Practice Guidelines Belief, Criticism, and Probability

Archives of internal medicine (Impact Factor: 17.33). 01/2011; 171(1):15-7. DOI: 10.1001/archinternmed.2010.453
Source: PubMed
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    ABSTRACT: Clinical guidelines are an important source of guidance for clinicians. Few studies have examined the quality of scientific data underlying evidence-based guidelines. We examined the quality of evidence that underlies the recommendations made by the American College of Obstetricians and Gynecologists (the College). The current practice bulletins of the College were examined. Each bulletin makes multiple recommendations. Each recommendation is categorized based on the quality and quantity of evidence that underlies the recommendation into one of three levels of evidence: A (good and consistent evidence), B (limited or inconsistent evidence), or C (consensus and opinion). We analyzed the distribution of levels of evidence for obstetrics and gynecology recommendations. A total of 84 practice bulletins that offered 717 individual recommendations were identified. Forty-eight (57.1%) of the guidelines were obstetric and 36 (42.9%) were gynecologic. When all recommendations were considered, 215 (30.0%) provided level A evidence, 270 (37.7%) level B, and 232 (32.3%) level C. Among obstetric recommendations, 93 (25.5%) were level A, 145 (39.7%) level B, and 117 (34.8%) level C. For the gynecologic recommendations, 122 (34.7%) were level A, 125 (35.5%) level B, and 105 (29.8%) level C. The gynecology recommendations were more likely to be of level A evidence than the obstetrics recommendations (P=.049). One third of the recommendations put forth by the College in its practice bulletins are based on good and consistent scientific evidence.
    Obstetrics and Gynecology 09/2011; 118(3):505-12. DOI:10.1097/AOG.0b013e3182267f43 · 5.18 Impact Factor
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    ABSTRACT: The aim of this quality control study was to assess the time to initial diagnostic procedures and the time to the first dose of antibiotics in patients with pneumococcal bacteremia, and to investigate whether the timeliness of these interventions influenced outcome. We retrospectively studied patient characteristics, chronological sequence of diagnostic and therapeutic steps, and the course of disease of all patients with pneumococcal bacteremia at a Swiss university hospital between 2003 and 2009, and we analyzed associations between these factors and the length of hospital stay (LOS) and mortality. A total of 102 episodes of pneumococcal bacteremia in 98 patients were analyzed, of whom 15.7% died during hospitalization. The median time (interquartile range [IQR]) to the first antibiotic dose was 4.0 (2.0-5.9) h, and the median times (IQR]) to blood cultures, chest radiograph, lumbar puncture, and brain computed tomography (CT) scan or magnetic resonance imaging (MRI) were 1.4 (0.5-3.3), 2.5 (1.2-4.2), 4.2 (2.7-7.2), and 2.3 (0.6-6.2) h, respectively. The time to diagnostic procedures and therapy were not associated with LOS or death. Risk factors for death in the univariable analysis were: Charlson comorbidity index [odds ratio [OR] (95% confidence interval) per unit increase, 1.3 (1.1-1.6)], neutropenia [OR 10.1 (2.0-51.0)], human immunodeficiency virus (HIV) infection [OR 3.9 (1.1-13.8)], chronic respiratory disease [OR 4.4 (1.2-16.0)], chronic liver disease [OR 3.2 (1.0-9.7)], smoking [OR 3.8 (1.1-13.5)], injection drug use [OR 9.7 (1.5-63.7)], and antibiotic therapy within 6 months before admission [OR 4.0 (1.3-12.5)]. The multivariable analysis revealed age >60 years (P = 0.048) and alcoholism (P = 0.009) as risks for prolonged LOS. The outcome of pneumococcal bacteremia may be more influenced by patient characteristics than by minor differences in the timeliness of initial diagnostic and therapeutic measures within the first several hours after hospital admission.
    Infection 11/2011; 39(6):519-26. DOI:10.1007/s15010-011-0218-1 · 2.62 Impact Factor
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    Clinical Infectious Diseases 03/2012; 54(12):1710-3. DOI:10.1093/cid/cis274 · 8.89 Impact Factor
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