Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review.

PURPOSE: Although specialized centers are generally accepted for treatment of relatively uncommon diseases, such as cystic fibrosis, statements regarding the amount of expertise or minimum number of patients treated are increasingly included in guidelines for the treatment of other chronic diseases such as rheumatoid arthritis and diabetes mellitus. DATA SOURCES: Medline and Embase from 1987 through March 2008 were searched. STUDY SELECTION: Studies reporting the effect of treatment in a specialized or high-volume center or by subspecialists on a clinically relevant outcome. Data extraction Two reviewers extracted the data independently and assessed the methodological quality. RESULTS OF DATA SYNTHESIS: We included 22 articles. Two randomized-controlled trials and a quasi-experimental study compared the effect of outpatient team care with traditional outpatient care for patients with rheumatoid arthritis. These studies showed no difference or were inconsistent. Studies on the outcomes of care for diabetic patients (5 prospective or historical cohort studies and 10 retrospective cohort studies) were generally of poor quality. Studies comparing the subspecialist care with the care provided by general internists or primary care providers produced inconsistent results. Similar inconsistency and poor quality were found for three observational studies on cystic fibrosis. CONCLUSION: The available literature suggests that among patients with rheumatoid arthritis, diabetes mellitus or cystic fibrosis, outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care.

Development of a research agenda for general practice based on knowledge gaps identified in Dutch guidelines and input from 48 stakeholders.

BACKGROUND: Several funding organizations using different agendas support research in general practice. Topic selection and prioritization are often not coordinated, which may lead to duplication and research waste. OBJECTIVES: To develop systematically a national research agenda for general practice involving general practitioners, researchers, patients and other relevant stakeholders in healthcare. METHODS: We reviewed knowledge gaps from 90 Dutch general practice guidelines and formulated research questions based on these gaps. In addition, we asked 96 healthcare stakeholders to add research questions relevant for general practice. All research questions were prioritized by practising general practitioners in an online survey (n = 232) and by participants of an invitational conference including general practitioners (n = 48) and representatives of other stakeholders in healthcare (n = 16), e.g. patient organizations and medical specialists. RESULTS: We identified 787 research questions. These were categorized in two ways: according to the chapters of the International Classification for Primary Care (ICPC) and in 12 themes such as common conditions, person-centred care and patient education, collaboration and organization of care. The prioritizing procedure resulted in top 10 lists of research questions for each ICPC chapter and each theme. CONCLUSION: The process resulted in a widely supported National Research Agenda for General Practice. We encourage both researchers and funding organizations to use this agenda to focus their research on the most relevant issues in general practice and to generate new evidence for the next generation of guidelines and the future of general practice.

Guideline development.

During the last decade many countries have become increasingly interested in the development and use of evidence-based practice guidelines, recognising that guidelines are key tools to improve the quality and appropriateness of health care. They are considered to be the ideal mediator for bridging the gap between the growing stream of research findings and actual clinical practice. Systematic reviews of guideline evaluations have shown that clinical practice guidelines can be an effective means of both changing the process of healthcare delivery and improving outcomes. A review of 59 guideline evaluation studies found that, in all but 4, statistically significant improvements occurred in clinical practice after implementation. A systematic review of 87 studies on the use of guidelines concluded that 81 studies revealed evidence of improved patient outcomes. Evidence-based guidelines are becoming an important and indispensable part of quality healthcare because of their potentials to improve quality and also reduce cost of health-care. Adherence to guidelines and protocols may reduce health-care costs up to a 25%. We will present an overview of the history of guideline development and give some widely used definitions of guidelines. Guidelines are developed in a structured and systematic way, this process will be explained later. Also implementation tools necessary to put the guidelines into practice in an active way, will be discussed.