Guidelines' risk assessment recommendations for venous thromboembolism prophylaxis: A comparison and implementability appraisal.

INTRODUCTION: Venous thromboembolism (VTE) prophylaxis guidelines for non-surgical patients recommend VTE- and bleeding risk assessment to guide prophylactic strategies. These recommendations differ between guidelines and implementation is suboptimal. Assessing a guideline's implementability characteristics helps predicting the ease of implementation and reveals barriers. OBJECTIVES: We aimed to compare guidelines' risk assessment recommendations and critically appraise the implementability characteristics. MATERIAL AND METHODS: Two guidelines, one from the American College of Chest Physicians and one from the National Institute for Health and Care Excellence were selected for comparison. Risk assessment methods and subsequent prophylactic recommendations were compared. Eight experts then appraised the guideline recommendations on intrinsic implementability characteristics using the GuideLine Implementability Appraisal (GLIA) instrument. GLIA identifies barriers and facilitators for guideline implementation in nine dimensions. RESULTS: Eleven out of 20 individual VTE-risk factors and 2 out of 19 individual bleeding-risk factors used, were present in both guidelines. Additionally, a high VTE- or bleeding risk was defined differently between the two guidelines. The GLIA appraisal identified implementation barriers within all recommendations analyzed. On content level, barriers were identified in recommendations addressing bleeding risk assessment, mechanical prophylaxis and critical care patients. On implementability level, barriers were identified in decidability, flexibility, effect on process of care and computability dimensions. CONCLUSION: Depending on the guideline used, VTE-prophylaxis will most likely be provided to different non-surgical patient populations, primarily due to discordance in bleeding risk assessment. Revising the recommendations, taking into account the most apparent implementation barriers, should be considered. However, insufficient evidence to support the recommendations currently complicates this.

Can preventable adverse events be predicted among hospitalized older patients? The development and validation of a predictive model.

OBJECTIVE: To develop and validate a predictive model for preventable adverse events (AEs) in hospitalized older patients, using clinically important risk factors that are readily available on admission. DESIGN: Data from two retrospective patient record review studies on AEs were used. Risk factors included patient characteristics as well as admission and organizational characteristics. Multilevel logistical regression analysis was used to develop the model. Backward elimination was applied to identify the most parsimonious model. SETTING: Twenty-one Dutch hospitals were included in the 2004 sample and 20 Dutch hospitals in the 2008 sample. PARTICIPANTS: A total of 3977 patients aged 70 years or over who were admitted to a Dutch hospital in 2004 and 2119 patients aged 70 years or over admitted in 2008. MAIN OUTCOME MEASURES: Identified predictors of preventable AEs in older patients. RESULTS: In 2004 predictors of preventable AEs in patients aged 70 years or over were increased age (OR 1.04, confidence interval (CI) 1.01-1.06); elective admission (OR 1.65, CI 1.14-2.40) and admission to a surgical department (OR 1.53, CI 1.08-2.16). The area under the receiver operating characteristic curve for the 2004 sample was 0.60 and for 2008, 0.59. CONCLUSIONS: This study showed that several expected risk factors for preventable AEs in older patients, including comorbidity, could not predict these events. It was not possible, using in-patient data available on admission and collected during the course of two patient record review studies, to develop a satisfactory predictive model for preventable AEs in older patients.

[Referral for rehabilitation in case of permanent visual handicap; guideline of the Dutch Society of Ophthalmology]. / Verwijzing naar revalidatie bij blijvende visuele beperkingen; richtlijn van het Nederlands Oogheelkundig Gezelschap.

The Dutch Society of Ophthalmology (NOG) has developed an evidence-based guideline for the referral of visually impaired people for rehabilitation and support. Referral for rehabilitation and support must be preceded by diagnosis and treatment. Consultation of an ophthalmologist is essential. Information about the disease should be given to the patient orally as well as in writing. The ophthalmologist brings up the possibility of rehabilitation in the presence of a visual acuity < 0.5 and/or visual field of < 30 degrees in the better eye and a well-defined request for help. Visually impaired patients with a relatively simple request for help are referred to a specialised optometrist whenever possible. Visually impaired patients with more complex requests for help are referred to a multidisciplinary (regional or national) rehabilitation centre for people with a visual handicap. Visually impaired and blind patients are informed about the existence of patient organisations. Referral for rehabilitation is done by means of a structured letter with all relevant information. A copy of this letter should be sent to the family physician and all other attending physicians.

Evidence-based guidelines on the referral of visually impaired persons to low vision services.

PURPOSE: One to two percent of the population in the Western world is visually impaired or blind. For most of these people there is no curative therapy. Therefore, the Dutch Ophthalmic Society has taken the initiative to develop an evidence-based guideline for the referral of visually impaired persons to low vision services. METHODS: A systematic literature search was performed in the Embase (1991-2001) and Medline (1966-2003) databases. Literature was searched for definitions of visual impairment, for physician-patient communication, and for outcome of interventions for visually impaired persons. Results of the articles that were selected were summarized and rated according to the level of evidence. Other considerations such as the current organization of rehabilitation for visually impaired persons in the Netherlands were also taken into account. RESULTS: The World Health Organization criteria were slightly adapted in order to include all people who experience problems with reading and other daily life activities due to visual impairment. A large number of recommendations were devised. Among these is that the complete diagnosis should be communicated to the patient and that a second appointment should be offered in which the diagnosis and potential treatment options are discussed again. Another recommendation is that in general visually impaired adults eligible for referral should be referred for the provision of low vision aids and that patients with complex problems or extensive rehabilitative demand should be referred to a rehabilitation center. CONCLUSIONS: This article presents a summary of the first European evidence-based guideline for the referral of visually impaired persons.