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Cusi K, Budd J, Johnson E, Shubrook J. Making Sense of the Nonalcoholic Fatty Liver Disease Clinical Practice Guidelines: What Clinicians Need to Know. Diabetes Spectr 2024; 37:29-38. [PMID: 38385100 PMCID: PMC10877212 DOI: 10.2337/dsi23-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Standards of care summarized in clinical practice guidelines for nonalcoholic fatty liver disease (NAFLD) offer clinicians a streamlined diagnostic and management approach based on the best available evidence. These recommendations have changed a great deal in recent years; today, there is a clear focus on screening for the early identification and risk stratification of patients at high risk of steatohepatitis and clinically significant fibrosis to promote timely referrals to specialty care when needed. This article reviews and provides the rationale for current guidelines for NAFLD screening, diagnosis, treatment, and monitoring and addresses barriers to providing evidence-based NAFLD care and how to overcome them. The current paradigm of care calls for primary care clinicians and specialists to work together, within a multidisciplinary care team familiar with obesity and diabetes care, to provide comprehensive management of these complex patients.
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Affiliation(s)
- Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, University of Florida, Gainesville, FL
| | - Jeff Budd
- Division of General Internal Medicine, University of Florida, Gainesville, FL
| | - Eric Johnson
- Department of Family and Community Medicine, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND
| | - Jay Shubrook
- Department of Clinical Sciences and Community Health, Touro University California College of Osteopathic Medicine, Vallejo, CA
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Ziegler MJ, Flores EJ, Epps M, Hopkins K, Glaser L, Mull NK, Pegues DA. Clostridioides difficile dynamic electronic order panel, an effective automated intervention to reduce inappropriate inpatient ordering. Infect Control Hosp Epidemiol 2023; 44:1294-1299. [PMID: 36927512 PMCID: PMC10750561 DOI: 10.1017/ice.2022.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities. METHODS We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record-based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used. RESULTS Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63-0.88; P = .001) and C. difficile-positive tests (IRR, 0.83; 95% CI, 0.76-0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals. CONCLUSIONS An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.
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Affiliation(s)
- Matthew J Ziegler
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emilia J Flores
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, Pennsylvania
| | - Mika Epps
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen Hopkins
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Glaser
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil K Mull
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, Pennsylvania
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Healthcare Epidemiology, Infection Prevention and Control, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Use of clinical pathways integrated into the electronic health record to address the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol 2023; 44:260-267. [PMID: 35314010 PMCID: PMC9043631 DOI: 10.1017/ice.2022.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has required healthcare systems to meet new demands for rapid information dissemination, resource allocation, and data reporting. To help address these challenges, our institution leveraged electronic health record (EHR)-integrated clinical pathways (E-ICPs), which are easily understood care algorithms accessible at the point of care. OBJECTIVE To describe our institution's creation of E-ICPs to address the COVID-19 pandemic, and to assess the use and impact of these tools. SETTING Urban academic medical center with adult and pediatric hospitals, emergency departments, and ambulatory practices. METHODS Using the E-ICP processes and infrastructure established at our institution as a foundation, we developed a suite of COVID-19-specific E-ICPs along with a process for frequent reassessment and updating. We examined the development and use of our COVID-19-specific pathways for a 6-month period (March 1-September 1, 2020), and we have described their impact using case studies. RESULTS In total, 45 COVID-19-specific pathways were developed, pertaining to triage, diagnosis, and management of COVID-19 in diverse patient settings. Orders available in E-ICPs included those for isolation precautions, testing, treatments, admissions, and transfers. Pathways were accessed 86,400 times, with 99,081 individual orders were placed. Case studies demonstrate the impact of COVID-19 E-ICPs on stewardship of resources, testing optimization, and data reporting. CONCLUSIONS E-ICPs provide a flexible and unified mechanism to meet the evolving demands of the COVID-19 pandemic, and they continue to be a critical tool leveraged by clinicians and hospital administrators alike for the management of COVID-19. Lessons learned may be generalizable to other urgent and nonurgent clinical conditions.
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Kaminski MR, Golledge J, Lasschuit JWJ, Schott KH, Charles J, Cheney J, Raspovic A. Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:53. [PMID: 35791023 PMCID: PMC9258081 DOI: 10.1186/s13047-022-00534-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are no current Australian guidelines on the prevention of diabetes-related foot ulceration (DFU). A national expert panel aimed to systematically identify and adapt suitable international guidelines to the Australian context to create new Australian evidence-based guidelines on prevention of first-ever and/or recurrent DFU. These guidelines will include for the first-time considerations for rural and remote, and Aboriginal and Torres Strait Islander peoples. METHODS The National Health and Medical Research Council procedures were followed to adapt suitable international guidelines on DFU prevention to the Australian health context. This included a search of public databases after which the International Working Group on the Diabetic Foot (IWGDF) prevention guideline was deemed the most appropriate for adaptation. The 16 IWGDF prevention recommendations were assessed using the ADAPTE and GRADE systems to decide if they should be adopted, adapted or excluded for the new Australian guideline. The quality of evidence and strength of recommendation ratings were re-evaluated with reference to the Australian context. This guideline underwent public consultation, further revision, and approval by national peak bodies. RESULTS Of the 16 original IWGDF prevention recommendations, nine were adopted, six were adapted and one was excluded. It is recommended that all people at increased risk of DFU are assessed at intervals corresponding to the IWGDF risk ratings. For those at increased risk, structured education about appropriate foot protection, inspection, footwear, weight-bearing activities, and foot self-care is recommended. Prescription of orthotic interventions and/or medical grade footwear, providing integrated foot care, and self-monitoring of foot skin temperatures (contingent on validated, user-friendly and affordable systems becoming available in Australia) may also assist in preventing DFU. If the above recommended non-surgical treatment fails, the use of various surgical interventions for the prevention of DFU can be considered. CONCLUSIONS This new Australian evidence-based guideline on prevention of DFU, endorsed by 10 national peak bodies, provides specific recommendations for relevant health professionals and consumers in the Australian context to prevent DFU. Following these recommendations should achieve better DFU prevention outcomes in Australia.
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Affiliation(s)
- Michelle R Kaminski
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia. .,Department of Podiatry, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | - Joel W J Lasschuit
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, New South Wales, Australia.,Healthy Ageing, Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Karl-Heinz Schott
- Southern Cross University School of Health and Human Sciences / Pedorthics, Gold Coast, Queensland, Australia
| | - James Charles
- First Peoples Health Unit, Health Group, Griffith University, Gold Coast, Queensland, Australia
| | - Jane Cheney
- Diabetes Victoria, Melbourne, Victoria, Australia
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
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Chuter V, Quigley F, Tosenovsky P, Ritter JC, Charles J, Cheney J, Fitridge R. Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:51. [PMID: 35787293 PMCID: PMC9254685 DOI: 10.1186/s13047-022-00550-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/06/2022] [Indexed: 11/20/2022] Open
Abstract
Background Peripheral artery disease (PAD) is implicated in up to 50% of diabetes-related foot ulcers (DFU) and significantly contributes to morbidity and mortality in this population. An evidence-based guideline that is relevant to the national context including consideration of the unique geographical and health care system differences between Australia and other countries, and delivery of culturally safe care to First Nations people, is urgently required to improve outcomes for patients with PAD and DFU in Australia. We aimed to identify and adapt current international guidelines for diagnosis and management of patients with PAD and DFU to develop an updated Australian guideline. Methods Using a panel of national content experts and the National Health and Medical Research Council procedures, the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines were adapted to the Australian context. The guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were applied to the IWGDF guideline for PAD by the expert panel. Recommendations were then adopted, adapted or excluded, and specific considerations for implementation, population subgroups, monitoring and future research in Australia were developed with accompanying clinical pathways provided to support guideline implementation. Results Of the 17 recommendations from the IWGDF Guideline on diagnosis, prognosis and management of PAD in patients with diabetes with and without foot ulcers, 16 were adopted for the Australian guideline and one recommendation was adapted due to the original recommendation lacking feasibility in the Australian context. In Australia we recommend all people with diabetes and DFU undergo clinical assessment for PAD with accompanying bedside testing. Further vascular imaging and possible need for revascularisation should be considered for all patients with non-healing DFU irrespective of bedside results. All centres treating DFU should have expertise in, and/or rapid access to facilities necessary to diagnose and treat PAD, and should provide multidisciplinary care post-operatively, including implementation of intensive cardiovascular risk management. Conclusions A guideline containing 17 recommendations for the diagnosis and management of PAD for Australian patients with DFU was developed with accompanying clinical pathways. As part of the adaptation of the IWGDF guideline to the Australian context, recommendations are supported by considerations for implementation, monitoring, and future research priorities, and in relation to specific subgroups including Aboriginal and Torres Strait Islander people, and geographically remote people. This manuscript has been published online in full with the authorisation of Diabetes Feet Australia and can be found on the Diabetes Feet Australia website: https://www.diabetesfeetaustralia.org/new-guidelines/. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00550-7.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia. .,Discipline of Podiatry, University of Newcastle, Ourimbah, Australia.
| | | | - Patrik Tosenovsky
- Department of Vascular & Endovascular Surgery, Royal Perth Hospital, Wellington Street, Perth, Australia
| | - Jens Carsten Ritter
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia.,Curtin University, School of Medicine, Perth, Australia
| | - James Charles
- First Peoples Health Unit, Griffith University, Gold Coast, Australia
| | | | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia.,Vascular and Endovascular Service, Central Adelaide Local Health Network, Adelaide, Australia
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Commons RJ, Charles J, Cheney J, Lynar SA, Malone M, Raby E. Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:47. [PMID: 35676695 PMCID: PMC9178854 DOI: 10.1186/s13047-022-00545-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes-related foot infections cause substantial morbidity and mortality, both globally and in Australia. There is a need for up-to-date evidence-based guidelines to ensure optimal management of patients with diabetes-related foot infections. We aimed to identify and adapt high quality international guidelines to the Australian context to become the new Australian evidence-based guideline for people with a diabetes-related foot infection. METHODS Following Australian National Health and Medical Research Council (NHMRC) procedures we identified the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines as suitable for adaptation to the Australian context. Guidelines were screened, assessed and judged by an expert panel for the Australian context using the guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Judgements led to recommendations being adopted, adapted or excluded, with additional consideration regarding their implementation, monitoring and future research for the Australian context. Clinical pathways were then developed to assist implementation. RESULTS Of 36 original diabetes-related foot infection IWGDF sub-recommendations, 31 were adopted, four were adapted and one was excluded. Adaption was primarily undertaken due to differences or clarification of the sub-recommendations' intended population. One sub-recommendation was excluded due to substantial differences in judgements between the panel and IWGDF and unacceptable heterogeneity of the target population. Therefore, we developed 35 evidence-based sub-recommendations for the Australian context that should guide best practice diagnosis and management of people with diabetes-related foot infection in Australia. Additionally, we incorporated these sub-recommendations into two clinical pathways to assist Australian health professionals to implement these evidence-based sub-recommendations into clinical practice. The six guidelines and the full protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/ . CONCLUSIONS A new national guideline for the diagnosis and management of people with diabetes-related foot infections were successfully developed for the Australian context. In combination with simplified clinical pathway tools they provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections across Australia and highlight considerations for implementation and monitoring.
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Affiliation(s)
- Robert J Commons
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia. .,Internal Medical Services, Ballarat Health Services, Ballarat, Australia.
| | - James Charles
- First Peoples Health Unit, Faculty of Health Griffith University, Gold Coast, Australia
| | | | - Sarah A Lynar
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Infectious Diseases Unit, Royal Darwin Hospital, Darwin, Australia
| | - Matthew Malone
- South West Sydney Limb Preservation and Wound Research, South Western Sydney LHD, Liverpool, Sydney, Australia.,Infectious Diseases and Microbiology, School of Medicine Western Sydney University, Campbelltown Campus, Sydney, Australia
| | - Edward Raby
- Infectious Diseases Department, Royal Perth Hospital, Perth, Australia.,Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Murdoch, Australia
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Fernando ME, Horsley M, Jones S, Martin B, Nube VL, Charles J, Cheney J, Lazzarini PA. Australian guideline on offloading treatment for foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:31. [PMID: 35513821 PMCID: PMC9069804 DOI: 10.1186/s13047-022-00538-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/11/2022] [Indexed: 01/22/2023] Open
Abstract
Background Pressure offloading treatment is critical for healing diabetes-related foot ulcers (DFU). Yet the 2011 Australian DFU guidelines regarding offloading treatment are outdated. A national expert panel aimed to develop a new Australian guideline on offloading treatment for people with DFU by adapting international guidelines that have been assessed as suitable to adapt to the Australian context. Methods National Health and Medical Research Council procedures were used to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines to the Australian context. We systematically screened, assessed and judged all IWGDF offloading recommendations using best practice ADAPTE and GRADE frameworks to decide which recommendations should be adopted, adapted or excluded in the Australian context. For each recommendation, we re-evaluated the wording, quality of evidence, strength of recommendation, and provided rationale, justifications and implementation considerations, including for geographically remote and Aboriginal and Torres Strait Islander peoples. This guideline, along with five accompanying Australian DFU guidelines, underwent public consultation, further revision and approval by ten national peak bodies (professional organisations). Results Of the 13 original IWGDF offloading treatment recommendations, we adopted four and adapted nine. The main reasons for adapting the IWGDF recommendations included differences in quality of evidence ratings and clarification of the intervention(s) and control treatment(s) in the recommendations for the Australian context. For Australians with plantar DFU, we recommend a step-down offloading treatment approach based on their contraindications and tolerance. We strongly recommend non-removable knee-high offloading devices as first-line treatment, removable knee-high offloading devices as second-line, removable ankle-high offloading devices third-line, and medical grade footwear as last-line. We recommend considering using felted foam in combination with the chosen offloading device or footwear to further reduce plantar pressure. If offloading device options fail to heal a person with plantar DFU, we recommend considering various surgical offloading procedures. For people with non-plantar DFU, depending on the type and location of the DFU, we recommend using a removable offloading device, felted foam, toe spacers or orthoses, or medical grade footwear. The six new guidelines and the full protocol can be found at: https://diabetesfeetaustralia.org/new-guidelines/. Conclusions We have developed a new Australian evidence-based guideline on offloading treatment for people with DFU that has been endorsed by ten key national peak bodies. Health professionals implementing these offloading recommendations in Australia should produce better DFU healing outcomes for their patients, communities, and country. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00538-3.
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Affiliation(s)
- Malindu E Fernando
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia.,Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Callaghan, Australia
| | - Mark Horsley
- Department of Orthopaedics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sara Jones
- Department of Rural Health, University of South Australia, Adelaide, Australia
| | - Brian Martin
- Department of Orthopaedics, Nepean Hospital, Sydney, Australia
| | - Vanessa L Nube
- Sydney Local Health District, Department of Podiatry, Sydney, Australia
| | - James Charles
- First Peoples Health Unit, Faculty of Health, Griffith University, Gold Coast, Queensland, Australia
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia. .,Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia.
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Lazzarini PA, Raspovic A, Prentice J, Commons RJ, Fitridge RA, Charles J, Cheney J, Purcell N, Twigg SM. Guidelines development protocol and findings: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:28. [PMID: 35440052 PMCID: PMC9017044 DOI: 10.1186/s13047-022-00533-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 03/15/2022] [Indexed: 12/14/2022] Open
Abstract
Background Diabetes-related foot disease (DFD) is a leading cause of the Australian disease burden. The 2011 Australian DFD guidelines were outdated. We aimed to develop methodology for systematically adapting suitable international guidelines to the Australian context to become the new Australian evidence-based guidelines for DFD. Methods We followed the Australian National Health Medical Research Council (NHMRC) guidelines for adapting guidelines. We systematically searched for all international DFD guideline records. All identified records were independently screened and assessed for eligibility. Those deemed eligible were further assessed and included if scoring at least moderate quality, suitability and currency using AGREE II and NHMRC instruments. The included international guidelines had all recommendations extracted into six sub-fields: prevention, wound classification, peripheral artery disease, infection, offloading and wound healing. Six national panels, each comprising 6–8 multidisciplinary national experts, screened all recommendations within their sub-field for acceptability and applicability in Australia using an ADAPTE form. Where panels were unsure of any acceptability and applicability items, full assessments were undertaken using a GRADE Evidence to Decision tool. Recommendations were adopted, adapted, or excluded, based on the agreement between the panel’s and international guideline’s judgements. Each panel drafted a guideline that included all their recommendations, rationale, justifications, and implementation considerations. All underwent public consultation, final revision, and approval by national peak bodies. Results We screened 182 identified records, assessed 24 full text records, and after further quality, suitability, and currency assessment, one record was deemed a suitable international guideline, the International Working Group Diabetic Foot Guidelines (IWGDF guidelines). The six panels collectively assessed 100 IWGDF recommendations, with 71 being adopted, 27 adapted, and two excluded for the Australian context. We received 47 public consultation responses with > 80% (strongly) agreeing that the guidelines should be approved, and ten national peak bodies endorsed the final six guidelines. The six guidelines and this protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/ Conclusion New Australian evidence-based guidelines for DFD have been developed for the first time in a decade by adapting suitable international guidelines. The methodology developed for adaptation may be useful for other foot-related conditions. These new guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00533-8.
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Affiliation(s)
- Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia. .,Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia.
| | - Anita Raspovic
- School of Allied Health, Human Services and Sport College of Science, Health & Engineering, La Trobe University, Bundoora, Australia
| | - Jenny Prentice
- Hall and Prior Health and Aged Care Group, Perth, Australia
| | - Robert J Commons
- Internal Medicine Services, Ballarat Health Services, Ballarat, Victoria, Australia.,Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Robert A Fitridge
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - James Charles
- First Peoples Health Unit, Faculty of Health, Griffith University, Gold Coast, Australia
| | | | - Nytasha Purcell
- Diabetes Feet Australia, Brisbane, Australia.,Australian Diabetes Society, Sydney, Australia
| | - Stephen M Twigg
- Sydney Medical School (Central), Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, Australia
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Brons M, Muller SA, Rutten FH, van der Meer MG, Vrancken AFJE, Minnema MC, Baas AF, Asselbergs FW, Oerlemans MIFJ. Evaluation of the cardiac amyloidosis clinical pathway implementation: a real-world experience. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac011. [PMID: 35919127 PMCID: PMC9242028 DOI: 10.1093/ehjopen/oeac011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 01/15/2023]
Abstract
Aims The aim of this study is to evaluate the implementation of the cardiac amyloidosis (CA) clinical pathway on awareness among referring cardiologists, diagnostic delay, and severity of CA at diagnosis. Methods and results Patients with CA were retrospectively included in this study and divided into two periods: pre-implementation of the CA clinical pathway (2007–18; T1) and post-implementation (2019–20; T2). Patients’ and disease characteristics were extracted from electronic health records and compared. In total, 113 patients (mean age 67.8 ± 8.5 years, 26% female) were diagnosed with CA [T1 (2007–18): 56; T2 (2019–20): 57]. The number of CA diagnoses per year has increased over time. Reasons for referral changed over time, with increased awareness of right ventricular hypertrophy (9% in T1 vs. 36% in T2) and unexplained heart failure with preserved ejection fraction (22% in T1 vs. 38% in T2). Comparing T1 with T2, the diagnostic delay also improved (14 vs. 8 months, P < 0.01), New York Heart Association Class III (45% vs. 23%, P = 0.03), and advanced CA stage (MAYO/Gillmore Stage III/IV; 61% vs. 33%, P ≤ 0.01) at time of diagnosis decreased. Conclusion After implementation of the CA clinical pathway, the awareness among referring cardiologists improved, diagnostic delay was decreased, and patients had less severe CA at diagnosis. Further studies are warranted to assess the prognostic impact of CA clinical pathway implementation.
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Affiliation(s)
- Maaike Brons
- Department of Cardiology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Steven A Muller
- Department of Cardiology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Monique C Minnema
- Department of Haematology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Annette F Baas
- Department of Genetics, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London , Gower Street, London WC1E 6BT, UK
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London , 222 Euston Rd, Kings Cross, London NW1 2DA , UK
| | - Marish I F J Oerlemans
- Department of Cardiology, University Medical Center Utrecht , PO Box 85500, 3508 GA Utrecht, The Netherlands
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Siddique SM, Tipton K, Leas B, Greysen SR, Mull NK, Lane-Fall M, McShea K, Tsou AY. Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review. JAMA Netw Open 2021; 4:e2125846. [PMID: 34542615 PMCID: PMC8453321 DOI: 10.1001/jamanetworkopen.2021.25846] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction. OBJECTIVE To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS. EVIDENCE REVIEW Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide. FINDINGS Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days). CONCLUSIONS AND RELEVANCE This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
| | - Kelley Tipton
- ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
| | - Brian Leas
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
| | - S. Ryan Greysen
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Nikhil K. Mull
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Meghan Lane-Fall
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
| | - Kristina McShea
- ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
| | - Amy Y. Tsou
- ECRI Evidence-based Practice Center, Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania
- Division of Neurology, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
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11
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Al Dandan HB, Galvin R, McClurg D, Coote S, Robinson K. Management strategies for neurogenic lower urinary tract dysfunction: a qualitative study of the experiences of people with multiple sclerosis and healthcare professionals. Disabil Rehabil 2021; 44:3805-3815. [PMID: 33617371 DOI: 10.1080/09638288.2021.1887378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Urinary symptoms are highly prevalent among people with MS. This study aimed to explore the experiences of people with MS and HCPs in managing urinary symptoms and explore their views on using TTNS to treat urinary symptoms. MATERIALS AND METHODS Audio-recorded semi-structured, interviews were employed with people with MS and HCPs. All transcribed interviews were exported to NVivo software (Version 12) and analyzed using a reflexive approach to thematic analysis. RESULTS Four main themes were identified; The wide-ranging negative impacts of urinary symptoms ("It's limited everything else"), Gaps in urinary services ("Is there somebody like that, sort of specialized in that area?"), Management strategies ("I don't go too far from the toilet in case I need to use one"), and optimism about TTNS ("Are you giving Me Hope?"). CONCLUSION Urinary symptoms are common and very troublesome for people with MS. Despite their prevalence, many people with MS continue to suffer in silence. People with MS require skilled multidisciplinary services guided by clinical care pathways to improve service provision and to address urinary symptoms. HCP's and people with MS are open to the use of TTNS for urinary symptoms and have clear preferences for location and duration of intervention delivery.Implications for rehabilitationUrinary symptoms are very common and troublesome for people with multiple sclerosis, yet many continue to suffer in silence.People with multiple sclerosis lack knowledge about treatment options for urinary symptoms.There is an on-going need for healthcare provider education on guidelines for screening and managing urinary symptoms in people with MS and the role of specialist urinary service providers.HCP's and people with MS are open to the use of TTNS for urinary symptoms.
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Affiliation(s)
- Hawra B Al Dandan
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Ireland.,Aging Research Centre, University of Limerick, Ireland
| | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Susan Coote
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Ireland.,Aging Research Centre, University of Limerick, Ireland
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12
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Bilò MB, Corsi A, Pravettoni V, Bignardi D, Bonadonna P, Quercia O, Mauro M, Novembre E, Micheletti R, Papa R. Development of a model care pathway for the management of Hymenoptera venom allergy: evidence-based key interventions and indicators. Clin Transl Allergy 2020; 10:8. [PMID: 32158533 PMCID: PMC7055031 DOI: 10.1186/s13601-020-00312-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/24/2020] [Indexed: 01/18/2023] Open
Abstract
Background Hymenoptera venom allergy (HVA) is an underestimated condition representing an important cause of morbidity and mortality worldwide. Preventing future allergic reactions in patients who have already developed a systemic reaction is based on the correct management of the acute phase of the reaction followed by a correct diagnosis and, where indicated, prescription of adrenaline autoinjectors and VIT. A possible strategy to optimize care processes and to improve outcomes is the implementation of a Diagnostic and Therapeutic Care Pathways, also known as Integrated Care Pathways or Clinical Pathways (CPWs). The aim of the care pathway is to enhance the quality of care by improving risk‐adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To our knowledge, currently in Italy as well as in Europe, there is no CPWs codified for the management of HVA patients. This paper describes the development of the clinical content of a care pathway for the management of HVA. Methods The methodology applied is based on the eight step method to build the clinical content of an evidence-based care pathway suggested by Lodewijckx et al. Results Three hundred and seventeen different clinical activities were extracted from the selected literature. The expert panel was involved in their evaluation, expressing a judgment of relevance through the Delphi study. As a result, 126 clinical activities were appraised to be valid and feasible. The final recommendations (126) were translated into 123 key interventions. Six indicators were produced by the clinical activities. Conclusion A set of 123 key interventions and of six process indicators were found to be appropriate for the development and standardization of the clinical content of the Hymenoptera venom allergy care pathway.
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13
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Sharaf RN, Khullar D, Umscheid CA. Health Technology Assessment Centers-an Infrastructure for Health Systems to Translate Evidence into Practice. J Gen Intern Med 2020; 35:1296-1299. [PMID: 31900729 PMCID: PMC7174520 DOI: 10.1007/s11606-019-05534-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Ravi N Sharaf
- Division of Gastroenterology, Department of Medicine, Department of Healthcare Policy and Research, Jay Monahan Center for Gastrointestinal Health, Weill Cornell Medical Cancer, 1315 York Avenue Ground Floor, New York, NY, 10021, USA.
| | - Dhruv Khullar
- Department of Healthcare Policy & Research, Department of Medicine, Weill Cornell Medical College, 402 E 67th St, New York, NY, 10065, USA
| | - Craig A Umscheid
- University of Chicago Medicine and Biological Sciences, American School Building, 850 E. 58th Street, Suite 123, Office 128, MC 1135, Chicago, IL, 60637, USA
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14
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Flores EJ, Jue JJ, Giradi G, Schoelles K, Mull NK, Umscheid CA. AHRQ EPC Series on Improving Translation of Evidence: Use of a Clinical Pathway for C. Difficile Treatment to Facilitate the Translation of Research Findings into Practice. Jt Comm J Qual Patient Saf 2019; 45:822-828. [PMID: 31672660 DOI: 10.1016/j.jcjq.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2018 the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program issued a call for strategies to disseminate AHRQ EPC systematic reviews. In this pilot, findings from the 2016 AHRQ EPC report on Clostridioides difficile infection were translated into a treatment pathway and disseminated via a cloud-based platform and electronic health record (EHR). METHODS An existing 10-step framework was used for developing and disseminating evidence-based clinical pathways. The development of the EHR intervention was informed by the Five Rights model for clinical decision support and human-computer interaction design heuristics. The researchers used observations and time measurements to describe the impact of the EPC report on pathway development and examined provider adoption using counts of pathway views. RESULTS Two main themes emerged: (1) discrepancies between the EPC report and existing guidelines prompted critical discussions about available treatments, and (2) lack of guideline and pathway syntheses in the EPC report necessitated a rapid literature review. Pathway development required 340 hours: 205 for the rapid literature review, 63 for pathway development and EHR intervention design, and 5 for technical implementation of the intervention. Pathways were viewed 1,069 times through the cloud-based platform and 47 times through a hyperlink embedded in key EHR ordering screens. CONCLUSION Pathways can be an approach for disseminating AHRQ EPC report findings within health care systems; however, reports should include guideline and pathway syntheses to meet their full potential. Embedding hyperlinks to pathway content within the EHR may be a viable and low-effort solution for promoting awareness of evidence-based resources.
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Affiliation(s)
- Emilia J Flores
- is Penn Pathways Program Manager, Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia.
| | - J Jane Jue
- is formerly Medical Director, ECRI Guidelines Trust, ECRI Institute, is Adjunct Assistant Professor, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Gina Giradi
- is Project Coordinator, ECRI Institute, Plymouth Meeting, Pennslyvania
| | - Karen Schoelles
- is Vice President, Clinical Excellence and Safety, ECRI Institute
| | - Nikhil K Mull
- is Assistant Professor of Clinical Medicine, University of Pennsylvania Perelman School of Medicine, and Director, Penn Medicine Center for Evidence-based Practice
| | - Craig A Umscheid
- is Chief Quality and Innovation Officer, Vice President for Healthcare Delivery Science, and Director of the Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine
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15
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Borsky AE, Flores EJ, Berliner E, Chang C, Umscheid CA, Chang SM. Next Steps in Improving Healthcare Value: AHRQ Evidence-based Practice Center Program-Applying the Knowledge to Practice to Data Cycle to Strengthen the Value of Patient Care. J Hosp Med 2019; 14:311-314. [PMID: 30794140 PMCID: PMC6609136 DOI: 10.12788/jhm.3157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/27/2018] [Indexed: 12/22/2022]
Abstract
For more than 20 years, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program has been identifying and synthesizing evidence to inform evidence-based healthcare. Recognizing that many healthcare settings continue to face challenges in disseminating and implementing evidence into practice, AHRQ's EPC program has also embarked on initiatives to facilitate the translation of evidence into practice and to measure and monitor how practice changes impact health outcomes. The program has structured its efforts around the three phases of the Learning Healthcare System cycle: knowledge, practice, and data. Here, we use a topic relevant to the field of hospital medicine-Clostridium difficile colitis prevention and treatment-as an exemplar of how the EPC program has used this framework to move evidence into practice and develop systems to facilitate continuous learning in healthcare systems.
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Affiliation(s)
- Amanda E Borsky
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
- Corresponding Author: Amanda E. Borsky, DrPH, MPP; E-mail: ; Telephone: 301-427-1602
| | - Emilia J Flores
- University of Pennsylvania Health System, Center for Evidence-based Practice, Philadelphia, Philadelphia
| | - Elise Berliner
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
| | - Christine Chang
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
| | - Craig A Umscheid
- University of Chicago Medicine, Center for Healthcare Delivery Science and Innovation, Chicago, Illinois
| | - Stephanie M Chang
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
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