BMC research notes
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Critically appraising the quality of clinical practice guidelines (CPGs) is an essential element of evidence implementation. Critical appraisal considers the quality of CPG construction and reporting processes, and the credibility of the body of evidence underpinning recommendations. To date, the focus on CPG critical appraisal has come from researchers and evaluators, using complex appraisal instruments. Rapid critical appraisal is a relatively new approach for CPGs, which targets busy end-users such as service managers and clinicians. This paper compares the findings of two critical appraisal instruments: a rapid instrument (iCAHE) and a complex instrument (AGREE II). They were applied independently to 16 purposively-sampled, heterogeneous South African CPGs, written for eleven primary health care conditions/health areas. Overall scores, and scores in the two instruments' common domains Scope and Purpose, Stakeholder involvement, Underlying evidence/Rigour of Development, Clarity), were compared using Pearson r correlations and intraclass correlation coefficients. CPGs with differences of 10 % or greater between scores were identified and reasons sought for such differences. The time taken to apply the instruments was recorded. ⋯ Either instrument could be used with confidence to assess the quality of CPGs. The choice of appraisal instrument depends on the needs and time of end-users. Having an alternative (rapid) critical appraisal tool will potentially encourage busy end-users to identify and use good quality CPGs to inform practice decisions.
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Pneumocystis jirovecii pneumonia (PCP) is potentially fatal infectious complication in patients with rheumatoid arthritis (RA) during immunosuppressive therapy. Hospital survival due to human immunodeficiency virus-unrelated PCP reaches to 60%. The high mortality rate results from difficulties in establishing an early diagnosis, concurrent use of prophylactic drugs, possible bacterial coinfection. We herein report a case of PCP in RA patients who developed the architectural distortions of lung in spite of combined modality therapy. ⋯ The architectural distortions of lung should be considered as a cause of death of PCP. For this reason, a high suspicion of this infectious complication must be kept in mind in order to establish an early diagnosis and treatment in patients with RA managed with MTX and biologics.
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Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. ⋯ Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.