Targeted clinical audits immediately following the establishment of clinical practice guidelines for multiple sclerosis in 17 neurology departments: A pragmatic and collaborative study.

UNLABELLED: Following the publication practice guidelines for multiple sclerosis by a group of neurologists (multiple sclerosis study group [GRESEP]), the primary objective of this study was to compare the reality of practice to the guidelines according to the targeted clinical audit (TCA) method. The study was conducted at 17 neurology sites and was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). Two complementary surveys were done on the record keeping and the root causes of the deviations. The percentages of compliance ranged from 8 to 98% for the TCA-DIAG, and from 15 to 99% for the TCA-EVOL, with wide disparity between sites. The audits were able to identify causes of the flaws in traceability or accessibility. At the end of the study, despite its limitations, we think that the sharing of the results from different sites provided interesting approaches for the use of the assessment criteria defined by GRESEP in a complete audit cycle. This study is to our knowledge the first report of an experiment in which guidelines were created, and subsequently followed by the development of assessment criteria and then the performance of targeted clinical audits using them, all by the same participants. CONTEXT: Clinical practice guidelines (CPGs) are intended to help practitioners and patients make informed treatment choices, but their integration into actual practice remains problematic. This study was done immediately following the publication of CPGs for multiple sclerosis (MS) by the multiple sclerosis study group [GRESEP]. The primary objective was to generate quality criteria, to test them within the same group, and to analyze the observed deviations. MATERIALS AND METHODS: The study was conducted in the 17 voluntary departments that had participated in the development of the CPGs. The targeted clinical audit method was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). All the files were evaluated by a clinical research technician using digital format, which ensured thoroughness of the collection. Two complementary surveys were done on the record keeping and the potential causes of the deviations. RESULTS: The percentages of compliance to the criteria ranged from 8 to 98% (out of 240 files) for the TCA-DIAG, and from 15 to 99% (221 files) for the TCA-EVOL, with wide disparity between sites (interquartile distance ranges: TCA-DIAG between 0% and 55%; TCA-EVOL between 0% and 70%). The mean percentage of compliance with all the criteria as measured by the TCA-DIAG was 83.9% for the sites with digital files vs. 76.4% for those with only paper files (P<0.01). For the TCA-EVOL, the difference was not significant. Explanations for the observed deviations were suggested (1 to 9 according to the participants). DISCUSSION AND CONCLUSION: The quantified results could not be compared to other studies given the unique nature of the experiment. The importance of the traceability of practices in the patient files was discussed and assessed with regard to continuity and safety of care, as well as the medical-legal perspectives. Causes of lack of compliance were suggested (particularly the absence of reminders, the lack of means and/or time). Despite the limitations of the study, we think it is advisable that when a group becomes involved in the development of CPGs that they follow with the development of assessment criteria in order to evaluate the validity as well as their character as intermediate indicators of the quality of practices.

[Influence of acute stroke care organization on the implementation of clinical practice guidelines]. / Influence de la structure unité neurovasculaire sur la mise en pratique des recommandations professionnelles.

INTRODUCTION: Patients who receive care in a dedicated stroke unit are more likely to survive and become independent. Specific guidelines describe evidence-based care practices. We examined the results of a French audit validation campaign to determine whether the presence of a stroke unit had an influence on the implementation of these recommendations. METHODS: Eleven hospital centers volunteered for self-evaluation. Care delivered to patients in the emergency room and in the hospital unit (dedicated stroke unit or not) was assessed with the clinical audit method. RESULTS: Compared with non-dedicated units, care delivered in stroke units was significantly more compliant with published recommendations. All aspects of acute stroke care were concerned: initial evaluation, acute phase treatment, screening for complications and their treatment, multidisciplinary team coordination, discharge preparation. Care delivered in dedicated stroke units was more reproducible, protocols were more widely used, acute phase risks were better prevented, and acute and postacute care was better coordinated between professionals. A second audit one year later showed increased quality of care in both dedicated and non-dedicated units, with more items improved in the latter. CONCLUSION: Although statistical bias cannot be excluded, this study suggests that recommendations are applied better in dedicated stroke units. A second audit showed better compliance with recommendations, especially in non-dedicated units.

[Congenital visual deficiency: chances and difficulties of management]. / La déficience visuelle congénitale: chances et difficultes d'aménagement.

The traditional theories according to which deprivation of the visual channel is directly responsible for every disturbance observed in children born blind or partially sighted prove to be unsatisfactory; they fail to answer why, given the same visual defect, some children develop in a healthy way while others present a typical picture of infantile psychosis. The authors put forward the following hypotheses: infantile psychosis is always both a sign of and a response to trauma, in the sense developed by Freud in Beyond the Pleasure Principle, which has struck the mother-child dual unit; the high frequency of psychotics among children born blind indicates that blindness is a particularly charged trauma. The traumatic neurosis of the parents and especially of the mother is catastrophic for the child; it is therefore necessary to understand why and how its works, how it can be avoided or dealth with. The authors present a detailed clinical description of the various possible mother-child constellations and regarding unfavourable outcomes, propose preventive measures.

[Pulmonary embolism and preventive anticoagulant treatment in hospitalized elderly patients. Statistical study of their respective risks]. / Embolies pulmonaires et traitement anticoagulant préventif chez les malades âgés hospitalisés. Etude statistique de leurs risques respectifs

Pulmonary embolism and preventive anticoagulant therapy of ederly patients in hospital. Statistical survey of their respective risks. The incidence of pulmonary embolism as a cause of death seems the higher as its strikes old people (above 60) affected by cardiovascular diseases and who are bed tied; the interest of preventive anticoagulant treatment (PAT) remains controversial. This matter has been studied over a period of 5 years from the files of a geriatric cardiology department; 455 anatomo-clinical documents have been set up. This survey confirms the frequency of mortality by pulmonary embolism (23,9 %) and its diminution under long-term preventive anticoagulant treatment 6,6 %). The anticoagulant therapy does not increase the risk of haemorrhagic accidents, from the point of view of frequency, but slightly increases it if one considers the number of days spent in hospital. As a conclusion, the preventive anticoagulant treatment seems positive insofar as contra-indications are strictly observed, in particular the digestive ones. The mechanism of some hemorrhagic accidents with or without PAT remains sometimes difficult to explain.

[The psychosis-epilepsy relationship in children]. / Les associations psychosepépilepsie chez l'enfant.

From four cases studied both clinically and with the help of repeated and prolonged electroencephalograms, the problems raised by the association psychosis-epilepsy in children are reconsidered. The difficulties in evaluating: the actual weight of the "epilepsy" component; the role of the epileptic discharge for the subject's psychic economy; the role of drug therapies, are particularly underlined.