Guideline Adherence and Implementation of Tumor Board Therapy Recommendations for Patients With Gastrointestinal Cancer

Purpose: Although participation in multidisciplinary tumor boards (MTBs) is an obligatory quality criterion for certification, there is scarce evidence, whether MTB recommendations are consistent with consensus guidelines and whether they are followed in clinical practice. Reasons of guideline and tumor board deviations are poorly understood so far. Methods: MTBs recommendations from the weekly MTB for gastrointestinal cancers at the University Cancer Center Leipzig/Germany (UCCL) in 2020 were analyzed for their adherence to therapy recommendations as stated in National German guidelines and implementation within an observation period of 3 months. To assess adherence, an objective classification system was developed assigning a degree of guideline and tumor board adherence to each MTB case. For cases with deviations, underlying causes and influencing factors were investigated and categorized. Results: 76% of MTBs were fully adherent to guidelines, with 16% showing deviations, mainly due to study inclusions and patient comorbidities. Guideline adherence in 8% of case discussions could not be determined, especially because there was no underlying guideline recommendation for the specific topic. Full implementation of the MTBs treatment recommendation occurred in 64% of all cases, while 21% showed deviations with primarily reasons of comorbidities and differing patient wishes. Significantly lower guideline and tumor board adherences were demonstrated in patients with reduced performance status (ECOG-PS ≥ 2) and for palliative intended therapy (p=.002/.007). Conclusion: The assessment of guideline deviations and adherence to MTB decisions by a systematic and objective quality assessment tool could become a meaningful quality criterion for cancer centers in Germany.

German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients

<b><i>Background:</i></b> Oxygen (O₂) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. <b><i>Methods:</i></b> A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System (“The Oxford 2011 Levels of Evidence”) was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. <b><i>Results:</i></b> The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O₂ therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. <b><i>Conclusion:</i></b> This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.

Ideal Anatomical Landmark Points for Thoracic Esophagus Segmentation in the Chinese Population

Introduction: The standards of esophagus segmentation remain different between the Japan Esophageal Society (JES) guideline and the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) guideline. This study aimed to present variations in the location of intrathoracic esophageal adjacent anatomical landmarks (EAALs) and determine an appropriate method for segmenting the thoracic esophagus based on the relatively fixed EAALs.Patients and Methods: The distances from the upper incisors to the upper border of the esophageal hiatus, lower border of the inferior pulmonary vein (LPV), tracheal bifurcation, lower border of the azygous vein (LAV), and thoracic inlet were measured in the patients undergoing thoracic surgery. The median distances between the EAALs and the specified starting points, as well as reference value ranges and ratios, were obtained. The variation coefficients of distances and ratios from certain starting points to different EAALs were calculated and compared to determine the relatively fixed landmarks.Results: This study included 305 patients. The average distance from the upper incisors to the upper border of the cardia, the midpoint between the tracheal bifurcation and esophageal hiatus (MTBEH), LPV, LAV, tracheal bifurcation, and thoracic inlet were 41.6, 35.3, 34.8, 29.4, 29.5, and 20.3 cm, respectively. The distances from the upper incisors or thoracic inlet to any intrathoracic EAALs in men were higher than in women. In addition, the height, weight, and body mass index (BMI) were correlated with the distances. The ratio of the distance between the upper incisors and tracheal bifurcation to the distance between the upper incisors and upper border of the cardia and the ratio of the distance between the thoracic inlet and tracheal bifurcation to the distance between the thoracic inlet and upper border of the cardia possessed relatively smaller coefficients of variation.Conclusion: The distances from the EAALs to the upper incisors vary with height, weight, BMI, and gender. Compared with distance, the ratios are more suitable for esophagus segmentation. Tracheal bifurcation and MTBEH are ideal EAALs for thoracic esophagus segmentation, and this is consistent with the JES guideline recommendation.

Pirfenidone vs. nintedanib in patients with idiopathic pulmonary fibrosis: a retrospective cohort study

Background Two antifibrotic drugs, pirfenidone and nintedanib, are licensed for the treatment of patients with idiopathic pulmonary fibrosis (IPF). However, there is neither evidence from prospective data nor a guideline recommendation, which drug should be preferred over the other. This study aimed to compare pirfenidone and nintedanib-treated patients regarding all-cause mortality, all-cause and respiratory-related hospitalizations, and overall as well as respiratory-related health care costs borne by the Statutory Health Insurance (SHI). Methods A retrospective cohort study with SHI data was performed, including IPF patients treated either with pirfenidone or nintedanib. Stabilized inverse probability of treatment weighting (IPTW) based on propensity scores was applied to adjust for observed covariates. Weighted Cox models were estimated to analyze mortality and hospitalization. Weighted cost differences with bootstrapped 95% confidence intervals (CI) were applied for cost analysis. Results We compared 840 patients treated with pirfenidone and 713 patients treated with nintedanib. Both groups were similar regarding two-year all-cause mortality (HR: 0.90 95% CI: 0.76; 1.07), one-year all cause (HR: 1.09, 95% CI: 0.95; 1.25) and respiratory-related hospitalization (HR: 0.89, 95% CI: 0.72; 1.08). No significant differences were observed regarding total (€− 807, 95% CI: €− 2977; €1220) and respiratory-related (€− 1282, 95% CI: €− 3423; €534) costs. Conclusion Our analyses suggest that the patient-related outcomes mortality, hospitalization, and costs do not differ between the two currently available antifibrotic drugs pirfenidone and nintedanib. Hence, the decision on treatment with pirfenidone versus treatment with nintedanib ought to be made case-by-case taking clinical characteristics, comorbidities, comedications, individual risk of side effects, and patients’ preferences into account.

Online educational module for paramedics on prehospital 15-lead ECG recording – results of the educational part of the “Finding LCX AMI With posterior ECG leads” (FLAWLESS) trial

Background The diagnosis of ST elevation myocardial infarction (STEMI) is challenging when the culprit is in the left circumflex coronary artery (CX) territory because ST elevations are often not captured by the standard 12-lead electrocardiogram (ECG). Although, guidelines recommend the acquisition of the additional posterior leads V7-V9 (pECG) when the suspicion of acute coronary syndrome (ACS) is high and the ECG non-diagnostic, this is not routinely done. Purpose The purpose of the FLAWLESS trial, was to improve the prehospital CX STEMI diagnostic. The study consisted of 2 parts: a) a training and implementation study, and b) an outcomes study after implementation. In the implementation study we evaluated the FLAWLESS process from the paramedic's point of view on experiences, implementation of pECG lead recordings and its barriers. Methods Before initiating the trial, all active paramedics in 2 health care regions were educated via a specifically designed and mandatory online 30 min course and all 250 ambulances equipped with a SMART-CARD (instructing how to record pECG leads) and FAQ-sheet. All paramedics were invited by email to anonymously answer an online questionnaire (OQ) designed in REDCap® and interviewed. Utility-score and difficulty-score, ranging from 0 (not useful at all/very easy) to 100 (very useful/very difficult), were introduced for quantitative assessments. Results A total of 1268 paramedics were invited to answer the OQ. The response rate was intermediate at 35%. Among responders, 89% had completed the OEP. On duty 80% had used FAQ-sheet and 74% SMART-CARD in the field. The median utility scores were 80 (25th and 75th quartiles 67–90) for OEP, 79 (61–90) for FAQ-sheet and 85 (75–97) for SMART-CARD, respectively. The implementation of pECG leads recordings was fairly high – 54% reported always recording V7-V9 in ACS patients and 36% reported doing it frequently. Difficulty-score for recording V7-V9 leads in the prehospital setting was 50 (19–70). Finally, 43% reported difficulties that were related to technicalities i.e. defibrillators not having dedicated V7, V8 and V9 cables, hence ambulance staff is forced to record and transmit a second ECG after moving the V4, V5 and V6 cables to the V7-V9 positioned electrodes. Conclusion We demonstrated that large-scale online training of paramedics in the recording of prehospital 15-lead ECG is feasible. The evaluation was positive regarding training and support tools in the ambulances but almost 50% of paramedics found the recording very difficult in the field. Future ECG machines used in emergency settings should be constructed with 13 instead of 10 cables to allow simultaneously recording of 15 leads (standard, precordial and the V7-V9 posterior). This would ease acquisition, facilitate implementation of guideline recommendation. FUNDunding Acknowledgement Type of funding sources: None.

Discrepancy between German S3 Guideline Recommendations and Daily Urologic Practice in the Management of Nonmuscle Invasive Bladder Cancer: Results of a Binational Survey

<b><i>Introduction:</i></b> Guideline recommendations are meant to help minimize morbidity and to improve the care of nonmuscle invasive bladder cancer (NMIBC) patients but studies have suggested an underuse of guideline-recommended care. The aim of this study was to evaluate the level of adherence of German and Austrian urologists to German guideline recommendations. <b><i>Methods:</i></b> A survey of 27 items evaluating diagnostic and therapeutic recommendations (15 cases of strong consensus and 6 cases of consensus) for NMIBC was administered among 14 urologic training courses. Survey construction and realization followed the checklist for reporting results of internet e-surveys and was approved by an internal review board. <b><i>Results:</i></b> Between January 2018 and June 2019, a total of 307 urologists responded to the questionnaire, with a mean response rate of 71%. The data showed a weak role of urine cytology (54%) for initial diagnostics although it is strongly recommended by the guideline. The most frequently used supporting diagnostic tool during transurethral resection of the bladder was hexaminolevulinate (95%). Contrary to the guideline recommendation, 38% of the participants performed a second resection in the case of pTa low-grade NMIBC. Correct monitoring of Bacille Calmette-Guérin (BCG) response with cystoscopy and cytology was performed by only 34% of the urologists. <b><i>Conclusions:</i></b> We found a discrepancy between certain guideline recommendations and daily routine practice concerning the use of urine cytology for initial diagnostics, instillation therapy with a low monitoring rate of BCG response, and follow-up care with unnecessary second resection after pTa low-grade NMIBC in particular. Our survey showed a moderate overall adherence rate of 73%. These results demonstrate the need for sharpening awareness of German guideline recommendations by promoting more intense education of urologists to optimize NMIBC care thus decreasing morbidity and mortality rates.

Impact of guideline awareness on the counseling of patients with acute cough among general practitioners and pharmacy personnel

Objective To explore the awareness and knowledge of applicable guidelines on acute cough among general practitioners, pharmacists and pharmacy technicians and to compare their recommendation behavior and clinical decision making to the evidence-based recommendation in the applicable guidelines. Methods An anonymous online survey was performed among 303 members of an existing panel of healthcare professionals (HCPs). They were presented with a hypothetical case vignette representative of their daily practice and asked for their treatment recommendations. After being shown an excerpt from the applicable guidelines, these questions were repeated. Results Forty-six % of participants reported to seek information on cough and respiratory conditions very often or often. Among 12 non-prescription treatments-commonly used over-the-counter-products for acute cough, HCPs most often recommended various plant extract-based products (phytotherapeutic remedies) for the acute cough case, whereas chemically defined options such as ambroxol or N-acetyl-cysteine were recommended less often. Following presentation of the guidelines excerpt, recommendations of the phytotherapeutic remedies decreased moderately whereas that of the guideline-recommended ambroxol more than doubled. Among stated reasons for the recommendation guideline conformity increased from 5% to 35% among the top-3 reasons. Conclusions The recommendations for the treatment of acute cough by professionals involved in primary healthcare deviated considerably from the applicable guideline recommendation but changed after presentation of a guidelines excerpt and knowledge thereof. We conclude that dissemination of applicable guideline knowledge is relevant to improve evidence-based healthcare and clinical decision making.