1
|
Villeneuve LM, Evans AR, Bowen I, Gernsback J, Balsara K, Jea A, Desai VR. A systematic review of the power of standardization in pediatric neurosurgery. Neurosurg Rev 2023; 46:325. [PMID: 38049561 DOI: 10.1007/s10143-023-02218-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 12/06/2023]
Abstract
In the current neurosurgical field, there is a constant emphasis on providing the best care with the most value. Such work requires the constant optimization of not only surgical but also perioperative services. Recent work has demonstrated the power of standardized techniques in limiting complication while promoting optimal outcomes. In this review article, protocols addressing operative and perioperative care for common pediatric neurosurgical procedures are discussed. These articles address how various institutions have optimized procedures through standardization. Our objective is to improve patient outcomes through the optimization of protocols.
Collapse
Affiliation(s)
- Lance M Villeneuve
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA.
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA.
| | - Alexander R Evans
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Ira Bowen
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Joanna Gernsback
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Karl Balsara
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Andrew Jea
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Virendra R Desai
- Department of Neurological Surgery, University of Oklahoma College of Medicine, 1000 N Lincoln Blvd, #4000, Oklahoma City, OK, 73104, USA
- Department of Pediatric Neurosurgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| |
Collapse
|
2
|
Neill S, Mokashi M, Goldberg A, Fortin J, Janiak E. Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2023; 55:210-217. [PMID: 37394759 DOI: 10.1363/psrh.12237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
CONTEXT Early pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice-related factors, and abortion stigma. METHODS We conducted qualitative, semi-structured interviews among obstetrician-gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use. RESULTS We interviewed 19 obstetrician-gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local-regional experts, leadership from a "champion," prior experience with abortion care, and hospital capacity constraints during the COVID-19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician-gynecologists. CONCLUSION The FDA Mifepristone REMS Program presents substantial barriers to obstetrician-gynecologists incorporating mifepristone into their EPL care.
Collapse
Affiliation(s)
- Sara Neill
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alisa Goldberg
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Jennifer Fortin
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Elizabeth Janiak
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Baissa OT, Hailu W, Tadesse F, Abubeker A, Aman MA, Fufa D, Paltiel O. Attitude, Perceived Barriers, and Challenges Toward Implementing Resource-Appropriate Guidelines for Hematologic Malignancies: Physicians' Survey in Ethiopia. JCO Glob Oncol 2023; 9:e2300104. [PMID: 37797282 PMCID: PMC10664861 DOI: 10.1200/go.23.00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/12/2023] [Accepted: 08/18/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE Cancer care in low-income countries poses formidable challenges. Care may be facilitated by resource-adapted guidelines, such as the National Comprehensive Cancer Network (NCCN) harmonized guidelines for sub-Saharan Africa (NCCN-HG). Understanding physicians' attitudes and knowledge toward guidelines, as well as patient- and resource-related barriers, is essential for promoting their effective implementation. METHODS We conducted an online survey among oncologists, hematologists, internists, residents/fellows, and generalists treating hematologic malignancies in Ethiopia. We assessed attitudes toward the use of guidelines, institutional capacity, and barriers/determinants to effective care. RESULTS Among the 47 physicians completing the survey (representing 64% of Ethiopian professionals treating hematologic malignancies), the majority (85%) reported using guidelines; however, only 22.7% (n = 10) used the NCCN-HG. While overall attitudes toward guidelines were favorable, 57.8% of physicians familiar with the NCCN-HG were either undecided or believed that it lowers the standard of care. Perceived lack of institutional regulation was negatively associated with guideline use (B = -3.23; P = .004). Lack of diagnostic facilities including immunohistochemistry and flow cytometry, supportive care, and poor utilization of guidelines were reported to be determinants of poor patient outcome. Regarding patient factors, 57.4% respondents identified treatment abandonment as an important contributor to poor outcome. Availability of chemotherapy/radiotherapy (89.4%), financial status (85.1%), distance from the hospital (74.5%), and harvest season (65%) had major influences on treatment decisions. Over 80% reported that targeted therapies were unavailable or rarely available. CONCLUSION Awareness and usage of the NCCN-HG are limited among Ethiopian physicians. Lack of facilities, therapies, and regulation, in addition to patient-related factors, was identified as barriers to guideline adherence and determinants of poor outcome.
Collapse
Affiliation(s)
- Obsie T. Baissa
- Faculty of Medicine, Braun School of Public Health Community Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Workagegnehu Hailu
- Department of Medicine, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Fisihatsion Tadesse
- Department of Medicine, College of Health Sciences, Addis Ababa University, Ababa, Ethiopia
| | - Abdulaziz Abubeker
- Department of Medicine, College of Health Sciences, Addis Ababa University, Ababa, Ethiopia
| | - Munir Awol Aman
- Department of Oncology, College of Health Sciences, Addis Ababa University, Ababa, Ethiopia
| | - Diriba Fufa
- Department of Pediatrics, Institute of Health Science, Jimma University, Jimma, Ethiopia
| | - Ora Paltiel
- Faculty of Medicine, Braun School of Public Health Community Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
4
|
Akyüz S, Çelik Y. Physicians’ Attitudes Against Clinical Practice Guidelines on the Use of Guidelines: A Scale Development Study. JOURNAL OF HEALTH MANAGEMENT 2022. [DOI: 10.1177/09720634221088109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aims at developing scale measuring attitudes of physicians against clinical practice guidelines (CPGs) and investigate whether the attitude of physicians against CPGs has an effect on the use of CPGs. ‘The Physicians’ Attitudes Against CPGs and The Use of CPGs’ was developed and used to collect data from the physicians working in a public education and research hospital. Physicians’ attitudes that were constructed as an upper latent variable were significant, positive and highly effective on the use of CPGs. Furthermore, the attitude upper latent variable explained 30% of the variance in the observed variable for the use of CPGs. The attitude upper latent variable was affected significantly, positively and at a remarkably high level by positive attitude latent variable while it was affected significantly, negatively and at a remarkably high level by negative attitude latent variable. Physicians’ attitudes against CPGs were found to be a highly important factor in the use of CPGs. And it was also observed that physicians’ positive attitudes against CPGs affected the use of CPGs in a positive way while negative attitudes had negative effect on use of CPGs.
Collapse
Affiliation(s)
- Selahattin Akyüz
- Dışkapı Yıldırım Beyazıt Education and Research Hospital, Neurology Clinic, Ankara, Turkey
| | - Yusuf Çelik
- Faculty of Health Sciences, Department of Health Management, Marmara University, Istanbul, Turkey
| |
Collapse
|
5
|
Adegboyega BC, Alabi AO, Joseph AO, Lasebikan N, Agaga LA, Ololade KO, Sowunmi AC. Assessment of guideline adherence in breast cancer management among oncologists in Nigeria. Ecancermedicalscience 2021; 15:1294. [PMID: 34824617 PMCID: PMC8580603 DOI: 10.3332/ecancer.2021.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Breast cancer management is evolving by the day and new discoveries is shifting the scale to more positive result mostly in developed countries and this is being reported and updated in the treatment guidelines to bridge the knowledge gaps and allow for global standardised management protocol. This study assessed the adherence to the breast cancer guideline use among oncologists in Nigeria, reviewing the commonly used guidelines, factors for the choice, effects on treatment and barriers to usage. METHODOLOGY A proforma was sent by mail to the oncologist in Nigeria assessing their socio-demographic characteristics, knowledge of guidelines, use of guidelines, barriers to use of guidelines and benefits of guideline use and all the those that completed the survey within 1-month period were included in the study. RESULTS A total of 109 oncologist responded to the survey with mean age of 42 years, mean year of oncology practice was 10 years. Sixty-four percent were consultants and 38% residents-in-training. All respondents were aware of breast cancer guidelines and 92.2% had used it in treatment decision making. The commonest used being National Comprehensive Cancer Network guideline in 87.4% and 82.6% had a choice guideline/institution adopted. The major reason for referring to a choice guideline by 66% of respondents was to gain access to evidence-based results and the major barrier to guideline use in 56% of cases was non compatibility with available resources. CONCLUSION The study revealed high level of adherence to breast cancer guideline use among oncologists in Nigeria but there is need for more awareness about the locally developed ones like sub-Saharan adapted version and institutional based breast cancer treatment guidelines so as to address the barrier of disparities in target population and resources availability.
Collapse
Affiliation(s)
- Bolanle C Adegboyega
- Department of Radiotherapy, Lagos University Teaching Hospital, Idi Araba Mushin, Lagos, 234, Nigeria
| | - Adewumi O Alabi
- Department of Radiotherapy, Lagos University Teaching Hospital, Idi Araba Mushin, Lagos, 234, Nigeria
- Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Idi Araba Mushin, Lagos, 234, Nigeria
| | - Adedayo O Joseph
- NSIA-LUTH Cancer Centre, Lagos University Teaching Hospital, Idi Araba Mushin, Lagos, 234, Nigeria
| | - Nwamaka Lasebikan
- Department of Radiation Oncology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, 234, Nigeria
| | - Luther A Agaga
- Lagos State University Teaching Hospital, Oba Akinjobi Way, Ikeja, Lagos, 234, Nigeria
| | - Kehinde O Ololade
- Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Idi Araba Mushin, Lagos, 234, Nigeria
- NSIA-LUTH Cancer Centre, Lagos University Teaching Hospital, Idi Araba Mushin, Lagos, 234, Nigeria
| | - Anthonia C Sowunmi
- Department of Radiotherapy, Lagos University Teaching Hospital, Idi Araba Mushin, Lagos, 234, Nigeria
- Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Idi Araba Mushin, Lagos, 234, Nigeria
| |
Collapse
|
6
|
Farquhar-Smith P. Clinical practice guidelines for cancer pain: problems and solutions. Curr Opin Support Palliat Care 2021; 15:84-90. [PMID: 33843763 DOI: 10.1097/spc.0000000000000550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Clinical practice guidelines (CPGs) should allow practitioners to follow the best evidence-based management for patients. The increasing specialisation of medicine and pain medicine has increased the number of CPGs, but practitioners are still facing contradictory advice that can be difficult to implement and follow. RECENT FINDINGS A recent comprehensive metareview of 25 reviews have highlighted that the same issues of quality, barriers to implementation and difficulties in applicability are as prevalent as they were years ago when assessment tools (e.g. AGREE II) and recommendations for CPG development were introduced. There remains a lack of consistency of recommendations and quality of evidence for CPGs in cancer pain that impedes the ability to provide the 'best' management for patients. SUMMARY Even the most renowned and apparently high-quality CPGs in many specialities, including cancer pain, still are potentially deficient especially in terms of applicability, implementation, and transparency of conflicts of interest. Despite the increased scrutiny, in part related to the opioid crisis, the situation has not changed. The development of CPGs should engender collaboration with multiple stakeholder groups and focus on transparency and facilitating implementation.
Collapse
|
7
|
Oh C, Lim J, Jung YS, Kim Y, Jung K, Hong S, Won Y. Decreasing trends in thyroid cancer incidence in South Korea: What happened in South Korea? Cancer Med 2021; 10:4087-4096. [PMID: 33979040 PMCID: PMC8209587 DOI: 10.1002/cam4.3926] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 03/22/2021] [Accepted: 04/05/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND South Korea has the highest incidence of thyroid cancer in the world. Our study examined the trends in thyroid cancer incidence by the histologic type, cancer stage, and age group and explored possible factors that affected thyroid cancer trends. METHODS We conducted a descriptive epidemiological study using the national cancer registry data and cause of death data from 1999 to 2016 in South Korea. Age-standardized rates were calculated using Segi's world standard population. Joinpoint regression analysis was applied to determine the changing point of thyroid cancer trends according to histologic type; Surveillance, Epidemiology, and End Results (SEER) summary stage; and age groups by sex. RESULTS The age-standardized incidence of thyroid cancer in both men and women increased from 6.3 per 100,000 people in 1999 to 63.4 per 100,000 in 2012 but declined from 2012 to 2016, before the debates for over diagnosis of thyroid cancer began in 2014. The age-standardized mortality rate of thyroid cancer, incidence of distant thyroid cancer, and incidence of regional and localized thyroid cancer started to decline since early 2000, 2010, and 2012, respectively. In addition, thyroid cancer prevalence in thyroid nodules showed decreasing trends from 1999-2000 to 2013-2014. CONCLUSIONS The incidence of thyroid cancer began declining from 2012, before the debates for over diagnosis of thyroid cancer began in 2014. Changes in guidelines for thyroid nodule examinations may have affected this inflection point. Moreover, the debates for over diagnosis of thyroid cancer may have accelerated the decline in thyroid cancer.
Collapse
Affiliation(s)
- Chang‐Mo Oh
- Department of Preventive MedicineSchool of MedicineKyung Hee UniversitySeoulSouth Korea
| | - Jiwon Lim
- Division of Cancer Registration and SurveillanceNational Cancer Control InstituteNational Cancer CenterGoyangSouth Korea
| | - Yuh Seog Jung
- Department of Otolaryngology‐Head and Neck SurgeryHead & Neck Oncology ClinicCenter for Thyroid CancerNational Cancer Center HospitalGoyangSouth Korea
- Department of Cancer Control and Population HealthNational Cancer Center Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
| | - Yeol Kim
- Department of Cancer Control and Population HealthNational Cancer Center Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
- Division of Cancer Management & PolicyNational Cancer Control InstituteNational Cancer CenterGoyangSouth Korea
| | - Kyu‐Won Jung
- Division of Cancer Registration and SurveillanceNational Cancer Control InstituteNational Cancer CenterGoyangSouth Korea
| | - Seri Hong
- Division of Cancer Registration and SurveillanceNational Cancer Control InstituteNational Cancer CenterGoyangSouth Korea
| | - Young‐Joo Won
- Division of Cancer Registration and SurveillanceNational Cancer Control InstituteNational Cancer CenterGoyangSouth Korea
- Department of Cancer Control and Population HealthNational Cancer Center Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
| |
Collapse
|
8
|
Desalu OO, Adeoti AO, Makusidi MA, Fadare JO, Aremu GO, Amao EA, Opadijo OG. Family physicians/GP and Internist opinions, familiarity and practice behaviour regarding clinical practice guidelines (CPGs) of common medical conditions in Nigeria. J Family Med Prim Care 2021; 10:502-508. [PMID: 34017778 PMCID: PMC8132848 DOI: 10.4103/jfmpc.jfmpc_1505_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Few studies exist on physicians' opinions, attitudes, familiarity and practice behaviour regarding clinical practice guidelines in sub-Saharan Africa. Objectives: To determine the opinions, familiarity, and practice behaviour regarding clinical practice guidelines (CPGs) and factors associated with their use among internists and family physicians/GP in Nigeria. Methods: A semi-structured questionnaire regarding guidelines of five common medical conditions: hypertension, diabetes mellitus, tuberculosis, asthma and hepatitis B encountered in everyday medical practice were self-administered by 183 doctors across the country. Results: Over 90% of respondents believed that guidelines were evidence-based, improved management outcomes, and quality of care, nevertheless, 57.4% were against using them in litigations against doctors. The majority (>70%) of the respondents were familiar with the guidelines except that of hepatitis B. Overall, guidelines were used regularly by 45.9%, used in part by 23.5% and 30.6% never used it. Approximately 50% of physicians had immediate accessibility to them at the point of care. The proportions of respondents reporting a change in practice behaviour ranged from 37.7-57.9% depending on the guideline. The factors associated with guideline-related behaviour change were familiarity with its contents, postgraduate educational training, increased helpfulness score, and practiced >5 years. Conclusions: The present study shows that most physicians have favourable opinions and are familiar with these guidelines, however, the proportions reporting changes in their patient management because of the guidelines are not satisfactory. It is important to ensure guidelines accessibility and promotes factors that encourage their implementation in medical practice.
Collapse
Affiliation(s)
- Olufemi O Desalu
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Adekunle O Adeoti
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Muhammad A Makusidi
- Department of Medicine, Usmanu Dan Fodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Joseph O Fadare
- Department of Pharmacology, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Gbolahan O Aremu
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Emmanuel A Amao
- Medical Director, Department of Family Medicine, Shallom Medical Centre, Ogbomoso, Nigeria
| | | |
Collapse
|
9
|
Kondylakis H, Axenie C, Kiran Bastola D, Katehakis DG, Kouroubali A, Kurz D, Larburu N, Macía I, Maguire R, Maramis C, Marias K, Morrow P, Muro N, Núñez-Benjumea FJ, Rampun A, Rivera-Romero O, Scotney B, Signorelli G, Wang H, Tsiknakis M, Zwiggelaar R. Status and Recommendations of Technological and Data-Driven Innovations in Cancer Care: Focus Group Study. J Med Internet Res 2020; 22:e22034. [PMID: 33320099 PMCID: PMC7772066 DOI: 10.2196/22034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/02/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The status of the data-driven management of cancer care as well as the challenges, opportunities, and recommendations aimed at accelerating the rate of progress in this field are topics of great interest. Two international workshops, one conducted in June 2019 in Cordoba, Spain, and one in October 2019 in Athens, Greece, were organized by four Horizon 2020 (H2020) European Union (EU)-funded projects: BOUNCE, CATCH ITN, DESIREE, and MyPal. The issues covered included patient engagement, knowledge and data-driven decision support systems, patient journey, rehabilitation, personalized diagnosis, trust, assessment of guidelines, and interoperability of information and communication technology (ICT) platforms. A series of recommendations was provided as the complex landscape of data-driven technical innovation in cancer care was portrayed. OBJECTIVE This study aims to provide information on the current state of the art of technology and data-driven innovations for the management of cancer care through the work of four EU H2020-funded projects. METHODS Two international workshops on ICT in the management of cancer care were held, and several topics were identified through discussion among the participants. A focus group was formulated after the second workshop, in which the status of technological and data-driven cancer management as well as the challenges, opportunities, and recommendations in this area were collected and analyzed. RESULTS Technical and data-driven innovations provide promising tools for the management of cancer care. However, several challenges must be successfully addressed, such as patient engagement, interoperability of ICT-based systems, knowledge management, and trust. This paper analyzes these challenges, which can be opportunities for further research and practical implementation and can provide practical recommendations for future work. CONCLUSIONS Technology and data-driven innovations are becoming an integral part of cancer care management. In this process, specific challenges need to be addressed, such as increasing trust and engaging the whole stakeholder ecosystem, to fully benefit from these innovations.
Collapse
Affiliation(s)
| | - Cristian Axenie
- Audi Konfuzius-Institut Ingolstadt Lab, Technische Hochschule Ingolstadt, Ingolstadt, Germany
| | - Dhundy Kiran Bastola
- School of Interdisciplinary Informatics, University of Nebraska, Omaha, NE, United States
| | | | | | - Daria Kurz
- Interdisziplinäres Brustzentrum, Helios Klinikum München West, Munich, Germany
| | - Nekane Larburu
- Vicomtech, Health Research Institute, San Sebastian, Spain
| | - Iván Macía
- Vicomtech, Health Research Institute, San Sebastian, Spain
| | - Roma Maguire
- University of Strathclyde, Glasgow, United Kingdom
| | - Christos Maramis
- eHealth Lab, Institute of Applied Biosciences - Centre for Research & Technology Hellas, Thessaloniki, Greece
| | | | - Philip Morrow
- School of Computing, Ulster University, Newtownabbey, United Kingdom
| | - Naiara Muro
- Vicomtech, Health Research Institute, San Sebastian, Spain
| | | | - Andrik Rampun
- Academic Unit of Radiology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | | | - Bryan Scotney
- School of Computing, Ulster University, Newtownabbey, United Kingdom
| | | | - Hui Wang
- School of Computing and Engineering, University of West London, London, United Kingdom
| | | | - Reyer Zwiggelaar
- Department of Computer Science, Aberystwyth University, Aberystwyth, United Kingdom
| |
Collapse
|
10
|
Emond YEJJM, Wolff AP, Peters YAS, Bloo GJA, Westert GP, Damen J, Calsbeek H, Wollersheim HC. Reducing work pressure and IT problems and facilitating IT integration and audit & feedback help adherence to perioperative safety guidelines: a survey among 95 perioperative professionals. Implement Sci Commun 2020; 1:49. [PMID: 32885205 PMCID: PMC7427904 DOI: 10.1186/s43058-020-00037-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 04/29/2020] [Indexed: 01/02/2023] Open
Abstract
Background To improve perioperative patient safety, guidelines for the preoperative, peroperative, and postoperative phase were introduced in the Netherlands between 2010 and 2013. To help the implementation of these guidelines, we aimed to get a better understanding of the barriers and drivers of perioperative guideline adherence and to explore what can be learned for future implementation projects in complex organizations. Methods We developed a questionnaire survey based on the theoretical framework of Van Sluisveld et al. for classifying barriers and facilitators. The questionnaire contained 57 statements derived from (a) an instrument for measuring determinants of innovations by the Dutch Organization for Applied Scientific Research, (b) interviews with quality and safety policy officers and perioperative professionals, and (c) a publication of Cabana et al. The target group consisted of 232 perioperative professionals in nine hospitals. In addition to rating the statements on a five-point Likert scale (which were classified into the seven categories of the framework: factors relating to the intervention, society, implementation, organization, professional, patients, and social factors), respondents were invited to rank their three most important barriers in a separate, extra open-ended question. Results Ninety-five professionals (41%) completed the questionnaire. Fifteen statements (26%) were considered to be barriers, relating to social factors (N = 5), the organization (N = 4), the professional (N = 4), the patient (N = 1), and the intervention (N = 1). An integrated information system was considered an important facilitator (70.4%) as well as audit and feedback (41.8%). The Barriers Top-3 question resulted in 75 different barriers in nearly all categories. The most frequently reported barriers were as follows: time pressure (16% of the total number of barriers), emergency patients (8%), inefficient IT structure (4%), and workload (3%). Conclusions We identified a wide range of barriers that are believed to hinder the use of the perioperative safety guidelines, while an integrated information system and local data collection and feedback will also be necessary to engage perioperative teams. These barriers need to be locally prioritized and addressed by tailored implementation strategies. These results may also be of relevance for guideline implementation in general in complex organizations. Trial registration Dutch Trial Registry: NTR3568.
Collapse
Affiliation(s)
- Yvette E J J M Emond
- Radboudumc, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.,Radboudumc, Radboud Institute for Health Sciences, Department of Anesthesiology, Pain and Palliative Care, Nijmegen, The Netherlands.,Radboudumc, IQ healthcare, PO Box 9101, 114 IQ healthcare, 6500 HB Nijmegen, The Netherlands
| | - André P Wolff
- University Medical Center Groningen, University of Groningen, Department of Anesthesiology, Pain Center, Groningen, The Netherlands
| | - Yvonne A S Peters
- Radboudumc, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Gerrit J A Bloo
- Radboudumc, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.,Radboudumc, Radboud Institute for Health Sciences, Department of Anesthesiology, Pain and Palliative Care, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboudumc, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Johan Damen
- Radboudumc, Radboud Institute for Health Sciences, Department of Anesthesiology, Pain and Palliative Care, Nijmegen, The Netherlands
| | - Hiske Calsbeek
- Radboudumc, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Hub C Wollersheim
- Radboudumc, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| |
Collapse
|
11
|
Kim JO, Hanumanthappa N, Chung YT, Beck J, Koul R, Bashir B, Cooke A, Dubey A, Butler J, Nashed M, Hunter W, Ong A. Does dissemination of guidelines alone increase the use of palliative single-fraction radiotherapy? Initial report of a longitudinal change management campaign at a provincial cancer program. Curr Oncol 2020; 27:190-197. [PMID: 32905177 PMCID: PMC7467795 DOI: 10.3747/co.27.6193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Despite level 1 evidence demonstrating the equivalence of single-fraction radiotherapy (sfrt) and multiple-fraction radiotherapy (mfrt) for the palliation of painful bone metastases, sfrt remains underused. In 2015, to encourage the sustainable use of palliative radiation oncology resources, CancerCare Manitoba disseminated, to each radiation oncologist in Manitoba, guidelines from Choosing Wisely Canada (cwc) that recommend sfrt. We assessed whether dissemination of the guidelines influenced sfrt use in Manitoba in 2016, and we identified factors associated with mfrt. Methods All patients treated with palliative radiotherapy for bone metastasis in Manitoba from 1 January 2016 to 31 December 2016 were identified from the provincial radiotherapy database. Patient, treatment, and disease characteristics were extracted from the electronic medical record and tabulated by fractionation schedule. Univariable and multivariable logistic regression analyses were performed to identify risk factors associated with mfrt. Results In 2016, 807 patients (mean age: 70 years; range: 35-96 years) received palliative radiotherapy for bone metastasis, with 69% of the patients having uncomplicated bone metastasis. The most common primary malignancies were prostate (27.1%), lung (20.6%), and breast cancer (15.9%). In 62% of cases, mfrt was used-a proportion that was unchanged from 2015. On multivariable analysis, a gastrointestinal [odds ratio (or): 5.3] or lung primary (or: 3.3), complicated bone metastasis (or: 4.3), and treatment at a subsidiary site (or: 4.4) increased the odds of mfrt use. Conclusions Dissemination of cwc recommendations alone did not increase sfrt use by radiation oncologists in 2016. A more comprehensive knowledge translation effort is therefore warranted and is now underway to encourage increased uptake of sfrt in Manitoba.
Collapse
Affiliation(s)
- J O Kim
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | | | - Y T Chung
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg
| | - J Beck
- Medical Physics, CancerCare Manitoba, Winnipeg
| | - R Koul
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - B Bashir
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - A Cooke
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - A Dubey
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - J Butler
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - M Nashed
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - W Hunter
- Radiation Oncology, Western Manitoba Cancer Centre, Brandon, MB
| | - A Ong
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| |
Collapse
|
12
|
Cuervo G, Garcia-Vidal C, Puig-Asensio M, Merino P, Vena A, Martín-Peña A, Montejo JM, Ruiz A, Lázaro-Perona F, Fortún J, Fernández-Ruiz M, Suarez AI, Castro C, Cardozo C, Gudiol C, Aguado JM, Paño JR, Pemán J, Salavert M, Garnacho-Montero J, Cisneros JM, Soriano A, Muñoz P, Almirante B, Carratalà J. Usefulness of guideline recommendations for prognosis in patients with candidemia. Med Mycol 2020; 57:659-667. [PMID: 30418567 DOI: 10.1093/mmy/myy118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/05/2018] [Accepted: 10/26/2018] [Indexed: 01/05/2023] Open
Abstract
We aimed to analyze whether the lack of inclusion of specific recommendations for the management of candidemia is an independent risk factor for early and overall mortality. Multicenter study of adult patients with candidemia in 13 hospitals. We assessed the proportion of patients on whom nine specific ESCMID and IDSA guidelines recommendations had been applied, and analyzed its impact on mortality. 455 episodes of candidemia were documented. Patients who died within the first 48 hours were excluded. Sixty-two percent of patients received an appropriate antifungal treatment. Either echinocandin or amphotericin B therapy were administered in 43% of patients presenting septic shock and in 71% of those with neutropenia. Sixty-one percent of patients with breakthrough candidemia underwent a change in antifungal drug class. Venous catheters were removed in 79% of cases. Follow-up blood cultures were performed in 72% of cases. Ophthalmoscopy and echocardiogram were performed in 48% and 50% of patients, respectively. Length of treatment was appropriate in 78% of cases. Early (2-7 days) and overall (2-30 days) mortality were 8% and 27.7%, respectively. Inclusion of less than 50% of the specific recommendations was independently associated with a higher early (HR = 7.02, 95% CI: 2.97-16.57; P < .001) and overall mortality (HR = 3.55, 95% CI: 2.24-5.64; P < .001). In conclusion, ESCMID and IDSA guideline recommendations were not performed on a significant number of patients. Lack of inclusion of these recommendations proved to be an independent risk factor for early and overall mortality.
Collapse
Affiliation(s)
- Guillermo Cuervo
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | | | - Mireia Puig-Asensio
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Antonio Vena
- Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Alba Ruiz
- Hospital Universitari i Politecnic "La Fe", Valencia, Spain
| | | | | | - Mario Fernández-Ruiz
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Celia Cardozo
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Carlota Gudiol
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - José María Aguado
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | | | - Javier Pemán
- Hospital Universitari i Politecnic "La Fe", Valencia, Spain
| | | | | | | | - Alex Soriano
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Patricia Muñoz
- Hospital General Universitario Gregorio Marañón e Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Benito Almirante
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Carratalà
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
13
|
The Source of the Message Matters: A Randomized Study Evaluating the Impact of a Survey Source on Response Rate. Ann Am Thorac Soc 2020; 17:525-527. [DOI: 10.1513/annalsats.201906-482rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
14
|
Neugut AI, MacLean SA, Dai WF, Jacobson JS. Physician Characteristics and Decisions Regarding Cancer Screening: A Systematic Review. Popul Health Manag 2019; 22:48-62. [DOI: 10.1089/pop.2017.0206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Alfred I. Neugut
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Wei F. Dai
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Judith S. Jacobson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York
| |
Collapse
|
15
|
Ayinbuomwan AS, Isah AO. Standard treatment guidelines: Perception and utilization in a tertiary health care facility in South-South, Nigeria. Ann Afr Med 2019; 18:47-50. [PMID: 30729933 PMCID: PMC6380114 DOI: 10.4103/aam.aam_25_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The Nigerian National Standard Treatment Guidelines (NSTG) was introduced in 2008 and the second edition was launched in 2017. This study evaluated the level of awareness, acceptance, and use of this tool within the Nigerian health-care system. Methodology: This study was carried out at the University of Benin Teaching Hospital, Benin City, Nigeria. A semistructured questionnaire was administered to doctors in the hospital. Information sought included the biodata, awareness of the STG, publication and use of the STG, the perceived advantages and disadvantages, and suggestions on how to improve its use. Results: There were 155 respondents with a mean age of 34.1 ± 6.4 years and response rate of 77.5%. The level of awareness was 46.5%, with 21.9% having received lessons on the subject; 53.0% received lessons as students. Awareness of the date of the initial introduction of the STG at the national level was 4.5% with 1.3% aware of the current edition of the NSTG. The description of the STG was satisfactory in 27.7% participants. Again only 20.6% currently use the NSTG, with 12.3% rating the entire STG utilization as successful. Conclusion: There is low awareness and poor utilization of the STG among doctors in the facility which may be a reflection of the situation in other health facilities in the country. There is need to encourage the use of this clinical tool to ensure appropriate use of medicines and delivery of health care in resource-limited settings.
Collapse
Affiliation(s)
- A Stephen Ayinbuomwan
- Department of Medicine, Clinical Pharmacology and Therapeutics Unit, University of Benin Teaching Hospital; Department of Clinical Pharmacology and Therapeutics, University of Benin, Benin City, Edo State, Nigeria
| | - Ambrose O Isah
- Department of Medicine, Clinical Pharmacology and Therapeutics Unit, University of Benin Teaching Hospital; Department of Clinical Pharmacology and Therapeutics, University of Benin, Benin City, Edo State, Nigeria
| |
Collapse
|
16
|
Bahmaid RA, Karim M, Al-Ghamdi N, Al-Tannir M. Impact of Research Educational Intervention on Knowledge, Attitudes, Perceptions, and Pharmacy Practices Towards Evidence-based Medicine Among Junior Pharmacists. Cureus 2018; 10:e2820. [PMID: 30131914 PMCID: PMC6101450 DOI: 10.7759/cureus.2820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Establishing evidence-based medicine (EBM) is important for pharmaceutical care services to be effective and for adding value to patient care. Increasing examples are illustrating that health professionals hold positive attitudes toward EBM. Nevertheless, their knowledge and skills are relatively insufficient. The objective of this study was to assess the impact of research educational intervention on knowledge, attitudes, perceptions, and pharmacy practices towards evidence-based medicine among junior pharmacists. Methods A one group pre-test/post-test quasi-experimental design was conducted on postgraduate junior pharmacy staff working or training at one of the three randomly selected tertiary care settings in Riyadh, Saudi Arabia. This study consisted of two phases. During the first phase, a structured questionnaire assessing the knowledge, perceptions, and attitudes of the participants regarding EBM, as well as basic biostatistics, epidemiology and the utilization of EBM, was administered. The second phase was scheduled to begin four weeks after the distribution of the educational materials, whereby the same questionnaire was redistributed among the same participants. Results Sixty-seven pharmacists participated in this study. The overall percentage mean score of correct responses of the study participants' knowledge was 37.0% in the pre-test compared to 44.4% in the post-test. The percentage mean score of correct responses for biostatistics and epidemiology and study design sections significantly increased after the study intervention (p < 0.001), (p = 0.02), respectively. Regarding the study participants' attitudes towards EBM, only one item, "Willingness to support the promotion of EBM implementation,” was statistically significantly higher in the post-test (61, 93.8%) participants compared to participants (53, 80.3%) in the pre-test, while "Possessing sufficient skills to implement EBM principles" was the only statistically significant item for the study participants' perceptions towards EBM in the pre-test compared to the post-test, (82.1%, 92.4%), respectively. Moreover, our results showed that 74.6% of the respondents were practicing EBM before the study intervention versus 81.5% after the intervention. Conclusion The results of this study reveal that comprehensive educational intervention might improve the knowledge, attitudes, and perceptions of EBM among pharmacists and encourage them to incorporate this into their everyday clinical practice.
Collapse
|
17
|
Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol 2018; 91:20170434. [PMID: 29271231 DOI: 10.1259/bjr.20170434] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The aim of this review is to survey CT and MRI overuse in the paediatric emergency department (ED) population. CT is one of the most important modalities employed in the ED. Not surprisingly, its high accuracy, rapid acquisition and availability have resulted in overuse. An obvious limitation of CT is ionizing radiation; in addition there are economic implications to overuse. Studies from the last two decades have shown increase in paediatric ED CT utilization in the first decade, reaching a plateau forming around 2008, followed by a decrease in the last decade. This decrease occurred in conjunction with campaigns raising awareness to the risks of radiation exposure. Although a trend of decrease in overuse have been observed, great variability has been shown across different facilities, as well as among physicians, with more pronounced overuse in non-teaching and non-children dedicated EDs. The leading types of paediatric ED CTs are head and abdominal scans. Decision rules, such as PECARN for head injury and the Alvarado score for abdominal pain, as well as using alternative imaging modalities, have been shown to reduce CT overuse in these two categories. MRI has the obvious benefit of avoiding radiation exposure, but the disadvantages of higher costs, less availability and less tolerability in younger children. Although anecdotally paediatric ED MRI usage has increased in recent years, only scarce reports have been published. In our opinion, there is need to conduct up-to-date studies covering paediatric CT and MRI overuse trends, usage variability and adherence to clinical protocols.
Collapse
Affiliation(s)
- Orly Ohana
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel
| | - Shelly Soffer
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel
| | - Eyal Zimlichman
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel.,2 The Chaim Sheba Medical Center, Tel Hashomer, Hospital Management , Ramat Gan , Israel
| | - Eyal Klang
- 1 Tel Aviv University, Sackler Faculty of Medicine , Tel Aviv , Israel.,3 Department of radiology, The Chaim Sheba Medical Center, Tel Hashomer , Ramat Gan , Israel
| |
Collapse
|
18
|
Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants. PLoS One 2018; 13:e0191943. [PMID: 29385203 PMCID: PMC5792011 DOI: 10.1371/journal.pone.0191943] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 01/13/2018] [Indexed: 11/21/2022] Open
Abstract
Objective To understand clinicians' beliefs about practice variation and how variation might be reduced. Methods We surveyed board-certified physicians (N = 178), nurse practitioners (N = 60), and physician assistants (N = 12) at an academic medical center and two community clinics, representing family medicine, general internal medicine, and cardiology, from February—April 2016. The Internet-based questionnaire ascertained clinicians' beliefs regarding practice variation, clinical practice guidelines, and costs. Results Respondents agreed that practice variation should be reduced (mean [SD] 4.5 [1.1]; 1 = strongly disagree, 6 = strongly agree), but agreed less strongly (4.1 [1.0]) that it can realistically be reduced. They moderately agreed that variation is justified by situational differences (3.9 [1.2]). They strongly agreed (5.2 [0.8]) that clinicians should help reduce healthcare costs, but agreed less strongly (4.4 [1.1]) that reducing practice variation would reduce costs. Nearly all respondents (234/249 [94%]) currently depend on practice guidelines. Clinicians rated differences in clinician style and experience as most influencing practice variation, and inaccessibility of guidelines as least influential. Time to apply standards, and patient decision aids, were rated most likely to help standardize practice. Nurse practitioners and physicians assistants (vs physicians) and less experienced (vs senior) clinicians rated more favorably several factors that might help to standardize practice. Differences by specialty and academic vs community practice were small. Conclusions Clinicians believe that practice variation should be reduced, but are less certain that this can be achieved. Accessibility of guidelines is not a significant barrier to practice standardization, whereas more time to apply standards is viewed as potentially helpful.
Collapse
|
19
|
Haessler S, Lagu T, Lindenauer PK, Skiest DJ, Priya A, Pekow PS, Zilberberg MD, Higgins TL, Rothberg MB. Treatment Trends and Outcomes in Healthcare-Associated Pneumonia. J Hosp Med 2017; 12:886-891. [PMID: 29091975 PMCID: PMC6005651 DOI: 10.12788/jhm.2877] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics. METHODS A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes. RESULTS Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change. CONCLUSIONS In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure.
Collapse
Affiliation(s)
- Sarah Haessler
- Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
- Tufts University School of Medicine, Boston MA, USA
| | - Tara Lagu
- Division of General Medicine, Baystate Medical Center, Springfield, MA, USA
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
- Tufts University School of Medicine, Boston MA, USA
| | - Peter K. Lindenauer
- Division of General Medicine, Baystate Medical Center, Springfield, MA, USA
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
- Tufts University School of Medicine, Boston MA, USA
| | - Daniel J. Skiest
- Division of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
- Tufts University School of Medicine, Boston MA, USA
| | - Aruna Priya
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
| | - Penelope S. Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | | | - Thomas L. Higgins
- Division of General Medicine, Baystate Medical Center, Springfield, MA, USA
- Tufts University School of Medicine, Boston MA, USA
- Division of Pulmonary and Critical Care, Baystate Medical Center, Springfield, MA, USA
| | - Michael B. Rothberg
- Department of Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
20
|
Reducing Second Gram-Negative Antibiotic Therapy on Pediatric Oncology and Hematopoietic Stem Cell Transplantation Services. Infect Control Hosp Epidemiol 2017; 38:1039-1047. [PMID: 28758610 DOI: 10.1017/ice.2017.118] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate interventions to reduce avoidable antibiotic use on pediatric oncology and hematopoietic stem cell transplantation (HSCT) services. DESIGN Interrupted time series. SETTING Academic pediatric hospital with separate oncology and HSCT services. PARTICIPANTS Children admitted to the services during baseline (October 2011-August 2013) and 2 intervention periods, September 2013-June 2015 and July 2015-June 2016, including 1,525 oncology hospitalizations and 301 HSCT hospitalizations. INTERVENTION In phase 1, we completed an update of the institutional febrile neutropenia (FN) guideline for the pediatric oncology service, recommending first-line β-lactam monotherapy rather than routine use of 2 gram-negative agents. Phase 2 included updating the HSCT service FN guideline and engagement with a new pediatric antimicrobial stewardship program. The use of target antibiotics (tobramycin and ciprofloxacin) was measured in days of therapy per 1,000 patient days collected from administrative data. Intervention effects were evaluated using interrupted time series with segmented regression. RESULTS Phase 1 had mixed effects-long-term reduction in tobramycin use (97% below projected at 18 months) but rebound with increasing slope in ciprofloxacin use (+18% per month). Following phase 2, tobramycin and ciprofloxacin use on the oncology service were both 99% below projected levels at 12 months. On the HSCT service, tobramycin use was 99% below the projected level and ciprofloxacin use was 96% below the projected level at 12 months. CONCLUSIONS Locally adapted guidelines can facilitate practice changes in oncology and HSCT settings. More comprehensive and ongoing interventions, including follow-up education, feedback, and engagement of companion services may be needed to sustain changes. Infect Control Hosp Epidemiol 2017;38:1039-1047.
Collapse
|
21
|
Kalies H, Schöttmer R, Simon ST, Voltz R, Crispin A, Bausewein C. Critical attitudes and beliefs towards guidelines amongst palliative care professionals - results from a national survey. BMC Palliat Care 2017; 16:20. [PMID: 28327170 PMCID: PMC5359819 DOI: 10.1186/s12904-017-0187-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about palliative care professionals' attitudes towards guidelines. In 2015, the German Association for Palliative Medicine (DGP) published an evidence based guideline for palliative care in adults with incurable cancer. Before publication we conducted a national survey among members of the DGP to detect possible barriers and facilitators for its implementation. The aim of the present publication was to evaluate critical attitudes and beliefs which could hinder the effective implementation of the new guideline and to evaluate differences within professional groups and medical specialisations. METHODS This web-based online survey was addressed to all members of the DGP in summer 2014. Twenty-one questions concerning attitudes and beliefs towards guidelines were a priori developed to represent the following topics: scepticism regarding the quality of guidelines, doubts about the implementation of guidelines, restrictions in treatment options through guidelines, discrepancy between palliative care values and guidelines. Differences within professions and specialisations were tested using Kruskal-Wallis tests. RESULTS All 4.786 members with known email address were invited, 1.181 followed the link, 1.138 began to answer the questionnaire and 1.031 completed the questionnaire. More than half of participating members were physicians and one third nurses. Scepticism regarding the quality of existing guidelines was high (range 12.8-73.2%). Doubts regarding practical aspects of guidelines were less prevalent but still high (range 21.8-57.6%). About one third (range 5.4-31.4%) think that guidelines restrict their treatment options. In addition, 38.8% believed that guidelines are a kind of cookbook and restrict the flexibility of individual patient care. The majority saw no or little discrepancy between palliative care values and guidelines (range 68.4-82.6%). There were relatively small but significant differences between professions and specialisations. CONCLUSION The person-centred and individual approach of palliative care does not seem to contradict the acceptance of guidelines. Main barriers were related to scepticism regarding the quality of guidelines and the implementation of guidelines in general.
Collapse
Affiliation(s)
- Helen Kalies
- Department of Palliative Medicine, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Rieke Schöttmer
- Department of Palliative Medicine, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Steffen T. Simon
- Center for Palliative Medicine, University of Cologne, Kerpener Str. 62, 50924 Köln, Germany
| | - Raymond Voltz
- Center for Palliative Medicine, University of Cologne, Kerpener Str. 62, 50924 Köln, Germany
| | - Alexander Crispin
- Institute of Medical Informatics, Biometry and Epidemiology (IBE), University of Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| |
Collapse
|
22
|
Johnson DC, Kassner CT, Kutner JS. Current use of guidelines, protocols, and care pathways for symptom management in hospice. Am J Hosp Palliat Care 2016; 21:51-7. [PMID: 14748524 DOI: 10.1177/104990910402100112] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Evidence-based guidelines or care pathways for symptom management could provide a means to reduce symptom distress in dying patients. We surveyed directors of nursing from hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) regarding their hospices’ current use of and attitudes toward written symptom management materials. A majority (53/78, 68 percent) of participating hospices reported use of written materials, such as guidelines, protocols, or care pathways, for one or more symptoms. Materials were based on multiple sources and varied from simple medication orders to more comprehensive, multicategory symptom management resources. Regardless of the composition, these materials were perceived as helpful. Given this favorable view, variations in the use and content of written materials may signify an opportunity to decrease symptom distress in hospice through the implementation of evidence-based symptom management resources.
Collapse
Affiliation(s)
- Daniel C Johnson
- Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA
| | | | | |
Collapse
|
23
|
Katz DA, Aufderheide TP, Bogner M, Rahko PR, Brown RL, Brown LM, Prekker ME, Selker HP. The Impact of Unstable Angina Guidelines in the Triage of Emergency Department Patients with Possible Acute Coronary Syndrome. Med Decis Making 2016; 26:606-16. [PMID: 17099199 DOI: 10.1177/0272989x06295358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain. Methods. The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups. Results. No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS. Conclusion. Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.
Collapse
Affiliation(s)
- David A Katz
- Department of Medicine, Population Health Sciences, University of Wisconsin - Madison, USA.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
|
25
|
Alexander PE, Li SA, Tonelli M, Guyatt G. Canadian Primary Care Physicians' Attitudes Toward Understanding Clinical Practice Guidelines for Diabetes Screening. Can J Diabetes 2016; 40:580-585. [PMID: 27590082 DOI: 10.1016/j.jcjd.2016.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/18/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The Canadian Task Force on Preventive Health Care (CTFPHC) produces guidelines for Canadian physicians regarding screening and prevention. To better appreciate the barriers to and facilitators of guideline adherence, we sought to explore physicians' views of guidelines in general and their understanding of this CTFPHC diabetes screening guideline in particular because they pertain to screening and positive treatment. METHODS We included Canadian physicians (N=10) who agreed to be interviewed regarding their use of guidelines as part of practice, focusing on the CTFPHC 2012 diabetes screening guideline. Individual semistructured interviews explored primary care physicians' experiences and perspectives on the use, relevance and feasibility of guidelines as part of practice, approaches to screening for diabetes, and suggestions for improving guidelines. RESULTS Overall, physicians recognized the need for guidelines and the benefits of using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods in the guideline development process. Physicians also noted several barriers to guideline adherence, including the lack of opportunity for physicians to provide input during guideline formulation, insufficient guidance on interpreting GRADE's weak or conditional recommendations, and feasibility issues concerning using risk calculators. The predominant challenge raised by physicians was the unclear guidance for pharmacologic interventions; all respondents were unclear about the guidelines' implicit assumption that screen-positive patients would be treated with statins and aspirin (ASA). CONCLUSIONS These interviews suggest the need for greater clarity in guideline recommendations, including clarification of the quality of evidence ratings and the strength of recommendation grading. Our low participation rate raises the issue of representativeness; replication in samples with greater willingness to participate would be desirable.
Collapse
Affiliation(s)
- Paul E Alexander
- Health Research Methods (HRM), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
| | - Shelly-Anne Li
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Marcello Tonelli
- Departments of Health Research and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada
| |
Collapse
|
26
|
Brown B, Young J, Kneebone AB, Brooks AJ, Dominello A, Haines M. Knowledge, attitudes and beliefs towards management of men with locally advanced prostate cancer following radical prostatectomy: an Australian survey of urologists. BJU Int 2016; 117 Suppl 4:35-44. [DOI: 10.1111/bju.13037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Bernadette Brown
- Sax Institute; Haymarket New South Wales Australia
- School of Public Health; University of Sydney; Camperdown New South Wales Australia
| | - Jane Young
- School of Public Health; University of Sydney; Camperdown New South Wales Australia
| | - Andrew B Kneebone
- Northern Sydney Cancer Centre; Sydney New South Wales Australia
- Northern Clinical School; University of Sydney; Camperdown New South Wales Australia
| | - Andrew J Brooks
- Westmead Private Hospital; Westmead New South Wales Australia
- Westmead Clinical School; University of Sydney; Camperdown New South Wales Australia
- NSW Agency for Clinical Innovation; Sydney New South Wales Australia
| | | | - Mary Haines
- Sax Institute; Haymarket New South Wales Australia
- School of Public Health; University of Sydney; Camperdown New South Wales Australia
| |
Collapse
|
27
|
Heffner JE. Update of Antithrombotic Guidelines: Medical Professionalism and the Funnel of Knowledge. Chest 2016; 149:293-294. [PMID: 26867824 DOI: 10.1016/j.chest.2015.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 11/15/2022] Open
|
28
|
Manikam L, Hoy A, Fosker H, Wong MHY, Banerjee J, Lakhanpaul M, Knight A, Littlejohns P. What drives junior doctors to use clinical practice guidelines? A national cross-sectional survey of foundation doctors in England & Wales. BMC MEDICAL EDUCATION 2015; 15:227. [PMID: 26692267 PMCID: PMC4687363 DOI: 10.1186/s12909-015-0510-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 12/11/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) aim to improve patient care, but their use remains variable. We explored attitudes that influence CPG use amongst newly qualified doctors. METHODS A self-completed, anonymous questionnaire was sent to all Foundation Doctors in England and Wales between December 2012 and May 2013. We included questions designed to measure the 11 domains of the validated Theoretical Domains Framework (TDF). We correlated these responses to questions assessing current and future intention to use CPGs. RESULTS A total of 13,138 doctors were invited of which 1693 [corrected] (13 %) responded. 1,035 (62.5 %) reported regular CPG use with 575 (34.4 %) applying CPGs 2-3 times per week. A significant minority of 606 (36.6 %) declared an inability to critically appraise evidence. Despite efforts to design a questionnaire that captured the domains of the TDF, the domain scales created had low internal reliability. Using previously published studies and input from an expert statistical group, an alternative model was sought using exploratory factor analysis. Five alternative domains were identified. These were judged to represent: "confidence", "familiarity", "commitment and duty", "time" and "perceived benefits". Using regression analyses, the first three were noted as consistent predictors of both current and future intentions to use CPGs in decreasing strength order. CONCLUSIONS In this large survey of newly qualified doctors, "confidence", "familiarity" and "commitment and duty" were identified as domains that influence use of CPGs in frontline practice. Additionally, a significant minority were not confident in critically appraising evidence. Our findings suggest a number of approaches that may be taken to improve junior doctors' commitment to CPGs through processes that increase their confidence and familiarity in using CPGs. Despite limitations of a self-reported survey and potential non-response bias, these findings are from a large representative sample and a review of existing implementation strategies may be warranted based on these findings.
Collapse
Affiliation(s)
- L. Manikam
- />Population, Policy and Practice, UCL Institute of Child Health, 30 Guildford Street, London, WC1N 1EH UK
- />National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU UK
| | - A. Hoy
- />National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU UK
| | - H. Fosker
- />University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW UK
| | - Martin Ho Yin Wong
- />University College London Hospitals NHS Foundation Trust, 235 Euston Road, London, NW1 2BU UK
| | - J. Banerjee
- />University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW UK
| | - M. Lakhanpaul
- />Department of Primary Care and Public Health Sciences, King’s College London, Addison House, London, SE1 IUL UK
| | - A. Knight
- />King’s Improvement Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, Addison House, London, SE1 IUL UK
| | - P. Littlejohns
- />Department of Primary Care and Public Health Sciences, King’s College London, Addison House, London, SE1 IUL UK
| |
Collapse
|
29
|
Mills AM, Raja AS, Marin JR. Optimizing diagnostic imaging in the emergency department. Acad Emerg Med 2015; 22:625-31. [PMID: 25731864 DOI: 10.1111/acem.12640] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/09/2015] [Accepted: 02/03/2015] [Indexed: 12/15/2022]
Abstract
While emergency diagnostic imaging use has increased significantly, there is a lack of evidence for corresponding improvements in patient outcomes. Optimizing emergency department (ED) diagnostic imaging has the potential to improve the quality, safety, and outcomes of ED patients, but to date, there have not been any coordinated efforts to further our evidence-based knowledge in this area. The objective of this article is to discuss six aspects of diagnostic imaging to provide background information on the underlying framework for the 2015 Academic Emergency Medicine consensus conference, "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The consensus conference aims to generate a high priority research agenda for emergency diagnostic imaging that will inform the design of future investigations. The six components herein will serve as the group topics for the conference: 1) patient-centered outcomes research; 2) clinical decision rules; 3) training, education, and competency; 4) knowledge translation and barriers to image optimization; 5) use of administrative data; and 6) comparative effectiveness research: alternatives to traditional CT use.
Collapse
Affiliation(s)
- Angela M. Mills
- The Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
| | - Ali S. Raja
- The Department of Emergency Medicine; Massachusetts General Hospital; Boston MA
- Center for Evidence Based Imaging and Department of Radiology; Brigham and Women's Hospital; Boston MA
| | - Jennifer R. Marin
- The Departments of Pediatrics and Emergency Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA
| |
Collapse
|
30
|
Isensee C, Hagmayer Y, Rothenberger A, Rothenberger LG, Becker A. [The AWMF-Guidelines for Hyperkinetic Disorders in therapeutic practice- knowledge, familiarity, utilization, and attitude of psychotherapists and physicians]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2015; 43:91-100. [PMID: 25769762 DOI: 10.1024/1422-4917/a000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The AWMF-Guidelines for Hyperkinetic Disorders (ADHD) provide psychotherapists and physicians with guidance concerning diagnostics and treatment for one of the most common disorders in children and adolescents. To date, however, it is unclear how these guidelines are being applied by practicing therapists (both physicians and psychotherapists) and what they consider to be its pros and cons. This study proposes (1) to analyze the differences between the estimation of ADHD-guidelines by users and nonusers, their corresponding attitudes, experiences, and evaluations of context factors; and (2) to analyze whether users and nonusers differ in their therapeutic practice. METHODS 71 therapists participated in a nonrepresentative online survey. RESULTS The hypothesis was confirmed that, on average, users had a more positive attitude toward and experience with guideline-driven treatment than did nonusers. The results also show a small positive effect of guideline use on treatment quality. However, the methods employed by users and nonusers only moderately corresponded with the recommendations of the guidelines. CONCLUSIONS It was shown that the ADHD guideline is only rarely being used, even under advantageous conditions, and that a practice-oriented form of the guideline does not exist until now.
Collapse
Affiliation(s)
- Corinna Isensee
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsmedizin Göttingen
| | - York Hagmayer
- Institut für Psychologie, Georg-August-Universität Göttingen
| | - Aribert Rothenberger
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsmedizin Göttingen
| | | | - Andreas Becker
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsmedizin Göttingen
| |
Collapse
|
31
|
Marin JR, Weaver MD, Barnato AE, Yabes JG, Yealy DM, Roberts MS. Variation in emergency department head computed tomography use for pediatric head trauma. Acad Emerg Med 2014; 21:987-95. [PMID: 25269579 DOI: 10.1111/acem.12458] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/26/2014] [Accepted: 04/27/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The objectives were to evaluate general emergency department (ED) variation in head computed tomography (CT) use for pediatric head trauma, hospital factors associated with CT use, and recent secular trends in CT utilization for pediatric head trauma. METHODS This was a cross-sectional study of a sample of general EDs in the Nationwide Emergency Department Sample (NEDS; 2006-2010). The authors included visits by patients <19 years of age with International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis codes for head trauma and determined head CT use via Current Procedural Terminology (CPT), Fourth Edition, codes. Crude and risk-adjusted proportions of visits with CT for each hospital were calculated using multilevel mixed effects logistic regression. The association between hospital-level characteristics and head CT were evaluated by constructing multivariable negative binomial regression models. RESULTS There were 324,435 pediatric head trauma visits to 848 EDs in the sample. Median patient age was 8 years (interquartile range [IQR] = 2 to 15 years) and 62% of visits were by males. A minority of patients (0.7%) were severely injured, and only 4.2% were admitted to the hospital. Most EDs (79%) were nonteaching institutions, and 84% were nontrauma centers. Risk-adjusted median CT use was 56.0% (IQR = 46.4% to 64.7%). In multivariate analysis, nontrauma centers were 9% (95% confidence interval [CI] = 4% to 15%) less likely to use head CT for pediatric head trauma patients and among discharged patients, EDs within nonteaching hospitals were 8% more likely to perform CT imaging (95% CI = 2% to 14%). There was no change in CT use from 2006 through 2010 (p = 0.31). CONCLUSIONS There is significant variability among general EDs in CT use for pediatric head trauma, indicating the need for strategies to reduce variation and improve ED imaging practices for this population.
Collapse
Affiliation(s)
- Jennifer R Marin
- The Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA; The Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | | | | | | |
Collapse
|
32
|
Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, Karpov I, McNeil M. Physician adherence to U.S. Preventive Services Task Force mammography guidelines. Womens Health Issues 2014; 24:e313-9. [PMID: 24794545 DOI: 10.1016/j.whi.2014.03.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 03/06/2014] [Accepted: 03/07/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2009, the U.S. Preventive Services Task Force (USPSTF) guidelines for screening mammography changed significantly, and are now in direct conflict with screening guidelines of other major national organizations. The extent to which physicians in different primary care specialties adhere to current USPSTF guidelines is unknown. METHODS We conducted a cross-sectional web-based survey completed by 316 physicians in internal medicine, family medicine (FM), and gynecology (GYN) from February to April 2012. Survey items assessed respondents' breast cancer screening recommendations in women of different ages at average risk for breast cancer. We used descriptive statistics to generate response distribution for survey items, and logistic regression models to compare responses among specialties. FINDINGS The response rate was 55.0% (316/575). A majority of providers in internal medicine (65%), FM (64%), and GYN (92%) recommended breast cancer screening starting at age 40 versus 50. A majority of providers in internal medicine (77%), FM (74%), and GYN (98%) recommended annual versus biennial screening. Gynecologists were significantly more likely than both internists and family physicians to recommend initial mammography at age 40 (p ≤ .0001) and yearly mammography (p = .0003). There were no other differences by respondent demographic. CONCLUSIONS Primary care providers, especially gynecologists, have not implemented USPSTF guidelines. The extent to which these findings may be driven by patient versus provider preferences should be explored. These findings suggest that patients are likely to receive conflicting breast cancer screening recommendations from different providers.
Collapse
Affiliation(s)
- Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Research Health Equity and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Rachel Bonnema
- Division of General Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Megan McNamara
- Division of General Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio; Louis Stokes VA Healthcare System, Cleveland, Ohio
| | - Kevin Kraemer
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Doris Rubio
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Irina Karpov
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Melissa McNeil
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
33
|
Panaitescu C, Moffat MA, Williams S, Pinnock H, Boros M, Oana CS, Alexiu S, Tsiligianni I. Barriers to the provision of smoking cessation assistance: a qualitative study among Romanian family physicians. NPJ Prim Care Respir Med 2014; 24:14022. [PMID: 25010432 PMCID: PMC4373378 DOI: 10.1038/npjpcrm.2014.22] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/03/2014] [Accepted: 05/06/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Smoking cessation is the most effective intervention to prevent and slow down the progression of several respiratory and other diseases and improve patient outcomes. Romania has legislation and a national tobacco control programme in line with the World Health Organization Framework for Tobacco Control. However, few smokers are advised to quit by their family physicians (FPs). AIM To identify and explore the perceived barriers that prevent Romanian FPs from engaging in smoking cessation with patients. METHODS A qualitative study was undertaken. A total of 41 FPs were recruited purposively from Bucharest and rural areas within 600 km of the city. Ten FPs took part in a focus group and 31 participated in semistructured interviews. Analysis was descriptive, inductive and themed, according to the barriers experienced. RESULTS Five main barriers were identified: limited perceived role for FPs; lack of time during consultations; past experience and presence of disincentives; patients' inability to afford medication; and lack of training in smoking cessation skills. Overarching these specific barriers were key themes of a medical and societal hierarchy, which undermined the FP role, stretched resources and constrained care. CONCLUSIONS Many of the barriers described by the Romanian FPs reflected universally recognised challenges to the provision of smoking cessation advice. The context of a relatively hierarchical health-care system and limitations of time and resources exacerbated many of the problems and created new barriers that will need to be addressed if Romania is to achieve the aims of its National Programme Against Tobacco Consumption.
Collapse
Affiliation(s)
| | - Mandy A Moffat
- Division of Medical and Dental Education, University of Aberdeen, Aberdeen, UK
| | - Siân Williams
- International Primary Care Respiratory Group, London, UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | | | - Ioanna Tsiligianni
- Agia Barbara Health Care Centre, Crete, Greece
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
34
|
Al Wahaibi A, Adawi SA, Shehhi WA, Rizvi SGA, Al-Kemyani N, Al-Amrani K, Al-Khabori M. Knowledge and Attitudes of Oman Medical Specialty Board Residents towards Evidence-Based Medicine. Oman Med J 2014; 29:178-84. [PMID: 24936266 DOI: 10.5001/omj.2014.45] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/09/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE This study aims to evaluate the knowledge and attitudes of Oman Medical Specialty Board (OMSB) residents towards Evidence-Based Medicine (EBM). METHODS This cross sectional study was conducted on all OMSB residents through a self-administered online questionnaire between October 2012 and March 2013. An electronic survey was designed to identify and determine residents' knowledge and attitudes toward the use of EBM. RESULTS The survey was completed by 93 (21%) OMSB residents, 76 (82%) of whom took part in continuing education courses and 50 (54%) belonged to professional practice-oriented organizations. On average, the residents were reportedly involved in patient care for approximately 70% (Standard Deviation [SD] 17%) of their time, while 14% (SD 12%) participated in research activities. The results showed that 53 respondents (57%) were competent users of medical search engines compared to 23 residents (25%) who rated their skills as neutral. Sixteen percent of the respondents strongly agreed and 46% only agreed that the facility supports the use of current research in practice. Fourteen percent strongly agreed and fifty-three percent only agreed that the foundation of EBM is part of OMSB academic preparation. On the other hand, 17% of the respondents thought that insufficient time is always a barrier against EBM, while another 27% perceived insufficient time as a usual barrier. The lack of information resources was reported to always be a barrier in 11% of the respondents while 32% thought that it usually acts as a barrier. CONCLUSION Time constraints and skills in EBM were found to be the two major obstacles. This study was, however, limited by the low response rate of the survey; thus larger studies with a previously validated questionnaire should be conducted in the future.
Collapse
Affiliation(s)
- Aiman Al Wahaibi
- Department of Medicine, Oman Medical Specialty Board, Muscat, Sultanate of Oman
| | - Saada Al Adawi
- Department of Medicine, Oman Medical Specialty Board, Muscat, Sultanate of Oman
| | - Wafa Al Shehhi
- Department of Medicine, Oman Medical Specialty Board, Muscat, Sultanate of Oman
| | - Syed Gauhar A Rizvi
- Department of Epidemiology and Medical Statistics, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Nasser Al-Kemyani
- Department of Anesthesia, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Khalfan Al-Amrani
- Emergency Department, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Murtadha Al-Khabori
- Departments of Hematology, Sultan Qaboos University Hospital, P.O Box: 35, PC: 123, AL-Koudh, Muscat, Sultanate of Oman
| |
Collapse
|
35
|
Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, Karpov I, McNeil M. Differences Among Primary Care Physicians' Adherence to 2009 ACOG Guidelines for Cervical Cancer Screening. J Womens Health (Larchmt) 2014; 23:397-403. [DOI: 10.1089/jwh.2013.4475] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jennifer Corbelli
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research Health Equity and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Rachel Bonnema
- University of Nebraska Medical Center Division of General Internal Medicine, Omaha, Nebraska
| | - Megan McNamara
- Case Western Reserve University School of Medicine Division of General Internal Medicine, Cleveland, Ohio
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Kevin Kraemer
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Doris Rubio
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Irina Karpov
- Center for Research on Health Care, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Melissa McNeil
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
36
|
Smith KL, Ashburn S, Aminawung JA, Mann M, Ross JS. Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions. BMC Health Serv Res 2014; 14:176. [PMID: 24742131 PMCID: PMC4021187 DOI: 10.1186/1472-6963-14-176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 04/14/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Physicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions. METHODS We conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections. RESULTS Our sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies "always" or "most of the time" when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies. CONCLUSIONS For eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.
Collapse
Affiliation(s)
- Kristofer L Smith
- Department of Medicine, North Shore-Long Island Jewish Health System, New Hyde Park, NY, USA
| | - Sarah Ashburn
- Hofstra-North Shore School of Medicine, Rego Park, NY, USA
| | - Jenerius A Aminawung
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208093, 06520 New Haven, CT, USA
| | - Micah Mann
- Division of Hospital Medicine, The Samuel Bronfman Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Joseph S Ross
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208093, 06520 New Haven, CT, USA
- Section of General Internal Medicine and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| |
Collapse
|
37
|
Quinonez RB, Kranz AM, Long M, Rozier RG. Care coordination among pediatricians and dentists: a cross-sectional study of opinions of North Carolina dentists. BMC Oral Health 2014; 14:33. [PMID: 24708785 PMCID: PMC3997217 DOI: 10.1186/1472-6831-14-33] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care coordination between physicians and dentists remains a challenge. This study of dentists providing pediatric dental care examined their opinions about physicians' role in oral health and identified factors associated with these opinions. METHODS North Carolina general and pediatric dentists were surveyed on their opinions of how physicians should proceed after caries risk assessment and evaluation of an 18-month-old, low risk child. We estimated two multinomial logistic regression models to examine dentists' responses to the scenario under the circumstances of an adequate and a limited dental workforce. RESULTS Among 376 dentists, 52% of dentists indicated physicians should immediately refer this child to a dental home with an adequate dental workforce. With a limited workforce, 34% recommended immediate referral. Regression analysis indicated that with an adequate workforce guideline awareness was associated with a significantly lower relative risk of dentists' recommending the child remain in the medical home than immediate referral. CONCLUSIONS Dentists' opinions and professional guidelines on how physicians should promote early childhood oral health differ and warrant strategies to address such inconsistencies. Without consistent guidelines and their application, there is a missed opportunity to influence provider opinions to improve access to dental care.
Collapse
Affiliation(s)
- Rocio B Quinonez
- Department of Pediatric Dentistry and Pediatrics, Schools of Medicine and Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ashley M Kranz
- Department of Dental Research, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - R Gary Rozier
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
38
|
Park JW, Ahn JA, Park MM. Factors influencing evidence-based nursing utilization intention in Korean practice nurses. Int J Nurs Pract 2014; 21:868-75. [DOI: 10.1111/ijn.12296] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jee-Won Park
- College of Nursing; Ajou University; Suwon Korea
| | - Jeong-Ah Ahn
- College of Nursing; Ajou University; Suwon Korea
| | | |
Collapse
|
39
|
King D, Greaves F, Vlaev I, Darzi A. Approaches based on behavioral economics could help nudge patients and providers toward lower health spending growth. Health Aff (Millwood) 2014; 32:661-8. [PMID: 23569045 DOI: 10.1377/hlthaff.2012.1348] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Policies that change the environment or context in which decisions are made and "nudge" people toward particular choices have been relatively ignored in health care. This article examines the role that approaches based on behavioral economics could play in "nudging" providers and patients in ways that could slow health care spending growth. The basic insight of behavioral economics is that behavior is guided by the very fallible human brain and greatly influenced by the environment or context in which choices are made. In policy arenas such as pensions and personal savings, approaches based on behavioral economics have provided notable results. In health care, such approaches have been used successfully but in limited ways, as in the use of surgical checklists that have increased patient safety and reduced costs. With health care spending climbing at unsustainable rates, we review the role that approaches based on behavioral economics could play in offering policy makers a potential set of new tools to slow spending growth.
Collapse
|
40
|
Petrocelli JV. Pitfalls of counterfactual thinking in medical practice: preventing errors by using more functional reference points. J Public Health Res 2013; 2:e24. [PMID: 25170495 PMCID: PMC4147742 DOI: 10.4081/jphr.2013.e24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 01/09/2023] Open
Abstract
Background Counterfactual thinking involves mentally simulating alternatives to reality. The current article reviews literature pertaining to the relevance counterfactual thinking has for the quality of medical decision making. Although earlier counterfactual thought research concluded that counterfactuals have important benefits for the individual, there are reasons to believe that counterfactual thinking is also associated with dysfunctional consequences. Of particular focus is whether or not medical experience, and its influence on counterfactual thinking, actually informs or improves medical practice. It is hypothesized that relatively more probable decision alternatives, followed by undesirable outcomes and counterfactual thought responses, can be abandoned for relatively less probable decision alternatives. Design and Methods Building on earlier research demonstrating that counterfactual thinking can impede memory and learning in a decision paradigm with undergraduate students, the current study examines the extent to which earlier findings can be generalized to practicing physicians (N=10). Participants were asked to complete 60 trials of a computerized Monty Hall Problem simulation. Learning by experience was operationalized as the frequency of switch-decisions. Results Although some learning was evidenced by a general increase in switch-decision frequency across block trials, the extent of learning demonstrated was not ideal, nor practical. Conclusions A simple, multiple-trial, decision paradigm demonstrated that doctors fail to learn basic decision-outcome associations through experience. An agenda for future research, which tests the functionality of reference points (other than counterfactual alternatives) for the purposes of medical decision making, is proposed. Significance for public health The quality of healthcare depends heavily on the judgments and decisions made by doctors and other medical professionals. Findings from this research indicate that doctors fail to learn basic decision-outcome associations through experience, as evidenced by the sample’s tendency to select the optimal decision strategy in only 50% of 60 trials (each of which was followed by veridical feedback). These findings suggest that professional experience is unlikely to enhance the quality of medical decision making. Thus, this research has implications for understanding how doctors’ reactions to medical outcomes shape their judgments and affect the degree to which their future treatment intentions are consistent with clinical practice guidelines. The current research is integrated with earlier research on counter-factual thinking, which appears to be a primary element inhibiting the learning of decision-outcome associations. An agenda for future research is proposed.
Collapse
Affiliation(s)
- John V Petrocelli
- Department of Psychology, Wake Forest University , Winston-Salem, NC, USA
| |
Collapse
|
41
|
Damiani G, Silvestrini G, Federico B, Cosentino M, Marvulli M, Tirabassi F, Ricciardi W. A systematic review on the effectiveness of group versus single-handed practice. Health Policy 2013; 113:180-7. [PMID: 23910731 DOI: 10.1016/j.healthpol.2013.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 06/25/2013] [Accepted: 07/04/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since the 1970s, many countries have employed the use of the General practitioner group practice, but there is contrasting evidence about its effectiveness. A systematic review was performed to assess whether group practice has a more positive impact compared with the single-handed practice on different aspects of health care. METHODS A systematic review was conducted by querying electronic databases and reviewing articles published between 1990 and 2012. A quality assessment was performed. The effect of group practice was evaluated by collecting all items analysed by the articles into four main categories: (1) studies of quality (measured in terms of clinical processes) and productivity (measured in terms of throughput), named "Clinical process measures and throughput"; (2) studies exploring physician's opinion--"Doctor's perspective"; (3) studies looking into the use of innovation, information and communication technology (ICT) and quality assurance--"Innovation, ICT and quality assurance"; (4) studies focused on patient's opinion--"Patient's perspective". The results were synthesized according to three levels of scientific evidence. RESULTS A total of 26 studies were selected. The most studied category was Clinical process measures and throughput (58%). A positive impact of group medicine on "Clinical process measures and throughput", "Doctor's perspective", "Innovation, ICT and quality assurance" was found. There was contrasting evidence considering the "Patient's perspective". CONCLUSIONS Group practice might be a successful organizational requirement to improve the quality of clinical practice in Primary Health Care. Further comparative studies are needed to investigate the impact of organizational and professional determinants such as physician's economic incentives, mode of payment, size of the groups and multispecialty on the effectiveness of medical primary care.
Collapse
Affiliation(s)
- Gianfranco Damiani
- Department of Public Health, Catholic University of the Sacred Heart, Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
42
|
Pace LE, He Y, Keating NL. Trends in mammography screening rates after publication of the 2009 US Preventive Services Task Force recommendations. Cancer 2013; 119:2518-23. [PMID: 23605683 DOI: 10.1002/cncr.28105] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/13/2013] [Accepted: 03/14/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND In November 2009, the US Preventive Services Task Force (USPSTF) issued new recommendations regarding mammography screening. The Task Force recommended against routine screening for women ages 40 to 49 years and recommended biennial screening for women ages 50 to 74 years. The recommendations met great controversy in mass media and medical literature; whether they have had an impact on screening patterns is not known. The objective of this study was to determine whether the 2009 USPSTF recommendations led to changes in screening rates among women ages 40 to 49 years and ages 50 to 74 years. METHODS The authors performed cross-sectional assessments of mammography screening in 2005, 2008, and 2011 using data from the National Health Interview Survey, a nationally representative, in-person, household survey of the civilian, noninstitutionalized US population. In total, 27,829 women ages ≥ 40 years responded to the 2005, 2008, or 2011 surveys and reported about their mammography use. The primary outcome assessed was self-reported mammography screening in the past year. RESULTS When adjusted for race, income, education level, insurance, and immigration status, mammography rates increased slightly from 2008 to 2011 (from 51.9% to 53.6%; P = .07) and did not decline within any age group. Among women ages 40 to 49 years, screening rates were 46.1% in 2008 and 47.5% in 2011 (P = 0.38). For women ages 50 to 74, screening rates were 57.2 in 2008 and 59.1 in 2011 (P = 0.09). CONCLUSIONS Mammography rates did not decrease among women aged >40 years after publication of the USPSTF recommendations in 2009, suggesting that the vigorous policy debates and coverage in the media and medical literature have had an impact on the adoption of these recommendations.
Collapse
Affiliation(s)
- Lydia E Pace
- Division of Women's Health, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | |
Collapse
|
43
|
Veldhuijzen W, Ram PM, van der Weijden T, van der Vleuten CPM. Communication guidelines as a learning tool: an exploration of user preferences in general practice. PATIENT EDUCATION AND COUNSELING 2013; 90:213-219. [PMID: 23116969 DOI: 10.1016/j.pec.2012.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 09/25/2012] [Accepted: 10/03/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To explore characteristics of written communication guidelines that enhance the success of training aimed at the application of the recommendations in the guidelines. METHODS Seven mixed focus groups were held consisting of communication skill teachers and communication skill learners and three groups with only learners. Analysis was done in line with principles of grounded theory. RESULTS Five key attributes of guidelines for communication skill training were identified: complexity, level of detail, format and organization, type of information, and trustworthiness/validity. The desired use of these attributes is related to specific educational purposes and learners' expertise. The low complexity of current communication guidelines is appreciated, but seems ad odds with the wish for more valid communication guidelines. CONCLUSIONS Which guideline characteristics are preferred by users depends on the expertise of the learners and the educational purpose of the guideline. PRACTICE IMPLICATIONS Communication guidelines can be improved by modifying the key attributes in line with specific educational functions and learner expertise. For example: the communication guidelines used in GP training in the Netherlands, seem to offer an oversimplified model of doctor patient communication. This model may be suited for undergraduate learning, but does not meet the validity demands of physicians in training.
Collapse
Affiliation(s)
- Wemke Veldhuijzen
- CAHPRI School for Public Health and Primary Care Research, Maastricht University, Maastricht, Netherlands.
| | | | | | | |
Collapse
|
44
|
van Gelder FE, de Graaff JC, van Wolfswinkel L, van Klei WA. Preoperative testing in noncardiac surgery patients. Eur J Anaesthesiol 2012; 29:465-70. [DOI: 10.1097/eja.0b013e32835423f0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
45
|
|
46
|
Nigam A. Changing health care quality paradigms: the rise of clinical guidelines and quality measures in American medicine. Soc Sci Med 2012; 75:1933-7. [PMID: 22920278 DOI: 10.1016/j.socscimed.2012.07.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 06/29/2012] [Accepted: 07/31/2012] [Indexed: 11/28/2022]
Abstract
Clinical guidelines and quality measures are important new paradigms for conceptualizing and managing quality in the United States. Researchers have proposed that professional elites-including members of academic medicine-were an important cause of the shift to guidelines and measures. This paper draws on content analysis of abstracts focused on quality in major American medical journals between 1975 and 2009 to empirically assess whether and how paradigms for managing quality changed in academic medicine. The content analysis shows that guidelines- and measures-based approaches to quality increased in prominence. Individual expertise-based approaches to quality, however, remain important. Concurrent with changing paradigms in academic medicine, there was a reorientation of policy toward increased use of guidelines and measures the late 1980s and early 1990s in the United States. This policy reorientation was informed by earlier work by medical researchers proposing new approaches to quality. The policy reorientation was followed by an increase in the prominence of guidelines and measures in medical research.
Collapse
Affiliation(s)
- Amit Nigam
- Wagner Graduate School of Public Service, New York University, 295 Lafayette St., 2nd Floor, New York, NY 10012, United States.
| |
Collapse
|
47
|
Ahn HS, Kim HJ. Development and implementation of clinical practice guidelines: current status in Korea. J Korean Med Sci 2012; 27 Suppl:S55-60. [PMID: 22661872 PMCID: PMC3360175 DOI: 10.3346/jkms.2012.27.s.s55] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 03/28/2012] [Indexed: 11/20/2022] Open
Abstract
Documentation of unexplained geographic variations in medical practices and use of inappropriate interventions has led to the proliferation of clinical practice guidelines. With increased enthusiasm for guidelines, evidence exists that clinical practice guidelines often influence clinical practices or health outcomes. Their successful implementation may improve the quality of care by decreasing in appropriate variation and expediting the application of effective advances to healthcare practices. In Korea, physicians and healthcare professionals have begun to take interests in clinical practice guidelines. Currently, over 50 practice guidelines have been developed through professional academic organizations or via other routes; however, the quality of the guidelines is unsatisfactory, implementation in clinical settings is incomplete, and there is insufficient infrastructure to develop clinical practice guidelines. Korea must develop policies and invest resources to enhance the development and implementation of clinical practice guidelines.
Collapse
Affiliation(s)
- Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea.
| | | |
Collapse
|
48
|
Yasmeen S, Romano PS, Tancredi DJ, Saito NH, Rainwater J, Kravitz RL. Screening mammography beliefs and recommendations: a web-based survey of primary care physicians. BMC Health Serv Res 2012; 12:32. [PMID: 22309456 PMCID: PMC3293074 DOI: 10.1186/1472-6963-12-32] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 02/06/2012] [Indexed: 12/04/2022] Open
Abstract
Background The appropriateness and cost-effectiveness of screening mammography (SM) for women younger than 50 and older than 74 years is debated in the clinical research community, among health care providers, and by the American public. This study explored primary care physicians' (PCPs) perceptions of the influence of clinical practice guidelines for SM; the recommendations for SM in response to hypothetical case scenarios; and the factors associated with perceived SM effectiveness and recommendations in the US from June to December 2009 before the United States Preventive Services Task Force (USPSTF) recently revised guidelines. Methods A nationally representative sample of 11,922 PCPs was surveyed using a web-based questionnaire. The response rate was 5.7% (684); (41%) 271 family physicians (FP), (36%) 232 general internal medicine physicians (IM), (23%) 150 obstetrician-gynaecologists (OBG), and (0.2%) 31 others. Cross-sectional analysis examined PCPs perceived effectiveness of SM, and recommendation for SM in response to hypothetical case scenarios. PCPs responses were measured using 4-5 point adjectival scales. Differences in perceived effectiveness and recommendations for SM were examined after adjusting for PCPs specialty, race/ethnicity, and the US region. Results Compared to IM and FP, OBG considered SM more effective in reducing breast cancer mortality among women aged 40-49 years (p = 0.003). Physicians consistently recommended mammography to women aged 50-69 years with no differences by specialty (p = 0.11). However, 94% of OBG "always recommended" SM to younger and 86% of older women compared to 81% and 67% for IM and 84% and 59% for FP respectively (p = < .001). In ordinal regression analysis, OBG specialty was a significant predictor for perceived higher SM effectiveness and recommendations for younger and older women. In evaluating hypothetical scenarios, overall PCPs would recommend SM for the 80 year woman with CHF with a significant variation by specialty (38% of OBG, 18% of FP, 17% of IM; p = < .001). Conclusions A majority of physicians, especially OBG, favour aggressive breast cancer screening for women from 40 through 79 years of age, including women with short life expectancy. Policy interventions should focus on educating providers to provide tailored recommendations for mammography based on individualized cancer risk, health status, and preferences.
Collapse
Affiliation(s)
- Shagufta Yasmeen
- Department of Internal Medicine and Centre for Healthcare Policy and Research University of California Davis School of Medicine, Sacramento, California, USA.
| | | | | | | | | | | |
Collapse
|
49
|
Hasan H, Zodpey S, Saraf A. Diabetologist's perspective on practice of evidence based diabetes management in India. Diabetes Res Clin Pract 2012; 95:189-93. [PMID: 22001282 DOI: 10.1016/j.diabres.2011.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 09/20/2011] [Indexed: 11/16/2022]
Abstract
Diabetes demands early diagnosis, prompt treatment, continuous monitoring and follow up. Physicians play a pivotal role in diabetes management. However, evidence suggests that sub-optimal knowledge of guidelines and other issues may lead to ineffective management and poor patient outcomes. The aim of this research was to identify clinical diabetologist's perspectives on evidence based diabetes management, benefits of and barriers to the practice of evidence based guidelines in management of type 2 diabetes. Clinical diabetologists were administered a semi-structured questionnaire. Qualitative responses were analysed to identify key words, phrases and concepts from respondents. Majority of diabetologist (78.2%) preferred ADA guidelines alone or in combination with others guidelines where as 12.7% diabetologist follow all the guidelines on case by case basis. 27% and 25% diabetologists opined that guidelines ensure uniform standard of care across patient and achievement of diabetes management goals respectively. Poor awareness among physicians (22.7%), western guidelines being not applicable to Indian patients (22.7%), cost to patient (18.2%) were some of the barrier to practice of evidence based diabetes management. Some of the mechanism suggested to improve the practice of evidence based diabetes management included education of physicians in EBM (28.9%), making practice of evidence based guidelines legally binding (10.5%) and wider dissemination of existing guidelines (7.8%).
Collapse
Affiliation(s)
- Habib Hasan
- Public Health Foundation of India, New Delhi, India.
| | | | | |
Collapse
|
50
|
Pavlidis N, Stahel R, Hansen H, Cervantes A. Fourteen years of evolution of ESMO Guidelines: from the minimum recommendations to the Consensus Conference-derived guidelines. Ann Oncol 2011; 22 Suppl 6:vi7-11. [PMID: 21908509 DOI: 10.1093/annonc/mdr370] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|