Competency in clinical decision making (r=.45, p<.001), perception of the decision maker role (r=.47, p<.001), and perception of the utility of clinical practice guidelines (r=.25, p=.043) were significantly correlated with participation. Competency in clinical decision making (Odds ratio [OR]=41.79, p=.007) and perception of the decision maker role (OR=15.09, p=.007) were significant factors predicting participation in clinical decision making by home healthcare nurses. In order to encourage participation in clinical decision making, education programs should be provided to home healthcare nurses. Official clinical practice guidelines should be used to support home healthcare nurses' participation in clinical decision making in cases where they can identify and solve the patient health problems.

Clinical Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review.

Review objective: The objective of this systematic review is to identify the effectiveness of different clinical practice guideline implementation strategies on team-based practice and/or patient outcomes. Inclusion criteria: Types of participants: This review will investigate studies concerning health care teams who collaborate in an active or proactive way. Studies involving multiple professions who simply follow the same guideline will be excluded from the review. This review will consider studies that include team-based practices, i.e. practices including two or more professions or disciplines (for example medicine, nursing, occupational therapy, physical therapy, dietetics/nutrition, speech language therapy, social work, dentists/hygienists, laboratory services, pharmacy, health administration). Types of intervention(s)/phenomena of interest: This review will consider studies that evaluate the implementation and/or dissemination of clinical practice guidelines. For this review the definition of clinical practice guidelines is broad and does not require that term to be explicitly stated. For inclusion in this review, clinical practice guidelines are considered to be any systematically developed statements used to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Types of outcome measures: This review will consider studies that include the following outcome measures: any objective measure of change in provider behaviour and/or patient outcome resulting from the assimilation of the clinical practice guideline specific to the implementation/ dissemination strategy.

What factors induce health care decision-makers to use clinical guidelines? Evidence from provincial health ministries, regional health authorities and hospitals in Canada

This paper addresses three questions: What is the extent of clinical guideline utilization by decision-makers in provincial health ministries, regional health authorities and hospitals in Canada? Are there differences between these work settings in regard to the extent of clinical guideline utilization? What are the determinants of clinical guidelines utilization in health ministries, regional health authorities and hospitals? Based on a survey of 899 decision-makers from Canadian provincial health ministries, regional health authorities and hospitals, the results indicate that there are large differences between work settings in regard to clinical guideline utilization. Not surprisingly, work settings like hospitals rely more intensively on clinical guidelines than the other work settings (health ministries or agencies and regional health authorities). The results of the regression models indicate that cognitive factors, social factors, technological factors, organizational factors and individual attributes significantly predict the utilization of clinical practice guidelines by decision-makers. However, the results of the regression models also indicate that some factors that predict clinical guideline utilization by decision-makers in hospitals do not predict clinical guidelines utilization by decision-makers working in ministries or in regional health authorities. Therefore, these results suggest that customized interventions would be appropriate in order to efficiently increase the utilization of clinical practice guidelines in different work settings. The paper concludes with suggestions for future research.

A COMPARISON OF CLINICAL PRACTICE GUIDELINE APPRAISAL INSTRUMENTS

To identify and compare clinical practice guideline appraisal instruments. Appraisal instruments, defined as instruments intended to be used for guideline evaluation, were identified by searching MEDLINE (1966-99) using the Medical Subject Heading (MeSH) practice guidelines, reviewing bibliographies of the retrieved articles, and contacting authors of guideline appraisal instruments. Two reviewers independently examined the questions/statements from all the instruments and thematically grouped them. The 44 groupings were collapsed into 10 guideline attributes. Using the items, two reviewers independently undertook a content analysis of the instruments. Fifteen instruments were identified, and two were excluded because they were not focused on evaluation. All instruments were developed after 1992 and contained 8 to 142 questions/statements. Of the 44 items used for the content analysis, the number of items covered by each instrument ranged from 6 to 34. Only the instrument by Cluzeau and colleagues included at least one item for each of the 10 attributes, and it addressed 28 of the 44 items. This instrument and that of Shaneyfelt et al. are the only instruments that have so far been validated. A comprehensive, concise, and valid instrument could help users systematically judge the quality and utility of clinical practice guidelines. The current instruments vary widely in length and comprehensiveness. There is insufficient evidence to support the exclusive use of any one instrument, although the Cluzeau instrument has received the greatest evaluation. More research is required on the reliability and validity of existing guideline appraisal instruments before any one instrument can become widely adopted.

Adherence to Asthma Guidelines in General Practices

Adherence to asthma practice guidelines is low. Improved compliance could potentially improve care of patients with asthma. The purpose of this study was to determine if patients managed in a general practice with an associated asthma clinic are more likely to use asthma medications according to clinical practice guidelines than patients managed in the general surgery of the practice. A cross-sectional study of adult asthmatics, aged 18-55 years, was conducted in six British general practices. Prescription data on all asthma medication was collected for a 6-month period. Information on asthma clinic attendance, age, sex, employment status, other medical illness, and how patients used their inhaled beta2-agonist was collected through questionnaire. The prescription data for asthma medication and patient use of inhaled beta2-agonist were compared to the British Thoracic Society's (BTS) Guidelines for Management of Asthma in Adults to determine if the patient's asthma medication regimen was appropriate. There was no significant association found between appropriate asthma medication and asthma clinic attendance or other patient characteristics. Adherence to the BTS guidelines was low. Fifty-eight percent of the asthma patients used asthma medication regimens that were not consistent with the BTS guidelines published 1 year earlier. Adherence to the BTS guidelines was low regardless of patient characteristics, including asthma clinic attendance, age, sex, employment status, other medical illness, or individual practice. These findings underscore the need to document the utility of clinical practice guidelines which may improve physician compliance.

A template-based approach to support utilization of clinical practice guidelines within an electronic health record.

Practice guidelines are an integral part of evidence-based health care delivery. When the authors decided to install the clinical documentation component of an electronic health record in a nurse practitioner faculty practice, however, they found that they lacked the resources to integrate it immediately with other systems and components that would support the processing of clinical rules. They were thus challenged to devise an initial approach for decision support related to clinical practice guidelines that did not include interfacing with an inference engine and set of decision rules. The authors developed a prototypic application within the WAVE electronic health record that demonstrates the feasibility of representing a guideline as structured encoded text organized into an online patient-encounter template. Although this approach may be more broadly applicable, it is described within the context of the management of diabetes mellitus by nurse practitioners. The advantages of the approach relate primarily to the integration of the guideline recommendations with the encounter form, the online interaction of the clinician with the system, and the ease of creation and modification of the guideline-based encounter form. However, there are several limitations of the current approach as a result of the inability to do inference and the lack of integration with patient-specific data to trigger specific rules.

Spinal cord injury

Spinal cord injury (SCI) is a catastrophic event that results in physical disability and impaired function of various organ systems. Although a cure still does not exist, with the advances in clinical practice, people with SCI have increased life expectancy as well as reduced morbidity. The worldwide adaptation of the International Standards for Neurologic Classification of SCI, the utilization of clinical practice guideline, the development of comprehensive multidisciplinary educational websites, the establishment of peer support organization and networks, and the advances of wheelchair and assistive devices all facilitate the management and improve the quality of life of SCI patients. Until we find a cure for this condition, people with SCI, their family, their caregivers, and society at large must work together to eliminate barriers to health care and ensure their full participation in all aspects of community life.