Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease.

OBJECTIVES: To evaluate 1) barriers to clinical guideline use and 2) the relationship between guideline use and inpatient outcomes in chronic obstructive pulmonary disease (COPD). METHODS: 1) Four focus groups of specific health professions (n = 30), from three metropolitan hospitals, and interview of 99 medical officers (MOs), linked to 349 admissions, both guided by behavioural modelling theory; 2) association between guideline use and patient outcomes (length of hospital stay > or = 14 days, and readmission within 28 or 90 days) was evaluated in a cohort of 405 COPD patients. RESULTS: 1) In focus groups, nurses and allied health professionals emphasized facilitation issues including paperwork duplication and time limitations as barriers, but considered improved patient care outcomes as the major guideline use determinant. There were similar findings in junior MOs (nonconsultants) by both focus group and interview, with the addition of a need for a sense of ownership. Senior MOs (consultants) greatly emphasized sense of ownership. Barriers to guideline use varied between types of units. Behavioural modelling explained 49% of the variation in intention to use the guideline for MOs. For nonconsultants, habit and intention were significantly associated with extent of guideline use. 2) Patient outcomes: guideline use was not associated with length of stay or readmission. CONCLUSIONS: 1) Guideline implementation should address issues relevant to different health professions, units and seniority of profession. 2) Guideline use was not associated with reductions in readmission or length of stay.

Impact on readmission rates and mortality of a chronic obstructive pulmonary disease inpatient management guideline.

AIMS: Chronic obstructive pulmonary disease (COPD) is a common condition associated with considerable morbidity, mortality and hospital admissions. However, published COPD management guidelines have major limitations and lack practical summaries. We aimed to optimally develop, implement, and evaluate a multidisciplinary COPD inpatient management 'ACCORD' guideline, including prompts for comprehensive day one assessments through to a discharge criteria checklist. METHOD: Two intervention and two control public teaching hospitals in Adelaide, South Australia, took part, with pre-intervention (721 COPD admissions over 7 months) and intervention phases (509 COPD admissions over 7 months). During the intervention stage the ACCORD guideline was placed in the case notes on the day of admission or soon after. Readmissions were categorized as either emergency or elective and compared between the study arms, as were mortality and potential confounders (age, gender, number of comorbidities), with Poisson regression analysis. RESULTS: Of case notes of eligible COPD patients, 60% had the ACCORD guideline placed, of which 76% had evidence of use as judged by completion of guideline entry and tick boxes. The ACCORD guideline was associated with an increase in elective admissions and a reduction in emergency admissions in the intervention group in relation to the control group (P < 0.01), with no difference in overall admissions or death rates. CONCLUSIONS: The ACCORD guideline was associated with a shift from emergency admissions to more planned elective care, suggesting more proactive care of health problems, but without overall reduction in admissions.

Systematic assessment of clinical practice guidelines for the management of chronic obstructive pulmonary disease.

OBJECTIVE: To systematically evaluate the quality of the development of guidelines for the management of chronic obstructive pulmonary disease (COPD). METHODOLOGY: MEDLINE and Excerpta Medica search for published guidelines, followed by independent evaluation by two reviewers, according to previously reported guideline development quality criteria, on a three-point scale. RESULTS: Five national COPD guidelines and two international COPD guidelines were retrieved. Reviewers demonstrated good inter-observer agreement in assessing the 10 combined guideline development criteria for the seven guidelines [kappa = 0.66]. Guidelines were only partly multi-disciplinary with little or no consumer input, were up to 48 pages in length, and often lacked practical summaries or management flow charts which could have facilitated retrieval of key management recommendations. Almost all the papers were based upon a consensus approach, rather than evidence based, and methods of resolution of differences of opinion were not stated. Patient outcomes, ethical and medico-legal implications were not addressed and six of the guidelines were sponsored directly or indirectly by a single drug company. CONCLUSIONS: In spite of COPD guidelines being reported by major national bodies for over a decade now, most fail to meet important criteria for high-quality guideline development, and evaluation of clinical impact remains undetermined.

Suicidal ideation and health-related quality of life in the community.

OBJECTIVE: To examine the health-related quality of life of people with suicidal ideation in the general community. DESIGN: A Health Omnibus Survey of a random, representative sample of the South Australian population in 1998, conducted by experienced interviewers. SUBJECTS: 3010 people over the age of 15 years. OUTCOME MEASURES: The survey included questions about utilisation of health services and the Short-form Health-related Quality of Life (SF-36) and Assessment of Quality of Life (AQoL) instruments. Suicidal ideation was determined in response to a direct question. RESULTS: 79 (2.6%) subjects reported suicidal ideation in the past two weeks. Compared with those without suicidal ideation, subjects with suicidal ideation reported significantly greater use of general practitioners, psychiatrists, psychologists, social workers and outpatient clinics (P<0.001), community health services and other counsellors (P<0.01), and more hospital admissions (P<0.05). Those subjects also scored significantly poorer on all subscales of both instruments (P<0.001), to the extent that they were below the 4th percentile on the role-emotional and mental health dimensions of the SF-36 and the social relationships, psychological wellbeing and overall scores of the AQoL. CONCLUSIONS: Suicidal ideation is associated with poor health-related quality of life. These results in a random and representative community sample add support to the need to improve targeting of those with suicidal ideation on a population basis with a view to earlier intervention.

Major depression and its associated morbidity and quality of life in a random, representative Australian community sample.

OBJECTIVE: The objective of this study is to describe health services utilisation and morbidity, including health-related quality of life, in those with major depression in a random and representative sample of the population. METHOD: Data were gathered in a Health Omnibus Survey of the South Australian population. Major depression was delineated on the basis of responses to the Primary Care Evaluation of Mental Disorders. Information about use of health services and absence from usual functioning was collated, and two measures of health-related quality of life, the Short-form Health Status Questionnaire and the Assessment of Quality of Life were also administered. Results of those with major depression were compared with those who had other depressive syndromes and those who had no depression. RESULTS: Those with major depression reported significantly greater use of all health services and poorer functioning in terms of carrying out their normal duties. Similarly, their health-related quality of life was significantly poorer than those with other depressive syndromes, which in turn was significantly poorer than those who were not depressed. Only one-fifth of those with major depression were currently taking antidepressants. CONCLUSIONS: These results are consistent with international studies. In addition to the potential for alleviating the depressive symptomatology of individuals, it is evident that even a modest improvement in functioning with appropriate treatment would have the potential to benefit the Australian community by one billion dollars a year.

Mental health status of the South Australian population.

OBJECTIVE: To determine, by the use of a telephone survey, the mental health status of SA adults (18+ years) using the GHQ-28, SF-12 and self-report as indicators of mental health, and to examine risk factors for mental health morbidity. SAMPLE: A random representative sample of South Australian adults selected from the Electronic White Pages. Overall, 2,501 interviews were conducted (74.0% response rate). RESULTS: Overall, 19.5% of respondents had a mental health problem as determined by the GHQ-28, 11.8% as determined by the mental health component summary score of the SF-12 and 11.9% self-reported a mental health condition. The percentage of people with a mental health problem who had used a psychologist or a psychiatrist in the previous 12 months was 9.6% for people diagnosed by the GHQ-28, 16.2% by SF-12 and 23.7% for self-report. The logistic regression analyses undertaken to describe people with a mental health problem as determined by the GHQ-28 and to describe people who visited a psychologist or psychiatrist produced different age categories, demographic and co-morbidity indicators. Variables found in both analyses included living in the metropolitan area, being economically inactive and being a high user of health services. CONCLUSIONS: One in five South Australian adults has a mental problem. Although the prevalence is higher for younger age groups, older adults are more likely to visit a psychologist or a psychiatrist. IMPLICATIONS: Telephone interviewing produces robust indicators of the prevalence of mental health problems and is a cost-effective way of identifying prevalence estimates or tracking changes over time.

The effectiveness of invitations from general practitioners in recruiting women to mammographic screening.

OBJECTIVE: To evaluate the effectiveness of general practitioner patient lists as a means of recruiting women to mammography screening. DESIGN: This study constitutes the first part of a comparative study of two alternative recruitment strategies involving invitation of women identified from: (i) general practitioner lists; and (ii) the electoral roll. SETTING AND SUBJECTS: The subjects were women aged 50-64 listed as patients of the first three private practices that agreed to collaborate with the South Australian (SA) Breast X-Ray Service to recruit by this method. These practices include five locations encompassing a spread of middle and upper class socioeconomic areas in Adelaide's southern suburbs. INTERVENTIONS: In all, 1505 women who had not already attended the SA Breast X-Ray Service were sent a letter of invitation by their general practitioner to attend the Service for a screening mammogram at a specified date and time. MAIN OUTCOME MEASURES: The primary outcome measures were eligibility status (eligible, not eligible) and attendance status (attended, cancelled appointment, failed to attend without notice). RESULTS: Excluding 34 letters that were returned unopened, 10% of invitees were classified as not eligible, mostly because they had had a recent mammogram elsewhere. Of the remaining invitees, 68.6% attended, 8.4% rang to cancel the appointment and 23% failed to attend without prior notice. CONCLUSIONS: This method of recruitment is viable, and it yields high participation rates close to the "Health for All Australians" target of 70% for mammography screening. Furthermore, the actual attendance rate for this population is expected to increase over time, because some of those initially classified as ineligible, or who cancelled or failed to attend, eventually will attend. The success of this method of recruitment will be measured against the relative cost and effectiveness of the electoral roll alternative, currently under investigation by the SA Breast X-Ray Service.