Improving Guideline Adherence in Urology

CONTEXT: Clinical practice guidelines (CPGs) distil an evidence base into recommendations. CPG adherence is associated with better patient outcomes. However, preparation and dissemination of CPGs are a costly task involving multiple skilled personnel. Furthermore, dissemination alone does not ensure CPG adherence. Reasons for nonadherence are often complex, but understanding practice variations and reasons for nonadherence is key to improving CPG adherence and harmonising clinically appropriate and cost-effective care. OBJECTIVE: To overview approaches to improving guideline adherence, to provide urology-specific examples of knowledge-practice gaps, and to highlight potential solutions informed by implementation science. EVIDENCE ACQUISITION: Three common approaches to implementation science (the Knowledge-To-Action framework, the Consolidated Framework for Implementation Research, and the Behaviour Change Wheel), are summarised. EVIDENCE SYNTHESIS: Three implementation problems in urology are illustrated: underuse of single instillation of intravesical chemotherapy in non-muscle-invasive bladder cancer, overuse of androgen deprivation therapy in localised prostate cancer, and guideline-discordant imaging in prostate cancer. Research using implementation science approaches to address these implementation problems is discussed. CONCLUSIONS: Urologists, patients, health care providers, funders, and other key stakeholders must commit to reliably capturing and reporting data on patient outcomes, practice variations, guideline adherence, and the impact of adherence on outcomes. Leverage of implementation science frameworks is a sound next step towards improving guideline adherence and the associated benefits of evidence-based care. PATIENT SUMMARY: Clinical practice guideline documents are created by expert panels. These documents provide overviews of the evidence for the tests and treatments used in patient care. They also provide recommendations and it is expected that in most circumstances clinicians will follow these recommendations. Sometimes, health care professionals cannot or do not follow these recommendations and it is not always clear why. In this review article we look at some examples of research approaches to addressing this problem of nonadherence and we provide some examples specific to urology

Human leukocyte antigen system in clozapine-lnduced agranulocytosis

Forty-three schizophrenic patients participating in this study were serotyped for human leukocyte antigens (HLA-A, -B, -C, -DR, -DQ antigens). Thirty-six of them were hospitalised in two state mental hospitals and 7 in our general hospital, psychiatric unit. The patients from our unit were typed for HLA before commencing clozapine treatment whereas the patients from state hospitals were typed after commencing treatment. Three out of 43 patients developed agranulocytosis. One had a combination of both ’high-risk’ haplotypes (HLA-B16(38,39), DR4, DQ3 and HLA-DR2, DQ1), another had HLA-DR2, DQ1, whereas the last had a totally different haplotype. Between non-agranulocytic patients 1 was found to carry the HLA-B16(38,39), DR4, DQ3 haplotype and 14 (out of 40) had the HLA-DR2, DQ1. Taking into account other factors supposed to be involved (a noxious metabolite, and the presence of a humoral cytotoxic factor) we must admit that despite the finding of a high-risk haplotye in Jewish populations there are other aspects of this question awaiting clarification. © 1997 S. Karger AG, Basel

TL/OSL properties of natural schist for archaeological dating and retrospective dosimetry

Schist, a metamorphic rock composed largely of quartz and muscovite, has been used as a building stone through the centuries in many parts of the world. In ancient Greece, it was used in buildings and monuments (Knossos, Karthaia, etc). Basic TL and OSL properties of schist are studied in the present work to evaluate its potential use in archaeological dating and retrospective dosimetry. In particular, the optical stability, as well as the linearity of the TL and OSL signal were investigated for samples of natural schist obtained from a roofing slate. The results indicate that both signals are rapidly bleached when the sample is exposed to sunlight. An exposure of 1 min reduces the TL signal by 93%, the IRSL signal by 99% and the post-IR BSL signal by 90%. The dose response was found to be linear for a radiation dose at least up to 75 Gy for the TL and the IR OSL signal and at least up to 25 Gy for the post-IR BSL signal. (C) 2007 Elsevier B.V. All rights reserved