Editorial
Considerations on the low adherence to clinical practice guidelines
Consideraciones sobre la baja adherencia a las guías de práctica clínica
E. Fernández Mondéjar
Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "267" "paginaFinal" => "269" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Qué nivel de PEEP debería utilizar en mi paciente?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1202 "Ancho" => 1920 "Tamanyo" => 252710 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estimation of PEEP level change effect over total Functional Residual Capacity (FRC) and evaluation of the regional changes through an imaging system (Electrical Impedance Tomography).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Gordo, I. Conejo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Gordo" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Conejo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0210569116302509" "doi" => "10.1016/j.medin.2016.10.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569116302509?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572717300966?idApp=WMIE" "url" => "/21735727/0000004100000005/v1_201706100124/S2173572717300966/v1_201706100124/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Considerations on the low adherence to clinical practice guidelines" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "265" "paginaFinal" => "266" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "E. Fernández Mondéjar" "autores" => array:1 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Fernández Mondéjar" "email" => array:1 [ 0 => "enrique.fernandez.mondejar.sspa@juntadeandalucia.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Consideraciones sobre la baja adherencia a las guías de práctica clínica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The application of scientific advances in the clinical practice is the biggest challenge of all medical fields. A study of 2003 on the level of adherence to clinical practice recommendations showed that only 55 per cent of all measures recommended were ultimately applied to patients.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> One decade has gone by and things have not changed significantly. In the case of severely traumatized patients there is not too much information about it, and the information available reveals that the implementation of scientific evidence can be improved significantly.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Something similar happens with sepsis; some studies show that yet despite a wide media campaign, less than 20 per cent of the measures recommended by the Surviving Sepsis Campaign were really implemented, even after an important specific educational effort, this percentage only reached 38 per cent.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> We could jump into discussing other medical fields but we would probably see the same results, which leads us to the conclusion that what is considered as the “standard therapy”, that is, the treatment that is recommended based on the available scientific evidence has, in many cases, the potential to be improved.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are multiple reasons that may explain the low level of adherence to the recommendations made by clinical guidelines. In intensive medicine, there is no doubt that one important factor is the complexity of the process or the patient's comorbidities. When one patient suffers from a specific condition without further complications, and when only one or two clinical guidelines may be applied, the implementation of such guidelines is usually very high,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> which could well be the case of patients with isolated pulmonary embolisms, thrombolysis-associated strokes, or patients with myocardial infarctions due to coronary procedures, etc. Nevertheless, when dealing with patients with multi-systemic affectation and the implementation of several clinical guidelines is a possibility, the level of adherence to such guidelines drops exponentially.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> One example of this situation may be anticoagulated patients with atrial fibrillation and intracranial haemorrhages who need mechanical ventilation and whose clinical course is complicated by sepsis, malnutrition, renal function impairment, need for vasoactive drugs… In this case, the presence of multiple clinical issues and, on some occasions, the incompatibility among them poses real therapeutic dilemmas that make the physician prioritize without having the certainty that the chosen path will be the right path. Under these circumstances, the intensivist needs to focus on life-threatening issues and ignore others that may not be so urgent.</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are other factors that should be taken into consideration and, although being aware of these factors may be uncomfortable, we should discuss them openly because in my opinion they contribute to the low applicability of the recommendations. I am talking about a certain crisis of credibility in the research process due to the publication of findings that will eventually prove uncertain, wrong, or irreproducible.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> The reproducibility of the most highly cited papers barely reaches 25 per cent.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> At present, the publication of manuscripts some times responds to interests that go beyond the scientific interests, which affects the credibility of “scientific evidence”. This situation has come to a point where there are authors who think that since there are so many researches of low credibility, the priority should be the assessment and reproducibility of such researches rather than making new discoveries.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Yet despite these setbacks, we have to admit that in the last two or three decades there have been significant scientific advances that have improved healthcare in most medical fields. Such scientific advances are arranged into sets of guidelines or recommendations that are an invaluable asset for the clinician. It is important to remember that when the scientific evidence has been confirmed, its application is associated with better prognosis,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8,9</span></a> this is the reason why its implementation should be a priority not only for healthcare providers (physicians, nurses, etc.) but also for the institutions that one way or another are responsible for the patients’ healthcare. The Spanish Society of Intensive and Critical Care Medicine and Coronary Units is aware of this issue and promotes the implementation of the recommendations attached to this editorial.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> The goal is to collect interventions that proved to be useful, disseminate them among intensivists and collaborate in their implementation. The ultimate goal is to contribute to improving critical patients’ healthcare. We should remember that the implementation of these “recommendations” and any clinical guidelines is not some mechanical process where one given circumstance is followed by one certain answer as some sort of mandatory dogma or uniform approach for the management of patients.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> On the contrary, our goal is to provide an updated informative framework that will eventually help clinicians make the most adequate individualized decision for each patient. It is the responsibility of the physician who manages this or that clinical problem to assess not only the available medical literature but also other sources of knowledge such as the physician's own experience, the peculiarities, the circumstances of each patient, the preferences from patients or families and any other aspects that may be a factor in the decision-making process. Also, we should not forget that, some times, scientific truths are merely transient and what today is indicated may not be indicated in the near future. This is why periodic re-evaluations of any recommendations are a must. Also, the dynamic nature of scientific production will lead to new findings susceptible to be included in our therapeutic armamentarium, which is why these recommendations should be evaluated periodically to confirm their validity or implement new aspects.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-30" "fechaAceptado" => "2017-04-02" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Mondéjar E. Consideraciones sobre la baja adherencia a las guías de práctica clínica. Med Intensiva. 2017;41:265–266.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The quality of health care delivered to adults in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.A. McGlynn" 1 => "S.M. Asch" 2 => "J. Adams" 3 => "J. Keesey" 4 => "J. Hicks" 5 => "A. 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| 2022 October | 81 | 36 | 117 |
| 2022 September | 75 | 41 | 116 |
| 2022 August | 66 | 49 | 115 |
| 2022 July | 53 | 60 | 113 |
| 2022 June | 54 | 31 | 85 |
| 2022 May | 66 | 38 | 104 |
| 2022 April | 60 | 55 | 115 |
| 2022 March | 77 | 75 | 152 |
| 2022 February | 75 | 42 | 117 |
| 2022 January | 73 | 48 | 121 |
| 2021 December | 71 | 57 | 128 |
| 2021 November | 56 | 47 | 103 |
| 2021 October | 87 | 88 | 175 |
| 2021 September | 61 | 36 | 97 |
| 2021 August | 50 | 45 | 95 |
| 2021 July | 29 | 36 | 65 |
| 2021 June | 38 | 36 | 74 |
| 2021 May | 65 | 49 | 114 |
| 2021 April | 178 | 86 | 264 |
| 2021 March | 140 | 30 | 170 |
| 2021 February | 110 | 21 | 131 |
| 2021 January | 130 | 20 | 150 |
| 2020 December | 77 | 12 | 89 |
| 2020 November | 92 | 24 | 116 |
| 2020 October | 77 | 39 | 116 |
| 2020 September | 75 | 26 | 101 |
| 2020 August | 55 | 16 | 71 |
| 2020 July | 51 | 26 | 77 |
| 2020 June | 51 | 19 | 70 |
| 2020 May | 46 | 11 | 57 |
| 2020 April | 38 | 27 | 65 |
| 2020 March | 26 | 6 | 32 |
| 2020 February | 76 | 22 | 98 |
| 2020 January | 34 | 24 | 58 |
| 2019 December | 35 | 12 | 47 |
| 2019 November | 34 | 32 | 66 |
| 2019 October | 37 | 14 | 51 |
| 2019 September | 24 | 26 | 50 |
| 2019 August | 39 | 20 | 59 |
| 2019 July | 25 | 15 | 40 |
| 2019 June | 20 | 9 | 29 |
| 2019 May | 39 | 28 | 67 |
| 2019 April | 17 | 23 | 40 |
| 2019 March | 12 | 25 | 37 |
| 2019 February | 21 | 21 | 42 |
| 2019 January | 30 | 32 | 62 |
| 2018 December | 39 | 26 | 65 |
| 2018 November | 100 | 32 | 132 |
| 2018 October | 52 | 21 | 73 |
| 2018 September | 38 | 9 | 47 |
| 2018 August | 21 | 7 | 28 |
| 2018 July | 33 | 16 | 49 |
| 2018 June | 52 | 12 | 64 |
| 2018 May | 22 | 7 | 29 |
| 2018 April | 33 | 14 | 47 |
| 2018 March | 43 | 8 | 51 |
| 2018 February | 20 | 9 | 29 |
| 2018 January | 48 | 20 | 68 |
| 2017 December | 25 | 14 | 39 |
| 2017 November | 41 | 15 | 56 |
| 2017 October | 35 | 0 | 35 |
| 2017 September | 5 | 0 | 5 |
| 2017 July | 3 | 4 | 7 |
| 2017 June | 0 | 1 | 1 |
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