Prodigy is designed to be a practical resource to aid healthcare professionals at the point of care, which is devised from rigorously reviewed and researched evidence, as well as providing a useful educational resource. Prodigy includes the following areas:

• Topic Summary providing a brief overview of the clinical topic, highlighting key clinical areas.
• Recommendations and guidance over key clinical areas.
• Goals and outcome measures including important treatment goals and quality indicators.
• Diagnosing information providing how best to diagnose or assess the patient.
• Prescribing information and drug recommendations to generate a prescription.
• Management – clinical scenarios containing specific detail as to how to treat particular patients.
• Evidence underpinning the recommendations in detail.

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Evidence based clinical information:

• For clinicians working in primary and first contact care.
• A comprehensive source of up-to-date clinical and prescribing information.
• Includes extensive topic coverage of over 350 topics consisting of over 1000 clinical presentations.

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Designed for healthcare professionals to:

• Reach a diagnosis.
• Prescribe rationally.
• Offer effective and safe treatment options.
• Appropriately refer for specialist assessment or management.
• Create local protocols and guidance.

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Provides clear & concise recommendations that:

• Address real-life clinical questions.
• Link to a summary of the reasoning behind the recommendation.
• Are supported by a fully referenced and detailed discussion of the evidence.

NICE has accredited the process used by Clarity Informatics to produce guidelines. Accreditation is valid for 5 years from May 2015 and is applicable to guidance produced using the processes described in the CKS Process Manual.

For full details on our accreditation visit: nice.org.uk/accreditation.

Clarity Informatics develops the clinical content for the Clinical Knowledge Summaries (CKS) for the National Institute for Health and Care Excellence for users in the UK, and publishes the clinical content on our Prodigy website for international users.

Topics are developed and reviewed by a multidisciplinary team consisting of clinicians, pharmacists, pharmacologists, information specialists, informatics analysts and technical authors. The processes used to develop and update the topics is overseen by the team leader and Clinical Editor (Dr Gerry Morrow).

A work programme is maintained to plan the specific activities of authoring team members and to inform external reviewers and stakeholders.

The topic development team is supported by the wider Clarity team which include customer support, administrators, project coordinators, software developers, database administrators and network support.

Prodigy topics are fully reviewed and updated at least every 5 years. The updated topic is quality assured by an internal and external review process before being released. We have a continuous Horizon scanning process to monitor current evidence, which may trigger a minor update of the topic. This ensures the topics are up to date and evidence published since the last review is available.

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The following principles are core to our topic development:

• Using evidence-based clinical information,
• Linking the recommendations to the evidence
• Supporting best practice
• Creating clear, concise, practical recommendations
• Guaranteeing independent review

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The process used to develop and review topics is detailed in the Quality Manual and includes the following high-level processes:

• Topic development and selection
• Scoping
• Developing clinical questions and scenarios
• Literature searching
• Evaluating and summarising the evidence
• Developing clinical recommendations
• External consultation
• Release

The best available evidence is selected to formulate recommendations and provide accurate background information (for example, on incidence and prevalence). The team are appropriately skilled to reliably assess the evidence identified by the structured literature review so that the recommendations can be formulated from the best available evidence and the limitations of the evidence base are appreciated.

• Guidelines are assessed for quality by the clinical authors using the principles outlined by the AGREE II.
• Where high quality guidance is not available, we use the best available evidence which:
  • Is dependent upon the type of clinical question being answered.
  • Have outcomes that are clinically relevant and patient-centred rather than disease-centred.
  • Has the lowest risk of bias.
  • Is generalizable to the scenario/clinical question being answered.

Prodigy has an Editorial Steering group in place to ensure that the clinical topics are safe, accurate, and responsive to the needs of users. The group consists of a mix of clinical professionals and stakeholders who will approve the processes by which:

• New topics are identified and prioritized.
• Topics are developed including:
• • Identifying and gathering the evidence
  • Selecting the evidence
  • Appraising the evidence
  • Summarizing the evidence and developing recommendations
  • External review
  • Content is kept up-to-date

In addition, the Editorial Steering Group will advise:

• • • On a course of action when specific clinical content or recommendations are contentious (for example when the views of experts are strong and polarized, or when service availability is an issue)
    • On implementation and adoption of clinical topics

The external review process is an essential part of topic development. Consultation with a wide range of stakeholders provides quality assurance of topics in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

International Distributors for Prodigy Clarity seeks international distributors for our Prodigy clinical decision support tool. The clinical content in this site provides recommendations for first contact diagnosis and treatment of over 350 clinical areas. The sale of this information has potential benefit for individual clinicians, professional organisation (such as universities or professional bodies) or even to nation states. We hope to attract enthusiastic sales people who are interested in an attractive rate of revenue sharing the income from international sales of access to this knowledge. If you would like to hear more about this opportunity please contact Dr Gerry Morrow, Medical Director gerry.morrow@clarity.co.uk

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Freelance Clinical Authors Clarity is keen to engage authors to create clinical content for our Clinical Knowledge Summaries and Prodigy sites. The clinical content in these sites is taken from national guidance and high quality evidence in order to provide recommendations for first contact diagnosis and treatment of over 350 clinical areas. We seek generalist clinicians, pharmacists and other biomedical graduates who have an interest and ability to create high quality written content using our accredited processes and Clarity house style. If you are interested in an attractive remuneration package and working with our team in a freelance capacity please contact Dr Gerry Morrow, Medical Director gerry.morrow@clarity.co.uk

Background

• Asthma can vary markedly in severity, clinical course, and response to treatment. Asthma is a chronic inflammatory condition of the airways, the cause of which is not completely understood. The airways are hyper-responsive and constrict easily in response to a wide range of stimuli. This may result in coughing, wheezing, chest tightness, and shortness of breath.
• Narrowing of the airways is usually reversible (either spontaneously or with medication), leading to intermittent symptoms, but in some people with chronic asthma, the inflammation may lead to irreversible airflow obstruction.
• Acute asthma exacerbation is a term used to describe onset of severe asthma symptoms.
• Work-aggravated asthma is pre-existing asthma that is aggravated non-specifically by dust and fumes at work.
• Occupational asthma is asthma due to exposure to specific substances at work.
• Exercise-induced asthma is asthma brought on by physical exertion. For most people, it is an indication of poorly controlled asthma.

More information available upon subscription purchase.

Initially, decide how likely it is that a person has asthma.

• For children, base this decision on recognizing features that increase or decrease the probability of asthma.

• For adults, base this decision on recognizing features that increase or decrease the probability of asthma and spirometry.

• Then use clinical judgement to categorize the person into one of three groups:
  • High probability: diagnosis of asthma likely.
  • Intermediate probability: diagnosis uncertain and insufficient evidence at first consultation to make a firm diagnosis, but no features to support an alternative diagnosis.
  • Low probability: diagnosis other than asthma likely.

• • For people with an intermediate and high probability of asthma, manage as suspected asthma (to confirm or refute the diagnosis).

• • For people with a low probability of asthma consider an alternative diagnosis.

• • Occupational asthma is diagnosed when the diagnosis of asthma is confirmed, the relationship between asthma and work exposure is made, and a specific cause is identified.

• Exercise-induced asthma is usually diagnosed based on symptoms related to exercise.
  • People with exercise-induced asthma report symptoms such as coughing and wheezing after 5–10 minutes of exercise or for up to 1–2 hours after finishing exercise. The symptoms are generally worse when breathing cold or dry air (outdoors), or with longer duration or higher intensity of exercise.

More information available upon subscription purchase.

 

• Scenario: New presentation of asthma: covers the management of adults and children with a new presentation of asthma and who have a high, intermediate or low probability of having asthma.
• Scenario: Uncontrolled asthma on current treatment: covers how to step up asthma therapy in adults and children with uncontrolled asthma.
• Scenario: Controlled asthma on current treatment: covers how to follow up people with asthma and when to consider stepping down asthma therapy.
• Scenario: Acute asthma exacerbation: covers how to assess someone with acute asthma, when admission to hospital is required, and how to manage people with acute asthma who do not require hospital admission.
• Scenario: Management of exercise-induced asthma: covers the management of people with exercise induced asthma.
• Scenario: Suspected occupational asthma: covers the management of occupational asthma.
• Scenario: Pregnancy and breastfeeding: covers the management of asthma in a pregnant or breastfeeding woman.

Goals: The aim of asthma management is control of the disease with minimal side effects. Control of the disease is defined as [SIGN and BTS, 2011]:

• No daytime symptoms
• No night-time awakening due to asthma
• No need for rescue medicine
• No exacerbations
• No limitations on activity including exercise
• Normal lung function (in practical terms — forced expiratory volume in 1 second (FEV1) and/or peak expiratory flow rate (PEF), greater than 80% predicted (or the person’s best value if unable to attain this)

More information available upon subscription purchase.

EXAMPLE:
Short-acting beta2-agonists
What do I need to know when prescribing a short-acting beta2-agonist?

• Inhaled short-acting beta2-agonists should be used as required unless an individual has shown to benefit from regular use:
  • As-required use of short-acting beta2-agonists is at least as effective as regular administration [SIGN and BTS, 2011] and is less likely to result in tolerance.
• Inhaled short-acting beta2-agonists have minimal adverse effects. Overuse can cause tremor, tension, headache, muscle cramps, and palpitations [BNF 53, 2007]. Hypokalaemia may result from high doses of inhaled beta2-agonists (or oral beta2-agonists); this may be potentiated by concomitant treatment with theophylline, corticosteroids, diuretics, and by hypoxia. The Committee on the Safety of Medicines has advised that plasma potassium should be monitored in people with severe asthma [CSM, 1990].
• There is some evidence from post-marketing data and published literature of myocardial ischaemia associated with short-acting beta2-agonists. The MHRA has issued advice that people with a history of heart disease, including angina or rhythm disturbance, should seek medical advice if symptoms such as shortness of breath or chest pain occur, as these may indicate worsening heart disease [MHRA, 2007].

More information available upon subscription purchase.

EXAMPLE:
Evidence on short-acting beta2-agonists
There is no clinically significant difference between regular or as-required short-acting beta2-agonists in terms of lung function, use of reliever medication, exacerbation rates, or quality of life:

• One systematic review (search date 2002, 22 crossover randomized controlled trials [RCTs] and eight parallel-group RCTs) examined regular versus as-required use of short-acting beta2-agonists in asthma control. Most studies did not allow concomitant use of inhaled corticosteroids, and only data from the crossover studies were suitable for pooling. The review found no difference in morning peak flow rates, but regular use improved evening peak flow rates, reduced diurnal variation, and reduced the need for reliever medication. However, the clinical relevance of these results is uncertain, because exacerbation rates, and quality-of-life scores did not differ and one RCT (n = 117) showed better symptom control over 24 hours with as-required use than with regular use. In some studies, regular use was associated with deterioration of airway responsiveness after stopping medication, increased allergen-induced bronchoconstriction, and tremor [Rodolfo et al, 2005].

More information available upon subscription purchase.

All references provided with subscription purchase.