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Introduction Clinical practice guidelines ( CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated aims of these CPGs and the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial ( RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. [ABSTRACT FROM AUTHOR]

This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the modular continuing health education (CHE) programme for family doctors, known as "Working with Depression", developed by the Canadian Network for Mood and Anxiety Treatments (CANMAT) to reduce patients with depression disability. It notes that the programme, using chronic disease management (CDM) strategies, explores the impact of depression in the work place. It also enhances clinical approaches to depression, and pharmacotherapy advises.

Objective The goal was to explore the perspectives of health care professionals on factors that influence change to policies, protocols and practices in the Neonatal Intensive Care Unit (NICU) with regard to nosocomial infection and chronic lung disease. Study design An exploratory descriptive design using semi-structured individual and focus group interviews was used. Individual interviews ( n = 76) and focus group sessions ( n = 14 with a total of 78 participants) were conducted for a total of 154 health professional participants. Methods Mayring’s qualitative content analysis approach was used to analyse the data. All interviews were audio-taped, transcribed and analysed using inductive reasoning. The data were then organized into categories that reflected emerging themes. Results Seven categories that influenced practice change were derived from the data including staffing issues, consistency in practice, the approval process, a multidisciplinary approach to care, frequency and consistency of communication, rationale for change and the feedback process. These categories were further delineated into three emerging themes related to human resources, organizational structure and communications. Pettigrew’s conceptual framework provided a lens to view the results in relation to the process of change. Conclusions This study has helped to further our understanding of individual and organizational factors that facilitate and hinder changes in clinical practice in the NICU. These factors will be used as a starting point for organizational change to enhance infant outcomes in the NICU. [ABSTRACT FROM AUTHOR]

Abstract The Canadian Medical Association (CMA) maintains a database of clinical practice guidelines (CPGs) developed or endorsed by Canadian organizations. The study purpose was to describe how these guidelines were developed, disseminated and evaluated. A survey was mailed to the developer of each CPG registered in the CMA Infobase between June 1996 and December 1999. Data were received for 730 unique guidelines (response rate of 70%) developed by 75 organizations. Of these, 72% were developed by committees that had a formal process for selecting their members. The scientific literature was reviewed for all of the guidelines, a computerized search undertaken for 88% and the search strategy included 34% of CPG documents. An attempt was made to grade the quality of the evidence underpinning 54% of the guidelines. For most guidelines, consensus about values or judgements was reached by expert opinion through open discussion (78% of guidelines). The most common strategies used to disseminate the guidelines were direct mailing of guidelines to members of the developing organization (80% of all guidelines), publishing guidelines in newsletters/journals (76%), direct mailing to others (73%), electronic dissemination (62%), educational or continuing medical education activities (50%), and providing information about guidelines to patients/consumers (47%). Overall, 5% of the guidelines have been evaluated to determine their impact on health outcomes. During the 5-year study period (1994–99), the more recent guidelines were more likely to use multidisciplinary development panels, report the literature search strategies and grade the quality of the evidence. The CPG development process in Canada is becoming more rigorous and reproducible, but there is still considerable room for improvement. In addition to encouraging Canadian guideline developers to use more rigorous and transparent methods, considerably more attention must be focused on using and identifying... [ABSTRACT FROM AUTHOR]