90-07-30-Sepehrvand-Practice guidelines and clinical risk assessment-Is it time to reform (original) (raw)
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Practice guidelines and clinical risk assessment models: is it time to reform?
BMC Medical Informatics and Decision Making, 2011
Background: Clinical practice guidelines and Risk Assessment Models (RAMs) are some useful tools to bring medical evidences into our daily clinical practice. Despite the improvement over the time, they still have some shortcomings. Discussion: One of these shortcomings is the arbitrary cutoffs used in these tools to facilitate the decision making process. This problem is to some extent due to the "Black or White" approach of modern medicine in making the decisions, whilst in the real world and our daily practice we used mostly an uncertain approach, which is called recently as "Fuzzy" thinking approach. Summary: The authors of this article believe that the fuzzy type of thinking may resolve the above mentioned shortcomings of clinical practice guideline or risk assessment models and they tried to discuss about this using an example about Venous Thromboembolism related guidelines and RAMs.
Practice guidelines and clinical risk assessment Is it time to reform
Background: Clinical practice guidelines and Risk Assessment Models (RAMs) are some useful tools to bring medical evidences into our daily clinical practice. Despite the improvement over the time, they still have some shortcomings. Discussion: One of these shortcomings is the arbitrary cutoffs used in these tools to facilitate the decision making process. This problem is to some extent due to the "Black or White" approach of modern medicine in making the decisions, whilst in the real world and our daily practice we used mostly an uncertain approach, which is called recently as "Fuzzy" thinking approach. Summary: The authors of this article believe that the fuzzy type of thinking may resolve the above mentioned shortcomings of clinical practice guideline or risk assessment models and they tried to discuss about this using an example about Venous Thromboembolism related guidelines and RAMs.
Guideline to Guidelines. Implementation of scientific evidence into clinical guidelines
Research Square (Research Square), 2023
Background: The knowledge and help provided by the medical guidelines are essential to make informed clinical decisions. However, there are no systematic methods to assess the e cacy of guidelines, i.e., how much contribution they provide to informed decisions in various health conditions. Methods: A mathematical analysis was developed to assess the e cacy of guidelines. As an example, the "2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease" (GL-SCE) was analysed/assessed. The analysis was conducted on the Classes of Recommendations (CLASS) and the Levels of Evidence (LEVEL). LEVEL areas under CLASS were calculated to form a Certainty Index (CI:-1 to+1). Results: The frequency of CLASS I ('to do') and CLASS III ('not to do') was relatively high in GL-SCE. Yet, the most frequent LEVEL was C, indicating a low quality of scienti c evidence. The GL-SCE showed a relatively high CI (+0.57), 78.4% Certainty and 21.6% Uncertainty. Conclusions: GL-SCE provides a substantial help to decision-making through the recommendations, but the supporting evidence in most CLASSes has low quality, which is well-re ected in the developed Certainty Index identifying issues that should be clari ed and investigated in future studies. We propose that the developed mathematical analysis should be used as a Guideline to Guidelines to assess their e cacy and support their implementation in clinical practice thus providing a 'quality control'. Contribution to the literature This study provides a mathematical analysis to objectively measure the help/contribution to medical decision-making provided by any medical Guidelines; this analysis allows a better understanding of the classes of recommendations and the levels of scienti c evidence. The higher level of scienti c evidence and/or clinical signi cance of lower evidence may be increased by conducting new experimental and clinical studies on uncertain issues revealed with this analysis on the Guidelines; thus, the e cacy of clinical decision-making can be increased. The outlined mathematical analysis provides a 'quality control', and as such, it can be used as a Guideline for assessing the e cacy of the Guidelines. Background Medical societies publish several guidelines to help medical professionals to make decisions in certain disease conditions. Recently by analysing four ESC GLs for CVDs, we revealed that the contribution provided by them to make a decision is uneven, based on the Certainty/Uncertainty ratio [1]. Indeed, the GLs' contribution to decision-making can vary based on the Levels of Evidence (LEVEL) and Classes of Recommendations (CLASS). It is obvious that in the recommendations of Class I (recommended/indicated) 'to do' and Class III (not recommended) 'not to do', the decision is clear
Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis. The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety. Methods: A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.
BMC Health Services Research, 2012
Objectives: To evaluate the implementation of NICE guidance and its impact on patient safety. Design: Before and after observational study design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance. A total of 816 patients were sampled in each year in four hospitals in the NHS South region. Results: The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p<0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference-3.5%% (95% CI:-15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI:-16.5% to 17.2%; p =0.97). Conclusions: The documentation of risk assessment improved following the implementation of NICE guidance but this did not lead to improved patient safety when prescribing prophylaxis.
Clinical and Applied Thrombosis/Hemostasis, 2013
Hospitalized acutely ill patients face high risk for venous thromboembolism (VTE) unless appropriate thromboprophylaxis is applied. This study aimed to determine VTE prophylaxis practices for inpatients in Turkey and to evaluate the impact of physicians' training via a modified ''Standard Medical Patients' VTE Risk Assessment Model (MERAM).'' A total of 607 inpatients included in this national multicenter noninterventional observational registry were evaluated in terms of demographics, VTE risk, and preventive measures at 2 consecutive cross-sectional visits. Physicians were asked to complete a questionnaire on current VTE method risk assessment and other models including MERAM. The VTE prophylaxis rates significantly increased from 49.4% to 62.4% between visits (P < .05). The lack of risk evaluation decreased from 74.6% to 19.5% (P < .001). Percentage of physicians using prophylaxis and use of MERAM increased between visits. Physician training proved effective for providing general ''awareness'' of VTE prophylaxis and led to higher rates of risk assessment model-based appropriate VTE prophylaxis.
A Clinical Decision Support System for Prevention of Venous Thromboembolism
JAMA, 2000
Computer-based clinical decision support systems (CDSSs) have been promoted for their potential to improve quality of health care. However, given the limited range of clinical settings in which they have been tested, such systems must be evaluated rigorously before widespread introduction into clinical practice.
BMJ Quality Improvement Reports, 2015
Sheikh Khalifa Medical City (SKMC) in Abu Dhabi is the main tertiary care referral hospital in the United Arab Emirates (UAE) with 560 bed capacity that is fully occupied most of the time. SKMC senior management has made a commitment to make quality and patient safety a top priority. Venous thromboembolism (VTE) risk assessment has been identified as a critical patient safety measure and key performance indicator. The electronic VTE risk assessment form a computerized decision support tool was introduced to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations.