Although Canadian best practice recommendations regarding assessment and management of poststroke depression (PSD) have been established, the degree to which these evidence-based guidelines have been translated into practice is not known. The objectives of the present study are to compare current and recommended best practice and examine possible reasons for identified care gaps.
Practice audit by chart review was performed to identify recorded screening, assessment, and treatment for PSD in patients discharged from a specialized inpatient rehabilitation program over a 6-month period. A questionnaire was administered to all clinical staff addressing current screening practices as well as opinions regarding the importance and feasibility of identification and treatment of PSD.
Of 123 patients, 40 (32.5%) had been prescribed antidepressants at discharge. However, evidence of screening was found for 4.9% of patients; another 9.8% were referred for psychological consult. Treatment was associated with previous antidepressant use or history of depression, but not screening or assessment. Of the survey respondents, 56.2% were not aware of best practice recommendations. However, most felt screening and assessment to be important and treatment was regarded as both simple and effective.
Despite potential benefit associated with identification and treatment of PSD and the availability of evidence-based best practice recommendations, PSD may remain unrecognized and undertreated. Given the juxtaposition of perceived importance with the lack of documented best practice, education regarding standardized screening and the development of consistent clinical protocols including roles and responsibilities in the identification, diagnosis, and treatment of PSD are underway.
Cancer screening guidelines reflect the costs and benefits of population-based screening based on evidence from clinical trials. While most of the existing literature on compliance with cancer screening guidelines only measures raw screening rates in the target age groups, we used a novel approach to estimate degree of guideline compliance across Canadian provinces for breast, colorectal and prostate cancer screening. Measuring compliance as the change in age-specific screening rates at the guideline-recommended initiation age (50), we generally found screening patterns across Canadian provinces that were not consistent with guideline compliance.
We calculated age-cancer-specific screening rates for ages 40-60 using the Canadian Community Health Survey (2003 and 2005), a cross-sectional, nationally representative survey of health status, health care utilization and health determinants in the Canadian population. We estimated the degree of compliance using logistic regression to measure the change in adjusted screening rates at the guideline-recommended initiation age for each province in the sample.
For breast cancer, after adjusting for age trends and other covariates, being above age 50 in Quebec increased the probability of being screened by 19 percentage points, from an average screening rate of 24% among 40-49 year olds. None of the other regions exhibited a statistically significant change in screening rates at age 50. Additional analyses indicated that these patterns reflect asymptomatic screening and that Quebec's breast cancer screening program enhanced the degree of guideline compliance in that province. Colorectal cancer screening practice was consistent with guidelines only in Saskatchewan, as screening rates increased at age 50 by 12 percentage points, from an average rate of 6% among 40-49 year olds. For prostate cancer, the regions examined here are not compliant with Canadian guidelines since screening rates were quite high, and there was not a discrete increase at any particular age.
Screening practice for breast, colorectal and prostate cancer was generally not consistent with Canadian clinical guidelines. Quebec (breast) and Saskatchewan (colorectal) were exceptions to this, and the impact of Quebec's breast cancer screening program suggests a role for policy in improving screening guideline compliance.
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Complete following existing guidelines for management of acute coronary syndrome (ACS) is known to be associated with better outcomes. Partly this is explained by lesser adherence to recommendations in high risk patients. Aim of our study was to assess relationship between degree of following current guidelines and in hospital outcomes independently from initial assessment of risk.
Each key recommendation from guidelines issued between 2008 and 2011 (13 for STE ACS, 12 for NSTE ACS) was given weight of 1. Sum of these units constituted index of guideline adherence (IGA). IGA was retrospectively calculated for 1656 patients included in Russian independent ACS registry RECORD-2 (7 hospitals, duration 04.2009 to 04.2011). The patients were divided into 2 groups according to quartiles of IGA distribution: 1) low adherence group (quartiles I-II); 2) high adherence group (quartiles III-IV).
In low adherence compared with high adherence group there were significantly more patients more or equal 65 years (=0.0007), with chronic heart failure [CHF] (
The calcium, phosphorus, and parathyroid hormone targets recommended by the Canadian Society of Nephrology (CSN) encompass a wider range of values as compared to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines. We sought to compare mineral metabolism parameters within the Manitoba Renal Program (MRP) to the CSN and NKF-K/DOQI guidelines. Medication use was also examined.
All hemodialysis patients in Manitoba were evaluated. Values for serum albumin, phosphorus, calcium, intact parathyroid hormone (PTH) and pertinent medications were collected.
Five hundred and forty-six patients were included in the analysis. Fifty-three per cent to 81% of MRP patients met individual CSN targets. However, only 26% of patients achieved all targets, despite high usage of phosphate (85.5% calcium carbonate, 16.1% sevelamer, 1.3% aluminum) and PTH-lowering drug therapies (30.2% calcitriol, 2.7% cinacalcet).
Only a small proportion of patients were able to achieve all three CSN mineral metabolism targets simultaneously. The majority of outliers presented with hyperphosphatemia or hypoparathyroidism.
AIMS: To study, within municipal care and county council care, (1) chief nurses' and registered nurses' perceptions of patient nutritional status assessment and nutritional assessment/screening tools, (2) registered nurses' perceptions of documentation in relation to nutrition and advantages and disadvantages with a documentation model. BACKGROUND: Chief nurses and registered nurses have a responsibility to identify malnourished patients and those at risk of malnutrition. DESIGN AND METHODS: In this descriptive study, 15 chief nurses in municipal care and 27 chief nurses in county council care were interviewed by telephone via a semi-structured interview guide. One hundred and thirty-one registered nurses (response rate 72%) from 14 municipalities and 28 hospital wards responded to the questionnaire, all in one county. RESULTS: According to the majority of chief nurses and registered nurses, only certain patients were assessed, on admission and/or during the stay. Nutritional assessment/screening tools and nutritional guidelines were seldom used. Most of the registered nurses documented nausea/vomiting, ability to eat and drink, diarrhoea and difficulties in chewing and swallowing, while energy intake and body mass index were rarely documented. However, the majority documented their judgement about the patient's nutritional condition. The registered nurses perceived the VIPS model (Swedish nursing documentation model) as a guideline as well as a model obstructing the information exchange. Differences were found between nurses (chief nurses/registered nurses) in municipal care and county council care, but not between registered nurses and their chief nurses. CONCLUSIONS: All patients are not nutritionally assessed and important nutritional parameters are not documented. Nutritionally compromised patients may remain unidentified and not properly cared for. RELEVANCE TO CLINICAL PRACTICE: Assessment and documentation of the patients' nutritional status should be routinely performed in a more structured way in both municipal care and county council care. There is a need for increased nutritional nursing knowledge.
Diagnostic imaging has been a part of medicine for the last century. It has been difficult to implement guidelines in this field, and unwarranted imaging has been a frequent problem. Some work has been done to explain these phenomena separately. Identifying the barriers to and facilitators of guideline use has been one strategy. The aim of this study is to offer a more comprehensive explanation of deviations from the guideline by studying the two phenomena together.
Eight general practitioners and 10 radiologists from two counties in Norway agreed to semi-structured interviews. Topics covered in the interviews were knowledge of the guideline, barriers to and facilitators of guideline use, implementation of guidelines and factors that influence unwarranted imaging.
Several barriers to and facilitators of guideline use were identified. Among these are lack of time, pressure from patients, and guidelines being too long, rigid or unclear. Facilitators of guideline use were easy accessibility and having the guidelines adapted to the target group. Some of the factors that influence unwarranted imaging are lack of time, pressure from patients and availability of imaging services.
There are similarities between the perceived barriers for guideline adherence and the perceived factors that influence unwarranted imaging. There may be a few reasons that explains the deviation from guidelines, and the amount of unwarranted imaging.
Cardiovascular disease (CVD) is the leading cause of death worldwide, and its prevention and treatment are important healthcare aims. Hypercholesterolemia is among the most important modifiable risk factors for CVD, and numerous guidelines exist for the treatment of this condition. Nevertheless, despite the existence of well-established and safe pharmacologic therapy for lowering cholesterol and preventing CVD, surveys in the United States and Europe have revealed that many patients have elevated cholesterol levels. There is a clear gap between what is known about treating CVD and the implementation of that knowledge. A survey assessing patients' knowledge about CVD observed that many patients are unaware of the disease prevalence and have little knowledge about the main risk factors, including the importance of cholesterol. Another survey demonstrated that many physicians overestimate patients' awareness of CVD and that physicians also overestimate the extent to which guidelines are implemented in clinical practice. Guideline implementation may be improved by narrowing the discrepancies between what patients and physicians believe and the reality. Many physicians claim that lack of time hinders guideline implementation and improvement of patient education. Physicians also appear to lack the motivation to implement lipid-lowering interventions. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment and prevention of CVD.
The Water Safety Plan (WSP) methodology, which aims to enhance safety of drinking water supplies, has been recommended by the World Health Organization since 2004. WSPs are now used worldwide and are legally required in several countries. However, there is limited systematic evidence available demonstrating the effectiveness of WSPs on water quality and health. Iceland was one of the first countries to legislate the use of WSPs, enabling the analysis of more than a decade of data on impact of WSP. The objective was to determine the impact of WSP implementation on regulatory compliance, microbiological water quality, and incidence of clinical cases of diarrhea. Surveillance data on water quality and diarrhea were collected and analyzed. The results show that HPC (heterotrophic plate counts), representing microbiological growth in the water supply system, decreased statistically significant with fewer incidents of HPC exceeding 10 cfu per mL in samples following WSP implementation and noncompliance was also significantly reduced (p
There is currently no consensus on best practice in systemic sclerosis (SSc). To determine if variability in treatment and investigations exists, practices among Canadian Sclerodermia Research Group (CSRG) centres were compared.
Prospective clinical and demographic data from adult SSc patients are collected annually from 15 CSRG treatment centres. Laboratory parameters, self-reported socio-demographic questionnaires, current and past medications and disease outcome measures are recorded. For centres with >50 patients enrolled, treatment practices were analysed to determine practice variability.
Data from 640 of 938 patients within the CSRG database met inclusion criteria, where 87.3% were female, the mean ± SEM age was 55.3±0.5, 48.9% had limited SSc and 47.8% had diffuse SSc (and 3.3% uncharacterised). Some investigation and treatment practices were inconsistent among 6 centres including proportion receiving: PDE5 (phosphodiesterase type 5) inhibitors for Raynaud's phenomenon (p=0.036); cyclophosphamide (p=0.037) and azathioprine (p=0.037) for treatment of ILD; and current use of D-penicillamine, although uncommon, varied among sites. Annual echocardiograms and PFTs were frequently done and did not vary among sites but the rate of pulmonary arterial hypertension (PAH) was directly related to site size and this was not the case for other organ involvement.
Despite routine tests within a database, site variation in SSc with respect to investigations and management among CSRG centres exists suggesting a need for a standardised approach to the investigation and treatment of SSc. One can speculate that larger centres are more export in detecting PAH.