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Literature update December 2011

A selection of guideline related literature covering the period October-November 2011.

Thanks to Leena Lodenius at Duodecim we now have a formal search strategy in place. We can now update the list of relevant literature on the website almost as soon as a new paper is made available and listed in PubMed. We already have more than 400 entries in this database and encourage you to subscribe to the feeds available on the pages: relevant-literature and literature-updates (note: you have to be logged in to be able to do so).

We include here editors’ pick of papers (abstracts by authors if available) retrieved during the period October – November 2011.

Van der Wees PJ, Moore AP, Powers CM, Stewart A, Nijhuis-van der Sanden MWJ, de Bie RA. Development of Clinical Guidelines in Physical Therapy: Perspective for International Collaboration. Physical Therapy. 2011 Oct;91(10):1551-63 (PMID: 21799137)

Gale EAM. Conflicts of interest in guideline panel members. BMJ 2011; 343:d5728 (

A change in the culture of medicine is needed; legislation is not enough.

It has been said that “it is difficult to get a man to understand something when his salary depends upon his not understanding it,” 1 and the medical profession has been slow to understand the importance of conflicts of interest. The linked study by Neuman and colleagues (doi: 10.1136/bmj.d5621 ) reports the prevalence of financial conflicts among guideline panel members in the United States and Canada. Of the 14 guidelines considered, six came from government sponsored organisations, six from specialist or professional organisations, and two from private non-profit organisations; three were from Canada and the remainder from the US. Five (four government sponsored) guidelines provided no conflict of interest statement, but their participants had presumably been screened, because only four of 77 panellists seemed to have a conflict. Six of 12 named chairpersons had a conflict, as did 138 of the 211 panellists who provided a disclosure statement; 12 more failed to disclose an interest, and 10 others received research funding from industry. Only 61 (29%) had no potential financial ties. 2

The guidelines in question related to the management of diabetes and hyperlipidaemia, …

Mickan S, Burls A, Glasziou P. Patterns of ‘leakage’ in the utilisation of clinical guidelines: a systematic review. Postgrad Med J 2011;87:670-679 (

Background: Research evidence is insufficient to change physicians' behaviour. In 1996, Pathman developed a four step model: that physicians need to be aware of, agree with, adopt, and adhere to guidelines.

Objective: To review evidence in different settings on the patterns of ‘leakage’ in the utilisation of clinical guidelines using Pathman's awareness-to-adherence model.

Methods: A systematic review was conducted in June 2010. Primary studies were included if they reported on rates of awareness and agreement and adoption and/or adherence.

Results: 11 primary studies were identified, reporting on 29 recommendations. Descriptive analyses of patterns and causes of leakage were tabulated and graphed. Leakage was progressive across all four steps. Median adherence from all recommendations was 34%, suggesting that potential benefits for patients from health research may be lost. There was considerable variation across different types of guidelines. Recommendations for drug interventions, vaccination and health promotion activities showed high rates of awareness. Leakage was most pronounced between adoption and adherence for drug recommendations and between awareness and agreement for medical management recommendations. Barriers were reported differentially for all steps of the model.

Conclusion: Leakage from research publication to guideline utilisation occurs in a wide variety of clinical settings and at all steps of the awareness-to-adherence pathway. This review confirms that clinical guidelines are insufficient to implement research and suggests there may be different factors influencing clinicians at each step of this pathway. Recommendations to improve guideline adherence need to be tailored to each step.

Kastner M, Estey E, Bhattacharyya O. Better guidelines for better care: enhancing the implementability of clinical practice guidelines. Expert Review of Pharmacoeconomics & Outcomes Research. 11(3):315-24, 2011 Jun.

The potential of clinical practice guidelines to promote evidence-based care has not been consistently realized. This article outlines how modifying guidelines, and specifically their implementability (the perceived characteristics that influence their use in practice), could be an inexpensive way to improve care. The article uses a planned action model, Graham's knowledge-to-action framework, to illustrate how this framework can be applied in the context of an ongoing research initiative. It describes each step from knowledge synthesis, to barrier analysis, intervention development and evaluation of a guideline implementability tool that could facilitate uptake of guidelines in clinical practice. This tool targets guideline developers, so that better guidelines may result in better care.

Cuello Garcia C A, Pacheco Alvarado K P, Perez Gaxiola Go. Grading recommendations in clinical practice guidelines: randomised experimental evaluation of four different systems. Archives of Disease in Childhood. 96(8):723-8, 2011 Aug.

Objective: To evaluate the effect of presenting a recommendation in a clinical practice guideline using different grading systems to determine to what extent the system used changes the clinician's eventual response to a particular clinical question.

Design: Randomised experimental study.

Setting: Clinician offices and academic settings.

Participants: Paediatricians and paediatric residents in private and public practice in Mexico.

Intervention: Case notes of a child with diarrhoea and a question about clinician preference for using racecadotril. The same evidence was provided in a clinical recommendation but with different presentations according to the following grading systems: NICE (National Institute for Health and Clinical Excellence), SIGN (Scottish Intercollegiate Guideline Network), GRADE (Grading of Recommendations Assessment, Development and Evaluation) and CEBM (Centre for Evidence-Based Medicine, Oxford).

Main outcome measure: Mean change in direction from baseline response (measured on a 10 cm visual scale and a Likert scale) and among groups.

Results: 216 subjects agreed to participate. Most participants changed their decision after reading the clinical recommendations (mean difference 0.7 cm, 95% CI 0.29 to 1.0; p<0.001). By groups, mean change (95% CI) from baseline was 0.04 (-0.68 to 0.77) for NICE, 0.31 (-0.41 to 1.05) for SIGN, 2.18 (1.48 to 2.88) for GRADE and 0.08 (-0.52 to 0.69) for CEBM (p=0.007 between groups). In a final survey, a small difference was noted regarding the clarity of the results presented with the GRADE system.

Conclusion: The clinician's decision to use a therapy was influenced most by the GRADE system.

Bloemendal E, Weenink JW, Harmsen M, Mistiaen P. [Adherence to Dutch clinical guidelines: a systematic review] Naleving van Nederlandse richtlijnen: een systematische review. 2011

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Page last updated: Dec 16, 2011
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