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To establish what GIN guideline community members see as the desirable features of a guidelines library and registry of guidelines in development An explorative mixed-methods study was undertaken, including scoping activity and semi-structured interviews with guideline developers and endorsers from nine member organizations of the Guidelines International Network. A small number of desirable features of a guideline library were identified: comprehensiveness; single source of information to avoid searching multiple sites; inclusion of related materials; being up to date; searchability and ease of use. No existing library of guidelines was considered to have all of these features. A number of issues arose out of the desire to have a comprehensive library of guidelines, including inclusion of ‘high quality guidelines’ and limiting the scope to include only national guidelines. For registries of guidelines in development, the data set should be limited to avoid placing undue burden on those entering information. Our findings identify ongoing issues for the guideline community, including the tension between comprehensiveness and ease of use, which can result in limited uptake, reporting of guideline quality and the need for clarity on the purpose of any library or registry.

“More research is needed” is a conclusion that fits most systematic reviews. But authors need to be more specific about what exactly is required

Abstract Objectives To determine whether the dose of inhaled corticosteroids can be stepped down in patients with chronic stable asthma while maintaining control. Design One year, randomised controlled, double blind, parallel group trial. Setting General practices throughout western and central Scotland. Participants 259 adult patients with asthma receiving regular treatment with inhaled corticosteroids at high dose (mean dose 1430 μg beclomethasone dipropionate). Interventions Participants were allocated to receive either no alteration to their dose of inhaled corticosteroid (control) or a 50% reduction in their dose if they met criteria for stable asthma (stepdown). Main outcome measures Comparison of asthma exacerbation rates, asthma related visits to general practice and hospital, health status measures, and corticosteroid dosage between the two groups. Results The proportions of subjects with asthma exacerbations were not significantly different (stepdown 31%, control 26%, P=0.354). Similarly, the numbers of visits to general practice or hospital and the disease specific and generic measures of health status over the one year period were not significantly different. On average the stepdown group received 348 μg (95% confidence interval 202 μgto494 μg) of beclomethasone dipropionate less per day than the controls (a difference of 25%), with no difference in the annual dose of oral corticosteroids between the two treatment regimens. Conclusions By adopting a stepdown approach to the use of inhaled steroids at high doses in asthma a reduction in the dose can be achieved without compromising asthma control.

BackgroundA key objective of the Guidelines International Network (GIN) is to reduce duplication of effort. To address this objective, a working group was established to define a minimum dataset for inclusion in all evidence tables.MethodsA literature review was conducted to identify existing evidence tables, and GIN member organisations were asked to provide the tables they use. The results were used to develop a minimum dataset (template) for studies addressing intervention questions. The template was pilot-tested by a group of guideline developers and reviewed at GIN conferences.ResultsThe literature search yielded 65 articles. These dealt with reporting standards and trial quality (eg, CONSORT statement) rather than which data should be extracted from studies. However, the checklist items given were considered useful. Nineteen GIN members provided evidence tables; 17 tables were used for analysis. The number of items included in the tables ranged from 8 to 19, with several items common to all tables. Within individual items, the level of detail varied widely. The draught template included a majority of items relating to objective data. Pilot testing revealed that the median time to read a paper and complete the template was 2 h for a randomised controlled trial and 2½ h for a non-randomised, controlled intervention study. The median rating for both relevance and clarity of items was high.ConclusionThe template listing the items needed to summarise an interventional study is now available for large-scale testing by all organisations.

Abstract Objective: To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface. Design: Cluster randomised controlled trial. Setting: General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area. Participants: All 221 general practices in Glasgow; 214 completed the trial. Intervention: General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings. Main outcome measures: The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups. Results: Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected. Conclusions: Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care. What is already known on this topic Most previous research into clinical guidelines has focused on their development and implementation Evidence is lacking about the outcomes and costs associated with the use of clinical guidelines What this study adds Clinical guidelines that may alter the balance of care between general practice and hospital settings require more intensive implementation than guidelines aimed at either setting on its own The cost effectiveness of clinical guidelines should not be assumed

Midwife-managed programmes of care are being widely implemented although there has been little investigation of their efficacy. We have compared midwife-managed care with shared care (ie, care divided among midwives, hospital doctors, and general practitioners) in terms of clinical efficacy and women's satisfaction. We carried out a randomised controlled trial of 1 299 pregnant women who had no adverse characteristics at booking (consent rate 81·9%). 648 women were assigned midwife-managed care and 651 shared care. The research hypothesis was that compared with shared care, midwife-managed care would produce fewer interventions, similar (or more favourable) outcomes, similar complications, and greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. Analysis was by intention to treat. Interventions were similar in the two groups or lower with midwife-managed care. For example, women in the midwife-managed group were less likely than women in shared care to have induction of labour (146 [23·9%] vs 199 [33·3%]; 95% CI for difference 4·4–14·5). Women in the midwife-managed group were more likely to have an intact perineum and less likely to have had an episiotomy (p=0·02), with no significant difference in perineal tears. Complication rates were similar. Overall, 32·8% of women were permanently transferred from midwife-managed care (28·7% for clinical reasons, 3·7% for non-clinical reasons). Women in both groups reported satisfaction with their care but the midwife-managed group were significantly more satisfied with their antenatal (difference in mean scores 0·48 [95% CI 0·41–0·55]), intrapartum (0·28 [0·18–0·37]), hospital-based postnatal care (0·57 [0·45–0·70]), and home-based postnatal care (0·33 [0·25–0·42]). We conclude that midwife-managed care for healthy women, integrated within existing services, is clinically effective and enhances women's satisfaction with maternity care.

In this multicenter, randomized trial of outcomes of uterine-artery embolization versus surgery for symptomatic fibroids, there were no differences between groups in quality of life at 1 year. Women who underwent embolization had a shorter duration of hospitalization and a shorter interval until the resumption of normal activities but were more likely to require rehospitalization for adverse outcomes or to need reintervention owing to treatment failure. Women who underwent embolization had a shorter duration of hospitalization but were more likely to require rehospitalization for adverse outcomes or to need reintervention owing to treatment failure. Uterine fibroids are the most common type of tumor in the female reproductive system. The presence of these tumors may cause menstrual disorder and can be associated with subfertility, miscarriage, and pressure effects. 1 For women who no longer plan to give birth, the established treatment is hysterectomy. In the United Kingdom, approximately 42,500 hysterectomies are performed annually, with approximately 30% indicated for fibroids (the second-most-frequent indication). 2 For women wishing to maintain their fertility, myomectomy is the principal option. Uterine-artery embolization was introduced in 1995 as an alternative technique for treating fibroids. 3 Since then it has become increasingly accepted as a . . .

Development by the organisation Action on Pre-eclampsia of a guideline for screening and early detection of pre-eclampsia in the community. The PRECOG guideline is presented as complementary to the NICE antenatal guidelines, with recommended action for early risk assessment and action plans for midwives or GPs, referrals, and action after 20 weeks. [(BNI unique abstract)] 24 references