[Guideline implementation study on asthma: Results of a pragmatic implementation approach]

Large Variation in Clinical Practice amongst Pediatricians in Treating Children with Recurrent Abdominal Pain

PURPOSE

To evaluate intra- and inter-observer variability and guideline adherence amongst pediatricians in treating children aged between 4 and 18 years referred with recurrent abdominal pain (RAP) without red flags.

METHODS

The first part of the study is a retrospective single-center cohort study. The diagnostic work-ups of eight pediatricians were compared to the national guidelines. Intra- and inter-observer variability were examined by Cramer's V test. Intra-observer variability was defined as the amount of variation within a pediatrician and inter-observer variability as the amount of variation between pediatricians in the application of diagnostic work-up in children with RAP. Prospectively, the same pediatricians were requested to provide a report on their management strategy with a fictitious case to prove similarities in retrospective diagnostic work-up.

RESULTS

A total of 10 patients per pediatrician were analyzed. Retrospectively, a (very) weak association between pediatricians' diagnostic work-ups was found (0.22), which implies high inter-observer variability. The association between intra-observer diagnostic was moderate (range, 0.35-0.46). The Cramer's V of 0.60 in diagnostic work-up between pediatricians in the fictitious case implied the presence of a moderately strong association and lower inter-observer variability than in the retrospective study. Adherence to the guideline was 66.8%.

CONCLUSION

We found a high intra- and inter-observer variability and moderate guideline adherence in daily clinical practice amongst pediatricians in treating children with RAP in a teaching hospital.

Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care

BACKGROUND

As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs).

METHODS

The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results.

RESULTS

The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]).

DISCUSSION

Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.