Impact of guideline adherence on the prognosis of Barcelona clinic liver cancer stage B hepatocellular carcinoma

BACKGROUND Patients with Barcelona clinic liver cancer(BCLC)stage B hepatocellular carcinoma(HCC)are considerably heterogeneous in terms of tumor burden,liver function,and performance status.To improve the poor survival outcomes of these patients,treatment approaches other than transarterial chemoembolization(TACE),which is recommended by HCC guidelines,have been adopted in realworld clinical practice.We hypothesize that this non-adherence to treatment guidelines,particularly with respect to the use of liver resection,improves survival in patients with stage B HCC.AIM To assess guideline adherence in South Korean patients with stage B HCC and study its impact on survival.METHODS A retrospective analysis was conducted using data from 2008 to 2016 obtained from the Korea Central Cancer Registry.Patients with stage B HCC were categorized into three treatment groups,guideline-adherent,upward,and downward,based on HCC guidelines recommended by the Asian Pacific Association for the Study of the Liver(APASL),the European Association for the Study of the Liver(EASL),and the American Association for the Study of Liver Diseases(AASLD).The primary outcome was HCC-related deaths;tumor recurrence served as the secondary outcome.Survival among the groups was compared using the Kaplan-Meier method and the log-rank test.Predictors of survival outcomes were identified using multivariable Cox regression analysis.RESULTS In South Korea, over the study period from 2008 to 2016, a notable trend was observed in adherence to HCCguidelines. Adherence to the EASL guidelines started relatively high, ranging from 77% to 80% between 2008 and2012, but it gradually declined to 58.8% to 71.6% from 2013 to 2016. Adherence to the AASLD guidelines began at71.7% to 75.9% from 2008 to 2010, and then it fluctuated between 49.2% and 73.8% from 2011 to 2016. In contrast,adherence to the APASL guidelines remained consistently high, staying within the range of 90.14% to 94.5%throughout the entire study period. Upward treatment, for example with liver resection, liver transplantation, orradiofrequency ablation, significantly improved the survival of patients with BCLC stage B HCC compared to thatof patients treated in adherence to the guidelines (for patients analyzed according to the 2000 EASL guidelines, the5-year survival rates were 63.4% vs 27.2%, P < 0.001), although results varied depending on the guidelines.Progression-free survival rates were also significantly improved upon the use of upward treatments in certaingroups. Patients receiving upward treatments were typically < 70 years old, had platelet counts > 105/μL, andserum albumin levels ≥ 3.5 g/dL.CONCLUSIONAdherence to guidelines significantly influences survival in South Korean stage B HCC patients. Curativetreatments outperform TACE, but liver resection should be selected with caution due to disease heterogeneity.

Impact of guideline adherence and race on asthma control in children

Background Asthma control in African Americans(AA)is considered more difficult to achieve than in Caucasian Americans(CA).The aim of this study was to compare asthma control over time among AA and CA children w hose asthma is managed per NAEPP(EPR-3)guidelines.Methods This was a one-year prospective study of children referred by their primary care physicians for better asthma care in a specialty asthma clinic.All children received asthma care per NAEPP guidelines.Results were compared between CA and AA children at baseline and then at three-month intervals for one year.Results Of the 345 children,ages 2-17 years(mean=6.2±4),220(63.8%)were CA and 125(36.2%)were AA.There were no significant differences in demographics other than greater pet ownership in CA families.At baseline,AA children had significantly more visits to the Emergency Department for acute asthma symptoms(mean=2.3±3)compared to CA(1.4±23,P=0.003).There were no other significant differences in acute care utilization,asthma symptoms(mean days/month),or mean asthma control test(ACT)scores at base line.Within 3-6 months,in both groups,mean ACT scores,asthma symptoms and acute care utilization significantly improved(P<0.05 for all)and change over time in both groups was comparable except for a significantly greater decrease in ED visits in AA children compared to CA children(P=002).Conclusion Overall,improvement in asthma control during longitudinal assessment was similar between AA and CA children because of consistent use of NAEPP asthma care guidelines.

Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome

Background Performance metrics currently focus on the measurement of the application of guideline-indi- cated medications without considering the appropriate dosing of these drugs.

Clinical usefulness of adherence to gastro-esophageal reflux disease guideline by Spanish gastroenterologists

AIM:To investigate usefulness of adherence to gastroesophageal reflux disease(GERD) guideline established by the Spanish Association of Gastroenterology.METHODS:Prospective,observational and multicentre study of 301 patients with typical symptoms of GERD who should be managed in accordance with guidelines and were attended by gastroenterologists in daily practice.Patients(aged > 18 years) were eligible for inclusion if they had typical symptoms of GERD(heartburn and/or acid regurgitation) as the major complaint in the presence or absence of accompanying atypical symptoms,such as dyspeptic symptoms and/or supraesophageal symptoms.Diagnostic and therapeutic decisions should be made based on specific recommendations of the Spanish clinical practice guideline for GERD which is a widely disseminated and well known instrument among Spanish in digestive disease specialists.RESULTS:Endoscopy was indicated in 123(41%) patients:50 with alarm symptoms,32 with age > 50 years without alarm symptom.Seventy-two patients(58.5%) had esophagitis(grade A,23,grade B,28,grade C,18,grade D,3).In the presence of alarm symptoms,endoscopy was indicated consistently with recommendations in 98% of cases.However,in the absence of alarm symptoms,endoscopy was indicated in 33% of patients > 50 years(not recommended by the guideline).Adherence for proton pump inhibitors(PPIs) therapy was 80%,but doses prescribed were lower(half) in 5% of cases and higher(double) in 15%.Adherence regarding duration of PPI therapy was 69%;duration was shorter than recommended in 1%(4 wk in esophagitis grades C-D) or longer in 30%(8 wk in esophagitis grades A-B or in patients without endoscopy).Treatment response was higher when PPI doses were consistent with guidelines,although differences were not significant(95% vs 85%).CONCLUSION:GERD guideline compliance was quite good although endoscopy was over indicated in patients > 50 years without alarm symptoms;PPIs were prescribed at higher doses and longer duration.

Distress management in cancer patients:Guideline implementation based on CAN-IMPLEMENT

Objective:To standardize the distress management of gastric cancer patients receiving chemotherapy,the adapted Cancer-related Distress Management Guidelines were implemented in nursing practice among gastric cancer patients receiving chemotherapy based on A Guideline Adaptation and Implementation Planning Resource(CAN-IMPLEMENT).Methods:Based on the theoretical framework of CAN-IMPLEMENT,A multidisciplinary team was established,barriers and facilitators obstacles of guidelines implementation in medical oncology units were assessed,corresponding solutions were formulated,the guidelines implementation process was monitored,and implementation results were evaluated.Results:The multidisciplinary team developed review criteria,standardized work paths,assessment tools,training manuals for healthcare professionals,education manuals for patients and their caregivers.After guidelines implementation,the completion rate of the distress management record came up to 97.9%(189/193).From September 2017 to December 2018,the compliance of medical staff on most items in the audit checklist was improved,ranging from 57.1%(100/175)to 100.0%(193/193).The positive distress rate of gastric cancer patients receiving chemotherapy was decreased from 22.7%(32/141)to 9.3%(18/193)(P<0.05),and the Median(range)of the distress score declined from 2(0e9)to 0(0e7)(P<0.001).Conclusions:The implementation of guidelines based on CAN-IMPLEMENT promotes the establishment of a distress management system in the medical oncology units.The review standards,standardized work paths,and evaluation tools for distress in cancer patients formulated by the multidisciplinary team had clinical applicability and effectiveness.Quality control in the practice of distress management was effective.The compliance of healthcare professionals with distress management was improved.The distress of gastric cancer patients receiving chemotherapy was alleviated effectively.

Acceptance of American society for gastrointestinal endoscopy’s guidelines for endoscopy reports

Background: Several studies indicate that endoscopy reports lack uniform content and terminology. Thus ASGE, ESGE, and WEO have prepared guidelines to improve the quality of endoscopy reports. However, the acceptance of such recommendations in the community of endoscopists has not been assessed. Objective: The aim of the present study was to determine Non-US endoscopists’ agreement to current ASGE guidelines for endoscopy reporting and ESGE recommendations for image documentation. Design: 137 endoscopists were invited to participate in this internet survey, covering 34 items regarding the content of the endoscopy reports. Non-responders received three e-mail reminders before the study was closed. Settings: A web-based survey tool developed at the University of Oslo was used to perform this study (https://wo.uio.no/as/WebObjects/nettskjema.woa). Results: Eighty (60%) of the 137 endoscopists responded, to the survey. Their agreement to the various items of the ASGE guidelines for text content ranged from 21% - 100%. Only 8.9% (95% CI, 4.4% - 17.2%) considered it necessary to perform routine image documentation according to the ESGE guidelines. Limitations: The response rate of 68%, is on the lower limit of acceptable. Conclusions: The cohort of endoscopists agrees partially to the ASGE guidelines. However, they do not consider systematic image documentation

Regional Variation in Mammography Use among Insured Women 40-49 Years Old： Impact of a USPSTF Guideline Change

Purpose： The impact of the USPSTF （US Preventive Services Task Force） recommendation that 40-49 year old women should no longer routinely receive screening mammography in November 2009 in different regions of the US is unknown. Methods： The authors conducted a retrospective cohort study using medical claims from administrative health records from privately insured 40-59 year old women enrolled between 2005 and 2012 to evaluate biennial screening trends. Results： There was a slight decrease in mammography usage among 40-49 year old US women after the 2008-2009 biennial period （p 〈 0.001）. There were some regional differences in mammography trends, with the West showing the greatest difference in odds of 40-49 year olds receiving a mammography in 2011-2012 compared to 2008-2009 （OR： 0.93; 95% CI： 0.91-0.94）. Although trends for 50-59 year olds mirrored that of 40-49 year olds, the younger age group had a stronger decline in 2009-2010 and 2010-2011. Conclusions： These findings show that USPSTF guideline changes made some differences in mammography usage among 40-49 year olds, but adherence was uneven across regions.

Adherence to clinical guidelines for monitoring diabetes in primary care settings

Objective:Adherence to clinical guidelines is key to improving diabetes care.Contemporary knowledge of guideline adherence is lacking.This study sought to produce a national snapshot of primary care physicians’(PCPs)adherence to the American Diabetes Association guidelines for monitoring diabetes and determine whether continuity of care promotes adherence.Methods:Using the 2013 National Ambulatory Medical Care Survey,we examined adher-ence to ordering hemoglobin A1c(HbA1c)and lipid profile tests as recommended by the American Diabetes Association for monitoring diabetes in 2379 primary care visits of patient with diabetes.Results:In the preceding 12 months,less than 60.0%of the patients were given a test rec-ommended for monitoring diabetes(58.0%for HbA1c and 57.0%for lipid profile).Continuity of care with PCPs increased the odds of adhering to diabetes monitoring guidelines by 36.0%for the HbA1c test(P=0.06)and by 76.0%for the lipid profile test(P=0.0006).Conclusion:A substantial gap exists in achieving optimal monitoring for diabetes in primary care settings in the United States.While PCPs are ideally positioned to ensure that guidelines are closely followed,we found that even in primary care settings,patient-provider continuity of care was associated with guideline adherence.

Nationwide survey analysis of esophagogastric varices in portal hypertension based on endoscopic management in China

Aims:The endoscopic treatment of esophagogastric varices is challenging,and the nationwide application of endoscopic therapies for various types of esophagogastric varices and different clinical scenarios remains unclear.This study investigated the use of endoscopic therapy for portal hypertension in China.Methods:This study used a questionnaire survey initiated by the Liver Health Consortium in China to investigate the use of endoscopic therapies for portal hypertension.Questionnaires were released online from January 30,2023 to February 28,2023 and filled out by chief physicians or senior instructors responsible for endoscopic therapies in participating hospitals across 31 provinces(autonomous regions and municipalities)in China.Comparisons of guideline adherence between primary and referral medical centers were performed using the chi‐square test or Fisher's exact test.Results:In total,836 hospitals participated in the survey.For primary and secondary prophylaxis of esophagogastric variceal bleeding(EGVB),adherence to the national guidelines was 72.5%(606/836)and 39.2%(328/836),respectively.Significant differences were observed in the rate of adherence between the primary and referral centers for primary(79.9%[111/139]vs.71.0%[495/697],p=0.033)and secondary prophylaxis(27.3%[38/139]vs.41.6%[290/697],p=0.002).Of the hospitals,78.2%(654/836)preferred endoscopic therapies for acute EGVB,and the timing of endoscopy was usually within 12 h(48.5%,317/654)and 12-24 h(36.9%,241/654)after bleeding.Endoscopic therapy was more likely to be the first choice of treatment for acute EGVB in referral centers than in primary centers(82.6%[576/697]vs.56.1%[78/139],p<0.001).Regarding the management of gastroesophageal varices type 2 and isolated gastric varices type 1,the most prevalent procedures were cyanoacrylate injection combined with sclerotherapy(48.2%[403/836]and 29.9%[250/836],respectively);however,substantial hospitals preferred clip-assisted therapies(12.4%[104/836]and 26.4%[221/836],respectively).Nonselective beta‐blockers were routinely used in 73.4%(614/836)of hospitals during the perioperative period of EGVB management,and propranolol(88.8%,545/614)and carvedilol(37.5%,230/614)were the most widely used nonselective beta-blockers.Conclusions:This survey clarified that various endoscopic procedures have been implemented nationwide in China.Participating hospitals have actively performed emergent endoscopy for acute EGVB;however,these hospitals do not adequately follow recommendations regarding primary and secondary prophylaxis of EGVB.In the future,standardizing the selection of endoscopic procedures and improving compliance with guidelines is crucial.

Low Concordance Between Blood Pressures Measured in Periodic Health Examinations and in a Workplace-Based Hypertension Management Program

Poor adherence to standard protocols of blood pressure(BP)measurement in routine clinical practice leads to higher readings than“research-quality”measurements.Whether this phenomenon exists in periodic health examinations was unknown.We aimed to explore the concordance between BP measurements in periodic health examinations and those measured following a standard measurement protocol.We used data from the Kailuan Study,an ongoing longitudinal cohort study in China,of which participants received biennial health examinations in health management centers.In addition,BPs were measured following standard protocols in a workplace-based hypertension management program nested in the Kailuan Study.We compared BP readings of the same person between the two settings using generalized linear mixed-effects models.A total of 3988 men(the mean age was 44.9 years)had at least two BP measurements both in health examinations and management program with a time interval between the two settings that less than 90 days.The mean systolic blood pressures(SBP)and diastolic blood pressures(DBP)in health examinations were 4.2(95%CI 3.9–4.5)mm Hg and 3.3(95%CI 3.1–3.5)mm Hg higher than those in the management program,respectively.Bland–Altman analyses showed the wide agreement inter-vals ranging from-27.7-to 36.5-mm Hg for SBP and-18.3-to 24.7-mm Hg for DBP.In conclusion,BP measurements in periodic health examinations were generally higher than BPs measured following a standard protocol.Our findings highlight the importance of standard BP measurement to avoid overestimation of hypertension prevalence and treatment initiation.