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Literature update April 2011

A selection of guideline related literature covering the period 13 January to 31 March 2011

Susan Flannery Wainwright, Katherine F. Shepard, Laurinda B. Harman, and James Stephens. Factors That Influence the Clinical Decision Making of Novice and Experienced Physical Therapists. Phys Ther 2011;91:87-101.

Background. The depth and breadth of prior experience informs clinical decision making in novice and experienced physical therapist clinicians. Objectives. The aims of this research were to identify differences in clinical decision-making abilities and processes between novice and experienced physical therapist clinicians and to develop a model of the factors that influence clinical decision making. Design. Qualitative research methods and grounded theory were used to gain insight into the factors and experiences that inform clinical decision making. Methods. Three participant pairs (each pair consisted of 1 novice physical therapist and 1 experienced physical therapist) were purposively selected from 3 inpatient rehabilitation settings. Case summaries from each participant provided the basis for within- and across-case analyses. The credibility of the results was established through checking of the case summaries by the participants, presentation of low-inference data, and triangulation across multiple data sources and within and across participant groups. Results. The factors that influenced clinical decision making were categorized as informative or directive. Novice participants relied more on informative factors, whereas experienced participants were more likely to rely on directive factors. An intermediate effect beyond novice practice was observed. Conclusions. The results of this study may be used by educators and employers to develop and structure learning experiences and mentoring opportunities for students and novice learners with the aim of facilitating the development of skills and abilities consistent with expert clinical decision making.

Alex B Haynes, Thomas G Weiser, William R Berry, Stuart R Lipsitz, Abdel-Hadi S Breizat, E Patchen Dellinger, Gerald Dziekan, Teodoro Herbosa, Pascience L Kibatala, Marie Carmela M Lapitan, Alan F Merry, Richard K Reznick, Bryce Taylor, Amit Vats, Atul A Gawande, for the Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 2011;20:102-107.


Objectives To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. Design Pre- and post intervention survey. Setting Eight hospitals participating in a trial of a WHO surgical safety checklist. Participants Clinicians actively working in the designated study operating rooms at the eight hospitals. Survey instrument Modified operating-room version Safety Attitudes Questionnaire (SAQ). Main outcome measures Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. Results Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. Conclusions Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

Damon C. Scales, Katie Dainty, Brigette Hales, Ruxandra Pinto, Robert A. Fowler, Neill K. J. Adhikari, Merrick Zwarenstein. A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial. JAMA 2011;305(4):363-372.

Context Evidence-based practices improve intensive care unit (ICU) outcomes, but eligible patients may not receive them. Community hospitals treat most critically ill patients but may have few resources dedicated to quality improvement. Objective To determine the effectiveness of a multicenter quality improvement program to increase delivery of 6 evidence-based ICU practices. Design, Setting, and Participants Pragmatic cluster-randomized trial among 15 community hospital ICUs in Ontario, Canada. A total of 9269 admissions occurred during the trial (November 2005 to October 2006) and 7141 admissions during a decay-monitoring period (December 2006 to August 2007). Intervention We implemented a videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 practices. We randomized ICUs into 2 groups. Each group received this intervention, targeting a new practice every 4 months, while acting as control for the other group, in which a different practice was targeted in the same period. Main Measure Outcomes The primary outcome was the summary ratio of odds ratios (ORs) for improvement in adoption (determined by daily data collection) of all 6 practices during the trial in intervention vs control ICUs. Results Overall, adoption of the targeted practices was greater in intervention ICUs than in controls (summary ratio of ORs, 2.79; 95% confidence interval [CI], 1.00-7.74). Improved delivery in intervention ICUs was greatest for semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs 50.0% in first month; OR, 6.35; 95% CI, 1.85-21.79) and precautions to prevent catheter-related bloodstream infection (70.0% of patients receiving central lines vs 10.6%; OR, 30.06; 95% CI, 11.00-82.17). Adoption of other practices, many with high baseline adherence, changed little. Conclusion In a collaborative network of community ICUs, a multifaceted quality improvement intervention improved adoption of care practices.

Paul C. Schroy III, Karen Emmons, Ellen Peters, Julie T. Glick, Patricia A. Robinson, Maria A. Lydotes, Shamini Mylvanaman, Stephen Evans, Christine Chaisson, Michael Pignone, Marianne Prout, Peter Davidson, and Timothy C. Heeren. The Impact of a Novel Computer-Based Decision Aid on Shared Decision Making for Colorectal Cancer Screening: A Randomized Trial. Med Decis Making 2011;31:93-107.

Background. Eliciting patients’ preferences within a framework of shared decision making (SDM) has been advocated as a strategy for increasing colorectal cancer (CRC) screening adherence. Our objective was to assess the effectiveness of a novel decision aid on SDM in the primary care setting. Methods. An interactive, computer-based decision aid for CRC screening was developed and evaluated within the context of a randomized controlled trial. A total of 665 average-risk patients (mean age, 57 years; 60% female; 63% black, 6% Hispanic) were allocated to 1 of 2 intervention arms (decision aid alone, decision aid plus personalized risk assessment) or a control arm. The interventions were delivered just prior to a scheduled primary care visit. Outcome measures (patient preferences, knowledge, satisfaction with the decision-making process [SDMP], concordance between patient preference and test ordered, and intentions) were evaluated using prestudy/poststudy visit questionnaires and electronic scheduling. Results. Overall, 95% of patients in the intervention arms identified a preferred screening option based on values placed on individual test features. Mean cumulative knowledge, SDMP, and intention scores were significantly higher for both intervention groups compared with the control group. Concordance between patient preference and test ordered was 59%. Patients who preferred colonoscopy were more likely to have a test ordered than those who preferred an alternative option (83% v. 70%; P < 0.01). Intention scores were significantly higher when the test ordered reflected patient preferences. Conclusions. Our interactive computer-based decision aid facilitates SDM, but overall effectiveness is determined by the extent to which providers comply with patient preferences.

Chris Cammisa, Gregory Partridge, Cynthia Ardans, Katrina Buehrer, Ben Chapman, and Howard Beckman. Engaging Physicians in Change: Results of a Safety Net Quality Improvement Program to Reduce Overuse. American Journal of Medical Quality 2011;26: 26-33.

Identifying, understanding, and addressing clinical variation is a useful tool to promote appropriate care while helping control health care costs. Although accurate, relevant, and useful data are important in the process, successfully engaging physicians to change behavior is often the most significant challenge. Using a commercially available variation analysis process, a California Medicaid managed care plan identified significant network practice pattern variation. A team of panel practitioners then developed a strategy to reduce overuse of 5 identified behaviors. The intervention was evaluated using a pre—post comparison of the panel’s use of the 5 behaviors. During the preintervention period, narcotics, muscle relaxants, magnetic resonance imaging (MRI), and spinal injections increased between 8% and 18% per month. Postintervention, the trends reversed. The differences were statistically significant (P < .0001) for muscle relaxant use, narcotic use, overall MRI use, and spinal injections. Peer comparison data and respectful feedback was associated with significant change in patterns of overuse.

Zoe A. Michaleff, Leonardo O.P. Costa, Anne M. Moseley, Christopher G. Maher, Mark R. Elkins, Robert D. Herbert, and Catherine Sherrington. CENTRAL, PEDro, PubMed, and EMBASE Are the Most Comprehensive Databases Indexing Randomized Controlled Trials of Physical Therapy Interventions. Phys ther 2011;91:190-197.


Background Many bibliographic databases index research studies evaluating the effects of health care interventions. One study has concluded that the Physiotherapy Evidence Database (PEDro) has the most complete indexing of reports of randomized controlled trials of physical therapy interventions, but the design of that study may have exaggerated estimates of the completeness of indexing by PEDro. Objective The purpose of this study was to compare the completeness of indexing of reports of randomized controlled trials of physical therapy interventions by 8 bibliographic databases. Design This study was an audit of bibliographic databases. Methods Prespecified criteria were used to identify 400 reports of randomized controlled trials from the reference lists of systematic reviews published in 2008 that evaluated physical therapy interventions. Eight databases (AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO, and PubMed) were searched for each trial report. The proportion of the 400 trial reports indexed by each database was calculated. Results The proportions of the 400 trial reports indexed by the databases were as follows: CENTRAL, 95%; PEDro, 92%; PubMed, 89%; EMBASE, 88%; CINAHL, 53%; AMED, 50%; Hooked on Evidence, 45%; and PsycINFO, 6%. Almost all of the trial reports (99%) were found in at least 1 database, and 88% were indexed by 4 or more databases. Four trial reports were uniquely indexed by a single database only (2 in CENTRAL and 1 each in PEDro and PubMed). Limitations The results are only applicable to searching for English-language published reports of randomized controlled trials evaluating physical therapy interventions. Conclusions The 4 most comprehensive databases of trial reports evaluating physical therapy interventions were CENTRAL, PEDro, PubMed, and EMBASE. Clinicians seeking quick answers to clinical questions could search any of these databases knowing that all are reasonably comprehensive. PEDro, unlike the other 3 most complete databases, is specific to physical therapy, so studies not relevant to physical therapy are less likely to be retrieved. Researchers could use CENTRAL, PEDro, PubMed, and EMBASE in combination to conduct exhaustive searches for randomized trials in physical therapy

N Mlika-Cabanne, R Harbour, H de Beer, M Laurence, R Cook, S Twaddle. Sharing hard labour: developing a standard template for data summaries in guideline development. BMJ Qual Saf 2011;20:141-145.


Background A key objective of the Guidelines International Network (GIN) is to reduce duplication of effort. To address this objective, a working group was established to define a minimum dataset for inclusion in all evidence tables. Methods A literature review was conducted to identify existing evidence tables, and GIN member organisations were asked to provide the tables they use. The results were used to develop a minimum dataset (template) for studies addressing intervention questions. The template was pilot-tested by a group of guideline developers and reviewed at GIN conferences. Results The literature search yielded 65 articles. These dealt with reporting standards and trial quality (eg, CONSORT statement) rather than which data should be extracted from studies. However, the checklist items given were considered useful. Nineteen GIN members provided evidence tables; 17 tables were used for analysis. The number of items included in the tables ranged from 8 to 19, with several items common to all tables. Within individual items, the level of detail varied widely. The draught template included a majority of items relating to objective data. Pilot testing revealed that the median time to read a paper and complete the template was 2 h for a randomised controlled trial and 2½ h for a non-randomised, controlled intervention study. The median rating for both relevance and clarity of items was high. Conclusion The template listing the items needed to summarise an interventional study is now available for large-scale testing by all organisations.

B Carlsen, B Bringedal. Attitudes to clinical guidelines—do GPs differ from other medical doctors? BMJ Qual Saf 2011;20:158-162.


Background Clinical guidelines are important for ensuring quality of treatment and care. For this reason, it is essential that clinicians adhere to guidelines. Review studies conclude that barriers to using guidelines are context specific. Nevertheless, there is a lack of studies that compare the attitudes of different groups of doctors to guidelines. Objectives To survey the attitudes of Norwegian medical practitioners to clinical guidelines and the reasons for any scepticism, and to compare general practitioners (GPs) with other medical doctors in Norway in this respect. Method Postal questionnaire to a panel of 1649 Norwegian medical doctors. Results 1072 doctors responded (65%). 97% claimed to be familiar with and following guidelines. A majority expressed confidence in guidelines issued by the health authorities and the medical association. GPs are significantly more uncertain about the legal status of, accessibility of and evidence in guidelines than other doctors. The most important barriers to guideline adherence are concerns about the uniqueness of individual cases and reliance on one's own professional discretion. Both groups rank attitudinal constraints higher than practical constraints, but GPs more often report practical issues as reasons for non-adherence. Conclusion It is suggested that creating trust in guidelines could be more important than more efforts to improve guideline format and accessibility. It may also be worth considering whether guidelines should be implemented using different processes in generalist and specialist care.


Salomeh Keyhani, Azalea Kim, Micah Mann, and Deborah Korenstein. ANALYSIS & COMMENTARY: A New Independent Authority Is Needed To Issue National Health Care Guidelines. Health Aff 2011;30:2256-265.


Health experts emphasize that getting doctors to follow clinical guidelines can save both lives and money. Less attention has been paid to how the guidelines are developed and the variability in the recommendations they include. We examined the quality and content of screening guidelines as a proxy for guidelines in general and found that the source of the guidelines affects their quality. Guidelines with inconsistent recommendations are unlikely to serve patients or physicians well. The creation of an independent organization that would work with multiple stakeholders to develop guidelines holds the potential to improve their quality.


Douglas K. Owens, Amir Qaseem, Roger Chou, Paul Shekelle, and for the Clinical Guidelines Committee of the American College of Physicians. High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions. Ann Intern Med 2011;154:174-180.

Health care costs in the United States are increasing unsustainably, and further efforts to control costs are inevitable and essential. Efforts to control expenditures should focus on the value, in addition to the costs, of health care interventions. Whether an intervention provides high value depends on assessing whether its health benefits justify its costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit.

Thus, the challenge becomes determining how to slow the rate of increase in costs while preserving high-value, high-quality care. A first step is to decrease or eliminate care that provides no benefit and may even be harmful. A second step is to provide medical interventions that provide good value: medical benefits that are commensurate with their costs. This article discusses 3 key concepts for understanding how to assess the value of health care interventions. First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value. Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed. Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention.


Zhao-xiang Bian and Hong-cai Shang. CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomized Trials. Ann Intern Med 2011;154:290-291.

Manuela De Allegri, Matthias Schwarzbach, Adrian Loerbroks, Ulrich Ronellenfitsch. Which factors are important for the successful development and implementation of clinical pathways? A qualitative study. BMJ Qual Saf  2011;20:203-208.


Introduction Clinical pathways (CPs) are detailed longitudinal care plans delineating measures to be conducted during a patient's treatment. Although positive effects on resource consumption and quality of care have been shown, CPs are still underutilised in many clinical settings because their development and implementation are difficult. Evidence underpinning successful development and implementation is sparse. Methods The authors conducted semistructured face-to-face interviews with key staff members involved in the design and implementation of CPs in a large surgery department. Interviewees were asked to provide opinions on various issues, which were previously identified as potentially important in CP development and implementation. The transcribed text was read and coded independently by two researchers. Results Respondents highlighted the importance of a multidisciplinary participatory approach for CP design and implementation. There was a strong initial fear of losing individual freedom of treatment, which subsided after people worked with CPs in clinical everyday life. It was appreciated that the project originated from people at different levels of the department's hierarchy. Likewise, it was felt that CP implementation granted more autonomy to lower-level staff. Conclusion The structured qualitative approach of this study provides information on what issues are considered important by staff members for CP design and implementation. Whereas some concepts such as the importance of a multidisciplinary approach or continuous feedback of results are known from theories, others such as strengthening the authority especially of lower-level health professionals through CPs have not been described so far. Many of the findings point towards strong interactions between factors important for CP implementation and a department's organisational structure.

Maartje Willekens, Paul Giesen, Erik Plat, Henk Mokkink, Jako Burgers, Richard Grol. Quality of after-hours primary care in the Netherlands: adherence to national guidelines. BMJ Qual Saf 2011;20:223-227.


Objective To assess the quality of after-hours clinical care as delivered by general practitioner (GP) cooperatives in the Netherlands. Methods A cross-sectional analysis was undertaken of patient health records of five GP cooperatives during 1 year. We used quality indicators derived from national guidelines for the appropriate prescription of pain medication and antibiotics, clinical performance in emergency cases and referral to medical specialists. Data were collected from electronic health records. Results We analysed 7660 patient contacts. Average adherence to the guidelines was 77%. The guidelines on referrals to medical specialists and prescription of pain medication had the highest adherence scores (92% and 90%, respectively). Prescribing antibiotics and treatment in emergency cases had the lowest scores (69% and 71%, respectively). Antibiotics were overprescribed in 42% of the cases and underprescribed in 21%. Conclusions In general, GPs adhered well to after-hours service national guidelines. There is room for improvement in care for people with acute illnesses and in the prescription of antibiotics.


B Fervers, J S Burgers, R Voellinger, M Brouwers, G P Browman, I D Graham, M B Harrison, J Latreille, N Mlika-Cabane, L Paquet, L Zitzelsberger, B Burnand, The ADAPTE Collaboration. Guideline adaptation: an approach to enhance efficiency in guideline development and improve utilisation. BMJ Qual Saf 2011;20:228-236


Background Developing and updating high-quality guidelines requires substantial time and resources. To reduce duplication of effort and enhance efficiency, we developed a process for guideline adaptation and assessed initial perceptions of its feasibility and usefulness. Methods Based on preliminary developments and empirical studies, a series of meetings with guideline experts were organised to define a process for guideline adaptation (ADAPTE) and to develop a manual and a toolkit made available on a website. Potential users, guideline developers and implementers, were invited to register and to complete a questionnaire evaluating their perception about the proposed process. Results The ADAPTE process consists of three phases (set-up, adaptation, finalisation), 9 modules and 24 steps. The adaptation phase involves identifying specific clinical questions, searching for, retrieving and assessing available guidelines, and preparing the draft adapted guideline. Among 330 registered individuals (46 countries), 144 completed the questionnaire. A majority found the ADAPTE process clear (78%), comprehensive (69%) and feasible (60%), and the manual useful (79%). However, 21% found the ADAPTE process complex. 44% feared that they will not find appropriate and high-quality source guidelines. Discussion A comprehensive framework for guideline adaptation has been developed to meet the challenges of timely guideline development and implementation. The ADAPTE process generated important interest among guideline developers and implementers. The majority perceived the ADAPTE process to be feasible, useful and leading to improved methodological rigour and guideline quality. However, some de novo development might be needed if no high quality guideline exists for a given topic.

Andrew Tomlin, Susan Dovey, Robin Gauld, Murray Tilyard. Better use of primary care laboratory services following interventions to ‘market’ clinical guidelines in New Zealand: a controlled before-and-after study. BMJ Qual Saf 2011;20:282-290.


Context Laboratory tests for inflammatory response, thyroid function and infectious diarrhoea were not being ordered as recommended by clinical guidelines. Objective To measure changes in community laboratory-test ordering following marketing programmes promoting guidelines recommendations. Design Controlled before-and-after study involving 2 years of national laboratory payment data before and after each intervention. Comparisons were with doctors ordering the same tests but not receiving interventions. Setting New Zealand primary care. Participants 3161, 3140 and 3335 general practitioners and 2424, 2443 and 2766 Comparison doctors ordering inflammatory response, thyroid function and acute diarrhoea tests from community laboratories, July 2003 to March 2009. Interventions Three separate marketing programmes to general practitioners, each comprising written material advising of guidelines recommendations, individual laboratory-test use feedback and professional development opportunities. Main outcome measures Number of tests, tests/doctor, patients having tests and tested patients/doctor/year before and after each intervention. Change in expenditure from before each intervention to after. Results For Intervention doctors, erythrocyte sedimentation rate tests decreased 60.0% after the intervention; tests for C-reactive protein increased 63.1%; simultaneous erythrocyte sedimentation rate and C-reactive protein orders decreased 32.6%. Tests for free thyroxine and free triiodothyronine decreased 44.1% and 36.0%. The proportion of thyroid function tests where thyroid-stimulating hormone was the sole test ordered increased from 43.2% before the intervention to 65.2% afterwards (p<0.001; 95% CI 21.7% to 22.2%). Testing for faecal culture decreased 31.5%, giardia and cryptosporidium 31.5%, and ova and parasites 56.9%. Faecal culture as the sole initial test increased from 31.4% to 39.1% (p<0.001; 95% CI 7.2% to 8.2%). Testing by Comparison doctors changed in the same direction but with significantly less magnitude. The estimated reduction in expenditure for study tests was 23.5%. Conclusions Clear information marketed to general practitioners improved the quality of laboratory test ordering for patients in New Zealand.

Désirée A. Lie, Elizabeth Lee-Rey, Art Gomez, Sylvia Bereknyei and Clarence H. Braddock. Does Cultural Competency Training of Health Professionals Improve Patient Outcomes? A Systematic Review and Proposed Algorithm for Future Research. Journal of General Internal Medicine 2011;26(3):317-325.

Background Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities. Objective The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research. Design The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included. Measurements Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted. Results Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect. Conclusion There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Ivan Moschetti, Daniel Brandt, Rafael Perera, M Clarke, Carl Heneghan. Adequacy of reporting monitoring regimens of risk factors for cardiovascular disease in clinical guidelines: systematic review. BMJ 2011;342:d1289.


Objective To assess the reporting of monitoring recommendations in guidelines on the prevention and treatment of cardiovascular disease. Data sources Medline, Trip database, National Guideline Clearinghouse, and databases containing guidelines published from January 2002 to February 2010. Data selection Three major risk factors for cardiovascular disease: cholesterol level, smoking, and hypertension. The primary outcome was the frequency with which the guidelines dealt with monitoring of risk factors. Secondary outcomes were completeness of monitoring recommendations, defined by the presence of what to monitor, when to monitor, what to do if the targets or variables were not met, and the reported level or strength of the evidence. Results 117 guidelines were identified, 84 (72%) of which contained a section on lipids. Of those guidelines with a section on lipids, 53% (n=44) provided no information or specific recommendations on what to monitor, 51% (n=43) provided no information on when to monitor, and 64% (n=54) provided no guidance on what to do if the target was out of range. Guidelines for hypertension (n=79) and smoking (n=65) were little better, with 63% (n=50) and 54% (n=35), respectively, providing no recommendation for what to monitor. The number of guidelines that explicitly referenced the level of evidence for monitoring was low, with most of the recommendations based on weak levels of evidence. Conclusion Many guidelines for cardiovascular disease do not report clearly what to monitor and what to do if a change is detected. If no evidence is available to support a specific monitoring schedule, this should be explicit in the guideline, with a description of the new research that would fill the gap.


Squires JE, Hutchinson AM, Bostrom AM, O'Rourke HM, Cobban SJ and Estabrooks CA. To what extent do nurses use research in clinical practice? A systematic review. Implementation Science 2011; 6:21 (17 March 2011)


Background. In the past forty years, many gains have been made in our understanding of the concept of research utilization. While numerous studies exist on professional nurses' use of research in practice, no attempt has been made to systematically evaluate and synthesize this body of literature with respect to the extent to which nurses use research in their clinical practice. The objective of this study was to systematically identify and analyze the available evidence related to the extent to which nurses use research findings in practice. Methods. This study was a systematic review of published and grey literature. The search strategy included 13 online bibliographic databases: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, EMBASE, HAPI, Web of Science, SCOPUS, OCLC Papers First, OCLC WorldCat, ABI Inform, Sociological Abstracts, and Dissertation Abstracts. The inclusion criteria consisted of primary research reports that assess professional nurses' use of research in practice, written in the English or Scandinavian languages. Extent of research use was determined by assigning research use scores reported in each article to one of four quartiles: low, moderate-low, moderate-high, or high. Results. Following removal of duplicate citations, a total of 12,418 titles were identified through database searches, of which 133 articles were retrieved. Of the articles retrieved, 55 satisfied the inclusion criteria. The 55 final reports included cross-sectional/survey (n = 51) and quasi-experimental (n = 4) designs. A sensitivity analysis, comparing findings from all reports with those rated moderate (moderate-weak and moderate-strong) and strong quality, did not show significant differences. In a majority of the articles identified (n = 38, 69%), nurses reported moderate-high research use. Conclusions. According to this review, nurses' reported use of research is moderate-high and has remained relatively consistent over time until the early 2000's. This finding, however, may paint an overly optimistic picture of the extent to which nurses use research in their practice given the methodological problems inherent in the majority of studies. There is a clear need for the development of standard measures of research use and robust well-designed studies examining nurses' use of research and its impact on patient outcomes. The relatively unchanged self-reports of moderate-high research use by nurses is troubling given that over 40 years have elapsed since the first studies in this review were conducted and the increasing emphasis in the past 15 years on evidence-based practice. More troubling is the absence of studies in which attempts are made to assess the effects of varying levels of research use on patient outcomes.

Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L and Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implementation Science 2011;6:26 (22 March 2011)


Background. Guidelines continue to be underutilized and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines. Methods. A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team. Results.The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic. Conclusions. Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

Robin Gauld, Jedediah Horwitt, Sheila Williams, and Alan B. Cohen. What Strategies Do US Hospitals Employ to Reduce Unwarranted Clinical Practice Variations? American Journal of Medical Quality 2011;26: 120-126.

Little is known about unwarranted clinical practice variations within US hospitals. The objectives of this study were to investigate whether hospitals are concerned about variations and their experiences with strategies to reduce variations. Case studies were conducted at 5 hospitals, and a survey of acute care hospitals was conducted in 4 states. Each of the case studies presented a different experience. Unwarranted variations were a concern for 90% of survey respondents, with no differences by state (P = .7) or hospital size (P = .2). Of these, 75% had a strategy in place to reduce variation. The likelihood of a multipronged approach was significantly higher in larger hospitals (P = .0009). This study revealed disparate approaches to reducing unwarranted clinical practice variations and also highlighted barriers to reducing variation. The case studies identified some models that could be emulated, but questions remain about whether there is a single best way forward.

Kylie A. McIntosh, David J. Maxwell, Lisa K. Pulver, Fiona Horn, Marion B. Robertson, Karen I. Kaye, Gregory M. Peterson, William B. Dollman, Angela Wai, and Susan E. Tett. A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments. Int J Qual Health Care 2011; 23(2): 142-150.

Objective The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). Design and Interventions Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. Setting and Participants Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. Main Outcome Measures Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. Results Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462–518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4–8) at baseline to 125/503 (25%, 95% CI 21–29; P < 0.0001) and 102/462 (22%, 95% CI 18–26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16–23) to 132/462 (30%, 95% CI 26–34; P < 0.0001) and 132/462 (29%, 95% CI 24–33; P < 0.001), respectively. Conclusions Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

Susanne Heiwe, Kerstin Nilsson Kajermo, Raija Tyni-Lenné, Susanne Guidetti, Monika Samuelsson, Inga-Lena Andersson, and Yvonne Wengström. Evidence-based practice: attitudes, knowledge and behaviour among allied health care professionals. Int J Qual Health Care 2011;23(2):198-209.

Objective To explore dieticians’, occupational therapists’ and physical therapists’ attitudes, beliefs, knowledge and behaviour concerning evidence-based practice within a university hospital setting. Design Cross-sectional survey. Setting University hospital. Participants All dieticians, occupational therapists and physical therapists employed at a Swedish university hospital (n = 306) of whom 227 (74%) responded. Main Outcome Measures Attitudes towards, perceived benefits and limitations of evidence-based practice, use and understanding of clinical practice guidelines, availability of resources to access information and skills in using these resources. Results Findings showed positive attitudes towards evidence-based practice and the use of evidence to support clinical decision-making. It was seen as necessary. Literature and research findings were perceived as useful in clinical practice. The majority indicated having the necessary skills to be able to interpret and understand the evidence, and that clinical practice guidelines were available and used. Evidence-based practice was not perceived as taking into account the patient preferences. Lack of time was perceived as the major barrier to evidence-based practice. Conclusions The prerequisites for evidence-based practice were assessed as good, but ways to make evidence-based practice time efficient, easy to access and relevant to clinical practice need to be continuously supported at the management level, so that research evidence becomes linked to work-flow in a way that does not adversely affect productivity and the flow of patients.

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