Clinical impact of guideline-based practice and patients' adherence in uncontrolled hypertension.
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ABSTRACT:
SUBMITTER: Sohn IS
PROVIDER: S-EPMC8672596 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Adherence to hypertension guidelines in the outpatient setting is low.To evaluate adherence to JNC VII guidelines in nursing home patients.Data were obtained from the 2004 National Nursing Home Survey (NNHS), a nationally representative sample of US nursing homes. Patients with hypertension were identified using ICD-9 codes. Adherence to JNC VII guidelines was defined as the use of a thiazide diuretic in patients without a compelling indication for a different class of antihypertensive medication, such as diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke.There were 13,507 patients in the 2004 NNHS survey, of whom 7,129 had hypertension.Of these 7,129 hypertensive patients, only 12.6% were on a thiazide. Out of the 7,129 hypertensive patients, 3,113 did not have diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. Of these 3,113 patients, only 13.9% were on a thiazide. After excluding patients with a potential contraindication to a diuretic, such as hospice care or incontinence, only 18% were prescribed a thiazide. Of the 3,113 patients, 1,148 were on a single class of antihypertensive and more were prescribed a beta blocker, ACE inhibitor, calcium channel blocker, loop diuretic, and ARB than a thiazide diuretic.Adherence to hypertension guidelines among nursing home patients is low. The appropriate use of thiazide diuretics could reduce costs and improve blood pressure control and patient outcomes.
| S-EPMC2659159 | biostudies-other
Project description:ObjectiveTo evaluate the individual-level impact of an electronic clinical decision support (ECDS) tool, PedsGuide, on febrile infant clinical decision making and cognitive load.MethodsA counterbalanced, prospective, crossover simulation study was performed among attending and trainee physicians. Participants performed simulated febrile infant cases with use of PedsGuide and with standard reference text. Cognitive load was assessed using the NASA-Task Load Index (NASA-TLX), which determines mental, physical, temporal demand, effort, frustration, and performance. Usability was assessed with the System Usability Scale (SUS). Scores on cases and NASA-TLX scores were compared between condition states.ResultsA total of 32 participants completed the study. Scores on febrile infant cases using PedsGuide were greater compared with standard reference text (89% vs 72%, P = .001). NASA-TLX scores were lower (ie, more optimal) with use of PedsGuide versus control (mental 6.34 vs 11.8, P < .001; physical 2.6 vs 6.1, P = .001; temporal demand 4.6 vs 8.0, P = .003; performance 4.5 vs 8.3, P < .001; effort 5.8 vs 10.7, P < .001; frustration 3.9 vs 10, P < .001). The SUS had an overall score of 88 of 100 with rating of acceptable on the acceptability scale.ConclusionsUse of PedsGuide led to increased adherence to guidelines and decreased cognitive load in febrile infant management when compared with the use of a standard reference tool. This study employs a rarely used method of assessing ECDS tools using a multifaceted approach (medical decision-making, assessing usability, and cognitive workload,) that may be used to assess other ECDS tools in the future.
| S-EPMC6732014 | biostudies-literature
Project description:PurposeEvaluating patients and treatment decisions in a multidisciplinary tumor board has led to better quality of care and longer survival in cancer patients. The aim of this study was to evaluate tumor board recommendations for thoracic oncology patients regarding guideline adherence and transferal of recommendations into clinical practice.MethodsWe evaluated tumor board recommendations of the thoracic oncology tumor board at Ludwig-Maximilians University (LMU) Hospital Munich between 2014 and 2016. We compared patient characteristics between guideline-adherent and non-guideline-adherent recommendations, as well as between transferred and non-transferred recommendations. We used multivariate logistic regression models to evaluate factors associated with guideline adherence.ResultsOver 90% of recommendations by the tumor board were either adherent to the guidelines (75.5%) or over fulfilling guidelines (15.6%). Almost 90% of recommendations were transferred to clinical practice. If a recommendation was not according to the guidelines, the reason was mostly associated with the general condition (age, Charlson comorbidity index, ECOG) of the patient or due to the patients' request. Surprisingly, sex also had a significant influence on the guideline adherence of recommendations, with females being more likely to get recommendations not according to the guidelines.ConclusionIn conclusion, the results of this study are promising, as the guideline adherence of recommendations as well as the transferal of recommendations into clinical practice were high. In the future, a special focus should be put on fragile patients as well as female patients.
| S-EPMC10465379 | biostudies-literature
Project description:ImportanceRural Black participants need effective intervention to achieve better blood pressure (BP) control.ObjectiveAmong Black rural adults with persistently uncontrolled hypertension attending primary care clinics, to determine whether peer coaching (PC), practice facilitation (PF), or both (PCPF) are superior to enhanced usual care (EUC) in improving BP control.Design, setting, and participantsA cluster randomized clinical trial was conducted in 69 rural primary care practices across Alabama and North Carolina between September 23, 2016, and September 26, 2019. The participating practices were randomized to 4 groups: PC plus EUC, PF plus EUC, PCPF plus EUC, and EUC alone. The baseline EUC approach included a laptop for each participating practice with hyperlinks to participant education on hypertension, a binder of practice tips, a poster showing an algorithm for stepped care to improve BP, and 25 home BP monitors. The trial was stopped on February 28, 2021, after final data collection. The study included Black participants with persistently uncontrolled hypertension. Data were analyzed from February 28, 2021, to December 13, 2022.InterventionsPractice facilitators helped practices implement at least 4 quality improvement projects designed to improve BP control throughout 1 year. Peer coaches delivered a structured program via telephone on hypertension self-management throughout 1 year.Main outcomes and measuresThe primary outcome was the proportion of participants in each trial group with BP values of less than 140/90 mm Hg at 6 months and 12 months. The secondary outcome was a change in the systolic BP of participants at 6 months and 12 months.ResultsA total of 69 practices were randomized, and 1209 participants' data were included in the analysis. The mean (SD) age of participants was 58 (12) years, and 748 (62%) were women. In the intention-to-treat analyses, neither intervention alone nor in combination improved BP control or BP levels more than EUC (at 12 months, PF vs EUC odds ratio [OR], 0.94 [95% CI, 0.58-1.52]; PC vs EUC OR, 1.30 [95% CI, 0.83-2.04]; PCPF vs EUC OR, 1.02 [95% CI, 0.64-1.64]). In preplanned subgroup analyses, participants younger than 60 years in the PC and PCPF groups experienced a significant 5 mm Hg greater reduction in systolic BP than participants younger than 60 years in the EUC group at 12 months. Practicewide BP control estimates in PF groups suggested that BP control improved from 54% to 61%, a finding that was not observed in the trial's participants.Conclusions and relevanceThe results of this cluster randomized clinical trial demonstrated that neither PC nor PF demonstrated a superior improvement in overall BP control compared with EUC. However, PC led to a significant reduction in systolic BP among younger adults.Trial registrationClinicalTrials.gov Identifier: NCT02866669.
| S-EPMC10949149 | biostudies-literature
Project description:BackgroundThis study aims to develop an evidence-based clinical practice guideline of acupuncture in the treatment of patients with moderate and severe cancer pain.MethodsThe development of this guideline was triggered by a systematic review published in JAMA Oncology in 2020. We searched databases and websites for evidence on patient preferences and values, and other resources of using acupuncture for treatment of cancer pain. Recommendations were developed through a Delphi consensus of an international multidisciplinary panel including 13 western medicine oncologists, Chinese medicine/acupuncture clinical practitioners, and two patient representatives. The certainty of evidence, patient preferences and values, resources, and other factors were fully considered in formulating the recommendations. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was employed to rate the certainty of evidence and the strength of recommendations.ResultsThe guideline proposed three recommendations: (1) a strong recommendation for the treatment of acupuncture rather than no treatment to relieve pain in patients with moderate to severe cancer pain; (2) a weak recommendation for the combination treatments with acupuncture/acupressure to reduce pain intensity, decrease the opioid dose, and alleviate opioid-related side effects in moderate to severe cancer pain patients who are using analgesics; and (3) a strong recommendation for acupuncture in breast cancer patients to relieve their aromatase inhibitor-induced arthralgia.ConclusionThis proposed guideline provides recommendations for the management of patients with cancer pain. The small sample sizes of evidence limit the strength of the recommendations and highlights the need for additional research.
| S-EPMC8728906 | biostudies-literature
Project description:BackgroundThe joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021.MethodsThe 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method.ResultsRecommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D).ConclusionsThis article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html ). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
| S-EPMC9263056 | biostudies-literature
Project description:Patient and public involvement (PPI) is recognized as a key component of clinical practice guideline development with important implications for guideline implementability. The impact of PPI on guidelines, however, has not been rigorously assessed. Better understanding of the impact of PPI must start with guideline question formation, which drives all subsequent development steps. The aim of this study was to investigate the effect of PPI on guideline question formation and validate a conceptual model of patient and public contributions to guidelines.For development of a clinical practice guideline on the topic of using amyloid positron emission tomography in the diagnosis of dementia, we convened two parallel guideline development groups, one with and one without patient representatives. Participating physicians were randomized to group assignment. Each group developed Population, Intervention, Comparator, Outcome, Time (PICOT) questions and identified key benefits and harms to incorporate in guideline development. Analysis included a descriptive comparison of proposed PICOT questions, benefits, and harms between groups and a qualitative analysis of discussion themes from audio recordings of the question development retreats.Proposed guideline questions, benefits, and harms were largely similar between groups, but only the experimental group proposed outcomes relating to development of cognitive impairment at specific time points and rate of progression. The qualitative analysis of the discussions occurring during guideline question development demonstrated key differences in group conduct and validated the proposed conceptual model of patient and public contributions to guidelines. PPI influenced the conduct of guideline development, scope, inclusion of patient-relevant topics, outcome selection, and planned approaches to recommendation development, implementation, and dissemination with implications for both guideline developers and the guideline development process.Evidence of how PPI impacts guideline development underscores the importance of engaging patient stakeholders in guideline development and highlights developer- and guideline-specific outcomes of PPI, both of which have implications for guideline implementation. It also raises the question of whether guidelines developed without such input are acceptable for use. PPI should be considered an essential element of trustworthy guideline development for purposes of development and funding.
| S-EPMC5902835 | biostudies-other
Project description:BACKGROUND:Evidence from several studies show poor guideline adherence to COPD treatment, but no such study has been undertaken in Norway. The objectives of this study, was to estimate and compare the guideline adherence to COPD treatment in general population-based and hospital-recruited COPD patients, and find possible predictors of guideline adherence. METHODS:From the prospective, observational EconCOPD-study, we analysed guideline adherence for 90 population-based COPD cases compared to 245 hospital-recruited COPD patients. Overall guideline adherence was defined as correct pharmacological treatment, and influenza vaccination the preceding year, and having received smoking cessation advice. Multivariate logistic regression analysis was performed with the dichotomous outcome overall guideline adherence adjusting for relevant variables. RESULTS:The overall guideline adherence for population-based COPD cases was 6.7%, significantly lower than the 29.8% overall guideline-adherence amongst hospital-recruited COPD patients. Adherence to pharmacological treatment guidelines was 10.0 and 35.5%, for the two recruitment sources, respectively. GOLD-stage 3 to 4 was associated with significantly better guideline adherence compared to GOLD-stage 2 (OR (95% CI) 18.9 (8.37,42.7)). The unadjusted difference between the two recruitment sources was completely explained by degree of airflow obstruction. CONCLUSION:Overall guideline adherence was very low for both recruitment sources. We call for increased attention from authorities and healthcare personnel to improve the quality of care given to this patient group.
| S-EPMC6302492 | biostudies-literature
Project description:In post-disaster situations, additional barriers may reduce antihypertensive medication adherence.Between November 2005 and August 2006, 210 hypertensive patients receiving care at a multispecialty group practice in New Orleans completed a structured questionnaire. Antihypertensive medication adherence was measured with the Hill-Bone medication compliance subscale. In a subset of patients, data on difficulties patients encountered with blood pressure medications in the aftermath of Hurricane Katrina were collected.: Seventy-six percent of patients reported damage to their residence and 46% of patients had less-than-perfect medication adherence. After multivariate adjustment, less than perfect medication adherence postdisaster was more common among people aged <65 years (prevalence ratio = 1.37; 95% confidence interval: 1.03-1.82) and non-whites (1.32; 95% confidence interval: 1.02-1.71). Uncontrolled blood pressure (systolic/diastolic > or =140/> or =90 mm Hg) was more common in those with less-than-perfect adherence than their counterparts with perfect adherence (51% versus 42%, respectively). In addition, 7% of patients reported not bringing their blood pressure medications when they evacuated, 28% ran out of blood pressure medications, 16% reported difficulties getting medications filled, and 28% reported a blood pressure medication change postdisaster.Opportunities exist to improve disaster planning and prescription refill processes and increase medication adherence and hypertension control postdisasters.
| S-EPMC2561300 | biostudies-literature
Project description:Despite intensive anti-hypertensive treatment, overall control rates of only 30 ~ 50 % have been reported in patients with hypertension (HTN). However, clinical significance and angiographic characteristics of patients with uncontrolled HTN following Below-the-knee arteries (BTK) interventions in patients with critical limb ischemia (CLI) are not clarified yet as compared to those with controlled HTN.A total 165 consecutive hypertensive patients with BTK lesions from August 2004 to November 2012 were enrolled for this study. Uncontrolled HTN was defined as a blood pressure of > 140 mmHg systolic and 90 mmHg diastolic under anti-hypertensive treatment. A total of 112 patients (67.8 %) had uncontrolled HTN. We compared the clinical and angiographic characteristics of patients with uncontrolled HTN following BTK interventions to those with controlled HTN at 12-month follow-up.The baseline characteristics are well balanced between the two groups. At 12 months, there was no difference in the incidence of mortality, target lesion revascularization (TLR), target extremity revascularization (TER), and limb salvage rate in both groups. However, amputation rates were higher in patients with controlled HTN (33.9 vs. 19.6 %, P = 0.045).Regardless of blood pressure control, HTN itself was an independent risk factor for BTK lesions, suggesting more intensive medical therapy with close clinical follow up will be required for all BTK patients with HTN.
| S-EPMC4770568 | biostudies-other