Clinical practice guidelines to inform evidence-based clinical practice.

BACKGROUND: With the volume of medical research currently published, any one practitioner cannot independently review the literature to determine best evidence-based medical care. Additionally, non-specialists usually do not have the experience to know best practice for all of the frequent clinical circumstances for which there is no good evidence. Clinical practice guidelines (CPGs) help clinicians to address these problems because they are systematically created documents that summarize knowledge and provide guidance to assist in delivering high-quality medicine. They aim to improve health care by identifying evidence that supports the best clinical care and making clear which practices appear to be ineffective. METHODS: Non-structured literature review. RESULTS: CPGs combine evidence-based medicine (on topics for which evidence exists) with expert opinion (on topics for which there is no evidence). The optimal CPG applies structured and transparent judgments, from an unbiased and diverse panel which includes both clinical experts and non-physicians, to a systematic evidence review. It includes decisions in areas in which clinical data are both available and unavailable. The resulting guideline statements should be clearly linked to the quality of the available evidence and the target patient(s) should be clearly defined, so that the reader can assess strength and applicability of the statements to an individual patient. CONCLUSIONS: The application of high-quality CPGs improves patient care, but all too often CPGs are not used to the greatest advantage because of inadequate dissemination and incorporation into practice. This article provides an overview of CPGs, focusing on their justification, creation, improvement, and use.

Staying at the cutting edge: a review and analysis of evidence reporting and grading; the recommendations of the American Urological Association.

The American Urological Association (AUA), as the premier urological organization in the USA, has been a pioneering force in the development of practice guidelines. Recently the AUA evaluated their guidelines development procedures and implemented several changes that resulted in more scientifically rigorous, transparent and efficient processes. These changes include narrowing the scope of the guideline, strengthening the systematic literature review, updating data-analysis capabilities, altering panel members' roles to exclude laborious data extraction, and identifying and specifying levels of evidence for guideline recommendations. In addition to a more scientifically sound guideline, the outcome of these modifications is a timely, less costly document involving fewer burdens on panel members.

The value of nurse leaders on federal advisory panels: experience with the Agency for Healthcare Research and Quality.

This article focuses on interviews with six nationally known nurse leaders who have been, or currently are, members of National Advisory Committee for the Healthcare Research and Quality (NAC). The nurse leaders are either deans and/or professors of schools of nursing. They discuss how their participation on the NAC serves the Federal Government and what they view as the benefits they now offer the nursing profession from being on the NAC such as an increased focus on evidence-based research. These nurse leaders also discuss what they bring to the table in terms of helping to influence public policy vis a vis health care quality, safety, and scientific evidence and their bearing on health care systems and services. They also talk about the myriad Federal opportunities that exist beyond this influential panel for nurse leaders to help continue shaping the future of health care.

Expanded newborn screening for genetic and metabolic disorders: modeling costs and outcomes.

Newborn screening for genetic and metabolic disorders is a state-based public health program in the United States, for the elimination and/or reduction of associated mortality, morbidity, and disabilities. As new technologies for newborn screening and new interventions for treatment are realized, it will be increasingly important for health leaders and policymakers to have data to inform their decisions regarding expanding newborn testing. The entire costs of a screening program, including not only instrumentation but also labor and time costs; initial, repeat, and confirmatory testing; screening sensitivity and specificity; and short and long-term followup, should be considered in decisions regarding expansion of screening programs. The decision model cited in this study can serve as a tool in exploring alternatives for critical decisions regarding the addition of new disorders to existing newborn screening panels. The evaluation of genetic disorders in this study can be used as a prototype of an approach to evaluating screening for any newborn genetic/metabolic disorder.

Policy issues related to expanded newborn screening: a review of three genetic/metabolic disorders.

In 2005, a federal advisory committee recommended that the number of disorders in state newborn screening programs be expanded from 9 to 29. In view of this recommendation, state leaders will need to make cogent decisions regarding the expanse of their state newborn screening programs. They must consider several factors, including the costs and outcomes of the screening program. The expense of the initial screening test can be misleading because it does not include the cost of the entire program (testing, tracking, notifying, retesting, confirmatory testing, and follow-up). Also, outcomes such as false positive findings can be costly to newborn screening programs, result in additional testing for infants, and lead to parental concern and worry. This article examines some of the policy issues related to newborn screening and specifically focuses on three disorders recommended for newborn screening, cystic fibrosis (CF), medium-chain acyl CoA dehydrogenase Deficiency (MCADD), and beta-ketothiolase (BKT).

A primer on economic evaluations related to expansion of newborn screening for genetic and metabolic disorders.

Newborns in every state are screened for genetic/metabolic disorders, but there is no uniform national screening program. Recently, a federal panel concluded that the number of disorders screened should be increased from 9 to Twenty-nine. In order for state leaders, and for the clinicians who inform them, to make sound decisions about expanding newborn screening programs, they need to be aware of the costs and outcomes of the entire screening program. This paper examines newborn screening from several perspectives: status of state programs, screening technology, and financing. In addition, various types of economic evaluations are defined, and a number of economic studies are explored.

The first national reports on United States healthcare quality and disparities.

In the Healthcare Research and Quality Act of 1999 (Public Law 106-129), Congress mandated that the Agency for Healthcare Research and Quality (AHRQ) produce annual reports on healthcare quality and disparities in the United States. The National Healthcare Quality Report and the National Healthcare Disparities Report were first released in 2003 by the AHRQ. These reports include broad sets of performance measures to portray the nation's progress toward improving the quality of care provided to all Americans. This article provides an overview of the framework, development, and future uses of the reports by consumers, practitioners, researchers, and policy makers.

Outcomes and effectiveness research: capacity building for nurse researchers at the Agency for Healthcare Research and Quality.

Several of AHRQ's priority areas including disease prevention, health promotion, primary care, quality of care, service delivery, and patient safety are particularly relevant to nurse researchers. With much national attention focused on nursing-related issues such as staff shortages, training, mandatory overtime, working conditions, and autonomy, it is mandatory that nursing research be conducted to inform healthcare delivery and policy. Nurses also need to contribute to the health services literature so that an even balance of discipline perspective is represented. AHRQ's mandate is represented by the slogan "quality research for quality health care." Although our understanding has expanded of contributors to and determinants of evidence-based practice and the relationship between clinical care and improved outcomes, we have much to learn. Appreciating how and which components of nursing care influence patient outcomes represents an essential area of research in need of development. While clarifying nursing contributions to improved outcomes is not the sole purview of nurse researchers, it is plausible to assume that a clinical background in nursing combined with strong methodological skills can help policy makers and health system leaders understand how nurses can most effectively contribute to outcomes and quality improvement. AHRQ is clearly interested in capacity building of researchers from all relevant disciplines. Nurses, the largest provider of healthcare, need to build capacity and develop a much stronger presence in the health services research community of scholars.