A national study on adherence to a basal cell carcinoma guideline; development of a tool to assess guideline adherence.

BACKGROUND: Clinical practice guideline implementation may be at variance with actual daily practice, as guideline adherence is a complex process depending on many actors and factors. Feedback regarding adherence is essential to monitor the effect that a guideline has in clinical practice and whether or not the quality of care is raised by implementation. OBJECTIVES: Developing a tool for obtaining and giving nationwide feedback regarding adherence. METHODS: From February 2010 to June 2013, a 32-item questionnaire was used as an audit tool during committee visits to assess adherence across 37 dermatological centres in The Netherlands. The questions were derived from the recommendations by the Dutch Dermatological and Venereological Society (NVDV) in the Dutch Basal Cell Carcinoma (BCC) guideline. Five selected medical records per dermatologist were audited and the results were discussed with the audited centre. Data were pooled to calculate the compliance with each recommendation across all participating centres. RESULTS: Adherence to recommended actions varied considerably (20·2-100%) across the domains of prevention, diagnostics, treatments and aftercare. Using and reporting surgical margins, giving patient advice, restricting the use of cryosurgery for certain BCCs and reporting on prognostic factors all failed to reach a threshold of 80%. Nonadherence to recommended actions proved to be related to whether or not a dermatologist was directly involved. CONCLUSIONS: The findings emphasize the importance of direct feedback to practitioners regarding adherence. Furthermore, together with existing frameworks, the method described could be used by developers in a guideline update to identify and anticipate barriers to successful implementation.

Prioritizing dermatoses: rationally selecting guideline topics.

BACKGROUND: Clinical practice guideline (CPG) development starts with selecting appropriate topics, as resources to develop a guideline are limited. However, a standardized method for topic selection is commonly missing and the way different criteria are used to prioritize is not clear. OBJECTIVES: To select and prioritize dermatological topics for CPG development and elucidate criteria dermatologists find important in selecting guideline topics. METHODS: All 410 dermatologists in the Netherlands were asked to create a top 20 of dermatological topics for which a guideline would be desirable, regardless of existing guidelines. They also rated, on a 5-point Likert scale, 10 determinative criteria derived from a combined search in literature and across (inter)national guideline developers. Top 20 topics received scores ranging from 0.01 to 0.2 and combined scores yielded a total score. RESULTS: The 118 surveys (response 29%) identified 157 different topics. Melanoma, squamous cell carcinoma, basal cell carcinoma, psoriasis and atopic dermatitis are top priority guideline topics. Venous leg ulcer, vasculitis, varicose veins, urticaria, acne, Lyme borreliosis, cutaneous lupus erythematosus, pruritus, syphilis, lymphoedema, decubitus ulcer, hidradenitis suppurativa, androgenic alopecia and bullous pemphigoïd complete the top 20. A further 15 topics have overlapping confidence intervals. Mortality and healthcare costs are regarded as less important criteria in topic selection (P < 0.04), than other criteria like the potential to reduce unwanted variation in practice. CONCLUSION: Dermatological professional organizations worldwide succeeded in developing guidelines for all top 20 topics. Respondents mostly agree with (inter)national guideline programmes and literature concerning the criteria important to selecting guideline topics.

Summary of the Dutch S3-guidelines on the treatment of psoriasis 2011. Dutch Society of Dermatology and Venereology.

This document provides a summary of the Dutch S3-guidelines on the treatment of psoriasis. These guidelines were finalized in December 2011 and contain unique chapters on the treatment of psoriasis of the face and flexures, childhood psoriasis as well as the patient's perspective on treatment. They also cover the topical treatment of psoriasis, photo(chemo)therapy, conventional systemic therapy and biological therapy.

[The practice guideline 'Consultation psychiatry' of the Dutch Psychiatric Association for psychiatric consultations in primary care and the hospital]. / Richtlijn 'consultatieve psychiatrie' van de nederlandse vereniging voor psychiatrie voor consulten in de eerste lijn en in de ziekenhuissetting.

Psychiatric consultation in primary care as well as in the hospital is both effective and cost-effective if certain procedures are followed. With the professional guideline 'Consultation psychiatry', the Dutch Psychiatric Association aims at setting a standard for psychiatric consultations in non-psychiatric settings. In general practice, the psychiatric consultation is preferably embedded in 'collaborative care', an integrated care model including the general practitioner and a case manager (usually a nurse), with the consultant psychiatrist being regularly available for clearly defined indications. The psychiatrist should see the patient himself or herself, establish a diagnosis and treatment plan, and provide the general practitioner and the patient with a so-called 'consultation letter', which is then discussed with both. In a general hospital, systematic screening of patients at risk of psychiatric comorbidity can be organised. Early detection of complex patients can further improve the effectiveness of psychiatric consultation. Follow-up contacts and investing in liaison contacts improve adherence to the advice provided.

[Guideline 'Precautionary measures for contrast media containing iodine']. / Richtlijn 'Voorzorgsmaatregelen bij jodiumhoudende contrastmiddelen'.

Annually, 0.5-1 million injections of contrast media containing iodine are administered in the Netherlands. Almost all contrast media nowadays are low-osmolar and nonionic. Nevertheless, the development ofcontrast-induced nephropathy is still a relevant clinical problem. Through an initiative by the Radiological Society of the Netherlands and with aid of the Dutch Institute for Healthcare Improvement (CBO), a guideline was conceived for the intravascular use of iodine-containing contrast media, based on recent scientific literature. The guideline defines the risk factors for contrast-induced nephropathy. One of the major risk factors is an impaired renal function. It is important to measure the glomerular filtration rate (GFR) in patients with a possible impaired kidney function, preferably by using the 'Modification of diet in renal disease' (MDRD)-study formula. The key measures for avoidance of contrast nephropathy are: limiting the amount of contrast agent used and to assure good hydration, by infusion of sodium chloride 0.9% 12-16 ml/kg body weight, both prior to and after contrast infusion. If time is limited, intravenous administration of sodium bicarbonate is an option. The guideline recommends discontinuation of metformin use from the day of contrast injection, if the GFR < 60 ml/min/1.73 m2, and to restart metformin 2 days following contrast infusion providing the GFR has not significantly deteriorated. Only in the case of previous moderate or severe adverse reactions to contrast media, prophylaxis with corticosteroids and antihistamines is recommended. Iodine allergy or an atopic condition is not a contraindication for the use of iodine-containing contrast media, and no prophylaxis is required. No specific measures are indicated in case of hyperthyroidism, acute pancreatitis, or phaeochromocytoma. Injection of contrast media is not contraindicated in case of pregnancy or lactation.

[The history of evidence-based psychiatry and evidence-based guideline development]. / De geschiedenis van evidence-based psychiatrie en richtlijnontwikkeling.

Evidence-based medicine, evidence-based psychiatry and evidence-based development of clinical guidelines are all flourishing today because of developments that have taken place in both science and society. These concepts will be explained and placed in their context. Medical treatment is based on the one hand on scientific knowledge and experience, on the other hand on compassion and consideration for others. Non-specific and relational factors play an important role, particularly in psychiatry and mental health care, but the scientific way of thinking remains as important as ever.

[The practice guideline 'atopic dermatitis']. / Richtlijn 'Constitutioneel eczeem'.

Since clear evidence is lacking that avoidance of exposure to inhalation or food allergens will have a favourable effect on the course of atopic dermatitis, allergological screening should be restricted to patients having acute allergic symptoms. Topical corticosteroids are the treatment of choice. The working group recommends starting with a class 2-3 corticosteroid daily followed by intermittent maintenance therapy with a corticosteroid of the same class or daily administration of a class 1 corticosteroid. When used in this way, corticosteroids are safe as far as local and systemic side effects are concerned; patients with severe atopic dermatitis have decreased serum-cortisol levels but this is due to the illness and not the corticosteroid. Serum-cortisol levels will usually return to normal following topical steroid therapy. Topical calcineurin inhibitors are a good second-line alternative for patients in whom corticosteroids are insufficiently effective or produce side effects. During such treatment, the skin should be protected against ultraviolet light. Non-sedating antihistamines have no place in the treatment of atopic dermatitis. Cyclosporin is the agent of choice for the systemic treatment of severe atopic dermatitis. The attending physician should also pay attention to psychosocial factors, since severe eczema in children, their parents and adults has a serious impact on the quality of life. Patients with severe atopic dermatitis should be discouraged from working in a wet environment. Patients with moderately active atopic dermatitis without eczema of the hands should avoid exposure to water and other irritating factors.

[Frankness regarding errors in medical care]. / Openheid over fouten in de gezondheidszorg.

In recent years, increasing attention has been given to the importance of disclosing medical errors. Many physicians are still reluctant to disclose errors and to discuss them with the patient. Recent legislative developments have reduced the existing uncertainty regarding the legal consequences of full disclosure. It is important that physicians are open and honest about the errors they make, that they apologise if necessary, and that measures are taken to prevent the same errors from happening again. Psychological factors hindering the full disclosure of errors require continued attention.

[Relationship between volume and quality of care for surgical interventions; results of a literature review]. / Verband tussen volume en kwaliteit van zorg bij heelkundige ingrepen; resultaten van een literatuuronderzoek.

OBJECTIVE: To examine the relationship between the number of procedures performed per hospital or per surgeon and health care outcomes. DESIGN: Literature review. METHOD: Relevant literature was identified using recent systematic reviews from Germany, England, France and the United States. The Cochrane Library, Medline and Embase were also searched for recent studies (2000-2005) published in German, English, French, or Dutch using the combined search terms 'surgery' and 'volume'; included studies reported mortality or morbidity as measures of health care quality. RESULTS: 5 systematic reviews were found, which described the results of a total of 41 relevant articles. 8 original articles of sufficient quality published since 2000 were also identified. Most of these articles were also included in the reviews. Relationships between volume per hospital and per surgeon and case fatality (or survival) and morbidity were found for a number of surgical procedures. The strongest associations between volume and case fatality were found for pancreatic and oesophageal resection and, to a lesser degree, elective repair ofabdominal aortic aneurysm. For other procedures the relationship was relatively weak, absent, or not studied. CONCLUSION: Volume appears to be related to quality for some surgical procedures. The magnitude of the relationship differs depending on the procedure. For technically less complex procedures, organisation within the hospital appears to have a greater influence on the differences between hospitals than the performing surgeon.

[Levels of evidence value are useful in the evaluation of studies and results]. / Niveaus van bewijskracht nuttig bij de beoordeling van onderzoeken en resultaten.

A classification of scientific evidence into 'levels', in which the type of research design is graded according to its strength, is useful because it helps the medical community to sort out a system that is accepted all over the world. It not only makes the highest levels of evidential value explicit for a particular clinical question, but also makes the lack of evidence visible. Selected articles will contain labels identifying the strength of evidence supporting key recommendations.

[The practice guideline 'vitiligo']. / Richtlijn 'vitiligo'.

A working group of the Dutch Society for Dermatology and Venereology (NVDV), in collaboration with the Dutch Institute for Health Care Improvement (CBO), has written an evidence-based guideline for the treatment of vitiligo. A distinction is made between generalised or non-segmental vitiligo and localised, including segmental, vitiligo. In patients with generalised vitiligo phototherapy (especially narrow-band ultraviolet B) is the treatment of first choice while in localised vitiligo, this is surgery, particularly autologous skin transplantation (Thiersch grafting, the use of blister epidermis and cell suspensions). However, on the basis of the results of the treatments proposed in the guideline, the working group cannot advise dermatologists to propose a particular treatment to each vitiligo patient they see. On the other hand, the working group is of the opinion that, based on a proper medical examination and an assessment of the disease burden, well-considered advice--and in some cases therapy--should be given to every vitiligo patient who requests it. The benefit of the guideline is that it provides clarity to dermatologists, general practitioners and patients regarding the therapeutic possibilities and limitations.

[Evidence-based guidelines in the organization of medical care]. / Evidence-based richtlijnen: ook voor de organisatie van medische zorg.

Organizational as well as managerial aspects can influence the outcome of patient care, in the establishment of a stroke service unit for instance. Critics wonder whether organisational aspects should be excluded from evidence-based guidelines as strong evidence is often lacking and managers are not included in the working party. It can be argued that it is neither the outcome nor the strength of the published evidence that determines whether a guideline is evidence-based but the method of guideline development. This includes a systematic search and critical appraisal of the literature as well as a rigorous external review in order to achieve consensus on statements including those pertaining to organization of care, for which evidence is poor or lacking.

[The new medical oath in The Netherlands]. / De nieuwe Nederlandse artseneed.

The Hippocratic oath derives its name from the ancient Greek physician Hippocrates. It has been embraced as a code of conduct by the medical profession throughout the ages, and is used by medical faculties as an explicit moment of reflection during graduation ceremonies. Although this oath is primarily of ceremonial value, it was felt that the text needed revision as it no longer reflected the current ethical norms in the Netherlands. The new Dutch oath drawn up in 2003 has a dual function: it is symbolic in that it represents the end of a doctor's training, but it is also intended to trigger the discussion of moral issues during the medical studies.

[The risk of pelvic inflammatory disease associated with urogenital infection with Chlamydia trachomatis; literature review]. / De kans op 'pelvic inflammatory disease' bij urogenitale infectie met Chlamydia trachomatis; literatuuronderzoek.

OBJECTIVE: To determine the rate of PID in women with genital Chlamydia trachomatis infection. DESIGN: Systematic literature review. METHOD: MEDLINE and EMBASE were searched over the years 1975-2003 using the keywords 'Chlamydia trachomatis', 'complication', 'pelvic (inflammatory disease)', 'PID', 'endometritis', 'adnexitis', and 'salpingitis'. The reference lists ofthe articles retrieved were checked for other relevant publications. The PID complication rate was determined, as were the characteristics of the study populations and the validity of the diagnostic methods and outcome measures used. RESULTS: 9 prospective studies were identified. The rate of PID in women with a genital C. trachomatis infection varied between o and 72%. Asymptomatic women who were diagnosed with C. trachomatis infection in general screening had the lowest rate of PID: 0-4%. PID occurred in 12-30% of symptomatic women or women with a higher risk of having an STD (e.g. visitor of an STD clinic, double-infection with gonorrhoea, high risk assessed by questionnaire, having a partner with symptomatic C. trachomatis infection). Women who underwent legal abortion had the highest rate of PID (27-72%). CONCLUSION: The PID rate in women with C. trachomatis varied considerably. Risk depended on whether the infection was symptomatic and the prior probability of having an STD.

[Guideline 'Melanoma' (3rd revision)]. / Richtlijn 'Melanoom' (3e herziening).

The guidelines 'Melanoma' (3rd revision) are evidence-based in nature. A number of outcomes are summarised in this article. Dermatoscopy deserves a standard role in the clinical diagnosis of pigmented skin abnormalities. Pathological findings from a diagnostic excision should be recorded meticulously to include anatomical localisation, type of intervention used, excision margin, diagnosis, Breslow thickness, and the completeness of the removal. The sentinel node procedure should be reserved for patients who want to be as informed as possible about their prognosis. The procedure is not considered a part of standard diagnosis. Sentinel node assessment should include stains for specific markers and should be conducted in multiple sections. The following margins of non-affected skin are recommended for therapeutic re-excision of melanoma: in situ melanoma, 0.5 cm; Breslow thickness < or = 2 mm, 1 cm; Breslow thickness > 2 mm, 2 cm. Pathological assessment of a re-excised specimen depends on the completeness of the first excision. Systematic adjuvant treatment of patients with melanoma is not recommended outside the context of a clinical study. Patients with metastatic melanoma are preferably treated within a clinical study. Outside of a clinical study, these patients should be treated with dacarbazine. There is no evidence to suggest that survival is improved by frequent follow-up. However, follow-up can be a useful way to meet the information needs of patients and care requirements for physicians.

[Evidence-based guideline development in the Netherlands: the EBRO platform]. / Evidence-based richtlijnontwikkeling in Nederland: het EBRO-platform.

In the Netherlands many institutes, associations and professional organisations are active in the development of guidelines for clinical practice. In 1997, the Dutch Cochrane Centre and the Dutch Institute for Healthcare Improvement (CBO) took the initiative and set up a national platform of guideline organisations (currently 28 in number) with the aim of harmonising methodology and promoting evidence-based guideline development. In 2003 the Guidelines International Network (G-I-N) was founded with similar goals but at international level. The Dutch platform (EBRO) offers the opportunity to establish a network that will plan and execute guideline development and updating. This will prevent duplication of efforts and controversy between stakeholders. Another task will be the promotion and transfer of knowledge on evidence-based guideline development by organising conferences and educational programmes. The ultimate goal is to support health-care providers in improving quality of patient care.

[The practice guideline 'Photo(chemo)therapy and systemic therapy in severe chronic plaque-psoriasis']. / Richtlijn 'Foto(chemo)therapie en systemische therapie bij ernstige chronische plaque-psoriasis'.

The guideline for the treatment of adults with moderate to severe chronic plaque-type psoriasis vulgaris is based on published scientific evidence. The efficacy of the treatment, its safety, the side effects, the patients' discomfort, the patients' preference and the costs of treatment and follow-up are listed as criteria that play a role in the choice of treatment. Photo(chemo)therapy is the treatment of choice for severe forms of psoriasis. Phototherapy with ultraviolet-B light (UVB), especially narrow-band UVB, is preferred above photochemotherapy with ultraviolet-A light and psoralenes (PUVA). Of the oral treatments, methotrexate and ciclosporin are preferred above retinoids and fumarates because they yield a higher percentage of patients with partial or nearly complete remission. Fumarates are not officially registered in The Netherlands and Belgium.

[The practice guideline 'Neuraxis blockade and anticoagulation']. / Richtlijn 'Neuraxisblokkade en antistolling'.

In a patient with a coagulation disorder, the administration of a local anaesthetic by means of a needle or via the insertion of a catheter into the epidural space or spinal cavity may lead to bleeding and haematoma formation, with a danger of pressure on the spinal cord or nerve roots. Employing the method of the Dutch Institute for Healthcare (CBO) for the development of practice guidelines, a working group of anaesthesiologists, a haematologist and a hospital chemist have drawn up recommendations for neuraxis blockade in combination with anticoagulant therapy. In patients with a clinically acquired tendency toward increased bleeding, the management is highly dependent on the cause of the bleeding tendency. If the patient uses acetylsalicylic acid or clopidogrel, the medication must be withdrawn at least 10 days before neuraxis blockade is started. Therapy with glycoprotein-IIb/IIIa-receptor antagonists is an absolute contra-indication for neuraxis blockade. In patients who are using coumarin derivatives, neuraxis blockade results in an increased risk of a neuraxial haematoma. The coumarin derivative should then be withdrawn and replaced by a different form of anticoagulation. The use of low-molecular-weight heparin at the usual prophylactic dosage is not a contra-indication for neuraxis blockade and the risk of a neuraxial haematoma following neuraxis blockade is also not increased significantly by the subcutaneous administration of unfractionated heparin.

[Systematic reviews in practice. IX. Determining their place in treatment recommendations in practice guidelines]. / De praktijk van systematische reviews. IX. Plaatsbepaling in behandelbeslissingen in richtlijnen.

In a systematic review (SR), the available evidence for a clinical problem is systematically and comprehensively collected from different studies, the likelihood of bias is assessed and the results are summarised in a reproducible manner. The results of an SR can be used in either individual patient care or the formulation of a practice guideline. Throughout the world, (national) organisations for guideline development use systems for classifying the validity of evidence according to the study design ('levels of evidence'), and this is also the case in the Netherlands. In formulating a treatment recommendation, consideration must be given to the various factors which determine the strength of the evidence: study design, consistency of the results (if more studies are available), quality of the individual studies, magnitude and precision of the reported effect and the clinical relevance of the outcome measures. If insufficient studies with the same outcome measure are available, problems can arise in an SR. In practice, problems can also arise with respect to estimating the cogency of an SR compared to another review or primary studies. For the same subject, there might be discordant reviews, differences between reviews and megatrials might exist or just one randomised clinical trial might be available. These problems can often be solved with the aid of a systematic analysis. This requires both methodological and clinical expertise.