Journal of evaluation in clinical practice
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Randomized controlled trials (RCTs) are the preferred source for evidence for the effect of treatment. However, patients participating in RCTs often manifest important differences from patients seen in practice. Therefore, guideline developers have to decide whether the results are generalizable to the target population not represented in RCTs. ⋯ We propose this last approach: focusing on RCTs unless there is a compelling reason not to do so. Compelling reasons will most often be found with respect to issues of rare adverse effects, for which observational studies are likely to provide the best estimates.
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Multicenter Study
Application of an evidence-based decision rule to patients with suspected pulmonary embolism.
To support doctors in diagnosing patients who are suspected to have pulmonary embolism, the Christopher evidence-based decision rule was implemented in hospitals in the Netherlands. This study examines whether the Christopher evidence-based decision rule is applied in clinical practice. In addition, doctors' considerations for not applying the decision rule are explored. ⋯ The Christopher evidence-based decision rule for diagnosing pulmonary embolism was not always followed in everyday clinical practice. Doctors seem to base their diagnostic strategy on their own estimate of the likelihood of pulmonary embolism, rather than the whole decision rule. Better adherence to the decision rule could be beneficial by making doctors aware that pulmonary embolism is more likely than they initially thought. However, in a substantial number of cases, it seemed justifiable that doctors deviated from the decision rule. Therefore, further research is needed to determine the value of the Christopher evidence-based decision rule in clinical practice.
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There is increasing concern that conflicts of interest affect the development process of clinical practice guidelines. We evaluated The American Psychiatric Association's Practice Guideline for the Treatment of Patients with Major Depressive Disorder to determine the existence of financial and intellectual conflicts of interest and examine their possible effects. We selected this guideline because of its influence on clinical practice and because this guideline recommends pharmacotherapy for all levels of depression, despite controversies over the evidence base. ⋯ The prevalence of conflicts of interest among panel members was high. The quality of the evidence cited raises questions about the validity of the recommendations. Attention to the quality of cited studies and to the risk of bias resulting from conflicts of interest should be a priority for guideline development groups.
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The objective of this study was to assess the quality of clinical practice guidelines providing diagnostic recommendations on pheochromocytoma (PHEO) using the new Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to promote the development of clinical guidelines. ⋯ The quality and rigour of guidelines for the diagnosis of PHEO vary. It is difficult to identify one guideline that performed well in all three fields for the diagnosis of PHEO based on the AGREE II instrument. Therefore, additional studies and greater efforts should be taken to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision making in diagnosing PHEO according to the AGREE II instrument.
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Decades of work on health disparities have culminated in identification of three contributors to variability in diagnosis and management of disease: (i) patient attributes; (ii) doctor's characteristics; and (iii) organizational factors. Understanding the relative influence of different contributors to variability in diagnosis and management of diabetes is important to improving quality and reducing disparities. This study was designed to examine the influence of patient, provider and organizational factors on the diagnosis and management of a major chronic disease - diabetes. ⋯ That half of all diabetes in the United States remains undiagnosed is unsurprising given only 60.9% of doctors would diagnose it when the condition is strongly suggested, and nearly one-quarter suspecting diabetes would not order tests necessary to confirm it. The diagnosis of diabetes is significantly influenced by a patient's race/ethnicity, and clinical management (specifically for foot neuropathy) is influenced by patient socio-economic status (SES), doctor's gender and access to clinical guidelines.