¿Es sustentable la aplicación de las guías de práctica clínica en la práctica clínica del mundo real? / Is the application of clinical practice guidelines sustainable in real-world clinical practice?

Las guías de práctica clínica han contribuido a resolver un problema al sintetizar la evidencia y ponerla al alcance del profesional sanitario, pero su desarrollo e implementación creciente en los últimos años ha dado lugar a nuevos inconvenientes que aún no han sido resueltos. En este artículo editorial, la autora repasa cuestiones no tenidas en cuenta por las guías de práctica clínica, incluso aquellas consideradas de buena calidad de acuerdo a los estándares actuales, y reflexiona en especial sobre el uso del tiempo de los médicos en la consulta, aspecto desatendido que atenta contra la sustentabilidad del modelo actual de cuidado propuesto por estas recomendaciones. (AU)

Clinical practice guidelines have contributed to solving a problem by synthesizing the evidence and making it available to healthcare professionals, but their development and increasing implementation in recent years has given rise to new problems that have not yet been resolved. In this editorial article, the author reviews issues not taken into account by clinical practice guidelines, even those considered to be of good quality according to current standards, and reflects inparticular on the use of physicians' time in the consultation, a neglected aspect that undermines the sustainability of the current care model proposed by these recommendations. (AU)

Implementation of an Evidence-Based Practice Change Removing Heparin From Implanted Vascular Access Devices.

The objective of this article was to describe the implementation and outcomes of an evidence-based practice change to remove heparin from implanted vascular access device (IVAD) management. An extensive search of the literature was performed, and articles were appraised and synthesized to determine the best practice. A common theme emerged from the literature, showing that 0.9% sodium chloride alone can be as effective as heparin in preventing occlusion in IVADs. In this nurse-led initiative, heparin was successfully removed from the IVAD deaccess process and replaced with a 0.9% sodium chloride flush using a pulsatile flushing technique. Alteplase administration rates were used to measure success of the project, with no statistically significant change observed in alteplase rates 6 mo postimplementation. Successful implementation of this practice change demonstrates that 0.9% sodium chloride may be used for IVAD lock when deaccessing.

Evidence-based clinical practice guidelines for nonalcoholic fatty liver disease/nonalcoholic steatohepatitis 2020.

Nonalcoholic fatty liver disease (NAFLD) has become a serious public health issue not only in Western countries but also in Japan. Within the wide spectrum of NAFLD, nonalcoholic steatohepatitis (NASH) is a progressive form of disease that often develops into liver cirrhosis and increases the risk of hepatocellular carcinoma (HCC). While a definite diagnosis of NASH requires liver biopsy to confirm the presence of hepatocyte ballooning, hepatic fibrosis is the most important prognostic factor in NAFLD. With so many NAFLD patients, it is essential to have an effective screening method for NAFLD with hepatic fibrosis. As HCC with non-viral liver disease has increased markedly in Japan, effective screening and surveillance of HCC are also urgently needed. The most common death etiology in NAFLD patients is cardiovascular disease (CVD) event. Gastroenterologists must, therefore, pay close attention to CVD when examining NAFLD patients. In the updated guidelines, we propose screening and follow-up methods for hepatic fibrosis, HCC, and CVD in NAFLD patients. Several drug trials are ongoing for NAFLD/NASH therapy, however, there is currently no specific drug therapy for NAFLD/NASH. In addition to vitamin E and thiazolidinedione derivatives, recent trials have focused on sodium glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) analogues, and effective therapies are expected to be developed. These practical guidelines for NAFLD/NASH were established by the Japanese Society of Gastroenterology in conjunction with the Japan Society of Hepatology. Clinical evidence reported internationally between 1983 and October 2018 was collected, and each clinical and background question was evaluated using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. This English summary provides the core essentials of these clinical practice guidelines, which include the definition and concept, screening systems for hepatic fibrosis, HCC and CVD, and current therapies for NAFLD/NASH in Japan.

Application of the Haddon matrix to COVID-19 prevention and containment in nursing homes.

COVID-19 has exacted a disproportionate toll on the health of persons living in nursing homes. Healthcare providers and other decision-makers in those settings must refer to multiple evolving sources of guidance to coordinate care delivery in such a way as to minimize the introduction and spread of the causal virus, SARS-CoV-2. It is essential that guidance be presented in an accessible and usable format to facilitate its translation into evidence-based best practice. In this article, we propose the Haddon matrix as a tool well-suited to this task. The Haddon matrix is a conceptual model that organizes influencing factors into pre-event, event, and post-event phases, and into host, agent, and environment domains akin to the components of the epidemiologic triad. The Haddon matrix has previously been applied to topics relevant to the care of older persons, such as fall prevention, as well as to pandemic planning and response. Presented here is a novel application of the Haddon matrix to pandemic response in nursing homes, with practical applications for nursing home decision-makers in their efforts to prevent and contain COVID-19.

Early colorectal cancer detection-Current and evolving challenges in evidence, guidelines, policy, and practices.

The understanding at the beginning of the last century that colorectal cancer began as a localized disease that progressed and became systemic, and that most colorectal cancer arose from adenomatous polyps gave rise to aggressive attempts at curative treatment and eventually attempts to detect advanced lesions before they progressed to invasive disease. In the last four decades, steadily greater uptake of screening has led to reductions in colorectal cancer incidence and mortality. However, the fullest potential of screening is not being met due to the lack of organized screening, where a systems approach could lead to higher rates of screening of average and high risk groups, higher quality screening, and prompt followup of adults with positive screening tests. ABSTRACT: Since the beginning of the 20th century, there has been a general understanding that colorectal cancer is a clonal disease that progresses from a localized stage with a favorable prognosis through progressively more advanced stages which have progressively worse prognosis. That understanding led first to determined efforts to detect and treat early stage symptomatic disease, and then to detect pre-symptomatic colorectal cancer and precursor lesions, where there was hope that the natural history of the disease could be arrested and the incidence and premature mortality of colorectal cancer averted. Toward the end of the last century, guidelines for colorectal cancer screening, growth in the number of technical options for screening, and a steady increase in the proportion of the adult population who attended screening contributed to the beginning of a significant decline in colorectal cancer incidence and mortality. Despite this progress, colorectal cancer remains the third leading cause of death among men and women in the United States. Screening for early detection of precursor lesions and localized cancer offers the single most productive opportunity to further reduce the burden of disease, and yet nearly four in five deaths from colorectal cancer are associated with having never been screened, not recently screened, or not followed up for an abnormal screening test. This simple observation is a call to action in all communities to apply existing knowledge to fulfill the potential to prevent avertable incidence and mortality.

Mapping Clinical Barriers and Evidence-Based Implementation Strategies in Low-to-Middle Income Countries (LMICs).

BACKGROUND: Low-to-middle income countries (LMICs) experience a high burden of disease from both non-communicable and communicable diseases. Addressing these public health concerns requires effective implementation strategies and localization of translation of knowledge into practice. AIM: To identify and categorize barriers and strategies to evidence implementation in LMICs from published evidence implementation studies. METHODS: A descriptive analysis of key characteristics of evidence implementation projects completed as part of a 6-month, multi-phase, intensive evidence-based clinical fellowship program, conducted in LMICs and published in the JBI Database of Systematic Reviews and Implementation Reports was undertaken. Barriers were identified and categorized to the Donabedian dimensions of care (structure, process, and outcome), and strategies were mapped to the Cochrane effective practice and organization of care taxonomy. RESULTS: A total of 60 implementation projects reporting 58 evidence-based clinical audit topics from LMICs were published between 2010 and 2018. The projects included diverse populations and were predominantly conducted in tertiary care settings. A total of 279 barriers to implementation were identified. The most frequently identified groupings of barriers were process-related and associated predominantly with staff knowledge. A total of 565 strategies were used across all projects, with every project incorporating more than one strategy to address barriers to implementation of evidence-based practice; most strategies were categorized as educational meetings for healthcare workers. LINKING EVIDENCE TO ACTION: Context-specific strategies are required for successful evidence implementation in LMICs, and a number of common barriers can be addressed using locally available, low-cost resources. Education for healthcare workers in LMICs is an effective awareness-raising, workplace culture, and practice-transforming strategy for evidence implementation.

The efficacy of reduced-visit prenatal care model during the coronavirus disease 2019 pandemic: A protocol for systematic review and meta-analysis.

BACKGROUND: While this reduced-visit prenatal care model during the COVID-19 pandemic is well-intentioned, there is still a lack of relevant evidence to prove its effectiveness. Therefore, in order to provide new evidence-based medical evidence for clinical treatment, we undertook a systematic review and meta-analysis to assess the efficacy of reduced-visit prenatal care model during the COVID-19 pandemic. METHODS: The online literature will be searched using the following combination of medical subject heading terms: "prenatal care" OR "prenatal nursing" AND "reduced-visit" OR "reduce visit" OR "virtual visit." MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science will be searched without any language restrictions. A standard data extraction form is used independently by 2 reviewers to retrieve the relevant data from the articles. The outcome measures are as following: pregnancy-related stress, satisfaction with care, quality of care. The present study will be performed by Review Manager Software (RevMan Version 5.3, The Cochrane Collaboration, Copenhagen, Denmark). P < .05 is set as the significance level. RESULTS: It is hypothesized that reduced-visit prenatal care model will provide similar outcomes compared with traditional care model. CONCLUSIONS: The results of our review will be reported strictly following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and the review will add to the existing literature by showing compelling evidence and improved guidance in clinic settings. OSF REGISTRATION NUMBER: 10.17605/OSF.IO/WYMB7.

Brazilian women's use of evidence-based practices in childbirth after participating in the Senses of Birth intervention: A mixed-methods study.

Brazil has a cesarean rate of 56% and low use of Intrapartum Evidence-based Practices (IEBP) of 3.4%, reflecting a medically centered and highly interventionist maternal health care model. The Senses of Birth (SoB) is a health education intervention created to promote normal birth, use of EBP, and reduce unnecessary c-sections. This study aimed to understand the use of intrapartum EBP by Brazilian women who participated in the SoB intervention. 555 women answered the questionnaire between 2015 and 2016. Bivariate analysis and ANOVA test were used to identify if social-demographic factors, childbirth information, and perceived knowledge were associated with the use of EBP. A qualitative analysis was performed to explore women's experiences. Research participants used the following EBP: birth plan (55.2%), companionship during childbirth (81.6%), midwife care (54.2%), freedom of mobility during labor (57.7%), choice of position during delivery (57.2%), and non-pharmacological pain relief methods (74.2%). Doula support was low (26.9%). Being a black woman was associated with not using a birth plan or having doula support. Women who gave birth in private hospitals were more likely not to use the EBP. Barriers to the use of EBP identified by women were an absence of individualized care, non-respect for their choices or provision of EBP by health care providers, inadequate structure and ambiance in hospitals to use EBP, and rigid protocols not centered on women's needs. The SoB intervention was identified as a potential facilitator. Women who used EBP described a sense of control over their bodies and perceived self-efficacy to advocate for their chosen practices. Women saw the strategies to overcome barriers as a path to become their childbirth protagonist. Health education is essential to increase the use of EBP; however, it should be implemented combined with changes in the maternal care system, promoting woman-centered and evidence-based models.

Pre-Implementation of the Age-Friendly Health Systems Evidence-Based 4Ms Framework in a Multi-State Convenient Care Practice.

BACKGROUND: Quality issues in the delivery of healthcare services to older adults and changes in societal demographics call for a social movement to improve the care of older adults in a variety of healthcare settings, including ambulatory care and convenient care clinics. AIMS: To describe the pre-implementation phase to integrate the Age-Friendly Health Systems (AFHS) 4Ms (i.e., What Matters, Medication, Mentation, and Mobility) Framework in 1,100 MinuteClinics (the retail medical clinic of CVS Health) using the Consolidated Framework for Implementation Research (CFIR) and RE-AIM (an evaluation implementation framework). METHODS: The CFIR and RE-AIM models guided data collection. Data were collected from all stakeholders (patients, healthcare providers, managers, educators, informatics staff, communications staff, and implementation consultants) via observations, surveys, interviews, focus groups, organizational readiness assessment, stakeholder assessment, and workflow mapping during a 15-month period to identify potential barriers, facilitators, and other opportunities for implementation. RESULTS: The CFIR and RE-AIM implementation frameworks provided a comprehensive approach to guide the pre-implementation phase of the AFHS 4Ms Framework at the MinuteClinic. The baseline assessments guided by the CFIR revealed important insights in the choice of implementation strategies that were developed and tested in the pre-implementation phase, and the RE-AIM guided meaningful components to the development of the logic model. LINKING ACTION TO EVIDENCE: As more healthcare systems integrate the AFHS 4Ms Framework, the approach reported in this quality improvement project can be used in other settings to facilitate a comprehensive implementation.

Stimulating Research to Advance Evidence-Based Applications of Telehealth in Occupational Therapy.

Occupational therapy focuses on therapeutic means to address participation in meaningful everyday tasks across the lifespan. No single setting is more conducive to this pursuit than individuals' authentic contexts. Occupational therapists are therefore uniquely suited to lead the charge toward stimulating research and advancing evidence-based application of telehealth. To this end, the American Occupational Therapy Foundation digitally convened their 2020 Planning Grant Collective to focus on the topic of Telehealth. Participants of the interdisciplinary collective collaboratively identified four themes: (1) Using technology to assess and intervene in the everyday context, (2) Partnerships with caregivers, (3) Telehealth delivery, and (4) Uniform data collection. Subgroups explored potential research and funding opportunities in their specialty area while also addressing the centralizing concepts of equity and diversity of telehealth delivery and COVID-19. Here, we provide a summary of the key concepts and recommendations from the 3 days of collaboration.

Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease.

Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.

An Examination of the Factors Associated With Implementation of Evidence-Based Management Practices for Improving Nurse Work Environments.

BACKGROUND: Evidence-based management practices (EBMPs) that improve nurses' work environments have been linked to improvements in patient outcomes such as patient satisfaction and mortality. Yet, the extent to which nurse managers implement these EBMP or the factors associated with their implementation is not known. AIMS: Guided by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework, we examined individual, evidence, and organizational characteristics associated with nurse managers' implementation of the five EBMPs. METHODS: A cross-sectional, correlational, survey design was used. Nurse managers from 10 public hospitals in New York City were recruited. Evidence and contextual variables were measured with the Organizational Readiness for Change Assessment instrument. EBMPs were measured with a modified version of the Practice Environment Scale of the Nursing Work Index. All multi-item scales were validated with confirmatory factors analysis in the studied sample. Additionally, the scales had Cronbach's alpha reliability greater than .8. A multivariate linear regression analysis with robust standard error correction was used to analyze the data and to adjust for clustering of managers in hospitals. RESULTS: A total of 331 nurse managers responded for a 47.4% response rate. Bachelor's degree, number of staff supervised, managers' personal experience with evidence for EBMPs, staff culture, and organizational resources were significant predictors of nurse managers' implementation of EBMPs for NWE improvement (p < .05). LINKING EVIDENCE TO ACTION: Staff culture was positively associated with implementation of all five EBMPs for improving nurses' work environments. Managers should prioritize nursing unit culture that encourages staff to innovate and change in order to improve care.

A conceptual framework for contemporary professional foot care practice: ''The value based digital foot care framework''.

BACKGROUND: A small minority of countries around the globe have podiatry as a recognized profession, hence, there are considerable differences among these countries when it comes to the curricula, the duration of training and legislation regulating the profession. The growth in research led evidence based practice, and the emerging digital landscape of health care practice, occur alongside trends in disease and health behaviours that strongly impact on foot health. As such, the changing complex role of the podiatrist requires critical reflection on current frameworks of practice and whether they are fit for purpose. This commentary presents a conceptual framework which sets the scene for further development of concepts in a podiatry context, reflecting contemporary health care beliefs and the changing expectations of health care and society. The proposed conceptual framework for podiatry practice utilizes the metaphor of an electronic circuit to reflect the vast and complex interconnections between factors that affect practice and professional behaviours. The framework helps in portraying and defining drivers of practice, actual practice as well potential barriers for current and future practice. The circuit emphasis the interconnectedness/interaction of three clusters: 1) internal factors, 2) interaction factors, 3) external factors. CONCLUSION: Whatever promise this new framework holds, it will only be realised through conscious development of community consensus, respectful dialogue, constructive critical appraisal, and maintaining passion and focus on improving the health of people with foot related problems.

Community pharmacists' use, perception and knowledge on dietary supplements: a cross sectional study

BACKGROUND: Pharmacists are commonly tasked with recommending the appropriate dietary supplement and advising the patients of their correct and safe use. Previous research, conducted on pharmacy students, showed that they did not always use the evidence based sources of information, with personal use identified as a significant predictor influencing the decision to recommend a supplement. OBJECTIVES: To compare use, perceptions and knowledge of dietary supplements of pharmacists with different years of work experience and to explore factors that could influence their recommendation of supplements. METHODS: A questionnaire based cross-sectional study was conducted on Croatian community pharmacists in September 2017. The questionnaire explored pharmacists' demographic characteristics, use, perceptions and knowledge of dietary supplements. Pharmacists (N=102) were divided in two groups based on their work experience: P0 (<10 years) and P1 (≥10 years). RESULTS: All included pharmacists had high knowledge scores without differences between groups (P0=10, IQR 9-12 vs P1=11, IQR 9-12, expressed as median and interquartile range (IQR), p = 0.275). Less experienced pharmacists perceived there was less research conducted on the dietary supplements compared to their more experienced counterparts (P0=1, IQR 1-2 vs P1=2, IQR 2-3, expressed as median and interquartile range, p < 0.001). Groups differed in sources used when choosing the appropriate supplement with P0 using higher quality sources such as systematic reviews in comparison to P1 (32.1% vs 8.7%, p = 0.004). Pharmacists' decision to recommend a dietary supplement was influenced by their personal use (odds ratio 0.216, 95%CI 0.068:0.689, p = 0.01) and work experience (odds ratio 0.154, 95%CI 0.045:0.530, p = 0.003). CONCLUSIONS: Pharmacists did not use the high quality sources when recommending dietary supplements and their decision to recommend the supplement was not based on objective evaluation of evidence. Further education about the practice of evidence-based pharmacy is necessary, with special emphasis on senior pharmacists who might have missed that aspect during their formal education

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Application of artificial intelligence in gastroenterology: Potential role in clinical practice.

Artificial intelligence (AI) based on deep learning boosted medical research in the past years and is expected to enormously change the style of health care in many aspects in the foreseeable future. Nowadays, there are exploding volumes of healthcare-related data being generated daily. Because of its time-sensitive characteristics, being able to process large amounts of data in real-time fashion is crucial in healthcare settings. In gastroenterology practice, AI can manage and interpret the sheer amount of data with different formats coming from a myriad of sources, including currently used endoscopic or imaging devices, digital record systems, and electronic health records, or from other sources such as governmental databases, social media, or wearable devices over a long period. Traditional gastroenterology is nowadays beginning to transform to a new personalized, predictive, and preventive paradigm. Evidence-based practices and recent studies are coming out every day, and big data-based approaches and the progress in basic sciences and its emerging applications are now becoming the indispensable part of precision medicine. In gastroenterology, AI can be applied in disease diagnosis, treatment guidance, outcome prediction, and reducing workload of the healthcare staff. As the healthcare community begins to embrace AI technology, how to seamlessly construct an interoperable platform to accommodate data with high variety and veracity with high velocity and implement AI in the clinical workflow would be the future challenges.

Preparing Nursing Contexts for Evidence-Based Practice Implementation: Where Should We Go From Here?

BACKGROUND: Context is important to the adoption and sustainability of evidence-based practices (EBPs). Currently, most published implementation efforts address context in relation to one specific EBP or a bundle of related EBPs. Since EBP and implementation are ongoing and dynamic, more discussion is needed on preparing nursing contexts to be more conducive to implementation generally. AIM: To discuss the need to create contexts that are more adaptable to ongoing change due to the dynamic nature of EBPs and the ever-changing healthcare environment. METHODS: This paper builds on a collection of our previous work, as nursing implementation scientists representing the Canadian and American healthcare contexts, and a literature review of the implementation science, knowledge translation, and sustainability literatures from 2006 to 2019. RESULTS: We argue for a different way of thinking about the influence of context and implementation of EBPs. We contend that nursing contexts must be prepared to be more flexible and conducive to ongoing EBP implementation more generally. Contexts that embrace, facilitate, and have the capacity for change may be more likely to effectively de-implement ineffective interventions or implement and sustain new EBPs. We outline future directions to build a program of research on preparing the soil for implementation of EBPs, including building capacity among nurses, supporting organizations to embrace change, co-producing research evidence, and contributing to implementation science. LINKING EVIDENCE TO ACTION: Supporting contexts to adopt and sustain evidence in nursing practice is essential for bridging the evidence to practice gap and improving outcomes for patients, clinicians, and the health system. Moving forward, we need to develop a better understanding of how to create contexts that embrace change prior to the implementation of EBPs in order sustain improvements to patient and health system outcomes.

Audit and Feedback: An Evidence-Based Practice Literature Review of Nursing Report Cards.

BACKGROUND: As more hospitals transition to electronic health records (EHR) and rely on technology to inform practice, what is done with that information is increasingly important. Performance report cards for physicians and nurses are not new, yet there is little recent evidence on nurse-specific audit and feedback. AIM: The aim of the project was to conduct an evidence-based practice (EBP) review to answer the question, "Does implementing an individualized audit and feedback report tool for nurses improve compliance, adherence, and/or performance of nursing tasks?". METHODS: Evidence was gathered from several databases. Reviewers read and appraised articles that answered the EBP question using the Johns Hopkins Nursing EBP Model. Data were then collated to synthesize and generate recommendations. RESULTS: Of the initial 613 unique articles, eight (two research and six quality improvement) were included. Six articles demonstrated improvements while two did not. Articles analyzed nursing documentation (n = 3), tasks or skills (n = 2), and best practice compliance (n = 3). One manuscript utilized an EHR-generated report; all others were completed by hand. Overall, there was not consistent and compelling evidence to support individualized audit and feedback report tools in nursing. However, several themes emerged related to sustainability, timing of feedback, audit, and feedback in the context of quality improvement, and the methods of acquiring and distributing data. LINKING EVIDENCE TO ACTION: The ubiquity and ease of the EHR make providing automated feedback to nurses tempting, yet it is not supported by the literature. More implementation science research is needed to explore audit and feedback reports in nursing. This article adds to the literature by highlighting a significant lack of consistent and compelling positive results from the well-established quality improvement strategy of audit and feedback in the nursing population. The absence of good data is as telling as its presence.

Towards Evidence-based Control of Opisthorchis viverrini.

Transmission of the carcinogenic liver fluke Opisthorchis viverrini is ongoing across Southeast Asia. Endemic countries within the region are in different stages of achieving control. However, evidence on which interventions are the most effective for reducing parasite transmission, and the resulting liver cancer, is currently lacking. Quantitative modelling can be used to evaluate different control measures against O. viverrini and assist the design of clinical trials. In this article we evaluate the epidemiological parameters that underpin models of O. viverrini and the data necessary for their estimation, with the aim of developing evidence-based strategies for parasite control at a national or regional level.