Barriers and facilitators to national guideline implementation for palliative cancer care in a Danish cross-sectoral healthcare setting: A qualitative study of healthcare professionals' experiences.

OBJECTIVE: Patients with incurable cancer should receive general palliative care according to their needs, as provided through collaboration between hospital departments, municipalities, and general practices and as outlined in national guidelines. However, the implementation of general palliative care in Denmark has been inadequate. This study aimed to investigate the healthcare professionals' (HCPs') perceptions on barriers to and facilitators of the implementation of the Danish National Guideline (NG) for general palliative care. METHODS: This descriptive, qualitative study was guided by the Consolidated Framework for Implementation Research (CFIR). Qualitative focus group and individual interviews were conducted with 23 HCPs. The interview guide, coding, analysis, and reporting of findings were developed within the CFIR framework. RESULTS: The main barriers to implementing NG were as follows: lack of knowledge about the NG, lack of an implementation plan, and insufficient communication and collaboration across sectors. Important facilitators were as follows: HCP motivation to meet palliative care needs, HCPs with special functions taking responsibility for incorporating NG into local guidelines, and the role of district nurses specialised in palliative care as opinion leaders providing security and continuity for the HCPs working in palliative care. CONCLUSIONS: To address the needs of patients with incurable cancer, greater efforts are required on implementing general palliative care. Although HCPs in our setting were motivated to improve NG implementation, financial resources and strategies are necessary to ensure sufficient knowledge uptake and accommodate identified barriers in order to translate the NG into practice.

Association of hydroxyurea adherence with transcranial Doppler screenings in children with sickle cell disease.

BACKGROUND: National sickle cell disease (SCD) guidelines recommend oral hydroxyurea (HU) starting at 9 months of age, and annual transcranial Doppler (TCD) screenings to identify stroke risk in children aged 2-16 years. We examined prevalence and proportion of TCD screenings in North Carolina Medicaid enrollees to identify associations with sociodemographic factors and HU adherence over 3 years. STUDY DESIGN: We conducted a longitudinal study with children ages 2-16 years with SCD enrolled in NC Medicaid from years 2016-2019. Prevalence of TCD screening claims was calculated for 3 years, and proportion was calculated for 12, 24, and 36 months of Medicaid enrollment. Enrollee HU adherence was categorized using HU proportion of days covered. Multivariable Poisson regression assessed for TCD screening rates by HU adherence, controlling for age, sex, and rurality. RESULTS: The prevalence of annual TCD screening was between 39.5% and 40.1%. Of those with 12-month enrollment, 77.8% had no TCD claims, compared to 22.2% who had one or higher TCD claims. Inversely, in children with 36 months of enrollment, 36.7% had no TCD claims compared to 63.3% who had one or higher TCD claims. The proportion of children with two or higher TCD claims increased with longer enrollment (10.5% at 12 months, 33.7% at 24 months, and 52.6% at 36 months). Children with good HU adherence were 2.48 (p < .0001) times more likely to have TCD claims than children with poor HU adherence. CONCLUSION: While overall TCD screening prevalence was low, children with better HU adherence and longer Medicaid enrollment had more TCD screenings. Multilevel interventions are needed to engage healthcare providers and families to improve both evidence-based care and annual TCD screenings in children with SCD.

Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies.

AIM: To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. METHODS: A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. RESULTS: Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. CONCLUSION: Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

Impact of policy change on late-term abortion: a two-decade analysis.

OBJECTIVE: Advances in ultrasound and molecular genetics have changed the field of late termination of pregnancy (LTOP), sparking ethical debates worldwide. In 2007, Israel updated its LTOP policies, requiring a 30% or higher probability of severe handicap for approval of LTOP after 24 weeks' gestation. PURPOSE: In this retrospective study, we compared LTOP indications and approval rates before (Group 1: 1998-2007) and after (Group 2: 2008-2021) this policy change. METHODS: Shamir medical records from January 1, 1998 to December 31, 2021 were examined and yielded 4047 abortions, of which 248 were identified as LTOP preformed after 24 weeks' gestation. These cases were then categorized into two groups. Data including maternal age, obstetric history, indications for abortion, diagnosis, week of termination, and genetic/sonographic findings were analyzed. The approval rates and indications pre- and post-policy change were compared. RESULTS: Group 1 (LTOP 1998-2007) comprised 95 cases (10.6%), and Group 2 (LTOP 2008-2021) was composed of 153 cases (4.9%). Fetal structural anomalies remained the dominant indication for both groups (67.4 and 65.3%, respectively), with a slight increase in confirmed genetic anomalies from 26.3% (Group 1) to 28% (Group 2). CONCLUSION: Our findings indicate a decrees in the proportion per year from 10.6 to 4.9% LTOP. Technological advances in genetic evaluation and sonography may have contributed to the early increased detection and decrees in cases reaching LTOP. These results highlight the importance of ongoing ethical reviews and adherence to strict protocols for early detection and termination before 24 weeks' gestation.

Evaluating national guidelines for monitoring early growth using routinely collected data in Bergen, Norway.

AIMS: The overarching aim of this study was to evaluate the Norwegian guidelines for growth monitoring using routinely collected data from healthy children up to five years of age. We analysed criteria for both status (size for age) and change (centile crossing) in growth. METHODS: Longitudinal data were obtained from the electronic health record (EHR) at the well-baby clinic for 2130 children included in the Bergen growth study 1 (BGS1). Measurements of length, weight, weight-for-length, body mass index (BMI) and head circumference were converted to z-scores and compared with the World Health Organization (WHO) growth standards and the national growth reference. RESULTS: Using the WHO growth standard, the proportion of children above +2SD was generally higher than the expected 2.3% for all traits at birth and for length at all ages. Crossing percentile channels was common during the first two years of life, particularly for length/height. By the age of five years, 37.9% of the children had been identified for follow-up regarding length/height, 33% for head circumference and 13.6% for high weight-for-length/BMI. CONCLUSIONS: The proportion of children beyond the normal limits of the charts is higher than expected, and a surprisingly large number of children were identified for rules concerning length or growth in head circumference. This suggests the need for a revision of the current guidelines for growth monitoring in Norway.

Evaluation of targeted implementation interventions for reducing investigations and therapies in infants with bronchiolitis.

AIM: To evaluate the impact of locally adapted targeted implementation interventions on bronchiolitis management through reduction in ineffective investigation and therapies within emergency departments. METHODS: A multi-centred, quality improvement study in four different grades of hospitals in Western Australia that provide paediatric emergency and inpatient care. All hospitals incorporated an adapted implementation intervention package for infants under 1 year with bronchiolitis. The proportion whose care complied with guideline recommendations to not receive investigations and therapies of minimal benefit were compared to pre-intervention care in a previous bronchiolitis season. RESULTS: A total of 457 infants in 2019 (pre-intervention) and 443 in 2021 (post-intervention) were included, with mean age of 5.6 months (SD 3.2, 2019; SD 3.0, 2021). In 2019, compliance was 78.1% versus 85.6% in 2021, RD 7.4 (95% CI -0.6; 15.5). The strongest evidence was reduced salbutamol use (compliance improvement: 88.6% to 95.7%, RD 7.1 95% CI (1.7; 12.4)). Hospitals initially at <80% compliance demonstrated greatest improvements (Hospital 2: 95 (78.5%) to 108 (90.8%) RD 12.2 95% CI (3.3; 21.2); Hospital 3: 67 (62.6%) to 63 (76.8%) RD 14.2 95% CI (1.3; 27.2)). CONCLUSION: Targeted site-adapted implementation interventions resulted in improvement in compliance with guideline recommendations, particularly for those hospitals with initial low compliance. Maximising benefits through guidance on how to adapt and effectively use interventions will enhance sustainable practice change.

Antibiotic prescriptions for child sinusitis varied between specialties after Finnish guidelines were updated in 2018.

AIM: We evaluated antibiotic prescriptions issued for Finnish children with acute sinusitis by a nationwide private outpatient clinic network from 2014-2020. Data were compared before and after updated guidelines in 2018. METHODS: The study comprised data on 45 296 children aged 2-17 years with acute sinusitis, namely diagnoses, ages, dates, the doctor's specialty and any antibiotics. We measured compliance with the updated 2018 Finnish guidelines, which recommended amoxicillin or amoxicillin-clavulanic acid for children under 12 years old, with doxycycline as an alternative for 12 years plus. RESULTS: There were 6621-7585 visits per year for acute sinusitis in 2014-2019 and 2954 in 2020. Antibiotics were prescribed for 37.9%-41.6% of patients during the study years. Amoxicillin, including penicillin, accounted for 35.9% of prescriptions, followed by amoxicillin-clavulanic acid (26.9%). Macrolides accounted for 20.6% and, encouragingly, decreased by 38% from 2014-2019. Doxycycline accounted for 5.3%. Paediatricians, general practitioners (GPs) and ear, nose and throat specialists followed the guidelines in 75.1%, 73.8% and 66.7% of cases, respectively. GPs prescribed antibiotics more often than other physicians. CONCLUSION: Antibiotics were prescribed for about 40% of acute sinusitis visits by Finnish children from 2014-2019. Specialities differed with regard to prescribing rates and whether they followed the guidelines.

Overweight children in rural Norway - public health nurses' possibilities and limitations within national guidelines.

INTRODUCTION: Globally, overweight and obesity are more prevalent in rural areas than in urban areas. The purpose of this study was to determine to what extent public health nurses in rural areas in Norway feel equipped to tackle the overweight and obesity epidemic within two sets of national guidelines: The National Guidelines for the Standardized Measurement of Height and Weight and The National Guidelines for the Prevention, Identification, and Treatment of Overweight and Obesity in Children and Adolescents. These guidelines are inspired by New Public Management (NPM) logic, which emphasises more market orientation within the public sector to obtain a more cost-effective supply of public goods. The focus is on the weighing of schoolchildren, available resources, inter-agency cooperation and the rural context. METHODS: The data were collected using a structured questionnaire among 40 public health nurses working with children in rural areas, as well as qualitative interviews with 25 informants involved in the prevention and treatment of overweight and obesity among rural children. RESULTS: The study shows that rural public health nurses worry about the lack of resources for follow-up with children with a body mass index greater than what is characterised as 'normal'. The public health nurses suggested better cooperation between different stakeholders to work around the lack of resources and at the same time be able to see the whole picture, considering that overweight and obesity are complex problems connected to different challenges. They believed that it is an advantage to see the individuals in their local surroundings, to know their family history, their leisure activities and so on. This might be easier in rural areas than in urban areas, as these areas are often more transparent. CONCLUSION: There was consensus among the public health nurses involved in this study that national guidelines for treating overweight and obesity in children with the principles of NPM, and simplifying and standardising services, adds challenges instead of solutions. Such practices also hinder the use of experience-based knowledge about both the individual and the local context. There is a need for more flexible guidelines that can easily be adapted to the local (rural) context.

Association of physical activity with utilization of long-term care in community-dwelling older adults in Germany: results from the population-based KORA-Age observational study.

BACKGROUND: Physical activity (PA) is a proven strategy to prevent chronic diseases and reduce falls. Furthermore, it improves or at least maintains performance of activities of daily living, and thus fosters an independent lifestyle in older adults. However, evidence on the association of PA with relevant subgroups, such as older adults with utilization of long-term care (LTC), is sparse. This knowledge would be essential for establishing effective, need-based strategies to minimize the burden on healthcare systems due to the increasing need for LTC in old age. METHODS: Data originate from the 2011/12 (t1) baseline assessment and 2016 (t2) follow-up of the population-based Cooperative Health Research in the Region of Augsburg (KORA-)Age study in southern Germany. In 4812 observations of individuals ≥65 years, the association between various types of PA (walking, exercise (i. e., subcategory of PA with the objective to improve or maintain one or more components of physical fitness), walking+exercise) and utilization of LTC (yes/no) was analyzed using generalized estimating equation logistic models. Corresponding models stratified by sex (females: 2499 observations; males: 2313 observations) examined sex-specific associations. Descriptive analyses assessed the proportion of individuals meeting the suggested minimum values in the German National Physical Activity Recommendations for older adults (GNPAR). RESULTS: All types of PA showed a statistically significant association with non-utilization of LTC in the entire cohort. "Walking+exercise" had the strongest association with non-utilization of LTC in the entire cohort (odds ratio (OR): 0.52, 95% confidence interval (CI): 0.39-0.70) and in males (OR: 0.41, CI: 0.26-0.65), whereas in females it was "exercise" (OR: 0.58; CI: 0.35-0.94). The proportion of individuals meeting the GNPAR was higher among those without utilization of LTC (32.7%) than among those with LTC (11.7%) and group differences were statistically significant (p ≤ 0.05). CONCLUSIONS: The GNPAR are rarely met by older adults. However, doing any type of PA is associated with non-utilization of LTC in community-dwelling older adults. Therefore, older adults should be encouraged to walk or exercise regularly. Furthermore, future PA programs should consider target-groups' particularities to reach individuals with the highest needs for support.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools.

OBJECTIVE: To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma. METHODS: Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care. RESULTS: We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV1% predicted and FEV1/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively). CONCLUSIONS: Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03032744.

National and State Level Opioid-Restricting Legislation in Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: The opioid epidemic is a health crisis in the United States. Within orthopedic surgery, opioid misuse and incautious prescription remains a concern. In the last several years, there has been a growing interest and public effort toward reducing opioid use in total joint arthroplasty (TJA) in response to the opioid epidemic in the United States. We aim to review opioid-limiting practices, policies, and legislations that are implemented at the state level and nationally that are relevant to TJA, as well as evaluate studies that measure the efficacy of these policies in the management of patients undergoing TJA. METHODS: Two independent reviewers conducted a systematic review of national and state level opioid-limiting policies implemented in the United States and their effects on opioid prescription, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). RESULTS: We identified 3 national bills and 9 policies set forth by national organizations that imposed limits on opioid prescription. Opioid-reducing legislation was also identified in 24 states, with the majority specifying a 7-day limit on initial opioid prescription for acute pain management. Six research studies evaluating the impact of opioid-restricting policies on postoperative opioid prescription for TJA patients were found. Three studies assessed legislation at the state level while the others were institution-based guidelines. Overall, these studies demonstrated a significant decrease in mean morphine milligram equivalents of initial opioid prescription after implementing the policies. CONCLUSION: Recent opioid-restricting legislation is effective in decreasing postoperative opioid prescriptions following TJA.

[International comparison of radiological aspects of the new German S3 guideline on hepatocellular carcinoma and intrahepatic cholangiocarcinoma]. / Radiologische Aspekte der neuen deutschen S3-Leitlinie zum hepatozellulären Karzinom und biliären Karzinomen im internationalen Vergleich.

The updated German S3 guideline "Diagnostics and therapy of hepatocellular carcinoma and biliary carcinomas" covers two tumor entities. The original guideline published in 2013 focusing only on the diagnosis and therapy of hepatocellular carcinoma (HCC) has been expanded to include intrahepatic cholangiocarcinoma. These guidelines were developed within the framework of the guideline program on oncology of the Scientific Medical Society e. V. (AWMF), the German Cancer Society (DKG) and German Cancer Aid Society (DKG) under the auspices of the German Society for Digestive and Metabolic Diseases (DGVS). In addition to updated recommendations regarding histopathology, radiological diagnostics and treatments, the main innovations of the revised guidelines on HCC include a complete revision of the section on the systemic therapeutic approach in advanced stages of the disease. This article presents the significance of the current recommendations for diagnostic and interventional radiology in comparison to other national and international guidelines and should serve to improve the quality of patient care through more widespread dissemination.

Drug treatment and prevention of malaria in pregnancy: a critical review of the guidelines.

BACKGROUND: Malaria caused by Plasmodium falciparum in pregnancy can result in adverse maternal and fetal sequelae. This review evaluated the adherence of the national guidelines drawn from World Health Organization (WHO) regions, Africa, Eastern Mediterranean, Southeast Asia, and Western Pacific, to the WHO recommendations on drug treatment and prevention of chloroquine-resistant falciparum malaria in pregnant women. METHODS: Thirty-five updated national guidelines and the President's Malaria Initiative (PMI), available in English language, were reviewed. The primary outcome measures were the first-line anti-malarial treatment protocols adopted by national guidelines for uncomplicated and complicated falciparum malaria infections in early (first) and late (second and third) trimesters of pregnancy. The strategy of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) was also addressed. RESULTS: This review evaluated the treatment and prevention of falciparum malaria in pregnancy in 35 national guidelines/PMI-Malaria Operational Plans (MOP) reports out of 95 malaria-endemic countries. Of the 35 national guidelines, 10 (28.6%) recommend oral quinine plus clindamycin as first-line treatment for uncomplicated malaria in the first trimester. As the first-line option, artemether-lumefantrine, an artemisinin-based combination therapy, is adopted by 26 (74.3%) of the guidelines for treating uncomplicated or complicated malaria in the second and third trimesters. Intravenous artesunate is approved by 18 (51.4%) and 31 (88.6%) guidelines for treating complicated malaria during early and late pregnancy, respectively. Of the 23 national guidelines that recommend IPTp-SP strategy, 8 (34.8%) are not explicit about directly observed therapy requirements, and three-quarters, 17 (73.9%), do not specify contra-indication of SP in human immunodeficiency virus (HIV)-infected pregnant women receiving cotrimoxazole prophylaxis. Most of the guidelines (18/23; 78.3%) state the recommended folic acid dose. CONCLUSION: Several national guidelines and PMI reports require update revisions to harmonize with international guidelines and emergent trends in managing falciparum malaria in pregnancy. National guidelines and those of donor agencies should comply with those of WHO guideline recommendations although local conditions and delayed guideline updates may call for deviations from WHO evidence-based guidelines.

Swedish guidelines for device-aided therapies in Parkinson's disease -Economic evaluation and implementation.

OBJECTIVES: The National Board of Health and Welfare in Sweden published the national guidelines for Parkinson's Disease 2016. The aim of this study was to summarize this evidence review and development of the guidelines, focusing on the economic evaluation of device-aided therapies (deep brain stimulation, pump-based infusion of levodopa-carbidopa intestinal gel or apomorphine) for Parkinson's disease, and the rate of implementation after 3 years in Sweden. MATERIAL AND METHODS: The evidence review underlying the guidelines-including systematic literature searches of clinical and economic evidence, model-based economic evaluation, and formal analysis and guideline development-was examined, condensed, and translated. The impact of the guidelines was assessed with treatment use statistics from 2009 to 2019. RESULTS: All device-aided therapies were assigned high priority. Based on a relatively low proportion of device-aided therapies (30%) in Parkinson's disease, a 5-year increase of 500 patients was recommended. This was estimated to reduce total costs by SEK 14 million (€1.7 million). Follow-up data found an increase of 217 patients between 2017 and 2019, following the same trend as before the guidelines. CONCLUSION: Three years after the guidelines were published, the use of device-aided therapies has increased in Sweden, albeit not in pace with recommendations. One reason for slow implementation may be poor incentivization related to budget silos in which the costs for device-aided therapies are borne by the regions but the cost offsets (eg, reduced need for home care) are reaped by local stakeholders.

Routine panendoscopy in oral squamous cell cancer patients: mandatory or facultative?

OBJECTIVES: This study investigated benefits of routine panendoscopy in staging of oral squamous cell cancer patients. MATERIALS AND METHODS: From 2013 to 2017, 194 oral squamous cell cancer patients were staged. Reports of routine flexible panendoscopy including oropharyngolaryngoscopy, bronchoscopy, and esophagogastroduodenoscopy were retrospectively analyzed for diagnoses of inflammation and second primary malignancies (carcinoma in situ or cancer) and compared to results of computed tomography. The effects of alcohol and tobacco history of 142 patients were assessed. RESULTS: Overall, a second primary malignancy was detected in seven patients. In four patients this discovery was only found by panendoscopy. One invasive carcinoma (esophagus) was detected as well as three carcinoma in situ. The second primary malignancies were located in the lung (3), esophagus (3), and stomach (1). In one patient index tumor therapy was modified after panendoscopy. Upper gastrointestinal inflammation was present in 73.2% of patients and 61.9% required treatment. About 91.8% of bronchoscopies and 34.5% of panendoscopies were without therapeutic consequences. Patients with higher risk from smoking were more likely to benefit from panendoscopy and to have a Helicobacter pylori infection. CONCLUSION: We do not recommend routine panendoscopy for all oral squamous cell cancer patients. Esophagogastroduodenoscopy benefitted smoking patients primarily concerning the secondary diagnosis of inflammation of the upper digestive tract. Selective bronchoscopy, esophagogastroduodenoscopy, and oropharyngolaryngoscopy should be performed if clinical examination or medical history indicates risks for additional malignancies of the upper aerodigestive tract. CLINICAL RELEVANCE: Routine panendoscopy is not recommended in all, especially not in low-risk oral cancer patients like non-smokers and non-drinkers.

Integrated cancer networks improve compliance with national guidelines and outcomes for resectable gastric cancer.

BACKGROUND: National Comprehensive Cancer Network (NCCN) guidelines recommend accurate clinical staging, perioperative therapy, and complete lymphadenectomy for patients with stage II to III gastric cancer. However, national compliance remains low. It was hypothesized that integrated cancer networks might improve compliance and outcomes within the community. METHODS: Patients with stage II to III gastric adenocarcinoma undergoing curative-intent resection (National Cancer Data Base, 2006-2015) were examined. Guideline compliance was defined as any perioperative adjunctive therapy, complete lymphadenectomy, complete clinical staging, and complete compliance (all measures). Univariate comparisons and multivariable regression were used to assess factors associated with compliance, and Kaplan-Meier analysis was used to assess survival. RESULTS: There were 27,210 patients identified: 7235 (26.6%) underwent surgery alone, whereas 19,975 (73.4%) received additional therapy. Half (53.1%) had complete lymphadenectomies, whereas complete clinical staging was available for 65.5%. Overall compliance with all 3 measures was 30.1%. Compliance improved by approximately 20% for each measure across the 10-year study period. Although patients treated at academic programs were most likely to receive concordant care in an adjusted analysis, those treated at integrated care networks were more likely to receive guideline-concordant care (odds ratio [OR], 0.69) than those treated at comprehensive community programs (OR, 0.48) or community programs (OR, 0.45; all P values <.001). The median overall survival was 45.5 months for patients who received guideline-concordant care and 32.0 months for those who did not (P < .001, reference for all ORs: academic programs). CONCLUSIONS: Compliance with guidelines was associated with improved outcomes. Although the rate of compliance with NCCN guidelines is improving, integrated care networks may be an important way of improving the quality of gastric cancer care within the community.

Introduction and methods of the evidence-based guidelines for the diagnosis and management of autism spectrum disorder by the Italian National Institute of Health.

BACKGROUND: Autism Spectrum Disorder (ASD) is a neuro-developmental disorder that affects communication and behavior with a prevalence of approximately 1% worldwide. Health outcomes of interventions for ASD are largely Participant Reported Outcomes (PROs). Specific guidelines can help support the best care for people with ASD to optimize these health outcomes but they have to adhere to standards for their development to be trustworthy. OBJECTIVE: The goal of this article is to describe the new methodological standards of the Italian National Institute of Health and novel aspects of this guideline development process. This article will serve as a reference standard for future guideline development in the Italian setting. METHODS: We applied the new standards of the Italian National Institute of Health to the two guidelines on diagnosis and management of children/adolescents and adults with ASD, with a focus on the scoping, panel composition, management of conflict of interest, generation and prioritization of research questions, early stakeholders' involvement, and PROs. Recommendations are based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision frameworks. RESULTS: Following a public application process, the ISS established two multidisciplinary panels including people with ASD and/or their caregivers. Seventy-nine research questions were identified as potentially relevant for the guideline on children and adolescents with ASD and 31 for the one on adults with ASD. Questions deemed to have the highest priority were selected for inclusion in the guidelines. Other stakeholders valued their early involvement in the process which will largely focus on PROs. The panels then successfully piloted the development of recommendations using the methodological standards and process set by the ISS with a focus on PROs. CONCLUSIONS: In this article, we describe the development of practice guidelines that focus on PROs for the diagnosis and management of ASD based on novel methods for question prioritization and stakeholder involvement. The recommendations allow for the adoption or adaptation to international settings.

A study of guidelines for respiratory tract infections and their references from Swedish GPs: a qualitative analysis.

Background: National guidelines are important instruments in reducing inappropriate antibiotic prescriptions. Low adherence to guidelines is an acknowledged problem that needs to be addressed.Method: We evaluated established characteristics for guidelines in the guidelines for lower respiratory tract infection, acute otitis media and pharyngotonsillitis in primary care. We studied how doctors used these guidelines by analysing interviews with 29 general practitioners (GPs) in Sweden.Results: We found important between-guidelines differences, which we believe affects adherence. The GPs reported persistent preconceptions about diagnosis and treatment, which we believe reduces their adherence to the guidelines.Conclusion: To increase adherence, it is important to consider doctors' preconceptions when creating new guidelines.

Surgical management of acute cholecystitis in a nationwide Danish cohort.

PURPOSE: In the Danish national guidelines from 2006 on the treatment of acute cholecystitis, early laparoscopic operation within 5 days after the debut of symptoms was recommended. The aim of this study was to analyze the outcome in patients with acute cholecystitis subjected to cholecystectomy in Denmark in the five-year period hereafter. METHODS: All patients undergoing cholecystectomy in the period 2006-2010 were registered in the Danish Cholecystectomy Database, from which outcome data were collected. The effect of potential risk factors such as age, gender, BMI, American Society of Anesthesiologists (ASA) score, previous pancreatitis, previous abdominal surgery, year of operation, surgical approach, and surgeon experience was analyzed. RESULTS: Of 33,853 patients registered with a cholecystectomy, 4667 (14%) were operated for acute cholecystitis. In 95% of the patients, laparoscopic cholecystectomy was intended and in 5% primary open access was chosen. The frequency of conversion from laparoscopic to open surgery was 18%. High age and ASA score, operation in the early years of the period, and open or converted procedure all increased the risk of hospital stay to > 3 days or readmission. High age and ASA score, converted or open operation, and previous pancreatitis increased the risk of additional procedures. Postoperative mortality was 1.2%, and significant risk factors for postoperative death were age, low BMI, high ASA score, early year of operation, and open procedures. CONCLUSIONS: Acute cholecystectomy was safely managed laparoscopically in most patients after the introduction of national guidelines, with an increasing rate of laparoscopically completed procedures during the study period.

Multi-centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries.

AIM: Our primary aim was to calculate the head computed tomography (CT) scan rate in children with a minor head injury (MHI) when the Dutch National guidelines were followed in clinical practice. The secondary aim was to determine the incidence of CT abnormalities and the guideline predictors associated with traumatic abnormalities. METHODS: We performed a multi-centre, prospective observational cross-sectional study in the emergency departments of six hospitals in The Netherlands between 1 April 2015 and 31 December 2016. RESULTS: Data on 1002 patients were studied and 69% of cases complied with the guidelines. The overall CT rate was 44% and the incidence of traumatic abnormal CT findings was 13%. CT scans were performed in 19% of children under two years of age, 48% of children between two and five years and 63% of children aged six years or more. Multivariate regression analysis for all age categories showed that CT abnormalities were predicted by a Glasgow Coma Scale of less than 15, suspicion of a basal skull fracture, vomiting and scalp haematomas or external lesions of the skull. CONCLUSION: Strict adherence to the Dutch national guidelines resulted in CT overuse. New guidelines are needed to safely reduce CT scan indications.