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Guideline Summary
Guideline Title
Best evidence statement (BESt). Best care environment for adolescent patients with eating disorders.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Best care environment for adolescent patients with eating disorders. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Mar 24. 6 p. [25 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Eating disorders, including:

  • Anorexia nervosa
  • Bulimia nervosa
  • Eating disorder not otherwise specified (NOS)

Note: Binge eating and overeating are excluded from this guideline.

Guideline Category
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Pediatrics
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)

To evaluate among adolescent patients diagnosed with an eating disorder acutely admitted to the hospital for treatment of the eating disorder if a strict environment at admission versus a lenient environment improves patient compliance with the plan of care and/or weight gain

Target Population

Adolescents (ages 13 to 21) with an eating disorder

Interventions and Practices Considered

Strict environment at admission versus a lenient environment

Major Outcomes Considered
  • Patient compliance with the plan of care
  • Weight gain

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Search Strategy

  • Databases: Ovid Medline, PubMed, Cinahl, Psychinfo, Nursing Reference Center, Google Scholar, and hand search
  • Keywords: Anorexia, Eating Disorders, inpatient, compliance, nursing interventions, practice guidelines, guidelines, treatment guidelines, strict, lenient
  • Limits: English language and adolescents, all dates included
  • Retrieved: July 29, 2010 – November 22, 2010
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 or 5a or 5b Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or visa-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence (see note above)
  2. Safety/Harm
  3. Health benefit to patient (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Reviewed against quality criteria by two independent reviewers

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of evidence (1a-5b) are defined at the end of the "Major Recommendations" field.

  1. It is recommended that for adolescent patients with eating disorders, acutely admitted to the hospital, a lenient environment be used to improve patient compliance with the plan of care (Colton & Pistrang, 2004 [2b]; Touyz et al., 1984 [2b]; Touyz, Beumont, & Dunn, 1987 [4b]).
  2. There is insufficient evidence and lack of consensus to make a recommendation on whether a strict environment or a lenient environment contributes to weight gain (Bhanji & Thompson, 1974 [4b]; Bossert et al., 1988 [4b]; Dalle Grave et al., 1993 [4b]; Halmi, Powers, & Cunningham, 1975 [4b]; Kreipe & Kidder, 1986 [3b]; Nusbaum & Drever, 1990 [4b]; Solanto et al., 1994 [4b]; Touyz et al., 1984 [2b]; Touyz, Beumont, & Dunn, 1987 [4b]; Treat et al., 2005 [4b]; Vandereycken & Pieters, 1978 [4b]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or visa-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence (see note above)
  2. Safety/Harm
  3. Health benefit to patient (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Improved patient compliance with the plan of care
  • Weight gain
  • A lenient environment is more acceptable to patients and less likely to impair self-esteem. It supports the patient's ability to take care of themselves. When patients can collaborate in decisions, feel listened to rather than presided over, and are offered rationale for practices, they are less confused and frustrated.
Potential Harms

The risk of a lenient program is that it places a high burden of adherence on the adolescent patient, and some patients may engage in deceptive or self-destructive behaviors.

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Best care environment for adolescent patients with eating disorders. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Mar 24. 6 p. [25 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2011 Mar 24
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Team Leader: Kathleen Hautman BS RNII, A6N, Adolescent Medical Surgical Unit, Cincinnati Children's Hospital Medical Center

Support Personnel: Barbara K. Giambra, MS, RN, CPNP, Center for Professional Excellence-Business Integration/Research and Evidence based Practice, Cincinnati Children's Hospital Medical Center

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Patient Resources

The following are available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on September 22, 2011.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents; and
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

Disclaimer

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