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Literature update October 2011

A selection of guideline related literature covering the period June-September 2011

Note: For the future we are planning to be more systematic and have asked support from Leena Lodenius at Duodecim in developing a search strategy that can be duplicated for each issue.

Alonso-Coello P, Martinez Garcia L, Carrasco Gimeno JM, Sola I, Qureshi S, Burgers JS, Ugwg UG. The updating of clinical practice guidelines: insights from an international survey. Implement Sci. 2011 Sep 13;6(1):107 (PMID: 21914177)

Background: Clinical practice guidelines (CPGs) have become increasingly popular and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the selection and appraisal of the available literature. We conducted an international survey to identify current practices in CPGs updating, and explored the needs to standardize and improve the methods. Methods: A questionnaire (28 items) was designed based on a review of the existing literature about guideline updating and expert comments. The survey was carried out between March and July 2009 and was sent by e-mail to 106 institutions: 69 members of the Guidelines International Network who declared developing CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee. Results: Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty six institutions (92%) reported that they updated their guidelines. Thirty one institutions (86%) had a formal procedure for updating their guidelines and 19 (53%) had a formal procedure for deciding when a guideline becomes out of date. Institutions described the process as moderately rigorous (36%) or acknowledging that it could certainly be more rigorous (36%). Twenty two institutions (61%) alert guideline users on their website when a guideline is older than 3-5 years or when there is a risk of being outdated. Twenty five institutions (64%) supported the concept of 'living guidelines', which are continuously being monitored and updated. Eighteen (46%) had plans to design a protocol to improve their guideline updating process and 21 (54%) were willing to share resources with other organizations. Conclusions: Our study is the first international survey about the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process, and to minimise duplication of effort internationally.

Lugtenberg M, Burgers JS, Besters CF, Han D, Westert GP. Perceived barriers to guideline adherence: a survey among general practitioners. BMC Family Practice. 2011, 12:98

Background: Despite considerable efforts to promote and support guideline use, adherence is often suboptimal. Barriers to adherence vary not only across guidelines but also across recommendations within guidelines. The aim of this study was to assess the perceived barriers to guideline adherence among GPs by focusing on key recommendations within guidelines. Methods: We conducted a cross-sectional electronic survey among 703 GPs in the Netherlands. Sixteen key recommendations were derived from four national guidelines. Six statements were included to address the attitudes towards guidelines in general. In addition, GPs were asked to rate their perceived adherence (one statement) and the perceived barriers (fourteen statements) for each of the key recommendations, based on an existing framework. Results: 264 GPs (38%) completed the questionnaire. Although 35% of the GPs reported difficulties in changing routines and habits to follow guidelines, 89% believed that following guidelines leads to improved patient care. Perceived adherence varied between 52 and 95% across recommendations (mean: 77%). The most perceived barriers were related to external factors, in particular patient ability and behaviour (mean: 30%) and patient preferences (mean: 23%). Lack of applicability of recommendations in general (mean: 22%) and more specifically to individual patients (mean: 25%) were also frequently perceived as barriers. The scores on perceived barriers differed largely between recommendations [minimum range 14%; maximum range 67%]. Conclusions: Dutch GPs have a positive attitude towards the NHG guidelines, report high adherence rates and low levels of perceived barriers. However, the perceived adherence and perceived barriers varied largely across recommendations. The most perceived barriers across recommendations are patient related, suggesting that current guidelines do not always adequately incorporate patient preferences, needs and abilities. It may be useful to provide tools such as decision aids, supporting the flexible use of guidelines to individual patients in practice.

Langton JM, Drew AK, Mellish L, Olivier J, Ward RL, Pearson SA.The quality of web-based oncology guidelines and protocols: how international sites stack-up? Br J Cancer. 2011 Sep 20 [Epub ahead of print]

Background: The Internet is a popular medium for disseminating information relevant to oncology practitioners. Despite the widespread use of web-based guidelines and protocols, the quality of these resources has not been evaluated. This study addresses this gap. Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument was used to assess the quality of breast and sarcoma guidelines and protocols according to six independent domains. The oncology resources were selected from eight websites developed for healthcare settings in North America, the United Kingdom, Europe, and Australia. Results: Mean quality scores across domains were highly variable for both guidelines (29-73%) and protocols (31-71%). Guidelines scored highly in terms of articulating their Scope and Purpose (72.6±11.2%) but poorly with respect to Applicability in clinical practice (29.0±17.3%). Protocols scored highly on Clarity of Presentation (70.6±17.6%) but poorly in terms of the processes used to synthesise underlying evidence, develop, and update recommendations (30.8±20.0%). Conclusion: Our evaluation provides a quick reference tool for clinicians about the strengths and limitations of oncology resources across several major websites. Further, it supports resource developers in terms of where to direct efforts to enhance guideline and protocol development processes or the communication of these processes to end-users.

Tripp SB, Perry JT, Romney S, Blood-Siegfried J. Providers as weight coaches: using practice guidelines and motivational interview to treat obesity in the pediatric office. J Pediatr Nurs. 2011 Oct;26(5):474-9

Motivational interview techniques combined with an evidence-based guideline provide valuable tools for the treatment of childhood obesity. The National Association of Pediatric Nurse Practitioners' Healthy Eating and Activity Together guidelines were adopted in a rural pediatric office. After a 6-month pilot, effectiveness of treatment was evaluated with a retrospective chart review. The results suggest that children were motivated for healthy lifestyle changes but had difficulty maintaining motivation and compliance with healthy change choices after 1-2 months; however, with consistent use of motivational interviewing techniques combined with diet and exercise counseling, there was a trend toward lowered body mass index and waist measurements.

Conway LJ, Larson EL. Guidelines to prevent catheter-associated urinary infection: 1980 to 2010. Heart Lung. 2011 Sep 17 [Epub ahead of print]

Objectives: We set out to review and compare guidelines to prevent catheter-associated urinary tract infection (CAUTI), examine the association between recent federal initiatives and CAUTI guidelines, and recommend practices for preventing CAUTI that are associated with strong evidence and are consistent across guidelines. Background: Catheter-associated urinary tract infections are the most common healthcare-associated infection, and a cause of significant morbidity and mortality in critically ill patients. Methods: A search of the English-language literature for guidelines in the prevention of adult CAUTI, published between 1980 and 2010, was conducted in Medline and the National Guideline Clearinghouse. Results: Many recommendations were consistent across 8 guidelines, including limited use of urinary catheters, the insertion of catheters aseptically, and the maintenance of a closed drainage system. The weight of evidence for some endorsed practices was limited, and different grading systems made comparisons across recommendations difficult. Federal initiatives are closely aligned with the 4 most recent guidelines. Conclusion: Additional research into the prevention of CAUTI is needed, as is a harmonization of guideline grading systems for recommendations.

Riley M, Galang S, Green LA. The impact of clinical reminders on prenatal care. Fam Med. 2011 Sep;43(8):560-5

Background and objectives: This study assessed the effect of automated prenatal care reminders on adherence to standards of prenatal care at two family medicine teaching clinics. Methods: This was a reversal-design prospective study using medical records of prenatal patients during baseline, intervention, and post-intervention periods. Results: A total of 9.5% of patients received all guideline-recommended care at baseline compared to 55.7% in the intervention period, decreasing to 17.1% after the intervention. The most commonly missed services were offering first trimester aneuploidy screening and genetic screening, HIV screening, considering the need for repeat third trimester gonorrhea and chlamydia (GC/Chl) screening, and influenza vaccination. The clinical reminders significantly improved the number of patients offered HIV testing, given influenza vaccination, and tested or considered for repeat GC/Chl. Improvement in first trimester aneuploidy screening approached but did not meet statistical significance due to lower numbers of patients qualifying for this service. HIV testing and repeat GC/Chl screening significantly decreased in the post-intervention period, and compliance with most other standards trended downward as well. Conclusions: Adherence to prenatal care standards by resident and faculty family medicine providers at baseline was less than optimal. Clinical reminders significantly improved overall adherence to prenatal standards and improved compliance with the most commonly missed standards. When the reminders were no longer active, compliance regressed toward baseline levels. These results support the use of prenatal care reminders as an effective way to help family physicians provide and document comprehensive prenatal care.

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Page last updated: Oct 06, 2011
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