Selection of the guidelines whose knowledge is to be
transformed and the specific recommendations that will be implemented
represents the first critical task in this project. Pending approval by the
Project Officer we have selected two guidelines that satisfy the constraints of
this RFP (evidence-based; public domain; not yet translated into broadly
available decision support tools; cover preventive services and clinical
management of common chronic illnesses):
1. Screening
and interventions for overweight in children and adolescents from the Expert
Committee on the Assessment, Prevention, and Treatment of Child and Adolescent
Overweight and Obesity, convened by the American Medical Association, the DHHS
Health Resources and Services Administration, and the Centers for Disease
Control and Prevention. The current epidemic of adult obesity and its attendant
morbidities and mortality has its onset in the pediatric age group.
Weight-related hypertension, type II diabetes, hyperlipidemia, sleep disorders,
and overweight-related orthopedic problems are now within the province of
pediatrics. Effective recognition of and intervention against overweight and
obesity can be expected to have major positive public health consequences.
2. The
recently released guidelines on management of asthma from the National Asthma
Education and Prevention Program of the National Heart Lung and Blood
Institute. Asthma is one of the most common chronic diseases of childhood,
affecting 6.2 million children (National Health Interview Study 2004) and
accounting for almost one half million hospitalizations annually. In addition
to its considerable morbidity, more than 4000 people die of asthma each year.
This guideline revision includes recommendations regarding diagnosis, control of
environmental factors, acute management of exacerbations, chronic management,
and patient education and represents a superb example of the challenges that
are involved in analysis and implementation of guidelines for chronic
management of complex disease. Because limited decision support based on the
current guideline already exists at Yale, implementation of the forthcoming
revision will require particular attention to knowledge and system maintenance
in the face of new statements about best practice.
Discussions at the selected demonstration sites have
confirmed that quality improvement initiatives in prevention of pediatric
overweight and obesity and chronic management of asthma would be well received.
Decision support is most effective when it is responsive to such local needs.
The two guidelines are expected to impact on:
·
Quality, safety, and cost-effectiveness of care at the patient
level
·
Regulatory compliance and resource use at the organization level
·
Areas of considerable interest to practicing clinicians
·
The existing gap between current and desired levels of care.
In selecting these guidelines, we have also aimed to
identify guidelines that will provide common implementation challenges,
including:
·
Recommendations that contain vague, underspecified, and ambiguous
language
·
Recommendations that fail to include recommendation strength (an
indication by the developer of expected adherence level and a concept distinct
from evidence quality)
·
Recommendations illustrating a range of action-types
·
Recommendations .not. to perform, i.e., recommendations of
omission as well as commission
·
Recommendations that are difficult to identify as such, including
recommendations delivered as statements rather than as prescriptions for
appropriate care.
We plan to address the challenges directly and will provide
feedback about them to guideline developers, health IT vendors, and other
stakeholders.
