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Aitchison C, Blackburn DJ, Khan A, Grünewald RA, Jenkins TM. Diagnostic and investigative approach of consultant neurologists in a real-world clinical setting: A pilot study. Int J Clin Pract 2021; 75:e13830. [PMID: 33184980 DOI: 10.1111/ijcp.13830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/05/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Whilst core curricula in neurology are nationally standardised, in real-world clinical practice, different approaches may be taken by individual consultants. The aims of this study were to investigate differences by assessing: (a) variance in diagnostic and investigative practice, using a case-based analysis of inter-rater agreement; (b) potential importance of any differences in terms of patient care; (c) relationships between clinical experience, diagnostic certainty, diagnostic peer-agreement and investigative approach. The objective was to develop novel individualised metrics to facilitate reflection and appraisal. METHODS Three neurologists with 6-23 years' experience at consultant level provided diagnosis, certainty (10-point Likert scale), and investigative approach for 200 consecutive general neurology outpatients seen by a newly qualified consultant in 2015. Diagnostic agreement was evaluated by percentage agreement. The potential importance of any diagnostic differences on patient outcome was assigned a score (6-point Likert scale) by the evaluating neurologist. Associations between diagnostic agreement, certainty and investigative approach were assessed using Spearman correlation, logistic and ordinal regression, and reported as individualised metrics for each rater. RESULTS Diagnostic peer-agreement was 3/3, 2/3 and 1/3 in 55.5%, 31.0% and 13.5% of cases, respectively. In 15.5%, differences in patient management were judged potentially important. Investigation rates were 42%-73%. Mean diagnostic certainty ranged from 6.63/10 (SD 1.98) to 7.72/10 (SD 2.20) between least and most experienced consultants. Greater diagnostic certainty was associated with greater diagnostic peer-agreement (individual-rater regression coefficients 0.33-0.44, P < .01) and lower odds of arranging investigations (individual-rater odds ratios 0.56-0.71, P < .01). CONCLUSIONS It appears that variance in diagnostic and investigative practice between consultant neurologists exists and may result in differing management. Mean diagnostic certainty was associated with greater diagnostic peer-agreement and lower investigation rates. Metrics reflecting concordance with peers, and relationships to diagnostic confidence, could be developed in larger cohorts to inform reflective practice.
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Affiliation(s)
| | - Daniel J Blackburn
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
- Neurology, Sheffield Institute for Translational Neuroscience, University of Sheffield, UK
| | - Aijaz Khan
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | | | - Tom M Jenkins
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
- Neurology, Sheffield Institute for Translational Neuroscience, University of Sheffield, UK
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Quek RG, Master VA, Portier KM, Ward KC, Lin CC, Virgo KS, Lipscomb J. Association of reimbursement policy and urologists׳ characteristics with the use of medical androgen deprivation therapy for clinically localized prostate cancer11Funding: This work was supported by the American Cancer Society, Intramural Research Department, Atlanta, GA. Urol Oncol 2014; 32:748-60. [DOI: 10.1016/j.urolonc.2014.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/14/2014] [Accepted: 02/19/2014] [Indexed: 11/30/2022]
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Justiss MD, Boustani M, Fox C, Katona C, Perkins AJ, Healey PJ, Sachs G, Hui S, Callahan CM, Hendrie HC, Scott E. Patients' attitudes of dementia screening across the Atlantic. Int J Geriatr Psychiatry 2009; 24:632-7. [PMID: 19115255 PMCID: PMC4570034 DOI: 10.1002/gps.2173] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Dementia is a common and growing global public health problem. It leads to a high burden of suffering for society with an annual cost of $100 billion in the US and $10 billion in the UK. New strategies for both treatment and prevention of dementia are currently being developed. Implementation of these strategies will depend on the presence of a viable community or primary care based dementia screening and diagnosis program and patient acceptance of such a program. OBJECTIVE To compare the acceptance, perceived harms and perceived benefits of dementia screening among older adults receiving their care in two different primary health care systems in two countries. DESIGN A Cross-sectional study. SETTING Primary care clinics in Indianapolis, USA and Kent, UK. PARTICIPANTS A convenience sample of 245 older adults (Indianapolis, n = 125; Kent, n = 120). OUTCOMES Acceptance of dementia screening and its perceived harms and benefits as determined by a 52-item questionnaire (PRISM-PC questionnaire). RESULTS Four of the five domains were significantly different across the two samples. The UK sample had significantly higher dementia screening acceptance scores (p < 0.05); higher perceived stigma scores (p < 0.05); higher perceived loss of independence scores (p < 0.01); and higher perceived suffering scores (p < 0.01) than the US sample. Both groups perceived dementia screening as beneficial (p = 0.218). After controlling for prior experience with dementia, acceptance and stigma were marginalized. CONCLUSIONS Older adults attending primary care clinics across the Atlantic value dementia screening but have significant concerns about dementia screening although these concerns differed between the two countries. Low acceptance rates and high rates of perceived harms might be a significant barrier for the introduction of treatment or preventive methods for dementia in the future.
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Affiliation(s)
- Michael D. Justiss
- Indiana University Center for Aging Research Indianapolis, IN, USA,Department of Occupational Therapy, School of Health and Rehabilitation Sciences Indianapolis, IN, USA
| | - Malaz Boustani
- Indiana University Center for Aging Research Indianapolis, IN, USA,Regenstrief Institute, Inc. Indianapolis, IN, USA,Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA,Correspondence to: Dr M. A. Boustani, Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012, USA.
| | - Chris Fox
- Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, Kent, UK
| | - Cornelius Katona
- Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, Kent, UK
| | - Anthony J. Perkins
- Indiana University Center for Aging Research Indianapolis, IN, USA,Regenstrief Institute, Inc. Indianapolis, IN, USA
| | | | - Greg Sachs
- Indiana University Center for Aging Research Indianapolis, IN, USA,Regenstrief Institute, Inc. Indianapolis, IN, USA,Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
| | - Siu Hui
- Indiana University Center for Aging Research Indianapolis, IN, USA,Regenstrief Institute, Inc. Indianapolis, IN, USA,Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
| | - Christopher M. Callahan
- Indiana University Center for Aging Research Indianapolis, IN, USA,Regenstrief Institute, Inc. Indianapolis, IN, USA,Department of Medicine, Indiana University School of Medicine Indianapolis, IN, USA
| | - Hugh C. Hendrie
- Indiana University Center for Aging Research Indianapolis, IN, USA,Regenstrief Institute, Inc. Indianapolis, IN, USA,Department of Psychiatry, Indiana University School of Medicine Indianapolis, IN, USA
| | - Emma Scott
- Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, Kent, UK
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Berg KM, Arnsten JH, Sacajiu G, Karasz A. Providers' experiences treating chronic pain among opioid-dependent drug users. J Gen Intern Med 2009; 24:482-8. [PMID: 19189194 PMCID: PMC2659151 DOI: 10.1007/s11606-009-0908-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 11/19/2008] [Accepted: 01/05/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Successful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and pre-existing addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described. OBJECTIVE Our objective was twofold. We sought first to explore providers' perceptions of ambiguity, and then to examine their strategies for making diagnostic and treatment decisions to manage chronic pain among patients on methadone maintenance therapy. DESIGN Qualitative semi-structured interviews. SETTING AND PARTICIPANTS We interviewed health-care providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program. RESULTS Providers treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers' experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers. CONCLUSIONS Providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse.
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Affiliation(s)
- Karina M Berg
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467, USA.
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Tan EK, Yeo AP, Tan V, Pavanni R, Wong MC. Prescribing pattern in Parkinson's disease: are cost and efficacy overriding factors? Int J Clin Pract 2005; 59:511-4. [PMID: 15857344 DOI: 10.1111/j.1368-5031.2005.00426.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Information on prescribing pattern of antiparkinsonian medications and factors influencing neurologists' choice of such drugs are important considerations in evaluating healthcare cost of Parkinson's disease (PD). We surveyed neurologists' perceived factors influencing their choice of drugs and actual prescribing pattern in PD. Three hundred and six patients at a tertiary hospital, diagnosed with idiopathic PD and who were dispensed antiparkinsonian drugs during a 6-month period were randomly selected. Patient demographics, type and dose of medications were analysed. A questionnaire survey evaluating the factors influencing choice of medications was administered to neurologists who practiced at the institution. The study population had a mean age of 64.4 years (SD +/- 9.9 years), and more than 80% were at Hoehn & Yahr stage 2-3. 92.3% of the study population were receiving levodopa and monotherapy, with levodopa being the most common treatment regimen. Patients who were prescribed levodopa were significantly older and at a later stage of disease compared to those without levodopa (p < 0.05). Only 26.8% of patients were prescribed dopamine agonists. In the survey, the neurologists cited severity of symptoms, and patients' intolerance of side effects, and efficacy as the most important factors influencing their choice of drugs. However, the actual prescribing pattern revealed a strong positive correlation of drug usage with cost subsidy by the institution. While factors affecting drug usage in PD are well recognised, cost and efficacy of a drug appear to be overriding practical factors in influencing usage pattern in clinical practice.
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Affiliation(s)
- E K Tan
- Department of Neurology, Singapore General Hospital, National Neuroscience Institute, SingHealth, National University of Singapore, Singapore.
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Ghosh AK, Ghosh K. Translating evidence-based information into effective risk communication: Current challenges and opportunities. ACTA ACUST UNITED AC 2005; 145:171-80. [PMID: 15962835 DOI: 10.1016/j.lab.2005.02.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent medical advances and the easy availability of evidence-based information at the point of care are believed to provide physicians with improved tools for risk communication. However, evidence indicates that physicians still display marked variability in ordering tests. Factors that determine a physician's test-ordering tendencies vary by specialization, practice, geographical location, defensive practice, and tolerance of uncertainty and are also modified by patient requests. Understanding of statistical terms on the part of both physicians and patients remains limited. Physicians may display limited ability to assess pretest and posttest probabilities, especially in low- and intermediate-risk patients, even after attending short courses in epidemiology, or may find the process impractical. Presentation of diagnostic-test results in a natural-frequency format might improve understanding. Both physicians and patients have difficulty grasping the term "number needed to treat" compared with "relative risk reduction" when comparing therapeutic options. Other patient-related factors that limit understanding include low literacy, individual risk tolerance, and framing patterns of the problem (potential gains vs losses). Despite numerous available modalities (quantitative and qualitative) of risk communication, consensus over the advantage of any single modality in translating evidence into risk communication is limited. It is essential that physicians remain patient-centered, generate trust, and build a partnership with the patient to achieve consensus for medical decision-making. Future studies are indicated to assess the effectiveness of novel risk-communication modalities based on patients' and physicians' characteristics and identify appropriate modality of translating evidence (quantitative or qualitative information).
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Affiliation(s)
- Amit Kumar Ghosh
- Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Daoud AS, Ajloni S, El-Salem K, Horani K, Otoom S, Daradkeh T. Risk of seizure recurrence after a first unprovoked seizure: a prospective study among Jordanian children. Seizure 2004; 13:99-103. [PMID: 15129838 DOI: 10.1016/s1059-1311(03)00137-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE There is wide variation in the reported recurrence rate after a first unprovoked seizure in children. We investigated the risk of recurrence after a first unprovoked seizure in Jordanian children and the risk factors associated with increased recurrence rate. METHODS All consecutive patients aged 3 months-14 years who presented with their first unprovoked seizures between January 1997 and 2000, were included in a prospective study and followed up for 3 years for possible recurrence. Of the patients studied, there was slight male predominance (56.6%) and 55% of them were 2-9 years of age. Generalised seizures were reported in 75% and the remaining 25% had partial seizures. The duration of seizure was 1-4 minutes in 59%. Family history of epilepsy was positive in 31% and parental consanguinity in 32%. The role of these factors in increasing the risk of recurrence was also investigated. RESULTS Two hundred sixty-five patients were included in the study and continued follow up for 3 years. Ninety-eight (37%) of them experienced seizure recurrence. Among the predictor factors for recurrence, partial seizure (P = 0.003) and positive family history (P = 0.000) were associated with a statistically significant increased risk. Sex, age, duration of seizure and consanguinity were not associated with increased risk of recurrence. CONCLUSION Thirty-seven percent of the children studied experienced a second attack after a first unprovoked seizure over the 3 years follows up period. The risk of recurrence was significantly higher in children with a partial seizure (55%) and among those with a positive family history of epilepsy (59%). Age at first seizure, sex, duration of seizure and consanguinity were not significantly related to the risk of recurrence.
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Affiliation(s)
- A S Daoud
- Department of Neuroscience, College of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
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Abstract
To assess the patterns of drug use in Parkinson's disease in Spain, information about the clinical characteristics and current treatment of 1803 parkinsonian patients was obtained from a nationwide survey, involving 241 physicians with practice based on the different assistance levels of the Spanish National Healthcare System. Approximately 90% of the patients were treated with levodopa, regardless of the characteristics of their physicians, but the use of the other available antiparkinsonian treatments was highly influenced by the medical specialty and interest in movement disorders of the prescribing doctors.
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Affiliation(s)
- Francisco Grandas
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Cordery R, Harvey R, Frost C, Rossor M. National survey to assess current practices in the diagnosis and management of young people with dementia. Int J Geriatr Psychiatry 2002; 17:124-7. [PMID: 11813273 DOI: 10.1002/gps.527] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Royal College of Psychiatrists has recommended that old age psychiatrists may be best placed to take responsibility for service provision for younger people with dementia. There are concerns however, that if referral between specialists, particularly neurologists and old age psychiatrists, is incomplete, patients may be under investigated or inappropriately followed up. OBJECTIVES We have assessed the current level of referral between these specialists, how each investigates their patients and details of follow up care. METHOD We conducted a postal survey of all consultant neurologists and consultant old age psychiatrists in the UK with an overall response rate of 64%. RESULTS AND CONCLUSIONS The ideal of full collaboration between old age psychiatrists and neurologists is not achieved. Young patients may be under investigated if managed solely by an old age psychiatrist and may not receive adequate follow up services if managed solely by a neurologist.
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Affiliation(s)
- Rebecca Cordery
- Dementia Research Group, Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
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Hui AC, Tang A, Wong KS, Mok V, Kay R. Recurrence after a first untreated seizure in the Hong Kong Chinese population. Epilepsia 2001; 42:94-7. [PMID: 11207791 DOI: 10.1046/j.1528-1157.2001.99352.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE There is wide variation in the reported prognosis after a first unprovoked generalized tonic-clonic convulsion and in the risk factors that are associated with recurrence. Estimates for the risk of recurrence range from 26 to 71%. We investigated the likelihood of a second attack in Hong Kong Chinese patients. METHODS One hundred thirty-two patients with a first convulsion that was unexplained by acute neurological or medical causes were retrospectively ascertained. Patients' demographic details, potential risk factors for recurrence, and current seizure status were recorded. Survival analysis was performed using the Kaplan-Meier procedure. RESULTS The cumulative probability of a second attack at 1, 2, 3, and 4 years was 30, 37, 42, and 47%, respectively. Seizures in patients with abnormal computer tomography scans of the brain were associated with an increased risk of recurrence on multivariate analysis. CONCLUSIONS Thirty percent of the sample population experienced a second seizure after 1 year. An additional 17% continue to be at risk of a second convulsion during the next 3 years.
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Affiliation(s)
- A C Hui
- Department of Medicine, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong Special Administrative Region, China.
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Gifford DR, Holloway RG, Frankel MR, Albright CL, Meyerson R, Griggs RC, Vickrey BG. Improving adherence to dementia guidelines through education and opinion leaders. A randomized, controlled trial. Ann Intern Med 1999; 131:237-46. [PMID: 10454944 DOI: 10.7326/0003-4819-131-4-199908170-00002] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Educational methods that encourage physicians to adopt practice guidelines are needed. OBJECTIVE To evaluate an educational strategy to increase neurologists' adherence to specialty society-endorsed practice recommendations. DESIGN Randomized, controlled trial. SETTING Six urban regions in New York State. PARTICIPANTS 417 neurologists. INTERVENTION The educational strategy promoted six recommendations for evaluation and management of dementia. It included a mailed American Academy of Neurology continuing medical education course, practice-based tools, an interactive evidence-based American Academy of Neurology-sponsored seminar led by local opinion leaders, and follow-up mailings. MEASUREMENTS Neurologists' adherence to guidelines was measured by using detailed clinical scenarios mailed to a baseline group 3 months before the intervention and to intervention and control groups 6 months after the intervention. In one region, patients' medical records were reviewed to determine concordance between neurologists' scenario responses and their actual care. RESULTS Compared with neurologists in the baseline and control groups, neurologists in the intervention group were more adherent to three of the six recommendations: neuroimaging for patients with dementia only when certain criteria are present (odds ratio, 4.1 [95% CI, 1.9 to 8.9]), referral of all patients with dementia and their families to the Alzheimer's Association (odds ratio, 2.8 [CI, 1.7 to 4.8]), and encouragement of all patients and their families to enroll in the Alzheimer's Association Safe Return Program (odds ratio, 10.8 [CI, 3.5 to 33.2]). For the other three recommendations, adherence did not differ between the intervention and the nonintervention groups. Agreement between scenario responses and actual care ranged from 27% to 99% for the six recommendations and was 95% or more for three of the recommendations. CONCLUSION A multifaceted educational program can improve physician adoption of practice guidelines.
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Affiliation(s)
- D R Gifford
- Brown University School of Medicine, Providence, Rhode Island, USA.
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Holloway RG, Gifford DR, Frankel MR, Vickrey BG. A randomized trial to implement practice recommendations: design and methods of the Dementia Care Study. CONTROLLED CLINICAL TRIALS 1999; 20:369-85. [PMID: 10440564 DOI: 10.1016/s0197-2456(99)00006-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of the Dementia Care Study was to design, implement, and evaluate, in a randomized controlled trial a multi-faceted, specialty-society sponsored intervention to encourage neurologists' adoption of practice recommendations. Eligible participants were 417 neurologists in six regions in New York State (NYS) who were identified through the American Academy of Neurology (AAN) Membership Database and the NYS Physician Masterfile. An Advisory Panel of experts on dementia, neurologists who were local opinion leaders, and local representatives of the Alzheimer's Association guided the development of the intervention. The intervention included six components: (1) a mailing of six practice recommendations in a course of continuing medical education (CME) sponsored by the AAN; (2) a mailing of supplementary, practice-based tools; (3) follow-up mailings reinforcing the recommendations; (4) an invitation to an AAN-sponsored seminar; (5) endorsement by opinion leaders; and (6) specialty-society sponsorship and endorsement. The primary outcome measure was neurologists' decision-making, as assessed through a mailed survey that used detailed clinical scenarios. Intervention and control neurologists received the survey six months after the intervention, and a baseline group received it three months prior to the intervention. To evaluate the concordance of responses to scenarios with actual processes of care, we reviewed medical records in one study region. Secondary outcome measures included number of patient referrals received by the local Alzheimer's Associations and by the Association's National Safe Return Program. The specialty society, the opinion leaders, the dementia experts, local advocacy groups, and the study investigators achieved a high degree of collaboration. Specialty societies can integrate within their educational programs the capability to design and evaluate the impact of novel strategies to encourage the adoption of practice recommendations that are linked to improved quality of care.
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Affiliation(s)
- R G Holloway
- Department of Neurology, University of Rochester, New York 14620, USA
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