Applying clinical guidelines in general practice: a qualitative study of potential complications

Decision Support for Managing Common Musculoskeletal Pain Disorders: Development of a Case-Based Reasoning Application

BACKGROUND

Common interventions for musculoskeletal pain disorders either lack evidence to support their use or have small to modest or short-term effects. Given the heterogeneity of patients with musculoskeletal pain disorders, treatment guidelines and systematic reviews have limited transferability to clinical practice. A problem-solving method in artificial intelligence, case-based reasoning (CBR), where new problems are solved based on experiences from past similar problems, might offer guidance in such situations.

OBJECTIVE

This study aims to use CBR to build a decision support system for patients with musculoskeletal pain disorders seeking physiotherapy care. This study describes the development of the CBR system SupportPrim PT and demonstrates its ability to identify similar patients.

METHODS

Data from physiotherapy patients in primary care in Norway were collected to build a case base for SupportPrim PT. We used the local-global principle in CBR to identify similar patients. The global similarity measures are attributes used to identify similar patients and consisted of prognostic attributes. They were weighted in terms of prognostic importance and choice of treatment, where the weighting represents the relevance of the different attributes. For the local similarity measures, the degree of similarity within each attribute was based on minimal clinically important differences and expert knowledge. The SupportPrim PT's ability to identify similar patients was assessed by comparing the similarity scores of all patients in the case base with the scores on an established screening tool (the short form Örebro Musculoskeletal Pain Screening Questionnaire [ÖMSPQ]) and an outcome measure (the Musculoskeletal Health Questionnaire [MSK-HQ]) used in musculoskeletal pain. We also assessed the same in a more extensive case base.

RESULTS

The original case base contained 105 patients with musculoskeletal pain (mean age 46, SD 15 years; 77/105, 73.3% women). The SupportPrim PT consisted of 29 weighted attributes with local similarities. When comparing the similarity scores for all patients in the case base, one at a time, with the ÖMSPQ and MSK-HQ, the most similar patients had a mean absolute difference from the query patient of 9.3 (95% CI 8.0-10.6) points on the ÖMSPQ and a mean absolute difference of 5.6 (95% CI 4.6-6.6) points on the MSK-HQ. For both ÖMSPQ and MSK-HQ, the absolute score difference increased as the rank of most similar patients decreased. Patients retrieved from a more extensive case base (N=486) had a higher mean similarity score and were slightly more similar to the query patients in ÖMSPQ and MSK-HQ compared with the original smaller case base.

CONCLUSIONS

This study describes the development of a CBR system, SupportPrim PT, for musculoskeletal pain in primary care. The SupportPrim PT identified similar patients according to an established screening tool and an outcome measure for patients with musculoskeletal pain.

GP preferences for, access to, and use of evidence in clinical practice: a mixed-methods study

BACKGROUND

GPs aim to provide patient-centred care combining clinical evidence, clinical judgement, and patient priorities. Despite a recognition of the need to translate evidence to support patient care, barriers exist to the use of evidence in practice.

AIM

To ascertain the needs and preferences of GPs regarding evidence-based guidance to support patient care. The study also aimed to prioritise content and optimise structure and dissemination of future evidence-based guidance.

DESIGN & SETTING

This was a convergent parallel mixed-methods study in collaboration with the national GP professional body in the Republic of Ireland (Irish College of General Practitioners [ICGP]). Quantitative and qualitative findings were integrated at the interpretive level.

METHOD

A national GP survey was administered via the ICGP (December 2020) and seven GP focus groups were undertaken (April-May 2021).

RESULTS

Of 3496 GPs, a total of 509 responders (14.6%) completed the survey and 40 GP participants took part in focus groups. Prescribing updates, interpretation of test results, chronic disease management, and older person care were the preferred topics for future evidence-based guidance. GPs reported that they required rapid access to up-to-date and relevant evidence summaries online for use in clinical practice. Access to more comprehensive reviews for the purposes of continuing education and teaching was also a priority. Multimodal forms of dissemination were preferred to increase uptake of evidence in practice.

CONCLUSION

GPs indicated that rapid access to up-to-date, summarised evidence-based resources, available from their professional organisation, is preferred. Evidence should reflect the disease burden of the population and involve multifaceted dissemination approaches.

Primary care utilisation, adherence to guideline-based pharmacotherapy and continuity of care in primary care patients with chronic diseases and multimorbidity - a cross-sectional study

BACKGROUND

To understand how to improve care for patients with chronic diseases and multimorbidity we wanted to describe the prevalence of different chronic diseases and the pattern of multimorbidity and to analyse the associations between occurrence of diseases and primary care utilization, adherence to guideline-based pharmacotherapy, and continuity of care.

METHODS

Retrospective cross-sectional study of routine care data of the general population in region Jönköping in Sweden (345 916 inhabitants using primary care services) covering 4.3 years.

PARTICIPANTS

Patients fulfilling the inclusion criteria of having ≥ 1 of 10 common chronic diseases and ≥ 3 visits to primary care between 2011 and 2015.

PRIMARY OUTCOME MEASURES

In order to determine diseases and multimorbidity, primary care utilisation, adherence to guideline-based pharmacotherapy, frequencies and percentages, interval and ratio scaled variables were described using means, standard deviations, and various percentiles in the population. Two continuity indices were used (MMCI, COC) to describe continuity.

RESULTS

Of the general population, 25 829 patients fulfilled the inclusion criteria (7.5% of the population). Number of diseases increased with increasing age, and multimorbidity was much more common than single diseases (mean 2.0 per patient). There was a slight positive correlation (0.29) between number of diseases and visits, but visits did not increase proportionally to the number of diseases. Patients with physical diseases combined with anxiety and/or depression made more visits than others. The number of diseases per patient was negatively associated with the adherence to pharmacotherapy guidelines. There was no association between continuity and healthcare utilisation or adherence to pharmacotherapy guidelines.

CONCLUSIONS

Multimorbid patients are common in primary care and for many chronic diseases it is more common to have other simultaneous diseases than having only one disease. This can make adherence to pharmacotherapy guidelines a questionable measure for aged multimorbid patients. Existing continuity indices also revealed limitations. Holistic and patient-centred measures should be used for quality assessment of care for multimorbid patients in primary care.

Virtual twin for healthcare management

Healthcare is increasingly fragmented, resulting in escalating costs, patient dissatisfaction, and sometimes adverse clinical outcomes. Strategies to decrease healthcare fragmentation are therefore attractive from payer and patient perspectives. In this commentary, a patient-centered smart phone application called Virtual Twin for Healthcare Management (VTHM) is proposed, including its organizational layout, basic functionality, and potential clinical applications. The platform features a virtual twin hub that displays the body and its health data. This is a physiologically based human model that is "virtualized" for the patient based on their unique genetic, molecular, physiological, and disease characteristics. The spokes of the system are a full service and interoperable electronic-health record, accessible to healthcare providers with permission on any device with internet access. Theoretical case studies based on real scenarios are presented to show how VTHM could potentially improve patient care and clinical efficiency. Challenges that must be overcome to turn VTHM into reality are also briefly outlined. Notably, the VTHM platform is designed to operationalize current and future precision medicine initiatives, such as access to molecular diagnostic results, pharmacogenomics-guided prescribing, and model-informed precision dosing.

Developing a Questionnaire Evaluating Knowledge, Attitudes and Behaviors on Audit & Feedback among General Practitioners: A Mixed Methods Study

BACKGROUND

Audit and Feedback (A&F) is one of the most common strategies used to improve quality in healthcare. However, there is still lack of awareness regarding the enabling factors and barriers that could influence its effectiveness. The aim of this study was to develop a questionnaire to measure the knowledge, attitudes and behaviors of general practitioners (GPs) regarding A&F. The study was performed in the context of the EASY-NET program (project code NET-2016-02364191).

METHODS

The survey was developed according to two steps. Firstly, a scoping review was performed in order to map the literature on the existing similar instruments with the aim of identifying the sub-domains and possible items to include in a preliminary version of the questionnaire. In the second phase, the questionnaire was reviewed by a multidisciplinary group of experts and administrated to a convenience sample in a pilot survey.

RESULTS

Ten papers were included in the scoping review. The survey target and development methodology were heterogenous among the studies. The knowledge, attitudes and behaviors domains were assessed in six, nine and seven studies, respectively. In the first step, 126 pertinent items were extracted and categorized as follows: 8 investigated knowledge, 93 investigated attitudes, and 25 investigated behaviors. Then, 2 sub-domains were identified for knowledge, 14 for attitudes and 7 for behavior. Based on these results, a first version of the survey was developed via consensus among two authors and then revised by the multidisciplinary group of experts in the field of A&F. The final version of the survey included 36 items: 8 in the knowledge domain, 19 in the attitudes domain and 9 in the behaviors domain. The results of the pilot study among 15 GPs suggested a good acceptability and item relevance and accuracy, with positive answers totaling 100% and 93.3% in the proposed questions.

CONCLUSIONS

The methodology used has shown to be a good strategy for the development of the survey. The survey will be administrated before and after the implementation of an A&F intervention to assess both baseline characteristics and changes after the intervention.

SupportPrim-a computerized clinical decision support system for stratified care for patients with musculoskeletal pain complaints in general practice: study protocol for a randomized controlled trial

BACKGROUND

Musculoskeletal disorders represented 149 million years lived with disability world-wide in 2019 and are the main cause of years lived with disability worldwide. Current treatment recommendations are based on "one-size fits all" principle, which does not take into account the large degree of biopsychosocial heterogeneity in this group of patients. To compensate for this, we developed a stratified care computerized clinical decision support system for general practice based on patient biopsychosocial phenotypes; furthermore, we added personalized treatment recommendations based on specific patient factors to the system. In this study protocol, we describe the randomized controlled trial for evaluating the effectiveness of computerized clinical decision support system for stratified care for patients with common musculoskeletal pain complaints in general practice. The aim of this study is to test the effect of a computerized clinical decision support system for stratified care in general practice on subjective patient outcome variables compared to current care.

METHODS

We will perform a cluster-randomized controlled trial with 44 general practitioners including 748 patients seeking their general practitioner due to pain in the neck, back, shoulder, hip, knee, or multisite. The intervention group will use the computerized clinical decision support system, while the control group will provide current care for their patients. The primary outcomes assessed at 3 months are global perceived effect and clinically important improvement in function measured by the Patient-Specific Function Scale (PSFS), while secondary outcomes include change in pain intensity measured by the Numeric Rating Scale (0-10), health-related quality of life (EQ-5D), general musculoskeletal health (MSK-HQ), number of treatments, use of painkillers, sick-leave grading and duration, referral to secondary care, and use of imaging.

DISCUSSION

The use of biopsychosocial profile to stratify patients and implement it in a computerized clinical decision support system for general practitioners is a novel method of providing decision support for this patient group. The study aim to recruit patients from May 2022 to March 2023, and the first results from the study will be available late 2023.

TRIAL REGISTRATION

The trial is registered in ISRCTN 11th of May 2022: 14,067,965.

A scoping review of evidence-based guidance and guidelines published by general practice professional organizations

BACKGROUND

General practitioners (GPs) need robust, up-to-date evidence to deliver high-quality patient care. There is limited literature regarding the role of international GP professional organizations in developing and publishing clinical guidelines to support GPs clinical decision making.

OBJECTIVE

To identify evidence-based guidance and clinical guidelines produced by GP professional organizations and summarize their content, structure, and methods of development and dissemination.

METHODS

Scoping review of GP professional organizations following Joanna Briggs Institute guidance. Four databases were searched and a grey literature search was conducted. Studies were included if they were: (i) evidence-based guidance documents or clinical guidelines produced de novo by a national GP professional organization, (ii) developed to support GPs clinical care, and (iii) published in the last 10 years. GP professional organizations were contacted to provide supplementary information. A narrative synthesis was performed.

RESULTS

Six GP professional organizations and 60 guidelines were included. The most common de novo guideline topics were mental health, cardiovascular disease, neurology, pregnancy and women's health and preventive care. All guidelines were developed using a standard evidence-synthesis method. All included documents were disseminated through downloadable pdfs and peer review publications. GP professional organizations indicated that they generally collaborate with or endorse guidelines developed by national or international guideline producing bodies.

CONCLUSION

The findings of this scoping review provide an overview of de novo guideline development by GP professional organizations and can support collaboration between GP organizations worldwide thus reducing duplication of effort, facilitating reproducibility, and identifying areas of standardization.

PROTOCOL REGISTRATION

Open Science Framework: https://doi.org/10.17605/OSF.IO/JXQ26.

Critically Appraising Pragmatist Critiques of Evidence-Based Medicine: Is EBM Defensible on Pragmatist Grounds?

Significant contributions to debates in the philosophy of evidence-based medicine (EBM) have come from a variety of different philosophical quarters, yet mainstream discourse in the field has been largely devoid of contributions from scholars working in the pragmatist tradition. This is a particularly conspicuous omission, given pragmatism's commitment to the melioristic view that philosophy both can, and should, be about the business of concretely bettering the human estate. Two exceptions to this oversight come from Brian Walsh and Maya Goldenberg. Unfortunately, in both cases, the misapplication of pragmatist thinking leads to the mistaken view that EBM is committed to some form of pernicious objectivism. This article aims to revise these pragmatist critiques in order to bring them more consistently in line with pragmatist values and commitments. Doing so shows that EBM is defensible on pragmatist grounds against objectivist attacks.

APPRAISE-RS: Automated, updated, participatory, and personalized treatment recommender systems based on GRADE methodology

Purpose

Clinical practice guidelines (CPGs) have become fundamental tools for evidence-based medicine (EBM). However, CPG suffer from several limitations, including obsolescence, lack of applicability to many patients, and limited patient participation. This paper presents APPRAISE-RS, which is a methodology that we developed to overcome these limitations by automating, extending, and iterating the methodology that is most commonly used for building CPGs: the GRADE methodology.

Method

APPRAISE-RS relies on updated information from clinical studies and adapts and automates the GRADE methodology to generate treatment recommendations. APPRAISE-RS provides personalized recommendations because they are based on the patient's individual characteristics. Moreover, both patients and clinicians express their personal preferences for treatment outcomes which are considered when making the recommendation (participatory). Rule-based system approaches are used to manage heuristic knowledge.

Results

APPRAISE-RS has been implemented for attention deficit hyperactivity disorder (ADHD) and tested experimentally on 28 simulated patients. The resulting recommender system (APPRAISE-RS/TDApp) shows a higher degree of treatment personalization and patient participation than CPGs, while recommending the most frequent interventions in the largest body of evidence in the literature (EBM). Moreover, a comparison of the results with four blinded psychiatrist prescriptions supports the validation of the proposal.

Conclusions

APPRAISE-RS is a valid methodology to build recommender systems that manage updated, personalized and participatory recommendations, which, in the case of ADHD includes at least one intervention that is identical or very similar to other drugs prescribed by psychiatrists.

Multimorbidity and health-related quality of life among patients attending chronic outpatient medical care in Bahir Dar, Northwest Ethiopia: The application of partial proportional odds model

BACKGROUND

Multimorbidity, the presence of two or more chronic non-communicable diseases (NCDs) in a given person affects all aspects of people's lives. Poor quality of life (QoL) is one of the major consequences of living with multimorbidity. Although healthcare should support multimorbid individuals to achieve a better quality of life, little is known about the effect of multimorbidity on the QoL of patients living with chronic conditions. This study aimed to determine the influence of multimorbidity on QoL among clients attending chronic outpatient medical care in Bahir Dar, Northwest Ethiopia.

METHODOLOGY

A multi-centered facility-based study was conducted among 1440 participants aged 40+ years. Two complementary methods were employed to collect sociodemographic and disease related data. We used the short form (SF-12 V2) instrument to measure quality of life (QoL). The data were analyzed by STATA V.16, and a multivariate partial proportional odds model was fitted to identify covariates associated with quality of life. Statistical significance was considered at p-value <0.05.

PRINCIPAL FINDINGS

Multimorbidity was identified in 54.8% (95% CI = 52.2%-57.4%) of the sample. A significant proportion (33.5%) of the study participants had poor QoL and a quarter (25.8%) of them had moderate QoL. Advanced age, obesity and living with multimorbidity were the factors associated with poor QoL. Conversely, perceived social support and satisfaction with care were the variables positively associated with better QoL.

CONCLUSION

The magnitude of multimorbidity in this study was high and individuals living with multimorbidity had a relatively poorer QoL than those without multimorbidity. Care of people with chronic multiple conditions has to be oriented to the realities of multimorbidity burden and its implication on QoL. It is also imperative to replicate the methods we employed to measure and analyze QoL data in this study for facilitating comparison and further development of the approaches.

Managing multimorbidity: a qualitative study of the Australian general practitioner experience

BACKGROUND

Multimorbidity is prevalent in general practice and general practitioners internationally report challenges in its management. Understanding the perspectives of general practitioners at the frontline of care is important for system sustainability and accessibility as populations age.

OBJECTIVE

To explore Australian general practitioner perspectives on managing multimorbidity, the factors supporting their work, and those impeding their ability to meet their own standards of care provision.

METHOD

A qualitative study conducted with Australian general practitioners using semistructured, in-depth interviews and inductive thematic data analysis.

RESULTS

Twelve interviews with general practitioners were conducted. Three main themes were constructed from the data: Multimorbidity as an encounter with complexity and contingency; Evidence constraints in multimorbidity care; and Concerns for patient safety. System structure and the Australian general practice model restrict general practitioners' ability to provide care to their level of satisfaction by linking short consultation times to practice remuneration. Attitudes toward the applicability of guideline evidence were mixed despite most general practitioners questioning its generalizability. Patient safety concerns pervaded most interviews and largely centered on system fragmentation and insufficient intersectoral communication. General practitioners rely on multiple sources of information to provide patient-centered care but chiefly the accumulated knowledge of their patients.

CONCLUSIONS

Australian general practitioners share many multimorbidity concerns with international colleagues. While multimorbidity-specific evidence may be unrealistic to expect in the immediate term, system investment and adaptation is needed to support general practice sustainability and clinician ability to provide adequate multimorbidity care, suitably remunerated, into the future.

Late-effect awareness and follow-up of cancer in general practice

OBJECTIVE

With increasing cancer incidence and survival rates, follow-up care becomes a major healthcare concern, placing increased demands on general practitioners (GPs). We explored GPs' awareness of late effects (LEs) after cancer treatment. Their degree of involvement and attitudes towards follow-up care was studied separately for solid cancers and Hodgkin's lymphoma (HL).

DESIGN AND SETTING

Mailed questionnaire study in Norwegian general practice.

SUBJECTS

185 responding GPs with responsibility for HL survivors, more than 10 years since diagnosis.

MAIN OUTCOME MEASURES AND RESULTS

All GPs reported some awareness of LEs. Increasing awareness of LEs was associated with female sex, being a specialist, having experience from hospital-based cancer care and familiarity with official guidelines on LEs after treatment. The majority of GPs were involved in follow-up care, which increased with patients' time since treatment and was associated with higher awareness of LEs. GPs with work experience in hospital-based cancer care were more likely to be engaged in HL follow-up. Most GPs were willing to provide follow-up care at some point after treatment. Older and more experienced GPs, and those satisfied with the collaboration with hospital specialists, were more likely to provide follow-up earlier.

CONCLUSION

GPs' awareness of LEs and their willingness to provide follow-up care were related to familiarity with guidelines and experience. GPs more involved in follow-up care also had higher knowledge of LEs. Distribution of guidelines on LEs and follow-up care, and improving collaboration with hospital specialists, might increase GPs' knowledge and willingness to become involved in follow-up care, especially early in their careers. GPs' involvement and attitude towards follow-up of survivors of common solid cancers and HL, a rare malignant disease, were similar.KEY POINTSNorwegian general practitioners (GPs) are involved in survivorship care after cancer treatment. We investigated their awareness of late effects (LEs), their involvement and their attitude towards follow-up care of solid cancers and Hodgkin's lymphoma. • GPs registered as specialists, aware of guidelines and with experience from hospital-based cancer care reported higher awareness of LEs.  • GPs with higher awareness of LEs were more frequently involved in follow-up care.  • GPs with longer experience in general practice were comfortable with follow-up care at an earlier stage after treatment.  • Results were similar for follow-up care of survivors of solid cancers and Hodgkin's lymphoma.

Do they cope or mope? A survey of GPs' experiences with the changes in the Norwegian Cervical Cancer Screening Programme

OBJECTIVE

To explore Norwegian general practitioners' (GPs) experiences with the changes in the cervical cancer screening programme and to uncover which aspects of the programme they find most challenging.

DESIGN

We conducted an electronic cross-sectional survey.

SETTING

Norwegian GPs were invited to participate in the survey between February and September in 2020.

SUBJECTS

One hundred and fifty-five of 429 invited Norwegian GPs responded.

MAIN OUTCOME MEASURES

Self-reported measures were used to analyse GPs experiences and beliefs related to the screening programme.

RESULTS

Most GPs did not find it particularly challenging to keep up with the changes in the screening programme, regardless of whether they came from areas with HPV-based or cytology-based cervical cancer screening implemented. Challenges concerning the follow-up of patients after an abnormal test were a frequently reported issue. We did not find any differences in how often GPs were uncertain of the follow-up of an abnormal test result in areas with HPV-based compared to cytology-based screening.

CONCLUSIONS

The implementation of HPV-based cervical cancer screening in women 34-69 years does not seem to have affected how challenging the GPs perceive the screening programme.Key PointsHow Norwegian general practitioners (GPs) keep up with changes in the Norwegian Cervical Cancer Screening Programme (NCCSP) has not been assessed previously.Most GPs did not find it particularly challenging to keep up with changes in the NCCSP regardless of whether they belonged to an area of HPV-based or cytology-based screening.The follow-up of patients with an abnormal test result was one of the main challenges reported by the GPs.

Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia

RATIONALE AND OBJECTIVES

Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources.

METHOD

We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings.

RESULTS

Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines^© ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively).

CONCLUSION

Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.

A scoping review protocol of evidence-based guidance and guidelines published by general practitioner professional organisations

Introduction: General practitioners (GPs) strive to use a patient centered approach to achieve shared decision making by integrating clinical evidence, clinical judgement, and patient priorities. In order to achieve this standard of care, GPs require relevant, up to date and high quality evidence. Currently there is a gap in the literature regarding the role of GP professional organisations internationally in producing and publishing evidence based guidance and clinical guidelines for GPs. This protocol outlines a scoping review to identify what evidence-based guidance is produced by general practitioner professional organisations internationally in terms of topic content, the structure and methods used to develop guidance and ways of disseminating this guidance, to support general practice clinical decision making. Methods: This scoping review will be conducted using the framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR), will be used to guide the reporting. Two researchers will search electronic databases (Medline, Embase, Cochrane Library and Scopus), grey literature sources and contact international GP professional organisations directly to identify appropriate studies for inclusion. Key information will be categorised and classified to generate a summary of the methods used internationally to develop and implement evidence-based guides for general practitioners and a narrative synthesis will be conducted. Conclusions: This scoping review will examine current practice internationally regarding the role of General Practice professional organisations in producing and publishing clinical guidelines and evidence based guidance to support general practitioner's clinical decision making to benefit patient care.

A scoping review protocol of evidence-based guidance and guidelines published by general practitioner professional organisations

Introduction: General practitioners (GPs) strive to use a patient centered approach to achieve shared decision making by integrating clinical evidence, clinical judgement, and patient priorities. In order to achieve this standard of care, GPs require relevant, up to date and high quality evidence. Currently there is a gap in the literature regarding the role of GP professional organisations internationally in producing and publishing evidence based guidance and clinical guidelines for GPs. This protocol outlines a scoping review to identify what evidence-based guidance is produced by general practitioner professional organisations internationally in terms of topic content, the structure and methods used to develop guidance and ways of disseminating this guidance, to support general practice clinical decision making.

Methods: This scoping review will be conducted using the framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR), will be used to guide the reporting. Two researchers will search electronic databases (Medline, Embase, Cochrane Library and Scopus), grey literature sources and contact international GP professional organisations directly to identify appropriate studies for inclusion. Key information will be categorised and classified to generate a summary of the methods used internationally to develop and implement evidence-based guides for general practitioners and a narrative synthesis will be conducted.

Conclusions: This scoping review will examine current practice internationally regarding the role of General Practice professional organisations in producing and publishing clinical guidelines and evidence based guidance to support general practitioner’s clinical decision making to benefit patient care.

Clinical and operational insights from data-driven care pathway mapping: a systematic review

Background

Accumulated electronic data from a wide variety of clinical settings has been processed using a range of informatics methods to determine the sequence of care activities experienced by patients. The “as is” or “de facto” care pathways derived can be analysed together with other data to yield clinical and operational information. It seems likely that the needs of both health systems and patients will lead to increasing application of such analyses. A comprehensive review of the literature is presented, with a focus on the study context, types of analysis undertaken, and the utility of the information gained.

Methods

A systematic review was conducted of literature abstracting sequential patient care activities (“de facto” care pathways) from care records. Broad coverage was achieved by initial screening of a Scopus search term, followed by screening of citations (forward snowball) and references (backwards snowball). Previous reviews of related topics were also considered. Studies were initially classified according to the perspective captured in the derived pathways. Concept matrices were then derived, classifying studies according to additional data used and subsequent analysis undertaken, with regard for the clinical domain examined and the knowledge gleaned.

Results

254 publications were identified. The majority (n = 217) of these studies derived care pathways from data of an administrative/clinical type. 80% (n = 173) applied further analytical techniques, while 60% (n = 131) combined care pathways with enhancing data to gain insight into care processes.

Discussion

Classification of the objectives, analyses and complementary data used in data-driven care pathway mapping illustrates areas of greater and lesser focus in the literature. The increasing tendency for these methods to find practical application in service redesign is explored across the variety of contexts and research questions identified. A limitation of our approach is that the topic is broad, limiting discussion of methodological issues.

Conclusion

This review indicates that methods utilising data-driven determination of de facto patient care pathways can provide empirical information relevant to healthcare planning, management, and practice. It is clear that despite the number of publications found the topic reviewed is still in its infancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01756-2.

Shared decision-making between older people with multimorbidity and GPs: focus group study

Background

Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice.

Aim

To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care.

Design and setting

Qualitative study. General practices (rural and urban) in Devon, England.

Method

Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis.

Results

Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators.

Conclusion

Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group.

Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary.

Data sources: Articles published between January 2010–March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults.

Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems.

Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no “gold standard” is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

Reasons for non-adherence to thromboprophylaxis prescribing guidelines in atrial fibrillation in Western Australia: A qualitative descriptive study of general practitioners' views

BACKGROUND

A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change.

METHODS

An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model.

RESULTS

Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools).

CONCLUSION

GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs.

General practitioner responses to concerns in chronic care consultations for patients with a history of cancer

We investigated general practitioners' (GPs') responses to patients' concerns in chronic care consultations. Video recordings of 14 consultations were analyzed with conversation analysis. We found two categories of responses: exiting and exploring the patient's concerns. Most GPs exited the concern by interrupting the patient, acknowledging the concern but then referring back to the progression of the consultation, or affiliating with the concern without exploring it. Only a few raised concerns were explored, and then most often the somatic rather than the emotional aspects of them. The findings point to the risk of missing patients' voiced concerns in consultations with a fixed agenda.

Does the Conservative Non-pharmacological Management of Knee Osteoarthritis in Switzerland Reflect the Clinical Guidelines? A Survey Among General Practitioners, Rheumatologists, and Orthopaedic Surgeons

Introduction: The International Guidelines recommend exercise, education and weight management (if appropriate) as the first-line conservative treatment for patients with knee osteoarthritis (OA) to enhance their self-management. The aim of this study was to investigate the current state of conservative non-pharmacological management of patients with knee OA in Switzerland and to explore the perceived barriers and facilitators to the application of the guideline recommendations.

Materials and methods: Eleven semi-structured interviews with selected general practitioners (GPs), rheumatologists and orthopaedic surgeons were performed. Based on these results, an online survey was developed and sent to the members of three scientific medical societies. Questions addressed the frequency of diagnostic measures, treatment options, reasons for referral to exercise and also barriers and facilitators.

Results: A total of 234 members responded. They indicated that patients normally present due to pain (n = 222, 98.2%) and functional limitations of the knee (n = 151, 66.8%). In addition to clinical assessment, X-ray (n = 214, 95.5%) and MRI (n = 70, 31.3%) were the most frequently used diagnostic measures. Treatment options usually involved patient education for diagnosis (n = 223, 98.6%) and suitable activities (n = 217, 96%), pharmacological treatment (n = 203, 89.8%) and referral to physiotherapy (n = 188, 83.2%). The participants estimated that they had referred 54% of their patients with knee OA for a specific exercise. The referral to exercise was driven by “patient expectation/high level of suffering” (n = 73, 37.1%) and their “own clinical experience” (n = 49, 24.9%). The specialists rated the most important barriers to referral to exercise as “disinterest of patient” (n = 88, 46.3%) and “physically active patient” (n = 59, 31.1%). As the most important facilitators, they rated “importance to mention exercise despite the short time of consultation” (n = 170, 89.4%) and “insufficiently physically active patient” (n = 165, 86.9%).

Discussion: A substantial evidence–performance gap in the management of patients with knee OA appears to exist in Switzerland. For the systematic referral to exercise as the first-line intervention, it might be useful for medical doctors to suggest a structured exercise programme to patients with knee OA, rather than just advising general exercise.

Easier Said Than Done: Healthcare Professionals' Barriers to the Provision of Patient-Centered Primary Care to Patients with Multimorbidity

Patient-centered care (PCC) has the potential to entail tailored primary care delivery according to the needs of patients with multimorbidity (two or more co-existing chronic conditions). To make primary care for these patients more patient centered, insight on healthcare professionals’ perceived PCC implementation barriers is needed. In this study, healthcare professionals’ perceived barriers to primary PCC delivery to patients with multimorbidity were investigated using a constructivist qualitative design based on semi-structured interviews with nine general and nurse practitioners from seven general practices in the Netherlands. Purposive sampling was used, and the interview content was analyzed to generate themes representing experienced barriers. Barriers were identified in all eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, emotional support, family and friends, continuity and transition, and coordination of care). They include difficulties achieving mutual understanding between patients and healthcare professionals, professionals’ lack of training and education in new skills, data protection laws that impede adequate documentation and information sharing, time pressure, and conflicting financial incentives. These barriers pose true challenges to effective, sustainable PCC implementation at the patient, organizational, and national levels. Further improvement of primary care delivery to patients with multimorbidity is needed to overcome these barriers.

Managing diabetes mellitus with comorbidities in primary healthcare facilities in urban settings: a qualitative study among physicians in Odisha, India

Aim

To explore the perceived barriers and facilitators in the management of the patients having diabetes with comorbidities by primary care physicians.

Methods

A qualitative In-Depth Interview study was conducted among the primary care physicians at seventeen urban primary health care centres at Bhubaneswar city of Odisha, India. The digitally recorded interviews were transcribed verbatim and translated into English. The data were analysed using thematic analysis.

Results

Barriers related to physicians, patients and health system were identified. Physicians felt lack of necessary knowledge and skills, communication skills and overburdening due to multiple responsibilities to be major barriers to quality care. Patients’ attitude and beliefs along with socio-economic status played an important role in treatment adherence and in the management of their disease conditions. Poor infrastructure, irregular medicine supply, and shortage of skilled allied health professionals were also found to be barriers to optimal care delivery, as was the lack of electronic medical records and personal treatment records.

Conclusion

Comprehensive guidelines with on the job training for capacity building of the physicians and creation of multidisciplinary teams at primary care level for a more holistic approach towards management of diabetes with comorbidities could be the way forward to optimal delivery of care.

Factors affecting nurse practitioners' integration of evidence into practice

BACKGROUND

Evidence-based clinical practice guidelines bridge the gap between clinical practice and research, improve patient outcomes, promote consistency of care, and enhance quality of care. However, guideline adherence varies widely among individual providers and organizations.

PURPOSE

To identify factors that facilitate or impede nurse practitioners' integration of guideline recommendations into practice.

METHODS

Every nurse practitioner in Alabama was invited to complete an online 45-question survey evaluating beliefs and attitudes regarding evidence-based guidelines, facilitators and barriers to implementation, and utilization of information resources in patient care.

RESULTS

The five most commonly identified barriers to evidence-based guideline implementation in participants' current work settings are patients with multiple comorbidities, time constraints, pressure from patients to provide nonrecommended care, insufficient staffing, and inadequate financial resources. The five most commonly identified facilitators in participants' current work settings are easy access to guidelines, support from leadership, free access to guidelines, in-person education regarding a guideline, and clinical decision support software programs. Participants expressed a desire for free and easy access to evidence-based practice (EBP) guidelines and clinical decision support programs, as well as education regarding guidelines and opportunities to discuss evidence with colleagues.

IMPLICATIONS FOR PRACTICE

The barriers and facilitators of guideline implementation that were identified in this study should be useful in the development and refinement of future studies and interventions to enhance guideline implementation among individuals and organizations.

A scoping review protocol of evidence-based guidance published by general practitioner professional organisations

Introduction: General practitioners (GPs) strive to use a patient centred approach to achieve shared decision making by integrating clinical evidence, clinical judgement, and patient priorities. This protocol outlines a scoping review to identify what evidence-based guidance is produced by general practitioner professional organisations internationally to support general practice clinical decision making. Methods: This scoping review will be conducted using the framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR), will be used to guide the reporting. Two researchers will search electronic databases (Medline, Embase, Cochrane Library and Scopus), grey literature sources and contact international GP professional organisations directly to identify appropriate studies for inclusion. Key information will be categorised and classified to generate a summary of the methods used internationally to develop and implement evidence-based guides for general practitioners and a narrative synthesis will be conducted. Conclusions: This scoping review will identify the role of GP professional organisations in generating, endorsing and/or disseminating evidence-based guidance for supporting general practitioner’s clinical decision making to benefit patient care.

Guideline deviation and its association with specific chronic diseases among patients with multimorbidity: a cross-sectional cohort study in a care management setting

OBJECTIVES

To assess whether the extent of deviation from chronic disease guideline recommendations is more prominent for specific diseases compared with combined-care across multiple conditions among multimorbid patients, and to examine reasons for this deviation.

DESIGN

A cross-sectional cohort.

SETTING

Multimorbidity care management programme across 11 primary care clinics.

PATIENTS

Patients aged 45-95 years with at least two common chronic conditions, sampled according to being new (≤6 months) or veteran (≥1 year) to the programme.

MAIN OUTCOME MEASURES

Deviation from guideline-recommended care was measured for each patient's relevant conditions, aggregated and stratified across disease groups, calculated as measures of 'disease-specific' guideline deviation and 'combined-care' (all conditions) guideline deviation for: atrial fibrillation, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disorder, depression, diabetes, dyslipidaemia, hypertension and ischaemic heart disease. Combined-care deviation was evaluated for its association with specific diseases. Frequencies of previously derived reason types for deviation (biomedical, patient personal and contextual) were reported by nurse care managers, assessed across diseases and evaluated for their association with specific diseases.

RESULTS

Among 204 patients, disease-specific deviation varied more (from 14.7% to 48.2%) across diseases than combined-care deviation (from 14.7% to 25.6%). Depression and diabetes were significantly associated with more deviation (mean: 6% (95% CI: 2% to 10%) and 5% (95% CI: 2% to 9%), respectively). For some conditions, assessments were among small patient samples. Guideline deviation was often attributed to non-disease-specific reasons, such as physical limitations or care burden, as much as disease-specific reasons, which was reflected in the likelihood for guideline deviation to be due to different types of reasons for some diseases.

CONCLUSIONS

When multimorbid patients are considered in disease groups rather than as 'whole persons', as in many quality of care studies, the cross-cutting factors in their care delivery can be missed. The types of reasons more likely to occur for specific diseases may inform improvement strategies.

TRIAL REGISTRATION NUMBER

NCT01811173; Pre-results.

Treatment for acute bronchiolitis before and after implementation of new national guidelines: a retrospective observational study from primary and secondary care in Oslo, Norway

BACKGROUND

Acute bronchiolitis treatment guidelines changed in Norway in 2013, no longer recommending the use of nebulised epinephrine. We aimed to assess whether these changes were successfully implemented in both primary and secondary care. Secondary aims were to compare the difference in management of acute bronchiolitis patients in primary and secondary care between 2009 and 2017.

METHODS

We retrospectively registered data on demographics, clinical features and management from electronic medical records of all infants (<12 months of age) diagnosed with acute bronchiolitis at a primary care centre (Oslo Accident and Emergency Outpatient Clinic) and a secondary care centre (Oslo University Hospital) in Norway in 2009, 2014 and 2017. All patient records were individually reviewed to ensure data accuracy.

RESULTS

We included 680 (36.3%) patients from primary care and 1195 (63.7%) from secondary care. There was a reduction in the use of nebulised epinephrine from 2009 to 2017 from 66.9% to 16.1% of cases (p<0.001) in primary care and from 59.1% to 4.9% (p<0.001) in secondary care. In parallel, there was an increase in the use of nebulised saline treatment, from 0.8% to 53.8% (p<0.001) in primary care and from 39.3% to 65.3% (p<0.001) in secondary care. The decrease in the use of nebulised racemic epinephrine occurred earlier in secondary care than in primary care; 13.4% vs 56.1%, respectively, in 2014.

CONCLUSIONS

Implementation of the new guidelines on the treatment of acute bronchiolitis was successfully implemented in both primary and secondary care.

Health and cost impact of stepping down asthma medication for UK patients, 2001-2017: A population-based observational study

BACKGROUND

Guidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs.

METHODS AND FINDINGS

We used nationwide UK primary care medical records, 2001-2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (long-acting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown (adjusted hazard ratio, 95% CI, p-value: ICS inhaler dose = 0.86, 0.77-0.93, p < 0.001; ICS mean daily = 0.80, 0.74-0.87, p < 0.001; LABA = 1.01, 0.92-1.11, p = 0.87, other add-on = 1.00, 0.91-1.09, p = 0.79) and no increase in reliever prescriptions (adjusted odds ratio, 95% CI, p-value: ICS inhaler dose = 0.99, 0.98-1.00, p = 0.59; ICS mean daily = 0.78, 0.76-0.79, p < 0.001; LABA = 0.83, 0.82-0.85, p < 0.001; other add-on = 0.86, 0.85-0.87, p < 0.001). Prognostic factors to initiate stepdown included medication burden, but not medication side effects. National Health Service (NHS) indicative prices were used for cost estimates. Stepping down medication, either LABAs or ICSs, could save annually around £17,000,000 or £8,600,000, respectively. Study limitations include the possibility that prescribed medication may not have been dispensed or adhered to and the reason for stepdown was not documented.

CONCLUSION

In this UK study, we observed that asthma patients were increasingly prescribed higher levels of treatment, often without clear clinical indication for such high doses. Stepping down medication did not adversely affect outcomes and was associated with substantial cost savings.

General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research

Background

General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care.

Methods

Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies.

Results

Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk.

Conclusions

GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient’s unique circumstances, and useable knowledge of each individual’s capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.

Acceptability and usability of a mobile application for management and surveillance of vector-borne diseases in Colombia: An implementation study

BACKGROUND

Vector-borne diseases are a public health problem in Colombia, where dengue virus infection is hyperendemic. The introduction of other arboviruses, such as chikungunya and Zika in the last three years, has aggravated the situation. Mobile health (mHealth) offers new strategies for strengthening health care and surveillance systems promoting the collection, delivery, and access of health information to professionals, researchers, and patients. Assessing mobile application performance has been a challenge in low- and middle-income countries due to the difficulty of implementing these technologies in different clinical settings. In this study, we evaluate the usability and acceptability of a mobile application, FeverDX, as a support tool in the management of patients with febrile syndrome and suspected arboviruses infection by general practitioners from Colombia.

METHODS

A pilot implementation study was conducted to evaluate the usability and acceptability of FeverDX using the modified version of the Mobile Application Rating Scale (uMARS). The evaluation form included 25 questions regarding quantity and quality of information, engagement, functionality, aesthetics, impact, and acceptability by healthcare workers. Each item uses a 5-point scale (1-Inadequate, 2-Poor, 3-Acceptable, 4-Good, 5-Excellent). A global score was obtained for the evaluation form test by determining the median scores of each subsection. A descriptive statistical analysis of the data obtained was performed.

RESULTS

Between December 2016 and January 2017, a total of 20 general practitioners from the Emergency room and hospitalization areas evaluated FeverDX. Less than half (9/20) of the evaluators had a comprehensive knowledge of the Colombian Ministry of Health's guidelines for the diagnosis and management of arboviruses, and evaluators partially (4/9) or completely (5/9) agreed that the content of the application follows the management guidelines. On uMARS scale, FeverDX excelled regarding impact (median 5; IQR = 5-5), functionality (median 5; IQR = 4.8-5), and information and scientific basis (median 4; IQR = 4-4). FeverDX scored well regarding user feedback (median 4; IQR = 4-4.5), design and aesthetics (median 4; IQR = 4-4.3), and subjective assessment of quality (median 4.5; IQR = 4.3-4.8).

CONCLUSIONS

FeverDX, a mobile application, is a novel mHealth strategy to strengthen care processes and facilitate the detection and reporting of notifiable surveillance diseases. It could improve adherence to clinical practice guidelines for the management and prevention of prevalent diseases as arboviruses in healthcare settings. Although this pilot study used a small sample size, FeverDx performed adequately in a simulated emergency consultation. Further implementation studies are needed to increase the reliability of mHealth technologies in different scenarios.

Patterns of Multimorbidity and Differences in Healthcare Utilization and Complexity Among Acutely Hospitalized Medical Patients (≥65 Years) - A Latent Class Approach

PURPOSE

The majority of acutely admitted older medical patients are multimorbid, receive multiple drugs, and experience a complex treatment regime. To be able to optimize treatment and care, we need more knowledge of the association between different patterns of multimorbidity and healthcare utilization and the complexity thereof. The purpose was therefore to investigate patterns of multimorbidity in a Danish national cohort of acutely hospitalized medical patients aged 65 and older and to determine the association between these multimorbid patterns with the healthcare utilization and complexity.

PATIENTS AND METHODS

Longitudinal cohort study of 129,900 (53% women) patients. Latent class analysis (LCA) was used to develop patterns of multimorbidity based on 22 chronic conditions ascertained from Danish national registers. A latent class regression was used to test for differences in healthcare utilization and healthcare complexity among the patterns measured in the year leading up to the index admission.

RESULTS

LCA identified eight distinct multimorbid patterns. Patients belonging to multimorbid patterns including the major chronic conditions; diabetes and chronic obstructive pulmonary disease was associated with higher odds of healthcare utilization and complexity than the reference pattern ("Minimal chronic conditions"). The pattern with the highest number of chronic conditions did not show the highest healthcare utilization nor complexity.

CONCLUSION

Our study showed that chronic conditions cluster together and that these patterns differ in healthcare utilization and complexity. Patterns of multimorbidity have the potential to be used in epidemiological studies of healthcare planning but should be confirmed in other population-based studies.

Applying evidence-based medicine in general practice: a video-stimulated interview study on workplace-based observation

Background

Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient’s preferences and the general practitioner’s (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other’s consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other’s EBM behaviour through observation, and by identifying aspects that influence their recognition.

Methods

We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner’s consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner’s actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other’s considerations well with those who did not, we developed a model describing the aspects that influence the observer’s recognition of an actor’s EBM behaviour.

Results

Overall, there was moderate similarity between an actor’s EBM behaviour and the observer’s recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role.

Conclusions

GP trainees and supervisors do not fully recognise EBM behaviour through observing each other’s consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.

Impact on core values of family medicine from a 2-year Master's programme in Gezira, Sudan: observational study

BACKGROUND

Training of family physicians should include not only clinical and procedural skills, but also core values as comprehensive care, continuity of care, leadership and patient-centeredness. The Gezira Family Medicine Project (GFMP) is a 2 years Master's programme in family medicine in Sudan. We assessed the impact of GFMP on the candidates' adherence to some core values of family medicine.

METHODS

This is a prospective study with before-after design based on repeated surveys. We used Patient-Practitioner Orientation Scale (PPOS) to assess physicians' attitude towards patient-centeredness. Practice based data from individual patients' consultations and self-assessment methods were used to assess physicians' adherence to core values.

RESULTS

At the end of the programme the candidates (N = 110) were significantly more active in community health promotion (p <  0.001), more confident as a team leader (p = 0.008), and showed increased adherence to national guidelines for managing diabetes (p = 0.017) and hypertension (p = 0.003). The responding candidates had more knowledge about patients' medical history (p <  0.001), family history (p < 0.001) and family situation (p < 0.001). There were more planned follow up consultations (p < 0.001) and more referrals (p = 0.040). In contrast, results from PPOS showed slightly less orientation towards patient-centeredness (p = 0.007).

CONCLUSIONS

The GFMP Master's programme induced a positive change in adherence to several core values of family medicine. The candidates became less patient-centered.

Stroke follow-up in primary care: a Norwegian modelling study on the implications of multimorbidity for guideline adherence

Background

Specialized acute treatment and high-quality follow-up is meant to reduce mortality and disability from stroke. While the acute treatment for stroke takes place in hospitals, the follow-up of stroke survivors largely takes place in general practice. National guidelines give recommendations for the follow-up. However, previous studies suggest that guidelines are not sufficiently adhered to. It has been suggested that this might be due to the complexity of general practice. A part of this complexity is constituted by patients’ multimorbidity; the presence of two or more chronic conditions in the same person. In this study we investigated the extent of multimorbidity among stroke survivors residing in the communities. The aim was to assess the implications of multimorbidity for the follow-up of stroke in general practice.

Methods

The study was a cross sectional analysis of the prevalence of multimorbidity among stroke survivors in Mid-Norway. We included 51 patients, listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ medical records for these patients. The medical records for each patient were reviewed in a search for diagnoses corresponding to a predefined list of morbidities, resulting in a list of chronic conditions for each participant. These 51 lists were the basis for the subsequent analysis. In this analysis we modelled different hypothetical patients and assessed the implications of adhering to all clinical guidelines affecting their diseases.

Result

All 51 patients met the criteria for multimorbidity. On average the patients had 4.7 (SD: 1.9) chronic conditions corresponding to the predefined list of morbidities. By modelling implications of guideline adherence for a patient with an average number of co-morbidities, we found that 10–11 annual consultations with the general practitioner were needed for the follow-up of the stable state of the chronic conditions. More consultations were needed for patients with more complex multimorbidity.

Conclusions

Multimorbidity had a clear impact on the basis for the follow-up of patients with stroke in general practice. Adhering to the guidelines for each condition is challenging, even for patients with few co-morbidities. For patients with complex multimorbidity, adhering to the guidelines is obviously unmanageable.

General Practitioners' Attitudes toward Municipal Initiatives to Improve Antibiotic Prescribing-A Mixed-Methods Study

Antimicrobial stewardship (AMS) interventions directed at general practitioners (GPs) contribute to an improved antibiotic prescribing. However, it is challenging to implement and maintain such interventions at a national level. Involving the municipalities’ Chief Medical Officer (MCMO) in quality improvement activities may simplify the implementation and maintenance, but may also be perceived challenging for the GPs. In the ENORM (Educational intervention in NORwegian Municipalities for antibiotic treatment in line with guidelines) study, MCMOs acted as facilitators of an AMS intervention for GPs. We explored GPs’ views on their own antibiotic prescribing, and their views on MCMO involvement in improving antibiotic prescribing in general practice. This is a mixed-methods study combining quantitative and qualitative data from two data sources: e-mail interviews with 15 GPs prior to the ENORM intervention, and online-form answers to closed and open-ended questions from 132 GPs participating in the ENORM intervention. The interviews and open-ended responses were analyzed using systematic text condensation. Many GPs admitted to occasionally prescribing antibiotics without medical indication, mainly due to pressure from patients. Too liberal treatment guidelines were also seen as a reason for overtreatment. The MCMO was considered a suitable and acceptable facilitator of quality improvement activities in general practice, and their involvement was regarded as unproblematic (scale 0 (very problematic) to 10 (not problematic at all): mean 8.2, median 10). GPs acknowledge the need and possibility to improve their own antibiotic prescribing, and in doing so, they welcome engagement from the municipality. MCMOs should be involved in quality improvement and AMS in general practice.

Prediction of Drug-Drug Interactions Related to Inhibition or Induction of Drug-Metabolizing Enzymes

Drug-drug interaction (DDI) is the phenomenon of alteration of the pharmacological activity of a drug(s) when another drug(s) is co-administered in cases of so-called polypharmacy. There are three types of DDIs: pharmacokinetic (PK), pharmacodynamic, and pharmaceutical. PK is the most frequent type of DDI, which often appears as a result of the inhibition or induction of drug-metabolising enzymes (DME). In this review, we summarise in silico methods that may be applied for the prediction of the inhibition or induction of DMEs and describe appropriate computational methods for DDI prediction, showing the current situation and perspectives of these approaches in medicinal and pharmaceutical chemistry. We review sources of information on DDI, which can be used in pharmaceutical investigations and medicinal practice and/or for the creation of computational models. The problem of the inaccuracy and redundancy of these data are discussed. We provide information on the state-of-the-art physiologically- based pharmacokinetic modelling (PBPK) approaches and DME-based in silico methods. In the section on ligand-based methods, we describe pharmacophore models, molecular field analysis, quantitative structure-activity relationships (QSAR), and similarity analysis applied to the prediction of DDI related to the inhibition or induction of DME. In conclusion, we discuss the problems of DDI severity assessment, mention factors that influence severity, and highlight the issues, perspectives and practical using of in silico methods.

Barriers and Facilitators to Weight and Lifestyle Management in Women with Polycystic Ovary Syndrome: General Practitioners' Perspectives

Background: Weight and lifestyle management is advocated as the first-line treatment for polycystic ovary syndrome (PCOS) by evidence-based guidelines. Current literature describes both systems- and individual-related challenges that general practitioners (GPs) face when attempting to implement guideline recommendations for lifestyle management into clinical practice for the general population. The GPs’ perspective in relation to weight and lifestyle advice for PCOS has not been captured. Methods: Fifteen GPs were recruited to take part in semi-structured interviews. NVIVO software was used for qualitative analysis. Results: We report that GPs unanimously acknowledge the importance of weight and lifestyle management in PCOS. Practice was influenced by both systems-related and individual-related facilitators and barriers. Individual-related barriers include perceived lack of patient motivation for weight loss, time pressures, lack of financial reimbursement, and weight management being professionally unrewarding. System-related barriers include costs of accessing allied health professionals and unavailability of allied health professionals in certain locations. Individual-related facilitators include motivated patient subgroups such as those trying to get pregnant and specific communication techniques such as motivational interviewing. System-related facilitators include the GP’s role in chronic disease management. Conclusions: This study contributes to the understanding of barriers and facilitators that could be addressed to optimize weight and lifestyle management in women with PCOS in primary care.

Stroke follow-up in primary care: a prospective cohort study on guideline adherence

Background

After a stroke, a person has an increased risk of recurrent strokes. Effective secondary prevention can provide significant gains in the form of reduced disability and mortality. While considerable efforts have been made to provide high quality acute treatment of stroke, there has been less focus on the follow-up in general practice after the stroke. One strategy for the implementation of high quality, evidence-based treatment is the development and distribution of clinical guidelines. However, from similar fields of practice, we know that guidelines are often not adhered to. The purpose of this study was to investigate to what degree patients who have suffered a stroke are followed up in general practice, if recommendations in the national guidelines are followed, and if patients achieve the treatment goals recommended in the guidelines.

Methods

The study included patients with cerebral infarction identified by the ICD-10 discharge diagnoses I63.0 trough I63.9 in two Norwegian local hospitals. In total 51 patients participated. They were listed with general practitioners in 18 different clinics. The material consists of the general practitioners’ (GPs’) medical records for these patients in the first year of follow-up; in total 381 consultations.

Results

Of the 381 consultations during the first year of follow-up, 71 (19%) had stroke as the main topic. The blood pressure (BP) target value < 140/90 mmHg was reached by 24 patients (47%). The low density lipoprotein (LDL) cholesterol target value < 2.0 mmol/L was reached by 14 (27%) of the 51 patients. In total six patients (12%) got advice on physical activity and three (6%) received dietary advice. No advice about alcohol consumption was recorded.

Conclusions

The findings support earlier claims that the development and distribution of guidelines alone is not enough to implement a certain practice. Despite being a serious condition, stroke gets limited attention in the first year of follow-up in general practice. This can be explained by the complexity of general practice, where even a serious condition loses the competition for attention to other apparently equally important issues.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0872-9) contains supplementary material, which is available to authorized users.

Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions

Although the majority of older adults in the developed world live with multiple chronic conditions (MCCs), the task of selecting optimal treatment regimens is still fraught with difficulty. Older adults with MCCs may derive less benefit from prescribed medications than healthier patients as a result of the competing risk of several possible outcomes including, but not limited to, death before a benefit can be accrued. In addition, these patients may be at increased risk of medication-related harms in the form of adverse effects and significant burdens of treatment. At present, the balance of these benefits and harms is often uncertain, given that older adults with MCCs are often excluded from clinical trials. In this review, we propose a framework to consider patients' own priorities to achieve optimal treatment regimens. To begin, the practicing clinician needs information on the patient's goals, what the patient is willing and able to do to achieve these goals, an estimate of the patient's clinical trajectory, and what the patient is actually taking. We then describe how to integrate this information to understand what matters most to the patient in the context of an array of potential tradeoffs. Finally, we propose conducting serial therapeutic trials of prescribing and deprescribing, with success measured as progress towards the patient's own health outcome goals. The process described in this manuscript is truly an iterative process, which should be repeated regularly to account for changes in the patient's priorities and clinical status. With this process, we aim to achieve optimal prescribing, that is, treatment regimens that maximize benefits that matter to the patient and minimize burdens and potential harms.

'I've put diabetes completely on the shelf till the mental stuff is in place'. How patients with doctor-assessed impaired self-care perceive disease, self-care, and support from general practitioners. A qualitative study

OBJECTIVE

This paper investigated patients' experiences of disease and self-care as well as perceptions of the general practitioner's role in supporting patients with impaired self-care ability.

DESIGN

Qualitative interviews with 13 patients with type 2 diabetes, concurrent chronic diseases, and impaired self-care ability assessed by a general practitioner. We analyzed our data using systematic text condensation. The shifting perspectives model of chronic illness formed the theoretical background for the study.

RESULTS

Although most patients experienced challenges in adhering to recommended self-care activities, many had developed additional, personal self-care routines that increased wellbeing. Some patients were conscious of self-care trade-offs, including patients with concurrent mental disorders who were much more attentive to their mental disorder than their somatic diseases. Patients' perspectives on diseases could shift over time and were dominated by emotional considerations such as insisting on leading a normal life or struggling with limitations caused by disease. Most patients found support in the ongoing relationship with the same general practitioner, who was valued as a companion or appreciated as a trustworthy health informant.

CONCLUSION

Patient experiences of self-care may collide with what general practitioners find appropriate in a medical regimen. Health professionals should be aware of patients' prominent and shifting considerations about the emotional aspects of disease. Patients valued the general practitioner's role in self-care support, primarily through the long-term doctor-patient relationship. Therefore, relational continuity should be prioritized in chronic care, especially for patients with impaired self-care ability who often have a highly complex disease burden and situational context. Key points   Little is known about the perspectives of disease and self-care in patients with a doctor-assessed impaired ability of self-care.   • Although patients knew the prescribed regimen they often prioritized self-care routines that increased well-being at the cost of medical recommendations.   • Shifting emotional aspects were prominent in patients' considerations of disease and sustained GPs' use of a patient-centred clinical method when discussing self-care.   • Relational continuity with general practitioners was a highly valued support and should be prioritized for patients with impaired self-care.

Small-scale implementation with pragmatic process evaluation: a model developed in primary health care

BACKGROUND

Research often fails to impose substantial shifts in clinical practice. Evidence-based health care requires implementation of documented interventions, with implementation research as a science-informed strategy to identify core experiences from the process and share preconditions for achievement. Evidence developed in hospital contexts is often neither relevant nor feasible for primary care. Different evidence types may constitute a point of departure, stretching and testing the transferability of the intervention by piloting it in primary care. Comprehensive descriptions of aims, context and procedures can be a more useful outcome than traditional effect studies.

MAIN TEXT

We present a model for small-scale implementation of relevant research evidence, monitored by pragmatic evaluation. The model, which is applicable in primary care, is supported by Weiner's theory about organizational readiness for change and consists of four steps: 1) recognize the problem - identify a workable intervention, 2) assess the context - prepare for inception, 3) pilot the intervention on site, and 4) upscale and accomplish the intervention. The process is evaluated by exploring selected relevant aspects of experiences and outcomes from the first to the last step. Process evaluation is a logical precondition for outcome evaluation - attempting to assess either the efficacy or the effectiveness of a "black box" intervention makes no sense. We argue why evidence beyond effect studies and evaluation beyond randomized controlled trials may be adequate for science-informed evaluation of a small-scale implementation project such as is often conducted by primary health care practitioners. The model is illustrated by an ongoing project, in which a strategy for upgrading the management of depression in nursing homes in Norway is currently being implemented.

CONCLUSIONS

A flexible and manageable approach is suggested, in which the inevitable unpredictability of clinical practice is incorporated. Finding the appropriate middle ground between rigour and flexibility, some compromises must be made. Our model recognizes the skills of practical knowing as something other than traditional medical research, while maintaining academic values such as systematic and transparent reflection, using adequate tools. Considering the purpose and context of our model, we argue that these priorities, emphasizing relevance and feasibility, are strengths, not limitations.

Management of patients with persistent medically unexplained symptoms: a descriptive study

BACKGROUND

In 2013 the Dutch guideline for management of medically unexplained symptoms (MUS) was published. The aim of this study is to assess medical care for patients with persistent MUS as recorded in their electronic medical records, to investigate if this is in line with the national guideline for persistent MUS and whether there are changes in care over time.

METHODS

We conducted an observational study of adult primary care patients with MUS. Routinely recorded health care data were extracted from electronic medical records of patients participating in an ongoing randomised controlled trial in 30 general practices in the Netherlands. Data on general practitioners' (GPs') management strategies during MUS consultations were collected in a 5-year period for each patient prior. Management strategies were categorised according to the options offered in the Dutch guideline. Changes in management over time were analysed.

RESULTS

Data were collected from 1035 MUS consultations (77 patients). Beside history-taking, the most frequently used diagnostic strategies were physical examination (24.5%) and additional investigations by the GP (11.1%). Frequently used therapeutic strategies were prescribing medication (24.6%) and providing explanations (11.2%). As MUS symptoms persisted, GPs adjusted medication, discussed progress and scheduled follow-up appointments more frequently. The least frequently used strategies were exploration of all complaint dimensions (i.e. somatic, cognitive, emotional, behavioural and social) (3.5%) and referral to a psychologist (0.5%) or psychiatrist (0.1%).

CONCLUSIONS

Management of Dutch GPs is partly in line with the Dutch guideline. Medication was possibly prescribed more frequently than recommended, whereas exploration of all complaint dimensions, shared problem definition and referral to mental health care were used less.

The clinical database and implementation of treatment guidelines by the Danish Breast Cancer Cooperative Group in 2007-2016

BACKGROUND

Since 40 years, Danish Breast Cancer Cooperative Group (DBCG) has provided comprehensive guidelines for diagnosis and treatment of breast cancer. This population-based analysis aimed to describe the plurality of modifications introduced over the past 10 years in the national Danish guidelines for the management of early breast cancer. By use of the clinical DBCG database we analyze the effectiveness of the implementation of guideline revisions in Denmark.

METHODS

From the DBCG guidelines we extracted modifications introduced in 2007-2016 and selected examples regarding surgery, radiotherapy (RT) and systemic treatment. We assessed introduction of modifications from release on the DBCG webpage to change in clinical practice using the DBCG clinical database.

RESULTS

Over a 10-year period data from 48,772 patients newly diagnosed with malignant breast tumors were entered into DBCG's clinical database and 42,197 of these patients were diagnosed with an invasive carcinoma following breast conserving surgery (BCS) or mastectomy. More than twenty modifications were introduced in the guidelines. Implementations, based on prospectively collected data, varied widely; exemplified with around one quarter of the patients not treated according to a specific guideline within one year from the introduction, to an almost immediate full implantation.

CONCLUSIONS

Modifications of the DBCG guidelines were generally well implemented, but the time to full implementation varied from less than one year up to around five years. Our data is registry based and does not allow a closer analysis of the causes for delay in implementation of guideline modifications.

Clinical drug trials in general practice: how well are external validity issues reported?

BACKGROUND

When reading a report of a clinical trial, it should be possible to judge whether the results are relevant for your patients. Issues affecting the external validity or generalizability of a trial should therefore be reported. Our aim was to determine whether articles with published results from a complete cohort of drug trials conducted entirely or partly in general practice reported sufficient information about the trials to consider the external validity.

METHODS

A cohort of 196 drug trials in Norwegian general practice was previously identified from the Norwegian Medicines Agency archive with year of application for approval 1998-2007. After comprehensive literature searches, 134 journal articles reporting results published from 2000 to 2015 were identified. In these articles, we considered the reporting of the following issues relevant for external validity: reporting of the clinical setting; selection of patients before inclusion in a trial; reporting of patients' co-morbidity, co-medication or ethnicity; choice of primary outcome; and reporting of adverse events.

RESULTS

Of these 134 articles, only 30 (22%) reported the clinical setting of the trial. The number of patients screened before enrolment was reported in 61 articles (46%). The primary outcome of the trial was a surrogate outcome for 60 trials (45%), a clinical outcome for 39 (29%) and a patient-reported outcome for 25 (19%). Clinical details of adverse events were reported in 124 (93%) articles. Co-morbidity of included participants was reported in 54 trials (40%), co-medication in 27 (20%) and race/ethnicity in 78 (58%).

CONCLUSIONS

The clinical setting of the trials, the selection of patients before enrolment, and co-morbidity or co-medication of participants was most commonly not reported, limiting the possibility to consider the generalizability of a trial. It may therefore be difficult for readers to judge whether drug trial results are applicable to clinical decision-making in general practice or when developing clinical guidelines.

Computer technologies to integrate medical treatments to manage multimorbidity

The high prevalence of multimorbid cases is a challenge for Health-Care Systems today. Clinical practice guidelines are the means to register and transmit the available evidence-based medical knowledge concerning concrete diseases. Several computer languages have been defined to represent this knowledge in a way that computers could use to help physicians in the daily practice of medicine. The generation of guidelines for all possible multimorbidities entails several issues that are difficult to address. Consequently, numerous medical informatics technologies have appeared merging computer information structures in a way that the treatment knowledge about single diseases could be combined in order to deliver health-care to patients suffering from multimorbidity. This paper proposes a classification of the most promising current technologies addressing this issue and provides an analysis of their maturity, strengths, and weaknesses. We conclude with an enumeration of ten relevant issues to consider when developing such technologies.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE

Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment.

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.