Primary care physicians' response to dissemination of practice guidelines

Comparing professional communities: Opioid prescriber networks and Public Health Preparedness Districts

Problem opioid use and opioid-related drug overdoses remain a major public health concern despite attempts to reduce and monitor opioid prescriptions and increase access to office-based opioid treatment. Current provider-focused interventions are implemented at the federal, state, regional, and local levels but have not slowed the epidemic. Certain targeted interventions aimed at opioid prescribers rely on populations defined along geographic, political, or administrative boundaries; however, those boundaries may not align well with actual provider-patient communities or with the geographic distribution of high-risk opioid use. Instead of relying exclusively on commonly used geographic and administrative boundaries, we suggest augmenting existing strategies with a social network-based approach to identify communities (or clusters) of providers that prescribe to the same set of patients as another mechanism for targeting certain interventions. To test this approach, we analyze 1 year of prescription data from a commercially insured population in the state of Indiana. The composition of inferred clusters is compared to Indiana's Public Health Preparedness Districts (PHPDs). We find that in some cases the correspondence between provider networks and PHPDs is very high, while in other cases the overlap is low. This has implications for whether an intervention is reaching its intended provider targets efficiently and effectively. Assessing the best intervention targeting strategy for a particular outcome could facilitate more effective interventions to tackle the ongoing opioid use epidemic.

Dissemination and use of the professional standards of practice for psychologists, social workers, and counselors in spinal cord injury rehabilitation

Objective: To determine the level of awareness and utilization of the Professional Standards of Practice for Psychologists, Social Workers, and Counselors in Spinal Cord Injury Rehabilitation, 4th Edition (The Standards) by members of professional organizations representing psychologists, social workers, and licensed professional counselors (PSWC) working in spinal cord injury (SCI) rehabilitation. Participants: Respondents belonged to members of professional organizations representing PSWC working in SCI rehabilitation, which included ASCIP (76%), APA's Division 22 (37%), ASIA (23%), USA (14%), PVA (12%), AVAPL (11%) and CRCC (3%). Method: Responses to an online questionnaire were solicited via email. Results: 63% of those that responded were aware of The Standards. Of those, (79%) had read all or a portion of The Standards. Colleagues were the most common source of awareness, followed by email announcements. Conclusions: The Standards are being used (in order of frequency) to improve clinical work, improve treatment efficacy, orientation of new staff, confirm current practice, education, advocacy, and other ways.

Assessing physician utilization of laboratory practice guidelines: barriers and opportunities for improvement

OBJECTIVES

To assess physician utilization of laboratory practice guidelines (LPGs)³ to improve LPG uptake and use.

DESIGN AND METHODS

A statewide survey of 4987 primary care physicians (PCPs) and 75 infectious disease (ID) specialists was conducted in 2005-2006 to correlate guideline source with users' awareness, utilization, and perceived usefulness of LPGs. We compared LPGs developed by the Centers for Disease Control and Prevention (CDC) to LPGs developed by the Washington State Department of Health through its Clinical Laboratory Advisory Council (CLAC).

RESULTS

Physician awareness of LPGs was a major impediment to utilization of CLAC LPGs, and they were perceived as inaccessible, too numerous and unhelpful. However, once aware, respondents tended to use LPGs and there were no important differences in impediments or the ways CDC and CLAC LPGs were used. Of the PCPs who had a computerized physician order entry system (CPOE), a majority (92%) found, or expected that they would find, the integration of guidelines into their system helpful.

CONCLUSIONS

For both CDC and CLAC LPGs, the greatest impediments to uptake were awareness and familiarity, which depended upon LPG source, physician specialty, and practice setting. There was no apparent impediment to uptake of CLAC or CDC LPGs based upon their credibility. Because better promotion could increase uptake, CLAC LPGs are now promoted by the Washington State Medical Association. Integration of LPGs into CPOE and smart phone applications could address major impediments to clinician use. The Cabana paradigm would be useful for any organization seeking to improve LPG impact.

Development and Initial Validation of a Client-Rated MET-CBT Adherence Measure

Traditional mechanisms for rating adherence or fidelity are labor-intensive. We developed and validated a tool to rate adherence to Motivational Enhancement Therapy—Cognitive Behavioral Treatment (MET-CBT) through anonymous client surveys. The instrument was used to survey clients in 3 methadone programs over 2 waves. Explanatory and Confirmatory Factor Analyses were used to establish construct validity for both MET and CBT. Internal consistency based on Cronbach’s alpha was within adequate range (α > 0.70) for all but 2 of the subscales in one of the samples. Consensus between clients’ ratings (r_wg(j) scores) were in the range of 0.6 and higher, indicating a moderate to strong degree of agreement among clients’ ratings of the same counselor. These results suggest that client surveys could be used to measure adherence to MET-CBT for quality monitoring that is more objective than counselor self-report and less resource-intensive than supervisor review of taped sessions. However, additional work is needed to develop this scale.

Impact of clinical reminder redesign on physicians' priority decisions

OBJECTIVE

Computerized clinical reminder (CCR) systems can improve preventive service delivery by providing patient-specific reminders at the point of care. However, adherence varies between individual CCRs and is correlated to resolution time amongst other factors. This study aimed to evaluate how a proposed CCR redesign providing information explaining why the CCRs occurred would impact providers' prioritization of individual CCRs.

DESIGN

Two CCR designs were prototyped to represent the original and the new design, respectively. The new CCR design incorporated a knowledge-based risk factor repository, a prioritization mechanism, and a role-based filter. Sixteen physicians participated in a controlled experiment to compare the use of the original and the new CCR systems. The subjects individually simulated a scenario-based patient encounter, followed by a semi-structured interview and survey.

MEASUREMENTS

We collected and analyzed the order in which the CCRs were prioritized, the perceived usefulness of each design feature, and semi-structured interview data.

RESULTS

We elicited the prioritization heuristics used by the physicians, and found a CCR system needed to be relevant, easy to resolve, and integrated with workflow. The redesign impacted 80% of physicians and 44% of prioritization decisions. Decisions were no longer correlated to resolution time given the new design. The proposed design features were rated useful or very useful.

CONCLUSION

This study demonstrated that the redesign of a CCR system using a knowledge-based risk factor repository, a prioritization mechanism, and a role-based filter can impact clinicians' decision making. These features are expected to ultimately improve the quality of care and patient safety.

Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model

BACKGROUND

Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach.

OBJECTIVE

The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC).

METHODS

In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt.

RESULTS

Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients' asthma control.

CONCLUSIONS

The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.

A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations

BACKGROUND

There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain.

METHODS

We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation).

RESULTS

Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing).

CONCLUSIONS

There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.

Measurement-based care for refractory depression: a clinical decision support model for clinical research and practice

Despite years of antidepressant drug development and patient and provider education, suboptimal medication dosing and duration of exposure resulting in incomplete remission of symptoms remains the norm in the treatment of depression. Additionally, since no one treatment is effective for all patients, optimal implementation focusing on the measurement of symptoms, side effects, and function is essential to determine effective sequential treatment approaches. There is a need for a paradigm shift in how clinical decision making is incorporated into clinical practice and for a move away from the trial-and-error approach that currently determines the "next best" treatment. This paper describes how our experience with the Texas Medication Algorithm Project (TMAP) and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial has confirmed the need for easy-to-use clinical support systems to ensure fidelity to guidelines. To further enhance guideline fidelity, we have developed an electronic decision support system that provides critical feedback and guidance at the point of patient care. We believe that a measurement-based care (MBC) approach is essential to any decision support system, allowing physicians to individualize and adapt decisions about patient care based on symptom progress, tolerability of medication, and dose optimization. We also believe that successful integration of sequential algorithms with MBC into real-world clinics will facilitate change that will endure and improve patient outcomes. Although we use major depression to illustrate our approach, the issues addressed are applicable to other chronic psychiatric conditions including comorbid depression and substance use disorder as well as other medical illnesses.

Assessing physicians' use of treatment algorithms: Project IMPACTS study design and rationale

Effective treatments for major depressive disorder have been available for 35 years, yet inadequate pharmacotherapy continues to be widespread leading to suboptimal outcomes. Evidence-based medication algorithms have the potential to bring much-needed improvement in effectiveness of antidepressant treatment in "real-world" clinical settings. Project IMPACTS (Implementation of Algorithms using Computerized Treatment Systems) addresses the critical question of how best to facilitate integration of depression treatment algorithms into routine care. It tests an algorithm implemented through a computerized decision support system using a measurement-based care approach for depression against a paper-and-pencil version of the same algorithm and non-algorithm-based, specialist-delivered usual care. This paper reviews issues related to the Project IMPACTS study rationale, design, and procedures. Patient outcomes include symptom severity, social and work function, and quality of life. The economic impact of treatment is assessed in terms of health care utilization and cost. Data collected on physician behavior include degree of adherence to guidelines and physician attitudes about the perceived utility, ease of use, and self-reported effect of the use of algorithms on workload. Novel features of the design include a two-tiered study enrollment procedure, which initially enroll physicians as subjects, and then following recruitment of physicians, enrollment of subjects takes place based initially on an independent assessment by study staff to determine study eligibility. The study utilizes brief, easy-to-use symptom severity measures that facilitate physician decision making, and it employs a validated, phone-based, follow-up assessment protocol in order to minimize missing data, a problem common in public sector and longitudinal mental health studies. IMPACTS will assess the success of algorithm implementation and subsequent physician adherence using study-developed criteria and related statistical approaches. These new procedures and data points will also allow a more refined assessment of algorithm-driven treatment in the future.

Developing and implementing a model for changing physicians' prescribing habits - the role of clinical pharmacy in leading the change

BACKGROUND AND OBJECTIVE

Budgetary constraints led the Israeli Hillel Yaffe Medical Center management to implement policies for reducing expenditure while maintaining the quality of care. For this purpose, the pharmacy services management developed and implemented a three-tier intervention feedback model for changing physicians' prescribing habits, and achieving cost-effective changes in antibiotic utilization.

METHODS

A prospective drug utilization evaluation was conducted to profile antibiotic utilization. The results established a base from which a three-tier feedback, evidence-based intervention model was built. This model corresponds to the following three hierarchical levels: Level 1 activities involved management actions that influenced all levels of staff and concentrated mainly on the creation of guidelines. Level 2 activities involved the reorganization of the restricted antibiotics prescription authorization system, through the co-operation of the clinical pharmacy unit and the hospital infection control specialist. Level 3 focussed on clinical pharmacist activities on the wards. The model was implemented and assessed in the hospital from June 2002 until December 2004.

RESULTS AND DISCUSSION

Implementation of the model resulted in a cumulative decrease of 6,473 i.v. antibiotics daily defined doses (DDDs) and a parallel increase in total oral antibiotic DDDs (Table 1). These changes were especially notable with high-bioavailability antibiotics and co-amoxiclav, where over 2.5 years there was a reduction of 2,472 and 4,752 i.v. DDDs, respectively (P < 0.000). The successful implementation of the model resulted in a reduction of 375,000 NIS ( approximately 66,190 euro) in pharmacy antibiotic costs, equivalent to 10 i.v. DDDs or 570 NIS ( approximately 102 euro) saved per clinical pharmacist working day.

CONCLUSIONS

Our study demonstrates the successful implementation of a three-tier model for changing physicians' antibiotic prescribing.

Impact of the national asthma guidelines on internal medicine primary care and specialty practice

OBJECTIVE

To evaluate documentation of compliance with the National Asthma Education and Prevention Program publication Guidelines for the Diagnosis and Management of Asthma.

DESIGN

A retrospective review of 114 charts coded as asthma. Fourteen chart evaluation questions were developed based on the 4 management components in the guidelines: assessment and monitoring of asthma, control of asthma factors, pharmacotherapy, and patient education.

SETTING

A hospital-based asthma clinic, a private pulmonary group, and a general internal medicine group in Dallas, Texas.

RESULTS

Nearly all physicians documented inquiries about daytime asthma symptoms, but only 64% of pulmonary group and 58% of internal medicine physicians documented inquiries about nighttime symptoms. In addition, in 14% of pulmonary group charts and 74% of internal medicine charts, no spirometry or peak flow data were documented. Most asthma clinic and pulmonary group charts (98% and 78%, respectively) included a history of triggers, but the pulmonary group and internal medicine group were more likely to document administration of the influenza vaccine than the asthma clinic (25% and 26% vs 13%). Of 38 patients with > or = 1 recorded forced expiratory volume in 1 second <60%, all but 1 were on inhaled steroids. However, many charts lacked adequate documentation to match drug selection to asthma severity. The asthma clinic group documented the 4 educational interventions 65% to 83% of the time, compared with the pulmonary group, at 17% to 50%, and the internal medicine group, at 5% to 18%.

CONCLUSIONS

Results showed significant variation with the recommendations. Areas in particular need of improvement were objective diagnosis and assessment, control of asthma-associated factors, and patient education. Furthermore, the study demonstrated significant variation between specialists and primary care physicians, with the more specialized clinics demonstrating better guideline compliance.

Educating health professionals to improve quality of care for asthma

Recent studies have shown significant progress in improving the quality of care for asthma. The most successful interventions have combined multiple elements: educational sessions that engage learners in discussing cases and practicing new skills; use of new resources, tools and practice patterns to enable quality improvement; and reinforcement of improvements through peer support, incentives or administrative review. Future research should include more randomised controlled trials to test the effectiveness of quality improvement interventions, more detailed descriptions of strategies to change health professional behaviour and studies to determine whether effective interventions can be translated to other settings, disseminated widely and sustained over time.

Development of a computerized assessment of clinician adherence to a treatment guideline for patients with bipolar disorder

The adoption of treatment guidelines for complex psychiatric illness is increasing. Treatment decisions in psychiatry depend on a number of variables, including severity of symptoms, past treatment history, patient preferences, medication tolerability, and clinical response. While patient outcomes may be improved by the use of treatment guidelines, there is no agreed upon standard by which to assess the degree to which clinician behavior corresponds to those recommendations. This report presents a method to assess clinician adherence to the complex multidimensional treatment guideline for bipolar disorder utilized in the Texas Medication Algorithm Project. The steps involved in the development of this system are presented, including the reliance on standardized documentation, defining core variables of interest, selecting criteria for operationalization of those variables, and computerization of the assessment of adherence. The computerized assessment represents an improvement over other assessment methods, which have relied on laborious and costly chart reviews to extract clinical information and to analyze provider behavior. However, it is limited by the specificity of decisions that guided the adherence scoring process. Preliminary findings using this system with 2035 clinical visits conducted for the bipolar disorder module of TMAP Phase 3 are presented. These data indicate that this system of guideline adherence monitoring is feasible.

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: the Multicenter Airway Research Collaboration

OBJECTIVES

To determine adherence of emergency department (ED) management of acute exacerbation of chronic obstructive pulmonary disease (COPD) to current treatment guidelines.

DESIGN

A prospective cohort study, as part of the Multicenter Airway Research Collaboration.

SETTING

The study was performed at 29 EDs in 15 U.S. states and three Canadian provinces.

PARTICIPANTS

ED patients, aged 55 and older, who presented with COPD exacerbation and underwent a structured interview in the ED and another by telephone 2 weeks later.

MEASUREMENTS

Adherence of ED management of COPD exacerbation to that recommended in current treatment guidelines.

RESULTS

The cohort consisted of 397 subjects, of whom 224 (56%) reported only COPD and 173 (44%) reported asthma and COPD. The average age was 70. Most (80%) patients had used rescue medications in the 6 hours before seeking emergency care. Only 31% were evaluated using spirometry and 48% using arterial blood gas measurement. ED treatment included inhaled short-acting beta-agonists for 91% of patients, inhaled anticholinergics for 77%, methylxanthines for 0.3%, systemic corticosteroids for 62%, and antibiotics for 28%. More than half the patients required hospitalization. At 2-week follow-up, 43% of patients reported a relapse event or ongoing exacerbation. Overall, adherence to national and international guidelines was low.

CONCLUSION

Important differences exist between guideline recommendations and actual ED management of COPD exacerbations in older adults. Outcomes after ED treatment are poor and may be related to these shortcomings in quality of care. Better adherence to guideline recommendations when caring for elderly patients with COPD exacerbations may lead to improved clinical outcomes and better resource usage.

The anatomy of asthma care visits in community family practice

BACKGROUND

We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management.

OBJECTIVE

To describe the content of asthma visits made to family physicians.

METHODS

Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages.

RESULTS

Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice.

CONCLUSIONS

Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.

Do rural and urban children have comparable asthma care utilization?

This study compares asthma-related health care visits and drug therapy for rural and nonrural Kentucky children with Medicaid health insurance in 1995. The 8,634 children with asthma had a mean age of 5.7 years. Ninety-two percent made at least one asthma office visit, and 13 percent were hospitalized. The urban and rural patterns of care for childhood asthma varied in some potentially important ways. Urban children were twice as likely as rural children to see an asthma specialist (5 percent vs. 2.5 percent, P < 0.05), 2.7 times as likely to receive asthma care in an emergency department (19 percent vs. 7 percent, P < 0.01) and 1.4 times as likely to receive oral steroids (16 percent vs. 12 percent, P = 0.04). If given inhaled anti-inflammatory medication, rural children were more likely to receive inhaled steroids while urban children were more likely to receive cromoglycates.

Dissemination of diabetes care guidelines: lessons learned from community health centers

PURPOSE

This study was conducted to evaluate the impact of a provider problem-based learning (PBL) intervention on screening for complications of diabetes in community health centers.

METHODS

A successive sampling design was used to compare selected standards of diabetes care delivered preintervention with the care delivered postintervention at 2 community health centers and 1 comparison centers. Two randomly assigned intervention sites received a PBL intervention focused on care guidelines for prevention of diabetes complications, with telephone follow-up over 12 months. Effects of the intervention were determined from an audit of 200 charts from each site.

RESULTS

The odds of having a glycosylated hemoglobin test more than doubled from preintervention to postintervention, and the odds of having a foot examination more than tripled across centers. Measurement of creatinine and glycosylated hemoglobin were associated; the odds of having one test tripled when the other had been measured. Rates for documentation of patient education were significantly lower at the intervention site where free patient education booklets were distributed.

CONCLUSIONS

Improvements in diabetes care were not consistent among community health centers. Interventions involving system and policy changes may be more effective in implementing and sustaining improvements than just provider education.

Update on pharmacologic therapy for chronic obstructive pulmonary disease

As described throughout this article, significant improvements continue to occur in the pharmacologic management of COPD. These improvements range from improved medication targeting to better understanding of mechanisms of action, to better delivery of medications, to lower side effects. New areas of pharmacologic intervention, if not ready for use today, hold great promise for the not-too-distant future. In addition to the many agents described here, multiple mediator antagonists and anti-inflammatory agents are also under investigation for use in COPD. Interestingly, repair of alveolar tissue may be possible. Indeed, preliminary animal studies suggest that retinoic acid may be able to induce regeneration of lung alveoli. Overall, more effort is needed to broaden awareness and provide for the appropriate diagnosis of COPD, better explain pharmacologic therapies for COPD, simplify and disseminate guidelines, and highlight key differences between asthma and COPD, including their treatment strategies. As interest in COPD continues to grow, future updates on COPD management will continue to add new pharmacologic options for this devastating and preventable disease.

Physician participation in TQM in geriatric medicine

BACKGROUND

Quality improvement (QI) approaches such as total quality management (TQM) and continuous quality improvement (CQI) have great potential for improving the care provided to older people. Geriatricians have the necessary experience and skills to initiate and lead these QI efforts. A national sample of practicing geriatricians was surveyed in 1998 regarding involvement in, satisfaction with, and insights regarding TQM processes in four care settings.

RESULTS

Of 537 questionnaires returned in time for analysis, 497 were included for analysis after omitting questionnaires that were undeliverable or unusable (n = 25) and those from respondents who worked fewer than 20 hours per week (n = 15). More than one-third of the respondents (37.1%) reported no TQM activity at all. For the remainder, the primary site for TQM activity was the nursing home (33.0%), the hospital (22.5%), the office (11.4%), and the patient's home (3.7%). A majority of the respondents spent two hours per week or less on TQM projects. Planning an intervention and acting to maintain it in practice after its evaluation were the two stages of the improvement cycle these respondents engaged in most frequently.

DISCUSSION

More geriatricians should be encouraged to participate in TQM training and in specific projects to improve systems of care for older people. Incentives to increase participation should be made available. Rapid-cycle improvement may fit better with physicians' culture of working for outcomes that have relatively short turnaround times.

Beliefs about diagnosing asthma in young children

OBJECTIVES

To determine what factors primary care pediatricians believe are important in establishing the initial diagnosis of childhood asthma and to identify variations in physicians' beliefs concerning this clinical decision.

STUDY DESIGN

Massachusetts American Academy of Pediatrics Fellows were surveyed about their beliefs concerning the importance of 20 clinical factors associated with establishing the initial diagnosis of asthma.

RESULTS

Most clinicians considered recurrent wheeze (96%), symptomatic improvement with a bronchodilator (90%), recurrent cough (89%), exclusion of alternative diagnoses (87%), and suggestive peak flow findings (82%) as important in diagnosing asthma. However, there was substantial heterogeneity among clinicians as to which combinations of factors they each considered relevant; for example, only 60% identified all 5 of the above factors to be necessary or important. Further, <50% identified presence of any of the 20 factors as necessary. Although national guidelines cite objective assessment of pulmonary function as essential, spirometry and peak expiratory flow testing were identified as necessary by only 8% and 10%, respectively. Two factors believed to contribute to establishing the asthma diagnosis contradicted the National Asthma Education and Prevention Program guidelines and expert opinion (age >2 years and absence of fever during episodes) and these beliefs were more likely held by those clinicians in practice for >5 years.

CONCLUSIONS

The majority of pediatricians believe several common clinical factors establish a diagnosis of childhood asthma, but disagree over what combinations of these factors are important. Some misconceptions persist despite wide dissemination of clinical practice guidelines. We believe that future asthma guidelines will need to organize diagnostic criteria in an easily understood format, like a decision tree, to facilitate early recognition of asthma in young children.

Changing doctor prescribing behaviour

The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.

Evaluation of physician preferences for guideline implementation

Although current literature supports the use of evidence-based clinical practice guidelines (CPGs) by physicians, there is limited research concerning operational issues that may be inhibiting effective CPG implementation. The objective of our research was to increase understanding of clinical practice patterns by identifying physician preferences for CPG accessibility, format, content and learning strategies. Semistructured interviews were conducted with resident and faculty physicians in an academic medical center after they were presented with a CPG during treatment of a patient with acute pancreatitis. The results of our study revealed that physicians prefer CPGs in the form of evidence-based algorithms with treatment-specific information that is placed on the front of the patient chart during treatment. In addition, they felt that discussion of the guideline with colleagues, reminder notes/stickers on front of the patient chart, and verbal reminders from a nurse were the most effective means of encouraging utilization.

Overcoming 10 roadblocks to initiating clinical practice guidelines

Canadian federal and provincial governments face relentless fiscal and societal pressures to reduce healthcare expenditures. A chief cause of this mounting stress is Canadians wanting to know how and why their healthcare dollars are being spent, as well as what evidence supports the use of new technology and alternative ways of treating specific medical conditions. One of the tools attracting attention and allowing this type of analysis is the clinical practice guideline. Physicians, who have come under increased scrutiny as the key players in health services delivery, are often asked to lead the clinical practice guideline process as project leaders. This article addresses some of the common roadblocks encountered as clinical practice guidelines are initiated, developed, and implemented in healthcare organizations.

Health services research and the endocrinologist

This article highlights the importance of health services research to endocrinologists. The content and goals of health services research are defined, and, with examples related to endocrinology, the field's focus and key themes are described and its methods and sources of data delineated. Considerations that informed readers should keep in mind when reading this literature are illustrated, with a recent example that has important implications for the role of endocrinologists in the management of diabetic patients.

Implementation of local guidelines for cost-effective management of hypertension. A trial of the firm system

OBJECTIVE

To evaluate the effects of an intensive intervention to implement guidelines for cost-effective management of hypertension on medication use and cost, blood pressure control, and other resource use.

DESIGN

Retrospective cohort trial based on the Cleveland Veterans' Affairs Medical Center Firm System.

SETTING

General internal medicine teaching clinic in a large university-affiliated Department of Veterans Affairs Medical Center.

PARTICIPANTS

All patients seen in the intervention firm (n = 1273) and control firm (n = 884) clinics in the 3-month period following the introduction of the guidelines.

INTERVENTIONS

The control firm received guidelines and usual education for the cost-effective outpatient management of hypertension. The intervention firm received guidelines plus intensive guideline-based education and supervision.

MEASUREMENTS AND MAIN RESULTS

The use of guideline medications was greater in the intervention firm as compared with the control. The intervention firm initiated more hydrochlorothiazide (HCTZ), 17.4% (95% confidence interval [CI] 14.8, 20.1) of patients versus 11.9% (CI 9.3, 14.8) in the control firm (p = .002). Atenolol was initiated in 7.2% (CI 5.6, 9.0) in intervention firm versus 4.7% (CI 3.2, 6.6) in the control (p = .03). In addition, the use of nonguideline medications was less in the intervention firm. The intervention firm initiated less long-acting nifedipine, 7.8% (CI 6.0, 9.8) versus 10.6% (CI 8.2, 13.5) in the control (p = .04). Blood pressure control demonstrated greater improvement in the intervention firm (p = .02). Use of guidelines was associated with decreased costs for antihypertensive medications in the intervention firm as a whole as compared with the control firm. There was no increased use in other measured resources in the intervention firm including the number of outpatient laboratory services obtained, clinic visits, emergency room visits, or hospitalizations.

CONCLUSIONS

Intensive implementation of guideline-based education and supervision was associated with an increased use of guideline medications, decreased use of costly alternative agents, and no decrement in the measured outcomes of care.