Percepciones y actitudes de médicos de atención primaria respecto de las Guías de Práctica Clínicas en el Régimen de Garantías en Salud / Perceptions and attitudes of Chilean primary care physicians toward clinical practice guidelines

Background: Clinical practice guidelines (CPGs) promote better quality and equity in health care and potentially they could improve patients' outcomes. However, their implementation is hindered by a number of factors including some related to health care professionals. Aim: To assess the perceptions and attitudes of primary care physicians regarding CPGs developed by the Chilean Ministry of Health in the context of the Health Sector Reform. Material and Methods: An adaptation of the survey "Knowledge, perceptions and attitudes towards Clinical Practice Guidelines" was sent to 1,264 primary care physicians in Chile and answered completely by 354. The analysis assessed the attitudes towards CPG, their use in primary care and their relationship with socio demographic features of respondents. Results: Eighty two percent of respondents reviewed the flowcharts of the guidelines, 85% consulted their online version. The classification of evidence levels and the strength of recommendations generated a high level of confidence with the guidelines in 70 and 64% of respondents. Eighty five percent considered that CPG could help to standardize clinical practice. The most relevant barrier hindering CPG use was the lack of a brief, simple and easy to access format in 63% of respondents. The three dimensions of the theory of planned behavior (attitude toward behavior, subjective norms, and perceived behavioral control) were associated with a greater frequency of guideline use. A higher age and not being Chilean were associated with a lower frequency of use. Conclusions: The identified factors associated with CPG use should be considered in future guideline design.

Atributos de las guías clínicas del régimen de garantías en salud relacionados con su adopción en la atención primaria: una evaluación en 3 centros de salud familiar / Attributes of recommendations included in clinical guidelines that influence their implementation in clinical practice

Background A number of attributes of recommendations included in clinical guidelines influence their implementation in clinical practice. Aim To assess the association between those attributes and the uptake of recommendations included in four Clinical Guidelines of the Chilean Ministry of Health. Material and Methods The compliance with recommendations was assessed auditing a random sample of 1,547 electronic medical records of patients with four selected clinical conditions (hypertension, diabetes, depression and asthma) in three primary care centers. Nine evaluators judged the presence or absence of six attributes in each recommendation (restrictive/prescriptive, complexity, trialability, actionability, observability, flexibility). We compared the degree of uptake of recommendations with the presence of these attributes. Results The compliance with recommendations was highly variable, with a median of 51% and ranging from 0 to 98%. There was an association between the uptake of recommendations and the presence of three of the above mentioned attributes. There was a higher implementation of restrictive rather than prescriptive recommendations, of rigid rather than flexible recommendations and those recommendations susceptible to be experimented first. Conclusions We have identified three attributes associated with the implementation of recommendations included in four primary care clinical guidelines. These findings could be useful for the guidelines development process in the Chilean national guidelines program.

Guías de práctica clínica: una introducción a su elaboración e implementación / Clinical practice guidelines development and implementation: an introduction

Clinical Practice Guidelines (CPG), defined as "statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options", are tools currently present in every level of our health system. This article introduces guidelines development and implementation processes and it reviews the Chilean experience. The main stages in a CPG development are question formulation, search and analysis of the existing evidence related to those questions, and making judgments about that evidence in order to formulate recommendations for clinical practice. At the national level, guidelines development processes are conducted by the Ministry of Health, and even when recent evaluations show some good results, there are a number of aspects - such as applicability - that should be improved. On the other hand, CPG should be implemented using effective strategies in order to obtain changes in clinical practice and patients' outcomes. The existing evidence about the effects of the different implementation strategies shows modest and highly variable results. At the national level, there is a dearth of research about the design and evaluation of implementation strategies, and most of it has been focused in the evaluation of adherence to specific recommendations.

Non-hormonal interventions for hot flushes in women with a history of breast cancer

BACKGROUND Hot flushes are common in women with a history of breast cancer. Hormonal therapies are known to reduce these symptoms but are not recommended in women with a history of breast cancer due to their potential adverse effects. The efficacy of non-hormonal therapies is still uncertain. OBJECTIVE To assess the efficacy of non-hormonal therapies in reducing hot flushes in women with a history of breast cancer. METHODS Search methods: We searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL (The Cochrane Library), Medline, Embase, Lilacs, CINAHL, PsycINFO (August 2008) and WHO ICTRP Search Portal. We handsearched reference lists of reviews and included articles, reviewed conference proceedings and contacted experts. Selection criteria: Randomized controlled trials (RCTs) comparing non-hormonal therapies with placebo or no therapy for reducing hot flushes in women with a history of breast cancer. Data collection and analysis: Two authors independently selected potentially relevant studies, decided upon their inclusion and extracted data on participant characteristics, interventions, outcomes and the risk of bias of included studies. MAIN RESULTS Sixteen RCTs met our inclusion criteria. We included six studies on selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitors, two on clonidine, one on gabapentin, two each on relaxation therapy and homeopathy, and one each on vitamin E, magnetic devices and acupuncture. The risk of bias of most studies was rated as low or moderate. Data on continuous outcomes were presented inconsistently among studies, which precluded the possibility of pooling the results. Three pharmacological treatments (SSRIs and SNRIs, clonidine and gabapentin) reduced the number and severity of hot flushes. One study assessing vitamin E did not show any beneficial effect. One ...

Guías de Práctica Clínica en el Régimen de Garantías en Salud: una evaluación crítica de su calidad / Clinical practice guidelines in the Chilean health sector reform: a critical assessment of their quality

Background: Clinical practice guidelines are widely used as tools for improving quality of health care. However, there is increasing concern about limitations in their development process conducting to inconsistent recommendations. During the last decade the use of guidelines has been promoted in the Chilean health system, but their quality has not yet been evaluated systematically. Aim: To assess the quality of clinical practice guidelines developed by the Chilean guidelines program. Material and Methods: All the guidelines developed by the Chilean program between 2005 and 2009 were retrieved from the Ministry of Health website. Each guideline was assessed independently by three appraisers using the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument. Standardized scores were obtained for each dimension in each guideline and across the whole set of guidelines. Results: Sixty guidelines were assessed. The 'scope and purpose' dimension scored significantly higher (mean 82.2%, range: 25.9%-100%) and the 'applicability' dimension scored significantly lower (mean 23.3%, range: 0%-72.4%) than any other dimension. 'Publication date' was the only variable consistently associated with dimension scores. Conclusions: The quality of Chilean clinical practice guidelines is far from ideal. Although they seem to have a strong sense of purpose and vision, methodological procedures should be strengthened, especially those related to applicability.

Guías de práctica clínica en atención primaria: Una evaluación crítica / Clinical practice guidelines in primary health care: A critical appraisal

Background: There are doubts about the real usefulness of clinical guidelines to induce changes in practice, specially in primary health care. Those guidelines with inconsistent recommendations can even be misleading. Aim: To assess the quality of Chilean primary health care guidelines and to identify factors associated with high quality guidelines. Material and methods: Chilean primary care guidelines published and disseminated using any strategy 1999 and 2004 were analyzed. Each selected guideline was assessed independently by two evaluators using the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument following standardized instructions. Descriptive statistics for each dimension of the AGREE instrument were calculated for each guideline. Results: A total of 33 guidelines were retrieved. Fifteen were located using a manual search and 18 from electronic sources. Twenty four did not match our definition of guidelines, therefore only nine were included in the final assessment. There were important differences in the scores obtained by each guideline in different dimensions, with relevant methodological shortcomings. However, no significant differences in scores were found when guidelines were compared by year of elaboration. Conclusions: Our results suggest that previous efforts in primary health care guideline development were misdirected and that important changes are necessary to generate high quality guidelines.

The Latin American Ongoing Clinical Trial Register (LATINREC)

Debido a los sesgos que afectan a la publicación de ensayos clínicos y sus resultados, los estudios cuyos resultados son positivos son más fáciles de encontrar que los que tienen resultados sin significación estadística y a ello se debe que los primeros estén sobrerrepresentados. Para contrarrestar este tipo de sesgo se ha propuesto ingresar en un registro toda investigación, desde sus comienzos. No obstante, estos registros se encuentran en distintas fases de evolución, especialmente en países en desarrollo, de tal manera que la Red Cochrane Iberoamericana, parte de la Colaboración Cochrane, ha establecido el Registro Latinoamericano de Ensayos Clínicos en Curso (LATINREC, por Latin American Clinical Trial Registry) con la idea de facilitar el registro de los datos contenidos en el protocolo de todo ensayo clínico que se esté llevando a cabo en un momento dado y poner esa información a la disposición del público. El LATINREC, que viene a respaldar los objetivos de la Organización Mundial de la Salud (OMS), representa un intento por reducir la duplicación de trabajo y el financiamiento poco equitativo de la investigación sobre enfermedades rezagadas al olvido; por evitar que se efectúen investigaciones sobre asuntos de poca cuantía o que se midan resultados poco útiles; y por fomentar las prácticas éticas y la transparencia. Se han detectado algunos obstáculos mayores que hasta ahora han impedido crear un registro único y común de ensayos clínicos. Con el fin de franquearlos, LATINREC será un registro gratuito que permitirá hacer búsquedas y que se ceñirá a la Plataforma Internacional de Registro de Ensayos Clínicos (ICTRP) de la OMS. Además, LATINREC permitirá que los investigadores ingresen en el registro cualquier modificación del protocolo, así como los resultados preliminares. LATINREC ofrecerá grandes ventajas para los consumidores, el gobierno, los profesionales de la salud pública y la industria farmacéutica al incrementar la accesibilidad de la información y la participación en los ensayos clínicos. La disponibilidad de información objetiva acerca de todo ensayo clínico que se inicie ayudará a garantizar que todos tengan libre acceso a los conocimientos generados.