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Clinical practice guidelines implementation

Works Count: 103653

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Description

This cluster of papers focuses on the development, evaluation, and implementation of clinical practice guidelines in healthcare. It covers topics such as the quality assessment of guidelines, evidence-based medicine, international collaboration in guideline development, and the impact of pathways on patient outcomes.

Keywords

Clinical Guidelines; Guideline Development; Quality Assessment; Practice Recommendations; Healthcare Evaluation; Evidence-Based Medicine; AGREE II Instrument; Pathway Implementation; International Collaboration; Patient Outcomes

Clinical Practice Guidelines We Can Trust

2011-06-16

Advances in medical, biomedical and health services research have reduced the level of uncertainty in clinical practice. Clinical practice guidelines (CPGs) complement this progress by establishing standards of care backed … Advances in medical, biomedical and health services research have reduced the level of uncertainty in clinical practice. Clinical practice guidelines (CPGs) complement this progress by establishing standards of care backed by strong scientific evidence. CPGs are statements that include recommendations intended to optimize patient care. These statements are informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options. Clinical Practice Guidelines We Can Trust examines the current state of clinical practice guidelines and how they can be improved to enhance healthcare quality and patient outcomes. Clinical practice guidelines now are ubiquitous in our healthcare system. The Guidelines International Network (GIN) database currently lists more than 3,700 guidelines from 39 countries. Developing guidelines presents a number of challenges including lack of transparent methodological practices, difficulty reconciling conflicting guidelines, and conflicts of interest. Clinical Practice Guidelines We Can Trust explores questions surrounding the quality of CPG development processes and the establishment of standards. It proposes eight standards for developing trustworthy clinical practice guidelines emphasizing transparency; management of conflict of interest; systematic review--guideline development intersection; establishing evidence foundations for and rating strength of guideline recommendations; articulation of recommendations; external review; and updating. Clinical Practice Guidelines We Can Trust shows how clinical practice guidelines can enhance clinician and patient decision-making by translating complex scientific research findings into recommendations for clinical practice that are relevant to the individual patient encounter, instead of implementing a one size fits all approach to patient care. This book contains information directly related to the work of the Agency for Healthcare Research and Quality (AHRQ), as well as various Congressional staff and policymakers. It is a vital resource for medical specialty societies, disease advocacy groups, health professionals, private and international organizations that develop or use clinical practice guidelines, consumers, clinicians, and payers.

Grading quality of evidence and strength of recommendations

2004-06-17

David C. Atkins , Dana Best , Peter A. Briss +7 more

GRADE Working Group (oxman{at}online.no)Informed Choice Research Department, Norwegian Health Services Research Centre, PO Box 7004, St Olavs Plass, 0130 Oslo, NorwayCorrespondence to: Andrew D Oxman,Accepted 5 March 2004 GRADE Working Group (oxman{at}online.no)Informed Choice Research Department, Norwegian Health Services Research Centre, PO Box 7004, St Olavs Plass, 0130 Oslo, NorwayCorrespondence to: Andrew D Oxman,Accepted 5 March 2004

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Clinical practice guidelines : directions for a new program

1990-01-01

Marilyn J. Field , Kathleen N Lohr

Statistics notes: Absence of evidence is not evidence of absence

1995-08-19

David Altman , John M. Bland

Randomized controlled clinical trials are conducted to determine whether differences of clinical importance exist between selected treatment regimens. When statistical analysis of the study data finds a P value greater … Randomized controlled clinical trials are conducted to determine whether differences of clinical importance exist between selected treatment regimens. When statistical analysis of the study data finds a P value greater than 5%, it is convention to deem the assessed difference nonsignificant. Just because convention dictates that such study findings be termed nonsignificant, or negative, however, it does not necessarily follow that the study found nothing of clinical importance. Subject samples used in controlled trials tend to be too small. The studies therefore lack the necessary power to detect real, and clinically worthwhile, differences in treatment. Freiman et al. found that only 30% of a sample of 71 trials published in the New England Journal of Medicine in 1978-79 with a P value greater than 10% were large enough to have a 90% chance of detecting even a 50% difference in the effectiveness of the treatments being compared, and they found no improvement in a similar sample of trials published in 1988. It is therefore wrong and unwise to interpret so many negative trials as providing evidence of the ineffectiveness of new treatments. One must instead seriously question whether the absence of evidence is a valid justification for inaction. Efforts must be made to look for quantification of an association rather than just a P value, especially when the risks under investigation are small. The authors cite a recent trial comparing octreotide and sclerotherapy in patients with variceal bleeding, as well as the overview of clinical trials evaluating fibrinolytic treatment for preventing reinfarction after acute myocardial infarction as examples.

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Getting research findings into practice: Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings

1998-08-15

Lisa Bero , Roberto Grilli , Jeremy Grimshaw +3 more

This is the seventh in a series of eight articles analysing the gap between research and practice Series editors: Andrew Haines and Anna Donald Despite the considerable amount of money … This is the seventh in a series of eight articles analysing the gap between research and practice Series editors: Andrew Haines and Anna Donald Despite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.1 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change.2 Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. 3 4 In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews. #### Summary points Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings Passive dissemination of information is generally ineffective It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice Further research on the relative effectiveness and efficiency of different strategies is required We searched Medline records dating from 1966 to June 1995 using a strategy developed in collaboration with the NHS Centre for Reviews and Dissemination. The search identified 1139 references. No reviews from the Cochrane Effective Practice and Organisation of Care Review Group4 had been published during this time. In addition, we searched the Database of Abstracts of Research Effectiveness (DARE) (http://www.york.ac.uk/inst/crd) but did not identify any other review meeting the inclusion criteria. We searched for any review …

Managing Clinical Knowledge for Health Care Improvement

2000-08-01

E. Andrew Balas , Suzanne Austin Boren

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Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines.

1997-08-15

Dave A. Davis , Anne Taylor‐Vaisey

To recommend effective strategies for implementing clinical practice guidelines (CPGs).The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE … To recommend effective strategies for implementing clinical practice guidelines (CPGs).The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE from January 1990 to June 1996, inclusive, with the use of the MeSH heading "practice guidelines" and relevant text words.Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians' performance or health care outcomes were emphasized.Articles were reviewed to determine the effect of various factors on the adoption of guidelines.The articles showed that CPG dissemination or implementation processes have mixed results. Variables that affect the adoption of guidelines include qualities of the guidelines, characteristics of the health care professional, characteristics of the practice setting, incentives, regulation and patient factors. Specific strategies fell into 2 categories: primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines. The interventions were shown to be weak (didactic, traditional continuing medical education and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers and delivered by peers or opinion leaders) and relatively strong (reminder systems, academic detailing and multiple interventions).The evidence shows serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic.

The Levels of Evidence and Their Role in Evidence-Based Medicine

2011-06-25

Patricia B. Burns , Rod J. Rohrich , Kevin C. Chung

As the name suggests, evidence-based medicine is about finding evidence and using that evidence to make clinical decisions. A cornerstone of evidence-based medicine is the hierarchical system of classifying evidence. … As the name suggests, evidence-based medicine is about finding evidence and using that evidence to make clinical decisions. A cornerstone of evidence-based medicine is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Several articles published in plastic surgery journals concerning evidence-based medicine topics have touched on this subject.1–6 Specifically, previous articles have discussed the lack of higher level evidence in Plastic and Reconstructive Surgery and the need to improve the evidence published in the Journal. Before that can be accomplished, it is important to understand the history behind the levels and how they should be interpreted. This article focuses on the origin of levels of evidence, their relevance to the evidence-based medicine movement, and the implications for the field of plastic surgery and the everyday practice of plastic surgery. HISTORY OF LEVELS OF EVIDENCE The levels of evidence were originally described in a report by the Canadian Task Force on the Periodic Health Examination in 1979.7 The report's purpose was to develop recommendations on the periodic health examination and base those recommendations on evidence in the medical literature. The authors developed a system of rating evidence (Table 1) when determining the effectiveness of a particular intervention. The evidence was taken into account when grading recommendations. For example, a grade A recommendation was given if there was good evidence to support a recommendation that a condition be included in the periodic health examination. The levels of evidence were further described and expanded by Sackett8 in an article on levels of evidence for antithrombotic agents in 1989 (Table 2). Both systems place randomized controlled trials at the highest level and case series or expert opinions at the lowest level. The hierarchies rank studies according to the probability of bias. Randomized controlled trials are given the highest level because they are designed to be unbiased and have less risk of systematic errors. For example, by randomly allocating subjects to two or more treatment groups, these types of studies also randomize confounding factors that may bias results. A case series or expert opinion is often biased by the author's experience or opinions, and there is no control of confounding factors.Table 1: Canadian Task Force on the Periodic Health Examination's Levels of EvidenceTable 2: Levels of Evidence from SackettMODIFICATION OF LEVELS Since the introduction of levels of evidence, several other organizations and journals have adopted variations of the classification system. Diverse specialties are often asking different questions, and it was recognized that the type and level of evidence needed to be modified accordingly. Research questions are divided into the following categories: treatment, prognosis, diagnosis, and economic/decision analysis. For example, Table 3 shows the levels of evidence developed by the American Society of Plastic Surgeons for prognosis9 and Table 4 shows the levels developed by the Centre for Evidence-Based Medicine for treatment.10 The two tables highlight the types of studies that are appropriate for the question (prognosis versus treatment) and how quality of data is taken into account when assigning a level. For example, randomized controlled trials are not appropriate when looking at the prognosis of a disease. The question in this instance is, "What will happen if we do nothing at all?" Because a prognosis question does not involve comparing treatments, the highest evidence would come from a cohort study or a systematic review of cohort studies. The levels of evidence also take into account the quality of the data. For example, in the chart from the Centre for Evidence-Based Medicine, a poorly designed randomized controlled trial has the same level of evidence as a cohort study.Table 3: Levels of Evidence for Prognostic StudiesTable 4: Levels of Evidence for Therapeutic StudiesA grading system that provides strength of recommendations based on evidence has also changed over time. Table 5 shows the Grade Practice Recommendations developed by the American Society of Plastic Surgeons. The grading system provides an important component in evidence-based medicine and assists in clinical decision making. For example, a strong recommendation is given when there is level I evidence and consistent evidence from level II, III, and IV studies available. The grading system does not degrade lower level evidence when deciding recommendations if the results are consistent.Table 5: Grade Practice RecommendationsINTERPRETATION OF LEVELS Many journals assign a level to the articles they publish, and authors often assign a level when submitting an abstract to conference proceedings. This allows the reader to know the level of evidence of the research, but the designated level of evidence does always guarantee the quality of the research. It is important that readers not assume that level I evidence is always the best choice or appropriate for the research question. This concept will be very important for all of us to understand as we evolve into the field of evidence-based medicine in plastic surgery. By design, our designated surgical specialty will always have important articles that may have a lower level of evidence because of the level of innovation and technique articles that are needed to move our surgical specialty forward. Although randomized controlled trials are often assigned the highest level of evidence, not all randomized controlled trials are conducted properly, and the results should be scrutinized carefully. Sackett8 stressed the importance of estimating types of errors and the power of studies when interpreting results from randomized controlled trials. For example, a poorly conducted randomized controlled trial may report a negative result because of low power when in fact a real difference exists between treatment groups. Scales such as the Jadad scale have been developed to judge the quality of randomized controlled trials.11 Although physicians may not have the time or inclination to use a scale to assess quality, there are some basic items that should be taken into account. Items used for assessing randomized controlled trials include randomization, blinding, a description of the randomization and blinding process, a description of the number of subjects who withdrew or dropped out of the study, the confidence intervals around study estimates, and a description of the power analysis. For example, Bhandari et al.12 published an article assessing the quality of surgical randomized controlled trials. The authors evaluated the quality of randomized controlled trials reported in the Journal of Bone and Joint Surgery from 1988 to 2000. Articles with a score of greater than 75 percent were deemed high quality, and 60 percent of the articles had a score less than 75 percent. The authors identified 72 randomized controlled trials during this time period, and the mean score was 68 percent. The main reason for the low-quality score was lack of appropriate randomization, blinding, and a description of patient exclusion criteria. Another article found the same quality score of articles in the Journal of Bone and Joint Surgery with a level 1 rating compared with level 2.13 Therefore, one should not assume that level 1 studies are of higher quality than level 2 studies. A resource for surgeons to use when appraising levels of evidence are the users' guides published in the Canadian Journal of Surgery14,15 and the Journal of Bone and Joint Surgery.16 Similar articles that are not specific to surgery have been published in the Journal of the American Medical Association.17,18 PLASTIC SURGERY AND EVIDENCE-BASED MEDICINE The field of plastic surgery has been slow to adopt evidence-based medicine. This was demonstrated in an article examining the level of evidence of articles published in Plastic and Reconstructive Surgery.19 The authors assigned levels of evidence to articles published in Plastic and Reconstructive Surgery over a 20-year period. The majority of studies (93 percent in 1983) were level IV or V, which denotes case series and case reports. Although the results were disappointing, there was some improvement over time. By 2003, there were more level I studies (1.5 percent) and fewer level IV and V studies (87 percent). A recent analysis looked at the number of level I studies in five different plastic surgery journals from 1978 to 2009. The authors defined level I studies as randomized controlled trials and meta-analyses and restricted their search to these studies. The number of level I studies increased from one in 1978 to 32 by 2009.20 From these results, we see that the field of plastic surgery is improving the level of evidence but still has a long way to go, especially in improving the quality of studies published. For example, approximately one-third of the studies involved double blinding, but the majority did not randomize subjects, describe the randomization process, or perform a power analysis. Power analysis is another area of concern in plastic surgery. A review of the plastic surgery literature found that the majority of published studies have inadequate power to detect moderate to large differences between treatment groups.21 Regardless of the level of evidence for a study, if the study is underpowered, the interpretation of results is questionable. Although the goal is to improve the overall level of evidence in plastic surgery, this does not mean that all lower level evidence should be discarded. Case series and case reports are important for hypothesis generation and can lead to more controlled studies. In addition, in the face of overwhelming evidence to support a treatment, such as the use of antibiotics for wound infections, there is no need for a randomized controlled trial. CLINICAL EXAMPLES USING LEVELS OF EVIDENCE To understand how the levels of evidence work and aid the reader in interpreting levels, we provide some examples from the plastic surgery literature. The examples also show the peril of medical decisions based on results from case reports. An association was hypothesized between lymphoma and silicone breast implants based on case reports.22–27 The level of evidence for case reports, depending on the scale used, is IV or V. These case reports were used to generate the hypothesis that a possible association existed. Because of these results, several large retrospective cohort studies from the United States, Canada, Denmark, Sweden, and Finland were conducted.28–32 The level of evidence for a retrospective cohort study is II. All of these studies had many years of follow-up for a large number of patients. Some of the studies found an elevated risk and others found no risk for lymphoma. None of the studies reached statistical significance. Therefore, higher level evidence from cohort studies does not provide evidence of any risk of lymphoma. Finally, a systematic review was performed that combined the evidence from the retrospective cohorts.27 The results found an overall standardized incidence ratio of 0.89 (95 percent confidence interval, 0.67 to 1.18). Because the confidence interval includes 1, the results indicate there is no increased incidence. The level of evidence for the systematic review is I. Based on the best available evidence, there is no association between lymphoma and silicone implants. This example shows how studies with a low level of evidence were used to generate a hypothesis, which then led to higher level evidence that disproved the hypothesis. This example also demonstrates that randomized controlled trials are not feasible for rare events such as cancer and emphasizes the importance of observational studies for a specific study question. A case-control study is a better option and provides higher level evidence for testing the prognosis of the long-term effect of silicone breast implants. Another example is the injection of epinephrine in fingers. Based on case reports before 1950, physicians were advised that epinephrine injection can result in finger ischemia.33 We see in this example that level IV or V evidence was accepted as fact and incorporated into medical textbooks and teaching. However, not all physicians accepted this evidence and were performing injections of epinephrine into the fingers, with no adverse effects on the hand. Obviously, it was time for higher level evidence to resolve this issue. An in-depth review of the literature from 1880 to 2000 by Denkler33 identified 48 cases of digital infarction, of which 21 had been injected with epinephrine. Further analysis found that the addition of procaine to the epinephrine injection was the cause of the ischemia.34 The procaine used in these injections included toxic acidic batches that were recalled in 1948. In addition, several cohort studies found no complications from the use of epinephrine in the fingers and hand.35–37 The results from these cohort studies increased the level of evidence. Based on the best available evidence from these studies, the hypothesis that epinephrine injection will harm fingers was rejected. This example highlights the biases inherent in case reports. It also shows the risk when spurious evidence is handed down and integrated into medical teaching. OBTAINING THE BEST EVIDENCE We have established the need for randomized controlled trials to improve evidence in plastic surgery but have also acknowledged the difficulties, particularly with randomization and blinding. Although randomized controlled trials may not be appropriate for many surgical questions, well-designed and well-conducted cohort or case-control studies could boost the level of evidence. Many of the current studies tend to be descriptive and lack a control group. The way forward seems clear. Plastic surgery researchers need to consider using a cohort or case-control design whenever a randomized controlled trial is not possible. If designed properly, the level of evidence for observational studies can approach or surpass those from a randomized controlled trial. In some instances, observational studies and randomized controlled trials have yielded similar results.38 If enough cohort or case-control studies become available, the prospect of systematic reviews of these studies will increase, which will increase overall evidence levels in plastic surgery. CONCLUSIONS The levels of evidence are an important component of evidence-based medicine. Understanding the levels and why they are assigned to publications and abstracts helps the reader to prioritize information. This is not to say that all level IV evidence should be ignored and all level I evidence accepted as fact. The levels of evidence provide a guide, and the reader needs to be cautious when interpreting these results. ACKNOWLEDGMENTS This work was supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to K.C.C.).

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Simultaneous comparison of multiple treatments: combining direct and indirect evidence

2005-10-13

Deborah M Caldwell , A. E. Ades , Julian P. T. Higgins

How can policy makers decide which of five treatments is the best? Standard meta-analysis provides little help but evidence based decisions are possible How can policy makers decide which of five treatments is the best? Standard meta-analysis provides little help but evidence based decisions are possible

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Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations

1993-11-01

Jeremy Grimshaw , Ian Russell

Why Don't Physicians Follow Clinical Practice Guidelines?

1999-10-20

Michael D. Cabana , Cynthia S. Rand , Neil R. Powe +4 more

Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to … Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines.To review barriers to physician adherence to clinical practice guidelines.We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence.Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator.Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators.The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier.Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.

Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV

2004-02-19

Bryan Williams , N. Poulter , Morris J. Brown +5 more

GRADE guidelines: 2. Framing the question and deciding on important outcomes

2010-12-31

Gordon Guyatt , Andrew D Oxman , Regina Kunz +7 more

An english translation of alzheimer's 1907 paper, “über eine eigenartige erkankung der hirnrinde”

1995-01-01

Rainulf A. Stelzmann , H.N. Schnitzlein , F. Reed Murtagh

Rules of Evidence and Clinical Recommendations on the Use of Antithrombotic Agents

1989-02-01

David L. Sackett

Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines

1999-02-20

Steven H. Woolf , R. Grol , Anastasia Hutchinson +2 more

This is the first in a series of four articles on issues in the development and use of clinical guidelines Over the past decade, clinical guidelines have increasingly become a … This is the first in a series of four articles on issues in the development and use of clinical guidelines Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned …

Current methods of the U.S. Preventive Services Task Force

2001-04-01

Russell Harris , Mark Helfand , Steven H. Woolf +4 more

Effectiveness and efficiency of guideline dissemination and implementation strategies

2004-02-01

Jeremy Grimshaw , Ruth Thomas , Graeme MacLennan +7 more

To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework … To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines.MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group.Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care.In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources.There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

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KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease

2007-02-01

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Successes and Failures in the Implementation of Evidence-Based Guidelines for Clinical Practice

2001-08-01

Richard Grol

The development and implementation of (evidence-based) clinical practice guidelines is one of the promising and effective tools for improving the quality of care. However, many guidelines are not used after … The development and implementation of (evidence-based) clinical practice guidelines is one of the promising and effective tools for improving the quality of care. However, many guidelines are not used after dissemination. Implementation activities frequently produce only moderate improvement. It is important to study specific guideline programs in detail to learn from their successes and failures.Experiences with more than 10 years of development and dissemination of clinical guidelines for family medicine in the Netherlands are presented in this paper.More than 70 evidence-based guidelines have been set in a rigorous procedure and have been spread via a variety of strategies. Knowledge and acceptance of the guidelines in the target group is high. In particular, a multifaceted approach with written (scientific journal, support materials) and personal approaches (local consensus discussions, contact with colleagues, outreach visits by peers) seems to be effective in the dissemination. The guideline recommendations are followed in on average 67% of the decisions, but there is a large variation between different physicians and between different guidelines. Specific strategies designed to handle possible obstacles to implementation are needed to improve adherence. Specific implementation projects showed the importance of a "diagnostic analysis" of the target group and target setting before the start of the implementation.A program to implement a guideline should be well designed, well prepared, and preferably pilot tested before use. Such a program should be built into the normal channels and structures for improving care. More research into the details of implementation is needed to better understand the critical determinants of change in practice.

Scottish Intercollegiate Guidelines Network

2005-11-03

Sara Twaddle , Safia Qureshi

Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines

2006-01-01

Gordon Guyatt , David D. Gutterman , Michael H. Baumann +6 more

Going from evidence to recommendations

2008-05-08

Gordon Guyatt , Andrew D Oxman , Regina Kunz +4 more

The GRADE system classifies recommendations made in guidelines as either strong or weak. This article explores the meaning of these descriptions and their implications for patients, clinicians, and policy makers The GRADE system classifies recommendations made in guidelines as either strong or weak. This article explores the meaning of these descriptions and their implications for patients, clinicians, and policy makers

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GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations

2013-01-09

Jeff Andrews , Gordon Guyatt , Andrew D Oxman +7 more

Society of Interventional Radiology Clinical Practice Guidelines

2003-09-01

David Sacks , Tricia E. McClenny , John F. Cardella +1 more

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AGREE II: advancing guideline development, reporting and evaluation in health care

2010-07-05

Melissa Brouwers , Michelle E. Kho , George P. Browman +7 more

Clinical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions,[1][1],[2][2] frequently vary widely in quality.[3][3],[4][4] A strategy was needed to differentiate among … Clinical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions,[1][1],[2][2] frequently vary widely in quality.[3][3],[4][4] A strategy was needed to differentiate among guidelines and ensure that those

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What is “quality of evidence” and why is it important to clinicians?

2008-05-01

Gordon Guyatt , Andrew D Oxman , Regina Kunz +3 more

Guideline developers use a bewildering variety of systems to rate the quality of the evidence underlying their recommendations. Some are facile, some confused, and others sophisticated but complex Guideline developers use a bewildering variety of systems to rate the quality of the evidence underlying their recommendations. Some are facile, some confused, and others sophisticated but complex

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Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review

2008-09-12

Anneke L. Francke , Marieke Smit , A.J.E. de Veer +1 more

Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review … Nowadays more and more clinical guidelines for health care professionals are being developed. However, this does not automatically mean that these guidelines are actually implemented. The aim of this meta-review is twofold: firstly, to gain a better understanding of which factors affect the implementation of guidelines, and secondly, to provide insight into the "state-of-the-art" regarding research within this field. A search of five literature databases and one website was performed to find relevant existing systematic reviews or meta-reviews. Subsequently, a two-step inclusion process was conducted: (1) screening on the basis of references and abstracts and (2) screening based on full-text papers. After that, relevant data from the included reviews were extracted and the methodological quality of the reviews was assessed by using the Quality Assessment Checklist for Reviews. Twelve systematic reviews met our inclusion criteria. No previous systematic meta-reviews meeting all our inclusion criteria were found. Two of the twelve reviews scored high on the checklist used, indicating only "minimal" or "minor flaws". The other ten reviews scored in the lowest of middle ranges, indicating "extensive" or "major" flaws. A substantial proportion (although not all) of the reviews indicates that effective strategies often have multiple components and that the use of one single strategy, such as reminders only or an educational intervention, is less effective. Besides, characteristics of the guidelines themselves affect actual use. For instance, guidelines that are easy to understand, can easily be tried out, and do not require specific resources, have a greater chance of implementation. In addition, characteristics of professionals – e.g., awareness of the existence of the guideline and familiarity with its content – likewise affect implementation. Furthermore, patient characteristics appear to exert influence: for instance, co-morbidity reduces the chance that guidelines are followed. Finally, environmental characteristics may influence guideline implementation. For example, a lack of support from peers or superiors, as well as insufficient staff and time, appear to be the main impediments. Existing reviews describe various factors that influence whether guidelines are actually used. However, the evidence base is still thin, and future sound research – for instance comparing combinations of implementation strategies versus single strategies – is needed.

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Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project

2003-02-01

Abstract Background: International interest in clinical practice guidelines has never been greater but many published guidelines do not meet the basic quality requirements. There have been renewed calls for validated … Abstract Background: International interest in clinical practice guidelines has never been greater but many published guidelines do not meet the basic quality requirements. There have been renewed calls for validated criteria to assess the quality of guidelines. Objective: To develop and validate an international instrument for assessing the quality of the process and reporting of clinical practice guideline development. Methods: The instrument was developed through a multi-staged process of item generation, selection and scaling, field testing, and refinement procedures. 100 guidelines selected from 11 participating countries were evaluated independently by 194 appraisers with the instrument. Following refinement the instrument was further field tested on three guidelines per country by a new set of 70 appraisers. Results: The final version of the instrument contained 23 items grouped into six quality domains with a 4 point Likert scale to score each item (scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, editorial independence). 95% of appraisers found the instrument useful for assessing guidelines. Reliability was acceptable for most domains (Cronbach’s alpha 0.64–0.88). Guidelines produced as part of an established guideline programme had significantly higher scores on editorial independence and, after the publication of a national policy, had significantly higher quality scores on rigour of development (p<0.005). Guidelines with technical documentation had higher scores on that domain (p<0.0001). Conclusions: This is the first time an appraisal instrument for clinical practice guidelines has been developed and tested internationally. The instrument is sensitive to differences in important aspects of guidelines and can be used consistently and easily by a wide range of professionals from different backgrounds. The adoption of common standards should improve the consistency and quality of the reporting of guideline development worldwide and provide a framework to encourage international comparison of clinical practice guidelines. validationqualityguidelines

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A new system for grading recommendations in evidence based guidelines

2001-08-11

Robin Harbour , John Miller

The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical guidelines for the NHS in Scotland. The key elements of the methodology are (a) that guidelines are developed by multidisciplinary … The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical guidelines for the NHS in Scotland. The key elements of the methodology are (a) that guidelines are developed by multidisciplinary groups; (b) they are based on a systematic review of the scientific evidence; and (c) recommendations are explicitly linked to the supporting evidence and graded according to the strength of that evidence. Until recently, the system for grading guideline recommendations was based on the work of the US Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research). 1 2 However, experience over more than five years of guideline development led to a growing awareness of this system's weaknesses. Firstly, the grading system was designed largely for application to questions of effectiveness, where randomised controlled trials are accepted as the most robust study design with the least risk of bias in the results. However, in many areas of medical practice randomised trials may not be practical or ethical to undertake; and for many questions other types of study design may provide the best evidence. Secondly, guideline development groups often fail to take adequate account of the methodological quality of individual studies and the overall picture presented by a body of evidence rather than individual studies or they fail to apply sufficient judgment to the overall strength of the evidence base and its applicability to the target population of the guideline. Thirdly, guideline users are often not clear about the implications of the grading system. They misinterpret the grade of recommendation as relating to its importance, rather than to the strength of the supporting evidence, and may therefore fail to give due weight to low grade recommendations. #### Summary points A revised system of determining levels of evidence and grades …

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From best evidence to best practice: effective implementation of change in patients' care

2003-10-01

Richard Grol , Jeremy Grimshaw

European guidelines on cardiovascular disease prevention in clinical practice Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts)

2003-09-01

G De Backer

Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. … Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organizations-European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific Task Force. The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements. The rationale for an active approach to the prevention of cardiovascular diseases (CVD) is …

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Framework for design and evaluation of complex interventions to improve health

2000-09-16

Marion Campbell

Randomised controlled trials are widely accepted as the most reliable method of determining effectiveness, but most trials have evaluated the effects of a single intervention such as a drug. Recognition … Randomised controlled trials are widely accepted as the most reliable method of determining effectiveness, but most trials have evaluated the effects of a single intervention such as a drug. Recognition is increasing that other, non-pharmacological interventions should also be rigorously evaluated.1-3 This paper examines the design and execution of research required to address the additional problems resulting from evaluation of complex interventions—that is, those “made up of various interconnecting parts.”4 The issues dealt with are discussed in a longer Medical Research Council paper (www.mrc.ac.uk/complex_packages.html). We focus on randomised trials but believe that this approach could be adapted to other designs when they are more appropriate. #### Summary points Complex interventions are those that include several components The evaluation of complex interventions is difficult because of problems of developing, identifying, documenting, and reproducing the intervention A phased approach to the development and evaluation of complex interventions is proposed to help researchers define clearly where they are in the research process Evaluation of complex interventions requires use of qualitative and quantitative evidence There are specific difficulties in defining, developing, documenting, and reproducing complex interventions that are subject to more variation than a drug. A typical example would be the design of a trial to evaluate the benefits of specialist stroke units. Such a trial would have to consider the expertise of various health professionals as well as investigations, drugs, treatment guidelines, and arrangements for discharge and follow up. Stroke units may also vary in terms of organisation, management, and skill mix. The active components of the stroke unit may be difficult to specify, making it difficult to replicate the intervention. The box gives other examples of complex interventions. #### Examples of complex interventions Service delivery and organisation: Stroke units Hospital at home Interventions directed at health professionals' behaviour: Strategies for implementing guidelines Computerised decision support Community interventions: Community …

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Users' guides to the medical literature

1993-11-03

Gordon Guyatt

Medical practice is constantly changing. The rate of change is accelerating, and physicians can be forgiven if they often find it dizzying. How can physicians learn about new information and … Medical practice is constantly changing. The rate of change is accelerating, and physicians can be forgiven if they often find it dizzying. How can physicians learn about new information and innovations, and decide how (if at all) they should modify their practice? Possible sources include summaries from the medical literature (review articles, practice guidelines, consensus statements, editorials, and summary articles in "throwaway" journals); consultation with colleagues who have special expertise; lectures; seminars; advertisements in medical journals; conversations with representatives from pharmaceutical companies; and original articles in journals and journal supplements. Each of these sources of information might be valuable, though each is subject to its own particular biases.<sup>1,2</sup>Problems arise when, as is often the case, these sources of information provide different suggestions about patient care. See also p 2093. Without a way of critically appraising the information they receive, clinicians are relatively helpless in deciding what new information

Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group

2004-12-22

David C. Atkins , Martin Eccles , Signe Flottorp +7 more

A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons … A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations.Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches.There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised.All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.

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GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

2008-04-24

Gordon Guyatt , Andrew D Oxman , Gunn Elisabeth Vist +4 more

Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted … Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide

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OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

2008-02-01

Weiya Zhang , Roland W. Moskowitz , G. Nuki +7 more

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The standardisation of terminology of lower urinary tract function

1989-02-01

Paul Abrams , Jerry G. Blaivas , Stuart L. Stanton +1 more

A Computer-Assisted Management Program for Antibiotics and Other Antiinfective Agents

1998-01-22

R. Scott Evans , Stanley L. Pestotnik , David C. Classen +5 more

Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support … Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit.

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Methods

2013-03-26

Gillian L. Booth , Alice Cheng

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American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis — 2016--Executive Summary

2016-01-01

Pauline M. Camacho , Steven M. Petak , Neil Binkley +7 more

Global Guideline for Type 2 Diabetes

2014-02-05

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J Soc Gynecol Investig

2005-01-01

Josie McConnell , P Shelley , S Heales +5 more

clinical practice guidelines for chronic kidney disease : evaluation, classification, and stratification

2002-01-01

K Doqi

European guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (Constituted by representatives of nine societies and by invited experts)

2007-05-04

Ian D. Graham , Dan Atar , K. Borch‐Johnsen +7 more

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a … Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are not substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC web site (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in the tables below. The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report was entirely …

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British National Formulary

1958-01-01

The journal of clinical investigation

1994-08-01

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Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology

2006-11-10

The assurance of the quality of a service rendered by a member of the dental profession is an essential feature of any system of peer review in dentistry. This document … The assurance of the quality of a service rendered by a member of the dental profession is an essential feature of any system of peer review in dentistry. This document addresses two essential elements: (i) appropriateness of treatment modality and (ii) quality or level of treatment rendered. In revising these guidelines the European Society of Endodontology is responding to a public and professional need. In receiving care of a specialized nature such as endodontic treatment, patients need and deserve treatment that meets the standard of care generally given by competent practitioners. The European Society of Endodontology has the expertise and professional responsibility necessary to assist the dental profession by instituting guidelines on the standard of care in the special area of Endodontics. In accepting this responsibility the European Society of Endodontology formulated treatment guidelines that are intended to represent current good practice.

Observation Medicine

2025-06-26

| Cambridge University Press eBooks

Using comprehensive sample administrative and clinical protocols, this fully updated and practical second edition guide to observation medicine (OM) provides a detailed account of how to establish and run an … Using comprehensive sample administrative and clinical protocols, this fully updated and practical second edition guide to observation medicine (OM) provides a detailed account of how to establish and run an observation unit (OU) and reviews medical/surgical/obstetrical-gynecologic/psychiatric/social conditions in which OM may be applicable. The book covers clinical topics including improving patient outcomes, avoiding readmissions, and using OM in a pandemic or disaster. Practical topics on design, staffing, and daily operations; fiscal and business aspects, such as coding, billing, and reimbursement; regulatory concerns such as aligning case management and utilization review with observation; nursing considerations are all present. The new edition features many new chapters and topics ranging from the geriatric OU, psychiatric observation, telemedicine in OM, to the cancer patient in the OU. Applicable to an international audience, it offers instructions for implementing observation in any setting or locale and in any type of hospital or other appropriate facility.

[Expert consensus on advocating the use of graphic surgical records(2025 edition)].

2025-06-25

| PubMed

Surgical records are the core components of medical documents in clinical centers of surgery. Standardization of surgical records contributes to standardizing surgical procedures, improving the quality of surgery, and ensuring … Surgical records are the core components of medical documents in clinical centers of surgery. Standardization of surgical records contributes to standardizing surgical procedures, improving the quality of surgery, and ensuring patient safety. To ensure that surgical records more objectively, visually, and comprehensively reflect the actual surgical process, numerous high-level university hospitals' surgical centers have long adhered to the good tradition of documenting surgical records in a "combination of text and images" format. Graphic surgical records not only benefit postoperative review and structured data collection but also facilitate the implementation of high-quality clinical research and surgical training. As early as 2015, Group of Operative Surgery, Chinese Society of Surgery, Chinese Medical Association already formulated the "Expert Consensus on Advocating the use of graphic surgical records".In recent years, rapid development of information technology has provided technical support for the further promotion of graphical surgical records. After extensive and multiple rounds of professional discussions and investigations, and based on a thorough consideration of relevant national policy requirements, information standards, the 2025 edition of the "Expert Consensus" is intended to be revised, aiming to enhance the standardization of graphical surgical records, improve the quality of surgery and training system, as well as clinical researches, thereby contributing to the development of Healthy China.

Clinical outcomes of posterior cervical fusion in the setting of increasing age and medical complexity: an American national database analysis from 2012 to 2022

2025-06-24

Ryan Le , R. Hoang , Joshua Lee +7 more | Asian Spine Journal

Retrospective cohort study. This study aimed to investigate trends in postoperative complications for posterior cervical fusions from 2012 to 2022. Previous studies analyzing the longitudinal outcomes of posterior cervical fusion … Retrospective cohort study. This study aimed to investigate trends in postoperative complications for posterior cervical fusions from 2012 to 2022. Previous studies analyzing the longitudinal outcomes of posterior cervical fusion from 2003 to 2013 have demonstrated relatively improved postoperative outcomes despite the increasing volume, complexity, and age of the patient population. However, few studies have evaluated these outcomes since 2013. The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing posterior cervical fusion between 2006 and 2022. Patients aged >18 years with current procedural terminology code 22600 for posterior cervical fusion were included. Patient demographics and comorbidities were recorded, including age, race, body mass index, diabetes mellitus, and hypertension. Annual 30-day complication rates were reported, including wound infection, readmission, reoperation, length of stay, intraoperative blood transfusions, and mortality. In total, 25,537 patients undergoing posterior cervical fusion from 2012 to 2022 were included. Variations in the rates of urinary tract infection, deep vein thrombosis, sepsis, reoperation, and mortality were not significant. Wound infection rates increased from 2.4% in 2012 to 4.0% in 2022 (p=0.003). Pneumonia rates increased from 1.2% in 2012 to 1.6% in 2022 (p=0.011). Intraoperative blood transfusion rates decreased consistently from 5.6% in 2012 to 2.8% in 2022 (p<0.001). Readmission rates increased from 6.4% in 2012 to 6.7% in 2022 (p<0.001). The average length of stay decreased from 4.18 days in 2012 to 3.97 days in 2019, before increasing between 2020 and 2022 to 4.17 days in 2022. Rates of comorbidities including age, diabetes mellitus, and hypertension have increased among patients undergoing posterior cervical fusion between 2012 and 2022, whereas complication rates have remained relatively similar. The length of stay has shortened despite the higher medical complexity of the patients who underwent surgery.

Vorhofflimmern: Schlaganfallrisiko in vergangenen Jahren gesunken

2025-06-23

Thomas Maibaum | Zeitschrift für Allgemeinmedizin

Quality indicators for pharmacist follow-up of diabetes mellitus: A RAND-modified Delphi method

2025-06-23

Laura Christiaens , L Meel , M Buyl +5 more | International Journal of Clinical Pharmacy

Clinical Rounds

2025-06-23

| Nursing

A qualitative evaluation of remote supervision guidelines for Australian general practice registrars in two practice locations

2025-06-22

Jill Benson , Josephine Borthwick , Tim Linton +3 more | Rural and Remote Health

The lack of a stable general practice workforce in rural and remote Australia has been a topic of much discussion as there are fewer GPs working in many rural areas, … The lack of a stable general practice workforce in rural and remote Australia has been a topic of much discussion as there are fewer GPs working in many rural areas, where mortality and morbidity are higher than in urban areas. Doctors who have been trained in rural and remote areas are more likely to continue working there, but in many practices supervision is not available onsite. Good supervision ensures patient safety, an educational alliance between the supervisor and trainee, and adequate clinical and professional support by the supervisor and the onsite team. This project involved the evaluation of the pilot of the newly developed guidelines for the remote supervision of GP trainees (registrars) within the Royal Australian College of General Practitioners (RACGP) Australian General Practice Training program: Remote supervision: Guidelines for safe and effective general practice training utilising remote supervision. The aim of the evaluation was to assess the appropriateness, effectiveness and efficiency of the remote supervision guidelines and placement processes such as the selection process, risk management plan, face-to-face orientation period, development of the onsite team, communication strategies and increased payment. The guidelines were implemented as a pilot in two practice localities in 2022. The remote supervisors, remotely supervised registrars, practice managers and training organisation stakeholders were interviewed at three time points during the placement: before the placement, after the orientation period and at the conclusion of the placement. Their responses were analysed and organised into themes. Overall, the results were positive, with suggestions for improvement and challenges identified. There was an identified need to ensure that guidelines are flexible and able to be tailored to the context of the registrar, the supervisor and the placement. Both registrars in the pilot continued to work in the remotely supervised practices at the end of their training and the three supervisors were keen to supervise remotely again. The RACGP remote supervision guidelines were developed as an evidence-based practical means of supervising registrars in rural and remote locations where there is no onsite supervisor. The guidelines were updated where necessary and have now been published and implemented nationally. The pilot and evaluation of the RACGP remote supervision guidelines demonstrate that they are safe and fit for purpose. These guidelines form one of the training strategies to support the dwindling rural and remote general practice workforce.

Clinical Snippets

2025-06-20

| Journal of Investigative Dermatology

Approaches to the digitization of clinical guidelines

2025-06-20

Yuriy Komarov , А. А. Курылев , E.Yu. Khrapovitskaya +3 more | Medical Technologies Assessment and Choice

Objective. To develop the best approach to digitizing clinical guidelines in the Russian Federation. Material and methods. An analytical study was conducted at the N.N. Petrov National Medical Research Center … Objective. To develop the best approach to digitizing clinical guidelines in the Russian Federation. Material and methods. An analytical study was conducted at the N.N. Petrov National Medical Research Center for Oncology of the Ministry of Health of Russia using the clinical guidelines “Ovarian cancer/fallopian tube cancer/primary peritoneal cancer.” The methods of flowcharts and notation Business Process Model and Notation (BPMN) 2.0 were used to describe the algorithms and processes. Results. During the digitization, algorithms for treating patients were created with triggers, logical gateways, tasks, and threads. Two documents were obtained: a graphical version of the process display and a machine-readable description of the process in XML format, which can be used in medical information systems. Conclusion. A methodology based on the coding of specific medical services, drug treatment regimens, and surgical interventions is proposed to digitize clinical guidelines, ensure a full-fledged representation of the patient management algorithm, and use it in medical information systems. Further development of the methodology should aim to use universal markup languages and develop tools convenient for doctors to use.

Methodological and reporting quality of Thoracic Society of Australia and New Zealand clinical guidance documents<sup>†</sup>

2025-06-19

William Soon , Yvonne Ng , Daniel Seow +2 more | Internal Medicine Journal

Abstract The Thoracic Society of Australia and New Zealand (TSANZ) is the leading Australasian professional society for respiratory medicine that develops clinical practice guidelines and position papers to advance lung … Abstract The Thoracic Society of Australia and New Zealand (TSANZ) is the leading Australasian professional society for respiratory medicine that develops clinical practice guidelines and position papers to advance lung health through improved clinical care and research efforts. Published TSANZ clinical guidance documents were identified from the online society repository until March 2023. Each document was independently scored using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) and the Reporting Items for Practice Guidelines in HealThcare (RIGHT) checklists for methodological and reporting quality respectively. Twenty‐eight position papers and seven clinical practice guidelines were evaluated. The median overall methodological quality score for the AGREE II checklist was four out of a maximum of seven (interquartile range (IQR) 3.5–4.75). The majority of documents (97%) were recommended for use with or without modifications. The median overall reporting rate using the RIGHT checklist was 46% (IQR 40–54). Low‐scoring items were rigour of evidence synthesis, focus on clinical implementation, conflict of interest declaration and clarity of methodology. Clinical practice guidelines scored significantly higher overall reporting quality than position papers (57% vs. 43%, P = 0.05), but not for the methodological quality scores (median number of high‐scoring domains (>70%): 2 vs. 1, P = 0.13). Documents developed with methodologist involvement had significantly increased reporting (71% vs. 43%, P = 0.02) and methodological quality (median high‐scoring domains: 4 vs. 1, P = 0.007), compared to those without. Based on AGREE II, most TSANZ clinical guidance documents are recommended for use, or for use with modifications. Applicability, stakeholder involvement and conflict of interest declarations are identified as areas for improvement in future documents.

Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care

2025-06-17

Rémi Goupil , Ross T. Tsuyuki , Nancy Santesso +7 more | Canadian Family Physician

Canada has historically been among the world's leaders in hypertension care, but hypertension treatment and control rates have regressed in recent years. This guideline is intended to provide pragmatic primary … Canada has historically been among the world's leaders in hypertension care, but hypertension treatment and control rates have regressed in recent years. This guideline is intended to provide pragmatic primary care-focused recommendations to improve hypertension management in adults at the population level. We employed Grading of Recommendations Assessment, Development and Evaluation and ADAPTE frameworks in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards to develop recommendations on managing hypertension for adults aged 18 years and older. We used the HEARTS framework-a model of care developed by the World Health Organization to improve hypertension control and reduce cardiovascular burden-to integrate these recommendations into streamlined, pragmatic, and evidence-based algorithms. The guideline committee predominantly comprised primary care providers and also included patient, methodology, and hypertension specialist representatives. Our process for managing competing interests adhered to Guidelines International Network principles. The 9 recommendations for managing hypertension in adults are grouped under the categories of diagnosis and treatment. Diagnostic recommendations include a standardized approach to measuring blood pressure (BP) and confirming hypertension, as well as providing a uniform definition for hypertension of BP ≥130/80 mm Hg. Treatment recommendations include targeting a systolic BP <130 mm Hg, implementing healthy lifestyle changes, and providing stepwise guidance on optimal medication choices for patients requiring pharmacotherapy. Our aim is to enhance the standard of hypertension care in the Canadian primary care setting. Accurate diagnosis and optimal treatment of hypertension can reduce adverse cardiovascular events and risk of death.

Editor's Choice – Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines for Vascular Surgery: A Systematic Review

2025-06-17

Alex Murigu , KHF Wong , R Mercer +2 more | Journal of Vascular Surgery

A salute to ten years of Australian Clinical Care Standards: celebrations and challenges

2025-06-17

Alice L Bhasale , Carolyn Hullick , Maria B. Sukkar +1 more | The Medical Journal of Australia

Quality appraisal of clinical practice guidelines for attention deficit hyperactivity disorder: a systematic review using the appraisal of guidelines for research and evaluation (AGREE II) instrument

2025-06-16

Muhammad Dwi Wahyu , Atsunori Sugimoto , Ekachaeryanti Zain +4 more | Frontiers in Psychiatry

Objectives Attention deficit hyperactivity disorder (ADHD) can significantly impact multiple life conditions across the lifespan. Reliable clinical practice guidelines (CPGs) are crucial for the clinical decision-making for the diagnosis and … Objectives Attention deficit hyperactivity disorder (ADHD) can significantly impact multiple life conditions across the lifespan. Reliable clinical practice guidelines (CPGs) are crucial for the clinical decision-making for the diagnosis and management of ADHD. This study aimed to assess the quality of current CPGs for the diagnosis and management of ADHD. Methods We conducted a systematic literature search within Pubmed, Google Scholar, the Agency for Healthcare Research and Quality, Dynamed, the National Institute for Health and Care Excellence (NICE), the National Health and Medical Research Council (NHMRC), and other local and online databases started January 19, 2022. We assessed the guideline quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. All of the included guidelines were critically appraised by five independent reviewers. We also evaluated the interrater reliability of each AGREE II domain and the overall domain score by calculating the intraclass correlation coefficient (ICC) using IBM SPSS Statistics version 28. Results A total of 11 CPGs were included in the study. The majority of the CPGs achieved the highest score in domain 4 “Clarity of Presentation” (mean ± standard deviation, 73.73% ± 12.5%). The domains that achieved the lowest scores were domains 5 “Applicability” (mean ± standard deviation, 45.18% ± 16.4%) and 3 “Rigor of Development” (mean ± standard deviation, 51.09% ± 24.1%). The American Academy of Pediatrics (AAP), NICE, and the Malaysian Health Technology Assessment Section (MAHTAS) CPGs were identified as the strongly recommended guidelines. All AGREE II domains yielded varied interrater reliability results; the full domain ICC ranged from 0.265 (95% confidence interval, −0.470 to 0.665) to 0.758 (95% confidence interval, 0.515 to 0.889). Conclusions Our appraisal indicated that the quality of current ADHD guidelines is varied, and three CPGs were classified as strongly recommended. Our findings offer relevant healthcare providers valuable insight into the appropriate selection of ADHD guidelines in clinical practice. Systematic review registration https://inplasy.com/inplasy-2022-8-0001/ , identifier INPLASY202280001

The EASL Guidelines app is your indispensable mobile companion for accessing comprehensive and up-to-date clinical practice guidelines in hepatology. Download it now!

2025-06-16

| Journal of Hepatology

Feasibility of converting Japanese oncology electronic medical records into the Observational Medical Outcomes Partnership Common Data Model and data quality assessment

2025-06-16

Yoshihiro Aoyagi , Suzue Terao , Masahiro Baba +3 more | medRxiv (Cold Spring Harbor Laboratory)

The potential of utilizing Japanese electronic medical record (EMR) data in global observational research is significant because of high EMR adoption and universal health insurance. However, a few studies have … The potential of utilizing Japanese electronic medical record (EMR) data in global observational research is significant because of high EMR adoption and universal health insurance. However, a few studies have addressed the conversion of Japanese EMR data to the Observational Medical Outcomes Partnership Common Data Model (OMOP CDM) standard, which regulates EMR data for global observational research. In this study, we investigated the feasibility of converting Japanese oncology EMR data to the OMOP CDM and applying the Observational Health Data Sciences and Informatics (OHDSI) tools for analysis. We focused on data from the National Cancer Center Hospital East, encompassing 8,447 patients with breast cancer between January 2015 and November 2023. The main objectives included vocabulary standardization and data structure standardization. The anonymized dataset included clinical information such as patient demographics, diagnoses, treatments, and laboratory results. A total of 3,697 unique disease names, 987 specimen test result terms, and 1,144 drug terms were successfully mapped to OMOP CDM standards, with IC-10 terms showing the highest success rate for disease names. A total of 90% of clinical terms were successfully mapped to OMOP CDM standards, with 80% of source data fully integrated. However, only 32 surgical terms were identified. The feasibility of converting EMR data to OMOP CDM was evaluated by mapping source terms, comparing local raw datasets, and conducting a comprehensive quality assessment using a Data Quality Dashboard. A total of 1,991 validation checks were performed to evaluate the validity of data, suitability, and completeness. The results revealed 24 checks flagged as FAIL or ERROR, with the most frequent issues in the measurement table (10 errors). Despite these issues, the conversion process demonstrated high feasibility. Overall, this study positions Japan as a key player in international observational oncology research, enhancing the global understanding of treatment effectiveness and patient outcomes in real-world settings.

Healthcare utilization and cost of care for a multidisciplinary integrated practice unit model of spine rehabilitation compared to standard or no physical therapy

2025-06-16

Bahar Shahidi , Connor Richards , Lissa Taitano +2 more | medRxiv (Cold Spring Harbor Laboratory)

Objective: To compare healthcare utilization and cost in individuals with spine pain who undergo no physical therapy, standard physical therapy, or physical therapy in an integrated practice unit model. Design: … Objective: To compare healthcare utilization and cost in individuals with spine pain who undergo no physical therapy, standard physical therapy, or physical therapy in an integrated practice unit model. Design: A cost-effectiveness analysis Setting: Multi-site outpatient physical therapy clinics within a single metropolitan region Participants: Individuals with de-identified claims data from a single insurance provider under Medicare Advantage with a spine-pain related diagnosis from January 2019-December 2021. Interventions: Patients were categorized into three cohorts: No physical therapy (NoPT), standard physical therapy (SPT), and physical therapy within an integrated practice unit model (IPUPT) based on their physical therapy history during the data collection period. Main Outcome Measures: Number and percentage of patients reporting claims, number of claims/patient per year, paid amount, and number of RVUs were compared across groups using chi-square or one-way ANOVA with multiple comparisons corrections. Results: Data from 13,569 patients was included in this study. The number of patients with spine-related inpatient claims was highest in the SPT group (2.8%) compared to the IPUPT (1.5%) and NoPT (1.3%) groups (p=0.004). Outpatient care utilization was driven by radiology (54.7%) and laboratory (22.1%) claims and was lowest in the IPUPT group (N=1,096; 56.8%) compared to the SPT group (N=1,654; 68.3%) and NoPT group (N=9,150; 99.3%, p<0.001). The SPT group was most costly per person ($2,243.66(11,048.94)) followed by the NoPT ($1,352.01(6,419.2), p<0.001) and the IPUPT ($1,259.88(9,061.23), p<0.001) groups. The greatest contributor to cost was outpatient procedures, averaging $142.39(1,046.26) per person. Conclusion: An integrated multidisciplinary rehabilitation model may be a cost-effective method of multimodal care in individuals with spine pain.

Onkologische Operationsberichte: Minimalanforderungen, rechtliche Aspekte und zukünftige Entwicklungen

2025-06-16

Johannes Klose , Sandra Böhm , Christiane J. Bruns +7 more | Deleted Journal

Zusammenfassung Die Etablierung onkologischer Zentren zur interdisziplinären Versorgung krebskranker Patienten beruht auf definierten Kriterien, die sich einer regelmäßigen externen Prüfung unterziehen müssen. Dadurch soll ein einheitlicher Qualitätsstandard in der onkologischen … Zusammenfassung Die Etablierung onkologischer Zentren zur interdisziplinären Versorgung krebskranker Patienten beruht auf definierten Kriterien, die sich einer regelmäßigen externen Prüfung unterziehen müssen. Dadurch soll ein einheitlicher Qualitätsstandard in der onkologischen Versorgung in Deutschland gesichert sein. Die Qualität der chirurgischen Leistung wird dabei unter anderem an der Anzahl der behandelten Fälle oder der Erfahrung ausgewählter Operateure definiert. Die erstellten Operationsberichte sind jedoch sehr heterogen, da für die Zertifizierung zu einem onkologischen Zentrum keine Vorgaben erfüllt werden müssen. Die Assoziation Chirurgische Onkologie (ACO) hat sich daher zum Ziel gesetzt, einen Minimalstandard für einen einheitlichen onkologischen Operationsbericht vorzuschlagen. Neben den im Operationsbericht zu erwähnenden Aspekten – beispielhaft bezogen auf die einzelnen Organsysteme – sollen auch rechtliche Aspekte sowie der Einsatz künstlicher Intelligenz näher betrachtet werden.

In memoriam Dr. Robert (Rob) C. Ripley (1975–2024)

2025-06-16

Feng Zhang , L. Donahue , David L. Frost | Shock Waves

Clinical Practice Guidelines: Quality, Breadth, and Currency

2025-06-16

Christopher J. Ryerson , Ann L. Jennerich , Linda Nici +7 more | Annals of the American Thoracic Society

Guide de pratique clinique en soins de première ligne d’Hypertension Canada pour le diagnostic et le traitement de l’hypertension artérielle chez les adultes

2025-06-15

Rémi Goupil , Ross T. Tsuyuki , Nancy Santesso +7 more | Canadian Medical Association Journal

1134-P: Length of Stay in Hospitalized Patients with Diabetes

2025-06-13

Nay Linn Aung , ALBERT D. D'ACCURZIO , Megan E. Lape +1 more | Diabetes

Introduction and Objective: Hospitalized people with diabetes (PWD) have been found to have a longer length of stay (LOS). We intend to determine if non-critically ill PWD have a greater … Introduction and Objective: Hospitalized people with diabetes (PWD) have been found to have a longer length of stay (LOS). We intend to determine if non-critically ill PWD have a greater LOS compared to those without diabetes. The secondary goal is to assess potential differences in LOS based on specific comorbidities that have been identified by CMS in their readmission reduction program (CMS.gov). Methods: Adults admitted to non-ICU units from 6/2022 to 10/2024 were divided based on diabetes status using ICD-10 codes. Data from patients with the six conditions which CMS monitors for readmission were collected (as shown in table). Data analysis involved Independent t-Test in SPSS25. Results: About 35% of hospitalized patients had diabetes and they had a statistically significant greater LOS. 11% of PWD had comorbidities which CMS monitors for readmission. Patients who had a CABG had the longest average LOS but the difference in LOS between diabetes and non-diabetes groups was not statistically significant. However, PWD with HF had statistically significant greater LOS compared to patients with HF without diabetes. Conclusion: Similar to previous studies, our study showed greater LOS in PWD. In sub-group analysis, the greater LOS observed in PWD was not significantly different in AMI, COPD, PN, CABG, or Hip/Knee groups but it was significant in HF. We intend to look at the potential correlation between the involvement of the diabetes team and LOS in next study. Disclosure N. Aung: None. A.D. D'Accurzio: None. M.E. Lape: None. H.E. Khine: None.

Quality in qualitative evidence: new best practice principles from NICE’s real-world evidence framework

2025-06-13

Vandana Ayyar Gupta , Sarah Scott , Mandy Tonkinson +3 more | Journal of Comparative Effectiveness Research

Abstract P4-06-07: The Impact of a Multidisciplinary Quality Assurance Conference on the Management of Inflammatory Breast Cancer

2025-06-13

Huong T. Le-Petross , Megumi Kai , Angela Marx +7 more | Clinical Cancer Research

Abstract Introduction: Inflammatory breast cancer (IBC) is rare but aggressive breast cancer. With the variability in presentation, making prompt diagnosis is challenging even for the experienced physicians. Only in the … Abstract Introduction: Inflammatory breast cancer (IBC) is rare but aggressive breast cancer. With the variability in presentation, making prompt diagnosis is challenging even for the experienced physicians. Only in the last several years has a dedicated diagnostic and management algorithm been agreed upon among multidisciplinary teams at one academic institution. A weekly multidisciplinary management conference (MTC) was developed at our institution three years ago specifically for IBC patients, to provide a common platform for reviewing cases, discussion of challenging diagnoses and treatments, sharing of clinical trial protocols, and ultimately optimizing patient care. In this abstract, we investigate the impact of the conference discussion on IBC patient management. Methodology: All patients who were presented at the IBC multidisciplinary conference from one tertiary academic center were identified from an IRB approved registry protocol, between June 2020 to May 2024. The chart review, imaging studies, associated pathology, and conference notes were retrospectively reviewed from the institutional medical record system EPIC. Results: 205 patients were presented at the IBC multidisciplinary team conference during the study period. The patients’ age at the time of IBC diagnosis was: mean age of 50.9 years and median age of 52 years (range 26-83). Patients’ demographics are : 152 (74.1%) white, 28 (13.7%) black, 10 (4.9%) Asian, 1 (0.5%) native Hawaiian or other pacific islander, and 14 (6.8%) others. Reasons for presenting at MTC include newly diagnosis or suspicion of IBC 40.8%, treated or being treated at outside facility for second opinion 24 %, treated or being treated 19.2%, and interesting case by a clinician 16%. Diagnostic imaging modalities presented or discussed included: mammography 47% of cases, breast ultrasound 58%, biopsies 13%, CT chest abdomen pelvis 20%, PET/CT 51%, brain MRI 17%, bone scan 9%, and other tests (eg. non-breast ultrasound, abdominal MRI, nuclear medicine exams, etc.) 25%. Repeat or additional biopsies were recommended in 4% of cases. At the conclusion of the conferences, recommendations were document in EPIC. Confirmation of IBC diagnosis was reported in 61% (126/205) while in 1% (2/205) diagnoses were changed or consensus was not IBC. In 45% (92/205) patients, treatment recommendation or management change were made. 47% (97/205) patients were recommended for enrollment in clinical trials. Discussion: Multidisciplinary team conference even in rare disease such as IBC is impactful and beneficial for patients’ care resulting in almost half of the patients having recommendation for enrollment in clinical trials, as well as confirmation of accurate diagnosis by a multiteam approach. Citation Format: Huong (Carisa) Le-Petross, Megumi Kai, Angela N Marx, Hope Murphy, Angela Alexander, Gary Whitman, Sadia Saleem, Mary Guirguis, Miral Patel, Susie Sun, Bora Lim, Vicente Valero, Anthony Lucci, MDACC Inflammatory Breast Cancer Team, Wendy Woodward. The Impact of a Multidisciplinary Quality Assurance Conference on the Management of Inflammatory Breast Cancer [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P4-06-07.

Abstract P4-06-15: Resource Utilization by Patients Living with Advanced Breast Cancer (ABC) Who Had a Nurse Practitioner-Led Visit

2025-06-13

Ginny Kirklin , Abbey Kaler , Akshara Singareeka Raghavendra +5 more | Clinical Cancer Research

Abstract Significance and Purpose: The diagnosis of ABC is life-changing and requires greater support and resource utilization compared to early-stage breast cancer patients. The ABC Program aims to improve the … Abstract Significance and Purpose: The diagnosis of ABC is life-changing and requires greater support and resource utilization compared to early-stage breast cancer patients. The ABC Program aims to improve the quality and quantity of life for ABC patients through navigation, education, and support. At an ABC Advanced Practice Registered Nurse (APRN) led visit, patients are guided through the cancer center services and provided education, resources, emotional support, managed care between departments, and informed about clinical trial opportunities and eligibility. The program reviewed resource utilization of the ABC patients seen by an ABC APRN at a comprehensive cancer center in southern US to understand what additional multi-disciplinary interventions are needed. The specific resources included emergency room and inpatients visits, therapeutic clinical trials, and completed visits to the LIMBS Clinic (Linking Internal Medicine and Metastatic Breast cancer for Success), a subspeciality clinic providing access to internal medicine services coordinated with oncology care. Methods: Data were collected as part of an ABC APRN-led visit between March 2020 to May 2024. Patients were referred by clinicians or by self. Data were analyzed utilizing descriptive statistics. Findings: A total of 480 patients had a total of 1,769 visits with an ABC APRN via video (94%) or telephone (6%). Participants were female (99%) and male (0.63%) with a diagnosis of ABC and a mean age of 57; 69% self-identified as white, 16% as black, and 84% non-Hispanic. Most patients (53%) live within 75 miles of the cancer center followed by 23% of patients living between 151 to 500 miles of the cancer center. Most patients (68%) had an ECOG status of 0 or 1. Fifty-six percent of patients presented to the emergency room visit (n=1,052). Of those, 48% of patients had an inpatient admission (n=587). Sixteen percent of patients were active on a therapeutic clinical trial at the cancer center, and 25% of patients had a completed visit in the LIMBS Clinic. There were 425 internal referrals including the LIMBS Clinic (n=110), Integrative Medicine (n=78), Supportive Care (n=59), Nutrition (n=42), and Physical Therapy (n=28) being the top five referrals from the ABC APRN visits. Most patients (52%) had at least one internal referral. Most incoming referrals to the ABC APRN clinic were from the Texas Medical Center site (77%) followed by a regional campus (14%) 41 miles north of the cancer center. Discussion and Implications: People living with ABC utilize multiple resources for management of disease and treatment. Limitations include only having access to data for resource utilization at the cancer center and not resources available through the community. Additional research needs to be completed to match ABC patient needs to the type and amount of services and resources. Robust programs are needed to streamline and proactively address ABCs patient’s needs. Citation Format: Ginny Kirklin, Abbey Kaler, Akshara Singareeka Raghavendra, Bei Wang, Ashley Anderson, Cathy Harris, Isabella Masso, Debasish Tripathy. Resource Utilization by Patients Living with Advanced Breast Cancer (ABC) Who Had a Nurse Practitioner-Led Visit [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P4-06-15.

1075-P: Enhancing Care Coordination between Endocrinology and Primary Care for Type 2 Diabetes through a Statewide Quality Improvement Collaborative

2025-06-13

Jennifer J. Iyengar , KARA R. MIZOKAMI-STOUT , Lynn Ang +7 more | Diabetes

Introduction and Objective: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a statewide quality improvement (QI) initiative aimed at enhancing type 2 diabetes (T2D) care via increased continuous glucose … Introduction and Objective: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a statewide quality improvement (QI) initiative aimed at enhancing type 2 diabetes (T2D) care via increased continuous glucose monitoring (CGM), guideline-directed medical therapy, and low-carbohydrate diets, while promoting coordination and collaboration among primary care, endocrinology, and nephrology members. We assessed baseline care coordination readiness among endocrinology practices newly joining MCT2D, and improved care coordination between established MCT2D endocrinology practices and a partnering primary care practice. Methods: Five newly joined endocrinology practices completed care coordination assessments. Nineteen continuing endocrinology and partnering primary care practices implemented QI projects addressing care coordination. Project selection occurred by 6/14/2024 with completion of at least one Plan-Do-Study-Act cycle by 11/21/2024. Results: Of 19 projects, topics included improving referral processes (e.g., wait times, tracking, pre-visit testing, n=8), patient co-management (n=5), increasing CGM utilization (n=4), and discharging stable patients back to primary care (n=2). Among 11 endocrinologists across 5 unique practices completing practice assessments, 10/11 (91%) deemed the majority of T2DM referrals appropriate for specialty care. However, 8/11 (73%) of endocrinologists indicated effective care coordination occurred in fewer than half of their co-managed patients, citing time constraints, electronic medical record compatibility, and communication with out-of-system providers as key barriers. Conclusion: MCT2D successfully launched joint QI projects between endocrinology and primary care, resulting in targeted improvements in care coordination. Persistent challenges underscore the need for ongoing collaborative efforts to improve outcomes for patients with T2D. Disclosure J.J. Iyengar: None. K.R. Mizokami-Stout: None. L. Ang: None. J. Rau: None. J. Reiss: None. L.A. Young: None. J. Weisensel: Stock/Shareholder; Senseonics. K. Watson: None. H.L. Diez: None. L. Oshman: Stock/Shareholder; Procter & Gamble, Merck & Co., Inc, AbbVie Inc. R. Pop-Busui: Board Member; American Diabetes Association. Consultant; Averitas Pharma, Inc. Research Support; Bayer Pharmaceuticals, Inc. Other Relationship; Biogen. Research Support; Juvenile Diabetes Research Foundation (JDRF). Advisory Panel; Lexicon Pharmaceuticals, Inc, Novo Nordisk. Research Support; Novo Nordisk, National Institute of Diabetes and Digestive and Kidney Diseases. Consultant; Roche Diagnostics. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK13129601A1)

1321-P: Quantifying and Adjusting for Classification Uncertainty in Type 2 Diabetes Subtypes

2025-06-13

TIM MORI , Oana‐Patricia Zaharia , Klaus Straßburger +4 more | Diabetes

Introduction and Objective: Despite continued interest in type 2 diabetes subtypes, the challenge of uncertainty in the classification of individuals into subtypes remains. This study introduces a novel method for … Introduction and Objective: Despite continued interest in type 2 diabetes subtypes, the challenge of uncertainty in the classification of individuals into subtypes remains. This study introduces a novel method for quantifying and adjusting for classification uncertainty in type 2 diabetes subtypes. Methods: Building on recommendations from the ADA/EASD Precision Medicine in Diabetes Initiative, we quantified individual classification uncertainty using the normalized relative entropy (NRE), computed from distances to cluster centroids. A lower NRE value indicates greater uncertainty. We examined the NRE of 859 individuals with recent-onset type 2 diabetes from the German Diabetes Study (GDS) and compared it across previously identified diabetes subtypes, defined by age, BMI, HbA1c, HOMA-IR, and HOMA-B. Predicted 10-year cardiovascular disease (CVD) risk (SCORE2-Diabetes) of the subtypes was evaluated with and without adjustment for classification uncertainty. Results: The median NRE of individuals with type 2 diabetes (age 54±10 years, BMI 31.6±6.2 kg/m2, HbA1c 6.4±0.9%) was 0.127 (95% CI: 0.119-0.135). Individuals with mild age-related diabetes (n=395) and mild obesity-related diabetes (n=316) had a median NRE of 0.155 (95% CI: 0.142-0.177) and 0.119 (95% CI: 0.107-0.131). By contrast, individuals with severe insulin-resistant diabetes (n=130) and severe insulin-deficient diabetes (n=18) had a lower median NRE of 0.086 (95% CI: 0.075-0.108) and 0.082 (95% CI: 0.071-0.109). After adjustment, the proportion of variation in SCORE2-diabetes explained by the subtypes (R2) increased from 17.4% (95% CI: 12.8-23.0) to 31.5% (95% CI: 26.4-37.1). The predicted 10-year CVD risk of the mild age-related diabetes subtype increased from 10.3% (95% CI: 9.8-10.7) to 11.6% (95% CI: 11.2-12.0). Conclusion: Classification uncertainty varied between subtypes and individuals with type 2 diabetes, and adjusting for it improved the ability of the subtypes to predict 10-year CVD risk. Disclosure T. Mori: None. O.P. Zaharia: None. K. Strassburger: None. J.M. Dennis: None. M. Roden: Research Support; Boehringer-Ingelheim. Advisory Panel; Echosens. Speaker's Bureau; Madrigal Pharmaceuticals, Inc. Advisory Panel; MSD Life Science Foundation. Board Member; Novo Nordisk. Advisory Panel; TARGET PharmaSolutions, Inc. R. Wagner: Speaker's Bureau; Boehringer-Ingelheim, Novo Nordisk. Advisory Panel; Sanofi. Speaker's Bureau; Sanofi. Advisory Panel; Lilly Diabetes. O. Kuss: None.

1088-P: The Impact of Patient–to–Diabetes Specialist Ratio on the Quality of Diabetes Management among People with Diabetes—Data from the Saudi National Diabetes Center (SNDC)

2025-06-13

MOHAMMED AL-SOFIANI , SHAHAD Y. ALFARIS , SARA ALABDULWAHED +2 more | Diabetes

Introduction and Objective: The Middle East and North Africa region has the highest regional prevalence of diabetes & diabetes-related deaths in people of working age. There is limited data examining … Introduction and Objective: The Middle East and North Africa region has the highest regional prevalence of diabetes & diabetes-related deaths in people of working age. There is limited data examining the impact of such high prevalence of diabetes on the quality of diabetes management provided at specialized diabetes centers Methods: Data from 27 diabetes centers, serving 330,066 people with diabetes (PWD), across 20 cities/towns in Saudi were examined as part of the Saudi National Diabetes Center (SNDC) audit. These centers represent 83% of the public diabetes centers across four major health sectors in Saudi. We examined the association between the patient-to-diabetes specialist ratio and quality of diabetes management at each sector. Metrics of quality of diabetes management included: proportion of PWD who had A1C ≤7%, blood pressure (BP) ≤140/80, and routine retinal and urinary albumin-creatinine ratio/eGFR exams during the past year. Diabetes specialists included: adult/pediatric endocrinologists and diabetologists Results: Diabetes centers in Saudi are overwhelmed by the staggering burden of diabetes with an average “patient-to-diabetes specialist” ratio in the four health sectors of 1100:1. Health sector “D” had the lowest patient-to-diabetes specialist ratio (206:1) and highest proportion of PWD meeting the A1C, BP, and annual retinal exam targets (70%, 90%, and 87%, respectively). Whereas health sector “A” had the highest patient-to-diabetes specialist ratio (2282:1) and lowest proportion of PWD meeting the A1C, BP, and annual retinal exam targets (33%, 60%, and 63% respectively) Conclusion: The high ratio of patients to diabetes specialists at specialized diabetes centers negatively impacts the quality of diabetes management and adherence to essential screening tests. The current high burden of diabetes and shortage of diabetes specialists in Saudi Arabia necessitate urgent interventions Disclosure M. Al-Sofiani: Advisory Panel; Medtronic. Speaker's Bureau; Insulet Corporation, Abbott, Lilly Diabetes. Advisory Panel; Dexcom, Inc., Roche Diabetes Care. Speaker's Bureau; Sanofi. Research Support; Medtronic. Speaker's Bureau; Vitalaire. S.Y. Alfaris: None. S. Alabdulwahed: None. M.S. Aljedaie: None. A.M. Alenzi: None.

693-P: Acceptability of Vasoterapia Diabetes—A Novel Tool to Support Mental Health and Peer Connection among Health Care Providers in Diabetes Care

2025-06-13

D. Camargo Rojas , Katherine Barnard-Kelly | Diabetes

Introduction and Objective: Healthcare providers (HCPs) working with people with diabetes experience significant burnout. Vasoterapia, a card game tool, was developed with experts in diabetes and psychology to enhance HCPs' … Introduction and Objective: Healthcare providers (HCPs) working with people with diabetes experience significant burnout. Vasoterapia, a card game tool, was developed with experts in diabetes and psychology to enhance HCPs' peer connections and well-being. This study evaluates the acceptability and usefulness of integrating this intervention into clinical practice. Methods: After a focus group, an online ad hoc Likert survey was completed to evaluate the tool's acceptability and perceived benefits. The survey reflected emotions, physical sensations, and specific benefits experienced during the session and their influence on prioritizing mental health. Descriptive analyses were performed. Results: A total of 68 HCPs participated (83.8% female, 16,2% male), 79.4% Latin, 16.2% Caucasian, and 4.4% others. Professions included 57.4% pediatric endocrinologists, 14.7% dietitians, 10.3% nurses, and 1.5% psychologists. Among participants, 26.9% found the tool "very helpful," 7.5% described it as "extremely helpful," and 28.4% found it "moderately helpful." Only 7.5% indicated "no impact at all." A total of 33% rated their mental health as poor/very poor, and 30% experienced anxiety related to work "almost always or always." Furthermore, 78% reported their professional performance had decreased due to mental health challenges, and 57% stated their work negatively impacted their relationships. Suggestions for improvement included a digital format, offering case study examples, and having follow-up sessions after use in clinical practice. Conclusion: Participants reported that using the tool would enhance their understanding of what to bring to patient visits and potentially impact performance. Modifications can be made to increase its effectiveness. These findings highlight the importance of integrating innovative mental health solutions into clinical practice. Disclosure D. Rojas: None. K. Barnard-Kelly: Speaker's Bureau; Roche Diabetes Care, Sanofi. Stock/Shareholder; Spotlight-AQ Ltd, BHR Ltd.

606-P: Addressing Diabetes Distress in Clinical Practice—Provider Feedback and Resource Gaps following Screening Implementation

2025-06-13

Jennifer J. Iyengar , HAYLEY CENTOLA , David T. Broome +7 more | Diabetes

Introduction and Objective: While diabetes-related distress is common, healthcare systems may lack resources for adequately addressing this aspect of diabetes care. As part of a quality improvement initiative, we surveyed … Introduction and Objective: While diabetes-related distress is common, healthcare systems may lack resources for adequately addressing this aspect of diabetes care. As part of a quality improvement initiative, we surveyed providers after implementation of annual diabetes distress (DD) screening for persons with Type 1 diabetes (PwT1D) in an academic center with the goal of better understanding how to best address DD in clinical practice. Methods: PwT1D were assigned the Type 1 Diabetes Distress Assessment System (T1DDAS) core scale prior to their adult endocrinology visits with results visible to providers in the electronic medical record during the clinical encounter. Providers were surveyed 1-year after screening implementation. Results: Between December 2023-2024, 2,081 T1DDAS questionnaires were completed by 1,852 unique patients out of 2,452 eligible patients (75.5%). The average score was 1.84±0.88 with 22.9% (n=477) reporting moderate (2.0-2.9) and 12.9% (n=268) reporting high (&gt;3.0) distress. Sixteen of 42 providers responded (38%) to the post-implementation survey. While 15 (94%) agreed that DD is an important to address, only 11 (69%) felt confident in their ability to identify DD, and 3 (19%) were satisfied with the resources currently available to address DD. The most common barriers were limited clinic time (56%), inadequate resources (56%), and insufficient training (31%). Providers identified social work referrals, an embedded psychologist, and handouts with local mental health resources as the most helpful supports for patients with DD. Conclusion: Over one-third of PwT1D in our clinic reported moderate to high diabetes distress (DD), emphasizing the need for strategies to address elevated DD scores. Providers recognize the importance of addressing DD but express dissatisfaction with available resources. These findings will guide future Plan-Do-Check-Act cycles to improve support for PwT1D experiencing DD. Disclosure J.J. Iyengar: None. H. Centola: None. D. Broome: Research Support; Fractyl Health, Inc., Sanofi, T1D Exchange, Rhythm Pharmaceuticals, Inc, Novo Nordisk. K.R. Mizokami-Stout: None. L. Ang: None. J. Lee: None. J. Wyckoff: None. B. Mezuk: None. S. Soleimanpour: Research Support; Ono Pharmaceutical Co., Ltd. J.M. Lee: Advisory Panel; GoodRx. Funding Michigan Nutrition Obesity Research Center (P30DK089503), Michigan Diabetes Research Center (P30DK020572), Michigan Center for Diabetes Translational Research (P30DK092926), the Elizabeth Weiser Caswell Diabetes Institute, and the Breakthrough T1D Center of Excellence at the University of Michigan.

146-OR: Understanding Early Disease Trajectories and Their Relationship to Microvascular Complications

2025-06-13

Sweta Singla , SHUBHASHREE M. PATIL , Anuj Maheshwari +1 more | Diabetes

Introduction and Objective: Understanding early disease trajectories and their relationship to microvascular complications remains crucial in type 2 diabetes mellitus (T2DM). We employed machine learning to identify critical intervention windows … Introduction and Objective: Understanding early disease trajectories and their relationship to microvascular complications remains crucial in type 2 diabetes mellitus (T2DM). We employed machine learning to identify critical intervention windows and predictive patterns of microvascular complications. Methods: Machine learning analysis of 591 T2DM patients, focusing on disease discovery patterns, peripheral vascular status, and complication rates. Neural network modeling was used to identify temporal relationships between early disease markers and complication development. Primary outcomes included peripheral pulse status, retinopathy, and foot abnormalities across age groups. Results: AI analysis revealed three critical findings: 1) A significant "vascular preservation window" in early disease (peripheral pulses well felt: 95.5% in &lt;40 years vs 83.5% in &gt;50 years, p&lt;0.001), 2) Early diagnosis patterns showed distinct clustering (26.1% diagnosed "today," with age-specific variations: 30.8% in &lt;40, 19.5% in 41-50, 26.3% in &gt;50 years), and 3) Novel "complication vulnerability phases" identified through machine learning, with the first phase occurring at 2.3±0.4 years post-diagnosis. Notably, liver function abnormalities showed age-specific patterns (ALT elevation: 25.0% overall, with significant age-group variations, p=0.013), emerging as an early marker for complication risk (OR: 1.9, 95% CI: 1.4-2.5). Conclusion: Our AI-driven analysis identifies a critical "vascular preservation window" and specific "complication vulnerability phases" in T2DM progression. These findings suggest optimal timing for aggressive intervention, particularly in patients diagnosed before age 40, and highlight liver function as a novel early marker for complication risk. This temporal framework provides new opportunities for precision-timed interventions in T2DM management. Disclosure S.K. Singla: None. S.M. Patil: None. A. Maheshwari: None. A.A. Shaikh: None.

1367-P: Clinical Relevance of Proposed Type 2 Diabetes Subgroups in Tertiary Care—A SwissDiab Study

2025-06-13

Michael Braendle | Diabetes

Introduction and Objective: An approach to classify patients with type 2 diabetes (T2D) into four different subgroups (severe insulin-deficient [SIDD], severe insulin-resistant [SIRD], mild obesity-related [MOD], and mild age-related [MARD] … Introduction and Objective: An approach to classify patients with type 2 diabetes (T2D) into four different subgroups (severe insulin-deficient [SIDD], severe insulin-resistant [SIRD], mild obesity-related [MOD], and mild age-related [MARD] diabetes) with different disease progression was recently proposed. The relevance of the proposed cluster algorithm among patients with longer-term diabetes in the tertiary care setting remains unclear. The aim of this study was to determine whether a simplified version of the clustering algorithm could successfully cluster outpatients with T2D in tertiary care. Methods: The study included patients with T2D enrolled in the Swiss Diabetes Registry. They were assigned to clusters based on age at diagnosis, BMI, and HbA1c at their first study visit. These variables were scaled and centered, and the Euclidean distance to each of the four clusters was calculated by summing the absolute differences between the scaled patient values and the center coordinates defined by Ahlqvist et al. Patients were assigned to the cluster with the smallest Euclidean distance. A Euclidean ratio &gt;0.8 indicates a bad cluster fit. Results: Among the 772 patients with available data, the distribution of clusters was as follows: SIDD, 18.1%; SIRD, 23.3%; MOD, 21.0%; MARD, 37.6%. The median (IQR) Euclidean ratio was 0.68 (0.55, 0.84), and 31.6% of the patients had a value &gt;0.8. Glycemic control was worse in SIDD, BMI was highest in SIRD and MOD, and age of onset was highest in SIRD and MARD and lowest in MOD. Microvascular complications were lowest in MARD and highest in SIDD. Insulin therapy was most common in SIDD (82.9%), and lowest in MARD (50.0%). Conclusion: Overall, the results are in line with the original study and replication efforts. However, one-third of patients had a bad cluster fit. This shows that the simplified clustering algorithm can group patients in tertiary care, but it needs improvements before it can be used regularly in clinical practice to guide diabetes care. Disclosure M. Braendle: Advisory Panel; AstraZeneca, Boehringer-Ingelheim, Novo Nordisk. Speaker's Bureau; Novartis Pharmaceuticals Corporation.

1142-P: Training and Technical Assistance to Support FQHCs in Implementing Diabetes Distress Screening

2025-06-13

ABIGAIL DURGAN , Erin M. Staab , Holly Wing +6 more | Diabetes

Introduction and Objective: Diabetes distress (DD), the emotional burden of managing diabetes, is linked to poor glycemic outcomes, especially for marginalized populations. Few Federally Qualified Health Centers (FQHCs) have adopted … Introduction and Objective: Diabetes distress (DD), the emotional burden of managing diabetes, is linked to poor glycemic outcomes, especially for marginalized populations. Few Federally Qualified Health Centers (FQHCs) have adopted systematic screening for DD. This program aimed to train and provide technical assistance (TA) to 2 FQHCs to integrate DD screening and intervention into clinical workflow for adults with type 2 diabetes. Methods: FQHC staff attended 4 biweekly Learning Session (LS) webinars about DD. The study team shared worksheets and feedback to guide teams’ implementation plans. Staff answered a short survey after each LS. During implementation, the study team held 4 monthly TA webinars: staff shared implementation updates and troubleshot issues. After implementation, staff were interviewed about implementation experiences, training gaps, and how to improve sustainability. Results: Both FQHC implementation teams were multidisciplinary (e.g., quality improvement, physicians, behavioral health). Respondents were satisfied (96%, n = 25/26) with the LS, and strongly agreed or agreed (96%, n = 27/28) that the LS clarified DD in clinical context. Staff shared in interviews and during TA webinars that the breakout discussion time during webinars was useful, due to the busy nature of their typical work duties and difficulty scheduling dedicated time to plan their intervention workflow. Both FQHCs had staff turnover, and the study team held extra training meetings as needed to support ongoing implementation. Conclusion: This study is the first specifically developed to support FQHCs with implementing DD screening and intervention. Results support the initial feasibility and acceptability of the program. Lessons will be integrated into future training to support DD screening and intervention at FQHCs. Disclosure A. Durgan: None. E.M. Staab: None. H. Wing: None. C.D. Kasir: None. C. Cochran: None. A. Campbell: None. C.T. Schaefer: None. D.M. Hessler: None. A.A. Baig: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK133603-01A1)

741-P: Impact of Virtual Patient Simulation on Improving T2D Treatment Intensification by PCPs

2025-06-13

AMY LARKIN , ASHWIN PRASANNA , Anne Le | Diabetes

Introduction and Objective: This study examines the impact of an online, virtual patient simulation (VPS)-based continuing medical education (CME) activity as part of a larger curriculum on PCP treatment intensification … Introduction and Objective: This study examines the impact of an online, virtual patient simulation (VPS)-based continuing medical education (CME) activity as part of a larger curriculum on PCP treatment intensification in people with uncontrolled T2D. Methods: The intervention was two different patient scenarios in a VPS open ended platform. Tailored clinical guidance (CG), based on guidelines followed each decision, with ability to modify to decisions. Decisions were collected post-CG and compared with each user’s baseline (pre-CG) decisions using a McNemar’s test to determine P values. The activity posted January 2024 and data were collected through April 2024. Results: 653 completed case 1 and 497 completed case 2. Case 1: 45 YO with T2D x 1 year (HbA1c 8.5%). Screening/monitoring: 24% improvement (P&lt;.001; baseline 44%). Recognizing uncontrolled T2D: 46% improvement (P&lt;.001; baseline 1%). Guideline-based treatment: 27% improvement (P&lt;.01; baseline 46%). Comprehensive treatment: 49% absolute improvement (P&lt;.001; baseline 15%). Case 2: 58 YO with T2D, obesity, and CVD. Screening/monitoring: 14% improvement (P&lt;.001; baseline 68%). Recognizing uncontrolled T2D: 38% improvement (P&lt;.001; baseline 9%). Guideline-based treatment: 27% improvement (P&lt;.01; baseline 46%). Comprehensive treatment: 39% improvement (P&lt;.001; baseline 21%). Rationales for ordering GLP-1-based therapy: patient profile (55%) and efficacy (49%). Rationales for NOT ordering GLP-1-based therapy: cost (38%) and unfamiliar with use (23%). Gaps: 53% of PCPs don't recognize uncontrolled T2D, which can lead to clinical inertia. 38% of PCPs need improved skills on use of GLP-1-based therapies. Conclusion: VPS that engages PCPs in a practical learning experience can improve evidence-based clinical decisions related to recognizing and treating uncontrolled T2D. While the simulation was successful at improving guideline-based care, the largest persistent gaps were related to recognition of uncontrolled T2D. Disclosure A. Larkin: None. A. Prasanna: None. A. Le: None. Funding Independent educational grant from Lilly

52-PUB: The Medical Status of Patients with Diabetes in Guangdong Province

2025-06-13

XUANRONG CHEN , YANLING YANG , Wei Jiang +2 more | Diabetes

Introduction and Objective: To assess metabolic profiles and medication prescription patterns in patients with diabetes in Guangdong province. Methods: Data of 1621 patients with diabetes in Guangdong province were collected … Introduction and Objective: To assess metabolic profiles and medication prescription patterns in patients with diabetes in Guangdong province. Methods: Data of 1621 patients with diabetes in Guangdong province were collected from the China National Diabetic Chronic Complications Survey conducted between March 2018 and January 2020. Questionnaires for medical history and blood tests for metabolic indices were collected. Results: The patients characteristics included: males 47.6%, urban residents 51.1%, medium diabetes duration 6.5 years, average BMI 24.8 kg/m², and average HbA1c 7.1%. The prevalences of hypertension and dyslipidemia were 55.5% and 92.7%, respectively, with the corresponding awarenesses of 37.9% and 23.3%. 79.6% of the patients received diabetes medications, with 48.2% on monotherapy. Only 42.6% of the patients met the glycemic target. The status of the prescriptions of hypoglycemic agents were shown in Figure 1. 59.1% of the patients with hypertension and 8.7% of the patients with dyslipidemia were on medical treatments, with 16.7% and 7.1% of the patients met the targets of blood pressure and lipid profiles. Among all the patients, only 1.7% of the patients achieved all the targets of blood glucose, blood pressure and lipid profiles. Conclusion: The control rates of medical disorders in patients with diabetes in Guangdong were still very low. Promising strategies to improve this status should be implemented. Disclosure X. Chen: None. Y. Yang: None. W. Jiang: None. W. Xu: None. L. Zeng: None.

552-P: Increasing Access to Diabetes Self-Management Support (DSMS) Programs via Electronic Health Record (EHR)–Based Clinical- (CDST) and Patient-Decision Support Tools (PDST)

2025-06-13

Michelle Stancil , Windsor Westbrook Sherrill , ABIGAIL DIBLIN +2 more | Diabetes

Introduction and Objective: Approximately 556,000 adults in the state of South Carolina live with diabetes and only 50% have participated in a diabetes self-management/support class. Community-based DSMS programs improve participant's … Introduction and Objective: Approximately 556,000 adults in the state of South Carolina live with diabetes and only 50% have participated in a diabetes self-management/support class. Community-based DSMS programs improve participant's A1C values, nutrition and physical activity behaviors, and diabetes knowledge. With ADA funding, Clemson University partnered with Prisma Health, the largest health system in the state, to create CDST/PDST to increase awareness and referrals to Health Extension for Diabetes (HED), a DSMS program. Methods: Two CDSTs were created: an EPIC SmartPhrase (.HEDREF) and a DSMES (Diabetes Self-Management Education and Support) referral order set which was modified to include HED. Inclusion criteria given to providers included: a diagnosis of Type 1 or Type 2 diabetes and being 18 years of age or older. Exclusion criteria included: pregnancy, end-stage renal disease, or patient not overseeing their own care plan. Healthfeed, the PDST created, displayed a banner with a program summary and sign-up link in the EHR MyChart of adults with Type 1 or 2 diabetes. Results: Since its creation in June of 2022, HEDREF has resulted in 1,888 referrals to the HED program. Since January 2024, the referral order set has resulted in 120 referrals. Healthfeed was activated in English from January to March 2024 and resulted in 2,325 patient interaction interest “clicks”. From September through December 2024, the Spanish Healthfeed banner resulted in 44 “clicks”. Conclusion: The EHR SmartPhrase tool was the most successful at increasing referrals to the diabetes management and support program. Nevertheless, adults with diabetes in the health system are largely unengaged by these decision support tools. Future efforts should focus on identifying more effective referral mechanisms and increasing the participation of underserved populations. Disclosure M.D. Stancil: None. W.W. Sherrill: None. A. Diblin: None. A. Pulido: None. J.H. Evatt: None. Funding American Diabetes Association (11-22ICTSN-04)

641-P: “Feeling secure is important to me, but I just don't… most of the time”—Patient Definitions of Success in Diabetes Management

2025-06-13

CHRISTOPHER A.N.A. OKINE , Alejandro Rodríguez-Putnam , Kara Mannor +2 more | Diabetes

Introduction and Objective: Healthcare systems focus diabetes management on clinical metrics (e.g., A1c). However, people with diabetes (PWD) may evaluate diabetes care in more complex ways. This mixed methods study … Introduction and Objective: Healthcare systems focus diabetes management on clinical metrics (e.g., A1c). However, people with diabetes (PWD) may evaluate diabetes care in more complex ways. This mixed methods study explores patient definitions of success in diabetes management within a diverse sample of PWD. Methods: Forty adults with type 1, type 2 or gestational diabetes were selected using maximum variation sampling based on their responses to a larger (n=573) quantitative study of PWD. Semi-structured 1:1 interviews assessed beliefs and experiences regarding psychosocial aspects of diabetes care. Thematic analysis was used to explore patient definitions of success in diabetes management. Results: Participant characteristics (mean age: 49 (SD: 16), 60% female, 58% non-hispanic white; A1c range: 4.7%-12.0%, PAID-11 range: 0-39). Preliminarily, emerging success-related themes included: (1) blood sugar (“I get up in the morning and the first thing I do is I check with my CGM, my blood sugar, kind of see what's going on.”); (2) feeling secure (“Feeling secure is important to me, which I don't.... around diabetes, so I can live semi-normally, but I just don't feel secure most of the time.”); (3) mental health (“I think it's important to have good counseling to keep you focused. Seeing an actual therapist about it.”); (4) and supportive relationships with providers ( “The most important to me is the communication between me and my diabetes team⋯ I've gone through so many doctors that don't actually care about the patient.”) Conclusion: While participants valued clinical measures, they defined success more broadly. Addressing these aspects when setting goals can enhance patient-centered diabetes care. Disclosure C.A. Okine: None. A.A. Rodriguez-Putnam: None. K.M. Mannor: None. D. LaQueen: None. B. Mezuk: None.

1090-P: Achievement of Guideline-Directed Diabetes Management in Patients Treated by Cardiologists vs. Endocrinologists after Myocardial Infarction—A Nationwide Population-Based Study

2025-06-13

Hyun Ju Yoon , Y. Seo | Diabetes

Introduction and Objective: We evaluated comprehensive diabetes management in patients treated by cardiologists vs. endocrinologists after MI and compared achievement of guideline recommendations. Methods: Data on Korean adults who were … Introduction and Objective: We evaluated comprehensive diabetes management in patients treated by cardiologists vs. endocrinologists after MI and compared achievement of guideline recommendations. Methods: Data on Korean adults who were diagnosed with first MI between 2008 and 2017 and received diabetes management from either endocrinologists or cardiologists through December 2022 were analyzed. Outpatient visits at least once per quarter, HbA1c test at least twice a year, nephropathy screening at least once a year, retinopathy screening at least once per two years, and use of SGLT2i and GLP1 RA were defined as a guideline-directed therapy. Results: We analyzed 19169 patients who were managed by endocrinologists and 26756 by cardiologists. Patients treated by endocrinologists had a greater achievement of outpatients visits (82.5% vs. 67.0%, P&lt;0.001), HbA1c test, (23.2% vs. 8.8%, P&lt;0.001), GFR test (63.5% vs. 41.9%, P&lt;0.001), proteinuria test (29.1% vs. 21.1%, P&lt;0.001), microalbuminuria test (4.7% vs. 1.5%, P&lt;0.001), retinopathy test (24.6% vs. 11.7%, P&lt;0.001), and GLP1 RA use (4.8% vs. 1.1%, P&lt;0.001) than those treated by cardiologists (Table). Conclusion: Achievement of guideline-directed diabetes management after MI was higher in patients treated by endocrinologists than in those treated by cardiologists. Disclosure H. Yoon: None. Y. Seo: None.

742-P: Impact of Virtual Patient Simulation on Improving T2D Diagnosis and Management

2025-06-13

Amy Larkin , Mario E. Lacouture , Anne Le | Diabetes

Introduction and Objective: This study examines the impact of online, virtual patient simulation (VPS)-based continuing medical education (CME) on performance related to diagnosis and management of T2D by diabetologists/endocrinologists (D/Es) … Introduction and Objective: This study examines the impact of online, virtual patient simulation (VPS)-based continuing medical education (CME) on performance related to diagnosis and management of T2D by diabetologists/endocrinologists (D/Es) and primary care physicians (PCPs). Methods: Intervention was 2 patient scenarios presenting in a VPS. Clinical guidance (CG) based on evidence was provided following each decision, followed by the opportunity to modify the decision. Decisions were collected post-CG and compared with each user’s baseline (pre-CG) using a McNemar’s test to determine P values. Data collected January-April 2024. Results: 37 D/Es and 303 PCPs were included. Case 1: 45 YO male with T2D with fatigue, shaking, sweating, and weight gain. D/Es: Diagnose uncontrolled T2D: 27% absolute improvement (P&lt;.01; baseline 38%), Guideline-based treatment: 27% absolute improvement (P&lt;.01; baseline 46%), PCPs: Diagnose uncontrolled T2D: 27% absolute improvement (P&lt;.001; baseline 32%), Guideline-based treatment: 30% absolute improvement (P&lt;.001; baseline 21%). Case 2: 50 YO woman with mild fatigue D/Es: Diagnose T2D: 45% absolute improvement (P&lt;.001; baseline 17%) Guideline-based treatment: 38% absolute improvement (P&lt;.001; baseline 33%). PCPs: Diagnose T2D: 44% absolute improvement (P&lt;.001; baseline 18%) Guideline-based treatment: 25% absolute improvement (P&lt;.001; baseline 22%). Top Rationales for Prescribing GLP-1 RAs were guidelines: (40%) and efficacy (37%). Top Rationales for NOT Prescribing GLP-1 RAs were Cost (14%) and Unfamiliar with use (11%). Continued Gaps: 50% of PCPs and 30% D/Es failed to select guideline-recommended treatment, with biggest gaps in case 2 (patient with newly diagnosed T2D), demonstrating a need for additional education on first-line treatment. Conclusion: VPS can improve evidence-based clinical decisions by D/Es and PCPs related to diagnosis and management of T2D. Continued gaps were identified for future educational initiatives. Disclosure A. Larkin: None. M. LaCouture: None. A. Le: None. Funding Independent educational grant from Novo Nordisk.

1099-P: Diabetes Device Reminders to Increase Data for Patient Appointments

2025-06-13

MELANIE HUNT , Roma Gianchandani , S. Masih +1 more | Diabetes

Introduction and Objective: Blood glucose data is crucial for adjusting and optimizing diabetes treatment. When patients do not bring diabetes devices to appointments, the lack of actionable data is a … Introduction and Objective: Blood glucose data is crucial for adjusting and optimizing diabetes treatment. When patients do not bring diabetes devices to appointments, the lack of actionable data is a significant barrier. Data impacts treatment decisions and empowers patients in diabetes self-management. At our diabetes outpatient center, &lt; 70% of patients brought devices to appointments despite being sent reminders via the electronic health record (EHR) portal. We prioritized increasing this number to ≥ 80% within 12 months. Methods: EHR messaging was found to be ineffective and burdensome for staff tasked with sending device reminders. To see messages, patients must log in to the portal, and this extra step led to many unread messages. Direct text messaging was presumed more convenient, therefore Artera (an EHR-integrated secure text messaging system) was implemented. With integrated clinic schedules and customized message templates, staff send device reminders in Artera with minimal clicks. Data were extracted for 277 patients (non-Bluetooth device users) for 12 months. Results: Pre-intervention, 68.1% of patients brought devices to appointments, which increased to 81.7% post-intervention (13.6%; p =.0092). Conclusion: Artera messaging significantly increased the number of patients bringing devices to appointments, enhancing diabetes care and reducing staff burden. Future endeavors include sustaining this success. Disclosure M. Hunt: None. R. Gianchandani: None. S.R. Masih: None. J.R. Spalding-Jackson: None.

498-P: A Patient Navigator Program for Post-discharge Diabetic Foot Care

2025-06-13

JESICA FLORES , K. Walkiria Zamudio-Coronado , MARCOS C. SCHECHTER +4 more | Diabetes

Introduction and Objective: Diabetic foot ulcer (DFUs) are a major cause of hospitalizations, yet post-discharge care coordination remains suboptimal. Effective care organization among specialists is crucial for limb salvage. Patient … Introduction and Objective: Diabetic foot ulcer (DFUs) are a major cause of hospitalizations, yet post-discharge care coordination remains suboptimal. Effective care organization among specialists is crucial for limb salvage. Patient navigators are an effective model for chronic disease management, but their impact on DFU care is understudied. Here, we evaluated the use of certified diabetes care and education specialist (CDCES) to improve post-hospitalization DFU care. Methods: We conducted this study at a safety-net hospital in Atlanta, GA where the historical 30-day post-hospital discharge outpatient clinic attendance rate among patients with DFUs is 55%. In December 2023, we enrolled participants hospitalized with DFUs and assigned them a CDCES who conducted weekly calls for 4 weeks. These calls consisted of diabetes management, outpatient care coordination, appointment reminders, and addressing DFU-related concerns. Results: Twelve participants were enrolled. The median (IQR) age was 53 (42-59) years; 8 (73%) were male and 8 (73%) identified as non-Hispanic Black. The median (IQR) baseline HbA1c was 8.2% (7.7-11.1). Diabetes distress scores were high [median (IQR): 2.9 (1.7-3.2)]. All participants attended a DFU-related outpatient visit within 30 days post-hospital discharge. Ten of the 12 participants used a CDCES intervention aside from appointment reminders, including setting up transportation (n=1), wound care plan clarification (n=1), antibiotic adverse effect management (n=1), rescheduling appointments (n=3), severe hyper/hypoglycemia management (n=2), and insulin education and dose - modification (n=6). Conclusion: A CDCES-led patient navigator program was associated with substantial improvement in 30 days post-discharge clinic attendance rates for patients hospitalized with DFUs and the CDCES provided comprehensive care, addressing multiple aspects of diabetes and wound management. Ongoing work will determine if this intervention improves DFU healing. Disclosure J. Flores: None. K. Zamudio-Coronado: None. M.C. Schechter: None. M. Fayfman: Research Support; Abbott, Dexcom, Inc. N.Y. Chaudhry: None. N. Soleimanmanesh: None. I.C. Flores: None.

Exploration of the role of health information managers in the world of clinical registries

2025-06-13

Catherine Burns , Ailie Sanders , Merilyn Riley +2 more | PubMed

Background: There is increased demand for health information managers (HIMs) to work at clinical registries. Objective: To explore and describe the (i) roles and responsibilities of HIMs and (ii) reported … Background: There is increased demand for health information managers (HIMs) to work at clinical registries. Objective: To explore and describe the (i) roles and responsibilities of HIMs and (ii) reported HIM workforce within Australian clinical registries. Method: Two cross-sectional surveys were undertaken with qualified HIMs and data custodians. Respondents were engaged through snowballing methods. Descriptive statistics were used to summarise quantitative data from both surveys. Inductive thematic analysis was used to summarise free-text responses. Results: Sixteen HIMs completed the survey (94% female; 50% aged <40 years; median 8 years post-graduation). The majority reported varied roles and responsibilities which spanned most of the domains of the profession, particularly tasks related to data and database management (81%), and data analysis and reporting (81%). Some HIMs are under-utilised, identifying that they would be more satisfied in their role if they could “ use more of [their] health information management skills .” From 27 responses to the data custodian survey, 12 employed HIMs and demonstrated a good understanding of their skills, which aligned with responses to the HIM survey. There was a gap identified in database management and analysis skills (n = 4) at clinical registries that do not employ HIMs. Conclusion: HIMs play an important role within clinical registries, especially related to data management, analysis and reporting. Ongoing advocacy is required to increase the understanding of HIMs’ skills and to increase the responsibilities and number of HIMs working at clinical registries. Implications for health information management practice: HIMs are well-positioned to contribute to Australian clinical registries.

Refining the Quality Indicator Set from the Dutch Audit for Treatment of Obesity to Ensure Usefulness in Clinical Practice

2025-06-12

Floris F. E. Bruinsma , Simon W. Nienhuijs , Ronald S. L. Liem +2 more | Obesity Surgery

Improving Health Service Delivery: Using Patient Pathway Analytics for Person-Centered Health System Assessments - Volume 2: An Introduction to Patient Pathway Analysis and Practical Examples from the Field and Published Literature

2025-06-12

Ahmad Hegazi , Judith Watson , Paul Ouma +2 more | Washington, DC: World Bank eBooks

Letter to the Editor “Comment on Tilson JK, Martinez C, Mickan S, Et Al. Understanding Behavior Change in Clinical Practice Guideline Implementation: A Qualitative Study” [J Neurol Phys Ther. 2025;49(1):13-23]

2025-06-12

Annie Tapp | Journal of Neurologic Physical Therapy

Delays in Medical Care: A Systematic Review of Determinants, Consequences and Interventions

2025-06-11

N Daniel , MOSSUS Tatiana , M. CHRISTIAN +2 more | SAS Journal of Medicine

Background: Delays in medical care represent a significant public health challenge with substantial impacts on morbidity, mortality, and healthcare costs. These delays can occur at various stages of the care … Background: Delays in medical care represent a significant public health challenge with substantial impacts on morbidity, mortality, and healthcare costs. These delays can occur at various stages of the care pathway, from symptom recognition by patients to treatment initiation. This systematic review aims to synthesize current evidence on the determinants, consequences, and interventions to reduce these delays through rigorous analysis of published studies. Materials and methods: A comprehensive search was conducted in PubMed, Embase, and Cochrane Library databases for studies published between January 2000 and December 2023. Search strategies combined MeSH terms and keywords: "delays in care," "access to care," "diagnosis," "treatment," and "interventions." Included studies were observational or interventional studies evaluating delayed care in adult patients with quantitative data on delays or consequences. Case studies, literature reviews, and in vitro studies were excluded. Methodological quality was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias Tool for interventional studies. Data extracted included study characteristics, delay determinants, consequences, and interventions. Meta-analyses were performed where appropriate using random-effects models. Results: Multiple factors influence delays in care. For instance, patients in rural areas experienced average delays 2.5 days longer for cardiac symptom consultation compared to urban residents. Patients with lower education levels were 1.8 times more likely to delay consultation for suspected cancer. Regarding consequences, meta-analysis revealed that each day of delay in stroke treatment increased death or disability risk by 5%. Interventions showed promise: patient education programs reduced cardiac symptom consultation delays by 30%, while telemedicine systems decreased specialist referral time for suspected cancer by 20%. Conclusion: Delayed medical care repr

[Watch-and-Wait strategy : the treatment for all rectal cancers?]

2025-06-11

Tiago G. Santos , Dieter Hahnloser , Fabian Grass +2 more | PubMed

The treatment of rectal cancer has evolved dramatically in recent years. Today, specialists have more options to choose from, ranging from primary surgical resection with or without neoadjuvant treatment to … The treatment of rectal cancer has evolved dramatically in recent years. Today, specialists have more options to choose from, ranging from primary surgical resection with or without neoadjuvant treatment to an organ-preserving strategy (such as Watch-and-Wait) after total neoadjuvant treatment. The aim of this article is to review the advantages, limits, and risks of the Watch-and-Wait strategy for the treatment of rectal cancer.