From trial data to practical knowledge: qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia

Factors influencing acceptance, adoption and adherence to sentinel node biopsy recommendations in the Australian Melanoma Management Guidelines: a qualitative study using an implementation science framework

BACKGROUND

Sentinel node biopsy (SN biopsy) is a surgical procedure used to accurately stage patients with primary melanoma at high risk of recurrence. Although Australian Melanoma Management Guidelines recommend SN biopsy be considered in patients with melanomas > 1 mm thick, SN biopsy rates in Australia are reportedly low. Our objective was to identify factors impacting the acceptance, adoption and adherence to the Australian SN biopsy guideline recommendations.

METHODS

Opinions of Australian key informants including clinicians, representatives from melanoma education and training providers, professional associations and colleges, and melanoma advocacy organisations were collected through semi-structured interviews (n = 29) and from publicly released statements (n = 14 news articles). Data analysis involved inductive and deductive thematic analysis using Flottorp's determinants framework.

RESULTS

A complex interplay of contemporary and historical factors was identified as influencing acceptance, adoption and adherence to the SN biopsy guideline recommendations at the individual, guideline, patient, organisational and social levels. Expert and peer opinion leaders have played an important role in facilitating or inhibiting adoption of guideline recommendations, as have financial incentives driven by healthcare-funding policies and non-financial incentives including professional identity and standing. Of critical importance have been the social and knowledge boundaries that exist between different professional groups to whom the guidelines apply (surgeons, dermatologists and primary care practitioners) with adherence to the guideline recommendations having the potential to shift work across professional boundaries, altering a clinician's workflow and revenue. More recently, the emergence of effective immunotherapies and targeted therapies for patients at high risk of recurrence, the emergence of new opinion leaders on the topic (in medical oncology), and patient demands for accurate staging are playing crucial roles in overcoming the resistance to change created by these social and knowledge boundaries.

CONCLUSIONS

Acceptance and adherence to SN biopsy guideline recommendations in Australia over the past 20 years has involved a process of renegotiation and reframing of the evidence for SN biopsy in melanoma by clinicians from different professional groups and networks. This process has helped to refine the evidence for SN biopsy and our understanding of appropriate adoption. New effective systemic therapies have changed the balance towards accepting guideline recommendations.

Impact of lowering the risk threshold for statin treatment on statin prescribing: a descriptive study in English primary care

BACKGROUND

In 2014, the National Institute for Health and Care Excellence (NICE) changed the recommended threshold for initiating statins from a 10-year risk of cardiovascular disease (CVD) of 20% to 10% (Clinical Guideline 181), making 4.5 million extra people eligible for treatment.

AIM

To evaluate the impact of this guideline change on statin prescribing behaviour.

DESIGN AND SETTING

A descriptive study using data from Clinical Practice Research Datalink (CPRD), a primary care database in England.

METHOD

People aged 25-84 years being initiated on statins for the primary prevention of CVD were identified. CVD risk predictions were calculated for every person using data in their medical record (calculated risks), and were extracted directly from their medical record if a QRISK score was recorded (coded risks). The 10-year CVD risks of people initiated on statins in each calendar year were compared.

RESULTS

The average 'calculated risk' of all people being initiated on statins was 20.65% in the year before the guideline change, and 20.27% after. When considering only the 'coded risks', the average risk was 21.85% before the guideline change, and 18.65% after. The proportion of people initiating statins that had a coded risk score in their medical record increased significantly from 2010-2017.

CONCLUSION

Currently available evidence, which only considers people with coded risk scores in their medical record, indicates the guideline change had a large impact on statin prescribing. However, that analysis likely suffers from selection bias. This new evidence indicates only a modest impact of the guideline change. Further qualitative research about the lack of response to the guideline change is needed.

Qualitative evaluation of A Safer Ramadan, a structured education programme that addresses the safer observance of Ramadan for Muslims with Type 2 diabetes

AIMS

Muslims can choose to fast during Ramadan. Guidelines exist for providing clinical support for this group, but there is a lack of culturally tailored diabetes management interventions to provide guidance. The study evaluates the implementation of a programme developed to meet this need.

METHODS

A Safer Ramadan is a multi-faceted package comprising a self-management and community awareness programme, and healthcare professional training. Implementation of the programme took place in two cities in the UK, prior to Ramadan 2017. Uptake and attendance were determined, and qualitative interviews and focus groups were completed with people attending the programme, and with various stakeholders involved in implementation and delivery.

RESULTS

Success of the implementation varied and engagement by primary care was limited. Three central themes emerged from the interviews highlighting barriers and facilitators of the programme implementation. These were the referral pathway, programme content and feedback on the delivery of the programme.

CONCLUSIONS

Provision of interventions that provide support and education for Muslims during Ramadan was implemented in communities and valued by GPs and practice nurses. However, heavy workloads to support delivery made it difficult for practices to engage. Recommendations for future delivery of the programme indicate that greater attention should be given to marketing and its supporting practices. Furthermore, training for practice nurses to support patients prior to Ramadan and provision of funding is required.

General practitioners' perspectives on the prevention of cardiovascular disease: systematic review and thematic synthesis of qualitative studies

OBJECTIVE

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality globally, and prevention of CVD is a public health priority. This paper aims to describe the perspectives of general practitioners (GPs) on the prevention of CVD across different contexts.

DESIGN

Systematic review and thematic synthesis of qualitative studies using the Enhancing Transparency of Reporting the Synthesis of Qualitative research (ENTREQ) framework.

DATA SOURCES

MEDLINE, Embase, PsycINFO and CINAHL from database inception to April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included qualitative studies on the perspectives of GPs on CVD prevention.

DATA EXTRACTION AND SYNTHESIS

We used HyperRESEARCH to code the primary papers and identified themes.

RESULTS

We selected 34 studies involving 1223 participants across nine countries. We identified six themes: defining own primary role (duty to prescribe medication, refraining from risking patients' lives, mediating between patients and specialists, delegating responsibility to patients, providing holistic care); trusting external expertise (depending on credible evidence and opinion, entrusting care to other health professionals, integrating into patient context); motivating behavioural change for prevention (highlighting tangible improvements, negotiating patient acceptance, enabling autonomy and empowerment, harnessing the power of fear, disappointment with futility of advice); recognising and accepting patient capacities (ascertaining patient's drive for lifestyle change, conceding to ingrained habits, prioritising urgent comorbidities, tailoring to patient environment and literacy); avoiding overmedicalisation (averting long-term dependence on medications, preventing a false sense of security, minimising stress of sickness) and minimising economic burdens (avoiding unjustified costs to patients, delivering practice within budget, alleviating healthcare expenses).

CONCLUSIONS

GPs sought to empower patients to prevent CVD, but consideration of patients' individual factors was challenging. Community-based strategies for assessing CVD risk involving other health professionals, and decision aids that address the individuality of the patient's health and environment, may support GPs in their decisions regarding CVD prevention.

Engaging More Nurses in Cancer Preventive Care: Challenges and Opportunities

EXECUTIVE SUMMARY

Nurse-led care is crucial to improving the effectiveness of cancer prevention, as demonstrated by research. However, barriers to nurse-led cancer preventive care are still prevalent. What are the challenges that impede nurses from providing effective preventive care? How can hospital leaders address these challenges to better engage nurses in preventive care? What should be the focal areas in terms of policy changes and training programs? This article explores those questions. We examine the difficulties nurses have encountered. We identify the barriers yet to be examined extensively. Finally, we propose that many barriers can be addressed through carefully designed nurses' training programs and substantial policy changes. Our data were collected from a Nurse Oncology Education Program survey that included questions on perceived oncology knowledge, current cancer-related preventive practices, and barriers to preventive practices. We identified the barriers for the nurse population studied and opportunities to overcome these barriers.

Lost in translation: transferring knowledge from research to clinical practice

Using a new treatment is not an instantaneous act. There is a gap between research and practice and carefully evaluated evidence often fails to achieve widespread use. Various factors intercede along the pathway from knowledge generation to knowledge utilisation. These can hinder, or indeed facilitate, the use of research evidence in psychiatry. Knowledge translation is a discipline that attempts to identify and understand these barriers and facilitators to knowledge transfer. In this article, the terminology and key concepts of knowledge translation will be outlined, the evidence transfer pipeline described and obstacles and facilitators to uptake of evidence explored. The article also identifies sources of information on knowledge transfer. Innovative approaches designed to enhance the uptake of evidence from research, such as summaries, systematic reviews and targeted messaging, are also described.

Describing knowledge encounters in healthcare: a mixed studies systematic review and development of a classification

Background

Implementation science seeks to promote the uptake of research and other evidence-based findings into practice, but for healthcare professionals, this is complex as practice draws on, in addition to scientific principles, rules of thumb and a store of practical wisdom acquired from a range of informational and experiential sources. The aims of this review were to identify sources of information and professional experiences encountered by healthcare workers and from this to build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practice.

Methods

This was a mixed studies systematic review of observational studies. DATA SOURCES: OVID MEDLINE and Embase and Google Scholar were searched using terms around information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to healthcare groups. ELIGIBILITY: Studies were eligible if one of the intentions was to identify information or experiential encounters by healthcare workers. DATA EXTRACTION: Data was extracted by one author after piloting with another. STUDY APPRAISAL: Studies were assessed using the Mixed Methods Appraisal Tool (MMAT). PRIMARY OUTCOME: The primary outcome extracted was the information source or professional experience encounter. ANALYSIS: Similar encounters were grouped together as single constructs. Our synthesis involved a mixed approach using the top-down logic of the Bliss Bibliographic Classification System (BC2) to generate classification categories and a bottom-up approach to develop descriptive codes (or “facets”) for each category, from the data. The generic terms of BC2 were customised by an iterative process of thematic content analysis. Facets were developed by using available theory and keeping in mind the pragmatic end use of the classification.

Results

Eighty studies were included from which 178 discreet knowledge encounters were extracted. Six classification categories were developed: what information or experience was encountered; how was the information or experience encountered; what was the mode of encounter; from whom did the information originate or with whom was the experience; how many participants were there; and where did the encounter take place. For each of these categories, relevant descriptive facets were identified.

Conclusions

We have sought to identify and classify all knowledge encounters, and we have developed a faceted description of key categories which will support richer descriptions and interrogations of knowledge encounters in healthcare research.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0564-1) contains supplementary material, which is available to authorized users.

Evidence-Based Medicine and the Implementation Gap

Evidence-based medicine was one of the earliest manifestations of evidence-based policy and practice, and has exercised substantial influence on other policy areas. Based on data from seven empirical studies carried out between 1993 and 1999, this article examines the origins and impact of EBM, and the complexities of implementation which have emerged. Policy makers and EBM enthusiasts alike have frequently taken a somewhat simplistic view of the implementation gap they seek to address. Understanding clinicians' mixed reactions to the rhetoric of EBM helps explain both why EBM has had as much impact as it has, and why it has sometimes been resisted and rejected. Although other areas of public policy can learn from the experience of EBM, there are distinctive features of health care which set it apart, notably the continued autonomy and dominance of the medical profession and the strong influence of the biomedical science model on what is considered legitimate evidence.

The barriers and facilitators to the implementation of clinical guidance in elective orthopaedic surgery: a qualitative study protocol

BACKGROUND

Clinical guidelines in orthopaedic surgery aim to improve the efficiency, quality and outcomes of patient care by ensuring that treatment recommendations are based on the best available evidence. The simple provision of guidelines, however, does not ensure fidelity or guarantee their uptake and use in surgical practice. Research exploring the factors that affect surgeons' use of evidence and guidelines has focused on understanding what evidence exists for current clinical decisions. This narrowed scope emphasises the technical, educational and accessibility issues but overlooks wider factors that help explain how and why guidelines are not implemented and used in surgery. It is also important to understand how we can encourage the implementation processes in practice. By taking a social science perspective to examine orthopaedic surgery, we move beyond the narrow focus and explore how and why clinical guidelines struggle to achieve full uptake. We aim to explore guideline uptake to discover the factors that contribute to, or complicate, appropriate implementation in this field. We need to go beyond traditional views and experimental methods to examine the barriers and facilitators of implementation in real-life NHS surgical practice. These could be multifactorial, linked to individual, organisational or contextual influences, which act on the guideline implementation process.

METHODS/DESIGN

We will use ethnographic methods to conduct case studies in three English NHS hospitals. Within each case, we will conduct observations, interviews and analysis of key documents to understand experiences, complex processes and decisions made and the role of clinical guidance and other sources of evidence within orthopaedic surgery. The data will be transcribed and analysed thematically. Comparisons will be made within cases and across cases.

DISCUSSION

Guidelines are a fundamental part of clinical practice, and various factors must be considered when preparing for their successful implementation into organisations. Understanding the views and experiences of a range of surgical, clerical and managerial staff across multiple orthopaedic departments will capture the complexity and variety of factors that can influence surgical decisions. The findings of our study will identify the specific features of orthopaedic practice to help guide the development of strategies to facilitate guideline uptake in everyday surgical work.

Barriers and challenges in researches by Iranian students of medical universities

Background:

Health sciences research (HSR) is an essential part of improving health care which plays a critical role in the field of medicine and clinical practice. The aim of the current study was to assess barriers to the research by students of medical sciences as well as to find out effective strategies for management of student researches in Iranian universities.

Materials and Methods:

This study utilized a hybrid design with quantitative and qualitative analytical approaches conducted on 627 students in six schools of medical sciences in two universities in Central Province in Iran from April to December, 2012. Questionnaires were distributed among researcher and non-researcher students to find barriers to the research. These barriers were approved and validated by similar studies and strategies using the Delphi technique on 36 students.

Results:

The most important barriers among researcher students were institutional barriers (3.3 ± 1.3), but in non-researcher students they were individual barriers (3.6 ± 1.7). The majority of barriers to involvement in the research among researcher students appeared to be time, lack of access to electronic resources and prolongation of the process of buying equipment. In addition, the greatest barriers among non-researcher students included the lack of time, scientific writing skills, and access to trained assistants.

Conclusion:

The results showed the issue of attitudes towards compulsory research as a component of critical scholarship in the curriculum of medical courses. Moreover, employment of the research experts can be helpful for research training in schools of medical sciences.

How well establishment of research plans can improve scientific ranking of medical universities

BACKGROUND

As a developing country, Iran has not had a substantial share in global science production activities; however, this country has recently been the forth country in the world regarding research output publications, and biomedical research has played a crucial role in achieving this honorable position.

OBJECTIVES

In this paper, we aimed to introduce the strategies employed at Baqiyatallah University of Medical Sciences of Iran, to enhance scientific research output of this university.

PATIENTS AND METHODS

The present study used the qualitative content analysis technique. The Research deputies and the head of research centers of Baqiyatallah University of Medical Sciences were the research subjects. The main researcher conducted all the interviews. The participants were all authorities of the university. Sampling continued until data saturation. After speaking with 16 participants, the interviews yielded no new information, and no new categories or subcategories were added to the previous ones. Deep and semi-structured interviews with open-ended questions were used to collect data.

RESULTS

Diplomacies employed to promote research, organizing educational classes, and foundation of infrastructural organizations for research and true surveillance of research programs were the main characteristics of Baqiyatallah University of Medical Sciences research strategies.

CONCLUSIONS

Baqiyatallah University of Medical Sciences is a military university of limited resources that has won several awards in the recent years, and has been categorized as one of the leading first ranked medical universities in Iran; a position quite higher than several other larger universities of the country. We recommend more enhanced strategies for other universities.

A cluster randomised controlled trial of a pharmacist-led collaborative intervention to improve statin prescribing and attainment of cholesterol targets in primary care

BACKGROUND

Small trials with short term follow up suggest pharmacists' interventions targeted at healthcare professionals can improve prescribing. In comparison with clinical guidance, contemporary statin prescribing is sub-optimal and achievement of cholesterol targets falls short of accepted standards, for patients with atherosclerotic vascular disease who are at highest absolute risk and who stand to obtain greatest benefit. We hypothesised that a pharmacist-led complex intervention delivered to doctors and nurses in primary care, would improve statin prescribing and achievement of cholesterol targets for incident and prevalent patients with vascular disease, beyond one year.

METHODS

We allocated general practices to a 12-month Statin Outreach Support (SOS) intervention or usual care. SOS was delivered by one of 11 pharmacists who had received additional training. SOS comprised academic detailing and practical support to identify patients with vascular disease who were not prescribed a statin at optimal dose or did not have cholesterol at target, followed by individualised recommendations for changes to management. The primary outcome was the proportion of patients achieving cholesterol targets. Secondary outcomes were: the proportion of patients prescribed simvastatin 40 mg with target cholesterol achieved; cholesterol levels; prescribing of simvastatin 40 mg; prescribing of any statin and the proportion of patients with cholesterol tested. Outcomes were assessed after an average of 1.7 years (range 1.4-2.2 years), and practice level simvastatin 40 mg prescribing was assessed after 10 years.

FINDINGS

We randomised 31 practices (72 General Practitioners (GPs), 40 nurses). Prior to randomisation a subset of eligible patients were identified to characterise practices; 40% had cholesterol levels below the target threshold. Improvements in data collection procedures allowed identification of all eligible patients (n = 7586) at follow up. Patients in practices allocated to SOS were significantly more likely to have cholesterol at target (69.5% vs 63.5%; OR 1.11, CI 1.00-1.23; p = 0.043) as a result of improved simvastatin prescribing. Subgroup analysis showed the primary outcome was achieved by prevalent but not incident patients. Statistically significant improvements occurred in all secondary outcomes for prevalent patients and all but one secondary outcome (the proportion of patients with cholesterol tested) for incident patients. SOS practices prescribed more simvastatin 40 mg than usual care practices, up to 10 years later.

INTERPRETATION

Through a combination of educational and organisational support, a general practice based pharmacist led collaborative intervention can improve statin prescribing and achievement of cholesterol targets in a high-risk primary care based population.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Register ISRCTN61233866.

Barriers and facilitators to the uptake of computerized clinical decision support systems in specialty hospitals: protocol for a qualitative cross-sectional study

BACKGROUND

Computerized clinical decision support systems (CDSSs) have been shown to improve the efficiency and quality of patient care by connecting healthcare professionals with high quality, evidence-based information at the point-of-care. The mere provision of CDSSs, however, does not guarantee their uptake. Rather, individual and institutional perceptions can foster or inhibit the integration of CDSSs into routine clinical workflow. Current studies exploring health professionals' perceptions of CDSSs focus primarily on technical and usability issues, overlooking the social or cultural variables as well as broader administrative or organizational roles that may influence CDSS adoption. Moreover, there is a lack of data on the evolution of perceived barriers or facilitators to CDSS uptake across different stages of implementation.

METHODS

We will conduct a qualitative, cross-sectional study in three Italian specialty hospitals involving frontline physicians, nurses, information technology staff, and members of the hospital board of directors. We will use semi-structured interviews following the Grounded Theory framework, progressively recruiting participants until no new information is gained from the interviews.

DISCUSSION

CDSSs are likely to become an integral and diffuse part of clinical practice. Various factors must be considered when planning their introduction in healthcare settings. The findings of this study will guide the development of strategies to facilitate the successful integration of CDSSs into the regular clinical workflow. The evaluation of diverse health professionals across multiple hospital settings in different stages of CDSS uptake will better capture the complexity of roles and contextual factors affecting CDSS uptake.

Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography

BACKGROUND

Evidence supports the implementation of primary prevention and health promotion (PP&HP) activities but primary care (PC) professionals show resistance to implementing these activities. The aim was to synthesize the available qualitative research on barriers and facilitators identified by PC physicians and nurses in the implementation of PP&HP in adults.

METHODS AND FINDINGS

A systematic search of three databases was conducted and supported by manual searches. The 35 articles included were translated into each other and a new interpretation of the concepts extracted was generated. The factors affecting the implementation of PP&HP activities in PC according to professionals were fitted into a five-level ecological model: intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. At the intrapersonal level we find professionals' beliefs about PP&HP, experiences, skills and knowledge, and selfconcept. The attitudes and behavior towards PP&HP of patients, specialists, practice managers and colleagues (interpersonal factors) affect the feasibility of implementing PP&HP. Institutional level: PC is perceived as well-placed to implement PP&HP but workload, lack of time and referral resources, and the predominance of the biomedical model (which prioritizes disease treatment) hamper the implementation of PP&HP. The effectiveness of financial incentives and tools such as guidelines and alarms/reminders is conditioned by professionals' attitudes to them. Community factors include patients' social and cultural characteristics (religion, financial resources, etc.), local referral resources, mass-media messages and pharmaceutical industry campaigns, and the importance given to PP&HP in the curriculum in university. Finally, policies affect the distribution of resources, thus affecting the implementation of PP&HP.

CONCLUSIONS

Research on barriers and facilitators in the implementation of PP&HP activities in multirisk management is scarce. The conceptual overview provided by this synthesis resulted in the development of practical recommendations for the design of PP&HP in PC. However, the effectiveness of these recommendations needs to be demonstrated.

An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices?

Background

Prescribing is a core activity for general practitioners, yet significant variation in the quality of prescribing has been reported. This suggests there may be room for improvement in the application of the current best research evidence. There has been substantial investment in technologies and interventions to address this issue, but effect sizes so far have been small to moderate. This suggests that prescribing is a decision-making process that is not sufficiently understood. By understanding more about prescribing processes and the implementation of research evidence, variation may more easily be understood and more effective interventions proposed.

Methods

An ethnographic study in three Scottish general practices with diverse organizational characteristics. Practices were ranked by their performance against Audit Scotland prescribing quality indicators, incorporating established best research evidence. Two practices of high prescribing quality and one practice of low prescribing quality were recruited. Participant observation, formal and informal interviews, and a review of practice documentation were employed.

Results

Practices ranked as high prescribing quality consistently made and applied macro and micro prescribing decisions, whereas the low-ranking practice only made micro prescribing decisions. Macro prescribing decisions were collective, policy decisions made considering research evidence in light of the average patient, one disease, condition, or drug. Micro prescribing decisions were made in consultation with the patient considering their views, preferences, circumstances and other conditions (if necessary).

Although micro prescribing can operate independently, the implementation of evidence-based, quality prescribing was attributable to an interdependent relationship. Macro prescribing policy enabled prescribing decisions to be based on scientific evidence and applied consistently where possible. Ultimately, this influenced prescribing decisions that occur at the micro level in consultation with patients.

Conclusion

General practitioners in the higher prescribing quality practices made two different ‘types’ of prescribing decision; macro and micro. Macro prescribing informs micro prescribing and without a macro basis to draw upon the low-ranked practice had no effective mechanism to engage with, reflect on and implement relevant evidence. Practices that recognize these two levels of decision making about prescribing are more likely to be able to implement higher quality evidence.

Starting and staying on preventive medication for cardiovascular disease

PURPOSE OF REVIEW

To synthesize the qualitative research literature regarding medication use to prevent cardiovascular disease in order to explain the variation in healthcare professional (HCP) and patient behaviours, and to evaluate the implications for practice.

RECENT FINDINGS

The decision to start preventive medication is affected by the patient-HCP relationship and by the design of the service. Both HCPs and patients are influenced by their understanding of the evidence regarding the value of preventive interventions; their values and preferences; and their sociopolitical context and the organizational structure of their practice environment. The design of their service affects uptake as a consequence of its impact on clinical communication and the extent to which the service is tailored to the needs of the local community. Continuing to take prescribed medication is affected by both contextual and practical factors. Recommendations for practice can be split into those with a clinical focus and those with a patient or community focus. More sophisticated analyses have moved beyond recommendations for patient and HCP education, and address constraints in the organization of clinical services and the social context of evidence translation.

SUMMARY

Qualitative health research provides important insights into the experience of and context for decision making about medication prescription and adherence that can help efforts to prevent cardiovascular disease.

Use of evidence-based practice among athletic training educators, clinicians, and students, part 2: attitudes, beliefs, accessibility, and barriers

CONTEXT

Successful implementation of evidence-based practice (EBP) within athletic training is contingent upon understanding the attitudes and beliefs and perceived barriers toward EBP as well as the accessibility to EBP resources of athletic training educators, clinicians, and students.

OBJECTIVE

To assess the attitudes, beliefs, and perceived barriers toward EBP and accessibility to EBP resources among athletic training educators, clinicians, and students.

DESIGN

Cross-sectional study.

SETTING

Online survey instrument.

PATIENTS OR OTHER PARTICIPANTS

A total of 1209 athletic trainers participated: professional athletic training education program directors (n = 132), clinical preceptors (n = 266), clinicians (n = 716), postprofessional athletic training educators (n = 24) and postprofessional students (n = 71).

MAIN OUTCOME MEASURE(S)

Likert-scale items (1 = strongly disagree, 4 = strongly agree) assessed attitudes and beliefs and perceived barriers, whereas multipart questions assessed accessibility to resources. Kruskal-Wallis H tests (P ≤ .05) and Mann-Whitney U tests with a Bonferroni adjustment (P ≤ .01) were used to determine differences among groups.

RESULTS

Athletic trainers agreed (3.27 ± 0.39 out of 4.0) that EBP has various benefits to clinical practice and disagreed (2.23 ± 0.42 out of 4.0) that negative perceptions are associated with EBP. Benefits to practice scores (P = .002) and negative perception scores (P < .001) differed among groups. With respect to perceived barriers, athletic trainers disagreed that personal skills and attributes (2.29 ± 0.52 out of 4.0) as well as support and accessibility to resources (2.40 ± 0.40 out of 4.0) were barriers to EBP implementation. Differences were found among groups for personal skills and attributes scores (P < .001) and support and accessibility to resources scores (P < .001). Time (76.6%) and availability of EBP mentors (69.6%) were the 2 most prevalent barriers reported. Of the resources assessed, participants were most unfamiliar with clinical prediction rules (37.6%) and Cochrane databases (52.5%); direct access to these 2 resources varied among participants.

CONCLUSIONS

Athletic trainers had positive attitudes toward the implementation of EBP within didactic education and clinical practice. However, accessibility and resource use remained low for some EBP-related resources. Although the perceived barriers to implementation are minimal, effective integration of EBP within athletic training will present challenges until these barriers dissolve.

A survey of the attitude and practice of research among doctors in Riyadh Military Hospital Primary Care Centers, Saudi Arabia

OBJECTIVES

To assess the attitude and practice of doctors in the Military Hospital Primary Care Centers in Riyadh (RMH) toward research and to identify the main barriers to conduct research.

MATERIALS AND METHODS

A cross-sectional study was conducted from March to April, 2010, at RMH primary care centers. The sample included all general practitioners (GPs) working in primary healthcare centers. A self-administered questionnaire was formulated from different sources and used as a tool for data collection.

RESULTS

The response rate was 75%. Among the respondents 96.9% agreed that research in primary care was important for different reasons. Most of the GPs had a positive attitude toward research: 68% had been influenced by research in their clinical practice and 66% had an interest in conducting research, and74.2% of the respondents had plans to do research in the future. Insufficient time was the most frequently cited barrier (83.5%) for participating in research, followed by the lack of support (58.8%).

CONCLUSIONS

Many of the GPs had a positive attitude toward research, but had no publications or plan for new research. Lack of time, support, and money were the main constraints for carrying out research.

Experimenting clinical pathways in general practice: a focus group investigation with italian general practitioners

Background

Clinical governance is considered crucial in primary care. Since 2005, clinical pathways have been experimentally implemented at the Local Health Authority of Monza Brianza (ASLMB), Italy, to develop general practitioners’ (GPs) care of patients affected by some chronic diseases. The experimentation was aimed at introducing clinical governance in primary care, increasing GPs’ involvement in the care of their patients, and improving both patients’ and professionals’ satisfaction. In the period 2005-2006, 12% of the 763 employed GPs in the ASLMB were involved in the experiment, while this percentage increased to 15-20% in 2007-2008.

Design and Methods

Twenty-four GPs were purposively sampled, randomly divided into two groups and asked to participate in focus groups (FGs) held in 2008, aimed at evaluating their perception of the experiment. The FGs were audio-recorded, dialogues were typed out and undergone to a thematic analysis, according to the Interpretative Phenomenological Approach.

Results

Four major themes emerged: i) clinical pathways can result in GPs working in a more efficient and effective fashion; ii) they can assure higher levels of both patient and professional satisfaction, since they sustain a caring approach and strengthen the GPs’ role; iii) nevertheless, clinical pathways increase the bureaucratic workload and problems can arise in relationships among GPs and the LHA; iv) the implementation of clinical pathways can be improved, especially by reducing bureaucracy and by assuring their continuity.

Conclusions

Managerial aspects should be considered with care in order to experimentally introduce clinical pathways in general practice, and continuity of the experimentation should be guaranteed to improve GPs’ adherence and commitment.

Acknowledgments

the Authors thank Dr. AP. Cantù and Dr D. Cereda who participated in the two focus groups as observers.

GPs' views in five European countries of interventions to promote prudent antibiotic use

BACKGROUND

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

AIM

To explore GPs' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

DESIGN AND SETTING

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

METHOD

Fifty-two semi-structured interviews explored GPs' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

RESULTS

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

CONCLUSION

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.

Are journal clubs effective in supporting evidence-based decision making? A systematic review. BEME Guide No. 16

BACKGROUND

Journal clubs (JCs) are a common form of interactive education in health care aiming to promote the uptake of research evidence into practice, but their effectiveness has not been established.

OBJECTIVE

This systematic review aimed to determine whether the JC is an effective intervention in supporting clinical decision making.

METHODS

We searched for studies which evaluated whether clubs promote changes in learner reaction, attitudes, knowledge, skills, behaviour or patient outcomes. We included undergraduate, postgraduate and practice JCs and excluded studies evaluating video/internet meetings or single meetings.

RESULTS

Eighteen studies were included. Studies reported improvements in reading behaviour (N = 5/11), confidence in critical appraisal (N = 7/7), critical appraisal test scores (N = 5/7) and ability to use findings (N = 5/7). No studies reported on patient outcomes. Sixteen studies used self-reported measures, but only four studies used validated tests. Interventions were too heterogeneous to allow pooling. Realist synthesis identified potentially 'active educational ingredients', including mentoring, brief training in clinical epidemiology, structured critical appraisal tools, adult-learning principles, multifaceted teaching approaches and integration of the JC with other clinical and academic activities.

CONCLUSION

The effectiveness of JCs in supporting evidence-based decision making is not clear. Better reporting of the intervention and a mixed methods approach to evaluating active ingredients are needed in order to understand how JCs may support evidence-based practice.

Qualitative research and the take-up of evidence-based practice

In this paper it is argued that evidence-based medicine (EBM) is a social movement as well as a scientific enterprise, and that as such it requires qualitative investigation of its various activities to understand its impact and take-up. Randomised controlled trials (RCTs) are a blunt instrument of assessing whether interventions achieve intended or unintended outcomes, or whether they are acceptable to those they are aimed at. To understand the success or failure of evidence-based interventions, it is necessary to investigate practitioners’ acceptance of, or resistance to, EBM. This involves exploration of the perceived relationships between practical clinical knowledge derived from everyday practice and scientific knowledge. The implementation of best evidence also requires the acknowledgement of local contextual factors. The goals of EBM will not be achieved if patients do not accept the advice and prescriptions they are given by professionals. One of the reasons that some professionals find it difficult to use the results of RCTs in their clinical practice is because they are aware of patients’ differing priorities and life experiences. If we accept that EBM is a social movement, then the methods needed to investigate its activities are those of the social sciences, including qualitative methods.

The influence of a topic-specific, research-based presentation on physical therapists' beliefs and practices regarding evidence-based practice

BACKGROUND/PURPOSE

Evidence-based practice (EBP) is an important objective as physical therapists strive for autonomous practice. The most commonly identified barrier to EBP is clinicians' lack of time. Purposes of this study were to determine (1) clinicians' opinions of EBP; (2) whether EBP presentations would influence clinicians' beliefs and practices; and (3) if additional barriers would be identified.

METHODS

Twenty-four physical therapists, representing four clinical settings, participated. Each facility selected one presentation topic. Presenations were prepared, then given at each facility. Data were collected from three surveys.

RESULTS

The majority of participants agreed that EBP is an essential component of practice. Most reported a willingness to change their practice to be more aligned with research. The top three barriers identified were lack of time, access to publications, and research in specific areas. Most reported gaining new information and integration of the material.

CONCLUSIONS

EBP is considered essential by most clinicians, but lack of time is consistently identified as a primary barrier. Clinicians found it helpful to have EB information presented to them. Many would welcome additional presentations. Clinicians may increase their use of EBP if the barrier "lack of time" is lessened by locating, synthesizing, and presenting this information to them.

Views on primary prevention of cardiovascular disease--an interview study with Swedish GPs

BACKGROUND

General practitioners (GPs) have gradually become more involved in the prevention of cardiovascular disease (CVD), both through more frequent prescribing of pharmaceuticals and by giving advice regarding lifestyle factors. Most general practitioners are now faced with decisions about pharmaceutical or non-pharmaceutical treatment for primary prevention every day. The aim of this study was to explore, structure and describe the views on primary prevention of cardiovascular disease in clinical practice among Swedish GPs.

METHODS

Individual interviews were conducted with 21 GPs in southern Sweden. The interview transcripts were analysed using a qualitative approach, inspired by phenomenography.

RESULTS

Two main categories of description emerged during the analysis. One was the degree of reliance on research data regarding the predictability of real risk and the opportunities for primary prevention of CVD. The other was the allocation of responsibility between the patient and the doctor. The GPs showed different views, from being convinced of an actual and predictable risk for the individual to strongly doubting it; from relying firmly on protection from disease by pharmaceutical treatment to strongly questioning its effectiveness in individual cases; and from reliance on prevention of disease by non-pharmaceutical interventions to a total lack of reliance on such measures.

CONCLUSIONS

The GPs' different views, regarding the rationale for and practical management of primary prevention of CVD, can be interpreted as a reflection of the complexity of patient counselling in primary prevention in clinical practice. The findings have implications for development and implementation of standard treatment guidelines, regarding long-time primary preventive treatment.

General practitioners and tutors' experiences with peer group academic detailing: a qualitative study

Background

The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice.

Methods

Data was collected through nine focus group interviews with a total of 39 GPs and 20 tutors. Transcripts from the interviews were analyzed by two researchers according to a procedure for thematic content analysis.

Results

A shared understanding of the complex decision-making involved in prescribing in general practice was reported by both GPs and tutors as essential for an open discussion in the CME groups. Tutors experienced that CME groups differed regarding structure and atmosphere, and in some groups it was a challenge to run the scheme as planned. Individual feedback motivated GPs to reflect on and to improve their prescribing practice, though feedback reports could cause distress if the prescribing practice was unfavourable. Explanations for inappropriate prescriptions were lack of knowledge, factors associated with patients, the GP's background, the practice, and other health professionals or health care facilities.

Conclusions

GPs and tutors experienced peer group academic detailing as a suitable method to discuss and learn more about pharmacotherapy. An important outcome for GPs was being more reflective about their prescriptions. Disclosure of inappropriate prescribing can cause distress in some doctors, and tutors must be prepared to recognise and manage such reactions.

Awareness, attitude and practice of evidence-based medicine among primary health care doctors in Jordan

OBJECTIVES

To assess the awareness, attitude and knowledge towards evidence-based medicine (EBM) among primary health care doctors in Jordan and to identify the perceived barriers for practising EBM.

METHODS

A simple random sample of 34 comprehensive primary health care centres was selected from a list of 64 centres in Jordan using random number table. A family doctor visited all selected centres and invited the available doctors to participate in the study. Participants were asked to fill the self-administrated questionnaire that was designed to assess beliefs and attitude of doctors towards EBM.

RESULTS

Of the total 220 clinicians approached, 202 (91.8%) completed the questionnaire. About 80.7% welcomed promotion of EBM and 91.1% agreed on that research findings are helpful in daily management of patients. About 85.1% stated that practising EBM improves patient care, 68.3% stated that EBM reduces health care costs, 74.8% stated that EBM improves quick knowledge update, 93.6% reported that the doctor-patient relationship is affected positively by practising EBM. About 60.9% reported that they know the concept of EBM and 56.1% reported that they ever used the EBM. Patient overload, limited resources and facilities, and the absence of an effective computer system were the most commonly reported barriers to the implementation of EBM.

CONCLUSIONS

In spite of the positive attitude towards EBM, this study demonstrated numerous personal, interpersonal and institutional barriers towards implementing EBM which necessitate prompt action to formulate a national plan to overcome such barriers.

Experiences, attitudes and barriers towards research amongst junior faculty of Pakistani medical universities

BACKGROUND

The developing world has had limited quality research and in Pakistan, research is still in its infancy. We conducted a study to assess the proportion of junior faculty involved in research to highlight their attitude towards research, and identify the factors associated with their research involvement.

METHODS

A cross-sectional study was conducted in four medical universities/teaching hospitals in Pakistan, representing private and public sectors. A pre-tested, self-administered questionnaire was used to collect information from 176 junior faculty members of studied universities/hospitals. Logistic regression analysis was used to identify factors related to attitudes and barriers in research among those currently involved in research with those who were not.

RESULTS

Overall, 41.5% of study subjects were currently involved in research. A highly significant factor associated with current research involvement was research training during the post-graduate period (p < 0.001). Other factors associated with current involvement in research were male gender, working in the public sector and previous involvement in research. Overall, a large majority (85.2%) of doctors considered research helpful in their profession and had a positive attitude towards research; nevertheless this positive attitude was more frequently reported by doctors who were currently involved in research compared to those who were not (OR = 4.69; 95% CI = 1.54-14.26). Similarly, a large proportion (83.5%) of doctors considered research difficult to conduct; higher by doctors who were not presently involved in research (OR = 2.74; 95% CI = 1.20-6.22)

CONCLUSION

Less than half of the study participants were currently involved in research. Research output may improve if identified barriers are rectified. Further studies are recommended in this area.

Getting a Better Grip on Research: The Fate of Those Who Ignore History

Those who ignore history are doomed to repeat it George Santayana American philosopher and poet, 1863–1952

This is the first paper in a series of five describing the use of evidence to support decisions made in clinical practice. The series covers large elements of Statement 2: The general practice consultation, Statement 3.3: Ethics and values based medicine and Statement 3.5: Evidence-based practice of the GP Curriculum.

Primary prevention of cardiovascular diseases by lipid-lowering treatment in German general practice: Results from GPs ignoring guidelines and risk calculators

OBJECTIVE

Guidelines/risk calculators for the primary prevention of cardiovascular disease have been developed, which could make decisions for or against therapy easier. However, it has been shown for different countries that there is still quite a discrepancy between what is done and what should be done according to guidelines/risk calculators. Usually, in Germany, neither guidelines nor risk calculators are used. On what basis, then, and with what result do German general practitioners decide for or against a treatment?

METHODS

26 GPs agreed to participate in the study. From their surgeries, data from a random sample of 401 patients diagnosed with hyperlipidaemia were taken, of which 290 were eligible for the study on primary prevention. Patient risk factors were taken from their files to analyse their need for treatment using risk calculators for ERCP III (US guideline) and the European guideline. These results were compared with the treatment they received from their GPs. In semi-structured interviews, GPs were asked about their decision-making process (in four randomly chosen patients from each surgery) concerning the chosen treatment. Additionally, GPs were asked about their attitude towards guidelines/risk calculators.

RESULTS

89% of the patients who received treatment would also have received it according to ERCP III. According to European guidelines, only 38% of those receiving treatment need it. Concerning those not receiving treatment, 54% would not receive it according to NCEP III and 89% would not according to the European guideline. In interviews, around 75% of doctors demonstrated that they follow a multifactorial approach and a high-risk strategy. However, about 50% and 70% explicitly stated not using guidelines or risk calculators, respectively, and even among those stating that they used them, the majority were unaware of names/sources. Patient values or wishes as well as the healthcare system influenced their decisions.

CONCLUSION

German GPs seem to follow quite effectively a high-risk strategy in primary prevention, usually using a multifactorial approach, even without using risk calculators/guidelines. This kind of personalized care is also reflected in the considered importance of patient wishes and values. It is difficult to judge GPs concerning their quality of care having as a "gold standard" different risk calculators/guidelines that define whether such different populations receive treatment or not.

Qualitative perspectives in translational research

The rapid uptake of qualitative approaches in translational research can be best understood in the context of recent innovations in health services research, as well as an overarching concern with improving the quality of health care. Qualitative approaches highlight the human dimension in health care by foregrounding the perceptions, experiences, and behaviors of both consumers and providers of care. As such, these methods are particularly useful for addressing the complex issues related to improving health care quality and implementing system change. This overview traces a brief history of the factors contributing to the recent and rapid growth of qualitative methods in health research in general and translational research in particular; describes the varieties of qualitative approaches employed in this research; and illustrates the utility of these approaches for variable identification, instrument development, description/explanation of patient/provider perceptions and behaviors, individual/organizational change, and theory refinement.

When is knowledge ripe for primary care? An exploratory study on the meaning of evidence

The objectives of this study were to explore the meaning of scientific evidence as it is understood by primary care physicians. Individual interviews were conducted with actors chosen for their roles in the production and use of knowledge: 22 family physicians, 13 specialist physicians, and 6 researchers. Two situations served as points of reference for these discussions: screening for genetic breast cancer and treatment of hypertension. The results suggest that there may be a misunderstanding between the producers of knowledge and primary care practitioners with respect to what constitutes "evidence"--knowledge ready for integration into the clinical practice of primary care. These potential differences go beyond the issues of how information is disseminated. Rather, many of the questions raised by family physicians concern how knowledge is developed. In the interests of fostering better dissemination of new knowledge and encouraging its adoption, new links should be created between knowledge "producers" and potential users.

Impact of short evidence summaries in discharge letters on adherence of practitioners to discharge medication. A cluster-randomised controlled trial

BACKGROUND

International concern about quality of medical care has led to intensive study of interventions to ensure care is consistent with best evidence. Simple, inexpensive, feasible and effective interventions remain limited.

OBJECTIVE

We examined the impact of one-sentence evidence summaries appended to consultants' letters to primary care practitioners on adherence of the practitioners to recommendations made by the consultants regarding medication for patients with chronic medical problems.

DESIGN

Cluster-randomised trial.

SETTING

Secondary/primary care interface (urban district hospital/referral practices).

PARTICIPANTS

178 practices received one or more discharge letters with evidence summaries. The 66 practices in the intervention group provided feedback on 172 letters, and the 56 practices in the control group provided feedback on 96 letters.

RESULTS

Appending an evidence summary to discharge letters resulted in a decrease in non-adherence to discharge medication from 29.6% to 18.5% (difference adjusted for underlying medical condition 12.5%; p = 0.039). Among the five possible reasons for discontinuing discharge medication, the evidence summaries seemed to have the largest impact on budget-related reasons for discontinuation (2.6% in the intervention versus 10.7% in the control group (p = 0.052)). Most clinicians (72%) were enthusiastic about continuing receiving evidence summaries with discharge letters in routine care.

CONCLUSIONS

The one-sentence evidence summary is a simple, inexpensive, well-accepted intervention that may improve primary care practitioners' adherence to evidence-based consultant recommendations.

Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke

BACKGROUND AND PURPOSE

The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists' implementation of evidence-based practice (EBP) for people with stroke.

SUBJECTS

The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada.

METHODS

A cross-sectional mail survey was conducted.

RESULTS

Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature.

DISCUSSION AND CONCLUSION

Lack of education, negative perceptions about research and physical therapists' role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.

Falling on stony ground? A qualitative study of implementation of clinical guidelines' prescribing recommendations in primary care

OBJECTIVES

We aimed to explore key themes for the implementation of guidelines' prescribing recommendations.

METHODS

We interviewed a purposeful sample of 25 participants in British primary care in late 2000 and early 2001. Thirteen were academics in primary care and 12 were non-academic GPs. We asked about implementation of guidelines for five conditions (asthma, coronary heart disease prevention, depression, epilepsy, menorrhagia) ensuring variation in complexity, role of prescribing in patient management, GP role in prescribing and GP awareness of guidelines. We used the Theory of Planned Behaviour to design the study and the framework method for the analysis.

RESULTS

Seven themes explain implementation of prescribing recommendations in primary care: credibility of content, credibility of source, presentation, influential people, organisational factors, disease characteristics, and dissemination strategy. Change in recommendations may hinder implementation. This is important since the development of evidence-based guidelines requires change in recommendations. Practitioners do not have a universal view or a common understanding of valid 'evidence'. Credibility is improved if national bodies develop primary care guidelines with less input from secondary care and industry, and with simple and systematic presentation. Dissemination should target GPs' perceived needs, improve ownership and get things right in the first implementation attempt. Enforcement strategies should not be used routinely.

CONCLUSIONS

GPs were critical of guidelines' development, relevance and implementation. Guidelines should be clear about changes they propose. Future studies should quantify the relationship between evidence base of recommendations and implementation, and between change in recommendations and implementation. Small but important costs and side effects of implementing guidelines should be measured in evaluative studies.

The role of etiquette and experimentation in explaining how doctors change behaviour: a qualitative study

Despite increasing interest over the last 30 years in individual variations in clinical practice, various research studies have thrown only limited light on either understanding or changing doctors' behaviour. This qualitative study explored a sample of British general practitioners' accounts of the influences on their prescribing, and identified the locus of the problem in their defence of professional identity through clinical autonomy, a tactic that precluded use of more customary change agents such as line management and economic incentives. The study identified two mechanisms, clinical etiquette and clinical experimentation, however, that enabled change to occur within the constraints imposed by the commitment to clinical autonomy.

Reduction of C-reactive protein by a single 80 mg of simvastatin in patients with unstable angina

BACKGROUND

Increased concentrations of C-reactive protein (CRP) became widely accepted as a risk factor of the higher incidence of coronary events, and rapid lowering CRP by administration of drugs may produce early benefit to the coronary endothelium in patients with coronary heart disease and reduce angina and coronary events after revascularization. Limited information has been available, however, with respect to evaluating a potential effect of a single high-dose simvastatin on CRP in patients with unstable angina (UA) within 48 h. We investigated whether a rapid CRP reduction can be achieved by a single 80 mg of simvastatin therapy in patients with UA given immediately on admission.

METHODS

Forty-two patients with rest chest pain were randomly assigned to a single placebo or 80 mg of simvastatin given at the time of admission plus standard therapy. Blood samples were also drawn at the time of admission, and 48 h later for measuring serum CRP concentrations.

RESULTS

We found that 80 mg of simvastatin induced significant reductions in serum median CRP concentrations and in mean CRP concentrations 48 h later following administration of simvastatin (25.4% and 32.7%, p<0.001, respectively).

CONCLUSIONS

A single high-dose simvastatin, given in the early time on admission, is an effective therapy for controlling inflammatory response in patients with UA, and the benefit to the vascular endothelium might occur quickly by reduction of CRP concentrations in this high-risk subgroup.

Time course of rapid C-reactive protein reduction by pravastatin in patients with stable angina

The evidence has indicated that rapid reduction of inflammatory marker, such as C-reactive protein (CRP) could be achieved by administration of a statin. However, limited information is available in evaluating the short-term time course of CRP reduction in patients with coronary artery disease by use of a statin. Forty-two patients with stable angina were randomly assigned to 20 mg/d or 40 mg/d group of pravastatin. Blood samples were drawn at days 0, 1, and 14 for measuring lipid profile, CRP levels, and hepatic enzymes in all patients. The results showed that both doses of pravastatin induced significant reductions in median CRP levels and in mean CRP levels, respectively, at day 1 (20% in the 20 mg/d group and 17.6% in the 40 mg/d group; 15% in the 20 mg/d group and 10% in the 40 mg/d group) as well as at day 14 (28.6% in the 20 mg/d group and 33.3% in the 40 mg/d group; 25% in the 20 mg/d group and 22.8% in the 40 mg/d group) compared with baseline data without a dose-dependent manner. In addition, no changes were found at day 1 regarding lipid profile; however, both doses of pravastatin induced significant reductions in total cholesterol (TC, 22% and 30%), and low-density lipoprotein (LDL) cholesterol (30% and 40%) compared with baseline at 14 days. The higher dose of pravastatin resulted in significantly greater reductions in TC and LDL cholesterol compared with the 20 mg/d dose (p = 0.05, p = 0.01, respectively). A less significant reduction was observed in triglycerides level (16% and 24%) compared with TC and LDL cholesterol. There was no significant difference in mean high-density lipoprotein (HDL) cholesterol levels compared with baseline in both groups. These data suggested that a common daily dose of pravastatin resulted in rapid reduction of CRP within 24 hours and of lipid profile within 2 weeks, and the benefit to the vascular endothelium might occur quickly by reduction of CRP levels, which may be clinically important for patients in a high-risk subgroup, such as acute coronary artery disease.

A meta-analysis of the placebo response in acute migraine and how this response may be influenced by some of the characteristics of clinical trials

Migraine is the most common cause of vascular headache and a highly prevalent illness. In the last 20 years, the discovery of new agents has increased clinical research on migraine. In most of clinical trials that have been conducted, the efficacy was established using a placebo as a control treatment. The objective of the study reported here was to analyse the response rate in patients who received a placebo as well as to determine how a number of the methodological factors may affect the effect of the placebo in clinical trials of acute migraine. Computer-based information searches were conducted on the Medline database. Data analysis included the outcomes 'pain relief', 'pain-free', 'associated symptoms', 'recurrence', 'patients' opinion' about pain relief and 'adverse events'. Administration route, study design and country in which the study was carried out were the methodological factors that were analyzed. Meta-analysis was computed using Mantel-Haenszel, and a total of 98 papers were considered in the final analysis. After 2 h, 28.6% of the patients of the placebo group improved and 8.8% were pain-free. The percentage of pain-free patients was the highest in the placebo and active drug groups in which the placebo or drug had been administered subcutaneously, in parallel design studies (vs. cross-over trials) and in studies performed in Europe (vs. North America). Adverse events in the placebo group were significantly higher in studies performed in North America. These data reinforce the need for knowing the magnitude of the placebo response in each specific situation during the planning of clinical trials on acute migraine.

Exploring 'clinical judgement': how do child and adolescent mental health professionals decide whether a young person needs individual psychotherapy?

This article reports on a small-scale, qualitative study based in a single CAMHS team, exploring the decision-making process used by mental health professionals when deciding whether or not to refer a child for one particular modality of treatment--individual psychotherapy. Building on an initial audit of child psychotherapy referrals within the team, this study analyses a small number of in-depth interviews with members of the multidisciplinary CAMHS team. Three themes emerged from the analysis, suggesting that referral-making decisions depend on wider conceptions of the particular modality of therapy, particular features of the child and family referred (but not reducible to diagnostic categories), and the stage at which therapeutic work with the family has reached at the time of referral. The implications of these findings are discussed specifically in relation to child psychotherapy, and more generally in relation to evidence-based practice. The authors conclude by arguing for the use of more clinically relevant research methodologies within evidence-based research.

Contextual Factors Influencing Research Use in Nursing

BACKGROUND

Contextual factors are perceived to be significant barriers to research-utilisation-related activity, but little is known about how context impacts on specific research-based decisions, or how the individual interacts with the organisation in the requirement for research-based change.

AIM

This study describes the impact of contextual factors on the practical reasoning of nurse specialists in the construction of policy for practice.

METHODS

Three groups of clinical nurse specialists were observed during a series of meetings convened to construct evidence-based guidelines for nursing practice. Transcripts of the meetings were analysed to identify and categorise the physical, social, political, and economic influences on 31 nursing issues.

FINDINGS

Multiple contextual factors influenced each decision made, with decisions about nursing practice bounded by setting and system considerations, relationships with others in the care team, and resource constraints. Practitioners were involved in weighing up alternative scenarios, contexts, and contingencies for each decision, requiring strategies to adapt and reconstruct the nature of care, to influence others, and to affect organisational decision-making processes.

DISCUSSION

The practical accomplishment of evidence-based practice required diverse skills: translating between evidence and practice; mediating the values, preferences, and working practices of multiple stakeholders; negotiating organisational complexity and the management of boundaries; and coordinating inter-organisational and inter-agency working. Nurse specialists in this study had a significant role in instigating, fuelling, and coordinating policy review, predominantly by communication across professional and organisational boundaries.

IMPLICATIONS/CONCLUSIONS

Clinical specialists acting as organisational boundary spanners require skills in the informal cultural work of organising, facilitating, and maintaining links across professional, team, and organisational boundaries. If their role in the negotiation of evidence-based practice patterns across professional and organisational boundaries is to be successful, wider skills than information management need to be recognised and their development and enactment supported.

Evaluating research for use in practice: what criteria do specialist nurses use?

AIM

This paper reports a study identifying the criteria chosen by nurses to evaluate whether to use research in practice. This work is part of a larger project on the process of research use by nurses.

BACKGROUND

Prescriptive models of research utilization direct practitioners to evaluate a range of criteria to assess the fit of the research to current practice. Criteria relating to the research, task and nursing context are specified, but it is not known whether nurses use these criteria in practice.

METHOD

Three different groups of nurse specialists from a number of health care providers in the North West of England were studied. The specialists were involved in a series of meetings at a local university to construct evidence-based policy recommendations for practice. The discussion was analysed to identify the evaluation criteria they used to assess what should be done in the practical setting.

FINDINGS

Three sets of evaluative criteria were identified relating to the research, the task and the fit of the task with the nursing context, and included relevance and quality of the research, effectiveness, practicality, effort and the impact of the task on client and staff, feasibility and fit with the status quo, and the availability of nursing control and feedback from practice. Criteria were domain-, task- and context-specific.

CONCLUSIONS

Three frames of reference for decisions relating to the use of research are identified: the debate between efficiency and effectiveness in health care, the difficulties of risk management and the responsibility for risk, and research use as a strategy for control in contested arenas. These frames of reference reflect how nurses are judged in a political and organizational context. Attempts to influence research uptake need to take into account how research is perceived and evaluated by practitioners and how it serves their purposes.

Effects of xuezhikang, an extract of cholestin, on lipid profile and C-reactive protein: a short-term time course study in patients with stable angina

BACKGROUND

Reduction of cholesterol and inflammation can be achieved by administration of a statin. Xuezhikang, an extract of cholestin, available from Chinese red yeast rice, could effectively modify the lipid profile. However, limited information is available regarding rapid effects of Xuezhikang on plasma C-reactive protein (CRP) and the lipid profile in patients with stable angina. We evaluated the short-term time course effects of lipid profile and CRP by Xuezhikang in patients with stable angina.

METHODS

Forty-eight consecutive patients with stable angina were randomly assigned to 1200 or 2400 mg/day of Xuezhikang. Blood samples were drawn at days 0, 1, 7 and 14 for lipid profile and CRP levels in all patients, and hepatic enzymes were also evaluated at days 0 and 14.

RESULTS

Both doses of Xuezhikang induced significant reductions in median CRP levels and in mean CRP levels at day 1 (13.0% with 1200 and 16.6% with 2400 mg/day; 14.7% with 1200 and 18.4% with 2400 mg/day), and at day 7 (18.3% with 1200 and 20.2% with 2400 mg/day; 18.5% with 1200 and 22.6% with 2400 mg/day) as well as at day 14 (28.6% with 1200 and 30.4% with 2400 mg/day; 21.7% with 1200 and 24.8% with 2400 mg/day) compared with baseline without a dose-dependent effect but a time-dependent manner. In addition, no changes were found at days 1 and 7 regarding lipid profile. However, both doses of Xuezhikang induced significant reductions in total cholesterol (TC, 13% and 22%), and low-density lipoprotein (LDL) cholesterol (23% and 32%) compared with baseline at day 14. The higher dose of Xuezhikang (2400 mg/day) resulted in significantly greater reductions in TC and LDL cholesterol compared with 1200 mg/day group (p<0.05, p<0.01, respectively). A less significant reduction was observed in triglycerides (TG) level (13% and 23%) compared with TC and LDL cholesterol. There was no significant difference in mean high-density lipoprotein (HDL) cholesterol levels compared with baseline in both groups.

CONCLUSIONS

Xuezhikang resulted in rapid reduction of CRP within 24 h and lipid profile within 2 weeks, which may be clinically important for patients with coronary artery disease.