Do clinical practice guidelines improve processes or outcomes in primary care?

BACKGROUND: Clinical practice guidelines (CPGs) are common, but it is not clear whether they improve care. METHODS: Quality indicators for processes and outcomes of care were obtained from a computerized system-wide database by patient administration and utilization management personnel unaware of this study and without connection to or interests in guideline implementation. These indicators were compared before and after guideline implementation. RESULTS: After the asthma CPG, nebulizer treatments, emergency department visits, and admissions decreased significantly (p < 0.001 for all three) and education increased significantly (p < 0.001). Periodic measurements of lung function and controller medication prescriptions were unchanged. After the diabetes mellitus CPG, microalbumin screens and education increased significantly (p < 0.001). Angiotensin-converting enzyme inhibitor prescriptions and yearly foot examinations decreased significantly, along with the percentage of patients with blood pressure of < or = 130/85 mm Hg (p < 0.001). Mean hemoglobin A(1C) levels did not change significantly. After the tobacco cessation CPG, screening and education increased significantly (p < 0.001 and p = 0.04, respectively). CONCLUSIONS: The asthma CPG improved some processes and all outcomes. The diabetes CPG improved two of the eight measured processes but had no effect on outcomes. Education and screening, but not counseling, improved with the tobacco CPG. CPGs appear to improve diagnostic and educational processes more than provider-dependent treatment processes. Outcomes were improved after implementation of the asthma CPG but not after the diabetes CPG.

Use of robotic telepathology for frozen-section diagnosis: a retrospective trial of a telepathology system for intraoperative consultation.

Telepathology is the practice of digitizing histological or macroscopic images for transmission along telecommunication pathways for diagnosis, consultation, or continuing medical education. Previous studies have addressed static versus dynamic imaging in several specimen types with a wide variety of systems and communication pathways. The goal of this paper was to assess the validity of a Web-based telepathology system for frozen section consultation within the Army Medical Department. The system provides real-time, dynamic remote control of a robotic microscope over standard Internet connections. Oftentimes, a solo pathologist is called on to provide diagnostic services without the support of immediate second or expert consultation during an intraoperative consultation. The use of telepathology is attractive because it provides an opportunity for pathologists to obtain immediate consultation. For purposes of the study, 120 consecutive frozen section cases were diagnosed at a distance using the system. Intraobserver agreement between the telepathology diagnosis and glass slide diagnosis was observed. Diagnostic agreement was 100% for a wide variety of specimens. This study suggests that such a system will help support pathologists located at distant sites.