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Adherence to guidelines denotes the degree of conformity between the knowledge, cognition and/or action of an agent with the recommendations of a guideline. Regarding this construct, an analysis of German and international publications of empirical research was conducted to reveal opportunities of operationalisation and measurement. The units of investigation of guideline conformity are actions. Analysis may focus upon agents (e.g., proportion of guideline-adherent specialists in a region), fields of action (e.g., percentage of guideline-adherent prescriptions or diagnostic procedures) or patients (percentage of patients treated according to the guideline). The construction of an appropriate instrument can follow an inductive or deductive approach, focusing either upon the reality of care or the relevant guideline(s) for the identification of candidate actions, decisions or guideline recommendations. The literature is dominated by percentage measurements of guideline conformity, the validity of which is limited to defined conditions. Conclusions for practice are only possible if one can distinguish between justified and non-justified non-adherence to guidelines. Evaluation of guideline adherence may contribute to an improvement of structural and process quality, the assessment of standards of practice and involved agents, and the improvement of guideline implementation. Whether guideline adherence is a valid surrogate parameter for the quality of care depends on the quality and appropriateness of the relevant guideline(s) and on the instrument used for measuring adherence. Guideline adherence does not prove that guidelines are used, but rather whether and to what extent the contents of guidelines are also contents of everyday care.

We report a court verdict in the second retrial of a murder case that was based exclusively on the witness account of a severely brain damaged victim, and its reversal by the German Federal Court. The assessment of evidence had to weigh up the probability of the presence of real accounts of the crime versus the possibility of alternative explanations, i. e. trauma related confabulation. The defendant was acquitted.

The application of evidence-based and standardized knowledge is an important basis for coordinated and effective clinical work. A multicenter study, which was conducted in 30 clinical neurology departments and included 99 junior and senior registrars, addressed aspects of practical knowledge of stroke treatment by open structured oral interviews which were analyzed with respect to interphysician and guideline conformity. In addition, the participants were asked to rate the usefulness of various informational sources and describe their informational sources used according to the aspects of practical knowledge addressed. The respective departmental directors were questioned about the sources of medical knowledge accessible in their clinic. In almost all hospitals, physicians had access to a library and the Internet. However, departments differed with respect to their information management (frequency and type of medical education, quality management, participation in research activities). In accordance with other studies, the knowledge sources reported most often were textbooks, journals and clinical studies. For most sources, the usefulness rankings largely corresponded to the rankings of user behavior. Both were only weak predictors for interphysician and guideline conformity. They are more closely related to the within-department homogeneity of practical knowledge than to interdepartmental and guideline conformity. Within-department homogeneity is enhanced by the use of recent, published and evidence-based sources and topical interaction with clinical colleagues. Guideline conformity was related to the use of databases and professional journals. A preference for colleagues from out-patient practices diminished both interphysician and guideline conformity. It seems there is still untapped potential for within-department knowledge management, such as medical education, implementation and use of guidelines and topical discussions, which may enhance the homogeneity and guideline conformity of the practical knowledge that clinicians apply.

Background: Legislation, professional medical societies and health care providers urge neurological departments to increase focus on more effective structures and processes. This, however, depends on the appreciation of quality features by the physicians involved., Goal: The present study aimed to identify neurologists' subjective quality criteria, the analysis of influential factors, and a comparison with existing guidelines., Method: In a multicentre survey, 99 registrars and senior registrars from 30 clinical departments of neurology were interviewed. The data were analysed both quantitatively and qualitatively., Results: In the participants' view, the quality of acute stroke care depends upon access to competent care, optimal acute management and the presence of trained and experienced personnel. Some subjective dimensions of service quality are dependent upon the interviewed neurologist's board certification status and the features of the respective department (stroke caseload, implementation of a stroke guideline). In comparison to national guidelines, early secondary prevention is underreported. Interviewed neurologists and guidelines agree on the importance of rapid diagnostic procedures and continuous monitoring., Conclusions: The focus upon early and rapid diagnosis and treatment underlines the importance of optimal emergency organisation for acute stroke patients. Early secondary prophylaxis, the prevention of complications and rehabilitation management are underestimated as relevant fields of action. Empirical research and medical education should address possible deficits concerning these aspects.

Background: Guidelines gain importance for medical services. Their perception and use by physicians does not only rely on their attitudes towards guidelines, but also on other parameters of influence., Purpose: to assess hospital physicians's attitudes concerning clinical guidelines and physician- and hospital- related factors of influence., Methods: multicenter survey with 99 junior and senior registrars from 30 departments of neurology (taking regional random samples)., Results: A majority of physicians regarded guidelines as a means of quality improvement and medical education. However, there were no generally positive or negative attitudes, but the physicians differentiated between the individual and the health system level. These patterns of attitudes did not depend upon aspects of the respective departments (such as size, internal guidelines, access to sources of information) and did not vary significantly between hospitals. Instead, there was a marked influence of personality traits on individual opinions concerning guideline utility. Senior registrars, less team-oriented physicians, younger physicians and the more prestige-motivated expressed positive attitudes. On the other hand, a sceptical and more negative attitude was found with professionals who expressed strong team orientation and scientific interest., Conclusions: The overall positive attitude is probably related to the identification of guideline users with their authors and also to the their present status as non-binding recommendations. The independence of attitudes from hospital characteristics, especially the existence of internal guidelines, may indicate either voluntary guideline use or rather a low impact of guidelines as management instruments or frequently used tools. The potential of guidelines for medical education does not seem to be fully utilised.

Setting preferences and expectations before and appraisals and criticisms after neurological rehabilitation of stroke patients who fulfilled German phase-D criteria (cooperative and independent in basic ADL-functions) were longitudinally assessed in a rehabilitation centre with in-patient and out-patient facilities of comparable therapeutic quality and intensities, and followed-up for 6 months. 53 patients fulfilled inclusion criteria, of whom 16 opted for and received out-patient rehabilitation, 21 opted for out-patient rehabilitation but had to receive in-patient treatment mainly for geographical reasons, and 16 preferred and received in-patient rehabilitation. Setting preferences and setting assignment did not influence patients' expectations. When assessed at discharge and after 6 months, a considerable number of patients expressed changes in setting preferences and altered reasons for setting choice. At rehabilitation onset, patients were generally optimistic that rehabilitation would lead to an improvement of functional abilities and health status. This optimism was not fulfilled, although patients improved in functional independence/activities of daily life and physical dimensions of quality of life. The subjective realization of expectations was neither associated with setting preference nor with realized setting. Improvements of functional disabilities and independence were not correlated with rehabilitation satisfaction. Patients were less disappointed with rehabilitation outcome the more they improved in dimensions of quality of life (or vice versa). The fact that setting preferences are indifferent and not stable over time indicates deficits of information and decision capacity in rehabilitation patients after stroke and may be explained by characteristics of this disease and a specific, short time-limit for decision-making. For the evaluation of rehabilitation programmes, it can also be concluded that multidimensional assessments such as the SF-36 cannot be replaced by patient satisfaction scores.

In a prospective longitudinal study, stroke patients with largely intact ADL-functions who were treated in a rehabilitation center were assessed at the beginning and end of rehabilitation treatment and 6 months afterwards. They were treated as outpatients, if they expressed a preference for this setting and if outpatient rehabilitation was logistically and geographically possible, otherwise as inpatients. We found medium- to large-size gains for physical and ADL function and associated quality-of-life dimensions (WHOQOL-BREF, SF-36). However, there were also losses in other aspects of quality of life, e. g. in the social domain. There were no differences with respect to type of setting. Patients' setting preferences influenced the development of perception of own health. There was only a small and insignificant influence of satisfaction with rehabilitation treatment. We propose an expansion of neurological outpatient rehabilitation services and a focus on factors outside the rehabilitation system that influence quality of life.

Fifty stroke patients who had already regained basic ADL-functions were investigated at the beginning and end of either inpatient or outpatient rehabilitation of similar therapeutic intensity in the same institution. For geographic reasons, outpatient treatment could only be offered to a subgroup of patients. Neurological deficits, extended ADL-functions and quality of life (SF-36) were assessed. Patients who chose outpatient rehabilitation exhibited milder neurological deficits and better ADL-function at onset. On average, outpatient rehabilitation took about 8 days more than inpatient treatment. Under rehabilitation, gains with respect to ADL-functions and the QoL-dimensions "physical role function" and "physical functional ability" were realized. The magnitude of changes did not depend on setting. A decrease in "general health perception" may be related to the inpatient treatment of patients who would have preferred an outpatient setting. Brief periods between stroke and onset of rehabilitation and longer duration of rehabilitation treatment were significantly associated with better outcome with respect to ADL-functions.