record_id,title,abstract,label_included,label_abstract_screening,duplicate_record_id
1,"A prospective, controlled trial of a pharmacy-driven alert system to increase thromboprophylaxis rates in medical inpatients.","Although venous thromboembolism is an important cause of morbidity and mortality within the hospital, a significant proportion of at-risk inpatients do not receive measures known to reduce the risk of deep vein thrombosis and pulmonary embolism. The objective of the present study was to determine whether a pharmacy-driven alert system would, compared to usual care, be associated with a higher rate of adequate venous thromboembolism prevention measures among at-risk inpatients on a general internal medicine service. The study was a prospective, controlled trial set at a university-based teaching hospital. The participants were adults who were admitted (Monday through Friday) to the general internal medicine inpatient service from 19 June to 21 September 2006. Their treatment included a pharmacist assessment of venous thromboembolism risk and a pharmacist-driven alert to the treating physician. The Proportion of at-risk patients receiving adequate thromboprophylaxis within 36 h of admission was recorded. Overall, 140 patients were at sufficient risk for venous thromboembolism to be included. In the usual care group, prophylactic measures were ordered for 49 (61%) of the 80 patients at moderate to high risk. In the pharmacist-alert group, 44 (73%) of the 60 moderate to high venous thromboembolism-risk patients received adequate thromboprophylaxis (P = 0.15). Although we did not observe a statistically significant difference between the groups, our results are consistent with previous reports suggesting that alert systems can increase the proportion of hospitalized patients who receive adequate measures to prevent venous thromboembolism.",0,1,
2,Effect of a clinical pharmacy service on lipid control in patients with peripheral arterial disease.,"Objective Our group and others have previously established that patients with peripheral artery disease (PAD) are significantly undertreated with respect to overall cardiovascular risk factor management, despite national guidelines to the contrary. In an effort to maximize risk factor control in our patients with PAD, we established a pharmacist-managed, physician-monitored algorithmic approach to the outpatient management of lipids in patients with PAD. The purpose of this study was to determine the effect of this service on lipid screening and control in patients with PAD.  Methods We analyzed the records of patients treated at a large, group-model, not-for-profit regional managed care system serving approximately 405,000 members. An electronic medical record provided full examination, laboratory, and pharmacy data for all patients. Pharmacy data were analyzed to determine prescriptions for lipid-lowering agents. Lipid control was assessed through fasting lipid data. Patients with validated PAD and the absence of clinical coronary artery disease (CAD) were offered the service between May 2003 and September 2004 and followed up for a minimum of 6 months.  Results We administratively identified 5159 active patients with a diagnosis of PAD. Of these, 1075 could be validated with a noninvasive arterial study. The exclusion of 384 patients with a diagnosis of CAD resulted in a cohort of 691 patients. Of these, 90 patients were enrolled in the lipid service (study group), and 601 received standard care. Mean follow-up was 17.1 months. Screening fasting lipid profiles were found in 95.6% (86/90) of patients in the study group and only 66.9% (402/601) of the standard care patients (P < .0001). Low-density lipoprotein cholesterol (LDL-C) control was improved in the pharmacist-managed group, with 79.1% (68/86) achieving an LDL-C of less than 100 mg/dL in comparison to the standard care group (54.8% [219/400]"";"" P < .0001). An LDL-C value of more than 130 mg/dL was noted in 1.2% and 14.0% (56/400) in the treatment and control groups, respectively (P < .001). Statin use was present in 51.9% (312/601) of the control group patients and 84.4% (76/90) of the pharmacist-managed group (P < .001).  Conclusions Despite national consensus of PAD as a CAD equivalent, patients are currently undertreated with regard to atherosclerotic risk factor modification. Initiation of a pharmacist-managed, physician-monitored lipid service provides improved compliance with national guidelines",0,1,
3,Using peer feedback to improve handwashing and glove usage among Thai health care workers.,"Background: Without protective practices such as Universal Precautions, health care workers are at substantial risk for bloodborne infection, especially in areas such as Thailand with high prevalence of HIV infection. The purpose of this study was to evaluate the effectiveness of a peer feedback program (PFP) on handwashing and glove wearing (HW/GW) among Thai health care workers. Methods: Subjects (N = 91) were randomly assigned to receive PFP versus no treatment. By using a checklist, peer observers rated HW/GW compliance in their coworkers during patient care. For 1 month, the investigator posted a report of compliance behaviors from each 3 days of observations. HW/GW was also assessed by the investigator by direct observation at 1 month before the intervention, during the intervention period, and 1 month after the intervention. Results: Baseline HW/GW rates for the PFP and control groups were 49.2% and 61.5%, respectively. The PFP group had a significantly higher adjusted compliance rate than the control group during the intervention period (P =.0001). However, there was no significant difference in the compliance scores obtained 1 month after the intervention. Conclusions: The PFP was effective during the intervention period, but there was no retention of effect. Therefore, adjunct methods should be sought to promote retention of effect. (AJIC Am J Infect Control 2000"";""28:365-9)",0,1,
4,"""Doctoring"" Doctors and Their Families","Being selected to provide medical care to other physicians or their family members represents not only a gratifying professional recognition of competence by one's peers but also a challenge. Many personal and psychological factors may influence the medical care of physicians. Ill physicians may have difficulty with role reversal and ""the VIP syndrome,"" while treating physicians may have to deal with their own anxiety and issues such as confidentiality, privacy, empathy, and intrusion by a physician-relative into the care of medical family members. Based on experience with more than 200 physician-patients and many adult family members of physicians, suggestions are offered for care of these patient groups.",0,0,
5,"""Ethics and clinical research"" revisited. A tribute to Henry K. Beecher","The doctrine of informed consent, borrowed from the law of torts, cannot be readily transplanted into therapeutic settings. The broader, as yet unrealized, idea of informed consent, which suggests that parties must make decisions jointly, should guide interactions between physicians and patients or investigators and subjects.",0,0,
6,"""First, do no harm"": legal guidelines for health programmes affecting adolescents aged 10-17 who sell sex or inject drugs","INTRODUCTION: There is a strong evidence base that the stigma, discrimination and criminalization affecting adolescent key populations (KPs) aged 10-17 is intensified due to domestic and international legal constructs that rely on law-enforcement-based interventions dependent upon arrest, pre-trial detention, incarceration and compulsory ""rehabilitation"" in institutional placement. While there exists evidence and rights-based technical guidelines for interventions among older cohorts, these guidelines have not yet been embraced by international public health actors for fear that international law applies different standards to adolescents aged 10-17 who engage in behaviours such as selling sex or injecting drugs. DISCUSSION: As a matter of international human rights, health, juvenile justice and child protection law, interventions among adolescent KPs aged 10-17 must not involve arrest, prosecution or detention of any kind. It is imperative that interventions not rely on law enforcement, but instead low-threshold, voluntary services, shelter and support, utilizing peer-based outreach as much as possible. These services must be mobile and accessible, and permit alternatives to parental consent for the provision of life-saving support, including HIV testing, treatment and care, needle and syringe programmes, opioid substitution therapy, safe abortions, antiretroviral therapy and gender-affirming care and hormone treatment for transgender adolescents. To ensure enrolment in services, international guidance indicates that informed consent and confidentiality must be ensured, including by waiver of parental consent requirements. To remove the disincentive to health practitioners and researchers to engaging with adolescent KPs aged 10-17 government agencies and ethical review boards are advised to exempt or grant waivers for mandatory reporting. In the event that, in violation of international law and guidance, authorities seek to involuntarily place adolescent KPs in institutions, they are entitled to judicial process. Legal guidelines also provide that these adolescents have influence over their placement, access to legal counsel to challenge the conditions of their detention and regular visitation from peers, friends and family, and that all facilities be subject to frequent and periodic review by independent agencies, including community-based groups led by KPs. CONCLUSIONS: Controlling international law specifies that protective interventions among KPs aged 10-17 must not only include low-threshold, voluntary services but also ""protect"" adolescent KPs from the harms attendant to law-enforcement-based interventions. Going forward, health practitioners must honour the right to health by adjusting programmes according to principles of minimum intervention, due process and proportionality, and duly limit juvenile justice and child protection involvement as a measure of last resort, if any.",0,0,
7,"""How much do you get paid if I volunteer?"" Suggested institutional policy on reward, consent, and research","Pharmaceutical companies often ask practicing physicians to conduct phase IV or postmarketing research on new drugs. Companies pay physicians to enroll their patients and report dosage and side-effect information. Postmarketing research embraces a multibillion dollar effort at promotion and familiarization, but subjects' informed consent to it normally does not include physician reward. Improving investigators' financial status while increasing medical risks to phase IV subjects is ethically unsound, especially if subjects are unaware of investigators' rewards. We suggest a model policy and guidelines that affirm subjects' need for informed consent, investigators' need for recognition and support, and institutions' need to protect patients from undisclosed risk and relations.",0,0,
8,"""If it ain't broke, don't fix it",,0,0,
9,"""Let Me Get You a Nicotine Patch"": Nurses' Perceptions of Implementing Smoking Cessation Guidelines for Hospitalized Veterans","Many hospitalized smokers do not receive guideline-recommended tobacco treatment, but little is known about the perceptions of inpatient nurses with regard to tobacco treatment. We used a sequential explanatory mixed methods design to help explain the findings of an academic detailing intervention trial on the inpatient medicine units of four Veterans Affairs (VA) hospitals. We surveyed 164 nurses and conducted semistructured interviews in a purposeful sample of 33 nurses with different attitudes toward cessation counseling. Content analysis was used to inductively characterize the issues raised by participants. Emerging themes were categorized using the knowledge-attitudes-behavior framework of guideline adherence. Knowledge-related and attitudinal barriers included perceived lack of skills in cessation counseling and skepticism about the effectiveness of cessation guidelines in hospitalized veterans. Nurses also reported multiple behavioral and organizational barriers to guideline adherence: resistance from patients, insufficient time and resources, the presence of smoking areas on VA premises, and lack of coordination with primary care. VA hospitals should train inpatient staff how to negotiate behavior change, integrate cessation counseling into nurses' workflow, develop alternative referral mechanisms for post-discharge cessation counseling, and adopt hospital policies to promote inpatient abstinence.",0,0,
10,"""Rules"" of evidence in assessing the efficacy and effectiveness of treatments","A brief review of the ""rules"" of evidence in assessing the efficacy and effectiveness of treatments leads to a discussion of what the future might hold in the development of the rules of randomized clinical trials (RCTs) in order to enhance the impact of such studies. The primary requisite for enhancing the impact of studies appears to be discussions and interactions among researchers, clinicians, policy makers, and patient advocates, on the one hand, and among the basic scientists and clinical researchers, on the other.",0,0,
11,(S)Partners for Heart Health: a school-based program for enhancing physical activity and nutrition to promote cardiovascular health in 5th grade students,"BACKGROUND: The American Heart Association Position Statement on Cardiovascular Health Promotion in Public Schools encourages school-based interventions for the primary prevention of cardiovascular disease (CVD) through risk factor prevention or reduction in children with an emphasis on creating an environment that promotes healthy food choices and physical activity (PA). In an effort to address issues related to CVD risk factors including obesity in Michigan children, a multi-disciplinary team of Michigan State University (MSU) faculty, clinicians, and health profession students was formed to ""(S)partner"" with elementary school physical education (PE) teachers and MSU Extension staff to develop and implement a cost-effective, sustainable program aimed at CVD risk factor prevention and management for 5th grade students. This (S)partnership is intended to augment and improve the existing 5th grade PE, health and nutrition curriculum by achieving the following aims: 1) improve the students' knowledge, attitudes and confidence about nutrition, PA and heart health""; 2) increase the number of students achieving national recommendations for PA and nutrition;"" and 3) increase the number of students with a desirable CVD risk factor status based on national pediatric guidelines. Secondary aims include promoting school staff and parental support for heart health to help children achieve their goals and to provide experiential learning and service for MSU health profession students for academic credit. METHODS/DESIGN: This pilot effectiveness study was approved by the MSU IRB. At the beginning and the end of the school year students undergo a CVD risk factor assessment conducted by MSU medical students and graduate students. Key intervention components include eight lesson plans (conducted bi-monthly) designed to promote heart healthy nutrition and PA behaviors conducted by PE teachers with assistance from MSU undergraduate dietetic and kinesiology students (Spartners). The final 10 minutes of each lesson, MSU Spartners conduct small breakout/discussion groups with the 5th grade students. Additionally, each Spartner case manages/mentors two to three 5th grade students using a web-based goal setting and tracking protocol throughout the school year. DISCUSSION: This paper describes the rationale, development, and methods of the Spartners for Heart Health program. This is a multi-level intervention designed to promote heart healthy behaviors and prevent or manage CVD risk factors in children. We believe this will be a viable sustainable intervention that can be disseminated and adopted by other institutions with minimal cost by engaging college students as an integral part of the measurement and intervention teams.",0,0,
12,“Value for money”: use with care,"In this issue, Owens and colleagues (1) claim that the goal of policy should be to “preserve the delivery of interventions that do provide good value.” They also acknowledge that evaluating costs without considering value is problematic because it could lead to “inadvertent reductions in effective and efficient care.” Cutler and colleagues (2) have argued that an intervention that yields more benefits than costs is socially beneficial regardless of whether it increases spending. The American College of Physicians Clinical Guidelines Committee makes an important contribution to this policy debate by offering definitions and concepts to guide the search for high-value health care, but the “value-for-money” goal raises many questions that warrant further discussion.",0,0,
13,100 Apples Divided by 15 Red Herrings: A Cautionary Tale from the Mid-19th Century on Comparing Hospital Mortality Rates,"In 1863, Florence Nightingale argued that London hospitals were dangerous, especially compared with provincial facilities. She bolstered this contention with statistics published in William Fair's Registrar-General report, which claimed that 24 London hospitals had mortality rates exceeding 90%, whereas rural hospitals had an average mortality rate of 13%. Farr had calculated mortality rates by dividing the total number of patients who died throughout the year by the number of inpatients on a single day. When calculated as the annual number of deaths divided by the total number of inpatients during the year, the mortality rate of London hospitals was 10%. A raucous debate erupted in the London medical press over how best to calculate hospital mortality rates. Critics claimed that Farr had not adjusted for differences in severity of illness between urban and rural hospitals and that his figures would mislead the public. Farr and Nightingale, in turn, criticized the poor quality of hospital data. This story reinforces the need to understand the methodologic derivation of statistics intended to compare provider quality.",0,0,
14,1931 German guidelines on human experimentation,,0,0,
15,2013 ACC/AHA cholesterol treatment guideline: Paradigm shifts in managing atherosclerotic cardiovascular disease risk,"The 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults represents a major shift from prior cholesterol management guidelines. The new guidelines include data from individual randomized trials as well as the most comprehensive meta-analyses, and introduce several major paradigm shifts, which include: aiming for ASCVD risk reduction as opposed to targeting LDL-C levels, advocating for the use of evidence-based doses of statins as first line therapy, and utilizing a new risk calculator and risk cut point to guide initiation of statin therapy. These major changes have created controversy and confusion among the medical community, with some clinicians hesitant to embrace the shift. We review the evidence that forms the basis for these major changes, compare them to other major lipid guidelines, and recommend an integrated approach to managing dyslipidemia to decrease atherosclerotic cardiovascular disease risk.",0,0,
16,2015 AAHA/AAFP pain management guidelines for dogs and cats,"RATIONALE: The robust advances in pain management for companion animals underlie the decision of the American Animal Hospital Association (AAHA) and American Association of Feline Practitioners (AAFP) to expand on the information provided in the 2007 AAHA/AAFP Pain Management Guidelines. The 2015 Guidelines summarize and offer a discriminating review of much of this new knowledge. RELEVANCE: Pain management is central to veterinary practice, alleviating pain, improving patient outcomes, and enhancing both quality of life and the veterinarian-client-patient relationship. These Guidelines support veterinarians in incorporating pain management into practice, improving patient care. APPROACHES: The management of pain requires a continuum of care that includes anticipation, early intervention, and evaluation of response on an individual patient basis. A team-oriented approach, including the owner, is essential for maximizing the recognition, prevention and treatment of pain in animals. EVIDENCE BASE: The Guidelines include both pharmacologic and non-pharmacologic modalities to manage pain""; they are evidence-based insofar as possible and otherwise represent a consensus of expert opinion. Behavioral changes are currently the principal indicator of pain and its course of improvement or progression, and the basis for recently validated pain scores. Post-surgical pain is eminently predictable but a strong body of evidence exists supporting strategies to mitigate adaptive as well as maladaptive forms. Chronic pain is dominated by degenerative joint disease (DJD), which is one of the most significant and under-diagnosed diseases of cats and dogs. DJD is ubiquitous, found in pets of all ages, and inevitably progresses over time;"" evidence-based strategies for management are established in dogs, and emerging in cats.",0,0,
17,5As Team obesity intervention in primary care: development and evaluation of shared decision-making weight management tools,"Despite several clinical practice guidelines, there remains a considerable gap in prevention and management of obesity in primary care. To address the need for changing provider behaviour, a randomized controlled trial with convergent mixed method evaluation, the 5As Team (5AsT) study, was conducted. As part of the 5AsT intervention, the 5AsT tool kit was developed. This paper describes the development process and evaluation of these tools. Tools were co-developed by the multidisciplinary research team and the 5AsT, which included registered nurses/nurse practitioners (n = 15), mental health workers (n = 7) and registered dieticians (n = 7), who were previously randomized to the 5AsT intervention group at a primary care network in Edmonton, Alberta, Canada. The 5AsT tool development occurred through a practice/implementation-oriented, need-based, iterative process during learning collaborative sessions of the 5AsT intervention. Feedback during tool development was received through field notes and final provider evaluation was carried out through anonymous questionnaires. Twelve tools were co-developed with 5AsT. All tools were evaluated as either 'most useful' or 'moderately useful' in primary care practice by the 5AsT. Four key findings during 5AsT tool development were the need for: tools that were adaptive, tools to facilitate interdisciplinary practice, tools to help patients understand realistic expectations for weight loss and shared decision-making tools for goal setting and relapse prevention. The 5AsT tools are primary care tools which extend the utility of the 5As of obesity management framework in clinical practice.",0,0,
18,6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial,"OBJECTIVE To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards. DESIGN Cluster randomised controlled trial. SETTING Six Australian hospitals. PARTICIPANTS All patients admitted to 24 acute wards during the trial period. INTERVENTIONS Participating wards were randomly assigned to receive either the nurse led 6-PACK programme or usual care over 12 months. The 6-PACK programme included a fall risk tool and individualised use of one or more of six interventions: ""falls alert"" sign, supervision of patients in the bathroom, ensuring patients' walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm. MAIN OUTCOME MEASURES The co-primary outcomes were falls and fall injuries per 1000 occupied bed days. RESULTS During the trial, 46 245 admissions to 16 medical and eight surgical wards occurred. As many people were admitted more than once, this represented 31 411 individual patients. Patients' characteristics and length of stay were similar for intervention and control wards. Use of 6-PACK programme components was higher on intervention wards than on control wards (incidence rate ratio 3.05, 95% confidence interval 2.14 to 4.34""; P<0.001). In all, 1831 falls and 613 fall injuries occurred, and the rates of falls (incidence rate ratio 1.04, 0.78 to 1.37; P=0.796) and fall injuries (0.96, 0.72 to 1.27;"" P=0.766) were similar in intervention and control wards. CONCLUSIONS Positive changes in falls prevention practice occurred following the introduction of the 6-PACK programme. However, no difference was seen in falls or fall injuries between groups. High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. Novel solutions to the problem of in-hospital falls are urgently needed. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12611000332921.",0,0,
19,"A before-after study using OncoDoc, a guideline-based decision support-system on breast cancer management: impact upon physician prescribing behaviour","Guideline-based decision support systems have been developed to influence the prescribing behaviour of clinicians, but they have not yet shown to increase physician compliance with best practices in routine. OncoDoc is a non-automated system that allows flexibility in guideline interpretation to obtain best patient-specific recommendations at the point of care. OncoDoc is applied to breast cancer management. We have experimented the system at the Institut Gustave Roussy with a before-after study in which treatment decisions for breast cancer patients were measured before and after using the system in order to evaluate its impact upon physicians' prescribing behaviour. After 4 months, 127 decisions were recorded. Physicians compliance with OncoDoc was significantly improved (p < 10(-4) ) to reach 85.03% after using the system. Comparison of initial and final decisions showed that physicians modified their prescription in 31% of the cases. Clinical trial accrual rate increased of 50%, though not statistically significant because estimated on small figures.",0,1,
20,A Behavioral-Economics View of Poverty,"Standard theorizing about poverty falls into  two camps. Social scientists regard the behav-  iors of the economically disadvantaged either as  calculated adaptations to prevailing circum-  stances or as emanating from a unique ""culture  of poverty,"" rife with deviant values. The first  camp presumes that people are highly rational,  that they hold coherent and justified beliefs and  pursue their goals effectively, without mistakes,  and with no need for help. The second camp  attributes to the poor a variety of psychological  and attitudinal short-fallings that render their  views often misguided and their choices falli-  ble, leaving them in need of paternalistic  guidance.  We propose a third view. The behavioral  patterns of the poor, we argue, may be neither  perfectly calculating nor especially deviant.  Rather, the poor may exhibit the same basic  weaknesses and biases as do people from other  walks of life, except that in poverty, with its  narrow margins for error, the same behaviors  often manifest themselves in more pronounced  ways and can lead to worse outcomes. In what  follows, we illustrate the kinds of insights that  might be gained from a behaviorally more real-  istic analysis of the economic conditions of the  poor, and we propose that alternative policies",0,0,
21,A behaviorally effective model for training of general health professionals by a rheumatology team,"This project evaluated a model for inservice arthritis education based in part on principles of applied behavior analysis. Thirty-seven public health nurses (PHN) from 10 rural midwestern counties received instruction about screening and management of patients with arthritis"";"" a random half of counties also received public and physician information interventions designed to increase arthritis referrals to community physicians under specific circumstances. In clinic interviews with patients of PHN showed modest, but significant, increases in 14 of 16 target behaviors attributable to inservice education. Because measured arthritis impact was low in this older adult population, physician referral rates were not affected by either intervention. This model illustrates generalizable behavior modification guidelines that are useful adjuncts to traditional procedures for development of professional arthritis education.",0,0,
22,"A case of osteomalacia, osteoporosis, and hypercalcaemia",,0,0,
23,A case of sarcoidosis with cryptococcal meningitis demonstrated at the Royal Postgraduate Medical School,A fatal case is described in a 30-yr-old army officer who had served abroad.,0,0,
24,"A case report of evaluating a large-scale health systems improvement project in an uncontrolled setting: a quality improvement initiative in KwaZulu-Natal, South Africa","Objective New approaches are needed to evaluate quality improvement (QI) within large-scale public health efforts. This case report details challenges to large-scale QI evaluation, and proposes solutions relying on adaptive study design.  Study design We used two sequential evaluative methods to study a QI effort to improve delivery of HIV preventive care in public health facilities in three districts in KwaZulu-Natal, South Africa, over a 3-year period. We initially used a cluster randomised controlled trial (RCT) design.  Principal findings During the RCT study period, tensions arose between intervention implementation and evaluation design due to loss of integrity of the randomisation unit over time, pressure to implement changes across the randomisation unit boundaries, and use of administrative rather than functional structures for the randomisation. In response to this loss of design integrity, we switched to a more flexible intervention design and a mixed-methods quasiexperimental evaluation relying on both a qualitative analysis and an interrupted time series quantitative analysis.  Conclusions Cluster RCT designs may not be optimal for evaluating complex interventions to improve implementation in uncontrolled ‘real world’ settings. More flexible, context-sensitive evaluation designs offer a better balance of the need to adjust the intervention during the evaluation to meet implementation challenges while providing the data required to evaluate effectiveness. Our case study involved HIV care in a resource-limited setting, but these issues likely apply to complex improvement interventions in other settings.",0,0,
25,A centralized cardiovascular risk service to improve guideline adherence in private primary care offices,"BACKGROUND: Many large health systems now employ clinical pharmacists in team-based care to assist patients and physicians with management of cardiovascular (CV) diseases. However, small private offices often lack the resources to hire a clinical pharmacist for their office. The purpose of this study is to evaluate whether a centralized, web-based CV risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in primary care medical offices in rural and small communities. METHODS: This study is a cluster randomized prospective trial in 12 primary care offices. Medical offices were randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. Primary outcomes will include adherence to treatment guidelines and control of key CV risk factors. Data will also be abstracted from the medical record at 30 months to determine if the intervention effect is sustained after it is discontinued. CONCLUSIONS: This study will enroll subjects through 2015 and results will be available in 2018. This study will provide information on whether a distant, centralized CV risk service can improve guideline adherence in medical offices that lack the resources to employ clinical pharmacists.",0,1,
26,A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior,"CONTEXT: Computer-based clinical decision support systems (CDSSs) have been promoted for their potential to improve quality of health care. However, given the limited range of clinical settings in which they have been tested, such systems must be evaluated rigorously before widespread introduction into clinical practice. OBJECTIVE: To determine whether presentation of venous thromboembolism prophylaxis guidelines using a CDSS increases the proportion of appropriate clinical practice decisions made. DESIGN: Time-series study conducted between December 1997 and July 1999. SETTING: Orthopedic surgery department of a teaching hospital in Paris, France. PARTICIPANTS: A total of 1971 patients who underwent orthopedic surgery. INTERVENTION: A CDSS designed to provide immediate information pertaining to venous thromboembolism prevention among surgical patients was integrated into daily medical practice during three 10-week intervention periods, alternated with four 10-week control periods, with a 4-week washout between each period. MAIN OUTCOME MEASURE: Proportion of appropriate prescriptions ordered for anticoagulation, according to preestablished clinical guidelines, during intervention vs control periods. RESULTS: Physicians complied with guidelines in 82.8% (95% confidence interval [CI], 77.6%-87.1%) of cases during control periods and in 94.9% (95% CI, 92.5%-96.6%) of cases during intervention periods. During each intervention period, the appropriateness of prescription increased significantly (P<.001). Each time the CDSS was removed, physician practice reverted to that observed before initiation of the intervention. The relative risk of inappropriate practice decisions during control periods vs intervention periods was 3.8 (95% CI, 2.7-5.4). CONCLUSIONS: In our study, implementation of clinical guidelines for venous thromboembolism prophylaxis through a CDSS used routinely in an orthopedic surgery department and integrated into the hospital information system changed physician behavior and improved compliance with guidelines. JAMA. 2000"";""283:2816-2821",1,1,
27,A clinical trial of a knowledge-based medical record,"To meet the needs of primary care physicians caring for patients with HIV infection, we developed a knowledge-based medical record to allow the on-line patient record to play an active role in the care process. These programs integrate the on-line patient record, rule-based decision support, and full-text information retrieval into a clinical workstation for the practicing clinician. To determine whether use of a knowledge-based medical record was associated with more rapid and complete adherence to practice guidelines and improved quality of care, we performed a controlled clinical trial among physicians and nurse practitioners caring for 349 patients infected with the human immuno-deficiency virus (HIV)"";"" 191 patients were treated by 65 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 61 physicians and nurse practitioners assigned to the control group. During the 18-month study period, the computer generated 303 alerts in the intervention group and 388 in the control group. The median response time of clinicians to these alerts was 11 days in the intervention group and 52 days in the control group (PJJ0.0001, log-rank test). During the study, the computer generated 432 primary care reminders for the intervention group and 360 reminders for the control group. The median response time of clinicians to these alerts was 114 days in the intervention group and more than 500 days in the control group (PJJ0.0001, log-rank test). Of the 191 patients in the intervention group, 67 (35%) had one or more hospitalizations, compared with 70 (44%) of the 158 patients in the control group (PJ=J0.04, Wilcoxon test stratified for initial CD4 count). There was no difference in survival between the intervention and control groups (P = 0.18, log-rank test). We conclude that our clinical workstation significantly changed physicians' behavior in terms of their response to alerts regarding primary care interventions and that these interventions have led to fewer patients with HIV infection being admitted to the hospital.",0,1,
28,A clinically integrated post-graduate training programme in evidence-based medicine versus 'no intervention' for improving disability evaluations: a cluster randomised clinical trial,"BACKGROUND: Although several studies have shown that teaching EBM is effective in improving knowledge, at present, there is no convincing evidence that teaching EBM also changes professional behaviour in practice. Therefore, the primary aim of this study was to evaluate the effectiveness of a clinically integrated post-graduate training programme in EBM on evidence-based disability evaluation. METHODS AND FINDINGS: In a cluster randomised controlled trial, fifty-four case-based learning groups consisting of 132 physicians and 1680 patients were randomly assigned to the intervention or control groups. A clinically integrated, post-graduate, 5-day training programme in evidence-based medicine, consisting of (home) assignments, peer teaching, interactive training in searching databases, lectures and brainstorming sessions was provided to the intervention group. The control group received no training. The primary outcome was evidence-based disability evaluation, as indicated by the frequency in use of evidence of sufficient quality in disability evaluation reports. There are no general EBM behaviour outcome measures available. Therefore, we followed general guidelines for constructing performance indicators and defined an a priori cut-off for determination of sufficient quality as recommended for evaluating EB training. Physicians trained in EBM performed more evidence-based disability evaluations compared to physicians in the control group (difference in absolute proportion 9.7%, 95% CI 3.5 to 15.9). The primary outcome differences between groups remained significant after both cluster-adjusted analysis and additional sensitivity analyses accounting for subjects lost to follow-up. CONCLUSIONS: A EBM programme successfully improved the use of evidence in a non-hospital based medical specialty. Our findings support the general recommendations to use multiple educational methods to change physician behaviour. In addition, it appeared important that the professional context of the intervention was very supportive in the sense that searches in databases, using and applying guidelines and other forms of evidence are considered standard practice and are encouraged by colleagues and management.",0,0,
29,A clinic-based mammography intervention targeting inner-city women.,"OBJECTIVE: The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.  DESIGN: A randomized controlled trial employing firm system methodology was conducted.  SETTING: The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.  PARTICIPANTS: Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314).  LNTERVENTIONS: The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, pre appointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.  MEASUREMENTS AND MAIN RESULTS: Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5: 95% confidence interval 1.9. 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.  CONCLUSIONS: A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.",0,1,
30,A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol,"Background Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.  Methods The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.  Discussion If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.",0,0,
31,A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics.,"Objectives Having shown previously that an electronic prescription writer and decision support system improved pediatric prescribing behavior for otitis media in an academic clinic setting, we assessed whether point-of-care delivery of evidence could demonstrate similar effects for a wide range of other common pediatric conditions.  Design Cluster randomized controlled trial.  Setting A teaching clinic/clinical practice site and a primary care pediatric clinic serving a rural and semi-urban patient mix.  Participants A total of 36 providers at the teaching clinic/practice site and eight providers at the private primary pediatric clinic.  Intervention An evidence-based message system that presented real-time evidence to providers based on prescribing practices for acute otitis media, allergic rhinitis, sinusitis, constipation, pharyngitis, croup, urticaria, and bronchiolitis.  Outcome measures The proportion of prescriptions dispensed in accordance with evidence.  Results The proportion of prescriptions dispensed in accordance with evidence improved four percentage points, from 38% at baseline to 42% following the intervention. The control group improved by one percentage point, from 39% at baseline to 40% at trial's conclusion. The adjusted difference between the intervention and control groups was 8% (95% confidence interval 1%, 15%). Intervention effectiveness did not decrease with time.  Conclusion For common pediatric outpatient conditions, a point-of-care evidence-based prescription writer and decision support system was associated with significant improvements in prescribing practices.",1,1,
32,A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol,"BACKGROUND: The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?""; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?;"" and what are the costs of implementing the strategy? METHODS: In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. DISCUSSION: We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.",0,0,
33,A cluster randomized trial of standard quality improvement versus patient-centered interventions to enhance depression care for African Americans in the primary care setting: study protocol NCT00243425,"BACKGROUND: Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes"";"" therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression. METHODS/DESIGN: A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up. DISCUSSION: The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT00243425.",0,0,
34,A combined paging alert and web-based instrument alters clinician behavior and shortens hospital length of stay in acute pancreatitis,"OBJECTIVES: There are many published clinical guidelines for acute pancreatitis (AP). Implementation of these recommendations is variable. We hypothesized that a clinical decision support (CDS) tool would change clinician behavior and shorten hospital length of stay (LOS). METHODS: DESIGN/SETTING: Observational study, entitled, The AP Early Response (TAPER) Project. Tertiary center emergency department (ED) and hospital. PARTICIPANTS: Two consecutive samplings of patients having ICD-9 code (577.0) for AP were generated from the emergency department (ED) or hospital admissions. Diagnosis of AP was based on conventional Atlanta criteria. The Pre-TAPER-CDS-Tool group (5/30/06-6/22/07) had 110 patients presenting to the ED with AP per 976 ICD-9 (577.0) codes and the Post-TAPER-CDS-Tool group (5/30/06-6/22/07) had 113 per 907 ICD-9 codes (7/14/10-5/5/11). INTERVENTION: The TAPER-CDS-Tool, developed 12/2008-7/14/2010, is a combined early, automated paging-alert system, which text pages ED clinicians about a patient with AP and an intuitive web-based point-of-care instrument, consisting of seven early management recommendations. RESULTS: The pre- vs. post-TAPER-CDS-Tool groups had similar baseline characteristics. The post-TAPER-CDS-Tool group met two management goals more frequently than the pre-TAPER-CDS-Tool group: risk stratification (P6L/1st 0-24 h (P=0.0003). Mean (s.d.) hospital LOS was significantly shorter in the post-TAPER-CDS-Tool group (4.6 (3.1) vs. 6.7 (7.0) days, P=0.0126). Multivariate analysis identified four independent variables for hospital LOS: the TAPER-CDS-Tool associated with shorter LOS (P=0.0049) and three variables associated with longer LOS: Japanese severity score (P=0.0361), persistent organ failure (P=0.0088), and local pancreatic complications (<0.0001). CONCLUSIONS: The TAPER-CDS-Tool is associated with changed clinician behavior and shortened hospital LOS, which has significant financial implications.",0,0,
35,A community capacity-enhancement approach to breast and cervical cancer screening among older women of color,"In the Screening Older Minority Women project, the authors applied a community capacity-enhancement approach to promoting breast and cervical cancer screening among older women of color. Members of informal support networks were recruited for this health promotion intervention to empower Latina and African American women to engage in positive health behaviors. The authors describe the phases of the intervention and the experiences from the community. Guidelines are identified to help researchers and practitioners in planning and implementing community health promotion intervention with women of color.",0,0,
36,A community-based approach to the promotion of breastfeeding in Mexico,"A comprehensive education strategy is presented that links training, community education, research, and mass-media efforts to enhance breastfeeding practices. Breastfeeding promotion models, an administrative system, and lessons learned during the project are described. The keys to effective breastfeeding promotion are shown to be accurate information""; appropriate education, training, and follow-up; and a supportive administrative system.;"" PIP: An operations research project designed to determine what model of intervention was most successful in promoting breast feeding among 585 urban women in Mexico began in 1986. The interventions involved having trained promoters teach and counsel breast feeding mothers in Irapuato, program supervisors teach groups of mothers in Chihuahua, and both trained promoters and program supervisors train individuals or groups in Cuauhtemoc. Jalapa served as the control site. The breast feeding prevalence rate in the 4 communities varied from 64.5%-81.3% prior to intervention with a mean in the target group of 74.9%. The mean climbed to 88.8% for this group after intervention. Further, the breast feeding prevalence rate for Jalapa fell from 65.9%-56%. In addition, 70% of the women in the experimental group exclusively breast fed their infants during the 1st month whereas only 63.3% in the control did. Subsequent months' breast feeding prevalence rates decreased o 13.7% and 14.7% (5 months) and 9.4% and 3.3% (6 months) in the experimental and control groups respectively. Informal support groups of breast feeding mothers formed unexpectedly as a result of the educational and outreach activities. The data showed that the intervention model using the promoters was the most successful strategy. They also provided the researchers and other health care professionals interested in promoting community based breast feeding programs with guidelines. For example, supervisors should not discourage promoters from addressing other community needs since discouraging them can jeopardize their dedication to breast feeding promotion. Further, program planners should gather geographic and sociodemographic data of the area and population prior to planning and intervention.",0,0,
37,A comparison of the effects of computer and manual reminders on compliance with a mental health clinical practice guideline.,"Objective: To evaluate the relative effectiveness of computer and manual reminder systems on the implementation of a clinical practice guideline.  Design: Seventy-eight outpatients in a mental health clinic were randomly assigned within clinician to one of the two reminder systems. The computer system, called CaseWalker, reminded clinicians when guideline-recommended screening for mood disorder was due, ensured the fidelity of the diagnosis of major depressive disorder to criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and generated a progress note. The manual system was a checklist inserted in the paper medical record.  Measures: Screening rates for mood disorder and the completeness of the documentation of which DSM-IV criteria were met by patients who were said to have major depressive disorder were compared.  Results: The CaseWalker, compared with the paper checklist, resulted in a higher screening rate for mood disorder (86.5 vs. 61 percent, P = 0.008) and a higher rate of complete documentation of DSM-IV criteria (100 vs. 5.6 percent, P < 0.001).  Conclusions: In an outpatient mental health clinic, computer reminders were shown to be superior to manual reminders in improving adherence to a clinical practice guideline for depression.",0,1,
38,A computer-based intervention for improving the appropriateness of antiepileptic drug level monitoring,"We designed and implemented 2 automated, computerized screens for use at the time of antiepileptic drug (AED) test order entry to improve appropriateness by reminding physicians when a potentially redundant test was ordered and providing common indications for monitoring and pharmacokinetics of the specific AED. All computerized orders for inpatient serum AED levels during two 3-month periods were included in the study. During the 3-month period after implementation of the automated intervention, 13% of all AED tests ordered were canceled following computerized reminders. For orders appearing redundant, the cancellation rate was 27%. For nonredundant orders, 4% were canceled when information on specific AED monitoring and pharmacokinetics was provided. The cancellation rate was sustained after 4 years. There has been a 19.5% decrease in total AED testing volume since implementation of this intervention, despite a 19.3% increase in overall chemistry test volume. Inappropriateness owing to repeated testing before pharmacologic steady state was reached decreased from 54% of all AED orders to 14.6%. A simple, automated, activity-based intervention targeting a specific test-ordering behavior effectively reduced inappropriate laboratory testing. The sustained benefit supports the idea that computerized interventions may durably affect physician behavior. Computerized delivery of such evidence-based boundary guidelines can help narrow the gap between evidence and practice.",1,1,
39,A computerized handheld decision-support system to improve pulmonary embolism diagnosis: a randomized trial.,"Background: Testing for pulmonary embolism often differs from that recommended by evidence-based guidelines.  Objective: To assess the effectiveness of a handheld clinical decision-support system to improve the diagnostic work-up of suspected pulmonary embolism among patients in the emergency department.  Design: Cluster randomized trial. Assignment was by random-number table, providers were not blinded, and outcome assessment was automated. (ClinicalTrials.gov registration number: NCT00188032)  Setting: 20 emergency departments in France.  Patients: 1103 and 1768 consecutive outpatients with suspected pulmonary embolism.  Intervention: After a preintervention period involving 20 centers and 1103 patients, in which providers grew accustomed to inputting clinical data into handheld devices and investigators assessed baseline testing, emergency departments were randomly assigned to activation of a decision-support system on the devices (10 centers, 753 patients) or posters and pocket cards that showed validated diagnostic strategies (10 centers, 1015 patients).  Measurements: Appropriateness of diagnostic work-up, defined as any sequence of tests that yielded a posttest probability less than 5% or greater than 85% (primary outcome) or as strict adherence to guideline recommendations (secondary outcome)""; number of tests per patient (secondary outcome).  Results: The proportion of patients who received appropriate diagnostic work-ups was greater during the trial than in the preintervention period in both groups, but the increase was greater in the computer-based guidelines group (adjusted mean difference in increase, 19.3 percentage points favoring computer-based guidelines [95% CI, 2.9 to 35.6 percentage points]; PÂ = 0.023). Among patients with appropriate work-ups, those in the computer-based guidelines group received slightly fewer tests than did patients in the paper guidelines group (mean tests per patient, 1.76 [SD, 0.98] vs. 2.25 [SD, 1.04];"" PÂ < 0.001).  Limitation: The study was not designed to show a difference in the clinical outcomes of patients during follow-up.  Conclusion: A handheld decision-support system improved diagnostic decision making for patients with suspected pulmonary embolism in the emergency department.",0,1,
40,A computerized intervention to decrease the use of calcium channel blockers in hypertension.,"Objective To determine whether a computer-assisted reminder would alter prescribing habits for the treatment of hypertension in accordance with current clinical guidelines in a general internal medicine clinic.  Design A randomized trial.  Setting The General Internal Medicine Clinic of the Veterans Affairs Puget Sound Health Care System, Seattle Division.  Patients/Participants Clinic providers were randomized to a control group (n=35) or intervention group (n=36). We targeted the providers of patients being treated for hypertension with calcium channel blockers, a class of drug not recommended for initial therapy.  Intervention An automated computer query identified eligible patients and their providers. A guideline reminder was placed in the charts of patients of intervention providers"";"" the charts of patients of control providers received no reminder.  Measurements and main results During the 5-month study period, 346 patients were seen by the 36 primary care providers (staff physicians, nurse practitioners, residents, and fellows) in the intervention group, and 373 patients were seen by the 35 providers in the control group. Intervention providers changed 39 patients (11.3%) to other medications during the study period, compared with 1 patient (<1.0%) of control providers (p<.0001). For patients whose therapy was unchanged, providers noted angina in 23.1%, indications other than those for hypertension in 9.5%, intolerable adverse effects with first-line therapy in 13.9%, and inadequte control with first-line therapy in 13.9%. Of those patients without provider-indicated contraindications, 23.6% were switched from calcium channel blockers to first-line agents during the intervention period.  Conclusions The use of a computerized, clinic-based intervention increased compliance with guidelines in the treatment of primary hypertension in general, and decreased the use of calcium channel blockers for the treatment of hypertension in particular.",1,1,
41,A computerized reminder for prophylaxis of deep vein thrombosis in surgical patients,"OBJECTIVE: To measure the effect of a computerized reminder system on the rate of deep vein thrombosis (DVT) prophylaxis in surgical patients. DESIGN: A prospective trial to measure change in compliance compared to historic controls. MEASUREMENTS: LDS Hospital surgeons developed local consensus as to which procedures should have DVT prophylaxis. The historic rate of prophylaxis for the procedures was measured through a database search of patient records. A computerized reminder system was then implemented which utilized an expert knowledge base and a time drive mechanism to flag surgical cases for DVT prophylaxis. For eligible patients, a DVT reminder appeared on the operating room schedule"";"" surgical staff used this as a guide to apply prophylaxis. During the 3 month trial the rate of DVT prophylaxis was remeasured and compared to the pre-intervention rate. RESULTS: The pre-intervention rate of DVT prophylaxis over a 3 month period was 85.2% (785 of 921 eligible cases). For the 3 months following the introduction of the computerized reminder, compliance with DVT prophylaxis increased to 99.3% (1084 of 1092 eligible cases). The difference between the historic controls and the study subjects was highly significant (p < 0.001). CONCLUSION: A computerized reminder is an effective method of increasing the rate of DVT prophylaxis in surgical patients.",1,1,
42,A computerized reminder system to increase the use of preventive care for hospitalized patients,"BACKGROUND Although they are effective in outpatient settings, computerized reminders have not been proved to increase preventive care in inpatient settings.  METHODS We conducted a randomized, controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for inpatients. During an 18-month study period, a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service (for a total of 10,065 hospitalizations), generating preventive care reminders as appropriate. Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for inpatients.  RESULTS The reminder system identified 3416 patients (53.6 percent) as eligible for preventive measures that had not been ordered by the admitting physician. For patients with at least one indication, computerized reminders resulted in higher adjusted ordering rates for pneumococcal vaccination (35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group, P<0.001), influenza vaccination (51.4 percent vs. 1.0 percent, P<0.001), prophylactic heparin (32.2 percent vs. 18.9 percent, P<0.001), and prophylactic aspirin at discharge (36.4 percent vs. 27.6 percent, P<0.001).  CONCLUSIONS A majority of hospitalized patients in this study were eligible for preventive measures, and computerized reminders significantly increased the rate of delivery of such therapies.",1,1,
43,"A concept for the implementation and evaluation of the guideline ""Early Detection of Breast Cancer in Germany""","Systematically developed, evidence- and consensus-based guidelines are important tools for improving health care services. The effectiveness of a guideline does not only relate to its methodological quality but also to the implementation strategy used. The following paper describes the systematic development of a strategy for implementing and evaluating the guideline ""Early Detection of Breast Cancer in Germany"" as part of a national project. A multi-faceted systematic implementation strategy has been developed addressing existing barriers and building on projects that have recently been introduced in Germany to improve the early detection and management of breast cancer. The aim is to induce behavioural changes in women as healthcare recipients and physicians as healthcare providers, both involved in the medical decision-making process within the scope of the guideline. Furthermore, it supports organisational changes to assure compliance with the guideline by means of quality assurance and quality management. To ensure evaluation of the implementation process a set of quality indicators have been identified for the baseline assessment of structures, provider performance and outcomes. Both the effectiveness of the implementation process and the effectiveness of the guideline itself will be measured by using the same set of indicators for reevaluation within a pre-defined time interval of 18 months. The quasi-experimental design of this uncontrolled before and after implementation study outlined in the present paper allows the assessment of clinically relevant changes using quality indicators that measure the effectiveness of the guideline on a national level.",0,0,
44,A controlled trial of including symptom data in computer-based care suggestions for managing patients with chronic heart failure,"Background Heart failure is common and associated with considerable morbidity and cost, yet physician adherence to treatment guidelines is suboptimal. We conducted a randomized controlled study to determine if adding symptom information to evidence-based, computer-generated care suggestions would affect treatment decisions among primary care physicians caring for outpatients with heart failure at two Veterans Affairs medical centers.  Methods Physicians were randomly assigned to receive either care suggestions generated with electronic medical record data and symptom data obtained from questionnaires mailed to patients within 2 weeks of scheduled outpatient visits (intervention group) or suggestions generated with electronic medical record data alone (control group). Patients had to have a diagnosis of heart failure and objective evidence of left ventricular systolic dysfunction. We assessed physician adherence to heart failure guidelines, as well as patients' New York Heart Association (NYHA) class, quality of life, satisfaction with care, hospitalizations, and outpatient visits, at 6 and 12 months after enrollment.  Results Patients in the intervention (n = 355) and control (n = 365) groups were similar at baseline. At 12 months, there were no significant differences in adherence to care suggestions between physicians in the intervention and control groups (33% vs. 30%, P = 0.4). There were also no significant changes in NYHA class (P = 0.1) and quality-of-life measures (P >0.1), as well as no differences in the number of outpatient visits between intervention and control patients (6.7 vs. 7.1 visits, P = 0.48). Intervention patients were more satisfied with their physicians (P = 0.02) and primary care visit (P = 0.02), but had more all-cause hospitalizations at 6 months (1.5 vs. 0.7 hospitalizations, P = 0.0002) and 12 months (2.3 vs. 1.7 hospitalizations, P = 0.05).  Conclusion Adding symptom information to computer-generated care suggestions for patients with heart failure did not affect physician treatment decisions or improve patient outcomes.",0,1,
45,A controlled trial of web-based diabetes disease management.,"OBJECTIVE—To test effects of a web-based decision support tool, the diabetes Disease Management Application (DMA), developed to improve evidence-based management of type 2 diabetes.  RESEARCH DESIGN AND METHODS—We conducted a group randomized controlled trial of 12 intervention and 14 control staff providers and 307 intervention and 291 control patients with type 2 diabetes in a hospital-based internal medicine clinic. Providers were randomly assigned from May 1998 through April 1999 to have access to the DMA (intervention) or not to have access (control). The DMA displays interactive patient-specific clinical data, treatment advice, and links to other web-based care resources. We compared patients in the intervention and control groups for changes in processes and outcomes of care from the year preceding the study through the year of the study by intention-to-treat analysis.  RESULTS—The DMA was used for 42% of scheduled patient visits. The number of HbA1c tests obtained per year increased significantly in the intervention group (+0.3 tests/year) compared with the control group (-0.04 tests/year, P = 0.008), as did the number of LDL cholesterol tests (intervention, +0.2 tests/year""; control, +0.01 tests/year; P = 0.02) and the proportions of patients undergoing at least one foot examination per year (intervention, +9.8%; control, -0.7%; P = 0.003). Levels of HbA1c decreased by 0.2 in the intervention group and increased by 0.1 in the control group (P = 0.09);"" proportions of patients with LDL cholesterol levels <130 mg/dl increased by 20.3% in the intervention group and 10.5% in the control group (P = 0.5).  CONCLUSIONS—Web-based patient-specific decision support has the potential to improve evidence-based parameters of diabetes care.",0,1,
46,A cross-sectional study of the number and frequency of terms used to refer to knowledge translation in a body of health literature in 2006: a Tower of Babel?,"The study of implementing research findings into practice is rapidly growing and has acquired many competing names (e.g., dissemination, uptake, utilization, translation) and contributing disciplines. The use of multiple terms across disciplines pose barriers to communication and progress for applying research findings. We sought to establish an inventory of terms describing this field and how often authors use them in a collection of health literature published in 2006.  Methods We refer to this field as knowledge translation (KT). Terms describing aspects of KT and their definitions were collected from literature, the internet, reports, textbooks, and contact with experts. We compiled a database of KT and other articles by reading 12 healthcare journals representing multiple disciplines. All articles published in these journals in 2006 were categorized as being KT or not. The KT articles (all KT) were further categorized, if possible, for whether they described KT projects or implementations (KT application articles), or presented the theoretical basis, models, tools, methods, or techniques of KT (KT theory articles). Accuracy was checked using duplicate reading. Custom designed software determined how often KT terms were used in the titles and abstracts of articles categorized as being KT.  Results A total of 2,603 articles were assessed, and 581 were identified as KT articles. Of these, 201 described KT applications, and 153 included KT theory. Of the 100 KT terms collected, 46 were used by the authors in the titles or abstracts of articles categorized as being KT. For all 581 KT articles, eight terms or term variations used by authors were highly discriminating for separating KT and non-KT articles (p < 0.001): implementation, adoption, quality improvement, dissemination, complex intervention (with multiple endings), implementation (within three words of) research, and complex intervention. More KT terms were associated with KT application articles (n = 13) and KT theory articles (n = 18).  Conclusions We collected 100 terms describing KT research. Authors used 46 of them in titles and abstracts of KT articles. Of these, approximately half discriminated between KT and non-KT articles. Thus, the need for consolidation and consistent use of fewer terms related to KT research is evident.",0,0,
47,A Formative Study of Colon Cancer Surveillance Care: Implications for Survivor-Centered Interventions,"Colon cancer is one of the most commonly diagnosed cancers in the United States, and an increasing number of survivors has underscored the need for improved colon cancer surveillance care quality. Post-treatment surveillance includes follow-up care visits and tests as well as psychosocial support and lifestyle counseling. This formative study explored the individual, interpersonal, and organizational-level factors related to adherence to surveillance care guidelines to identify modifiable factors for potential educational intervention strategies. A convenience sample of 22 survivors (12 women and 10 men) from two cancer centers were recruited to participate in focus groups or key informant telephone interviews to explore their experiences with care after completing treatment and complete a brief survey. Content analysis was used to identify themes. Results confirmed that survivors navigated a complex surveillance care schedule and described a strong trust in their health care providers that guided their follow-up care experiences. Participants defined the terms ""survivorship"" and ""follow-up"" in a variety of different ways. Individual-level themes critical to survivors' experiences included having a positive attitude, relying on one's faith, and coping with fears. Interpersonal-level themes centered around interactions and communication with family and health care providers in follow-up care. While organizational-level factors were highlighted infrequently, participants rated office reminder systems and communication among their multiple providers as valuable. Educational interventions capitalizing on survivors' connections with their physicians and focusing on preparing survivors for what to expect in the next phase of their cancer experience, could be beneficial at the end of treatment to activate survivors for the transition to the post-treatment period.",0,0,
48,A framework for good practice in interagency interventions with cases of self-neglect,"Self-neglect is probably more common than has generally been thought and gives rise to a number of difficult conceptual, identification and intervention problems for health and social care workers. These patient management issues are compounded by the lack of any evidence-base for practice which nurses can draw on when faced with managing people who self-neglect. Nurses working with self-neglecters operate in an interdisciplinary context which includes professional groups, such as environmental health officers, who do not normally figure within health and social care teams. In the absence of such an evidence-base, a pragmatic solution in the form of a framework for interagency practice has been proposed. The background underpinning this framework, including a research study of housing in self-neglect and interagency responses, is briefly outlined in this paper.",0,0,
49,A Framework to Assist Health Professionals in Recommending High-Quality Apps for Supporting Chronic Disease Self-Management: Illustrative Assessment of Type 2 Diabetes Apps,"BACKGROUND: This paper presents an approach to assist health professionals in recommending high quality apps for supporting chronic disease self-management. Most app reviews focus on popularity, aesthetics, functionality, usability, and information quality. There is no doubt these factors are important in selecting trustworthy apps which are appealing to users, but behavioral theory may be also be useful in matching the apps to user needs. OBJECTIVE: The framework developed aims to be methodologically sound, capable of selecting popular apps which include content covered by evidence-based programs, consistent with behavioral theory, as well as a patient-centered approach for matching apps to patients' individual needs. METHODS: A single disease-type 2 diabetes-was selected to illustrate how the framework can be applied as this was deemed to represent the types of strategies used in many chronic diseases. A systematic approach based on behavioral theory and recommendations from best practice guidelines was developed for matching apps to patients' needs. In March 2014, a series of search strategies was used to identify top-rated iPhone and Android health apps, representing 29 topics from five categories of type 2 diabetes self-management strategies. The topics were chosen from published international guidelines for the management of diabetes. The senior author (KH) assessed the most popular apps found that addressed these topics using the Behavioral Theory Content Survey (BTS), which is based on traditional behavioral theory. A tool to assist decision making when using apps was developed and trialed with health professionals for ease of use and understanding. RESULTS: A total of 14 apps were assessed representing all five topic categories of self-management. Total theoretical scores (BTS scores) were less than 50 on a 100-point scale for all apps. Each app scored less than 50% of the total possible BTS score for all four behavioral theories and for most of the 20 behavioral strategies"";"" however, apps scored higher than 50% of the total possible BTS score for specific strategies related to their primary focus. Our findings suggest that the apps studied would be more effective when used in conjunction with therapy than as stand-alone apps. Apps were categorized according to topic and core intervention strategies. A framework for matching apps to identified patient needs was developed based on app categorization and principles of patient-centered care. The approach was well accepted and understood by a convenience sample of health practitioners. CONCLUSIONS: The framework presented can be used by health practitioners to better match apps with client needs. Some apps incorporate highly interactive strategies of behavioral theory, and when used as an adjunct may increase patient participation and the effectiveness of therapy.",0,0,
50,A French adaptation of the Overt Behaviour Scale (OBS) measuring challenging behaviours following acquired brain injury: The Echelle des comportements observables (ECO),"PURPOSE: To develop a French version of the Overt Behaviour Scale (OBS) and examine some of its psychometric properties. METHODS: The scale was adapted and validated according to standard guidelines for cross-cultural adaptation of questionnaires (Echelle des comportements observables"";"" ECO). The reliability and construct validity of the ECO were studied among 29 inpatients and outpatients who sustained an acquired brain injury. The instruments were administered by 12 clinicians located at eight rehabilitation centres and the local brain injury association. RESULTS: The ECO provided behaviour profile descriptives much like the original scale. It showed excellent reliability and good convergent and divergent validity, as reflected by significant associations with other measures that contained similar behavioural items and by the absence of signification correlations with broader constructs such as physical and cognitive abilities. CONCLUSION: This study provides evidence that the ECO behaves much like the original OBS, has promising initial findings with respect to reliability and validity and is a valuable research and clinical instrument to assess the severity and typology of challenging behaviour after an acquired brain injury and to monitor the evolution of behaviours after intervention in French and bilingual communities.",0,0,
51,A handheld computer smoking intervention tool and its effects on physician smoking cessation counseling,"OBJECTIVE: The objective of this study was to evaluate a handheld computer smoking cessation intervention tool designed to assist physicians in their smoking cessation counseling with patients. METHODS: This study used a pre/post survey design, with a 4-month trial period for the software. Study participants included 22 faculty and resident physicians from the University of Virginia. Paired samples t tests were used to assess mean differences in the 4 main subscales (physician behavior, attitudes, comfort related to counseling patients about smoking cessation, and knowledge). RESULTS: No statistically significant mean differences were found for physician behavior (mean increase = 0.44, P = .55) or physician attitude (mean increase = 0.44, P = .16). A statistically significant mean increase of 2.29 was observed for the physician comfort subscale (t = 3.87, df = 16, P = .001). Physicians indicated improved comfort in counseling patients about smoking cessation (P = .007) and improved comfort in using the Public Health Service Clinical Practice Guidelines (P = .012). CONCLUSION: Physician comfort level in counseling patients about smoking cessation can be improved through handheld computer software. When used in conjunction with other practice modifications, this tool has the potential to improve physician smoking cessation intervention practices.",0,1,
52,"A hybrid effectiveness-implementation cluster randomized trial of group CBT for anxiety in urban schools: rationale, design, and methods","Background Schools present a context with great potential for the implementation of psychosocial evidence-based practices. Cognitive behavioral therapy (CBT) is an evidence-based practice that has been found to be very effective in treating anxiety in various community settings, including schools. Friends for Life (FRIENDS) is an efficacious group CBT protocol for anxiety. Unfortunately, evidence-based practices for anxiety are seldom employed in under-resourced urban schools, because many treatment protocols are not a good fit for the urban school context or the population, existing behavioral health staff do not receive adequate training or support to allow them to implement the treatment with fidelity, or school districts do not have the resources to contract with external consultants. In our prior work, we adapted FRIENDS to create a more culturally sensitive, focused, and feasible CBT protocol for anxiety disorders (CBT for Anxiety Treatment in Schools (CATS)).  Methods/design The aim of this 5-year study is to evaluate both the effectiveness of CATS for urban public schools compared to the original FRIENDS as well as compare the implementation strategies (train-the-trainer vs. train-the-trainer?+?ongoing consultation) by conducting a three-arm, parallel group, type 2 hybrid effectiveness-implementation trial in 18 K-8 urban public schools. We will also assess the cost-effectiveness and the mediators and moderators of fidelity. Ninety therapists, 18 agency supervisors, and 360 children will participate. The interactive systems framework for dissemination and implementation guides the training and support procedures for therapists and supervisors.  Discussion This study has the potential to demonstrate that agency therapists and supervisors who have had little to no prior exposure to evidence-based practices (EBPs) can implement an anxiety disorder EBP with fidelity. Comparisons of the implementation strategies would provide large urban mental health systems with data to make decisions about the adoption of EBPs.",0,0,
53,"A low-fat vegan diet elicits greater macronutrient changes, but is comparable in adherence and acceptability, compared with a more conventional diabetes diet among individuals with type 2 diabetes","BACKGROUND: Although therapeutic diets are critical to diabetes management, their acceptability to patients is largely unstudied. OBJECTIVE: To quantify adherence and acceptability for two types of diets for diabetes. DESIGN: Controlled trial conducted between 2004 and 2006. SUBJECTS/SETTING: Individuals with type 2 diabetes (n=99) at a community-based research facility. Participants were randomly assigned to a diet following 2003 American Diabetes Association guidelines or a low-fat, vegan diet for 74 weeks. MAIN OUTCOME MEASURES: Attrition, adherence, dietary behavior, diet acceptability, and cravings. STATISTICAL ANALYSES: For nutrient intake and questionnaire scores, t tests determined between-group differences. For diet-acceptability measures, the related samples Wilcoxon sum rank test assessed within-group changes""; the independent samples Mann-Whitney U test compared the diet groups. Changes in reported symptoms among the groups was compared using chi(2) for independent samples. RESULTS: All participants completed the initial 22 weeks; 90% (45/50) of American Diabetes Association guidelines diet group and 86% (42/49) of the vegan diet group participants completed 74 weeks. Fat and cholesterol intake fell more and carbohydrate and fiber intake increased more in the vegan group. At 22 weeks, group-specific diet adherence criteria were met by 44% (22/50) of members of the American Diabetes Association diet group and 67% (33/49) of vegan-group participants (P=0.019); the American Diabetes Association guidelines diet group reported a greater increase in dietary restraint;"" this difference was not significant at 74 weeks. Both groups reported reduced hunger and reduced disinhibition. Questionnaire responses rated both diets as satisfactory, with no significant differences between groups, except for ease of preparation, for which the 22-week ratings marginally favored the American Diabetes Association guideline group. Cravings for fatty foods diminished more in the vegan group at 22 weeks, with no significant difference at 74 weeks. CONCLUSIONS: Despite its greater influence on macronutrient intake, a low-fat, vegan diet has an acceptability similar to that of a more conventional diabetes diet. Acceptability appears to be no barrier to its use in medical nutrition therapy.",0,0,
54,A meta-analysis of the association between adherence to drug therapy and mortality,"OBJECTIVE To evaluate the relation between adherence to drug therapy, including placebo, and mortality. DESIGN Meta-analysis of observational studies. DATA SOURCES Electronic databases, contact with investigators, and textbooks and reviews on adherence. Review methods Predefined criteria were used to select studies reporting mortality among participants with good and poor adherence to drug therapy. Data were extracted for disease, drug therapy groups, methods for measurement of adherence rate, definition for good adherence, and mortality. RESULTS Data were available from 21 studies (46,847 participants), including eight studies with placebo arms (19,633 participants). Compared with poor adherence, good adherence was associated with lower mortality (odds ratio 0.56, 95% confidence interval 0.50 to 0.63). Good adherence to placebo was associated with lower mortality (0.56, 0.43 to 0.74), as was good adherence to beneficial drug therapy (0.55, 0.49 to 0.62). Good adherence to harmful drug therapy was associated with increased mortality (2.90, 1.04 to 8.11). CONCLUSION Good adherence to drug therapy is associated with positive health outcomes. Moreover, the observed association between good adherence to placebo and mortality supports the existence of the ""healthy adherer"" effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour.",0,0,
55,A midwifery-led in-hospital birth center within an academic medical center: successes and challenges,"The University of California San Diego Community Women's Health Program (CWHP) has emerged as a successful and sustainable coexistence model of women's healthcare. The cornerstone of this midwifery practice is California's only in-hospital birth center. Located within the medical center, this unique and physically separate birth center has been the site for more than 4000 births. With 10% cesarean delivery and 98% breast-feeding rates, it is an exceptional example of low-intervention care. Integrating this previously freestanding birth center into an academic center has brought trials of mistrust and ineffectual communication. Education, consistent leadership, and development of multidisciplinary guidelines aided in overcoming these challenges. This collaborative model provides a structure in which residents learn to be respectful consultants and appreciate differences in medical practice. The CWHP and its Birth Center illustrates that through persistence and flexibility a collaborative model of maternity services can flourish and not only positively influence new families but also future generations of providers.",0,0,
56,"A migraine management training program for primary care providers: An overview of a survey and pilot study findings, lessons learned, and considerations for further research","BACKGROUND: There are five to nine million primary care office visits a year for migraine in the United States. However, migraine care is often suboptimal in the primary care setting. A prior study indicated that primary care physicians (PCPs) wanted direct contact with headache specialists to improve the migraine care they provide. OBJECTIVE: We sought to further examine PCPs' knowledge of migraine management and assess the feasibility of a multimodal migraine education program for PCPs. METHODS: We conducted a survey assessing PCPs' knowledge about migraine. We then held three live educational sessions and developed an email consultative service for PCPs to submit questions they had about migraine. We report both quantitative and qualitative findings. RESULTS: Twenty-one PCPs completed the survey. They were generally familiar with the epidemiology of migraine (mean prevalence of migraine reported was 12.6% +/- 10.1), the psychiatric comorbidities (mean prevalence of comorbid depression was 24.5% +/- 16.7, mean prevalence of comorbid anxiety was 24.6% +/- 18.3), and evidence-based behavioral treatments. Fifty-six percent cited cognitive behavioral therapy, 78% cited biofeedback, and 61% cited relaxation therapy as evidence based treatments. Though most were aware of the prevalence of psychiatric comorbidities, they did not routinely assess for them (43% did not routinely assess for anxiety, 29% did not routinely assess for depression). PCPs reported frequently referring patients for non-level A evidence based treatments: special diets (60%), acupuncture (50%), physical therapy (30%), and psychoanalysis (20%). Relaxation therapy was a therapy recommended by 40% of the PCPs. Only 10% reported referring for cognitive behavioral therapy or biofeedback. Nineteen percent made minimal or no use of migraine preventive medications. Seventy-two percent were unaware of or only slightly aware of the American Academy of Neurology guidelines for migraine. There was variable attendance at the educational sessions (N=22 at 1st session, 6 at 2nd session, 15 at 3rd session). Very few PCPs used the email consultative service (N=4). CONCLUSIONS: Though PCPs are familiar with many aspects of migraine care, there is a need and opportunity for improvement. The three live sessions were poorly attended and the email consultative service was rarely used. We provide an in depth discussion of targeted areas for educational intervention, of the challenges in developing a migraine educational program for PCPs, and areas for future study.",0,0,
57,A model for collaboration in quality improvement projects: implementing a weight-based heparin dosing nomogram across an integrated health care delivery system,"BACKGROUND: At Aurora Health Care, an integrated delivery system based in Milwaukee, a system-level clinical quality improvement department was established in 1995 to facilitate collaboration on clinical quality improvement (QI) initiatives. THE COLLABORATIVE MODEL: A model was developed to use expertise within the system and avoid unnecessary duplication of efforts, while maintaining buy-in for the project's interventions at the point of service delivery. It was believed that a single team could design the improvement efforts or guidelines, and then work at a more local level with a different group of people to implement the processes. APPLYING THE MODEL TO THE HEPARIN QI PROJECT: Anticoagulation with heparin is considered the mainstay of treatment for pulmonary embolism and deep venous thrombosis. However, a large gap was found between present anticoagulation practices and published best practice in regards to achieving a key process measure. To reduce the overall time to achieving effective anticoagulation, a system-level team created an intervention primarily consisting of a preprinted order sheet, including the weight-based heparin dosing nomogram, and an education plan for physicians and other health care professionals. Significant improvement was observed at all pilot sites with overall rates of adequate anticoagulation within the first 24 hours improving from 73% to 95%. DISCUSSION: The system was able to standardize care at four of its five major hospitals and provide for better patient outcomes to a larger segment of the community, and then to replicate the heparin project to four additional sites during a six-month period. This model has been successfully applied to other quality improvement projects.",0,0,
58,A modelling tool for policy analysis to support the design of efficient and effective policy responses for complex public health problems,"Background In the design of public health policy, a broader understanding of risk factors for disease across the life course, and an increasing awareness of the social determinants of health, has led to the development of more comprehensive, cross-sectoral strategies to tackle complex problems. However, comprehensive strategies may not represent the most efficient or effective approach to reducing disease burden at the population level. Rather, they may act to spread finite resources less intensively over a greater number of programs and initiatives, diluting the potential impact of the investment. While analytic tools are available that use research evidence to help identify and prioritise disease risk factors for public health action, they are inadequate to support more targeted and effective policy responses for complex public health problems.  Discussion This paper discusses the limitations of analytic tools that are commonly used to support evidence-informed policy decisions for complex problems. It proposes an alternative policy analysis tool which can integrate diverse evidence sources and provide a platform for virtual testing of policy alternatives in order to design solutions that are efficient, effective, and equitable. The case of suicide prevention in Australia is presented to demonstrate the limitations of current tools to adequately inform prevention policy and discusses the utility of the new policy analysis tool.  Summary In contrast to popular belief, a systems approach takes a step beyond comprehensive thinking and seeks to identify where best to target public health action and resources for optimal impact. It is concerned primarily with what can be reasonably left out of strategies for prevention and can be used to explore where disinvestment may occur without adversely affecting population health (or equity). Simulation modelling used for policy analysis offers promise in being able to better operationalise research evidence to support decision making for complex problems, improve targeting of public health policy, and offers a foundation for strengthening relationships between policy makers, stakeholders, and researchers.",0,0,
59,A national cross-sectional study on socio-behavioural factors that influence physicians' decisions to begin antimicrobial therapy,"PURPOSE: Current efforts to prevent antimicrobial resistance include limiting antimicrobial use, providing education about appropriate use, and developing better point-of-care tests, but what do physicians actually think of rational prescribing and potential interventions? We tried to ascertain which factors can influence a physician's decision to start antimicrobial therapy on a patient, and their opinions on measures to promote rational prescribing. METHODS: We conducted a nationwide, cross-sectional survey of 10,600 physicians from medical registries of all known board-certified physicians in Germany. RESULTS: Among respondents (n = 3,492"";33%;"" detailed non-response bias analysis included), 90% indicated that they decide to start antimicrobial therapy on a patient at least weekly, and 66% reported that they decide daily. We identified correlates for deciding to start antimicrobial therapy on a patient. Predictors were status as a hospital physician (odds ratio (OR) 1.29 (95% confidence interval (CI) 1.00-1.68)), male physician (OR 1.81 (95% CI 1.42-2.31)), being age 50-59 (OR 1.56 (95% CI 1.10-2.21)), and practising in states in the former East Germany (OR 1.60 (95% CI 1.15-2.21)). Each specialist was significantly less likely to decide to start a course of antimicrobial therapy than ENTs and urologists. Other predictors were agreeing to prescribe to be on the safe side (OR 1.34 (95% CI 1.03-1.76)), believing that the quality of prescribing practice improves after receiving continuing education from pharmaceutical companies (OR 1.43 (95% CI 1.11-1.84)), and having experience with failed therapy for resistant pathogens (OR 2.42 (95% CI 1.83-3.19)). CONCLUSIONS: Physicians in our sample decide to start antimicrobial therapy on a patient, and they value intervention to support prudent use, for example continuing education, practice guidelines and implementation of surveillance measures. Socio-behavioural factors, regional variation, gender, and age merit further research to promote rational antimicrobial prescribing and explore related influencing factors.",0,0,
60,A new tool to asses risk of wandering in hospitalized patients,"This article describes the development and implementation of a wandering screening and intervention program based on identifying hospitalized patients with impaired cognition and mobility. A wandering screening tool developed by a multidisciplinary team was linked to appropriate levels of interventions available in the electronic health record. Advanced practice nurses (APNs) confirmed the accuracy of screening and interventions by bedside nurses for all patients who screened positive. Of 1,528 patients hospitalized during a 3-week period, 48 (3.1%) screened positive for wandering. At-risk patients were older (age >/= 65) (66.7%), those admitted to surgical units (41.7%), Caucasian (89.6%), and men (58.3%). Thirteen (27.1%) had dementia and 45 (93.8%) had impaired cognition. Of those patients who screened positive for wandering, the APNs agreed with the bedside nurses' assessment in 79.2% of cases (38/48) about wandering risk and 89.5% (34/38 true positives) for the interventions. A two-item wandering screening tool and intervention was feasible for use by bedside nurses. Further studies are needed to determine whether this tool is effective in preventing wandering.",0,0,
61,"A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer","PURPOSE: This study aims to provide recommendations on the optimal strategies and interventions for the prevention, screening, assessment, and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) in adult cancer populations. METHODS: A systematic search of the published health literature was conducted to identify randomized controlled trials, clinical practice guidelines, systematic reviews, and other guidance documents. The Sleep Disturbance Expert Panel [comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers, and guideline methodologists] reviewed, discussed, and approved the final version of the guideline. Health care professionals across Canada were asked to provide feedback through an external review process. RESULTS: Three clinical practice guidelines and 12 randomized controlled trials were identified as the evidence base. Overall, despite the paucity of evidence, the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using standardized screening tools on a routine basis. While prevention of sleep disturbance is the desired objective, cognitive behavioral therapies are effective in improving sleep outcomes. As part of the external review with 16 health care providers, 81 % indicated that they agreed with the recommendations as written. CONCLUSIONS: Sleep difficulty is a prevalent problem in cancer populations that needs greater recognition by health professionals. Prevention, screening, assessment, and treatment strategies supported by the best available evidence are critical. Recommendations and care path algorithms for practice are offered.",0,0,
62,A patient-initiated system for preventive health care.,"Objective  To test the effectiveness of a patient-initiated, touch-sensitive computer system (TSCS) for improving screening rates for cancers of the breast, cervix, colon and rectum, and oral cavity. Design  One-year, randomized, controlled trial with primary care practice as the unit of analysis.  Setting  Sixty primary care practices, randomly recruited from 329 nonteaching practices in a southeastern state.  Subjects  Random sample of the medical records of 50 male and female adult patients before intervention and 50 adult patients after intervention in each practice and a random sample of 507 TSCS users.  Interventions  Touch-sensitive computer system and a registered nurse who served as liaison to the study practices. The TSCS provided patient-specific preventive service recommendations and facilitated work flow to increase the completion of these interventions.  Main Outcome Measure  Average change, adjusted for health maintenance examination (HME) and use of the TSCS, in the proportion of eligible patients undergoing screening mammography, clinical breast examination, digital rectal examination, fecal occult blood test, flexible sigmoidoscopy, Papanicolaou smear, and oral cavity examination.  Results  We observed a significant increase in the completion of screening mammography (6.6%""; P<=.05) and clinical breast examination (6.1%; P<=.01) in women 50 years of age and older, particularly for those who had an HME during the study year.  Conclusions  Patients who have HMEs are more likely to receive cancer screening;"" however, a computer-based system for preventive services can contribute to improvement in screening. Among those patients who did not have an HME, TSCS users had higher rates of breast cancer screening than nonusers.",0,1,
63,A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic,"BACKGROUND: Simple distribution of clinical practice guidelines to physicians does not change practice behavior. A low-cost, continuous peer review feedback method was used to promote resident physicians' compliance with nine preventive care guidelines at the ambulatory care clinic at the Marshall University School of Medicine (Huntington, West Virginia). METHODS: Preventive care guidelines were distributed and a peer review feedback program was instituted in the resident physician primary care practice. The frequency of resident physician use of nine preventive care services was assessed and compared during three periods: preguideline (September 1, 1993, to March 1, 1994""; 148 patients), guideline (September 1, 1994, to March 1, 1995; 148 patients), and one-year follow-up (September 1, 1995, to March 1, 1996;"" 150 patients). The patients in the three periods were similar in age, gender, and risk for influenza and pneumococcal infection. RESULTS: During the guideline period, resident physicians offered patients four preventive care services-tetanus toxoid immunization, clinical breast examination, Papanicolaou smear testing, and hemoccult testing significantly more often than during the preguideline period. All services were offered significantly more often during the one-year follow-up period compared with the preguideline period and as often as in the guideline period. CONCLUSION: A low-cost, continuous peer review feedback program significantly and durably improves resident physician compliance with clinical practice guidelines on preventive care services. However, the effectiveness of the poor review feedback method may not generalize to private practice or other settings. Research on other methods to promote compliance with clinical practice guidelines and to influence physician behavior in general should continue.",0,1,
64,A pilot study of an electronic interprofessional evidence-based care planning tool for clients with mental health problems and addictions,"BACKGROUND: The health system must develop effective solutions to the growing challenges it faces with respect to individuals who suffer with mental health disorders and addictions. The purpose of this study was to evaluate the usability and potential impact on outcomes of a knowledge translation system aimed at improving client-centered, evidence-based care for hospitalized individuals with schizophrenia. METHODOLOGY: A pre-posttest design was used. The e-Volution-TREAT system was implemented on two inpatient units at a large mental health facility. Thirty-seven nurses, allied health workers, and physicians participated from two units. Data collection involved questionnaires, semistructured interviews, and observations. Thirty-eight consenting clients' outcome data were collected from organizational records. RESULTS: Overall, staff participants were very satisfied with the functions of the e-Volution-TREAT system. Barriers to using the system were identified by participants related to the work environment, to understaffing, equipment problems, discomfort with technology, and a focus on short-term rather than long-term goals. There was moderate uptake of guidelines related to social issues, and low uptake of guidelines related to family support and addictions. There were significant improvements in four client outcomes over time, specifically aggressive behavior, depression, withdrawal, and psychosis. CONCLUSIONS: In conclusion, users were overall satisfied with the e-Volution-TREAT system, although expressed challenges related to workload that interfered with time to utilize the system. It would be premature to conclude the change in client outcomes was related to the e-Volution-TREAT system without a randomized controlled trial with outcomes compared to a control group. Future research needs to incorporate strategies for modifying the context and engage clinicians who are in a position of influence to model change.",0,1,
65,A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients,"BACKGROUND: The aim of this study was to determine the proportions and predictors of first-degree relatives (FDRs) of colorectal cancer (CRC) patients (i) ever receiving any CRC testing and (ii) receiving CRC screening in accordance with CRC screening guidelines. METHODS: Colorectal cancer patients and their FDRs were recruited through the population-based Victorian Cancer Registry, Victoria, Australia. Seven hundred and seven FDRs completed telephone interviews. Of these, 405 FDRs were deemed asymptomatic and eligible for analysis. RESULTS: Sixty-nine percent of FDRs had ever received any CRC testing. First-degree relatives of older age, those with private health insurance, siblings and FDRs who had ever been asked about family history of CRC by a doctor were significantly more likely than their counterparts to have ever received CRC testing. Twenty-five percent of FDRs ""at or slightly above average risk"" were adherent to CRC screening guidelines. For this group, adherence to guideline-recommended screening was significantly more likely to occur for male FDRs and those with a higher level of education. For persons at ""moderately increased risk"" and ""potentially high risk"", 47% and 49% respectively adhered to CRC screening guidelines. For this group, guideline-recommended screening was significantly more likely to occur for FDRs who were living in metropolitan areas, siblings, those married or partnered and those ever asked about family history of CRC. CONCLUSIONS: A significant level of non-compliance with screening guidelines was evident among FDRs. Improved CRC screening in accordance with guidelines and effective systematic interventions to increase screening rates among population groups experiencing inequality are needed. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry: ACTRN12609000628246.",0,0,
66,A primary care nurse-delivered walking intervention in older adults: PACE (pedometer accelerometer consultation evaluation)-Lift cluster randomised controlled trial,"BACKGROUND: Brisk walking in older people can increase step-counts and moderate to vigorous intensity physical activity (MVPA) in >/=10-minute bouts, as advised in World Health Organization guidelines. Previous interventions have reported step-count increases, but not change in objectively measured MVPA in older people. We assessed whether a primary care nurse-delivered complex intervention increased objectively measured step-counts and MVPA. METHODS AND FINDINGS: A total of 988 60-75 year olds, able to increase walking and randomly selected from three UK family practices, were invited to participate in a parallel two-arm cluster randomised trial""; randomisation was by household. Two-hundred-ninety-eight people from 250 households were randomised between 2011 and 2012;"" 150 individuals to the intervention group, 148 to the usual care control group. Intervention participants received four primary care nurse physical activity (PA) consultations over 3 months, incorporating behaviour change techniques, pedometer step-count and accelerometer PA intensity feedback, and an individual PA diary and plan. Assessors were not blinded to group status, but statistical analyses were conducted blind. The primary outcome was change in accelerometry assessed average daily step-counts between baseline and 3 months, with change at 12 months a secondary outcome. Other secondary outcomes were change from baseline in time in MVPA weekly in >/=10-minute bouts, accelerometer counts, and counts/minute at 3 months and 12 months. Other outcomes were adverse events, anthropometric measures, mood, and pain. Qualitative evaluations of intervention participants and practice nurses assessed the intervention's acceptability. At 3 months, eight participants had withdrawn or were lost to follow-up, 280 (94%) individuals provided primary outcome data. At 3 months changes in both average daily step-counts and weekly MVPA in >/=10-minute bouts were significantly higher in the intervention than control group: by 1,037 (95% CI 513-1,560) steps/day and 63 (95% CI 40-87) minutes/week, respectively. At 12 months corresponding differences were 609 (95% CI 104-1,115) steps/day and 40 (95% CI 17-63) minutes/week. Counts and counts/minute showed similar effects to steps and MVPA. Adverse events, anthropometry, mood, and pain were similar in the two groups. Participants and practice nurses found the intervention acceptable and enjoyable. CONCLUSIONS: The PACE-Lift trial increased both step-counts and objectively measured MVPA in >/=10-minute bouts in 60-75 year olds at 3 and 12 months, with no effect on adverse events. To our knowledge, this is the first trial in this age group to demonstrate objective MVPA increases and highlights the value of individualised support incorporating objective PA assessment in a primary care setting. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN42122561.",0,0,
67,A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder,"There remain large discrepancies between pediatricians' practice patterns and the American Academy of Pediatrics (AAP) guidelines for the assessment and treatment of children with attention-deficit/hyperactivity disorder (ADHD). Several studies raise additional concerns about access to ADHD treatment for girls, blacks, and poorer individuals. Barriers may occur at multiple levels, including identification and referral by school personnel, parents' help-seeking behavior, diagnosis by the medical provider, treatment decisions, and acceptance of treatment. Such findings confirm the importance of establishing appropriate mechanisms to ensure that children of both genders and all socioeconomic, racial, and ethnic groups receive appropriate assessment and treatment. Publication of the AAP ADHD toolkit provides resources to assist with implementing the ADHD guidelines in clinical practice. These resources address a number of the barriers to office implementation, including unfamiliarity with Diagnostic and Statistical Manual of Mental Disorders criteria, difficulty identifying comorbidities, and inadequate knowledge of effective coding practices. Also crucial to the success of improved processes within clinical practice is community collaboration in care, particularly collaboration with the educational system. Such collaboration addresses other barriers to good care, such as pressures from parents and schools to prescribe stimulants, cultural biases that may prevent schools from assessing children for ADHD or may prevent families from seeking health care, and inconsistencies in recognition and referral among schools in the same system. Collaboration may also create efficiencies in collection of data and school-physician communications, thereby decreasing physicians' non-face-to-face (and thus nonreimbursable) elements of care. This article describes a process used in Guilford County, North Carolina, to develop a consensus among health care providers, educators, and child advocates regarding the assessment and treatment of children with symptoms of ADHD. The outcome, ie, a community protocol followed by school personnel and community physicians for >10 years, ensures communication and collaboration between educators and physicians in the assessment and treatment of children with symptoms of ADHD. This protocol has the potential to increase practice efficiency, improve practice standards for children with ADHD, and enhance identification of children in schools. Perhaps most importantly, the community process through which the protocol was developed and implemented has an educational component that increases the knowledge of school personnel about ADHD and its treatment, increasing the likelihood that referrals will be appropriate and increasing the likelihood that children will benefit from coordination of interventions among school personnel, physicians, and parents. The protocol reflects a consensus of school personnel and community health care providers regarding the following: (1) ideal ADHD assessment and management principles""; (2) a common entry point (a team) at schools for children needing assessment because of inattention and classroom behavior problems, whether the problems present first to a medical provider, the behavioral health system, or the school; (3) a protocol followed by the school system, recognizing the schools' resource limitations but meeting the needs of community health care providers for classroom observations, psychoeducational testing, parent and teacher behavior rating scales, and functional assessment; (4) a packet of information about each child who is determined to need medical assessment; (5) a contact person or team at each physician's office to receive the packet from the school and direct it to the appropriate clinician; (6) an assessment process that investigates comorbidities and applies appropriate diagnostic criteria; (7) evidence-based interventions; (8) processes for follow-up monitoring of children after establishment of a treatment plan; (9) roles for central participants (school personnel, physicians, school nurses, and mental health professionals) in assessment, management, and follow-up monitoring of children with attention problems; (10) forms for collecting and exchanging information at every step; (11) processes and key contacts for flow of communication at every step; and (12) a plan for educating school and health care professionals about the new processes. A replication of the community process, initiated in Forsyth County, North Carolina, in 2001, offers insights into the role of the AAP ADHD guidelines in facilitating development of a community consensus protocol. This replication also draws attention to identification and referral barriers at the school level. The following recommendations, drawn from the 2 community processes, describe a role for physicians in the collaborative community care of children with symptoms of ADHD. (1) Achieve consensus with the school system regarding the role of school personnel in collecting data for children with learning and behavior problems;"" components to consider include (a) vision and hearing screening, (b) school/academic histories, (c) classroom observation by a counselor, (d) parent and teacher behavior rating scales (eg, Vanderbilt, Conner, or Achenbach scales), (e) consideration of speech/language evaluation, (f) screening intelligence testing, (g) screening achievement testing, (h) full intelligence and achievement testing if discrepancies are apparent in abbreviated tests, and (i) trials of classroom interventions. (2) Use pediatric office visits to identify children with academic or behavior problems and symptoms of inattention (history or questionnaire). (3) Refer identified children to the contact person at each child's school, requesting information in accordance with community consensus. (4) Designate a contact person to receive school materials for the practice. (5) Review the packet from the school and incorporate school data into the clinical assessment. (6) Reinforce with the parents and the school the need for multimodal intervention, including academic and study strategies for the classroom and home, in-depth psychologic testing of children whose discrepancies between cognitive level and achievement suggest learning or language disabilities and the need for an individualized educational plan (special education), consideration of the ""other health impaired"" designation as an alternate route to an individualized educational plan or 504 plan (classroom accommodations), behavior-modification techniques for targeted behavior problems, and medication trials, as indicated. (7) Refer the patient to a mental health professional if the assessment suggests coexisting conditions. (8) Use communication forms to share diagnostic and medication information, recommended interventions, and follow-up plans with the school and the family. (9) Receive requested teacher and parent follow-up reports and make adjustments in therapy as indicated by the child's functioning in targeted areas. (10) Maintain communication with the school and the parents, especially at times of transition (eg, beginning and end of the school year, change of schools, times of family stress, times of change in management, adolescence, and entry into college or the workforce).",0,0,
68,"A prospective, multicenter study of a pneumonia practice guideline","OBJECTIVE: To study the effect of a length of stay practice guideline on patient outcomes. DESIGN: A prospective, nonrandomized, interventional trial. SETTING: Six geographically distributed hospitals. PATIENTS: Two hundred forty-two consecutively hospitalized ""low-risk"" patients with pneumonia. MEASUREMENTS AND RESULTS: One hundred fifty-two patients (63%) completed the mailed postdischarge survey and were included in the analysis. Data were prospectively collected for 85 patients from the baseline observation period (B) and 67 patients from the intervention period (I). During the I, case managers provided physicians with patient risk information based on guideline recommendations. There was no significant change in guideline compliance (B vs I: 76.5% vs 83.6%"";"" p=0.32) or length of stay (B vs I: 3.5 days [95% confidence interval, 3.2 to 3.8] vs 3.6 days [95% confidence interval, 3.3 to 4.0]). Also, there were no statistically significant effects of the intervention on patient outcomes, care following hospital discharge, and patient satisfaction scores. CONCLUSION: Patients in this study often had shorter lengths of stay than recommended by the practice guideline. This suggests that the external environment may have had a greater effect on physician behavior and length of stay than the practice guideline itself. Moreover, it demonstrates the importance of continuous assessment of physician practices immediately prior to, during, and after application of the clinical practice guideline.",0,0,
69,A protocol for the pharmacologic treatment of major depression. A field test of a potential prototype,"BACKGROUND: Much attention is being given to developing clinical practice guidelines for management of mental health disorders. The aim of this study was to field test a prototype protocol for the pharmacologic treatment of Major Depression. METHOD: The protocol consisted of four, six week, treatment phases with critical choices in therapy defined by scores on the MADRS (Montgomery Asberg Depression Rating Scale). Observational data as collected on the behaviour of the protocol in terms of relevance, acceptability, ease of use and effectiveness. RESULTS: Effectiveness of the protocol was good for those patients who were retained within it, with three quarters of them attaining remission. However more than half of all patients dropped out-non attendance and adverse events being the most common reasons for this. CONCLUSION: The protocol for the treatment of Major Depression appeared relevant, easy to use and potentially effective. LIMITATION: Problems with non-adherence by both doctors and patients posed major challenges to the protocol's design. Such difficulties demonstrate the need to field test any proposed design as preconceptions about a protocol's performance may be misplaced. CLINICAL RELEVANCE: The protocol tested represents progress towards the goal of developing optimal strategies for the use of pharmacotherapeutic agents in the treatment of depression.",0,0,
70,A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the Surgical Checklist Implementation Project,"Objectives: To evaluate how the World Health Organization (WHO) surgical safety checklist was implemented across hospitals in England""; to identify barriers and facilitators toward implementation;"" and to draw out lessons for implementing improvement initiatives in surgery/health care more generally.  Background: The WHO checklist has been linked to improved surgical outcomes and teamwork, yet we know little about the factors affecting its successful uptake.  Methods: A longitudinal interview study with operating room personnel was conducted across a representative sample of 10 hospitals in England between March 2010 and March 2011. Interviews were audio recorded over the phone. Interviewees were asked about their experience of how the checklist was introduced and the factors that hindered or aided this process. Transcripts were submitted to thematic analysis.  Results: A total of 119 interviews were completed. Checklist implementation varied greatly between and within hospitals, ranging from preplanned/phased approaches to the checklist simply ""appearing"" in operating rooms, or staff feeling it had been imposed. Most barriers to implementation were specific to the checklist itself (eg, perceived design issues) but also included problematic integration into preexisting processes. The most common barrier was resistance from senior clinicians. The facilitators revealed some positive steps that can been taken to prevent/address these barriers, for example, modifying the checklist, providing education/training, feeding-back local data, fostering strong leadership (particularly at attending level), and instilling accountability.  Conclusions: We identified common themes that have aided or hindered the introduction of the WHO checklist in England and have translated these into recommendations to guide the implementation of improvement initiatives in surgery and wider health care systems.",0,1,
71,A qualitative study to understand guideline-discordant use of imaging to stage incident prostate cancer,"BACKGROUND: Approximately half of veterans with low-risk prostate cancer receive guideline-discordant imaging. Our objective was to identify and describe (1) physician knowledge, attitudes, and practices related to the use of imaging to stage prostate cancer, (2) patient attitudes and behaviors related to use of imaging, and (3) to compare responses across three VA medical centers (VAMCs). METHODS: A qualitative approach was used to explore patient and provider knowledge and behaviors relating to the use of imaging. We conducted 39 semi-structured interviews total-including 22 interviews with patients with newly diagnosed with prostate cancer and 17 interviews with physicians caring for them-between September 2014 and July 2015 at three VAMCs representing a spectrum of inappropriate imaging rates. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was selected to explore linkages between themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed verbatim, and then coded and analyzed using Nvivo software. RESULTS: Themes from patient interviews were categorized within four TDF domains. Patients reported little interest in staging as compared to disease treatment (goals), and many could not remember if they had imaging at all (knowledge). Patients tended to trust their doctor to make decisions about appropriate tests (beliefs about capabilities). Some patients expressed a minor concern for radiation exposure, but anxiety about cancer outcomes outweighed these fears (emotion). Themes from physician interviews were categorized within five TDF domains. Most physicians self-reported that they know and trust imaging guidelines (knowledge) yet some were still likely to follow their own intuition, whether due to clinical suspicion or years of experience (beliefs about capabilities). Additionally, physicians reported that medico-legal concerns, fear of missing associated diagnoses (beliefs about consequences), influence from colleagues who image frequently (social influences), and the facility where they practice influences rates of imaging (environmental context). CONCLUSIONS: Interviews with patients and physicians suggest that physicians are the primary (and in some cases only) decision-makers regarding staging imaging for prostate cancer. This finding suggests a physician-targeted intervention may be the most effective strategy to improve guideline-concordant prostate cancer imaging.",0,0,
72,A quality improvement intervention to address provider behaviour as it relates to utilisation of CA-MRSA guidelines,"AIMS AND OBJECTIVES: To evaluate the impact of a provider focused quality improvement educational intervention on appropriate prescribing for community associated methicillin-resistant Staphylococcus aureus infection. BACKGROUND: Patient, provider and health system factors contribute to appropriate antibiotic prescription. Achieving appropriate prescribing is critical in decreasing the burden of antibiotic resistance. Knowledge of appropriate prescribing for community associated methicillin-resistant Staphylococcus aureus infection is the first step in shifting prescriber behaviour to evidence-based recommendations. DESIGN: Quality Improvement Project. METHOD: Following a review of best practice guidelines and application of the Stetler Research Utilization model, a brief educational intervention was delivered using voice over PowerPoint. Items in the educational intervention included indications for screening, particularly focusing on the role of watch and wait after culturing for simple abscesses. The intervention was delivered in a for-profit, nonacademic, urgent care setting, and assessed prescribing providers' knowledge and practice. RESULTS: Out of 48 medical doctor, physician assistant and nurse practitioner providers, 18 (37.5%) participated"";"" 12 of the 18 (67%) participants showed an increase in knowledge. Forty three per cent of prescribers' charts demonstrated improved practice through use of the guidelines. Out of 18 prescribers, 44% sent a total of 21 cultures for abscesses. There was no difference in practice behaviours between professional groups. CONCLUSIONS: In spite of the increase in knowledge scores, this improvement in knowledge did not translate in dramatic change in practice, although trends in a positive direction were noted. RELEVANCE TO CLINICAL PRACTICE: This quality improvement project underscores the complexity of changing prescriber behaviour and the need for ongoing interventions.",0,0,
73,A quantitative method for assessment of prescribing patterns using electronic health records,"BACKGROUND: Most available quality indicators for hospitals are represented by simple ratios or proportions, and are limited to specific events. A generalized method that can be applied to diverse clinical events has not been developed. The aim of this study was to develop a simple method of evaluating physicians' prescription patterns for diverse events and their level of awareness of clinical practice guidelines. METHODS AND FINDINGS: We developed a quantitative method called Prescription pattern Around Clinical Event (PACE), which is applicable to electronic health records (EHRs). Three discrete prescription patterns (intervention, maintenance, and discontinuation) were determined based on the prescription change index (PCI), which was calculated by means of the increase or decrease in the prescription rate after a clinical event. Hyperkalemia and Clostridium difficile-associated diarrhea (CDAD) were used as example cases. We calculated the PCIs of 10 drugs related to hyperkalemia, categorized them into prescription patterns, and then compared the resulting prescription patterns with the known standards for hyperkalemia treatment. The hyperkalemia knowledge of physicians was estimated using a questionnaire and compared to the prescription pattern. Prescriptions for CDAD were also determined and compared to clinical knowledge. Clinical data of 1698, 348, and 1288 patients were collected from EHR data. The physicians prescribing behaviors for hyperkalemia and CDAD were concordant with the standard knowledge. Prescription patterns were well correlated with individual physicians' knowledge of hyperkalemia (kappa = 0.714). Prescribing behaviors according to event severity or clinical condition were plotted as a simple summary graph. CONCLUSION: The algorithm successfully assessed the prescribing patterns from the EHR data. The prescription patterns were well correlated with physicians' knowledge. We expect that this algorithm will enable quantification of prescribers' adherence to clinical guidelines and be used to facilitate improved prescribing practices.",0,0,
74,"A Randomized Clinical Trial of a Tailored Lifestyle Intervention for Obese, Sedentary, Primary Care Patients","PURPOSE: The aim of the study was to test a tailored lifestyle intervention for helping obese primary care patients achieve weight loss and increase physical activity. METHODS: We conducted a 24-month randomized clinical trial in Rhode Island. Primary care physicians identified obese, sedentary patients motivated to lose weight and increase their moderate to vigorous physical activity. These patients were randomized to 1 of 2 experimental groups: enhanced intervention (EI) or standard intervention (SI). Both groups received 3 face-to-face weight loss meetings. The enhanced intervention group also received telephone counseling calls, individually tailored print materials, and DVDs focused on diet and physical activity. Active intervention occurred in year 1 with a tapered maintenance phase in year 2. RESULTS: Two hundred eleven obese, sedentary patients were recruited from 24 primary care practices. Participants were 79% women and 16% minorities. They averaged 48.6 years of age, with a mean body mass index (BMI) of 37.8 kg/m(2), and 21.2 minutes/week of moderate to vigorous physical activity. Significantly more EI participants lost 5% of their baseline weight than SI participants (group by visit, P <.001). The difference was significant during active treatment at 6 months (37.2% EI vs 12.9% SI) and 12 months (47.8% vs 11.6%), but was no longer significant during the maintenance phase at 18 months (31.4% vs 26.7%,) or 24 months (33.3% vs 24.6%). The EI group reported significantly more minutes of moderate to vigorous physical activity over time than the SI group (group by visit, P = 0.04). The differences in minutes per week at 6 months was 95.7 for the EI group vs 68.3 minutes for the SI group""; at 12 months, it was 126.1 vs 73.7;"" at 18 months, 103.7 vs 63.7, and at 24 months, 101.3 vs 75.4. Similar trends were found for absolute weight loss and the percentage reaching national guidelines for physical activity. CONCLUSION: A home-based tailored lifestyle intervention in obese, sedentary primary care patients was effective in promoting weight loss and increasing moderate to vigorous physical activity, with the effects peaking at 12 months but waning at 24 months.",0,0,
75,A randomized controlled trial of a drug use review intervention for sedative hypnotic medications,"OBJECTIVES: Drug use review is used by both the public and private sector to influence prescribing behavior and patient drug use. Past interventions mailed to prescribers have had mixed results. The objective was to evaluate the effect of a one-time, mailed intervention on subsequent use of sedative hypnotic medication. METHODS: An experimental design was used. The intervention contained guidelines for the use of sedative hypnotics, a prescriber profile detailing sedative hypnotic prescribing, and a patient profile. Clustering of patients and their shared prescribers was done to avoid contamination bias and statistical problems associated with a lack of independence of observations. Subjects were 189 Washington State Medicaid recipients who had received at least one tablet per day of a sedative hypnotic medication for 1 year and their prescribing physicians or (when information about the physician was lacking) the dispensing pharmacy. RESULTS: A significant reduction in the use of targeted sedative hypnotic medications was measured in the intervention group (-27.6%) versus the control group (-8.5%). In the intervention group, 9.4% of patients began a new prescription for a benzodiazepine not targeted by the drug use review, whereas no control patients had new use of nontarget benzodiazepines. CONCLUSIONS: The intervention achieved a statistically significant decrease in targeted drug use, and the amount of reduction is likely to have decreased the risk of fractures associated with benzodiazepine use. This study adds to the recent evidence that mailed drug use review interventions can have a desirable impact on patient drug use.",0,0,
76,A randomized controlled trial of an extensive lifestyle management intervention (ELMI) following cardiac rehabilitation: study design and baseline data,"BACKGROUND: Cardiac rehabilitation programs (CRP) represent comprehensive interventions that are typically limited to four months. Following completion of CRP, it appears that risk factors and lifestyle behaviours may deteriorate. The Extensive Lifestyle Management Intervention (ELMI) Following Cardiac Rehabilitation trial will investigate the benefits of a randomized intervention to prevent these adverse changes. METHODS: Patients with ischemic heart disease (IHD) were randomized following a standard CRP to the ELMI or to usual care. The ELMI program is a case-managed intervention aimed at individualizing risk factor and lifestyle management based on current treatment guidelines. The program consists of cardiac rehabilitation sessions, telephone follow-up and risk factor and lifestyle counselling sessions. Health professionals work with participants using behavioural counselling and communications with participants' family physicians. Usual care participants return to their family physicians' care, and come to the study clinic only to undergo annual outcomes assessment. The primary outcome is change in IHD global risk after four years. Secondary outcomes include combined cardiovascular events, health care utilization, lifestyle adherence, quality of life and risk factors. RESULTS: Over 28 months, 302 men and women were randomized. This represented 29% of the total population screened. The average age of study participants is 64 years, 18% are women, 53% have had a previous myocardial infarction, 73% have undergone previous revascularization and 20% have diabetes mellitus. Ischemic heart disease risk factors for the entire cohort improved significantly after subjects had gone through previous CRPs. Baseline risk factors, lifestyle behaviours and medications were similar between the groups. CONCLUSIONS: This study population is representative of patients completing a standard CRP. Results of the ELMI trial will provide valuable information for the future design of CRPs.",0,0,
77,A Randomized Controlled Trial of IVR-Based Alcohol Brief Intervention to Promote Patient-Provider Communication in Primary Care,"BACKGROUND: Brief interventions for unhealthy drinking in primary care settings are efficacious, but underutilized. Efforts to improve rates of brief intervention though provider education and office systems redesign have had limited impact. Our novel brief intervention uses interactive voice response (IVR) to provide information and advice directly to unhealthy drinkers before a physician office visit, with the goals of stimulating in-office dialogue about drinking and decreasing unhealthy drinking. This automated approach is potentially scalable for wide application. OBJECTIVE: We aimed to examine the effect of a pre-visit IVR-delivered brief alcohol intervention (IVR-BI) on patient-provider discussions of alcohol during the visit. DESIGN: This was a parallel group randomized controlled trial with two treatment arms: 1) IVR-BI or 2) usual care (no IVR-BI). PARTICIPANTS: In all, 1,567 patients were recruited from eight university medical center-affiliated internal medicine and family medicine clinics. INTERVENTIONS: IVR-BI is a brief alcohol intervention delivered by automated telephone. It has four components, based on the intervention steps outlined in the National Institute of Alcohol Abuse and Alcoholism guidelines for clinicians: 1) ask about alcohol use, 2) assess for alcohol use disorders, 3) advise patient to cut down or quit drinking, and 4) follow up at subsequent visits. MAIN MEASURES: Outcomes were patient reported: patient-provider discussion of alcohol during the visit""; patient initiation of the discussion;"" and provider's recommendation about the patient's alcohol use. KEY RESULTS: Patients randomized to IVR-BI were more likely to have reported discussing alcohol with their provider (52 % vs. 44 %, p = 0.003), bringing up the topic themselves (20 % vs. 12 %, p < 0.001), and receiving a recommendation (20 % vs. 14 %, p < 0.001). Other predictors of outcome included baseline consumption, education, age, and alcohol use disorder diagnosis. CONCLUSIONS: Providing automated brief interventions to patients prior to a primary care visit promotes discussion about unhealthy drinking and increases specific professional advice regarding changing drinking behavior.",0,0,
78,A randomized controlled trial to evaluate the effectiveness of a distance asthma learning program for pediatricians,"OBJECTIVES: To assess provider acceptability of a distance learning program for pediatric asthma and pilot test its effects on physician knowledge, attitudes and treatment practices. DESIGN: Randomized controlled trial. SETTING: Louisville and the surrounding central Kentucky region. PARTICIPANTS: Twenty-four pediatricians in clinical practice. Interventions. A distance learning program for pediatric asthma consisting of Web- or CD-ROM-based multimedia learning modules and two teleconference calls. OUTCOME MEASURES: Learner satisfaction and change in physician asthma knowledge, attitudes, and treatment behavior at 1 to 4 months (short term) and 6 to 8 months (long term). RESULTS: Pediatricians had graduated from medical school a mean of 11.6 years before baseline (SD +/-8.9)"";"" 56% were female. On all learner satisfaction items, the average score was a 4.0 or greater on a 5-point scale, indicating a favorable response from the participants. Participants in the education group reported increased familiarity with asthma guideline for prescribing daily-inhaled corticosteroids compared to control physicians (p = .03) at short-term follow-up. Participants also expressed increased confidence in selecting a medicine for patients requiring a low-dose inhaled steroid (p = .03). However, these differences were not seen at long-term follow-up. Compared to the control group, there was no significant increase in the proportion of patients receiving inhaled steroids for persistent asthma at short- or long-term follow-up. CONCLUSIONS: Pediatricians utilizing an asthma distance learning program expressed a high degree of learner satisfaction. The program was associated with a temporary increase in familiarity and confidence in implementing components of the asthma guidelines.",0,0,
79,A randomized controlled trial to improve lymph node assessment in stage II colon cancer,"HYPOTHESIS: Physicians seem to learn best from their peers, yet the impact of opinion leaders on physician behavior is unclear. Because colon cancer staging has been identified as being suboptimal in Ontario, Canada, we sought to evaluate the influence of expert and local opinion leaders for colon cancer on optimizing colon cancer lymph node assessment. DESIGN, SETTING, PARTICIPANTS: A cluster-randomized trial including all hospitals in Ontario that identified a local opinion leader with intervention between January 5 and June 17, 2004. INTERVENTION: All 42 centers received a standardized lecture about colon cancer lymph node assessment delivered by an expert opinion leader in colon cancer. The 21 intervention hospitals also received academic detailing of a local opinion leader by the expert opinion leader and a toolkit. MAIN OUTCOME MEASURES: Mean number of lymph nodes assessed in patients with stage II colon cancer and the proportion of cases staged with a minimum of 12 lymph nodes before and after a standardized lecture were assessed. RESULTS: Patient demographic and tumor factors were similar in both groups before and after the standardized lecture. Lymph node assessment significantly improved after the standardized lecture at intervention and control sites (P < .001). No additional benefit of academic detailing and toolkit provision in the intervention was demonstrated. CONCLUSIONS: In-person provision of information by an expert opinion leader in colon cancer may stimulate performance regarding lymph node assessment for colon cancer. Academic detailing of a local opinion leader did not further improve lymph node assessment.",0,0,
80,A randomized outpatient trial of a decision-support information technology tool.,"Background  Decision-support information technology is often adopted to improve clinical decision making, but it is rarely rigorously evaluated. Congress mandated the evaluation of Problem-Knowledge Couplers (PKC Corp, Burlington, Vt), a decision-support tool proposed for the Department of Defense’s new health information network.  Methods  This was a patient-level randomized trial conducted at 2 military practices. A total of 936 patients were allocated to the intervention group and 966 to usual care. Couplers were applied before routine ambulatory clinic visits. The primary outcome was quality of care, which was assessed based on the total percentage of any of 24 health care quality process measures (opportunities to provide evidence-based care) that were fulfilled. Secondary outcomes included medical resources consumed within 60 days of enrollment and patient and provider satisfaction.  Results  There were 4639 health care opportunities (2374 in the Coupler group and 2265 in the usual-care group), with no difference in the proportion of opportunities fulfilled (33.9% vs 30.7%"";"" P = .12). Although there was a modest improvement in performance on screening/preventive measures, it was offset by poorer performance on some measures of acute care. Coupler patients used more laboratory and pharmacy resources than usual-care patients (logarithmic mean difference, $71). No difference in patient satisfaction was observed between groups, and provider satisfaction was mixed.  Conclusion  This study provides no strong evidence to support the utility of this decision-support tool, but it demonstrates the value of rigorous evaluation of decision-support information technology.",0,1,
81,"A randomized trial of ""corollary orders"" to prevent errors of omission.","Objective: Errors of omission are a common cause of systems failures. Physicians often fail to order tests or treatments needed to monitor/ameliorate the effects of other tests or treatments. The authors hypothesized that automated, guideline-based reminders to physicians, provided as they wrote orders, could reduce these omissions.  Design: The study was performed on the inpatient general medicine ward of a public teaching hospital. Faculty and housestaff from the Indiana University School of Medicine, who used computer workstations to write orders, were randomized to intervention and control groups. As intervention physicians wrote orders for 1 of 87 selected tests or treatments, the computer suggested corollary orders needed to detect or ameliorate adverse reactions to the trigger orders. The physicians could accept or reject these suggestions.  Results: During the 6-month trial, reminders about corollary orders were presented to 48 intervention physicians and withheld from 41 control physicians. Intervention physicians ordered the suggested corollary orders in 46.3% of instances when they received a reminder, compared with 21.9% compliance by control physicians (p < 0.0001). Physicians discriminated in their acceptance of suggested orders, readily accepting some while rejecting others. There were one third fewer interventions initiated by pharmacists with physicians in the intervention than control groups.  Conclusion: This study demonstrates that physician workstations, linked to a comprehensive electronic medical record, can be an efficient means for decreasing errors of omissions and improving adherence to practice guidelines.",1,1,
82,A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests,"PURPOSE: To determine the impact of giving physicians computerized reminders about apparently redundant clinical laboratory tests.  SUBJECTS AND METHODS: We performed a prospective randomized controlled trial that included all inpatients at a large teaching hospital during a 15-week period. The intervention consisted of computerized reminders at the time a test was ordered that appeared to be redundant. Main outcome measures were the proportions of clinical laboratory orders that were canceled and the proportion of the tests that were actually performed.  RESULTS: During the study period, there were 939 apparently redundant laboratory tests among the 77,609 study tests that were ordered among the intervention (n = 5,700 patients) and control (n = 5,886 patients) groups. In the intervention group, 69% (300 of 437) of tests were canceled in response to reminders. Of 137 overrides, 41% appeared to be justified based on chart review. In the control group, 51% of ordered redundant tests were performed, whereas in the intervention group only 27% of ordered redundant tests were performed (P <0.001). However, the estimated annual savings in laboratory charges was only $35,000. This occurred because only 44% of redundant tests performed had computer orders, because only half the computer orders were screened for redundancy, and because almost one-third of the reminders were overridden.  CONCLUSIONS: Reminders about orders for apparently redundant laboratory tests were effective when delivered. However, the overall effect was limited because many tests were performed without corresponding computer orders, and many orders were not screened for redundancy.",1,1,
83,A randomized trial of computer-based reminders and audit and feedback to improve HIV screening in a primary care setting.,"Despite recommendations for voluntary HIV screening, few medical centres have implemented screening programmes. The objective of the study was to determine whether an intervention with computer-based reminders and feedback would increase screening for HIV in a Department of Veterans Affairs (VA) health-care system. The design of the study was a randomized controlled trial at five primary care clinics at the VA Palo Alto Health Care System. All primary care providers were eligible to participate in the study. The study intervention was computer-based reminders to either assess HIV risk behaviours or to offer HIV testing""; feedback on adherence to reminders was provided. The main outcome measure was the difference in HIV testing rates between intervention and control group providers. The control group providers tested 1.0% (n = 67) and 1.4% (n = 106) of patients in the preintervention and intervention period, respectively;"" intervention providers tested 1.8% (n = 98) and 1.9% (n = 114), respectively (P = 0.75). In our random sample of 753 untested patients, 204 (27%) had documented risk behaviours. Providers were more likely to adhere to reminders to test rather than with reminders to perform risk assessment (11% versus 5%, P < 0.01). Sixty-one percent of providers felt that lack of time prevented risk assessment. In conclusion, in primary care clinics in our setting, HIV testing rates were low. Providers were unaware of the high rates of risky behaviour in their patient population and perceived important barriers to testing. Low-intensity clinical reminders and feedback did not increase rates of screening.",0,1,
84,A randomized trial of computerized reminders for blood pressure screening in primary care.,"In a randomized, controlled trial (N = 8,298) the authors compared three ways of encouraging patients in a large family practice to obtain a blood pressure check. Working from computerized medical records at a teaching family-medicine center, the study included patients aged 18 years and over who had not had a blood pressure measurement during the previous year. In a normal-care control group, 21.1% of those due for a blood pressure reading obtained one during the trial year. In one intervention group, a computer-generated message reminded the doctor to check the blood pressure of patients who happened to visit the center for an appointment;"" 30.7% of patients allocated to this group were checked. In the second group, the nurse contacted patients by telephone and encouraged 24.1% of those who were due for a check to obtain one. Sending a letter to patients in the third group yielded a 35.7% compliance rate. Considering the costs of the three interventions, the physician reminder was the most cost effective, followed by the letter reminder. Although statistically significant, the impact of the reminders was modest. A better approach might involve a combination of routine reminders to the physician, followed by letters to noncompliant patients.",0,1,
85,A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease.,"Objective: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.  Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.  Measurements: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.  Results: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01–1.67) and CAD (OR 1.25, 95% CI 1.01–1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.  Conclusion: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist.",1,1,
86,A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primary care.,"Objectives: Prescribing alerts generated by computerized drug decision support (CDDS) may prevent drug-related morbidity. However, the vast majority of alerts are ignored because of clinical irrelevance. The ability to customize commercial alert systems should improve physician acceptance because the physician can select the circumstances and types of drug alerts that are viewed. We tested the effectiveness of two approaches to medication alert customization to reduce prevalence of prescribing problems: on-physician-demand versus computer-triggered decision support. Physicians in each study condition were able to preset levels that triggered alerts.  Design: This was a cluster trial with 28 primary care physicians randomized to either automated or on-demand CDDS in the MOXXI drug management system for 3,449 of their patients seen over the next 6 months.  Measurements: The CDDS generated alerts for prescribing problems that could be customized by severity level. Prescribing problems included dosing errors, drug–drug, age, allergy, and disease interactions. Physicians randomized to on-demand activated the drug review when they considered it clinically relevant, whereas physicians randomized to computer-triggered decision support viewed all alerts for electronic prescriptions in accordance with the severity level they selected for both prevalent and incident problems. Data from administrative claims and MOXXI were used to measure the difference in the prevalence of prescribing problems at the end of follow-up.  Results: During follow-up, 50% of the physicians receiving computer-triggered alerts modified the alert threshold (n = 7), and 21% of the physicians in the alert-on-demand group modified the alert level (n = 3). In the on-demand group 4,445 prescribing problems were identified, 41 (0.9%) were seen by requested drug review, and in 31 problems (75.6%) the prescription was revised. In comparison, 668 (10.3%) of the 6,505 prescribing problems in the computer-triggered group were seen, and 81 (12.1%) were revised. The majority of alerts were ignored because the benefit was judged greater than the risk, the interaction was known, or the interaction was considered clinically not important (computer-triggered: 75.8% of 585 ignored alerts; on-demand: 90% of 10 ignored alerts). At the end of follow-up, there was a significant reduction in therapeutic duplication problems in the computer-triggered group (odds ratio 0.55;"" p = 0.02) but no difference in the overall prevalence of prescribing problems.  Conclusion: Customization of computer-triggered alert systems is more useful in detecting and resolving prescribing problems than on-demand review, but neither approach was effective in reducing prescribing problems. New strategies are needed to maximize the use of drug decision support systems to reduce drug-related morbidity.",1,1,
87,A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance,"This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180)""; in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185);"" in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.",0,0,
88,A real-world stepped wedge cluster randomized trial of practice facilitation to improve cardiovascular care,"BACKGROUND: Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery. METHODS: A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention. RESULTS: Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively. CONCLUSIONS: IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT00574808.",0,0,
89,A Research Agenda for High-Value Palliative Care,"Palliative care has catapulted from being misunderstood and viewed cautiously by many clinicians to being among the most sought-after services by health care systems nationwide. This is the greatest possible testimony to the field's potential value. However, because demand has quickly outstripped the supply of palliative care specialists (1), the field's ability to sustainably provide high-value care is paradoxically threatened by its own success. We propose a research agenda organized around 5 key questions on the optimal organization and allocation of limited resources in specialty palliative care to close the gap between the workforce and patient need. The Table provides important considerations and proposed approaches for addressing each research challenge. Amid a growing body of evidence on the potential value of specialty palliative care (2), we posit that answering these questions is essential to maximize value and inform much-needed policies to support such care (3).",0,0,
90,A Resolution for Physicians: Time to Focus on the Public Health Threat of Gun Violence,,0,0,
91,A review of family intervention guidelines for pediatric acquired brain injuries,"Pediatric acquired brain injury (BI) not only affects the child with the injury, but also greatly impacts their family. Studies suggest there are higher rates of caregiver and sibling psychological distress after a child in the family has sustained a BI. Also, family functioning after BI impacts the child's recovery. In reviewing the literature, we identified seven theoretical clinical guidelines for working with families of children and adolescents with BI. These clinical guidelines are as follows: (1) select developmentally appropriate interventions, (2) match the intervention to the family, (3) provide advocacy, (4) provide injury education, (5) focus on family realignment, (6) appropriately adjust the child's environment, and (7) provide skills training to the family and child. The existing research on family interventions for BI is reviewed within the context of these theoretical guidelines, and the empirical support for each guideline is subsequently evaluated using specific criteria for empirically supported treatments. Unfortunately, very few randomized controlled studies exist, and continued research is needed to classify all clinical guidelines as ""efficacious."" In addition, continued research will aid in informing professionals of specific approaches to utilize when working with a family of a child with BI. Currently, clinicians and researchers can turn to the existing clinical guidelines to help address the numerous barriers posed by implementing and studying family interventions for pediatric BI.",0,0,
92,A review of quantitative studies of adherence to mental health clinical practice guidelines,"Mental health clinical practice guidelines have proliferated, but there is little evidence regarding the degree to which they are actually implemented in clinical practice. The goal of this study was to locate and review all peer-reviewed reports published through 2000 that provide quantitative information on rates of adherence to specific mental health guidelines. A literature search yielded 41 pertinent studies. These studies were of three types: 26 were cross-sectional investigations performed after the release of guidelines, six were conducted before and after release of guidelines without any specific intervention (pre/post), and nine involved a controlled trial of a specific intervention. Only 37% were conducted in the mental health specialty sector. Adequate adherence was found in 27% of the cross-sectional and pre/post studies but in 67% of the controlled trials. Successful interventions tended to be complex, involving system redesign or additional resources. Only six of 13 investigations (46%) that also measured patient outcome found that better outcome was associated with greater guideline adherence. Several studies showed that after cessation of interventions, adherence rates returned to preintervention levels. Thus, evidence indicates that guideline adherence is not high without specific intervention, but that certain interventions (typically multifaceted and resource-intensive ones) improve adherence. However, the public health challenge is to design and implement interventions that are sustainable in general clinical practice.",0,0,
93,A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions,"AIMS: The review examines from international research: the extent to which practitioners comply with infection control precautions""; the pertinent issues that are considered influential in compliance; what strategies have been evaluated to instigate positive behaviour changes amongst practitioners and the effect of these interventions. BACKGROUND: Internationally, standard/universal precautions (UP) are regarded as fundamental in the prevention and control of infection, and effective in protecting practitioners and patients. However, adherence has been problematic and the practice of standard/UPs is globally suboptimal. DESIGN AND METHODS: Literature review where relevant evidence was identified using several electronic databases, from 1994 to 2006, with number of key terms utilized. Data were extracted by using key headings, which facilitated analysis. RESULTS: Thirty-seven studies were appraised. Twenty-four related to measuring practitioner compliance and 13 studies that evaluated the effect of a research intervention on compliance. In addition, other studies were included which examined the specific reasons for suboptimal compliance, or discussed infection control precautions generally. CONCLUSIONS: Compliance to infection control precautions is internationally suboptimal. The evidence confirms that compliance to specific aspects of standard/UPs varies, and practitioners are selective in their application of recommended practice. Compliance does improve following a structured intervention;"" however, research fails to indicate for how long the intervention affects practitioner compliance, or whether compliance after a period of time returns to the norm. Several reasons for non-compliance are discussed, and recommendations for future research are suggested. Relevance to clinical practice. Suboptimal compliance has significant implications for staff safety, patient protection and the care environment. Infection control teams and researchers need to consider the reasons for non-compliance and provide a supportive environment that is conducive to the routine, long-term application of standard precautions.",0,1,
94,A review of the literature on remote monitoring technology in incentive-based interventions for health-related behavior change.,"Use of technology (e.g., Internet, cell phones) to allow remote implementation of incentives interventions for health-related behavior change is growing. To our knowledge, there has yet to be a systematic review of this literature reported. The present report provides a systematic review of the controlled studies in which technology was used to remotely implement financial incentive interventions targeting substance use and other health behaviors published between 2004 and 2015. For inclusion in the review, studies had to use technology to remotely accomplish 1 of the following 2 aims, alone or in combination: (a) monitor the target behavior, or (b) deliver incentives for achieving the target goal. Studies also had to examine financial incentives (e.g., cash, vouchers) for health-related behavior change, be published in peer-reviewed journals, and include a research design that allowed evaluation of the efficacy of the incentive intervention relative to another condition (e.g., noncontingent incentives, treatment as usual). Of the 39 reports that met inclusion criteria, 18 targeted substance use, 10 targeted medication adherence or home-based health monitoring, and 11 targeted diet, exercise, or weight loss. All 39 (100%) studies used technology to facilitate remote monitoring of the target behavior, and 26 (66.7%) studies also incorporated technology in the remote delivery of incentives. Statistically significant intervention effects were reported in 71% of studies reviewed. Overall, the results offer substantial support for the efficacy of remotely implemented incentive interventions for health-related behavior change, which have the potential to increase the cost-effectiveness and reach of this treatment approach. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
95,A review on laboratory tests' utilization: A trigger for cutting costs and quality improvement in health care settings,"BACKGROUND: Considering the role of laboratory tests as a central part of controlling health expenditure, this study intends to investigate laboratory tests overutilization in Iran to pave the way for future interventions. METHODS: Inappropriate laboratory utilization was reviewed in a cross-sectional survey through the retrospective analysis of 384 medical records at a tertiary center. To pave the way for future intervention, overutilization tests were classified into two categories, inappropriate and inefficient, and then they were analyzed. Frequency analysis was used to analysis patient's age, gender, hospital wards, length of stay, and diagnosis as well as inappropriate test and inefficient tests. RESULTS: A total of 143 (1.50 %) of the tests were inefficient and was ordered due to laboratory errors including hemolysis, inefficient sampling, or absurd results. 2522 (26.40%) of the tests were inappropriate and stem from failure to meet medical/clinical appropriateness criteria. CONCLUSION: Whereas, inappropriate test ordering was more frequent than inefficient tests, the initial improvement strategy should focus on physicians' test ordering behavior through conducting proper teaching strategies, ongoing audit and educational feedback, implementing health information technology tools and employing laboratory practice guidelines (LPGs) and testing algorithms. Conducting continuous quality improvement cycle for laboratory services and training of personnel involved in blood sampling is recommended for inefficient tests.",0,0,
96,A simple intervention to improve hospital antibiotic prescribing,"OBJECTIVE: To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 x 6 cm laminated card suitable for clipping to a hospital identification badge. INTERVENTION: Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 x 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff. DESIGN: We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs. MAIN OUTCOME MEASURES: Proportion of cases in which antibiotic choice was appropriate""; proportion of cases in which antibiotic dose was appropriate;"" annualised costs of third-generation cephalosporins. RESULTS: For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards. CONCLUSION: The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.",0,1,
97,A simple way to improve DVT protocol compliance,"Objective: To assess the impact on deep vein thrombosis (DVT) protocol violations of the introduction of a label attached to the patient's drug chart, which specifically allows low-dose subcutaneous heparin or thromboembolic deterrent stockings (TEDS) to be prescribed as appropriate.  Design: An audit study.  Setting: Department of General Surgery of a District General Hospital in the United Kingdom.  Method: All adult general surgical inpatients on a Weekday were studied. Staff were not forewarned of the studies. Patient details and risk factors for DVT were noted. Details of administered DVT prophylaxis were recorded. In total four separate studies were undertaken, namely: with original protocols (I), with refined protocol 1 and 3 years later (II, III) and finally after introduction of the label (IV).  Results: Protocol violations were defined as being ‘acceptable’ or ‘unacceptable’. Raising awareness between studies I and II reduced acceptable violations to zero. There was no statistically significant reduction in unacceptable violations (24 in 80 patients, 1""; 17 in 75, II;"" 13 in 60, III). In study IV, following introduction of the label, there were only 6 violations in 51 patients (p<0.02).  Conclusion: Combining increased awareness with the attachment of a label to the drug chart reduced unacceptable violations by 63%.",0,1,
98,"A snapshot of general practitioner attitudes, levels of confidence and self-reported paediatric asthma management practice","The prevalence of asthma in Australia is high. Previous findings have suggested that asthma management, particularly in primary care, remains suboptimal and recent government initiatives to improve asthma management and encourage the use of written asthma action plans (WAAPs) in general practice have been implemented. We aimed to assess the attitudes, confidence and self-reported paediatric asthma management practices of a convenience sample of Australian general practitioners (GPs). A baseline questionnaire was administered to GPs as part of a randomised controlled trial. General practitioners (GPs) were recruited from two areas of greater metropolitan Sydney, NSW between 2006 and 2008. Invitations were sent to an estimated 1200 potentially eligible GPs. Of 150 (12.5%) GPs that enrolled, 122 (10.2%) completed the baseline questionnaire. Though 89% were aware of the Australian National Asthma Guidelines, less than 40% were familiar with guideline recommendations. While 85.2% had positive attitudes towards WAAPs, only 45.1% reported providing them frequently. For children with frequent symptoms, 90% agreed they should prescribe daily, inhaled corticosteroids (ICS), and 83% reported currently prescribing ICS to such patients. These findings indicate gaps between GP attitudes and behaviours and highlights opportunities for interventions to improve paediatric asthma management.",0,0,
99,A statewide controlled trial intervention to reduce use of unproven or ineffective breast cancer care,"BACKGROUND: Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop ""Top Five"" lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown. METHODS: We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) ""basic"" public reporting and (ii) an ""enhanced"" intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely(R) or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states""; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention;"" and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions. DISCUSSION: The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care. TRIAL REGISTRATION: ClinicalTrials.gov number pending.",0,1,
100,A study of factors associated with cost and variation in prescribing among GPs,"BACKGROUND: Inappropriate prescribing has the potential to harm both the individual and society. Previous research has identified doctor or demographic characteristics that influence prescribing variation but which were not amenable to change. OBJECTIVES: To identify modifiable factors associated with GP prescribing variance and cost. METHOD: Qualitative research methods were used in semi-structured taped interviews with 17 GPs in Avon, South West NHS Region, UK. RESULTS: GPs considered themselves cautious and conservative prescribers. Prescribing decisions often were justified by the prescriber, despite conflicting clinical or cost arguments. A personally developed drug formulary was used to reduce dilemmas potentially associated with prescribing uncertainty. Willingness to reflect upon, and measure, prescribing habits against set professional standards varied considerably. The absence of monitoring mechanisms of prescribing decisions, coupled with under utilization of the community pharmacist, resulted in uncertain prescribing outcomes. Some GPs found it difficult to keep up to date professionally due to perceived time constraints. Excessive patient demand was considered to influence their prescribing, but GPs stated that they were not unduly influenced by the drug representative. CONCLUSIONS: Prescribing makes a considerable impact on health and budgets and yet remains a contentious issue. Improved partnerships between patient, doctor and pharmacist must be established. Better prescribing decision monitoring and support through policy development and educational intervention is needed to reduce prescribing uncertainty. Newly established Primary Care Groups may need to reflect upon the difficulties facing prescribers, particularly when prescribing within cash-limited budgets, to avoid discord between prescribing behaviour and local policy development.",0,0,
101,A successful experiment to reduce unnecessary laboratory use in a community hospital,"A series of interventions at a 228-bed general hospital provided physicians with feedback at regular intervals concerning the amount of laboratory services employed in treating their patients. Case-mix-adjusted estimates of laboratory tests allowed each physician to compare use of laboratory tests with that of peers in the same department at the same hospital. Physicians with ""excess"" practice patterns ordered hundreds more laboratory tests than average each year. A multifaceted educational program included the following: 1) meetings were held concerning costs and unnecessary laboratory tests""; 2) physicians were given descriptions of their practice patterns relative to their peers as part of both large and small departmental discussions; 3) the feedback was repeated a year later; 4) a consensus conference established guidelines for test ordering;"" and 5) a sample of patient records was examined for appropriateness of laboratory test ordering. A total of 37% of a sample of tests ordered during the baseline period by physicians with ""excess"" practice patterns was classified as inappropriate. The intervention resulted in a reduction of 1.8 tests per patient (P = 0.0005). Eight of the nine tests individually showed reductions in use. Charge data from the target hospital showed a statistically significant reduction in laboratory charges per patient in the quarter following program initiation (P = 0.02) and no evidence for change in a group of five comparison hospitals. There was no evidence for reductions in the ordering of essential tests. These results demonstrate a cost-effective approach to reducing unnecessary costs that can be implemented in hospitals with integrated data systems.",0,1,
102,"A survey of tobacco-related knowledge, attitudes and behaviours of primary care providers in Mississippi","RATIONALE: Relative to other regions in the USA, Mississippi has a high prevalence of tobacco use and tobacco-related disease. This study assessed the tobacco-related knowledge, attitudes and intervention behaviours of family doctors, dentists and nurse practitioners in the state of Mississippi. METHODS: The Provider Attitude Survey, an 85-item measure of tobacco-related knowledge, attitudes and intervention behaviours was mailed to all members of Mississippi's Family Medicine, Dentistry and Nurse Practitioner professional organizations (N=2043). RESULTS: Over one-third (n=802, 39.2%) of eligible providers responded. Just 24.3% had received training in tobacco cessation and 33.7% were aware of the Public Health Service clinical practice guideline. Over 90% indicated that it was their role to prevent tobacco use""; felt rewarded when they helped patients quit;"" and were bothered and upset by the health effects of tobacco. Doctors assisted more patients than nurses or dentists. Doctors and nurses reported more self-efficacy, motivation and preparedness for treating tobacco use than dentists. Providers with training performed more interventions and reported more self-efficacy, preparedness and fewer barriers than those without training. Training was associated with greater increases in self-efficacy, preparedness and intervention behaviours for dentists than for the other groups. CONCLUSIONS: Despite a high prevalence of tobacco use and tobacco-related disease in Mississippi, primary care providers in Mississippi provide tobacco cessation interventions at an unacceptably low frequency relative to other regions. Training is likely to increase the frequency of intervention behaviours.",0,0,
103,A sustainable strategy to prevent misuse of antibiotics for acute respiratory infections,"Backgrounds Over 50% of antibiotics prescriptions are for outpatients with acute respiratory infections (ARI). Many of them are not needed and thus contribute both avoidable adverse events and pressures toward the development of bacterial resistance. Could a clinical decision support system (CDSS), interposed at the time of electronic prescription, adjust antibiotics utilization toward consensus treatment guidelines for ARI?  Methods This is a retrospective comparison of pre- (2002) and post-intervention (2003–2006) periods at two comprehensive health care systems (intervention and control). The intervention was a CDSS that targeted fluoroquinolone and azithromycin""; other antibiotics remained unrestricted. 7000 outpatients visits flagged by an ARI case-finding algorithm were reviewed for congruence with the guidelines (antibiotic prescribed-when-warranted or not-prescribed-when-unwarranted).  Results 3831 patients satisfied the case definitions for one or more ARI: pneumonia (537), bronchitis (2931), sinusitis (717) and non-specific ARI (145). All patients with pneumonia received antibiotics. The relative risk (RR) of congruent prescribing was 2.57 (95% CI?=?(1.865 to 3.540) in favor of the intervention site for the antibiotics targeted by the CDSS;"" congruence did not change for other antibiotics (adjusted RR?=?1.18 (95% CI?=?(0.691 to 2.011)). The proportion of unwarranted prescriptions of the targeted antibiotics decreased from 22% to 3%, pre vs. post-intervention (p<0.0001).  Conclusions A CDSS interposed at the time of e-prescription nearly extinguished unwarranted use targeted antibiotics for ARI for four years. This intervention highlights a path toward sustainable antibiotics stewardship for outpatients with ARI.",1,1,
104,A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer,"PURPOSE/OBJECTIVES: To determine whether research-based recommendations can be made about the clinical management of depression in patients with cancer. DATA SOURCES: Reports of scientific studies, qualitative or quantitative systematic reviews of scientific studies, and practice guidelines published from 1980-2000. DATA SYNTHESIS: In all, 36 pieces of evidence supported the conclusion that psychoeducational interventions benefit depressive symptoms. Evidence included two well-conducted meta-analyses and nine well-designed randomized clinical trials with large samples (N > 100). With regard to intervention content, 70% of behavior therapy studies and 66% of counseling studies drew conclusions that supported the hypothesis. In addition, 58% of studies that tested behavior therapy or counseling in combination with cancer education had positive results. CONCLUSIONS: The evidence supports the conclusion that psychoeducational interventions reduce depressive symptoms in patients with cancer and that behavior therapy or counseling alone or in combination with cancer education is beneficial. IMPLICATIONS FOR NURSING PRACTICE: Nurses can select from a variety of educational, behavioral, and counseling techniques to prevent or manage depression in their patients.",0,0,
105,A systematic review of clinical decision support systems for antimicrobial management: are we failing to investigate these interventions appropriately?,"OBJECTIVES: Clinical decision support systems (CDSS) for antimicrobial management can support clinicians to optimize antimicrobial therapy. We reviewed all original literature (qualitative and quantitative) to understand the current scope of CDSS for antimicrobial management and analyse existing methods used to evaluate and report such systems. METHOD: PRISMA guidelines were followed. Medline, EMBASE, HMIC Health and Management and Global Health databases were searched from 1 January 1980 to 31 October 2015. All primary research studies describing CDSS for antimicrobial management in adults in primary or secondary care were included. For qualitative studies, thematic synthesis was performed. Quality was assessed using Integrated quality Criteria for the Review Of Multiple Study designs (ICROMS) criteria. CDSS reporting was assessed against a reporting framework for behaviour change intervention implementation. RESULTS: Fifty-eight original articles were included describing 38 independent CDSS. The majority of systems target antimicrobial prescribing (29/38"";76%), are platforms integrated with electronic medical records (28/38;74%), and have a rules-based infrastructure providing decision support (29/38;""76%). On evaluation against the intervention reporting framework, CDSS studies fail to report consideration of the non-expert, end-user workflow. They have narrow focus, such as antimicrobial selection, and use proxy outcome measures. Engagement with CDSS by clinicians was poor. CONCLUSION: Greater consideration of the factors that drive non-expert decision making must be considered when designing CDSS interventions. Future work must aim to expand CDSS beyond simply selecting appropriate antimicrobials with clear and systematic reporting frameworks for CDSS interventions developed to address current gaps identified in the reporting of evidence.",0,1,
106,A systematic review of computer-based patient record systems and quality of care: more randomized clinical trials or a broader approach?,"PURPOSE: To analyse the impact of computer-based patient record systems (CBPRS) on medical practice, quality of care, and user and patient satisfaction. DATA SOURCES: Manual and electronic search of the Medline, Cochrane, and Embase databases. STUDY SELECTION: Selected articles were published from 2000 to March 2003. CBPRS was defined as computer software designed to be used by clinicians as a direct aid in clinical decision making. To be included, the systems should have recorded patient characteristics and offered online advice, or information or reminders specific to clinicians during the consultation. DATA EXTRACTION: Keywords used for the search were: electronic record, informatic record, electronic medical record, electronic patient record, patient order entry, computer-based patient system, clinical decision support systems, and evaluation. RESULTS: Twenty-six articles were selected. Use of a CBPRS was perceived favourably by physicians, with studies of satisfaction being mainly positive. A positive impact of CBPRS on preventive care was observed in all three studies where this criterion was examined. The 12 studies evaluating the impact on medical practice and guidelines compliance showed that positive experiences were as frequent as experiences showing no benefit. None of the six studies analysing the impact of CBPRS on patient outcomes reported any benefit. CONCLUSIONS: CBPRS increased user and patient satisfaction, which might lead to significant improvements in medical care practices. However, the studies on the impact of CBPRS on patient outcomes and quality of care were not conclusive. Alternative approaches considering social, cultural, and organizational factors may be needed to evaluate the usefulness of CBPRS.",0,0,
107,A systematic review of education for the prevention of HIV/AIDS among older adults,"Through a comprehensive literature search, the authors of this systematic review identified 21 articles focused on primary prevention of HIV/AIDS for adults aged 50 and over. Three major challenges to providing HIV/AIDS education for older adults include health professionals' ageism, older adults' reluctance to discuss sexuality, and their misconception of their HIV risk. Clinical guidelines for social workers, nurses, and physicians identified the importance of sharing information and assessing risk, considering cultural diversity, and devising creative delivery strategies. Three models of HIV/AIDS education include group education programs delivered by social workers or other health professionals, peer education models, and one-on-one early intervention models including HIV/AIDS testing. Additional outreach and research on HIV/AIDS prevention among older adults is needed.",0,0,
108,A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8,"BACKGROUND: Preparing healthcare professionals for teaching is regarded as essential to enhancing teaching effectiveness. Although many reports describe various faculty development interventions, there is a paucity of research demonstrating their effectiveness. OBJECTIVE: To synthesize the existing evidence that addresses the question: ""What are the effects of faculty development interventions on the knowledge, attitudes and skills of teachers in medical education, and on the institutions in which they work?"" METHODS: The search, covering the period 1980-2002, included three databases (Medline, ERIC and EMBASE) and used the keywords: staff development""; in-service training; medical faculty; faculty training/development;"" continuing medical education. Manual searches were also conducted. Articles with a focus on faculty development to improve teaching effectiveness, targeting basic and clinical scientists, were reviewed. All study designs that included outcome data beyond participant satisfaction were accepted. From an initial 2777 abstracts, 53 papers met the review criteria. Data were extracted by six coders, using the standardized BEME coding sheet, adapted for our use. Two reviewers coded each study and coding differences were resolved through discussion. Data were synthesized using Kirkpatrick's four levels of educational outcomes. Findings were grouped by type of intervention and described according to levels of outcome. In addition, 8 high-quality studies were analysed in a 'focused picture'. RESULTS: The majority of the interventions targeted practicing clinicians. All of the reports focused on teaching improvement and the interventions included workshops, seminar series, short courses, longitudinal programs and 'other interventions'. The study designs included 6 randomized controlled trials and 47 quasi-experimental studies, of which 31 used a pre-test-post-test design. KEY POINTS: Despite methodological limitations, the faculty development literature tends to support the following outcomes: Overall satisfaction with faculty development programs was high. Participants consistently found programs acceptable, useful and relevant to their objectives. Participants reported positive changes in attitudes toward faculty development and teaching. Participants reported increased knowledge of educational principles and gains in teaching skills. Where formal tests of knowledge were used, significant gains were shown. Changes in teaching behavior were consistently reported by participants and were also detected by students. Changes in organizational practice and student learning were not frequently investigated. However, reported changes included greater educational involvement and establishment of collegiate networks. Key features of effective faculty development contributing to effectiveness included the use of experiential learning, provision of feedback, effective peer and colleague relationships, well-designed interventions following principles of teaching and learning, and the use of a diversity of educational methods within single interventions. Methodological issues: More rigorous designs and a greater use of qualitative and mixed methods are needed to capture the complexity of the interventions. Newer methods of performance-based assessment, utilizing diverse data sources, should be explored, and reliable and valid outcome measures should be developed. The maintenance of change over time should also be considered, as should process-oriented studies comparing different faculty development strategies. CONCLUSIONS: Faculty development activities appear highly valued by participants, who also report changes in learning and behavior. Notwithstanding the methodological limitations in the literature, certain program characteristics appear to be consistently associated with effectiveness. Further research to explore these associations and document outcomes, at the individual and organizational level, is required.",0,0,
109,A tailored intervention to implement guideline recommendations for elderly patients with depression in primary care: a pragmatic cluster randomised trial,"Background Elderly patients with depression are underdiagnosed, undertreated and run a high risk of a chronic course. General practitioners adhere to clinical practice guidelines to a limited degree. In the international research project Tailored Implementation for Chronic Diseases, we tested the effectiveness of tailored interventions to improve care for patients with chronic diseases. In Norway, we examined this approach to improve adherence to six guideline recommendations for elderly patients with depression targeting healthcare professionals, patients and administrators. Methods We conducted a cluster randomised trial in 80 Norwegian municipalities. We identified determinants of practice for six recommendations and subsequently tailored interventions to address these determinants. The interventions targeted healthcare professionals, administrators and patients and consisted of outreach visits, a website presenting the recommendations and the underlying evidence, tools to manage depression in the elderly and other web-based resources, including a continuous medical education course for general practitioners. The primary outcome was mean adherence to the recommendations. Secondary outcomes were improvement in depression symptoms as measured by patients and general practitioners. We offered outreach visits to all general practitioners and practice staff in the intervention municipalities. We used electronic software that extracted eligible patients from the general practitioners’ lists. We collected data by interviewing general practitioners or sending them a questionnaire about their practice for four patients on their list and by sending a questionnaire to the patients. Results One hundred twenty-four of the 900 general practitioners (14 %) participated in the data collection, 51 in the intervention group and 73 in the control group. We interviewed 77 general practitioners, 47 general practitioners completed the questionnaire, and 134 patients responded to the questionnaire. Amongst the general practitioners who provided data, adherence to the recommendations was 1.6 percentage points higher in the intervention group than in the control group (95 % CI -6 to 9). Conclusions The effectiveness of our tailored intervention to implement recommendations for elderly patients with depression in primary care is uncertain, due to the low response rate in the data collection. However, it is unlikely that the effect was large. It remains uncertain how best to improve adherence to evidence-based recommendations and thereby improve the quality of care for these patients. Trial registration ClinicalTrials.gov: NCT01913236.",0,1,
110,A Teachable Moment Communication Process for smoking cessation talk: description of a group randomized clinician-focused intervention,"BACKGROUND: Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness. METHODS/DESIGN: This group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinicianpatient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively. DISCUSSION: Findings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01575886.",0,0,
111,A telephone coaching intervention to improve asthma self-management behaviors,"Long recognizing that asthma, one of the most common chronic childhood diseases, is difficult to manage, the National Asthma Education Prevention Program developed clinical practice guidelines to assist health care providers, particularly those in the primary care setting. Yet, maintenance asthma care still fails to meet national standards. Therefore, in an attempt to improve and support asthma self-management behaviors for parents of children 5 to 12 years of age with persistent asthma, a novel nurse telephone coaching intervention was tested in a randomized, controlled trial. A detailed description of the intervention is provided along with parent satisfaction results, an overview of the training used to prepare the nurses, and a discussion of the challenges experienced and lessons learned.",0,0,
112,A theory of international bioethics: the negotiable and the non-negotiable,"The preceding article in this issue of the Kennedy Institute of Ethics Journal presents the argument that ""moral fundamentalism,"" the position that international bioethics rests on ""basic"" or ""fundamental"" moral prinicples that are universally accepted in all eras and cultures, collapses under a variety of multicultural and postmodern critiques. The present article looks to the contractarian tradition of Hobbes and Locke -- as reinterpreted by David Gauthier, Robert Nozick, and John Rawls -- for an alternative justification for international bioethics. Drawing on the central themes of this tradition, it is argued that international bioethics can be rationally reconstructed as a negotiated moral order that respects culturally and individually defined areas of nonnegotiability. Further, the theory of a negotiated moral order is consistent with traditional ideals about human rights, is flexible enough to absorb the genuine insights of multiculturalism and postmodernism, and yet is strong enough to justify transcultural and transtemporal moral judgments, including the condemnation of the Nazi doctors at Nuremberg. This theory also is consistent with the history of the ethics of human subjects experimentation and offers insights into current controversies such as the controversy over changing the consent rule for experiments in emergency medicine and the controversy over exempting certain clinical trials of inexpensive treatments for preventing the perinatal transmission of AIDS from the ethical standards of the sponsoring country.",0,0,
113,A theory-based educational intervention targeting nurses' attitudes and knowledge concerning cancer-related pain management: a study protocol of a quasi-experimental design,"BACKGROUND: Pain is one of the most frequent problems among patients diagnosed with cancer. Despite the availability of effective pharmacological treatments, this group of patients often receives less than optimal treatment. Research into nurses' pain management highlights certain factors, such as lack of knowledge and attitudes and inadequate procedures for systematic pain assessment, as common barriers to effective pain management. However, educational interventions targeting nurses' pain management have shown promise. As cancer-related pain is also known to have a negative effect on vital aspects of the patient's life, as well as being commonly associated with problems such as sleep, fatigue, depression and anxiety, further development of knowledge within this area is warranted. METHODS/DESIGN: A quasi-experimental study design will be used to investigate whether the implementation of guidelines for systematic daily pain assessments following a theory-based educational intervention will result in an improvement in knowledge and attitude among nurses. A further aim is to investigate whether the intervention that targets nurses' behaviour will improve hospital patients' perception of pain. Data regarding nurses' knowledge and attitudes to pain (primary outcome), patient perception regarding pain (secondary outcome), together with socio-demographic variables, will be collected at baseline and at four weeks and 12 weeks following the intervention. DISCUSSION: Nursing care is nowadays acknowledged as an increasingly complicated activity and ""nursing complexity is such that it can be seen as the quintessential complex intervention."" To be able to change and improve clinical practice thus requires multiple points of attack appropriate to meet complex challenges. Consequently, we expect the theory-based intervention used in our quasi-experimental study to improve care as well as quality of life for this group of patients and we also envisage that evidence-based guidelines targeting this patient group's pain will be implemented more widely. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT01313234.",0,0,
114,A Tool for Assessing a Community's Capacity for Substance Abuse Care,"Evidence-based programs for prevention and intervention in substance abuse are increasing. Community needs assessments and health rankings provide descriptions of local behavioral health needs but do not provide public health practitioners and policy makers with guidelines on the number of programs, health care practitioners, or interventions needed in the local substance abuse care system. This article presents a new framework for measuring and assessing the substance abuse care system in a community. The assessment can inform resource allocation across the continuum of care to more equitably and efficiently distribute interventions and care. We conducted 2 literature reviews and synthesized our findings to create a community assessment methodology and needs calculator, CAST (calculating for an adequate system tool). We reviewed 212 articles to produce an inventory of community and social correlates of behavioral health, components of a substance abuse care system, and numerical values for guidelines for estimating community needs. CAST produces community-specific assessments of the capacity of the components of a community substance abuse care system. CAST generates recommendations by the application of social and community determinants of health as risk coefficients to each estimate of component need. CAST can assist public health practitioners in evaluation and improvement of the capacity of community-based, substance abuse care systems. By using recommendations for component needs across the continuum of care, community leaders can use CAST to prioritize resource allocation more effectively and efficiently.",0,0,
115,A universal precautions education intervention for health workers in Sardjito and PKU Hospital Indonesia,"A non-randomized control trial was conducted to develop and evaluate a culturally appropriate academic detailing intervention on the universal precautions knowledge, attitude and behavior of health care workers in hospitals. Fivety-five health care workers (44 nurses and 11 doctors) participated in the study. They were visited individually to discuss principles of universal precautions as well as the effect of automatic pilot on their work practices. Self-reported measures of knowledge and attitudes were collected from each participant before and after the intervention. A nurse observer collected measures of participants' compliance with the universal precautions guidelines according to a pre-determined protocol before and after the intervention. There was a significantly different level of knowledge, attitudes and compliance on universal precautions between the control and intervention hospital with p=0.0007, p=0.038 and p=0.03 respectively following the intervention. It is concluded that an academic detailing approach of education used in this study has significantly improved knowledge, attitudes and compliance scores.",0,0,
116,A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis,"Background National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis.  Methods We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record–based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis.  Results Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites.  Conclusions Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent.",1,1,
117,Abnormalities of adult personality and behaviour (section F 6)--results of the ICD-10 field trial,"Personality disorders, the most important category of section F6, were studied in the ICD-10 field trial. The overall Kappa values for interrater reliability of section F6 is 0.64, for personality disorders 0.61 and for dyssocial personality 0.73. These results are very close to those of the DSM-III field trials. Subjective assessments of feasibility, suitability and goodness of fit demonstrate good acceptance of the diagnostic guidelines by the clinicians. A comparison of ICD-9, DSM-III and ICD-10 diagnoses yielded broad agreement for diagnoses of personality disorders with overlapping Kappa values of 0.91 and 0.94. The acceptance and reliability of the new classification could be increased by a number of improvements and the planned introduction of a multiaxial system.",0,0,
118,Academic detailing has no effect on prescribing of asthma medication in Danish general practice: a 3-year randomized controlled trial with 12-monthly follow-ups,"BACKGROUND: Educational outreach visits, particularly when combined with social marketing, appear to be a promising approach to modifying health professional behaviour, especially prescribing. Results from previous studies have shown a varying effect. OBJECTIVE: The purpose of the study is to examine the effect of academic detailing as a method of implementing a clinical guideline in general practice. METHODS: A cluster randomized, controlled, blinded study was carried out of the effect of an academic detail visit compared with postal distribution of a guideline for prescribing asthma medication. Half the practices in a Danish county with 100 practices were visited once. The outcome measure was routinely collected data from all Danish pharmacies on the sales of asthma medication. Data were collected monthly for 2 years before to 1 year after the intervention. RESULTS: There was no effect on the pattern of prescription of asthma medicines following the visit, neither immediately nor long term. CONCLUSION: We found no effect of academic detailing as a single intervention.",0,0,
119,Access to medical records for the purposes of medical audit,,0,0,
120,Accident prevention,,0,0,
121,Accuracy of Rapid and Point-of-Care Screening Tests for Hepatitis C,,0,0,
122,Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews,"Background This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.  Design This study is a systematic review of reviews.  Methods MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis.  Results Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term ¡°cause¡± or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed ¡°causes¡± in terms of ¡°barriers and facilitators¡± to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders¡¯ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the ¡°fit¡± between the intervention and the context is critical in determining the success of implementation.  Conclusions This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.",0,0,
123,Achieving guidelines for the treatment of depression in primary care: is physician education enough?,"OBJECTIVES: The authors examine whether physician education has enduring effects on treatment of depression. METHODS: Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied. Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes. Intervention consisted of extensive physician education that spanned a 12-month period. This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians), and role-play of optimal treatment. Main outcome measures were divided into two groups. Quasi-experimental samples included: (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy. Survey samples included: (3) intensity of follow-up""; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction;"" and (6) depression outcomes. RESULTS: No lasting educational effect was observed consistently in any of the outcomes measured. CONCLUSIONS: There was no enduring improvement in the treatment of depression for primary care patients. Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period. These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.",0,0,
124,Action to Stop Smoking in Suspected Tuberculosis (ASSIST) in Pakistan,"Background: Tobacco use is responsible for a large proportion of the total disease burden from tuberculosis. Pakistan is one of the 10 high-burden countries for both tuberculosis and tobacco use. Objective: To assess the effectiveness of a behavioral support intervention and bupropion in achieving 6-month continuous abstinence in adult smokers with suspected pulmonary tuberculosis. Design: Cluster randomized, controlled trial. (Current Controlled Trials: ISRCTN08829879) Setting: Health centers in the Jhang and Sargodha districts in Pakistan. Patients: 1955 adult smokers with suspected tuberculosis. Intervention: Health centers were randomly assigned to provide 2 brief behavioral support sessions (BSS), BSS plus 7 weeks of bupropion therapy (BSS+), or usual care. Measurements: The primary end point was continuous abstinence at 6 months after the quit date and was determined by carbon monoxide levels in patients. Secondary end points were point abstinence at 1 and 6 months. Results: Both treatments led to statistically significant relative risks (RRs) for abstinence compared with usual care (RR for BSS+, 8.2 [95% CI, 3.7 to 18.2]"";"" RR for BSS, 7.4 [CI, 3.4 to 16.4]). Equivalence between the treatments could not be established. In the BSS+ group, 275 of 606 patients (45.4% [CI, 41.4% to 49.4%]) achieved continuous abstinence compared with 254 of 620 (41.0% [CI, 37.1% to 45.0%]) in the BSS group and 52 of 615 (8.5% [CI, 6.4% to 10.9%]) in the usual care group. There was substantial heterogeneity of program effects across clusters. Limitations: Imbalances in the urban and rural proportions and smoking habits among treatment groups, and inability to confirm adherence to bupropion treatment and validate longer-term abstinence or the effect of smoking cessation on tuberculosis outcomes. Conclusion: Behavioral support alone or in combination with bupropion is effective in promoting cessation in smokers with suspected tuberculosis. Primary Funding Source: International Development Research Centre.",0,0,
125,Acute B viral hepatitis becomes fulminant after infection with hepatitis A virus,,0,0,
126,"Acute coronary syndromes without ST-segment elevation. From randomized clinical trials, to consensus guidelines, to clinical practice in Italy: need to close the circle","Recent therapeutic advances in the treatment of acute ischemic heart disease have been proven by randomized clinical trials and approved by formal practice guidelines. This rigorous approach has led to a sizable reduction in mortality and morbidity across the spectrum of acute coronary syndromes (ACS). However, contemporary registries of non-ST-elevation ACS set up by the cardiological community in Italy, as well as in the rest of Europe and in America, have shown only limited compliance to the general indication of treating high-risk patients by an early invasive approach protected by the use of glycoprotein IIb/IIIa receptor blockers. This partial failure in the process of improving patient care may be attributed to several reasons, including the suspect that practice guidelines may be biased by conflict of interest, concern about the applicability of the results of clinical trials to the real world, unrealistic expectations about treatment effects and, finally, logistic and economic obstacles including the availability of cath-labs and the high cost of platelet receptor blockers. Although the practice guidelines may provide a cultural support for translating the results of clinical research into patient care, and national and local cardiological associations can help in increasing awareness of the real benefits of an early aggressive approach in high-risk patients, the health care managers should remove bureaucratic obstacles and reallocate resources from treatments of unproven benefit to those that have been clearly shown to reduce mortality and the risk of reinfarction in ACS patients.",0,0,
127,Acute fatty liver of pregnancy and diagnosis by computed tomography,"A 39 year old woman was admitted to a maternity unit at 34 weeks' gestation with nausea, vomiting, and jaundice. Her condition deteriorated, and she was transferred to hospital, deeply unconscious and hypotensive. The diagnosis of acute fatty liver of pregnancy was initially suggested by the typical history of prodromal malaise and vomiting and the rapid onset of hepatic encephalopathy with profound hypoglycaemia and only small increases in transaminase activities. Computed tomography was performed: there was no enlargement of the liver or spleen, but the attenuation value over the liver indicated appreciable fatty infiltration of the liver, establishing the diagnosis of acute fatty liver of pregnancy. Computed tomography is of value in the diagnosis of liver disease of late pregnancy, and this technique may become the method of choice for the investigation of acute fatty liver of pregnancy.",0,0,
128,Adding evidence-based interventions to assertive community treatment: a feasibility study,"OBJECTIVE: This 24-month study, conducted in The Netherlands, examined the feasibility of enhancing the effectiveness of assertive community treatment (ACT) by adding evidence-based interventions. METHODS: A total of 159 patients were randomly assigned to two ACT teams, one providing standard ACT (N585) and an ACT Plus team that also provided evidence-based interventions (N574): psychoeducation, family interventions, individual placement and support, and cognitive behavioral therapy. The interventions were conducted by psychologists and nurse practitioners working independently from the ACT team. RESULTS: Although most patients were judged eligible for each of the four interventions (range 65% to 89%), only 12 of the 74 patients (16%) successfully completed an intervention. Outcomes, such as use of inpatient care, for ACT Plus and standard ACT patients did not differ significantly. CONCLUSIONS: Guidelines for the treatment of schizophrenia should consider the feasibility of delivering evidence-based interventions to difficult-to-engage patients.",0,0,
129,Adding exercise or subtracting sitting time for glycaemic control: where do we stand?,"While regular structured exercise is a well-established (though arguably under-utilised) cornerstone in the prevention and management of type 2 diabetes, population adherence to recommended exercise guidelines remains stubbornly low. Indeed, most adults are exposed to environmental settings (at work, in automobile travel and in the domestic environment) that may not only limit their physical activity, but also promote sitting for prolonged periods of time. However, recent experimental evidence indicates that reducing and breaking up sitting time may also be a useful strategy to improve glycaemic control. In this issue of Diabetologia, Duvivier and colleagues report findings which suggest that reducing sitting time with standing and light-intensity activity could be a potential alternative to structured exercise for improving glycaemic control in type 2 diabetes patients. We review and discuss the findings of this study, its potential clinical implications, and a number of knowledge gaps and opportunities that could be considered in the interest of future research. The findings from Duvivier and colleagues should encourage healthcare practitioners, researchers and type 2 diabetes patients to consider the whole spectrum of physical activity, from sedentary behaviour through to structured exercise.",0,0,
130,Addition of motivational interventions to exercise and traditional physiotherapy: a review and meta-analysis,"BACKGROUND: Incontestable epidemiological trends indicate that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases. International guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. Motivational interventions to increase adherence and physical activity are not part of traditional physiotherapy for any condition. OBJECTIVE: To evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions. DATA SOURCES: A literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database using keywords and subject headings. STUDY SELECTION: Only randomised controlled trials comparing two or more arms, with one arm focused on motivational interventions influencing exercise and one control arm, were included. The search identified 493 titles, of which 14 studies (comprising 1504 participants) were included. DATA EXTRACTION: The principal investigator extracted data that were reviewed independently by another author. Methodological quality was assessed independently by two authors using the Cochrane Risk of Bias tool and the PEDro scale. Outcomes were measured at the level of impairment, activity limitation and participation restriction. The standardised mean difference between the control and intervention groups at follow-up time points was used as the mode of analysis. I2</=50% was used as the cut-off point for acceptable heterogeneity, above which a random effects model was applied. RESULTS: Exercise attendance was measured in six studies (n=378), and the results indicate that there was no significant difference in exercise attendance between the groups (Random effects model, standardised mean difference 0.33, 95% confidence interval -0.03 to 0.68, I2 62%). Perceived self-efficacy results were pooled from six studies (n=722), and a significant difference was found between the groups in favour of the interventions (Fixed effects model, standardised mean difference 0.71, 95% confidence interval 0.55 to 0.87, I2 41%). The results for levels of activity limitation were pooled (n=550), and a significant difference was found between the groups in favour of the interventions (REM, standardised mean difference -0.37, 95% confidence interval -0.65 to -0.08, I(2) 61%). LIMITATIONS: The majority of the included studies were of medium quality, and four studies were of low quality. Data were pooled from a wide variety of different populations and settings, increasing the assortment of study characteristics. CONCLUSIONS: Motivational interventions can help adherence to exercise, have a positive effect on long-term exercise behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory choice and the most beneficial length and type of intervention have not been defined, although all interventions showed benefits. There is a need to determine how practising physiotherapists currently optimise adherence, and their current levels of knowledge about motivational interventions. IMPLICATIONS OF KEY FINDINGS: The results indicate that motivational interventions are successful for increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice.",0,0,
131,Addressing nicotine addiction in women. Role of the midwife,"Smoking is the leading preventable cause of cancer, cardiovascular disease, and other premature deaths among women in the United States. Tobacco use accounts for 10% of perinatal mortality and is 100% preventable. Smoking is now more common among adolescent girls than among boys. Women's health care providers are in an excellent position to intervene in this growing epidemic. This article addresses the health consequences of smoking as well as the social, economic, and emotional toll of cigarette smoking on the woman and her family. The reasons women begin and continue smoking in spite of known risks are examined. The role of the midwife in treating nicotine addiction in women throughout the life span is examined. A theoretical model based on the woman's stage of change is presented as a framework for intervention. Behavioral and pharmacologic treatment recommendations are included. Opportunities for professional activities for community education and advocacy for a tobacco-free society are presented.",0,0,
132,Adherence to NICE guidelines on diabetes prevention in the UK: Effect on patient knowledge and perceived risk,"BACKGROUND: NICE Guidelines for prevention of diabetes include identifying people at risk followed by cost-effective intervention if necessary. Based on assessment of risk via a questionnaire and/or blood test the intervention may comprise a brief discussion of risk factors and preventive advice or referral to intensive lifestyle intervention. DESIGN AND SETTING: In this cross-sectional study 59 subjects recruited from local GP practices were invited by letter to attend a screening for a diabetes prevention study. METHOD: Following a telephone screening during which subjects were asked whether they had been informed if they were at high-risk of type 2 diabetes, eligible subjects completed a Risk Perception Survey for Developing Diabetes (RPS-DD), a validated diabetes risk score and underwent an oral glucose tolerance test (OGTT) at a medical screening. RESULTS: As measured by the Diabetes UK Risk Score, 44.1% were at high risk, 42.4% moderate risk and 13.6% at increased risk. 42% of patients had been informed they were at high-risk by a health professional. Those who had been informed of their risk had significantly higher perceived risk scores (p<0.001), higher knowledge scores (p<0.001) and decreased optimism scores (p=0.004), but were not more aware that diet (p=0.42) and weight management (p=0.57) can play a role in preventing diabetes. CONCLUSIONS: People at high-risk of diabetes are not being informed of their risk status as recommended by NICE guidelines. There is scope for education for health professionals and the public.",0,0,
133,Adolescent contraception,"PIP: Many adolescents in the United States remain at risk for an unplanned pregnancy despite advances in contraceptive technology and increased availability of birth control methods. Physicians who care for adolescents need to be familiar with the various contraceptive measures and their appropriateness for adolescents. A health professional must also be prepared to participate in sex education and to counsel or refer individual teenage patients when sexual problems occur. Attention in this discussion of adolescent contraception is directed to the following: reasons for nonuse of contraception, postcoital contraception, oral contraception (contraindications, side effects, guidelines for use in adolescents, and the mini-pill (progestogen only), IUDs, diaphragms, vaginal chemical contraceptives, condoms, withdrawal or rhythm, intervention techniques, and selection of the proper method. The average adolescent is exposed to unprotected intercourse for a year or longer before requesting contraception. Available evidence suggests that teenagers today may be using contraceptives more than ever before, yet a significant number fail to use a method for a variety of reasons. Most reasons reflect lack of knowledge"";"" some reflect nonavailability. The reasons include ignorance of fertile periods, a belief that their age is protective, infrequent or unanticipated intercourse, and strong guilt feelings evoked by the idea of being prepared for the possibility of sexual intercourse. Many adolescents are hesitant to ask for contraceptive advice or prescriptions from private physicians because they fear lectures on morality and refusal of their requests. There is evidence in at least 1 study that locating the family planning clinic within the school is effective in lowering pregnancy rates and ensuring high continuation rates after 36 months of followup. Intervention techniques that might be effective include providing a method immediately following an event (abortion, birth, rape) when motivation is highest and tailoring the method to the individual life style and preference. If no contraindications exist, the teenager should be given the method preferred and a method that is geared to frequency of intercourse. A backup method should also be provided if the preferred method is not tolerated or never started. To maximize continuation rates, frequent followup is essential.",0,0,
134,Adolescent overweight and obesity--how best to manage in the general practice setting,"BACKGROUND: The prevalence of overweight and obesity continues to increase in adolescents. Community level management is necessary as specialist services are limited. OBJECTIVE: This article outlines a management plan for the overweight adolescent in general practice, using a chronic care approach and follows the National Health and Medical Research Council Clinical practice guidelines for the management of overweight and obesity in children and adolescents. DISCUSSION: Overweight and obesity will not resolve spontaneously at puberty, and active intervention is required both to improve current health and wellbeing and to reduce the risks of premature morbidity and mortality in adult life. Modest, cumulative changes to lifestyle together with modest weight loss goals to reduce the risk of weight rebound are important. Any intervention has to take account of the rapid cognitive and behavioural changes of adolescence.",0,0,
135,Adolescent violence prevention practices among California pediatricians,"OBJECTIVES: To examine pediatricians' provision of violence prevention services to their adolescent patients and to identify factors associated with pediatricians' implementation of these services. DESIGN: A cross-sectional sample of California pediatricians completed a self-report questionnaire. The ""Precede/Proceed"" theoretical model guided the questionnaire in identification of factors associated with pediatricians' screening and intervening practices in preventing adolescent violence. RESULTS: Two hundred twenty pediatricians (54% female, 66% white, 24% Asian, 5% Latino, and 5% other) participated in the study. On average, participants screened their patients for violence-related risk factors 31% of the time for fighting, 39% of the time for violence in the home, and 29% of the time for weapon carrying. Participants provided their at-risk patients with violence-related interventions less than 50% of the time (on average) implementing the following interventions: written materials, follow-up appointments, discipline counseling, or referral to a community organization, Child Protective Services, or a specialized adolescent clinic. Factors associated with violence prevention screening practices included the following: positive attitudes and beliefs regarding screening for violence, familiarity with violence prevention guidelines, use of prompts in medical records, perceptions of greater skills, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.44""; P<.001). Factors associated with violence prevention intervention practices included: positive attitudes and beliefs in screening for violence, availability of resources, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.37;"" P<.001). CONCLUSIONS: California pediatricians are not widely screening their adolescent patients for risk factors associated with adolescent violence, nor are they providing interventions to their adolescent patients who may be at risk for violence. The factors associated with pediatricians' implementation of violence prevention services may assist in the development of effective interventions designed to enhance their delivery of these services to their adolescent patients.",0,0,
136,"Adoption, reach, implementation, and maintenance of a behavioral and mental health assessment in primary care","PURPOSE: Guidelines recommend screening patients for unhealthy behaviors and mental health concerns. Health risk assessments can systematically identify patient needs and trigger care. This study seeks to evaluate whether primary care practices can routinely implement such assessments into routine care. METHODS: As part of a cluster-randomized pragmatic trial, 9 diverse primary care practices implemented My Own Health Report (MOHR)-an electronic or paper-based health behavior and mental health assessment and feedback system paired with counseling and goal setting. We observed how practices integrated MOHR into their workflows, what additional practice staff time it required, and what percentage of patients completed a MOHR assessment (Reach). RESULTS: Most practices approached (60%) agreed to adopt MOHR. How they implemented MOHR depended on practice resources, informatics capacity, and patient characteristics. Three practices mailed patients invitations to complete MOHR on the Web, 1 called patients and completed MOHR over the telephone, 1 had patients complete MOHR on paper in the office, and 4 had staff help patients complete MOHR on the Web in the office. Overall, 3,591 patients were approached and 1,782 completed MOHR (Reach = 49.6%). Reach varied by implementation strategy with higher reach when MOHR was completed by staff than by patients (71.2% vs 30.2%, P <.001). No practices were able to sustain the complete MOHR assessment without adaptations after study completion. Fielding MOHR increased staff and clinician time an average of 28 minutes per visit. CONCLUSIONS: Primary care practices can implement health behavior and mental health assessments, but counseling patients effectively requires effort. Practices will need more support to implement and sustain assessments.",0,1,
137,Adult education program in palliative care for nursing facility physicians: design and pilot test,"Nursing facilities (NF) are important sites for the care of dying patients. Curricula likely to improve end-of-life care are needed for NF physicians. To this end, a model medical school palliative care curriculum was modified for experienced NF physicians. Adult learning techniques were emphasized, as well as interactions likely to change physician behavior. Inclusion of the opinion leader, audit with feedback, use of consensus guidelines, and other techniques for changing physician behavior were included. Written materials to supplement the course were identified. This new program was pilot tested and improved. An initial audit of physician practices and survey of the NF staff, a half-day adult educational session, and follow-up with the NF medical director is suggested. This intervention should be tested to determine if it improves patient end-of-life care outcomes in this setting.",0,0,
138,Adult respiratory distress syndrome,,0,0,
139,Advancing the literature on designing audit and feedback interventions: identifying theory-informed hypotheses,"Background Audit and feedback (A&F) is a common strategy for helping health providers to implement evidence into practice. Despite being extensively studied, health care A&F interventions remain variably effective, with overall effect sizes that have not improved since 2003. Contributing to this stagnation is the fact that most health care A&F interventions have largely been designed without being informed by theoretical understanding from the behavioral and social sciences. To determine if the trend can be improved, the objective of this study was to develop a list of testable, theory-informed hypotheses about how to design more effective A&F interventions.  Methods Using purposive sampling, semi-structured 60–90-min telephone interviews were conducted with experts in theories related to A&F from a range of fields (e.g., cognitive, health and organizational psychology, medical decision-making, economics). Guided by detailed descriptions of A&F interventions from the health care literature, interviewees described how they would approach the problem of designing improved A&F interventions. Specific, theory-informed hypotheses about the conditions for effective design and delivery of A&F interventions were elicited from the interviews. The resulting hypotheses were assigned by three coders working independently into themes, and categories of themes, in an iterative process.  Results We conducted 28 interviews and identified 313 theory-informed hypotheses, which were placed into 30 themes. The 30 themes included hypotheses related to the following five categories: A&F recipient (seven themes), content of the A&F (ten themes), process of delivery of the A&F (six themes), behavior that was the focus of the A&F (three themes), and other (four themes).  Conclusions We have identified a set of testable, theory-informed hypotheses from a broad range of behavioral and social science that suggest conditions for more effective A&F interventions.  This work demonstrates the breadth of perspectives about A&F from non-healthcare-specific disciplines in a way that yields testable hypotheses for healthcare A&F interventions. These results will serve as the foundation for further work seeking to set research priorities among the A&F research community.",0,0,
140,Advancing the Science of Patient Safety,"Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.",0,0,
141,Advantages and Challenges of A Village Doctor-Based Cognitive Behavioral Therapy for Late-Life Depression in Rural China: A Qualitative Study,"BACKGROUND: The delivery of mental health services in rural China has been notably limited due to lack of qualified mental health professionals among other impeding factors. A village doctor-based cognitive behavioral therapy intervention may be one way of improving accessibility. The purpose of this study was to explore the advantages and challenges of implementing this intervention, as delivered by trained village doctors, to treat late-life depression in rural China. METHODS: We conducted one focus group discussion with 10 village doctors, 10 individual interviews with each of the village doctors, and individual interviews with 19 older adults. The topic guides were advantages and challenges of the intervention program from the perspective of the village doctors and older adults. Interviews were audio-recorded, transcribed, coded using NVivo 8, and analyzed using thematic analysis. RESULTS: The village doctors stressed the importance of role-playing and using instructive manuals in the training. Proper supervision was also a key component of the program. The benefits received from the intervention for the village doctors and the elders were positive such that both the doctors and the older adults were willing to implement/receive this intervention. Cultural and political factors (renqing and perceived policy consideration) facilitated the elders' access to mental health services. Challenges included a lack of real therapy (in contrast to role-playing) demonstrated in the training and lack of a step-by-step manual based on different types of problems encountered. Other impediments to the successful implementation of the intervention included the time constraints of village doctors and the presence of other people when conducting the intervention. CONCLUSIONS: The present study has demonstrated that the intervention program is likely to be an acceptable geriatric depression intervention in rural China if several challenges are appropriately addressed.",0,0,
142,Advising Patients Who Seek Complementary and Alternative Medical Therapies for Cancer,"Many patients with cancer use complementary and alternative medical (CAM) therapies. Physicians need authoritative information on CAM therapies to responsibly advise patients who seek these interventions. This article summarizes current evidence on the efficacy and safety of selected CAM therapies that are commonly used by patients with cancer. The following major categories of interventions are covered: dietary modification and supplementation, herbal products and other biological agents, acupuncture, massage, exercise, and psychological and mind–body therapies. Two categories of evidence on efficacy are considered: possible effects on disease progression and survival and possible palliative effects. In evaluating evidence on safety, two types of risk are considered: the risk for direct adverse effects and the risk for interactions with conventional treatments. For each therapy, the current balance of evidence on efficacy and safety points to whether the therapy may be reasonably recommended, accepted (for example, dietary fat reduction in well-nourished patients with breast or prostate cancer), or discouraged (for example, high-dose vitamin A supplementation). This strategy allows the development of an approach for providing responsible, evidence-based, patient-centered advice to persons with cancer who seek CAM therapies.",0,0,
143,Alcohol consumption and dependence in elderly patients in an urban community,,0,0,
144,"Alcohol: prevention, policy and primary care responses","BACKGROUND: Alcohol is Australia's most socially acceptable legal drug""; however alcohol-related harms have increased significantly over time. Encouraging safer levels of alcohol consumption should be a national health priority and a key focus for health practitioners. OBJECTIVE: The purpose of this paper is to discuss some of the reasons that alcohol is such a popular and valued commodity in Australia, as well as some of the common problems caused by alcohol. We outline the most effective policy and treatment approaches to reduce alcohol consumption and related harms. DISCUSSION: Research evidence suggests that the most effective policies for reducing alcohol consumption and related harms are those focused on restricting its availability and accessibility;"" however, such strategies are often not implemented or enforced for political and economic reasons. Undertaking screening and brief intervention are effective ways of addressing problematic alcohol consumption within primary care and can be further supported through promoting community-organised periods of abstinence.",0,0,
145,Alcohol-related and alcohol-free activity participation and enjoyment among college students: A behavioral theories of choice analysis.,"College student alcohol abuse remains a significant public health problem, and there is a need for theory-driven and empirically based models to guide prevention efforts. Behavioral theories of choice assume that the decision to consume alcohol is influenced by the relative value of alcohol versus other available activities. In the present study, a sample of college student drinkers (N=108"";"" 56% female, 44% male) who had previously completed a mandatory alcohol intervention completed a measure of alcohol-related and alcohol-free activity participation and enjoyment. The goals of the study were to examine the influence of drinking quantity and contextual variables on activity enjoyment and to identify enjoyable alcohol-free activities that take place on evenings when students might otherwise be drinking. Overall, students found alcohol-related activities more enjoyable than alcohol-free activities, and drinking quantity was positively related to enjoyment. However, alcohol-free activities such as watching movies, going to the theater or museums, going to bars or parties, hanging out with friends, eating at restaurants, and engaging in creative activity were generally as enjoyable as drinking. Alcohol-free activities that included peers or dates were more enjoyable than solitary activities. Men were less likely to engage in alcohol-free activities that included peers and reported less enjoyment related to alcohol-free activities than did women. Further research is required to identify procedures for increasing participation in alcohol-free activities and to determine whether increased alcohol-free activity participation results in decreased alcohol consumption. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
146,All you need to read in the other general journals,"Between 1998 and 2009 a single surgeon in France reconstructed the genitals of 2938 women who had been mutilated or cut as girls. The case series, one of the largest so far, suggests that surgery can help at least some women with a history of female genital mutilation achieve an acceptable sex life, free from pain. Most of the women were from French speaking West Africa, although more than 564 had undergone female genital mutilation while growing up in France. Almost all wanted surgery, above all, to restore their female identity and autonomy. Four fifths were also seeking a better sex life. All had undergone female genital mutilation that removed or damaged the clitoris, at a mean age of 6 years. One of the aims of surgery was to reconstruct a normal clitoris. More than three quarters of the women presenting for surgery (78% (2053/2613)) had never had an orgasm. Only 866 women (29%) returned for follow-up one year after surgery. About half (414/840) reported improvements in pain. Slightly fewer reported improvements in sexual pleasure (385/834), and 430 now had orgasms. We don’t know how they felt about their bodies after surgery, and future studies should include validated measures of identity, satisfaction with surgery, and global satisfaction with sex, says a linked comment (doi:10.1016/S0140-6736(12)60636-9). Lancet2012"";""doi:10.1016/S0140-6736(12)60813-7 Citicoline is already licensed in some countries as a neuroprotector for adults with acute stroke. Animal models suggest it can protect surviving neurones close to the infarct and may even enhance repair. Trial results in humans have been mixed, however, and the latest and largest recently found no difference in recovery between people treated with citicoline and controls given a placebo (odds ratio for global recovery 1.03, 95% CI 0.86 to 1.25). Treatment started within …",0,0,
147,Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes,"PURPOSE: To explore strategies for improving patient outcomes in type 2 diabetes. DATA SOURCES: The literature related to type 2 diabetes management, behavior change, communication, diabetes self-management, and coaching. CONCLUSIONS: The strategies currently suggested for improving patient outcomes, e.g., increasing provider adherence to evidence-based management guidelines, streamlining practice systems, and promoting patient lifestyle changes through intensive education, have produced mixed outcomes. Of the many complexities involved in managing type 2 diabetes, motivating patients to change behavior may be the most challenging. A suggestion for improving patient self-management of type 2 diabetes is to use coaching communication within a framework of behavior change in the context of the primary care encounter between nurse practitioners (NPs) and their patients. IMPLICATIONS FOR PRACTICE: Given the varied outcomes of current strategies, coaching by NPs may provide a feasible alternative for improving patient outcomes in type 2 diabetes. Coaching communication can be implemented during office visits as an intervention without cost. To effectively implement this approach, however, practicing NPs and NP students need more formal education in this expected but underdeveloped NP role competency. NPs are called upon to contribute to the body of knowledge needed to validate the merits of coaching for their patients.",0,0,
148,Alprazolam prescribing in Tasmania: a two-fold intervention designed to reduce inappropriate prescribing and concomitant opiate prescription,"OBJECTIVE: The population rate of alprazolam prescribing in Tasmania has been more than double that of national rates. Serious adverse events have been observed through co-administration of opioid medications with alprazolam. A two-fold intervention, comprising GP education coupled with changes to prescribing regulations, was designed with the intention to decrease inappropriate prescribing of alprazolam and thereby reduce adverse outcomes. The aim of this study was to assess the impact of the intervention on prescribing rates. METHOD: We measured the number of alprazolam prescriptions for the years prior to and the year following the intervention. Health Insurance Commission data were utilized to enable comparison of subsidized prescription rates for alprazolam in Tasmania, and compared with national data. Participants were registered medical practitioners in Tasmania who were potential prescribers of alprazolam. The interventions were three GP Education Meetings during June 2007, one in each of the major regions of Tasmania, regarding evidence-based interventions for panic disorder. Changes to regulatory procedures to minimize co-prescription of alprazolam with opioids was implemented in September 2007. RESULTS: A reduction in alprazolam prescribing in Tasmania occurred after the interventions. CONCLUSION: Education can be an effective strategy to influence prescribing behaviour of doctors. It is likely that this effect can be augmented by adoption of more stringent regulatory requirements.",0,0,
149,Alternative Perspectives on the Biased Foundations of Medical Technology Assessment,"Medical technology assessment seeks to improve the care of individual patients (the conventional unit of clinical practice) through evaluation studies conducted in groups of patients (the conventional unit of clinical investigation).This distinction between individuals and groups has practical relevance to the design, analysis, and clinical applicability of technology assessment studies. We define several biased perspectives about technology assessment that derive from the distinction between individuals and groups: a misguided emphasis on efficacy versus effectiveness, on statistical significance versus clinical importance, and on objective versus subjective outcomes. In each case, we contrast these alternative perspectives and speculate on their implications for health care policy.",0,0,
150,American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity,"OBJECTIVE: Development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and the American College of Endocrinology (ACE) Board of Trustees and adheres to published AACE protocols for the standardized production of clinical practice guidelines (CPGs). METHODS: Recommendations are based on diligent review of clinical evidence with transparent incorporation of subjective factors. RESULTS: There are 9 broad clinical questions with 123 recommendation numbers that include 160 specific statements (85 [53.1%] strong [Grade A]"";"" 48 [30.0%] intermediate [Grade B], and 11 [6.9%] weak [Grade C], with 16 [10.0%] based on expert opinion [Grade D]) that build a comprehensive medical care plan for obesity. There were 133 (83.1%) statements based on strong (best evidence level [BEL] 1 = 79 [49.4%]) or intermediate (BEL 2 = 54 [33.7%]) levels of scientific substantiation. There were 34 (23.6%) evidence-based recommendation grades (Grades A-C = 144) that were adjusted based on subjective factors. Among the 1,790 reference citations used in this CPG, 524 (29.3%) were based on strong (evidence level [EL] 1), 605 (33.8%) were based on intermediate (EL 2), and 308 (17.2%) were based on weak (EL 3) scientific studies, with 353 (19.7%) based on reviews and opinions (EL 4). CONCLUSION: The final recommendations recognize that obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life. The detailed evidence-based recommendations allow for nuanced clinical decision-making that addresses real-world medical care of patients with obesity, including screening, diagnosis, evaluation, selection of therapy, treatment goals, and individualization of care. The goal is to facilitate high-quality care of patients with obesity and provide a rational, scientific approach to management that optimizes health outcomes and safety. ABBREVIATIONS: A1C = hemoglobin A1c AACE = American Association of Clinical Endocrinologists ACE = American College of Endocrinology ACSM = American College of Sports Medicine ADA = American Diabetes Association ADAPT = Arthritis, Diet, and Activity Promotion Trial ADHD = attention-deficit hyperactivity disorder AHA = American Heart Association AHEAD = Action for Health in Diabetes AHI = apnea-hypopnea index ALT = alanine aminotransferase AMA = American Medical Association ARB = angiotensin receptor blocker ART = assisted reproductive technology AUC = area under the curve BDI = Beck Depression Inventory BED = binge eating disorder BEL = best evidence level BLOOM = Behavioral Modification and Lorcaserin for Overweight and Obesity Management BLOSSOM = Behavioral Modification and Lorcaserin Second Study for Obesity Management BMI = body mass index BP = blood pressure C-SSRS = Columbia Suicidality Severity Rating Scale CAD = coronary artery disease CARDIA = Coronary Artery Risk Development in Young Adults CBT = cognitive behavioral therapy CCO = Consensus Conference on Obesity CHF = congestive heart failure CHO = carbohydrate CI = confidence interval COR-I = Contrave Obesity Research I CPG = clinical practice guideline CV = cardiovascular CVD = cardiovascular disease DASH = Dietary Approaches to Stop Hypertension DBP = diastolic blood pressure DEXA = dual-energy X-ray absorptiometry DPP = Diabetes Prevention Program DSE = diabetes support and education EL = evidence level ED = erectile dysfunction ER = extended release EWL = excess weight loss FDA = Food and Drug Administration FDG = 18F-fluorodeoxyglucose GABA = gamma-aminobutyric acid GERD = gastroesophageal reflux disease GI = gastrointestinal GLP-1 = glucagon-like peptide 1 HADS = Hospital Anxiety and Depression Scale HDL-c = high-density lipoprotein cholesterol HR = hazard ratio HTN = hypertension HUNT = Nord-Trondelag Health Study ICSI = intracytoplasmic sperm injection IFG = impaired fasting glucose IGT = impaired glucose tolerance ILI = intensive lifestyle intervention IVF = in vitro fertilization LAGB = laparoscopic adjustable gastric banding LDL-c = low-density lipoprotein cholesterol LES = lower esophageal sphincter LSG = laparoscopic sleeve gastrectomy LV = left ventricle LVH = left ventricular hypertrophy LVBG = laparoscopic vertical banded gastroplasty MACE = major adverse cardiovascular events MAOI = monoamine oxidase inhibitor MI = myocardial infarction MNRCT = meta-analysis of non-randomized prospective or case-controlled trials MRI = magnetic resonance imaging MUFA = monounsaturated fatty acid NAFLD = nonalcoholic fatty liver disease NASH = nonalcoholic steatohepatitis NES = night eating syndrome NHANES = National Health and Nutrition Examination Surveys NHLBI = National Heart, Lung, and Blood Institute NHS = Nurses' Health Study NICE = National Institute for Health and Care Excellence OA = osteoarthritis OGTT = oral glucose tolerance test OR = odds ratio OSA = obstructive sleep apnea PHQ-9 = Patient Health Questionnaire PCOS = polycystic ovary syndrome PCP = primary care physician POMC = pro-opiomelanocortin POWER = Practice-Based Opportunities for Weight Reduction PPI = proton pump inhibitor PRIDE = Program to Reduce Incontinence by Diet and Exercise PSA = prostate specific antigen QOL = quality of life RA = receptor agonist RCT = randomized controlled trial ROC = receiver operator characteristic RR = relative risk RYGB = Roux-en-Y gastric bypass SAD = sagittal abdominal diameter SBP = systolic blood pressure SCOUT = Sibutramine Cardiovascular Outcome Trial SG = sleeve gastrectomy SHBG = sex hormonebinding globulin SIEDY = Structured Interview on Erectile Dysfunction SNRI = serotonin-norepinephrine reuptake inhibitors SOS = Swedish Obese Subjects SS = surveillance study SSRI = selective serotonin reuptake inhibitors STORM = Sibutramine Trial on Obesity Reduction and Maintenance TCA = tricyclic antidepressant TONE = Trial of Nonpharmacologic Intervention in the Elderly TOS = The Obesity Society T2DM = type 2 diabetes mellitus UKPDS = United Kingdom Prospective Diabetes Study U.S = United States VAT = visceral adipose tissue VLDL = very low-density lipoprotein WC = waist circumference WHO = World Health Organization WHR = waist-hip ratio WHtR = waist-to-height ratio WMD = weighted mean difference WOMAC = Western Ontario and McMaster Universities osteoarthritis index XENDOS = XEnical in the Prevention of Diabetes in Obese Subjects.",0,0,
151,American Cancer Society Colorectal Cancer Survivorship Care Guidelines,"Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer death in both men and women and second leading cause of cancer death when men and women are combined in the United States (US). Almost two-thirds of CRC survivors are living 5 years after diagnosis. Considering the recent decline in both incidence and mortality, the prevalence of CRC survivors is likely to increase dramatically over the coming decades with the increase in rates of CRC screening, further advances in early detection and treatment and the aging and growth of the US population. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment. Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.",0,0,
152,American College of Physicians Ethics Manual,"Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The sixth edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.",0,0,
153,American Medical Society for Sports Medicine position statement: concussion in sport,"UNLABELLED: PURPOSE OF THE STATEMENT: black triangle right To provide an evidence-based, best practises summary to assist physicians with the evaluation and management of sports concussion. black triangle right To establish the level of evidence, knowledge gaps and areas requiring additional research. IMPORTANCE OF AN AMSSM STATEMENT: black triangle right Sports medicine physicians are frequently involved in the care of patients with sports concussion. black triangle right Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play (RTP) decisions. black triangle right The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty. black triangle right While this statement is directed towards sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion. DEFINITION: black triangle right Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum. PATHOPHYSIOLOGY: black triangle right Animal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell. black triangle right Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction. INCIDENCE: black triangle right It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities"";"" however, as many as 50% of the concussions may go unreported. black triangle right Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball. RISK FACTORS FOR SPORT-RELATED CONCUSSION: black triangle right A history of concussion is associated with a higher risk of sustaining another concussion. black triangle right A greater number, severity and duration of symptoms after a concussion are predictors of a prolonged recovery. black triangle right In sports with similar playing rules, the reported incidence of concussion is higher in female athletes than in male athletes. black triangle right Certain sports, positions and individual playing styles have a greater risk of concussion. black triangle right Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury. black triangle right Preinjury mood disorders, learning disorders, attention-deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion. DIAGNOSIS OF CONCUSSION: black triangle right Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion. black triangle right Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations. black triangle right Standardised assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available. SIDELINE EVALUATION AND MANAGEMENT: black triangle right Any athlete suspected of having a concussion should be stopped from playing and assessed by a licenced healthcare provider trained in the evaluation and management of concussions. black triangle right Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination. black triangle right While standardised sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown. black triangle right Balance disturbance is a specific indicator of a concussion, but not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injury. black triangle right Imaging is reserved for athletes where intracerebral bleeding is suspected. black triangle right There is no same day RTP for an athlete diagnosed with a concussion. black triangle right Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status. NEUROPSYCHOLOGICAL TESTING: black triangle right Neuropsychological (NP) tests are an objective measure of brain-behaviour relationships and are more sensitive for subtle cognitive impairment than clinical exam. black triangle right Most concussions can be managed appropriately without the use of NP testing. black triangle right Computerised neuropsychological (CNP) testing should be interpreted by healthcare professionals trained and familiar with the type of test and the individual test limitations, including a knowledgeable assessment of the reliable change index, baseline variability and false-positive and false-negative rates. black triangle right Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion. black triangle right NP testing should be used only as part of a comprehensive concussion management strategy and should not be used in isolation. black triangle right The ideal timing, frequency and type of NP testing have not been determined. black triangle right In some cases, properly administered and interpreted NP testing provides an added value to assess cognitive function and recovery in the management of sports concussions. black triangle right It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long-term complications. black triangle right Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses. RETURN TO CLASS: black triangle right Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion. RETURN TO PLAY: black triangle right Concussion symptoms should be resolved before returning to exercise. black triangle right A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact. black triangle right If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step. black triangle right RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and management of concussions. SHORT-TERM RISKS OF PREMATURE RTP: black triangle right The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms. LONG-TERM EFFECTS: black triangle right There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae. black triangle right Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment. DISQUALIFICATION FROM SPORT: black triangle right There are no evidence-based guidelines for disqualifying/retiring an athlete from a sport after a concussion. Each case should be carefully deliberated and an individualised approach to determining disqualification taken. EDUCATION: black triangle right Greater efforts are needed to educate involved parties, including athletes, parents, coaches, officials, school administrators and healthcare providers to improve concussion recognition, management and prevention. black triangle right Physicians should be prepared to provide counselling regarding potential long-term consequences of a concussion and recurrent concussions. PREVENTION: black triangle right Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play. black triangle right Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions. black triangle right There is no current evidence that mouth guards can reduce the severity of or prevent concussions. black triangle right Secondary prevention may be possible by appropriate RTP management. LEGISLATION: black triangle right Legislative efforts provide a uniform standard for scholastic and non-scholastic sports organisations regarding concussion safety and management. FUTURE DIRECTIONS: black triangle right Additional research is needed to validate current assessment tools, delineate the role of NP testing and improve identification of those at risk of prolonged post-concussive symptoms or other long-term complications. black triangle right Evolving technologies for the diagnosis of concussion, such as newer neuroimaging techniques or biological markers, may provide new insights into the evaluation and management of sports concussion.",0,0,
154,Americans want to water down Helsinki Declaration,,0,0,
155,An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project,"BACKGROUND: Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This study's objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers. METHODS: This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios. RESULTS: Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35""; 95% CI.99-1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16-2.75;"" P = 0.008). CONCLUSION: An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.",0,0,
156,An administrative intervention to improve the utilization of laboratory tests within a university hospital,"BACKGROUND: Improving the appropriateness of testing behavior and reducing the number of laboratory tests have been recognized as essential parts of quality improvement. OBJECTIVE: To assess the effectiveness of an administrative and a short-term educational intervention aimed at reducing clinical biochemistry laboratory utilization. DESIGN: An analysis comparing utilization of laboratory tests performed on in-patients before and after the intervention. SETTING: Computerized database of all laboratory tests performed in Hadassah Ein Kerem Medical Center, Jerusalem, Israel during 1999-2003. INTERVENTION: The administrative intervention included restricting available emergency laboratory tests and frequency of repeated orders. The educational measures included: discussion of the misuse of laboratory tests and its consequences with the hospital medical staff, and presentation of the new restrictive policy. A feedback of the intervention's results was sent to the wards and reviewed with senior medical staff. MAIN OUTCOME MEASURES: Change in utilization (measured as rates per 100 hospital days) of clinical biochemistry tests by hospital division and by selected laboratory tests. RESULTS: An overall reduction of 19% in laboratory tests (95% CI: 18.8-19.2%) was observed in the year after the intervention. Utilization decreased significantly in all the hospital's medical divisions, within a range of 14.9-43.8%. During the intervention period, utilization of hematology tests was reduced by 7.6% (P = 0.009). Statistically significant reductions were noted in the ordering of all 12 selected clinical biochemistry tests. Although the orders of total cholesterol decreased by 72.2%, the utilization of 'high-volume' tests, such as glucose and electrolytes, showed only a modest decrease (7.9% and 6.9%, respectively). CONCLUSIONS: The present study included all hospital medical staff and covered all the available clinical biochemistry tests. This rather simple and low-cost intervention resulted in significant reductions in clinical biochemistry test orders as well as in the ordering of hematological blood tests.",0,1,
157,An assessment of user acceptance and satisfaction with the tobacco use cessation automated clinical practice guideline,"OBJECTIVE: To describe user acceptance of and satisfaction with the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG) at the Henry Ford Health System. STUDY DESIGN: A previous investigation assessed compliance with the 5 As (ask, advise, assess, assist, and arrange) of the TUC ACPG across 3 study arms. This article describes user satisfaction with the TUC ACPG after implementation. METHODS: In all study arms, providers completed a survey before participating in a focus group. RESULTS: All providers in the TUC arm indicated that they ""almost always"" asked their patients about tobacco use. Providers in the TUC arm were generally satisfied with the features of the TUC ACPG, particularly the ease of electronically referring a patient to the Smoking Intervention Program. Barriers to use included time constraints, lack of staff, and the desire to ""opt out"" of the program for patients in specific situations (eg, patients with terminal illnesses). CONCLUSION: Because ACPGs are incorporated into electronic medical records, it is important to obtain provider input before implementation, to supply technology that is user friendly and fits into the work flow of the clinic, and to afford physicians the autonomy to opt out of the guideline in specific clinical circumstances.",0,0,
158,"An automated minimum retest interval rejection rule reduces repeat CRP workload and expenditure, and influences clinician-requesting behaviour","Aims Repeat serum C-reactive protein (CRP) measurements on the same day or on consecutive days are of limited clinical value. Minimum retesting intervals are recommended for managing unnecessary repeat testing. As not previously reported, we studied the effect of minimum retesting interval test rejection on laboratory workload and expenditure and on clinician-requesting behaviour.  Methods In a prospective study, we evaluated the effect of an automated 48 h CRP minimum retesting interval rule on inpatient and outpatient CRP workload and costs. Control data on inpatient and outpatient serum urea and electrolytes (UE) workload were collected during the study.  Results Over 1 year, there was a 7.0% and 12.3% decrease in CRP requests and CRP tests analysed, respectively, following the introduction of the minimum retesting interval rule when compared to the 1 year baseline period. This equated to an estimated annual reduction in revenue costs of £10 500, but cash savings in consumable costs of £3000. There was no significant change in UE requests.  Conclusions We report, for the first time, that automated minimum retesting interval rejection rules as a stand-alone strategy are a cheap and sustainable method for reducing unnecessary repeat CRP tests, resulting in small laboratory cash savings, more efficient use of laboratory resources and standardisation of patient care pathways. The minimum retesting interval rejection rule also altered clinician test-requesting behaviour towards more appropriate requesting.",0,1,
159,"An education programme influencing health professionals to recommend exercise to their type 2 diabetes patients - understanding the processes: a case study from Oxfordshire, UK","BACKGROUND: Increasing levels of physical activity decreases the risk of premature mortality associated with chronic diseases e.g., coronary heart disease, type 2 diabetes, stroke. Despite this, most adults in England do not meet physical activity guidelines. Physical activity advice and signposting offered to at-risk patients by primary care providers is recommended. However, exercise medicine education is sparse, leading to poor practitioner knowledge of the risk reduction evidence and strategies to implement effective patient behaviour change. The 'Generation Games' intervention seeks physical activity increase in the 50+ population of Oxfordshire. It offers a Health Professional Education Programme (HPEP) providing exercise medicine education, and promotion of Generation Games to which health professionals can signpost patients. There is a poor evidence base concerning how such education translates into patient exercise behaviour change. METHODS: The research aimed to create more understanding of how an education programme can influence health professionals to recommend Generation Games to and increase exercise behaviour in type 2 diabetes patients. A case study method facilitated examination of the routines and cultures studied - the experience of Diabetes nurses was used as an example of best practice engagement with the HPEP. Observation, interviews and documentation were employed to triangulate data. Data analysis refined and developed themes within key theoretical frameworks. RESULTS: Firstly, there is a lack of knowledge about physical activity risk reduction benefits and a belief that efforts to motivate patients to increase their physical activity are ineffective, thus creating barriers to engagement with the HPEP. Secondly, practice nurses tasked with delivering lifestyle advice to diabetes patients - themselves suffering a motivational interviewing skill deficit - find ingrained physical activity behaviours extremely challenging, and therefore highly value the HPEP for providing helpful tools. Thirdly, patients who hear of Generation Games from a health professional may have mismatched expectations of how their exercise behaviour can change. CONCLUSIONS: Exercise medicine education has the potential to improve patient care and services. Before initiatives like the HPEP can succeed, primary care practice requires a more supportive exercise medicine culture. Also necessary is adequate resourcing of patient-centred behaviour change advice, training, encouragement and monitoring services.",0,0,
160,An educational approach to improve outcomes in acute kidney injury (AKI): report of a quality improvement project,"OBJECTIVE: To assess the impact of a quality improvement project that used a multifaceted educational intervention on how to improve clinician's knowledge, confidence and awareness of acute kidney injury (AKI). SETTING: 2 large acute teaching hospitals in England, serving a combined population of over 1.5 million people. PARTICIPANTS: All secondary care clinicians working in the clinical areas were targeted, with a specific focus on clinicians working in acute admission areas. INTERVENTIONS: A multifaceted educational intervention consisting of traditional didactic lectures, case-based teaching in small groups and an interactive web-based learning resource. OUTCOME MEASURES: We assessed clinicians' knowledge of AKI and their self-reported clinical behaviour using an interactive questionnaire before and after the educational intervention. Secondary outcome measures included clinical audit of patient notes before and after the intervention. RESULTS: 26% of clinicians reported that they were aware of local AKI guidelines in the preintervention questionnaire compared to 64% in the follow-up questionnaire (chi&sup2"";=60.2, p<0.001). There was an improvement in the number of clinicians reporting satisfactory practice when diagnosing AKI, 50% vs 68% (chi&sup2;=12.1, p<0.001) and investigating patients with AKI, 48% vs 64% (chi&sup2;""=9.5, p=0.002). Clinical audit makers showed a trend towards better clinical practice. CONCLUSIONS: This quality improvement project utilising a multifaceted educational intervention improved awareness of AKI as demonstrated by changes in the clinician's self-reported management of patients with AKI. Elements of the project have been sustained beyond the project period, and demonstrate the power of quality improvement projects to help initiate changes in practice. Our findings are limited by confounding factors and highlight the need to carry out formal randomised studies to determine the impact of educational initiatives in the clinical setting.",0,0,
161,An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service,"OBJECTIVES: This study sought to prospectively study the impact of an appropriate use criteria (AUC)-based educational intervention on transthoracic echocardiography (TTE) ordering among house staff on the inpatient general internal medicine service at an academic medical center. BACKGROUND: AUC for TTE were developed in response to concerns about inappropriate use of TTE. To date, educational interventions based on the AUC to reduce inappropriate use of TTE have not been prospectively studied. METHODS: A prospective, time series analysis of an educational intervention was conducted and then compared with TTE ordering on the same medical service during a control period. The intervention consisted of: 1) a lecture to house staff on the 2011 AUC for TTE""; 2) a pocket card that applied the AUC to common clinical scenarios;"" and 3) biweekly e-mail feedback regarding ordering behavior. TTE ordering was tracked over the intervention period on a daily basis and feedback reports were e-mailed at 2-week intervals. The primary outcome was the proportion of inappropriate and appropriate TTE ordered during the intervention period. RESULTS: Of all TTEs ordered in the control and study periods, 99% and 98%, respectively, were classifiable using the 2011 AUC. During the study period, there was a 26% reduction in the number of TTE ordered per day compared with the number ordered during the control period (2.9 vs. 3.9 TTE, p < 0.001). During the study period, the proportion of inappropriate TTE was significantly lower (5% vs. 13%, p < 0.001) and the proportion of appropriate TTE was significantly higher (93% vs. 84%, p < 0.001). CONCLUSIONS: A simple educational intervention produced a significant reduction in the proportion of inappropriate TTE and increased the proportion of appropriate TTE ordered on an inpatient academic medical service. This study provides a practical approach for using the AUC to reduce the number of inappropriate TTE. Further study in other practice environments is warranted.",0,0,
162,An effectiveness trial of cognitive behaviour therapy in a representative sample of outpatients with psychosis,"OBJECTIVES: The efficacy of cognitive behaviour therapies for psychosis (CBTp) has been sufficiently established for its inclusion in some national treatment guidelines. However, treatment efficacy does not guarantee effectiveness in routine practice, where clinician expertise and patient mix may be different. Thus, we evaluated the applicability, acceptability and effectiveness of CBTp when offered routinely in a public mental health service. DESIGN: A prospectively recruited representative sample (N=94) of patients with psychotic disorders from a geographic catchment area in Melbourne, Australia, was randomized to CBTp or treatment as usual. METHOD: The CBTp intervention included psychoeducation, positive symptom, and co-morbid problem components. Therapists collaboratively negotiated goals with patients and utilized treatment components from a manual. Intention-to-treat analyses used data at baseline, 9 months and 18 months. RESULTS: Working alliance and client satisfaction measures indicated excellent acceptability. Both groups improved to a similar degree on the Positive And Negative Syndrome Scale, with no advantage for the CBTp group. The most frequent CBTp components implemented were co-morbid disorders/personal issues and personalized psychoeducation""; working with persisting symptoms was the main focus in relatively few sessions. CONCLUSIONS: The lack of advantage for the CBTp group may be due to: the infrequent focus on positive symptoms (the most replicated outcome domain for CBTp); the unselected nature of the patients (rather than those with distressing symptoms or referred by clinicians);"" or, to insufficient therapist expertise.",0,0,
163,An electronic health record–based intervention to improve tobacco treatment in primary care: a cluster-randomized controlled trial,"Background  To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1)smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals.  Methods  We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing.  Results  During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P < .001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices""; P < .001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P < .001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices;"" P = .40).  Conclusion  This electronic health record–based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication.",0,1,
164,An electronic medical record-based intervention to improve quality of care for gastro-esophageal reflux disease (GERD) and atypical presentations of GERD.,"Background Gastro-esophageal reflux disease (GERD) is common in primary care but is often underdiagnosed and untreated. GERD can also present with atypical symptoms like chronic cough and asthma, and physicians may be unaware of this presentation. We aimed to implement and evaluate an intervention to improve diagnosis and treatment for GERD and atypical GERD in primary care. Method This was a randomised controlled trial in primary care office practice using a national network of US practices (the Medical Quality Improvement Consortium – MQIC) that share the same electronic medical record (EMR). Thirteen offices with 53 providers were randomised to the intervention of EMRbased prompts and education, and 14 offices with 66 providers were randomised to the control group totalling over 67 000 patients and examining outcomes of GERD diagnosis and appropriate treatment. Results Among patients who did not have GERD at baseline, new diagnoses of GERD increased significantly in the intervention group (3.1%) versus the control group (2.3%) (P<0.01). This remained significant after controlling for clustering with an odds of diagnosis of 1.33 (95% CI 1.13–1.56) for the intervention group. For patients with atypical symptoms, those in the intervention group had both higher odds of being diagnosed with GERD (OR 2.02, 95% CI 1.41–2.88) and of being treated for GERD (OR 1.40, 95% CI 1.08–1.83) than those in the control group. Conclusions GERD diagnosis and treatment in primary care, particularly among patients with atypical symptoms, can be improved through the use of an EMR-based tool incorporating decision support and education. However, significant room for improvement exists in use of appropriate treatment.",1,1,
165,An evaluation of the prescription of opioids for chronic nonmalignant pain by Australian general practitioners,"OBJECTIVE: Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). DESIGN: An anonymous, cross-sectional questionnaire-based survey. SETTING: The setting was five Australian divisions of general practice (geographically based associations of GPs). METHODS: A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. RESULTS: We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (+/-8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. CONCLUSIONS: In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions.",0,0,
166,An Evidence-Based Guide to Writing Grant Proposals for Clinical Research,"In 1863, Florence Nightingale argued that London hospitals were dangerous, especially compared with provincial facilities. She bolstered this contention with statistics published in William Fair's Registrar-General report, which claimed that 24 London hospitals had mortality rates exceeding 90%, whereas rural hospitals had an average mortality rate of 13%. Farr had calculated mortality rates by dividing the total number of patients who died throughout the year by the number of inpatients on a single day. When calculated as the annual number of deaths divided by the total number of inpatients during the year, the mortality rate of London hospitals was 10%. A raucous debate erupted in the London medical press over how best to calculate hospital mortality rates. Critics claimed that Farr had not adjusted for differences in severity of illness between urban and rural hospitals and that his figures would mislead the public. Farr and Nightingale, in turn, criticized the poor quality of hospital data. This story reinforces the need to understand the methodologic derivation of statistics intended to compare provider quality.",0,0,
167,An evolving perspective on physical activity counselling by medical professionals,"BACKGROUND: Physical inactivity is a modifiable risk factor for many chronic conditions and a leading cause of premature mortality. An increasing proportion of adults worldwide are not engaging in a level of physical activity sufficient to prevent or alleviate these adverse effects. Medical professionals have been identified as potentially powerful sources of influence for those who do not meet minimum physical activity guidelines. Health professionals are respected and expected sources of advice and they reach a large and relevant proportion of the population. Despite this potential, health professionals are not routinely practicing physical activity promotion. DISCUSSION: Medical professionals experience several known barriers to physical activity promotion including lack of time and lack of perceived efficacy in changing physical activity behaviour in patients. Furthermore, evidence for effective physical activity promotion by medical professionals is inconclusive. To address these problems, new approaches to physical activity promotion are being proposed. These include collaborating with community based physical activity behaviour change interventions, preparing patients for effective brief counselling during a consultation with the medical professional, and use of interactive behaviour change technology. SUMMARY: It is important that we recognise the latent risk of physical inactivity among patients presenting in clinical settings. Preparation for improving patient physical activity behaviours should commence before the consultation and may include physical activity screening. Medical professionals should also identify suitable community interventions to which they can refer physically inactive patients. Outsourcing the majority of a comprehensive physical activity intervention to community based interventions will reduce the required clinical consultation time for addressing the issue with each patient. Priorities for future research include investigating ways to promote successful referrals and subsequent engagement in comprehensive community support programs to increase physical activity levels of inactive patients. Additionally, future clinical trials of physical activity interventions should be evaluated in the context of a broader framework of outcomes to inform a systematic consideration of broad strengths and weaknesses regarding not only efficacy but cost-effectiveness and likelihood of successful translation of interventions to clinical contexts.",0,0,
168,An experimental study of determinants of group judgments in clinical guideline development,"BACKGROUND: Clinical guidelines for improving the quality of care are a familiar part of clinical practice. Formal consensus methods such as the nominal group technique are often used as part of guideline development, but little is known about factors that affect the statements produced by nominal groups, and on their consistency with the research evidence. METHODS: Cognitive behavioural therapy, behavioural therapy, brief psychodynamic interpersonal therapy, and antidepressants for irritable bowel syndrome, chronic fatigue syndrome, and chronic back pain were selected for study. 16 nominal groups in a factorial design allowed comparison of GP-only with mixed groups of GPs and specialists, provision of a literature review with no provision, and ratings made in the context of realistic or ideal levels of health-care resources. Participants rated appropriateness independently, and again after a facilitated meeting. Audiotapes of four group discussions were analysed. FINDINGS: There was agreement with the research evidence for 51% of 192 scenarios. Agreement was more likely if the group was GP-only, if a literature review was provided, or if the evidence was in accordance with clinicians' beliefs. Assumptions about the level of resources available had no impact. Clinical and social cues had mixed effects, irrespective of the research evidence. Qualitative analysis showed the modifying effect of clinical experience and beliefs about research evidence. INTERPRETATION: Guidelines cannot be based on data alone"";"" judgment is unavoidable. The nominal group technique is a method of eliciting and aggregating judgments in a transparent and structured way. It can provide important information on levels of agreement between experts. However, conclusions can be at odds with the published literature. If they are, reasons need to be explicit.",0,0,
169,An experimental study of determinants of group judgments in clinical guideline development,"BackgroundClinical guidelines for improving the quality of care are a familiar part of clinical practice. Formal consensus methods such as the nominal group technique are often used as part of guideline development, but little is known about factors that affect the statements produced by nominal groups, and on their consistency with the research evidence."";"" BackgroundClinical guidelines for improving the quality of care are a familiar part of clinical practice. Formal consensus methods such as the nominal group technique are often used as part of guideline development, but little is known about factors that affect the statements produced by nominal groups, and on their consistency with the research evidence.",0,0,168
170,An experimental study of determinants of the extent of disagreement within clinical guideline development groups,"OBJECTIVE: To assess the effect of design features and clinical and social cues on the extent of disagreement among participants in a formal consensus development process. METHODS: Factorial design involving 16 groups consisting of 135 general practitioners (GPs) and 42 mental health professionals from England. The groups rated the appropriateness of four mental health interventions for three conditions (chronic back pain, irritable bowel syndrome, and chronic fatigue syndrome) in the context of various clinical and social cues. The groups differed in three design features: provision of a systematic literature review (versus not provided), group composition (mixed versus GP only), and assumptions about the healthcare resources available (realistic versus idealistic). Disagreement was measured using the mean absolute deviation from a group's median rating for a scenario. RESULTS: None of the design features significantly affected the extent of disagreement within groups (all p>0.3). Disagreement did differ between treatments (closer consensus for cognitive behavioural therapy and behavioural therapy than for brief psychodynamic intervention therapy and antidepressants) and cues (closer consensus for depressed patients and patients willing to try any treatment). CONCLUSION: In terms of the extent of disagreement in the groups in this study, formal consensus development was a robust technique in that the results were not dependent on the way it was conducted.",0,0,
171,An implementation research agenda,"In October 2006, the Chief Medical Officer (CMO) of England asked Professor Sir John Tooke to chair a High Level Group on Clinical Effectiveness in response to the chapter 'Waste not, want not' in the CMOs 2005 annual report 'On the State of the Public Health'. The high level group made recommendations to the CMO to address possible ways forward to improve clinical effectiveness in the UK National Health Service (NHS) and promote clinical engagement to deliver this. The report contained a short section on research needs that emerged from the process of writing the report, but in order to more fully identify the relevant research agenda Professor Sir John Tooke asked Professor Martin Eccles to convene an expert group – the Clinical Effectiveness Research Agenda Group (CERAG) – to define the research agenda. The CERAG's terms of reference were 'to further elaborate the research agenda in relation to pursuing clinically effective practice within the (UK) National Health Service'. This editorial presents the summary of the CERAG report and recommendations.",0,0,
172,"An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification","More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach"";"" 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to “get it right” by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.",0,0,
173,An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint,"UNLABELLED: WHAT IS KNOWN ON THE SUBJECT?: There is emerging evidence highlighting the counter therapeutic impact of the use of restraint and promoting the minimization of this practice in mental health care. Mental health nurses are often the professional group using restraint and understanding factors influencing their decision-making becomes critical. To date, there are no other published papers that have undertaken a similar broad search to review this topic. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Eight emerging themes are identified as factors influencing mental health nurses decisions-making in the use of restraint. The themes are: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. 'Last resort' appears to be the mantra of acceptable restraint use, although, to date, there are no studies that specifically consider what this concept actually is. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These findings should be considered in the evaluation of the use of restraint in mental health settings and appropriate strategies placed to support shifting towards restraint minimization. As the concept of 'last resort' is mentioned in many policies and guidelines internationally with no published understanding of what this means, research should prioritize this as a critical next step in restraint minimization efforts. INTRODUCTION: While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses' decision-making related to restraint use are therefore warranted. AIM: To explore what influences mental health nurses' decision-making in the use of restraint. METHOD: An integrative review using Cooper's framework was undertaken. RESULTS: Eight emerging themes were identified: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. These themes highlight how mental health nurses' decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors. CONCLUSION: Research to further understand the experience and actualization of 'last resort' in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed.",0,0,
174,An intervention to change clinician behavior: Conceptual framework for the multicolored simplified asthma guideline reminder (MSAGR),"Clinical practice guidelines decrease variation in health care because they standardize the care offered by healthcare providers. Seventeen years after publication, the National Asthma Education and Prevention Program (NAEPP) guidelines are considered the ""gold standard"" in asthma care, yet they remain underutilized despite three revisions with the latest in July 2007. Multiple factors are presented for lack of adherence to the guidelines. This article discusses the Multicolored, Simplified Asthma Guideline Reminder (MSAGR), an algorithm chart intervention for helping change clinicians' behavior for better adherence to the NAEPP guidelines, and describes the conceptual framework underpinning this intervention as a means of predicting better outcomes for providers and children.",0,1,
175,An investigative journalist looks at medical ethics,"KIE: Campbell criticizes Britain's medical and research community and the General Medical Council (GMC) for their lack of initiative in investigating the activities of Drs. James Sharp and Jabar Sultan. Sharp and Sultan conducted a series of highly-publicized but unethical and potentially harmful experiments with private patients that was eventually brought to public attention by Campbell's report and a BBC television program. Campbell questions why senior doctors, journal reviewers, and others failed to speak out against Sharp and Sultan or to alert the GMC, and why the GMC did not investigate the researchers independently. He warns that with the increasing commercialization of British medicine, legislation is needed to create a national regulatory body to oversee standards in the private sector.",0,0,
176,"An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings","BACKGROUND: Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university. METHOD: Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3-25 years in educational settings. RESULTS: Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption. CONCLUSION: This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.",0,0,
177,An update on management of the patient presenting with non-ST-elevation acute coronary syndromes,"Over 780,000 patients in the United States are diagnosed with an acute coronary syndrome (ACS) each year. As physicians, it is our responsibility to provide prompt workup, diagnosis and management of these patients. After identification of the patient with ACS and confirming there is not ST-segment elevation MI requiring immediate revascularization, physicians should pursue a work-up for non-ST-elevation acute coronary syndrome (NSTE-ACS). It is important to understand the latest best practice guidelines in the treatment and management of patients with NSTE-ACS who carry high rates of in-hospital mortality. Physicians must integrate the clinical history and examination, electrocardiogram and laboratory findings in order to properly diagnose an NSTE-ACS. Early treatment with guideline directed medical therapy is imperative even in the setting of an early invasive strategy with cardiac catheterization and percutaneous coronary intervention. The focus of this review is to discuss the appropriate strategies for evaluation and management of patients with NSTE-ACS based on the most recent ACC/AHA practice guidelines.",0,0,
178,Anaesthetic and other treatments of shell shock: World War I and beyond,"Post-traumatic stress disorder (PTSD) is an important health risk factor for military personnel deployed in modern warfare. In World War I this condition (then known as shell shock or 'neurasthenia') was such a problem that 'forward psychiatry' was begun by French doctors in 1915. Some British doctors tried general anaesthesia as a treatment (ether and chloroform), while others preferred application of electricity. Four British 'forward psychiatric units' were set up in 1917. Hospitals for shell shocked soldiers were also established in Britain, including (for officers) Craiglockhart War Hospital in Edinburgh"";"" patients diagnosed to have more serious psychiatric conditions were transferred to the Royal Edinburgh Asylum. Towards the end of 1918 anaesthetic and electrical treatments of shell shock were gradually displaced by modified Freudian methods psychodynamic intervention. The efficacy of 'forward psychiatry' was controversial. In 1922 the War Office produced a report on shell shock with recommendations for prevention of war neurosis. However, when World War II broke out in 1939, this seemed to have been ignored. The term 'combat fatigue' was introduced as breakdown rates became alarming, and then the value of pre-selection was recognised. At the Maudsley Hospital in London in 1940 barbiturate abreaction was advocated for quick relief from severe anxiety and hysteria, using i.v. anaesthetics: Somnifaine, paraldehyde, Sodium Amytal. 'Pentothal narcosis' and 'narco-analysis' were adopted by British and American military psychiatrists. However, by 1945 medical thinking gradually settled on the same approaches that had seemed to be effective in 1918. The term PTSD was introduced in 1980. In the UK the National Institute for Health and Clinical Excellence (NICE) guidelines for management (2005) recommend trauma-focussed Cognitive Behavioural Therapy and consideration of antidepressants.",0,0,
179,Analgesia and anesthesia for neonates: study design and ethical issues,"OBJECTIVE: The purpose of this article is to summarize the clinical, methodologic, and ethical considerations for researchers interested in designing future trials in neonatal analgesia and anesthesia, hopefully stimulating additional research in this field. METHODS: The MEDLINE, PubMed, EMBASE, and Cochrane register databases were searched using subject headings related to infant, newborn, neonate, analgesia, anesthesia, ethics, and study design. Cross-references and personal files were searched manually. Studies reporting original data or review articles related to these topics were assessed and critically evaluated by experts for each topical area. Data on population demographics, study characteristics, and cognitive and behavioral outcomes were abstracted and synthesized in a systematic manner and refined by group members. Data synthesis and results were reviewed by a panel of independent experts and presented to a wider audience including clinicians, scientists, regulatory personnel, and industry representatives at the Newborn Drug Development Initiative workshop. Recommendations were revised after extensive discussions at the workshop and between committee members. RESULTS: Designing clinical trials to investigate novel or currently available approaches for analgesia and anesthesia in neonates requires consideration of salient study designs and ethical issues. Conditions requiring treatment include pain/stress resulting from invasive procedures, surgical operations, inflammatory conditions, and routine neonatal intensive care. Study design considerations must define the inclusion and exclusion criteria, a rationale for stratification, the confounding effects of comorbid conditions, and other clinical factors. Significant ethical issues include the constraints of studying neonates, obtaining informed consent, making risk-benefit assessments, defining compensation or rewards for participation, safety considerations, the use of placebo controls, and the variability among institutional review boards in interpreting federal guidelines on human research. For optimal study design, investigators must formulate well-defined study questions, choose appropriate trial designs, estimate drug efficacy, calculate sample size, determine the duration of the studies, identify pharmacokinetic and pharmacodynamic parameters, and avoid drug-drug interactions. Specific outcome measures may include scoring on pain assessment scales, various biomarkers and their patterns of response, process outcomes (eg, length of stay, time to extubation), intermediate or long-term outcomes, and safety parameters. CONCLUSIONS: Much more research is needed in this field to formulate a scientifically sound, evidence-based, and clinically useful framework for management of anesthesia and analgesia in neonates. Newer study designs and additional ethical dilemmas may be defined with accumulating data in this field.",0,0,
180,Analysis of information submitted by clinical trial sponsors regarding the safety of investigational drugs,"During performance of clinical trials in medical institutions, information regarding the safety of investigational drugs is submitted by trial sponsors according to guidelines for good clinical practice. In the present study, reports of clinical trials conducted at the University of Tokyo Hospital were examined, focusing on the safety information provided to the Institutional Review Board (IRB). Two hundred two reports (52 protocols) of safety information were submitted to the IRB by clinical trial sponsors between April 2000 and March 2001, of which 185 contained a total of 3021 cases of adverse events. Of those, 194 reports were judged by clinical investigators/physicians not to be associated with any significant problems and the trials were continued. For 157 of those 194 reports, it was considered unnecessary to inform the test subjects of the report contents, including the adverse events. The decision of whether or not the test subjects should be informed of such contents tended to depend on the causal relationship between the adverse events and drug intake, as well as the predictability of the adverse events. For 8 of those 194 reports, the IRB recommended that the clinical investigators/ physicians provide information to the test subjects and/or submit detailed information on the status of these subjects to the IRB. From these results, we suggest that establishment of a system to unify and evaluate drug safety information is necessary to provide safe and efficient clinical trials.",0,0,
181,Angina on the Palm: randomized controlled pilot trial of Palm PDA software for referrals for cardiac testing.,"OBJECTIVE Personal digital assistants (PDAs) are popular with physicians: in 2003, 33% of Canadian doctors reported using them in their practices. We do not know, however, whether using a PDA changes the behaviour of practising physicians. We studied the effectiveness of a PDA software application to help family physicians diagnose angina among patients with chest pain.  DESIGN Prospective randomized controlled pilot trial using a cluster design.  SETTING Primary care practices in the Toronto area.  PARTICIPANTS Eighteen family physicians belonging to the North Toronto Primary Care Research Network (Nortren) or recruited from a local hospital.  INTERVENTIONS We randomized physicians to receive a Palm PDA (which included the angina diagnosis software) or to continue conventional care. Physicians prospectively recorded the process of care for patients aged 30 to 75 presenting with suspected angina, over 7 months.  MAIN OUTCOME MEASURES Did the process of care for patients with suspected angina improve when their physicians had PDAs and software? The primary outcomes we looked at were frequency of cardiac stress test orders for suspected angina, and the appropriateness of referral for cardiac stress testing at presentation and for nuclear cardiology testing after cardiac stress testing. Secondary outcome was referrals to cardiologists.  RESULTS The software led to more overall use of cardiac stress testing (81% vs 50%). The absolute increase was 31% (P = .007, 95% confidence interval [CI] 8% to 58%). There was a trend toward more appropriate use of stress testing (48.6% with the PDA vs 28.6% control), an increase of 20% (P = .284, 95% CI -11.54% to 51.4%). There was also a trend toward more appropriate use of nuclear cardiology following cardiac stress testing (63.0% vs 45.5%), an absolute increase of 17.5% (P =.400, 95% CI -13.9% to 48.9%). Referrals to cardiologists did not increase (38.2% with the PDA vs 40.9%, P =.869).  CONCLUSION A PDA-based software application can lead to improved care for patients with suspected angina seen in family practices"";"" this finding requires confirmation in a larger study.",0,1,
182,Anorexia nervosa,,0,0,
183,"Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation","OBJECTIVES: To explore healthcare professionals' views of antibiotic prescribing in long-term care facilities (LTCFs). To use the findings to recommend intervention strategies for antimicrobial stewardship in LTCFs. DESIGN: Qualitative semistructured interviews were conducted. The data were analysed by thematic content analysis. After the interviews, the emerging findings were mapped to the theoretical domains framework (TDF), and the behaviour change wheel and behaviour change technique (BCT) taxonomy were used to recommend future intervention strategies. PARTICIPANTS: Interviews were conducted with 37 healthcare professionals who work in LTCFs (10 general practitioners, 4 consultants, 14 nurses, 9 pharmacists) between December 2012 and March 2013. SETTING: Interviews were conducted in the greater Cork region. RESULTS: The main domains from the TDF which emerged were: 'Knowledge', 'Environmental context and resources', 'Social influences', 'Beliefs about consequences', 'Memory, attention and decision making', with the findings identifying a need for 'Behavioural regulation'. Many participants believed that antibiotic prescribing was satisfactory at their LTCF, despite the lack of surveillance activities. CONCLUSIONS: This study, using the TDF and BCT taxonomy, has found that antibiotic prescribing in LTCFs is influenced by many social and contextual factors. The challenges of the setting and patient population, the belief about consequences to the patient, and the lack of implementation of guidelines and knowledge regarding antibiotic prescribing patterns are significant challenges to address. On the basis of the study findings and the application of the TDF and BCT taxonomy, we suggest some practical intervention functions for antimicrobial stewardship in LTCFs.",0,0,
184,Antibiotic resistance,Resistance to antibiotics is economically and physiologically costly. Control of antibiotic resistance will require aggressive implementation of numerous strategies. Ongoing surveillance is needed to monitor known antibiotic types and to be able to identify the development of other potential types. Early intervention is needed to combat the rising rate of resistance. Persistent use of hygiene measures and controlled use of antibiotics will limit the spread of antibiotic resistance. Health care providers need to monitor adherence to control measures. Hand and environmental control measures remain a critical component of staff education activities. Active management of infections with non-pharmacologic treatments should be promoted. Motivational campaigns will reinforce positive infection control behaviors. Consistent surveillance of antibiotic use will help fulfill the CDC directive to combat antibiotic resistance and keep the population healthy.,0,0,
185,"Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial","BackgroundDuration of treatment for patients with vertebral osteomyelitis is mainly based on expert recommendation rather than evidence. We aimed to establish whether 6 weeks of antibiotic treatment is non-inferior to 12 weeks in patients with pyogenic vertebral osteomyelitis."";"" BackgroundDuration of treatment for patients with vertebral osteomyelitis is mainly based on expert recommendation rather than evidence. We aimed to establish whether 6 weeks of antibiotic treatment is non-inferior to 12 weeks in patients with pyogenic vertebral osteomyelitis.",0,0,
186,"Antimalarial prescribing patterns in state hospitals and selected parastatal hospitals in Lagos, Nigeria","BACKGROUND: Malaria is a curable and preventable disease and it is a major public health problem in Nigeria. Chloroquine was the first line drug in its treatment in Nigeria until recently where the Artemisinin based Combination Therapies (ACTs) are being promoted. Inappropriate prescribing, i.e., the failure to prescribe drugs in accordance with guidelines based on scientific evidence to ensure safe, effective, and economic use, is an irrational drug use behavior. Increased benefits from chloroquine or a slowdown of progression to resistance could be achieved by improving prescribing practice, drug quality, and patient compliance. OBJECTIVE: To determine the antimalarial prescribing pattern and to assess rational prescribing of chloroquine by prescribers in government hospitals and parastatals in Lagos State. METHODS: The study was carried out in all the ten government General Hospitals under Lagos State Hospitals Management Board (now Lagos State Health Service Commission), one parastatal hospital and one oil company clinic, using patient prescriptions. One hundred prescriptions each for adults and children for each month for a period of one year (January to December 2000) were systematically sampled. Where there were fewer than 100 prescriptions in a month, all the prescriptions available were sampled for analysis. RESULTS: Average number of drugs per encounter in all the hospitals was 4.259 +/- 0.009. Average number of injections per encounter was 1.215 +/- 0.009. About 48.5% of all the presriptions had at least one injection while 40.9% of the prescriptions had dipyrone injection. Average drug cost per encounter was N 147.40 +/- 0.765. Percentage of encounters with chloroquine was 82.5% followed by sulphadoxine-pyrimethamine 14.2%. Percentage of prescriptions with correct dose of chloroquine was 47.5% CONCLUSIONS: Polypharmacy exists in all the hospitals. The average number of drugs per encounter for the majority of the hospitals was above 4. Less than half of the prescriptions had the correct dose of chloroquine. This study can serve as a baseline for intervention on irrational prescribing.",0,0,
187,Antioxidant vitamin supplementation in the prevention of cardiovascular disease,"Oxidative stress, in particular oxidative modification of LDL-cholesterol, appears to be of great importance in the pathogenesis of atherosclerosis. Various observational epidemiological studies have suggested that antioxidant vitamin intake is associated with reduced cardiovascular morbidity and mortality. Also, experimental studies in animals have demonstrated that antioxidant vitamins slow the progression of atherosclerosis. However, prospective controlled clinical trials have failed to demonstrate a benefit of antioxidant vitamin supplementation in primary or secondary prevention of cardiovascular disease. Thus, the use of antioxidants and vitamin supplements as a preventive or therapeutic intervention can not be recommended.",0,0,
188,Antipruritic therapy in atopic eczema,"In patients with atopic eczema, the quality of life is seriously affected by tormenting pruritus. As the pathogenesis of pruritus is not understood, symptomatic measures are the mainstay of treatment along with avoiding aggravating factors. They include emollients, topical and systemic active ingredients and physical therapy (e. g. phototherapy) adjusted to the acuity the disease. Behavioral therapy offers additional support. New treatment modalities, partly still in experimental stage, such as immunomodulators, immunosuppressive agents and opiate antagonists are reserved for nonresponding patients"";"" they too are reviewed.",0,0,
189,Antipsychotic polypharmacy in schizophrenia: benefits and risks,"Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50% in some clinical settings. A common reason for prescribing more than one antipsychotic is to gain a greater or more rapid therapeutic response than has been achieved with antipsychotic monotherapy. However, the evidence on the risks and benefits for such a strategy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry. Combined antipsychotics are a major contributor to high-dose prescribing, associated with an increased adverse effect burden, and of limited value in helping to establish the optimum maintenance regimen for a patient. The relatively widespread use of antipsychotic polypharmacy identified in cross-sectional surveys reflects not only the addition of a second antipsychotic to boost therapeutic response, but also the use of as-required antipsychotic medication (mainly to treat disturbed behaviour), gradual cross-titration while switching from one antipsychotic to another, and augmentation of clozapine with a second antipsychotic where the illness has failed to respond adequately to an optimized trial of clozapine. This review addresses the clinical trial data and other evidence for each of these pharmacological approaches. Also reviewed are examples of systematic, practice-based interventions designed to reduce the prevalence of antipsychotic polypharmacy, most of which have met with only modest success. Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments such as clozapine have been exhausted. Further, their prescription for each patient should be in the context of an individual trial, with monitoring of the clinical response and adverse effects, and appropriate physical health monitoring.",0,0,
190,Application of a hospital audit to the use of nebulizers: the Case of the Hotel-Dieu de France-Lebanon,"PROBLEM: The aim of the study was to reduce the unjustified prescriptions of nebulised therapy, in order to comply with the international guidelines and to reduce healthcare costs. METHODS: DESIGN: We performed a controlled, prospective study to evaluate the impact of local guidelines aimed at improving doctors' behaviour on appropriateness and costs of implementation. BACKGROUND AND SETTING: All the departments of a university hospital: medical and surgical wards, intensive care units, emergency rooms and one-day admission units. KEY MEASURE FOR CHANGE: Reduction in the number of inappropriate prescriptions of nebulised therapy. STRATEGIES FOR CHANGE: Implementation included two educational presentations, posters displayed in all departments, emails sent to all doctors and residents, and reassessment of the prescription one week after. RESULTS: Prior to the intervention, the rate of inappropriate prescriptions was 11.9% (42/358 of patients treated with nebulizers did not have an indication for this treatment and 3/19 of patients had an indication for nebulisation but were not treated)"";"" in the postintervention, the rate of inappropriate prescriptions was 14.6% (15.7% of patients without indication for treatment, but no patient with an indication for treatment untreated), reflecting a lack of significant impact of the intervention. CONCLUSIONS: Simple presentation of clinical guidelines did not lead to a change in medical practices. Another approach is needed to improve this outcome effectively.",0,0,
191,Application of the MAT-CHDSP to assess guideline adherence and therapy goal achievement in secondary prevention of coronary heart disease after percutaneous coronary intervention,"PURPOSE: Numerous studies have documented suboptimal adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD(SP)). Clinical practice guidelines (CPGs) are continuously developed to define appropriate patient care, aiming to reduce risk of morbidity and death. The Medication Assessment Tool for CHD(SP) (MAT-CHD(SP)) was developed to assess adherence to CPGs concerning medication therapy and follow-up of patients with CHD(SP). The aim of this study was to explore whether the MAT-CHD(SP) could be applied retrospectively to assess guideline adherence and therapy goal achievement in secondary prevention of CHD. METHODS: We collected data from electronic medical records of all patients who underwent percutaneous coronary intervention with stent implantation from January to March 2008 (n = 300) and applied the MAT-CHD(SP). We measured time for data collection and MAT application and tested reproducibility by calculating Cohen's kappa (kappa) value for inter and intraobserver agreement. RESULTS: A total of 247 MAT applications were analyzed, showing overall applicability of 66 % of the 4,446 MAT-CHD(SP) criteria and a high reproducibility of MAT-CHD(SP) application (kappa values 0.93 and 0.95 for intra- and interobserver agreement, respectively). Mean time for data collection and MAT-CHD(SP) application was 11 min. Adherence to criteria concerning prescription was high (>75 %), but achievement of therapy goals for cholesterol and blood pressure was low (<50 %). Documentation of lifestyle advice achieved intermediate (50-75 %) or low adherence, as did therapy amendments in patients in whom therapy goals were unachieved at hospital admission. CONCLUSIONS: The MAT-CHD(SP) offers a means to identify both adherence and nonadherence to CPGs concerning CHD(SP) is applicable in retrospective assessment of CHD(SP), and identifies potentials for improved patient care.",0,0,
192,Application of theory to enhance audit and feedback interventions to increase the uptake of evidence-based transfusion practice: an intervention development protocol,"BACKGROUND: Audits of blood transfusion demonstrate around 20% transfusions are outside national recommendations and guidelines. Audit and feedback is a widely used quality improvement intervention but effects on clinical practice are variable, suggesting potential for enhancement. Behavioural theory, theoretical frameworks of behaviour change and behaviour change techniques provide systematic processes to enhance intervention. This study is part of a larger programme of work to promote the uptake of evidence-based transfusion practice. OBJECTIVES: The objectives of this study are to design two theoretically enhanced audit and feedback interventions"";"" one focused on content and one on delivery, and investigate the feasibility and acceptability. METHODS: Study A (Content): A coding framework based on current evidence regarding audit and feedback, and behaviour change theory and frameworks will be developed and applied as part of a structured content analysis to specify the key components of existing feedback documents. Prototype feedback documents with enhanced content and also a protocol, describing principles for enhancing feedback content, will be developed. Study B (Delivery): Individual semi-structured interviews with healthcare professionals and observations of team meetings in four hospitals will be used to specify, and identify views about, current audit and feedback practice. Interviews will be based on a topic guide developed using the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Analysis of transcripts based on these frameworks will form the evidence base for developing a protocol describing an enhanced intervention that focuses on feedback delivery. Study C (Feasibility and Acceptability): Enhanced interventions will be piloted in four hospitals. Semi-structured interviews, questionnaires and observations will be used to assess feasibility and acceptability. DISCUSSION: This intervention development work reflects the UK Medical Research Council's guidance on development of complex interventions, which emphasises the importance of a robust theoretical basis for intervention design and recommends systematic assessment of feasibility and acceptability prior to taking interventions to evaluation in a full-scale randomised study. The work-up includes specification of current practice so that, in the trials to be conducted later in this programme, there will be a clear distinction between the control (usual practice) conditions and the interventions to be evaluated.",0,0,
193,Applying Choice Architecture Principles to Understand HIV Testing: Findings From Malawi and Zimbabwe,"Improvements spearheaded by the World Health Organization in antenatal HIV counseling in sub-Saharan Africa from 2004 to 2011 have seen a parallel increase in HIV testing. We sought to determine the extent to which the use of choice architecture principles (one that introduces an opt-out option as the default) affect uptake of HIV testing, above and beyond individual-level attitudes and cognitions. Demographic and Health Survey data collected between 2004 and 2011 from Zimbabwe (N = 1,330) and Malawi (N = 4,043)—countries where over 10% of adults have HIV—were analyzed. We explored the influence of demographic variables, modes of knowledge about HIV, stigma against people living with HIV, attitudes about spousal abuse, and whether or not HIV testing had been offered during antenatal visits. Results demonstrated that, taking into account secular trends in higher testing rates, structural-level support was the strongest predictor of HIV testing above and beyond individual-level attitudes and cognitions.   Read More: https://guilfordjournals.com/doi/abs/10.1521/aeap.2015.27.4.362",0,1,
194,Approaches based on behavioral economics could help nudge patients and providers toward lower health spending growth,"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.",0,1,
195,Architectural frameworks: defining the structures for implementing learning health systems,"Background The vision of transforming health systems into learning health systems (LHSs) that rapidly and continuously transform knowledge into improved health outcomes at lower cost is generating increased interest in government agencies, health organizations, and health research communities. While existing initiatives demonstrate that different approaches can succeed in making the LHS vision a reality, they are too varied in their goals, focus, and scale to be reproduced without undue effort. Indeed, the structures necessary to effectively design and implement LHSs on a larger scale are lacking. In this paper, we propose the use of architectural frameworks to develop LHSs that adhere to a recognized vision while being adapted to their specific organizational context. Architectural frameworks are high-level descriptions of an organization as a system"";"" they capture the structure of its main components at varied levels, the interrelationships among these components, and the principles that guide their evolution. Because these frameworks support the analysis of LHSs and allow their outcomes to be simulated, they act as pre-implementation decision-support tools that identify potential barriers and enablers of system development. They thus increase the chances of successful LHS deployment.  Discussion We present an architectural framework for LHSs that incorporates five dimensions¡ªgoals, scientific, social, technical, and ethical¡ªcommonly found in the LHS literature. The proposed architectural framework is comprised of six decision layers that model these dimensions. The performance layer models goals, the scientific layer models the scientific dimension, the organizational layer models the social dimension, the data layer and information technology layer model the technical dimension, and the ethics and security layer models the ethical dimension. We describe the types of decisions that must be made within each layer and identify methods to support decision-making.  Conclusion In this paper, we outline a high-level architectural framework grounded in conceptual and empirical LHS literature. Applying this architectural framework can guide the development and implementation of new LHSs and the evolution of existing ones, as it allows for clear and critical understanding of the types of decisions that underlie LHS operations. Further research is required to assess and refine its generalizability and methods.",0,0,
196,Are nonspecific practice guidelines potentially harmful? A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making,"OBJECTIVE: To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain. DATA SOURCES/STUDY DESIGN: Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes. Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians, and general internists. INTERVENTION: Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel. The two guidelines were similar in content but varied in the specificity of their recommendations. DATA COLLECTION: The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline, or vignettes plus the specific version of the guideline. PRINCIPAL FINDINGS: The response rate to the survey was 71 percent. The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group, and 79 percent for the specific guideline group (p = .002). The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent, and 26 percent, respectively (p = .08). Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02). Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04). CONCLUSIONS: The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines.",0,0,
197,Are Nurses an Answer to New Primary Care Needs?,,0,0,
198,Are psychiatric Crisis Assessment and Treatment team clinicians on the psychotherapy front line?,"OBJECTIVE: There is limited data on the psychological interventions used by Crisis Assessment and Treatment (CAT) team clinicians, even though practice guidelines stipulate part of their role to be the provision of counselling. This study aimed to catalogue and categorise the range of psychotherapeutic interventions utilised by clinicians of a CAT team operating within a metropolitan area. METHODS: Self-report, episode of care data was collected regarding clinicians' views of the type of psychotherapeutic intervention they employed and details of what they discussed with patients, and location and duration of interventions. RESULTS: Thirty-two care episodes were catalogued. On average, clinicians spent 74% of their total contact time with patients engaged in psychological interventions. A wide range of strategies, drawn from a broad theoretical base, was used. Aside from general approaches aiding engagement, interventions could be classified into the following categories: meta-strategy ('treatment about the treatment'), 'critical', 'practical', specific psychotherapeutic (cognitive-behavioural therapy (CBT) and others), and supportive. CONCLUSIONS: Clinicians saw themselves as spending the majority of patient contact time engaged in psychological interventions drawn from a broad theoretical base. Observational studies of what clinicians actually do and empirical investigation of the efficacy thereof may have implications for clinician training and supervision.",0,0,
199,Are the NHS national outcomes frameworks past their sell-by date?,,0,0,
200,Are we adequately preparing the next generation of physicians to prescribe exercise as prevention and treatment? Residents express the desire for more training in exercise prescription,"BACKGROUND: Physical activity (PA) is a key intervention for chronic disease, yet few physicians provide exercise prescription (EP). EP is an important component in larger strategies of reducing non-communicable disease (NCD). Our objective was to assess Family Medicine Residents (FMR) knowledge, competence, and perspectives of EP to help inform future curriculum development. METHODS: A 49-item cross-sectional survey was administered to 396 University of British Columbia FMR. Residents' EP knowledge, competence, attitudes/beliefs, current practices, personal physical activity levels, and perspectives of training were assessed using, primarily, a 7-point Likert scale. RESULTS: The response rate was 80.6% (319/396). After eliminating 25 that failed to meet the inclusion criteria, 294 were included in the final analysis. The majority 95.6% of FMR reported EP as important in their future practice, despite having low knowledge of the Canadian PA Guidelines (mean score 1.77/4), low self-reported competence prescribing exercise as prevention (mean score 13.35/21), and rating themselves ""somewhat incompetent"" prescribing exercise to patients with chronic disease (mean score 11.26/21). FMR believe PA is integral to their patients' health (98.0%), sedentary behaviour is harmful (97.9%), and feel a responsibility to discuss PA with patients (99.7%). Few FMR (14.9%) perceived their training in EP as adequate and 91.0% desire more. CONCLUSIONS: FMR report EP is important, yet do not perceive they are sufficiently prepared to provide EP. In future curricular development, medical educators should consider residents' low knowledge, competence, perceived program support, and their expressed desire for more training in exercise prescription.",0,0,
201,ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle,"The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA-disseminated and implemented in over 70 countries globally-is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.",0,0,
202,Arriba: effects of an educational intervention on prescribing behaviour in prevention of CVD in general practice,"BACKGROUND: Evidence on the effectiveness of educational interventions on prescribing behaviour modification in prevention of cardiovascular disease is still insufficient. We evaluated the effects of a brief educational intervention on prescription of hydroxymethylglutaryl-CoA reductase inhibitors (statins), inhibitors of platelet aggregation (IPA), and antihypertensive agents (AH). DESIGN: Cluster randomised controlled trial with continuous medical education (CME) groups of general practitioners (GPs). METHODS: Prescription of statins, IPA, and AH were verified prior to study start (BL), immediately after index consultation (IC), and at follow-up after 6 months (FU). Prescription in patients at high risk (>15% risk of a cardiovascular event in 10 years, based on the Framingham equation) and no prescription in low-risk patients (</= 15%) were considered appropriate. RESULTS: An intervention effect on prescribing could only be found for IPA. Generally, changes in prescription over time were all directed towards higher prescription rates and persisted to FU, independent of risk status and group allocation. CONCLUSIONS: The active implementation of a brief evidence-based educational intervention on global risk in CVD did not lead directly to risk-adjusted changes in prescription. Investigations on an extended time scale would capture whether decision support of this kind would improve prescribing risk-adjusted sustainably.",0,0,
203,Articles on Diagnostic Tests: A New Series and an Invitation to Authors,,0,0,
204,"Assessing availability of scientific journals, databases, and health library services in Canadian health ministries: a cross-sectional study","Background Evidence-informed health policymaking logically depends on timely access to research evidence. To our knowledge, despite the substantial political and societal pressure to enhance the use of the best available research evidence in public health policy and program decision making, there is no study addressing availability of peer-reviewed research in Canadian health ministries.  Objectives To assess availability of (1) a purposive sample of high-ranking scientific journals, (2) bibliographic databases, and (3) health library services in the fourteen Canadian health ministries.  Methods From May to October 2011, we conducted a cross-sectional survey among librarians employed by Canadian health ministries to collect information relative to availability of scientific journals, bibliographic databases, and health library services. Availability of scientific journals in each ministry was determined using a sample of 48 journals selected from the 2009 Journal Citation Reports (Sciences and Social Sciences Editions). Selection criteria were: relevance for health policy based on scope note information about subject categories and journal popularity based on impact factors.  Results We found that the majority of Canadian health ministries did not have subscription access to key journals and relied heavily on interlibrary loans. Overall, based on a sample of high-ranking scientific journals, availability of journals through interlibrary loans, online and print-only subscriptions was estimated at 63%, 28% and 3%, respectively. Health Canada had a 2.3-fold higher number of journal subscriptions than that of the provincial ministries¡¯ average. Most of the organisations provided access to numerous discipline-specific and multidisciplinary databases. Many organisations provided access to the library resources described through library partnerships or consortia. No professionally led health library environment was found in four out of fourteen Canadian health ministries (i.e. Manitoba Health, Northwest Territories Department of Health and Social Services, Nunavut Department of Health and Social Services and Yukon Department of Health and Social Services).  Conclusions There is inequity in availability of peer-reviewed research in the fourteen Canadian health ministries. This inequity could present a problem, as each province and territory is responsible for formulating and implementing evidence-informed health policies and services for the benefit of its population.",0,0,
205,Assessing the impact of national guidelines on the management of children hospitalized for acute bronchiolitis,"BACKGROUND: Acute bronchiolitis is a common illness accounting for $500 million annually in hospitalizations. Despite the frequency of bronchiolitis, its diagnosis and management is variable. To address this variability, the American Academy of Pediatrics (AAP) published an evidence-based practice management guideline for bronchiolitis in 2006. OBJECTIVE: Assess for changes in physician behavior in the management of bronchiolitis before and after publication of the 2006 AAP bronchiolitis guideline. METHODS: A retrospective chart review was performed at two academic medical centers of children <24 months of age admitted to the hospital with a primary or secondary discharge diagnosis of bronchiolitis. Pre-guideline charts were gathered from 2004 to 2005 and post-guideline charts from 2007 to 2008. Evaluation and therapeutic interventions prior to and during hospitalization were analyzed. Data were analyzed using chi-squared analysis for categorical variables, Mann-Whitney testing for continuous variables. RESULTS: One thousand two hundred thirty-three patients met inclusion criteria. Diagnostic laboratory testing rates did not decline after guideline publication. The number of chest X-rays obtained decreased from 72.9% to 66.7% post-guidelines (P = 0.02). Fewer children received a trial of racemic epinephrine (17.8% vs. 12.2%, P = 0.006) or albuterol (81.6% vs. 72.6%, P < 0.0001) post-guidelines, and physicians more often discontinued albuterol when documented ineffective in the post-guidelines period (28.6% vs. 78.9%, P < 0.0001). Corticosteroid use in children without a history of RAD or asthma dropped post-guidelines (26.5% vs. 17.5%, P < 0.0001). CONCLUSIONS: A modest change in physician behavior in the inpatient management of bronchiolitis was seen post-guidelines. Additional health care provider training and education is warranted to reduce unnecessary interventions and healthcare resources use.",0,0,
206,Assessing treatment-as-usual provided to control groups in adherence trials: Exploring the use of an open-ended questionnaire for identifying behaviour change techniques,"OBJECTIVE: Reporting guidelines call for descriptions of control group support in equal detail as for interventions. However, how to assess the active content (behaviour change techniques (BCTs)) of treatment-as-usual (TAU) delivered to control groups in trials remains unclear. The objective of this study is to pre-test a method of assessing TAU in a multicentre cost-effectiveness trial of an HIV-treatment adherence intervention. DESIGN: HIV-nurses (N = 21) completed a semi-structured open-ended questionnaire enquiring about TAU adherence counselling. Two coders independently coded BCTs. MAIN OUTCOME MEASURES: Completeness and clarity of nurse responses, inter-coder reliabilities and the type of BCTs reported were examined. RESULTS: The clarity and completeness of nurse responses were adequate. Twenty-three of the 26 identified BCTs could be reliably coded (mean kappa = .79"";"" mean agreement rate = 96%) and three BCTs scored below kappa = .60. Total number of BCTs reported per nurse ranged between 7 and 19 (M = 13.86, SD = 3.35). CONCLUSIONS: This study suggests that the TAU open-ended questionnaire is a feasible and reliable tool to capture active content of support provided to control participants in a multicentre adherence intervention trial. Considerable variability in the number of BCTs provided to control patients was observed, illustrating the importance of reliably collecting and accurately reporting control group support.",0,0,
207,Assessment and lifestyle management of patients with obesity: clinical recommendations from systematic reviews,"IMPORTANCE: Even though one-third of US adults are obese, identification and treatment rates for obesity remain low. Clinician engagement is vital to provide guidance and assistance to patients who are overweight or obese to address the underlying cause of many chronic diseases. OBJECTIVES: To describe current best practices for assessment and lifestyle management of obesity and to demonstrate how the updated Guidelines (2013) for Managing Overweight and Obesity in Adults based on a systematic evidence review sponsored by the National Heart, Lung, and Blood Institute (NHLBI) can be applied to an individual patient. EVIDENCE REVIEW: Systematic evidence review conducted for the Guidelines (2013) for Managing Overweight and Obesity in Adults supports treatment recommendations in 5 areas (risk assessment, weight loss benefits, diets for weight loss, comprehensive lifestyle intervention approaches, and bariatric surgery)""; for areas outside this scope, recommendations are supported by other guidelines (for obesity, 1998 NHLBI-sponsored obesity guidelines and those from the National Center for Health and Clinical Excellence and Canadian and US professional societies such as the American Association of Clinical Endocrinologists and American Society of Bariatric Physicians; for physical activity recommendations, the 2008 Physical Activity Guidelines for Americans); a PubMed search identified recent systematic reviews covering depression and obesity, motivational interviewing for weight management, metabolic adaptation to weight loss, and obesity pharmacotherapy. FINDINGS: The first step in obesity management is to screen all adults for overweight and obesity. A medical history should be obtained assessing for the multiple determinants of obesity, including dietary and physical activity patterns, psychosocial factors, weight-gaining medications, and familial traits. Emphasis on the complications of obesity to identify patients who will benefit the most from treatment is more useful than using body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) alone for treatment decisions. The Guidelines (2013) recommend that clinicians offer patients who would benefit from weight loss (either BMI of >/=30 with or without comorbidities or >/=25 along with 1 comorbidity or risk factor) intensive, multicomponent behavioral intervention. Some clinicians do this within their primary care practices;"" others refer patients for these services. Weight loss is achieved by creating a negative energy balance through modification of food and physical activity behaviors. The Guidelines (2013) endorse comprehensive lifestyle treatment by intensive intervention. Treatment can be implemented either in a clinician's office or by referral to a registered dietitian or commercial weight loss program. Weight loss of 5% to 10% is the usual goal. It is not necessary for patients to attain a BMI of less than 25 to achieve a health benefit. CONCLUSIONS AND RELEVANCE: Screening and assessment of patients for obesity followed by initiation or referral of treatment should be incorporated into primary care practice settings. If clinicians can identify appropriate patients for weight loss efforts and provide informed advice and assistance on how to achieve and sustain modest weight loss, they will be addressing the underlying driver of many comorbidities and can have a major influence on patients' health status.",0,0,
208,Assessment of a distant collaborative program for the treatment of depression in primary care,"BACKGROUND: In the treatment of depression, primary care teams play an important role, whose effectiveness improves when inserted into a collaborative model of disease management. AIM: To report the results of a clinical trial carried out to test the effectiveness of a collaborative program between primary health teams and specialists supported by an electronic platform. MATERIAL AND METHODS: Physicians from four community hospitals belonging to the Reloncavi Health Service network, recruited 81 patients with depression aged 37 to 43 years, 84% of whom were female. Participants were divided in an active group, which participated in the collaborative program and a control group, which received the usual care, according to the Ministry of Health's Guidelines for Depression. The main outcome was the Beck Depression Inventory (BDI-I) score at three months of intervention. RESULTS: Participants had an average of 29.6 points (95% CI: 27.6-31.6) in the BDI-I and 38% of them had a high suicide risk. There were no statistically significant baseline differences between active and control group. In the intervention group, the BDI-I score changed from 30.0 (95% CI 27.0 to 32.8) to 15.3 (95% CI 11.8 to 18.8). In the control group the score changed from 29.2 (95% CI: 26.4-31.9) points to 20.8 (95% CI 16.8 to 24.7). The decrease was significantly higher in the intervention groups. CONCLUSIONS: A program of this kind may be useful to assist primary care teams in remote areas of the country to improve treatment outcomes for depression.",0,0,
209,Assessment of a pay-for-performance program in primary care designed by target users.,"Background: Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. Objective: To assess changes in performance after introducing a participatory P4P program. Design: An observational study with a pre- and post-measurement. Setting and subjects: Sixty-five general practices in the south of the Netherlands. Intervention: A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. Main outcome measures: Quality indicators for clinical care (process and outcome) and patient experience. Results: We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. Conclusions: A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
210,Assessment of decision support for blood test ordering in primary care. a randomized trial,"BACKGROUND: Different methods for changing blood test-ordering behavior in primary care have been proven effective. However, randomized trials comparing these methods are lacking. OBJECTIVE: To compare the effect of two versions of BloodLink, a computer-based clinical decision support system, on blood test ordering among general practitioners. DESIGN: Randomized trial. SETTING: 44 practices of general practitioners in the region of Delft, the Netherlands. PARTICIPANTS: 60 general practitioners in 44 practices who used computer-based patient records in their practices. INTERVENTION: After stratification by solo practices and group practices, practices were randomly assigned to use BloodLink-Restricted, which initially displays a reduced list of tests, or BloodLink-Guideline, which is based on the guidelines of the Dutch College of General Practitioners. MEASUREMENTS: Average number of blood tests ordered per order form per practice. RESULTS: General practitioners who used BloodLink-Guideline requested 20% fewer tests on average than did practitioners who used BloodLink-Restricted (mean [+/-SD], 5.5 +/- 0.9 tests vs. 6.9 +/- 1.6 tests, respectively"";"" P = 0.003, Mann-Whitney test). CONCLUSIONS: Decision support based on guidelines is more effective in changing blood test-ordering behavior than is decision support based on initially displaying a limited number of tests. Guideline-driven decision support systems can be effective in reducing the number of laboratory tests ordered by primary care practitioners.",1,1,
211,Assessment of radiological referral practice and effect of computer-based guidelines on radiological requests in two emergency departments.,"AIM: To assess medical emergency radiology referral practice compared with a set of French guidelines and to measure the efficiency of computer-based guidelines on unnecessary medical imaging. MATERIALS AND METHODS: All radiological requests were computerized in the medical emergency departments of two French teaching hospitals. During control periods, radiological requests were recorded but no action was taken. During intervention periods, reminder displays on screen indicated the appropriate recommendations. Three control and three intervention periods of 1 month each were conducted. The percentage of requests that did not conform to the guidelines and variation related to periods of control and intervention were measured. RESULTS: The proportion of requests that did not conform to the guidelines was 33·2% when the guidelines were inactive and decreased to 26·9% when the recommendations were active (P < 0·0001). The three imaging examinations (chest radiographs, abdominal plain radiographs and CT of the brain) accounted for more than 80% of all requests""; more than 50% of abdominal plain radiographs requests did not conform with recommendations while this percentage was respectively 24·9% and 15·8% for chest radiographs and computed tomography (CT) of the brain. Seven situations accounted for 70% of non-conforming radiological referrals; in these situations, junior practitioners' knowledge was inadequate. CONCLUSION: While the computer provided advice that was tailored to the needs of individual patients, concurrent with care, the effect of our intervention was weak. However, our study identified the few situations that were responsible for the majority of unnecessary radiological requests;"" we expect that this result could help clinicians and radiologists to develop more specific actions for these situations. Carton, M. et al. (2002). Clinical Radiology (2002)57 , 123–128.",1,1,
212,Assessment of self harm in an accident and emergency service - the development of a proforma to assess suicide intent and mental state in those presenting to the emergency department with self harm,"INTRODUCTION: the UK has one of the highest rates of self harm in Europe, around 400 per 100,000 people (Horrocks et al. 2002). It accounts for 150,000 attendances to the Emergency department each year and is one of the top five causes of acute medical admissions in the UK (NICE 2002). AIMS: objectives included to explore the method of self harm and the demographic factors of those presenting the Emergency department with self harm. In addition we wanted to review the exploration of suicide risk factors and suicide intent by the Emergency department doctor and ascertain whether a psychiatric assessment with full mental state examination had been conducted with referral to psychiatric services if deemed necessary. We wanted to explore the current practice around self harm presentations in the Emergency department accordance with NICE guidelines. METHODS: data was collected retrospectively from February to August 2009. Twenty-five sets of medical notes were collated at random for patients who had presented with self harm to the Emergency department. Notes were reviewed for evidence of exploration of the event, psychiatric assessment, risk factors for suicide and further referral. RESULTS: 14 of the 25 patients presented having taken an overdose. 9 had inflicted some other form of self injury, namely lacerations to self. In 2 cases a mixed presentation was found. Previous psychiatric history was documented in 16 cases. 11 had a previous history of depression or anxiety disorder""; 1 was known to have bipolar affective disorder; 1 was diagnosed in the past with borderline personality disorder; and 3 patients had no previous history. In 9 cases previous history was not documented. DISCUSSION: twenty-five sets of medical notes were reviewed from February to August 2009 for individuals presenting to the Emergency department with self harm. Of those, 12 fell into the over 25 age group. 17 were female and 8 were male. The majority of patients were of white British ethnicity. 14 had taken an overdose; 9 had inflicted some other form of self injury;"" and 2 had a mixed presentation. Suicide risk factors and suicidal intent was poorly documented with mental state examination found not to be documented in all 25 cases reviewed. 18 were deemed medically fit in the Emergency department and were referred for psychiatric review. These unfortunate findings may be a reflection on the time pressures faced by Emergency department doctors, namely the four hour targets, and perhaps lack of adequate training in psychosocial risk assessment. With such poor documentation made by the Emergency department doctors, a proforma was produced which incorporates suicide risk factors and assessment of suicide intent in addition to a brief version of the mental state examination. CONCLUSION: concerns have been raised by the recent Royal College of Psychiatrists report on self harm, that current level of care provided to service users fall short of the standards set out in policies and guidelines, with poor assessments, unskilled staff and insufficient care pathways (Royal College of Psychiatrists. Report CR 158. 2010). Indeed evidence suggest that appropriate training and intervention given to A&E staff can lead to improvements in the quality of psychosocial assessment of patients with deliberate self harm (Crawford et al. 1998).",0,0,
213,Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study,"Background Computerized decision support systems (DSS) have mainly focused on improving clinicians' diagnostic accuracy in unusual and challenging cases. However, since diagnostic omission errors may predominantly result from incomplete workup in routine clinical practice, the provision of appropriate patient- and context-specific reminders may result in greater impact on patient safety. In this experimental study, a mix of easy and difficult simulated cases were used to assess the impact of a novel diagnostic reminder system (ISABEL) on the quality of clinical decisions made by various grades of clinicians during acute assessment.  Methods Subjects of different grades (consultants, registrars, senior house officers and medical students), assessed a balanced set of 24 simulated cases on a trial website. Subjects recorded their clinical decisions for the cases (differential diagnosis, test-ordering and treatment), before and after system consultation. A panel of two pediatric consultants independently provided gold standard responses for each case, against which subjects' quality of decisions was measured. The primary outcome measure was change in the count of diagnostic errors of omission (DEO). A more sensitive assessment of the system's impact was achieved using specific quality scores""; additional consultation time resulting from DSS use was also calculated.  Results 76 subjects (18 consultants, 24 registrars, 19 senior house officers and 15 students) completed a total of 751 case episodes. The mean count of DEO fell from 5.5 to 5.0 across all subjects (repeated measures ANOVA, p < 0.001); no significant interaction was seen with subject grade. Mean diagnostic quality score increased after system consultation (0.044;"" 95% confidence interval 0.032, 0.054). ISABEL reminded subjects to consider at least one clinically important diagnosis in 1 in 8 case episodes, and prompted them to order an important test in 1 in 10 case episodes. Median extra time taken for DSS consultation was 1 min (IQR: 30 sec to 2 min).  Conclusion The provision of patient- and context-specific reminders has the potential to reduce diagnostic omissions across all subject grades for a range of cases. This study suggests a promising role for the use of future reminder-based DSS in the reduction of diagnostic error.",0,1,
214,Association Between Academic Medical Center Pharmaceutical Detailing Policies and Physician Prescribing,"Importance  In an effort to regulate physician conflicts of interest, some US academic medical centers (AMCs) enacted policies restricting pharmaceutical representative sales visits to physicians (known as detailing) between 2006 and 2012. Little is known about the effect of these policies on physician prescribing.  Objective  To analyze the association between detailing policies enacted at AMCs and physician prescribing of actively detailed and not detailed drugs.  Design, Setting, and Participants  The study used a difference-in-differences multivariable regression analysis to compare changes in prescribing by physicians before and after implementation of detailing policies at AMCs in 5 states (California, Illinois, Massachusetts, Pennsylvania, and New York) that made up the intervention group with changes in prescribing by a matched control group of similar physicians not subject to a detailing policy.  Exposures  Academic medical center implementation of policies regulating pharmaceutical salesperson visits to attending physicians.  Main Outcomes and Measures  The monthly within-drug class market share of prescriptions written by an individual physician for detailed and nondetailed drugs in 8 drug classes (lipid-lowering drugs, gastroesophageal reflux disease drugs, diabetes drugs, antihypertensive drugs, hypnotic drugs approved for the treatment of insomnia [sleep aids], attention-deficit/hyperactivity disorder drugs, antidepressant drugs, and antipsychotic drugs) comparing the 10- to 36-month period before implementation of the detailing policies with the 12- to 36-month period after implementation, depending on data availability.  Results  The analysis included 16?121?483 prescriptions written between January 2006 and June 2012 by 2126 attending physicians at the 19 intervention group AMCs and by 24?593 matched control group physicians. The sample mean market share at the physician-drug-month level for detailed and nondetailed drugs prior to enactment of policies was 19.3% and 14.2%, respectively. Exposure to an AMC detailing policy was associated with a decrease in the market share of detailed drugs of 1.67 percentage points (95% CI, ?2.18 to ?1.18 percentage points""; P?<?.001) and an increase in the market share of nondetailed drugs of 0.84 percentage points (95% CI, 0.54 to 1.14 percentage points; P?<?.001). Associations were statistically significant for 6 of 8 study drug classes for detailed drugs (lipid-lowering drugs, gastroesophageal reflux disease drugs, antihypertensive drugs, sleep aids, attention-deficit/hyperactivity disorder drugs, and antidepressant drugs) and for 9 of the 19 AMCs that implemented policies. Eleven of the 19 AMCs regulated salesperson gifts to physicians, restricted salesperson access to facilities, and incorporated explicit enforcement mechanisms. For 8 of these 11 AMCs, there was a significant change in prescribing. In contrast, there was a significant change at only 1 of 8 AMCs that did not enact policies in all 3 areas.  Conclusions and Relevance  Implementation of policies at AMCs that restricted pharmaceutical detailing between 2006 and 2012 was associated with modest but significant reductions in prescribing of detailed drugs across 6 of 8 major drug classes;"" however, changes were not seen in all of the AMCs that enacted policies.",0,0,
215,Association Between Efavirenz as Initial Therapy for HIV-1 Infection and Increased Risk for Suicidal Ideation or Attempted or Completed Suicide,"Background The relationship between efavirenz use and suicidality is not well defined. Objective Compare time to suicidality with efavirenz-containing versus efavirenz-free antiretroviral regimens for initial treatment of HIV. Design Participant-level data were analyzed from four AIDS Clinical Trials Group (ACTG) antiretroviral-na?ve studies conducted from 2001 to 2010. Within each study, participants were randomly assigned to an efavirenz-containing (n=3241) or efavirenz-free regimen (n=2091). Setting ACTG sites""; 74% enrolled in the United States. Patients Antiretroviral-na?ve participants. Intervention Efavirenz versus efavirenz-free regimens. Measurements Suicidality was defined as suicidal ideation, attempted or completed suicide. Groups were compared with a hazard ratio (HR) and 95% confidence interval (CI) estimated from a Cox model stratified by study. Results 73% were men, median age was 37 years;"" 32% had documented psychiatric history or received psychoactive medication within 30 days prior to study entry. Median follow-up was 96 weeks. Suicidality incidence per 1000 person-years was 8.08 (47 events) in the efavirenz group and 3.66 (15 events) in the efavirenz-free group, HR: 2.28 (95% CI: 1.27 to 4.10, p=0.006). Incidence of attempted or completed suicide was 2.90 (17 events) and 1.22 (5 events) in the efavirenz and efavirenz-free groups, respectively, HR: 2.58 (95% CI: 0.94 to 7.06, p=0.065). Eight suicide deaths in the efavirenz group and one in the efavirenz-free group were reported. Limitations There was not a standardized questionnaire regarding suicidal ideation or attempt. Efavirenz was open-label in three of four studies. Conclusions Initial treatment with an efavirenz-containing antiretroviral regimen was associated with a two-fold increased hazard of suicidality compared to a regimen without efavirenz. Keywords: efavirenz, suicide, suicidal ideation, suicidal behavior, HIV, adverse event, psychiatry",0,0,
216,Association of a Low-Frequency Variant in HNF1A With Type 2 Diabetes in a Latino Population,"Importance  Latino populations have one of the highest prevalences of type 2 diabetes worldwide.  Objectives  To investigate the association between rare protein-coding genetic variants and prevalence of type 2 diabetes in a large Latino population and to explore potential molecular and physiological mechanisms for the observed relationships.  Design, Setting, and Participants  Whole-exome sequencing was performed on DNA samples from 3756 Mexican and US Latino individuals (1794 with type 2 diabetes and 1962 without diabetes) recruited from 1993 to 2013. One variant was further tested for allele frequency and association with type 2 diabetes in large multiethnic data sets of 14?276 participants and characterized in experimental assays.  Main Outcome and Measures  Prevalence of type 2 diabetes. Secondary outcomes included age of onset, body mass index, and effect on protein function.  Results  A single rare missense variant (c.1522G>A [p.E508K]) was associated with type 2 diabetes prevalence (odds ratio [OR], 5.48""; 95% CI, 2.83-10.61; P?=?4.4?¡Á?10?7) in hepatocyte nuclear factor 1-¦Á (HNF1A), the gene responsible for maturity onset diabetes of the young type 3 (MODY3). This variant was observed in 0.36% of participants without type 2 diabetes and 2.1% of participants with it. In multiethnic replication data sets, the p.E508K variant was seen only in Latino patients (n?=?1443 with type 2 diabetes and 1673 without it) and was associated with type 2 diabetes (OR, 4.16; 95% CI, 1.75-9.92;"" P?=?.0013). In experimental assays, HNF-1A protein encoding the p.E508K mutant demonstrated reduced transactivation activity of its target promoter compared with a wild-type protein. In our data, carriers and noncarriers of the p.E508K mutation with type 2 diabetes had no significant differences in compared clinical characteristics, including age at onset. The mean (SD) age for carriers was 45.3 years (11.2) vs 47.5 years (11.5) for noncarriers (P?=?.49) and the mean (SD) BMI for carriers was 28.2 (5.5) vs 29.3 (5.3) for noncarriers (P?=?.19).  Conclusions and Relevance  Using whole-exome sequencing, we identified a single low-frequency variant in the MODY3-causing gene HNF1A that is associated with type 2 diabetes in Latino populations and may affect protein function. This finding may have implications for screening and therapeutic modification in this population, but additional studies are required.",0,0,
217,Association of Combatant Status and Sexual Violence With Health and Mental Health Outcomes in Postconflict Liberia,"Context Liberia's wars since 1989 have cost tens of thousands of lives and left many people mentally and physically traumatized.  Objectives To assess the prevalence and impact of war-related psychosocial trauma, including information on participation in the Liberian civil wars, exposure to sexual violence, social functioning, and mental health.  Design, Setting, and Participants A cross-sectional, population-based, multistage random cluster survey of 1666 adults aged 18 years or older using structured interviews and questionnaires, conducted during a 3-week period in May 2008 in Liberia.  Main Outcome Measures Symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), social functioning, exposure to sexual violence, and health and mental health needs among Liberian adults who witnessed or participated in the conflicts during the last 2 decades.  Results In the Liberian adult household¨Cbased population, 40% (95% confidence interval [CI], 36%-45%""; n = 672/1659) met symptom criteria for MDD, 44% (95% CI, 38%-49%; n = 718/1661) met symptom criteria for PTSD, and 8% (95% CI, 5%-10%; n = 133/1666) met criteria for social dysfunction. Thirty-three percent of respondents (549/1666) reported having served time with fighting forces, and 33.2% of former combatant respondents (182/549) were female. Former combatants experienced higher rates of exposure to sexual violence than noncombatants: among females, 42.3% (95% CI, 35.4%-49.1%) vs 9.2% (95% CI, 6.7%-11.7%), respectively; among males, 32.6% (95% CI, 27.6%-37.6%) vs 7.4% (95% CI, 4.5%-10.4%). The rates of symptoms of PTSD, MDD, and suicidal ideation were higher among former combatants than noncombatants and among those who experienced sexual violence vs those who did not. The prevalence of PTSD symptoms among female former combatants who experienced sexual violence (74%; 95% CI, 63%-84%) was higher than among those who did not experience sexual violence (44%; 95% CI, 33%-53%). The prevalence of PTSD symptoms among male former combatants who experienced sexual violence was higher (81%; 95% CI, 74%-87%) than among male former combatants who did not experience sexual violence (46%;"" 95% CI, 39%-52%). Male former combatants who experienced sexual violence also reported higher rates of symptoms of depression and suicidal ideation. Both former combatants and noncombatants experienced inadequate access to health care (33.0% [95% CI, 22.6%-43.4%] and 30.1% [95% CI, 18.7%-41.6%], respectively).  Conclusions Former combatants in Liberia were not exclusively male. Both female and male former combatants who experienced sexual violence had worse mental health outcomes than noncombatants and other former combatants who did not experience exposure to sexual violence.",0,0,
218,Association of Socioeconomic Position With Health Behaviors and Mortality,"Context Previous studies may have underestimated the contribution of health behaviors to social inequalities in mortality because health behaviors were assessed only at the baseline of the study.  Objective To examine the role of health behaviors in the association between socioeconomic position and mortality and compare whether their contribution differs when assessed at only 1 point in time with that assessed longitudinally through the follow-up period.  Design, Setting, and Participants Established in 1985, the British Whitehall II longitudinal cohort study includes 10 308 civil servants, aged 35 to 55 years, living in London, England. Analyses are based on 9590 men and women followed up for mortality until April 30, 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate, and low) at baseline. Smoking, alcohol consumption, diet, and physical activity were assessed 4 times during the follow-up period.  Main Outcome Measures All-cause and cause-specific mortality.  Results A total of 654 participants died during the follow-up period. In the analyses adjusted for sex and year of birth, those with the lowest socioeconomic position had 1.60 times higher risk of death from all causes than those with the highest socioeconomic position (a rate difference of 1.94/1000 person-years). This association was attenuated by 42% (95% confidence interval [CI], 21%-94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%-154%) when they were entered as time-dependent covariates. The corresponding attenuations were 29% (95% CI, 11%-54%) and 45% (95% CI, 24%-79%) for cardiovascular mortality and 61% (95% CI, 16%-425%) and 94% (95% CI, 35%-595%) for noncancer and noncardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality, respectively), physical activity (from 5% to 21% for all-cause mortality), and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality).  Conclusion In a civil service population in London, England, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.",0,0,
219,Asthma education programme in Russia: educating patients,"To address the recent rise in asthma morbidity and mortality in Russia, an intervention study was conducted to improve asthma diagnosis, treatment and prevention. US recommendations for asthma management were adapted for use in educating Moscow families with children with asthma. Two hundred and fifty-two children with asthma aged 4-14 years receiving health care in eight Moscow public health clinics together with their parents were enrolled in the study to see whether US teaching manuals for asthma management would be acceptable and effective in Russia. Children at four of the clinics with recent asthma attacks were randomly assigned to either the education or control group to test if patient education and guided asthma care would improve outcomes for patients. Modern medications were made available to both groups to see if training in the US guidelines was necessary to get physicians to use the medications. Children with recent asthma attacks at the other four clinics were defined as comparison group 1 to control for the possible effect of medication availability. All children at the eight clinics who had no asthma attacks composed comparison group 2 to see if the outcomes for these children would change over time. One-year follow-up results showed significant improvement in asthma self-management skills of children and parents, in terms of asthma treatment, only among those in the education group. Significant increases were observed in the subgroup of children in the education group using anti-inflammatory drugs for asthma control. Children in the education group had markedly increased peak flow rates and reduced daily peak flow variability as compared to control and comparison groups. There was a significantly greater reduction in doctor visits by the education group of children compared to control. Presumably, changes in parents' and children's behaviour in terms of asthma treatment and prevention skills, proper treatment of the disease and access to medications could be responsible for reducing asthma morbidity in children.",0,0,
220,Attitudes towards reproduction in Latin America. Teachings from the use of modern reproductive technologies,"The use of modern reproductive technology, such as in-vitro fertilization and its related procedures, has opened new areas of legal, religious and public concern. Thirty years ago, the development of effective methods to control procreation generated a debate on whether couples had the right to enjoy sex in the absence of its procreative effect. Today, assisted reproductive technology (ART) allows couples to have their own children in the absence of a direct intermediation of sex. The Catholic Church has reacted against both contraception and ART, and specific instructions have been directed to the public, the medical profession and legislators. In a recent survey, 88.4% of the population in Latin America claims to be Catholic"";"" therefore, bioethical considerations and legal implications concerning intervention in reproduction are strongly permeated by the moral teachings of Catholicism. In 1996, 83 medical doctors and scientists, participating in the Latin American Network of Assisted Reproduction, produced a consensus document on ethical aspects and legal implications of ART. The document contains minimal ethical guidelines that Latin American professionals have decided to adhere to, even in the absence of legal regulations. This article examines how the medical profession, legislators and the public react to religious influence when confronted by difficult bioethical decisions such as the right to procreate.",0,0,
221,Audit and feedback as a clinical practice guideline implementation strategy: a model for acute care nurse practitioners,"BACKGROUND: The transfer of research evidence into practice and changing provider behavior is challenging, even when the advantages are strong. Despite the availability of supportive care clinical practice guidelines (CPG), consistent integration of these principles into practice has not been achieved. The failure of dissemination strategies has been identified as a key barrier to successful implementation. A potentially effective approach to facilitating the transfer of research evidence into practice is audit and feedback. Audit and feedback is a summary of provider performance over a specified period of time, with or without recommendations to improve practice. RATIONALE: Cancer pain is an optimal symptom to examine when studying the effect of an audit and feedback intervention. It is a common condition with important consequences, established CPG are available, measurable outcomes are defined, and there is potential for improvement in current practice. Acute care nurse practitioners (NPs) are often responsible for overseeing and directly managing symptoms such as pain and are well positioned to implement CPG and study the effects of adherence to guidelines on patients' pain outcomes. METHODOLOGY: A systematic review of published articles, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library computerized databases was performed to evaluate the state of the science on audit and feedback as a professional practice change strategy. A behavior change model is proposed for its application to advanced practice nursing. IMPLICATIONS FOR PRACTICE: Recognized in medicine as a valuable intervention to improve healthcare quality, audit and feedback is a strategy that has not been widely studied in nursing. Although cancer pain cannot always be entirely eliminated, appropriate use of available therapies can effectively relieve pain in a majority of patients. This article is a review of the literature on audit and feedback as a professional practice change strategy and indicates a model for operationalizing the intervention.",0,1,
222,Audit and feedback: effects on professional practice and health care outcomes,"BACKGROUND: Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective. OBJECTIVES: To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004. SELECTION CRITERIA: Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality. MAIN RESULTS: Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies. AUTHORS' CONCLUSIONS: Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.",0,1,
223,Audit of a tuberculosis contact tracing clinic,"OBJECTIVE To determine the efficiency of tuberculosis contact tracing in South Glamorgan 1987-9. DESIGN Review of records of contact tracing clinic and of data from the Mycobacterium Reference Unit. The clinic's practice was compared with 1983 British Thoracic Society's recommendations. SETTING Health authority tuberculosis control programme. MAIN OUTCOME MEASURES Proportion of contacts screened, follow up attendance rates, number of secondary cases detected, and quality of record keeping. RESULTS 101 index patients and 611 contacts were identified. 596 (97.5%) contacts were screened, of whom 139 should not have been. Of 356 contacts requiring a Heaf test, 237 were tested, seven refused the test, and 112 had chest radiography without a Heaf test. 95 contacts were unnecessarily tested. 87 contacts had chest radiography unnecessarily and seven should have had radiography but did not. 34 contacts were given follow up appointments inappropriately and seven were overlooked for follow up. Tuberculosis was diagnosed in five asymptomatic contacts, all at initial screening and all close contacts of index patients with pulmonary disease. CONCLUSION Inadequacy of data, non-adherence to contact tracing guidelines, and failure to define the term highly infectious index case resulted in many contacts being unnecessarily screened or followed up. IMPLICATIONS The efficiency of tracing contacts would be improved by specifying smear results and ethnic origin of the index case on the notification form, clearly classifying contacts as close or causal, and clearly defining the term highly infectious.",0,0,
224,Australian and New Zealand clinical practice guidelines for the treatment of depression,"BACKGROUND: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health. METHOD: The CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted meta-analyses of outcome research. TREATMENT RECOMMENDATIONS: Establish an effective therapeutic relationship""; provide the patient with information about the condition, the rationale for treatment, the likelihood of a positive response and the expected timeframe; consider the patient's strengths, life stresses and supports. Treatment choice depends on the clinician's skills and the patient's circumstances and preferences, and should be guided but not determined by these guidelines. In moderately severe depression, all recognized antidepressants, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are equally effective;"" clinicians should consider treatment burdens as well as benefits, including side-effects and toxicity. In severe depression, antidepressant treatment should precede psychological therapy. For depression with psychosis, electroconvulsive therapy (ECT) or a tricyclic combined with an antipsychotic are equally helpful. Treatments for other subtypes are discussed. Caution is necessary in people on other medication or with medical conditions. If response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. Second opinions are useful. Depression has a high rate of recurrence and efforts to reduce this are crucial.",0,0,
225,Author disclosure of conflict of interest in vascular surgery journals,"OBJECTIVES: Advances in vascular surgery are increasingly technology-driven, and the relationships between surgeons and the medical device industry can be complex. This study reviewed conflict of interest (COI) disclosure in the vascular surgery journals regarding several selected technology-driven topics, including endovascular stent grafts (EV), carotid artery stenting (CAS), and peripheral arterial interventions (PI), to suggest further directions. METHODS: Authors' COI disclosures were reviewed from all clinical papers published in 2008 and 2009 in each of six vascular surgery journals, and pertaining to three selected topics (EV, CAS, and PI). Rate of COI disclosure was evaluated as a function of journal, topic, article type (randomized trial, case series, case report, review, or meta-analysis), and authors' region of origin. Secondarily, consistency of authors' disclosure was evaluated by reviewing papers by the same author and of the same topic. RESULTS: Six hundred thirty-five papers were reviewed from the six journals. A COI was declared in 125 (19.7%) of these papers. This rate differed between journals (range, 3.2%-34.1%""; P < .0001). Rate of disclosure did not differ between topics (range, 12.8%-21.2%; P = .12), article type (range, 14.7%-30%; P = .28), or region of origin (range, 0%-33.3%;"" P = .09). There were 116 instances of the same author writing papers describing the same general topic. COI disclosure was consistent in the majority of these instances (72.4%), but inconsistent in 32 cases (27.6%). The most common (P = .006) inconsistencies involved the same type of article in different journals (46.9%), or in the same journal (25%). CONCLUSIONS: Rates of disclosure of COI, and inconsistencies in disclosure in the vascular surgery literature are at least partially due to differences in journals' reporting policies, while a smaller proportion of these inconsistencies are due to individual author behavior. Journals should adopt a consistent requirement for a separate COI declaration where all relevant financial arrangements are disclosed.",0,0,
226,Authors’ response: hand washing is about respect for patients,,0,0,
227,Automated hand hygiene auditing with and without an intervention,"BACKGROUND: Daily feedback from continuous automated auditing with a peer reminder intervention was used to improve compliance. Compliance rates from covert and overt automated auditing phases with and without intervention were compared with human mandatory audits. METHODS: An automated system was installed to covertly detect hand hygiene events with each depression of the alcohol-based handrub dispenser for 5 months. The overt phase included key clinicians trained to share daily rates with clinicians, set compliance goals, and nudge each other to comply for 6 months. During a further 6 months, the intervention continued without being refreshed. Hand Hygiene Australia (HHA) human audits were performed quarterly during the intervention in accordance with the World Health Organization guidelines. Percentage point (PP) differences between compliance rates were used to determine change. RESULTS: HHA rates for June 2014 were 85% and 87% on the medical and surgical wards, respectively. These rates were 55 PPs and 38 PPs higher than covert automation rates for June 2014 on the medical and surgical ward at 30% and 49%, respectively. During the intervention phase, average compliance did not change on the medical ward from their covert rate, whereas the surgical ward improved compared with the covert phase by 11 PPs to 60%. On average, compliance during the intervention without being refreshed did not change on the medical ward, whereas the average rate on the surgical ward declined by 9 PPs. CONCLUSIONS: Automation provided a unique opportunity to respond to daily rates, but compliance will return to preintervention levels once active intervention ceases or human auditors leave the ward, unless clinicians are committed to change.",1,1,
228,Automated Identification of Postoperative Complications Within an Electronic Medical Record Using Natural Language Processing,"Context Currently most automated methods to identify patient safety occurrences rely on administrative data codes"";"" however, free-text searches of electronic medical records could represent an additional surveillance approach.  Objective To evaluate a natural language processing search–approach to identify postoperative surgical complications within a comprehensive electronic medical record.  Design, Setting, and Patients Cross-sectional study involving 2974 patients undergoing inpatient surgical procedures at 6 Veterans Health Administration (VHA) medical centers from 1999 to 2006.  Main Outcome Measures Postoperative occurrences of acute renal failure requiring dialysis, deep vein thrombosis, pulmonary embolism, sepsis, pneumonia, or myocardial infarction identified through medical record review as part of the VA Surgical Quality Improvement Program. We determined the sensitivity and specificity of the natural language processing approach to identify these complications and compared its performance with patient safety indicators that use discharge coding information.  Results The proportion of postoperative events for each sample was 2% (39 of 1924) for acute renal failure requiring dialysis, 0.7% (18 of 2327) for pulmonary embolism, 1% (29 of 2327) for deep vein thrombosis, 7% (61 of 866) for sepsis, 16% (222 of 1405) for pneumonia, and 2% (35 of 1822) for myocardial infarction. Natural language processing correctly identified 82% (95% confidence interval [CI], 67%-91%) of acute renal failure cases compared with 38% (95% CI, 25%-54%) for patient safety indicators. Similar results were obtained for venous thromboembolism (59%, 95% CI, 44%-72% vs 46%, 95% CI, 32%-60%), pneumonia (64%, 95% CI, 58%-70% vs 5%, 95% CI, 3%-9%), sepsis (89%, 95% CI, 78%-94% vs 34%, 95% CI, 24%-47%), and postoperative myocardial infarction (91%, 95% CI, 78%-97%) vs 89%, 95% CI, 74%-96%). Both natural language processing and patient safety indicators were highly specific for these diagnoses.  Conclusion Among patients undergoing inpatient surgical procedures at VA medical centers, natural language processing analysis of electronic medical records to identify postoperative complications had higher sensitivity and lower specificity compared with patient safety indicators based on discharge coding.",0,0,
229,Availability and prescription practice of anti-malaria drugs in the private health sector in Yemen,"INTRODUCTION: Although the government of Yemen changed the national policy for treating malaria in November 2005 from chloroquine to combination drugs in the form of artesunate + sulphadoxine-pyrimethamine (SP) as first line and lumefantrine + artemether as second line treatment for uncomplicated malaria, clinicians in public and private health facilities continued to prescribe chloroquine because their knowledge about the new treatment policy was poor. METHODOLOGY: A non-randomized trial of pre- and post-evaluation of the training and reporting interventions about prescription behaviors and availability of anti-malaria drugs among clinicians and pharmacists in the private sector in three governorates in Yemen was conducted. RESULTS: Adherence of clinicians in the private sector to the new national guidelines for anti-malaria drugs improved from 21% in pre-intervention period to 38% after the intervention for artesunate + SP being prescribed as the first-line treatment. Prescription of lumefantrine + artemether as the second-line anti-malaria treatment was also improved from 18% before the intervention to 22% post-intervention. Unfortunately the combination of halofantrine + SP continued to be frequently prescribed by clinicians in Sana'a city (18%). Artesunate + SP and quinine are increasing their marketing significantly from 8% in the pre-intervention period to 22% post-intervention (P-value 0.001). CONCLUSIONS: The study provides evidence of usefulness of the training intervention on the national guidelines for malaria treatment. Additionally, the involvement of private health-care providers in reporting procedures will promote the rational prescription and availability of anti-malaria drugs.",0,0,
230,Available screening tools for adults suffering from bipolar affective disorder in primary care: An integrative literature review,"PURPOSE: To assess the efficacy of six tools utilized in primary care for the screening of bipolar affective disorder (BPAD). BPAD has historically been underdiagnosed or misdiagnosed followed by inappropriate treatment leading to detrimental relapses, suicide, and increased risks for comorbidities. DATA SOURCES: An electronic search was conducted to identify articles in the following databases: MEDLINE, CINAHL, Cochrane Library, ERIC, National Guideline Clearinghouse, PsycINFO, Psychology and Behavioral Sciences collection, and PsycARTICLES. Other information was also collected from the NIH, CDC, Healthy People 2020, the Black Dog Institute, and the Center for Quality Assessment and Improvement for Mental Health. CONCLUSION: Evidence indicates that primary care providers are often the first and sometimes sole provider, which signifies the importance of early detection and screening of BPAD in primary care. By implementing the use of appropriate screening tools and following recommended treatment and intervention guidelines, the prevention of relapse is increased, and comorbidities are more frequently diagnosed leading to an overall improved quality of life. IMPLICATIONS FOR PRACTICE: Primary care practitioners play a vital role in appropriately screening for BPAD and implementing the recommended treatments to increase prevention of relapse and promote a healthier and more socially successful quality of life.",0,0,
231,Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study,"BACKGROUND: Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit. METHODS: A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance""; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005). RESULTS: Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice;"" (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler). CONCLUSIONS: Findings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.",0,0,
232,Barriers and Facilitators Associated with Non-Surgical Treatment Use for Osteoarthritis Patients in Orthopaedic Practice,"INTRODUCTION: International evidence-based guidelines for the management of patients with hip and knee osteoarthritis (OA) recommend to start with (a combination of) non-surgical treatments, and using surgical intervention only if a patient does not respond sufficiently to non-surgical treatment options. Despite these recommendations, there are strong indications that non-surgical treatments are not optimally used in orthopaedic practice. To improve the adoption of non-surgical treatments, more insight is needed into barriers and facilitators of these treatments. Therefore, this study assessed which barriers and facilitators are associated with the use and prescription of different non-surgical treatments before hip and knee OA in orthopaedic practice among patients and orthopaedic surgeons in the Netherlands. MATERIALS AND METHODS: We performed two internet-based surveys among 172 orthopaedic surgeons and 174 OA patients. Univariate association and multivariable regression techniques are used to identify barriers and facilitators associated with the use of non-surgical treatments. RESULTS: Most barriers and facilitators among patients were associated with the use of physical therapy, lifestyle advice and dietary therapy. Among orthopaedic surgeons, most were associated with prescription of acetaminophen, dietary therapy and physical therapy. Examples of barriers and facilitators among patients included ""People in my environment had positive experiences with a surgery"" (facilitator for education about OA), and ""Advice of people in my environment to keep on moving"" (facilitator for lifestyle and dietary advice). For orthopaedic surgeons, examples were ""Lack of knowledge about guideline"" (barrier for lifestyle advice), ""Agreements/ deliberations with primary care"" and ""Easy communication with a dietician"" (facilitators for dietary therapy). Also the belief in the efficacy of these treatments was associated with increased prescription. CONCLUSIONS: Strategies to improve non-surgical treatment use in orthopaedic practice should be targeted at changing the beliefs of orthopedic surgeons, communication with other OA care providers and involving patient's environment in OA treatment.",0,0,
233,Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study,"Background Veterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions.  Methods A qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs.  Results There was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs.  Conclusions Since program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings.",0,0,
234,Barriers to and enablers of evidence-based practice in perinatal care in the SEA-ORCHID project,"RATIONALE, AIMS AND OBJECTIVES: The South-East Asia Optimising Reproductive and Child Health in Developing Countries (SEA-ORCHID) project aimed to improve health outcomes for mothers and babies in nine hospitals in South-East Asia by supporting evidence-based perinatal health care. In this research, we aimed to identify and explore the factors that may have acted as barriers to or enablers of evidence-based practice change at each of the hospitals. METHODS: During the final 6 months of the intervention phase of the project, semi-structured, face-to-face interviews were undertaken with 179 nurses, midwives and doctors from the maternal and neonatal departments at each of the nine participating South-East Asian hospitals. RESULTS: The interviews identified several factors that participants believed had a substantial impact on the effectiveness of the SEA-ORCHID intervention. These included knowledge, skills, hierarchy, multidisciplinarity and leadership, beliefs about consequences, resources, and the nature of the behaviours. The success of the SEA-ORCHID intervention in improving practice may reflect the extent to which tailored strategies were effective in overcoming these barriers. CONCLUSION: Effective interventions to align practice with evidence rely on identifying and addressing barriers to practice change. The barriers identified in this study may be useful for those designing similar clinical practice improvement projects, as well as for continued efforts to improve practice in the SEA-ORCHID hospitals.",0,0,
235,Barriers to breast and cervical cancer screening in underserved women of the District of Columbia,"PURPOSE/OBJECTIVES: To identify barriers to breast and cervical cancer screening services from the perspective of medically underserved women of the District of Columbia (DC) that may influence intentions to perform breast and cervical cancer screening behaviors""; to determine any relationship between attitudes and influence of significant others on intended behaviors;"" and to identify a relationship between the site where services are provided and the underserved women's intentions to engage in screening behaviors. DESIGN: Cross-sectional, correlational. SETTING: Breast and cervical cancer screening clinics in DC. SAMPLE: 339 medically underserved, adult women. METHODS: Face-to-face investigator-conducted interviews. MAIN RESEARCH VARIABLES: Demographic and contextual variables as well as attitudes and influence of significant others. Intention to have a mammogram or Pap test or perform breast self-examination (BSE) monthly. FINDINGS: Intention to have a mammogram was positively related to influence of significant others and negatively related to uncaring healthcare professionals. Intention to have a Pap test had a positive relationship with one's attitude toward the test and with the influence of significant others. Intention to perform BSE was positively related to attitude toward and previous performance of BSE and influence of significant others. No significant relationships were observed between intention to perform screening behaviors and demographic variables. CONCLUSIONS: Factors that influence women's attitudes toward screening and intention to perform these behaviors include previous screening behaviors, influence of significant others, and relationships with healthcare professionals. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses are well-positioned to develop and test intervention strategies designed to increase access to and compliance with recommended screening guidelines among the medically underserved. Findings from this study potentially could guide development and evaluation of such strategies that are sensitive to this special population.",0,0,
236,Barriers to the implementation of preconception care guidelines as perceived by general practitioners: a qualitative study,"BACKGROUND: Despite strong evidence of the benefits of preconception interventions for improving pregnancy outcomes, the delivery and uptake of preconception care and periconceptional folate supplementation remain low. General practitioners play a central role in the delivery of preconception care. Understanding general practitioners' perceptions of the barriers and enablers to implementing preconception care allows for more appropriate targeting of quality improvement interventions. Consequently, the aim of this study was to examine the barriers and enablers to the delivery and uptake of preconception care guidelines from general practitioners' perspective using theoretical domains related to behaviour change. METHODS: We conducted a qualitative study using focus groups consisting of 22 general practitioners who were recruited from three regional general practice support organisations. Questions were based on the theoretical domain framework, which describes 12 domains related to behaviour change. General practitioners' responses were classified into predefined themes using a deductive process of thematic analysis. RESULTS: Beliefs about capabilities, motivations and goals, environmental context and resources, and memory, attention and decision making were the key domains identified in the barrier analysis. Some of the perceived barriers identified by general practitioners were time constraints, the lack of women presenting at the preconception stage, the numerous competing preventive priorities within the general practice setting, issues relating to the cost of and access to preconception care, and the lack of resources for assisting in the delivery of preconception care guidelines. Perceived enablers identified by general practitioners included the availability of preconception care checklists and patient brochures, handouts, and waiting room posters outlining the benefits and availability of preconception care consultations. CONCLUSIONS: Our study has identified some of the barriers and enablers to the delivery and uptake of preconception care guidelines, as perceived by general practitioners. Relating these barriers to a theoretical domain framework provides a clearer understanding of some of the psychological aspects that are involved in the behaviour of general practitioners towards the delivery and uptake of preconception care. Further research prioritising these barriers and the theoretical domains to which they relate to is necessary before a methodologically rigorous intervention can be designed, implemented, and evaluated.",0,0,
237,Barriers to the Use of Breast Cancer Risk Reduction Therapies,"Evidence from randomized clinical trials supports the use of tamoxifen, raloxifene, exemestane, and anastrozole for the reduction of risk of invasive breast cancer, predominately estrogen receptor-positive tumors. Revised clinical guidelines now strongly recommend that physicians offer high-risk women medication for breast cancer risk reduction. Although only a small portion of eligible women receive risk reduction medication, evidence suggests higher acceptance among women with atypical hyperplasia or lobular carcinoma in situ. Among physicians, barriers for prescribing risk reduction medications include inadequate training in risk assessment, lack of reimbursement for prevention counseling, and the unavailability of easily accessible and user-friendly prediction tools for estimating risk/benefit profiles. Strategies to improve uptake among women have focused on providing education about breast cancer risk and information that accurately conveys the risks and benefits of risk reduction medications. Priority areas of research that have been identified to improve the use of risk reduction medications are the (1) development of risk assessment tools that more accurately identify women most likely to benefit, (2) identification of circulating or tissue biomarkers that can predict and monitor responsiveness of treatment, and (3) better understanding of patient-related barriers, including patients' subjective beliefs and experiences.",0,0,
238,Baseline Depression Severity as Moderator of Depression Outcomes Between Cognitive Behavioral Therapy vs Pharmacotherapy: An Individual Patient Data Meta-analysis,"IMPORTANCE: Current guidelines recommend treating severe depression with pharmacotherapy. Randomized clinical trials as well as traditional meta-analyses have considerable limitations in testing for moderators of treatment outcomes. OBJECTIVES: To conduct a systematic literature search, collect primary data from trials, and analyze baseline depression severity as a moderator of treatment outcomes between cognitive behavioral therapy (CBT) and antidepressant medication (ADM). DATA SOURCES: A total of 14902 abstracts were examined from a comprehensive literature search in PubMed, PsycINFO, EMBASE, and Cochrane Registry of Controlled Trials from 1966 to January 1, 2014. STUDY SELECTION: Randomized clinical trials in which CBT and ADM were compared in patients with a DSM-defined depressive disorder were included. DATA EXTRACTION AND SYNTHESIS: Study authors were asked to provide primary data from their trial. Primary data from 16 of 24 identified trials (67%), with 1700 outpatients (794 from the CBT condition and 906 from the ADM condition), were included. Missing data were imputed with multiple imputation methods. Mixed-effects models adjusting for study-level differences were used to examine baseline depression severity as a moderator of treatment outcomes. MAIN OUTCOMES AND MEASURES: Seventeen-item Hamilton Rating Scale for Depression (HAM-D) and Beck Depression Inventory (BDI). RESULTS: There was a main effect of ADM over CBT on the HAM-D (beta = -0.88""; P = .03) and a nonsignificant trend on the BDI (beta = -1.14; P = .08, statistical test for trend), but no significant differences in response (odds ratio [OR], 1.24; P = .12) or remission (OR, 1.18; P = .22). Mixed-effects models using the HAM-D indicated that baseline depression severity does not moderate reductions in depressive symptoms between CBT and ADM at outcome (beta = 0.00; P = .96). Similar results were seen using the BDI. Baseline depression severity also did not moderate the likelihood of response (OR, 0.99; P = .77) or remission (OR, 1.00;"" P = .93) between CBT and ADM. CONCLUSIONS AND RELEVANCE: Baseline depression severity did not moderate differences between CBT and ADM on the HAM-D or BDI or in response or remission. This finding cannot be extrapolated to other psychotherapies, to individual ADMs, or to inpatients. However, it offers new and substantial evidence that is of relevance to researchers, physicians and therapists, and patients.",0,0,
239,Baseline feature of a randomized trial assessing the effects of disease management programs for the prevention of recurrent ischemic stroke,"BACKGROUND: Comprehensive and long-term patient education programs designed to improve self-management can help patients better manage their medical condition. Using disease management programs (DMPs) that were created for each of the risk factor according to clinical practice guidelines, we evaluate their influence on the prevention of stroke recurrence. METHODS: This is a randomized study conducted with ischemic stroke patients within 1 year from their onset. Subjects in the intervention group received a 6-month DMPs that included self-management education provided by a nurse along with support in collaboration with the primary care physician. Those in the usual care group received ordinary outpatient care. The primary end points are stroke recurrence and stroke death. Patients were enrolled for 2 years with plans for a 2-year follow-up after the 6-month education period (total of 30 months). RESULTS: A total of 321 eligible subjects (average age, 67.3 years"";"" females, 96 [29.9%]), including 21 subjects (6.5%) with transient ischemic attack, were enrolled in this study. Regarding risk factors for stroke, 260 subjects (81.0%) had hypertension, 249 subjects (77.6%) had dyslipidemia, 102 subjects (31.8%) had diabetes mellitus, 47 subjects (14.6%) had atrial fibrillation, and 98 subjects (30.5%) had chronic kidney disease. There were no significant differences between the 2 groups with respect to subject characteristics. CONCLUSIONS: This article describes the rationale, design, and baseline features of a randomized controlled trial that aimed to assess the effects of DMPs for the secondary prevention of stroke. Subject follow-up is in progress and will end in 2015.",0,0,
240,Befriending carers of people with dementia: randomised controlled trial,"OBJECTIVE To evaluate the effectiveness of a voluntary sector based befriending scheme in improving psychological wellbeing and quality of life for family carers of people with dementia. DESIGN Single blind randomised controlled trial. SETTING Community settings in East Anglia and London. PARTICIPANTS 236 family carers of people with primary progressive dementia. INTERVENTION Contact with a befriender facilitator and offer of match with a trained lay volunteer befriender compared with no befriender facilitator contact"";"" all participants continued to receive ""usual care."" MAIN OUTCOME MEASURES Carers' mood (hospital anxiety and depression scale-depression) and health related quality of life (EuroQoL) at 15 months post-randomisation. RESULTS The intention to treat analysis showed no benefit for the intervention ""access to a befriender facilitator"" on the primary outcome measure or on any of the secondary outcome measures. CONCLUSIONS In common with many carers' services, befriending schemes are not taken up by all carers, and providing access to a befriending scheme is not effective in improving wellbeing. Trial registration Current CONTROLLED TRIALS: ISRCTN08130075.",0,0,
241,Behavior change without behavior change communication: nudging handwashing among primary school students in Bangladesh.,"Behavior change communication for improving handwashing with soap can be labor and resource intensive, yet quality results are difficult to achieve. Nudges are environmental cues engaging unconscious decision-making processes to prompt behavior change. In this proof-of-concept study, we developed an inexpensive set of nudges to encourage handwashing with soap after toilet use in two primary schools in rural Bangladesh. We completed direct observation of behaviors at baseline, after providing traditional handwashing infrastructure, and at multiple time periods following targeted handwashing nudges (1 day, 2 weeks, and 6 weeks). No additional handwashing education or motivational messages were completed. Handwashing with soap among school children was low at baseline (4%), increasing to 68% the day after nudges were completed and 74% at both 2 weeks and 6 weeks post intervention. Results indicate that nudge-based interventions have the potential to improve handwashing with soap among school-aged children in Bangladesh and specific areas of further inquiry are discussed.",0,1,
242,Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force,"Background:Alcohol misuse, which includes the full spectrum from risky drinking to alcohol dependence, is a leading cause of preventable death in the United States.Purpose:To evaluate the benefits and harms of behavioral counseling interventions for adolescents and adults who misuse alcohol.Data Sources:MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and reference lists of published literature (January 1985 through January 2012, limited to English-language articles).Study Selection:Controlled trials at least 6 months' duration that enrolled persons with alcohol misuse identified by screening in primary care settings and evaluated behavioral counseling interventions.Data Extraction:One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings and graded the strength of the evidence.Data Synthesis:The 23 included trials generally excluded persons with alcohol dependence. The best evidence was for brief (10- to 15-minute) multicontact interventions. Among adults receiving behavioral interventions, consumption decreased by 3.6 drinks per week from baseline (weighted mean difference, 3.6 drinks/wk [95% CI, 2.4 to 4.8 drinks/wk]""; 10 trials; 4332 participants), 12% fewer adults reported heavy drinking episodes (risk difference, 0.12 [CI, 0.07 to 0.16]; 7 trials; 2737 participants), and 11% more adults reported drinking less than the recommended limits (risk difference, 0.11 [CI, 0.08 to 0.13]; 9 trials;"" 5973 participants) over 12 months compared with control participants (moderate strength of evidence). Evidence was insufficient to draw conclusions about accidents, injuries, or alcohol-related liver problems. Trials enrolling young adults or college students showed reduced consumption and fewer heavy drinking episodes (moderate strength of evidence). Little or no evidence of harms was found.Limitations:Results may be biased to the null because the behavior of control participants could have been affected by alcohol misuse assessments. In addition, evidence is probably inapplicable to persons with alcohol dependence and selective reporting may have occurred.Conclusion:Behavioral counseling interventions improve behavioral outcomes for adults with risky drinking.Primary Funding Source:Agency for Healthcare Research and Quality.",0,0,
243,Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement,"DESCRIPTION: New U.S. Preventive Services Task Force (USPSTF) recommendations about behavioral counseling of adolescents and adults to prevent sexually transmitted infections (STIs).METHODS: The USPSTF reviewed the evidence on the benefits and harms of counseling. The review included studies evaluating behavioral counseling interventions conducted in primary settings, those judged feasible in primary care, and those to which patients might be referred from primary care.RECOMMENDATIONS: The USPSTF recommends high-intensity behavioral counseling for all sexually active adolescents and for adults at increased risk for STIs. (B recommendation) Current evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in non-sexually active adolescents and in adults not at increased risk for STIs. (I statement).",0,0,
244,Behavioral Counseling to Promote Physical Activity and a Healthful Diet to Prevent Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force,"Background:Poor diet and lack of physical activity can worsen cardiovascular health, yet most Americans do not meet diet and physical activity recommendations.Purpose:To assist the U.S. Preventive Services Task Force in updating its previous recommendations by systematically reviewing trials of physical activity or dietary counseling to prevent cardiovascular disease.Data Sources:MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (2001 to January 2010), experts, and existing systematic reviews.Study Selection:Two investigators independently reviewed 13 562 abstracts and 481 articles against a set of a priori inclusion criteria and critically appraised each study by using design-specific quality criteria.Data Extraction and Analysis:Data from 73 studies (109 articles) were abstracted by one reviewer and checked by a second reviewer. Random-effects meta-analyses were conducted for multiple intermediate health and behavioral outcomes.Data Synthesis:Long-term observational follow-up of intensive sodium reduction counseling showed a decrease in the incidence of cardiovascular disease"";"" however, other direct evidence for reduction in disease morbidity is lacking. High-intensity dietary counseling, with or without physical activity counseling, resulted in changes of ?0.3 to ?0.7 kg/m2 in body mass index (adiposity), ?1.5 mm Hg (95% CI, ?0.9 to ?2.1 mm Hg) in systolic blood pressure, ?0.7 mm Hg (CI, ?0.6 to ?0.9 mm Hg) in diastolic pressure, ?0.17 mmol/L (CI, ?0.09 to ?0.25 mmol/L) (?6.56 mg/dL [CI, ?3.47 to ?9.65 mg/dL]) in total cholesterol level, and ?0.13 mmol/L (CI, ?0.06 to ?0.21 mmol/L) (?5.02 mg/dL [CI, ?2.32 to ?8.11 mg/dL]) in low-density lipoprotein cholesterol level. Medium- and high-intensity counseling resulted in moderate to large changes in self-reported dietary and physical activity behaviors.Limitations:Meta-analyses for some outcomes had large statistical heterogeneity or evidence for publication bias. Only 11 trials followed outcomes beyond 12 months.Conclusion:Counseling to improve diet or increase physical activity changed health behaviors and was associated with small improvements in adiposity, blood pressure, and lipid levels.Primary Funding Source:Agency for Healthcare Research and Quality.",0,0,
245,Behavioral economics and physician compensation—promise and challenges.,,0,1,
246,Behavioral programs for type 2 diabetes mellitus: a systematic review and network meta-analysis,"Background: Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. Purpose: To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. Data Sources: 6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists. Study Selection: Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. Data Extraction: One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. Data Synthesis: Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ¡Ý11 contact hours) led to clinically important improvements in glycemic control (¡Ý0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support¡ªespecially those offering 10 or fewer contact hours¡ªprovided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ¡Ý75% nonwhite participants). Limitations: All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. Conclusion: Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515)",0,0,
247,Behavioral Sexual Risk-Reduction Counseling in Primary Care to Prevent Sexually Transmitted Infections: A Systematic Review for the U.S. Preventive Services Task Force,"Background: Sexually transmitted infections (STIs) are common and preventable. Purpose: To update a previous systematic review about the benefits and harms of sexual risk-reduction counseling to prevent STIs for the U.S. Preventive Services Task Force. Data Sources: Selected databases from January 2007 through October 2013, manual searches of references lists and gray literature, and studies from the previous review. Study Selection: English-language fair- or good-quality trials conducted in adolescents or adults. Data Extraction: One investigator abstracted data and a second checked the abstraction. Study quality was dual-reviewed. Data Synthesis: 31 trials were included: 16 (n = 56 110) were newly published and 15 (n = 14 214) were from the previous review. Most trials targeted persons at increased risk for STIs based on sociodemographic characteristics, risky sexual behavior, or history of an STI. High-intensity (>2 hours) interventions reduced STI incidence in adolescents (odds ratio, 0.38 [95% CI, 0.24 to 0.60]) and adults (odds ratio, 0.70 [CI, 0.56 to 0.87]). Lower-intensity interventions were generally not effective in adults, but some approaches were promising. Although moderate-intensity interventions may be effective in adolescents, data were very sparse. Reported behavioral outcomes were heterogeneous and most likely to show a benefit with high-intensity interventions at 6 months or less. No consistent evidence was found that sexual risk-reduction counseling was harmful. Limitations: Low-risk populations and male adolescents were underrepresented. Reliability of self-reported behavioral outcomes was unknown. Conclusion: High-intensity counseling on sexual risk reduction can reduce STIs in primary care and related settings, especially in sexually active adolescents and in adults at increased risk for STIs. Primary Funding Source: Agency for Healthcare Research and Quality.",0,0,
248,Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence,"Context Although behavioral therapy has been shown to improve postoperative recovery of continence, there have been no controlled trials of behavioral therapy for postprostatectomy incontinence persisting more than 1 year.  Objective To evaluate the effectiveness of behavioral therapy for reducing persistent postprostatectomy incontinence and to determine whether the technologies of biofeedback and pelvic floor electrical stimulation enhance the effectiveness of behavioral therapy.  Design, Setting, and Participants A prospective randomized controlled trial involving 208 community-dwelling men aged 51 through 84 years with incontinence persisting 1 to 17 years after radical prostatectomy was conducted at a university and 2 Veterans Affairs continence clinics (2003-2008) and included a 1-year follow-up after active treatment. Twenty-four percent of the men were African American""; 75%, white.  Interventions After stratification by type and frequency of incontinence, participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20 Hz, current up to 100 mA (behavior plus); or delayed treatment, which served as the control group.  Main Outcome Measure Percentage reduction in mean number of incontinence episodes after 8 weeks of treatment as documented in 7-day bladder diaries.  Results Mean incontinence episodes decreased from 28 to 13 per week (55% reduction; 95% confidence interval [CI], 44%-66%) after behavioral therapy and from 26 to 12 (51% reduction; 95% CI, 37%-65%) after behavior plus therapy. Both reductions were significantly greater than the reduction from 25 to 21 (24% reduction; 95% CI, 10%-39%) observed among controls (P = .001 for both treatment groups). However, there was no significant difference in incontinence reduction between the treatment groups (P = .69). Improvements were durable to 12 months in the active treatment groups: 50% reduction (95% CI, 39.8%-61.1%; 13.5 episodes per week) in the behavioral group and 59% reduction (95% CI, 45.0%-73.1%;"" 9.1 episodes per week) in the behavior plus group (P = .32).  Conclusions Among patients with postprostatectomy incontinence for at least 1 year, 8 weeks of behavioral therapy, compared with a delayed-treatment control, resulted in fewer incontinence episodes. The addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness.",0,0,
249,Behavioral treatment of obesity in patients encountered in primary care settings: a systematic review,"IMPORTANCE: In 2011, the Centers for Medicare & Medicaid Services (CMS) approved intensive behavioral weight loss counseling for approximately 14 face-to-face, 10- to 15-minute sessions over 6 months for obese beneficiaries in primary care settings, when delivered by physicians and other CMS-defined primary care practitioners. OBJECTIVE: To conduct a systematic review of behavioral counseling for overweight and obese patients recruited from primary care, as delivered by primary care practitioners working alone or with trained interventionists (eg, medical assistants, registered dietitians), or by trained interventionists working independently. EVIDENCE REVIEW: We searched PubMed, CINAHL, and EMBASE for randomized controlled trials published between January 1980 and June 2014 that recruited overweight and obese patients from primary care""; provided behavioral counseling (ie, diet, exercise, and behavioral therapy) for at least 3 months, with at least 6 months of postrandomization follow-up; included at least 15 participants per treatment group and objectively measured weights;"" and had a comparator, an intention-to-treat analysis, and attrition of less than 30% at 1 year or less than 40% at longer follow-up. FINDINGS: Review of 3304 abstracts yielded 12 trials, involving 3893 participants, that met inclusion-exclusion criteria and prespecified quality ratings. No studies were found in which primary care practitioners delivered counseling that followed the CMS guidelines. Mean 6-month weight changes from baseline in the intervention groups ranged from a loss of 0.3 kg to 6.6 kg. In the control group, mean change ranged from a gain of 0.9 kg to a loss of 2.0 kg. Weight loss in both groups generally declined with longer follow-up (12-24 months). Interventions that prescribed both reduced energy intake (eg, >/= 500 kcal/d) and increased physical activity (eg, >/=150 minutes a week of walking), with traditional behavioral therapy, generally produced larger weight loss than interventions without all 3 specific components. In the former trials, more treatment sessions, delivered in person or by telephone by trained interventionists, were associated with greater mean weight loss and likelihood of patients losing 5% or more of baseline weight. CONCLUSIONS AND RELEVANCE: Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on primary care practitioners providing such care. The present findings suggest that a range of trained interventionists, who deliver counseling in person or by telephone, could be considered for treating overweight or obesity in patients encountered in primary care settings.",0,0,
250,Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme,"BACKGROUND: The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. METHODS: Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. RESULTS: There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation. CONCLUSIONS: The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.",0,0,
251,Behavioural insights in health care,,0,1,
252,Beliefs and attitudes about breast cancer and screening practices among Arab women living in Qatar: a cross-sectional study,"BACKGROUND: Despite rising breast cancer incidence and mortality rates, breast cancer screening (BCS) rates among women in Qatar remain low. Previous studies indicate the need to better understand the many complex beliefs, values, and attitudes that influence Arab women's health seeking behavior for the development of culturally appropriate and effective intervention strategies to address breast cancer in the Middle East. This study investigates beliefs, attitudes, and BCS practices of Arabic-speaking women in Qatar. METHODS: A multicenter, cross-sectional quantitative survey of 1,063 (87.5% response rate) Arabic-speaking female Qatari citizens and non-Qatari residents, 35 years of age or older, was conducted in Qatar from March 2011 to July 2011. Associations between beliefs and BCS practice were estimated using chi-square tests and multivariate logistic regression analyses. Participants who adhered to BCS guidelines (BCS practice = Yes) were compared to those who did not (BCS practice = No). RESULTS: In addition to low levels of awareness and low participation rates in BCS, one quarter of the participants stated their doctors talked to them about breast cancer, and less than half of the women interviewed believed breast cancer can be prevented. Women who engaged in BCS practice were more likely to have a doctor who talked to them about breast cancer, to believe they were in good-excellent health, that cancer can be prevented, or that cancer might be hereditary. The majority wanted to know if they had cancer and felt their health care needs were being met. The main reasons given for not planning BCS were lack of a doctor's recommendation, fear, and embarrassment. CONCLUSIONS: These findings indicate that a variety of channels (health care providers, media, breast cancer survivors, community leaders) should be utilized to create culturally appropriate breast cancer intervention programs and increased awareness of breast cancer, BCS, and the benefits of early detection of breast cancer. Employment of these measures will reduce breast cancer mortality rates among Arabic-speaking women living in the State of Qatar.",0,0,
253,Beliefs regarding mammography screening among women visiting the emergency department for nonurgent care,"INTRODUCTION: One in 8 US women will develop invasive breast cancer in their lifetime. Despite evidence that mammography is an effective method of early detection, certain vulnerable groups, such as those using the emergency department as a medical home, do not adhere to mammography screening guidelines, and suffer disparate mortality from breast cancer. The purpose of this study was to investigate differences in beliefs regarding mammography screening among women attending the emergency department for nonurgent care and ultimately to develop interventions that promote mammography for this vulnerable population. METHODS: We explored the relationship between stage of readiness to adopt mammography behavior and barriers, benefits, and perceived susceptibility by administering scales for risk, benefits, and barriers to a sample of 110 women who had presented to the emergency department of a public hospital for nonurgent complaints or were seated in the ED waiting room. We also collected sociodemographic information and stage of readiness. RESULTS: Mammography adherence was about 60%. Most women who were not compliant with current guidelines were contemplators. Those who were not contemplating being screened were significantly less likely to perceive themselves to be at risk of getting breast cancer. Women who had more barriers to mammography perceived less benefit from having a mammogram. African American women perceived less benefit from having a mammogram. DISCUSSION: Mammography promotion is appropriately placed in the ED waiting room given the suboptimal rate at which this population is being screened. Beliefs regarding mammography differ for women in various stages of mammography adoption and for minority women. Understanding these differences will allow intervention in this setting to be tailored to the population. ED nurses are an important and sometimes sole point of health care contact for patients who routinely visit the emergency department. As such, they have a valuable opportunity to provide cancer screening promotion messages. It is critical that nurses in this setting understand the complexities of delivering this information and the need to do so.",0,0,
254,Beneficial and harmful effects of augmented feedback on physicians' clinical-teaching performances,"PURPOSE: To evaluate whether clinical-teaching skills could be improved by providing teachers with augmented student feedback. METHOD: A randomized, controlled trial in 1994 included 42 attending physicians and 39 residents from the Department of Medicine at the Indiana University School of Medicine who taught 110 students on medicine ward rotations for one-month periods. Before teaching rotations, intervention group teachers received norm-referenced, graphic summaries of their teaching performances as rated by students. At mid-month, intervention group teachers received students' ratings augmented by individualized teaching-effectiveness guidelines based on the Stanford Faculty Development Program framework. Linear models were used to analyze the students' mean ratings of teaching behaviors at mid-month and end-of-month. Independent variables included performance ratings, intervention status, teacher status, teaching experience, and interactions with baseline ratings. RESULTS: Complex interactions with baseline performance were found for most teaching categories at mid-month and end-of-month. The intervention-group teachers who had high baseline performance scores had higher student ratings than did the control group teachers with similar baseline scores""; the intervention group teachers who had low baseline performance scores were rated lower than were the control group teachers with comparable baseline scores. The residents who had medium or high baseline scores were rated higher than were the attending physicians with comparable baseline scores;"" the performance of the residents who had low baseline scores was similar to that of the attending physicians with comparable baseline scores. CONCLUSION: Baseline performance is important for targeting those teachers most likely to benefit from augmented student feedback. Potential deterioration in teaching performance warrants a reconsideration of distributing students' ratings to teachers with low baseline performance scores.",0,0,
255,Benefits and Harms of Pharmacologic Treatment for Urinary Incontinence in Women,"Background: Urinary incontinence (UI) in women adversely affects quality of life. Purpose: To conduct a systematic literature review of drugs for urgency UI in women. Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, SCIRUS, and Google Scholar were searched for articles published from 1966 to November 2011. Study Selection: Randomized, controlled trials (RCTs) reported in English. Data Extraction: Rates of outcomes and risk of bias were extracted by using a standardized form to pool absolute risk differences and calculate the number of attributable events per 1000 patients treated, with 95% CIs. Data Synthesis: 94 RCTs were eligible. Pooled analyses showed that among drugs for urgency UI, per 1000 treated women, continence was restored in 130 with fesoterodine (CI, 58 to 202), 85 with tolterodine (CI, 40 to 129), 114 with oxybutynin (CI, 64 to 163), 107 with solifenacin (CI, 58 to 156), and 114 with trospium (CI, 83 to 144). Rates of treatment discontinuation due to adverse effects were 31 per 1000 treated with fesoterodine (CI, 10 to 56), 63 with oxybutynin (CI, 12 to 127), 18 with trospium (CI, 4 to 33), and 13 with solifenacin (CI, 1 to 26). The studies' inconsistent definitions of reduction in UI and quality of life hampered synthesis of evidence. Limitation: Evidence for quality-of-life improvements and comparative effectiveness with drugs was limited, and evidence for the effects of race, baseline severity of UI, and comorbid conditions on treatment success was insufficient. Conclusion: Overall, drugs for urgency UI showed similar small benefit. Therapeutic choices should consider the harms profile. Evidence for long-term adherence and safety of treatments is lacking. Primary Funding Source: Agency for Healthcare Research and Quality.",0,0,
256,"Benzodiazepines, opioids and driving: an overview of the experimental research","ISSUES: Road crashes contribute significantly to the total burden of injury in Australia, with the risk of injury being associated with the presence of drugs and/or alcohol in the driver's blood. Increasingly, some of the most commonly detected drugs include prescription medicines, the most notable of these being benzodiazepines and opioids. However, there is a paucity of experimental research into the effects of prescribed psychoactive drugs on driving behaviours. APPROACH: This paper provides an overview of experimental studies investigating the effects of prescribed doses of benzodiazepines and opioids on driving ability, and points to future directions for research. KEY FINDINGS: There is growing epidemiological evidence linking the therapeutic use of benzodiazepines and opioids to an increased crash risk. However, the current experimental literature remains unclear. Limitations to study methodologies have resulted in inconsistent findings. IMPLICATIONS: Limited experimental evidence exists to inform policy and guidelines regarding fitness-to-drive for patients taking prescribed benzodiazepines and opioids. CONCLUSION: Further experimental research is required to elucidate the effects of these medications on driving, under varying conditions and in different medical contexts. This will ensure that doctors prescribing benzodiazepines and opioids are well informed, and can appropriately advise patients of the risks associated with driving whilst taking these medications.",0,0,
257,Bereavement interventions for adults with intellectual disabilities: what works?,"Examination of the theory base for bereavement and loss is currently just beginning for adults with intellectual disabilities (ID). Yet, as life spans increase for individuals with ID, these adults experience more and more loss and bereavement events. Practitioners, especially grief counselors, are finding it increasingly critical for them to understand best practice principles for working with bereaved adults with ID in their daily work. Practitioners also are asked to guide families and care providers regarding grief and death education. This article provides counselors and other professionals with a review of existing bereavement intervention research for adults with ID. Practice recommendations are made on three levels: informal support""; formal intervention;"" and community education.",0,0,
258,Best practice in the management of primary nocturnal enuresis in children: a systematic review,"OBJECTIVE: Nocturnal enuresis is the involuntary loss of urine at night in a child of an age and physical health where they would be expected to be dry. The prevalence of this condition in Australia has been estimated at 18.9% in children 5 to 12 years of age, with up to 19% of boys and 16% of girls aged 5 years wetting the bed at least once per month. Up to the age of 13 years bedwetting is more common in boys and more common in girls after this age. Nocturnal enuresis has a spontaneous cure rate of approximately 14% however up to 3% of children remain enuretic as adults. Although this condition is pathologically benign, it can have serious social and psychological repercussions for the sufferer including affects on self esteem, school success, parental disapproval and even sexual activity in later life. Despite the volume of information available for the management of enuresis, the majority of research has been conducted outside Australia. Therefore, the purpose of this work was to produce management guidelines for nocturnal enuresis in children specific to Australian clinical practice. INCLUSION CRITERIA: This review considered systematic reviews or concurrently controlled trials (randomised controlled trials (RCT), pseudo-randomised controlled trials, controlled clinical trials (CCT), interrupted time series (ITS) and controlled before and after trials (CBA)), for examining effectiveness of interventions to manage nocturnal enuresis in children up to the age of 16 years. SEARCH STRATEGY: A systematic search of the literature was performed to identify all available evidence. Cochrane and other health technology assessment websites were searched for existing systematic reviews. For recent randomised controlled trials and controlled trials (1990 to 2007) Pubmed, Embase, and CINAHL databases were searched. Reference lists of all retrieved articles were searched for relevant trials. These reviews and guidelines were summarised and presented to an advisory panel of nurse continence advisors and clinicians to ensure relevance to Australian clinical practice. METHODOLOGICAL QUALITY: Methodological quality of all studies was assessed by two reviewers using the JBI critical appraisal forms for experimental studies located within the JBI-MAStARI software. This tool was used to identify all sources of bias. Where disagreement existed between the two reviewers a third reviewer adjudicated. RESULTS: Seven systematic reviews, eight new trials and two guidelines were used in the development of these guidelines.Briefly management recommendations include: CONCLUSIONS: Despite the high prevalence of nocturnal enuresis and the negative psychosocial sequelae that can arise from this condition, management is both readily available and effective. IMPLICATIONS FOR PRACTICE: The practice of managing nocturnal enuresis in children should start with addressing both daytime wetting and any evidence of constipation. Following this, less invasive behavioural therapies should be attempted. If these measures fail then the use of alarms with or without short-term administration of desmopressin could be attempted. Other interventions have yet to be proven to be definitively effective and should be considered with caution.It should be emphasized however, that the vast majority of children will become continent at some future time point, with or without the benefit of interventions. IMPLICATIONS FOR RESEARCH: While it is clear that some behavioural methods, alarms and desmopressin can be effective interventions, the evidence for other treatments is not so definitive. The observation however that even alarms and/or desmopressin do not work for all children suggests that research to establish the effectiveness of other interventions (especially behavioural and complementary treatments) should be performed in the form of large, carefully designed RCTs.",0,0,
259,Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial,"Background The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ¡®point of care¡¯ management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.  Design/methods We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma¡ªthe proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge"";"" and Gastroenteritis¡ªthe proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.  Discussion This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.",0,0,
260,Best-practice intervention for care of clients who self-mutilate,"PURPOSE: To describe the development of a best practice intervention to guide nurse practitioners (NPs) who care for individuals who self-mutilate. DATA SOURCES: The evidence on which the guideline was based includes six descriptive studies and expert clinical opinion articles. The framework for development of the guideline is a systematic process to obtain and analyze the best available evidence, develop a theory-driven intervention, and propose a system for ongoing evaluation of the effectiveness of the intervention. CONCLUSIONS: The guideline is an information sheet, containing the definition of self-mutilation, background of the problem, target population affected, and intervention. The three components of the intervention are (a) the NP's self-evaluation of values, beliefs, and assumptions about individuals who self-mutilate""; (b) a focused, in-depth assessment of the client;"" and (c) therapeutic strategies to address the emotional, social, and biological dimensions of self-mutilation. IMPLICATIONS FOR PRACTICE: This Best-Practice Intervention for Care of Clients Who Self-Mutilate guideline provides direction for NPs to address a preventable, self-injury behavior effectively. Further study is needed to examine the effectiveness of the use of the guideline and the intervention.",0,0,
261,Better medicine by default,"Background. American health care is transitioning to electronic physician ordering. These computerized systems are unique because they allow custom order interfaces. Although these systems provide great benefits, there are also potential pitfalls, as the behavioral sciences have shown that the very format of electronic interfaces can influence decision making. The current research specifically examines how defaults in electronic order templates affect physicians’ treatment decisions and medical errors. Methods. Forty-five medical residents completed order sets for 3 medical case studies. Participants were randomly assigned to receive order sets with either “opt-in” defaults (options visible but unselected) or “opt-out” defaults (options visible and preselected). Results compare error rates between conditions and examine the type and severity of errors most often made with opt-in versus opt-out defaults. Results. Opt-out defaults resulted in a greater number of items ordered and specifically increased commission errors (overordering) compared with opt-in defaults. However, while opt-in defaults resulted in fewer orders, they also increased omission errors. When the severity of the errors is taken into account, the default effects seem limited to less severe errors. Conclusion. The defaults used in electronic order sets influence medical treatment decisions when the consequences to a patient’s health are low. This pattern suggests that physicians cognitively override incorrect default choices but only to a point, and it implies tradeoffs that maximize accuracy and minimize cognitive effort. Results indicate that defaults for low-impact items on electronic templates warrant careful attention because physicians are unlikely to override them.",1,1,
262,Better practices in collaborative mental health care: an analysis of the evidence base,"OBJECTIVES: To conduct a systematic review of the experimental literature in order to identify better practices in collaborative mental health care in the primary care setting. METHODS: A review of Canadian and international literature using Medline, PsycInfo, Embase, the Cochrane Library, and other databases yielded over 900 related reports, of which, 38 studies met the inclusion criteria. A systematic review and descriptive analysis is presented, with key conclusions and best practices. RESULTS: Successful collaboration requires preparation, time, and supportive structures, building on preexisting clinical relationships. Collaborative practice is likely to be most developed when clinicians are colocated and most effective when the location is familiar and nonstigmatizing for patients. Degree of collaboration does not appear to predict clinical outcome. Enhanced collaboration paired with treatment guidelines or protocols offers important benefits over either intervention alone in major depression. Systematic follow-up was a powerful predictor of positive outcome in collaborative care for depression. A clear relation between collaborative efforts to increase medication adherence and clinical outcomes was not evident. Collaboration alone has not been shown to produce skill transfer in PCP knowledge or behaviours in the treatment of depression. Service restructuring designed to support changes in practice patterns of primary health care providers is also required. Enhanced patient education was part of many studies with good outcomes. Education was generally provided by someone other than the PCP. Collaborative interventions that are part of a research protocol may be difficult to sustain long-term without ongoing funding. Consumer choice about treatment modality may be important in treatment engagement in collaborative care (for example, having the option to choose psychotherapy vs medication). CONCLUSIONS: A body of experimental literature evaluating the impact of enhanced collaboration on patient outcomes-primarily in depressive disorders-now exists. Better practices in collaborative mental health care are beginning to emerge.",0,0,
263,Between collegial conversation and controlled trials: hospital-based neurologists' sources of information and their practical knowledge in the treatment of stroke patients,"The application of evidence-based and standardized knowledge is an important basis for coordinated and effective clinical work. A multicenter study, which was conducted in 30 clinical neurology departments and included 99 junior and senior registrars, addressed aspects of practical knowledge of stroke treatment by open structured oral interviews which were analyzed with respect to interphysician and guideline conformity. In addition, the participants were asked to rate the usefulness of various informational sources and describe their informational sources used according to the aspects of practical knowledge addressed. The respective departmental directors were questioned about the sources of medical knowledge accessible in their clinic. In almost all hospitals, physicians had access to a library and the Internet. However, departments differed with respect to their information management (frequency and type of medical education, quality management, participation in research activities). In accordance with other studies, the knowledge sources reported most often were textbooks, journals and clinical studies. For most sources, the usefulness rankings largely corresponded to the rankings of user behavior. Both were only weak predictors for interphysician and guideline conformity. They are more closely related to the within-department homogeneity of practical knowledge than to interdepartmental and guideline conformity. Within-department homogeneity is enhanced by the use of recent, published and evidence-based sources and topical interaction with clinical colleagues. Guideline conformity was related to the use of databases and professional journals. A preference for colleagues from out-patient practices diminished both interphysician and guideline conformity. It seems there is still untapped potential for within-department knowledge management, such as medical education, implementation and use of guidelines and topical discussions, which may enhance the homogeneity and guideline conformity of the practical knowledge that clinicians apply.",0,0,
264,Between control and therapy: an evolutionary concept analysis of special observation in acute psychiatric wards,"OBJECTIVE: Special observation is a seriously invasive and resource intensive intervention. It is necessary to scientifically conceptualise this measure for further investigations and practice. METHODS: Evolutionary concept analysis. RESULTS: The identified antecedents, attributes and consequences of special observation range between control and therapy as well as the safety of patients and the coverage of the professionals. Antecedents comprise of legitimisation (indication, assessment, prescription), resources (internal guidelines, architectural structures, information) as well as context factors (security needs, personal attitudes). The identified attitudes are organisation (qualification, shifting carers, length, place), intervention (relationship, re-assessment, transparency) as well as the field of tension between control and therapy. The consequences consist of side effects (patients, nurses, resources) and conflicts (ethical dilemmas, role conflicts). CONCLUSION: Society and discipline have influenced the concept over time and a distinction between the custodial and controlling pattern versus a therapeutic approach is recommended.",0,0,
265,Between scientific application and therapy: the ethical consideration,"The development of bioscience and biotechnology during the last thirty years exerted a tremendous influence on medicine. New techniques have risen and new kinds of treatment have been and still are introduced. The theories concerning the pathogenesis and the causes of disease change, while new therapeutical drug become constantly available on the market. The way in which new technologies and drugs are introduced contains more and more an experimental phase in which animals and human beings are used to test the outcomes of research. As a rule, these experiments are performed in accordance with the Declaration of Helsinki (WMA, Helsinki 1964, Tokyo, 1975). The guidelines of this Declaration are concerned with the ethical aspects of those experiments which involve human subjects. Although the guidelines are intended to have a global import, it still remains a matter of fact that some of them are a matter of debate in several regions of the world. They seem to have a cultural background (e.g. respect for the individual) and bioscientists sometimes argue that fort this reason they have to be considered as non-scientific restrictions. On the basis of a general philosophical and ethical consideration, it will be argued in this paper that ethical guidelines belong to the heart of biomedicine and biology itself. It is the common interest of researchers, clinicians, patients and scientists to consider the ethical implications of research outcomes before it can be stated that any worthwhile knowledge is obtained. The implementation of monoclonal-antibodies in clinical practice can be seen as a sample of this argument.",0,0,
266,Beyond screening for domestic violence: a systems model approach in a managed care setting,"BACKGROUND: Implementation of screening guidelines for domestic violence has been challenging. The multifaceted ""systems model"" may provide an effective means to improve domestic violence screening, identification, and intervention in the healthcare setting. METHODS: We developed: (1) a systems model approach using tools for effective referral, evaluation, and reporting of domestic violence""; (2) materials for distribution to female patients; (3) training for social service and mental health clinicians to provide domestic violence evaluation; and (4) strong links to the community. SETTING: A nonprofit, managed care facility in Richmond, California. PARTICIPANTS: Staff and members of the managed care plan. MAIN OUTCOME MEASURES: (1) Increased screening for domestic violence by clinicians; (2) increased awareness of the healthcare facility as a resource for domestic violence assistance;"" and (3) increased member satisfaction with the health plan's efforts to address domestic violence. RESULTS: The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. A pre-intervention and post-intervention phone survey of members seen for routine checkup showed an increase in member recall of being asked about domestic violence. After intervention, statistically significant increases were seen in members' perception that the health plan was concerned about the health effects of domestic violence (p<0.0001) and about members' satisfaction with the health plan's efforts to address this issue (p<0.0001). CONCLUSIONS: A systems model approach improved domestic violence services in a managed care health setting within 1 year and affected clinicians' behavior as well as health plan members' experience. This successful implementation makes it possible to address critical research questions about the impact of a healthcare intervention for victims of domestic violence in a managed healthcare setting.",0,0,
267,Big pharma and health care: unsolvable conflict of interests between private enterprise and public health,"A landmark paper on Game Theory showed that individual maximization of profit necessarily endangers the public good, and since the problem has no technical solution, ""it requires a fundamental extension in morality"" (1). We propose here that public health, as a public good, now emerges as a grave example of this problem. Recent events and reports increasingly suggest misalignment between the interests of the pharmaceutical industry and those of public health. Johnson & Johnson illegally and effectively promoted Propulsid off-label for children despite internal company documents raising safety concerns. Death in drug trial has been described as a ""trade secret."" On Vioxx, Topol wrote: ""Sadly, it is clear that Merck's commercial interest exceeded its concern about the drug's toxicity"" (2). More and more concerns are raised by scholars and major journal editors about the type and the quality of published evidence, often biased towards efficacy of new products. The industry, funding over 80% of trials, sets up a research agenda guided more by marketing than by clinical considerations. Smart statistical and epidemiological tactics help obtain the desired results. Budget for marketing is by far greater than for research. Massive advertising to physicians and to the public gets increasingly sophisticated: ghost writing, professional guidelines, targeting of consumer groups and manipulating media for disease mongering. Pervasive lobbying and political ties limit the independence of regulatory bodies. Obligation to shareholders overriding public health considerations is not unique to the pharmaceutical industry. The chemical, tobacco and food industries share similar tactics: proclaiming doubts about safety issues, buying researchers, infiltrating universities, boards, media and legislative agencies. By contrast, powerful and cheap health promoting activities, poorly supported by industry because they are too cheap and not patented, are markedly underutilized: technologies for changing behavior (e.g., cardiac rehabilitation), palliative care and use of old, effective and safe drugs - all could benefit from industry's tools of marketing and quality. As those most affected are the sick, the poor and the least educated, free market successes appear to pose unsolvable challenges to social justice in public health.",0,0,
268,Binge-eating disorder in adults: a systematic review and meta-analysis,"BACKGROUND: The best treatment options for binge-eating disorder are unclear.PURPOSE: To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder.DATA SOURCES: English-language publications in EMBASE, the Cochrane Library, Academic OneFile, CINAHL, and ClinicalTrials.gov through 18 November 2015, and in MEDLINE through 12 May 2016.STUDY SELECTION: 9 waitlist-controlled psychological trials and 25 placebo-controlled trials that evaluated pharmacologic (n = 19) or combination (n = 6) treatment. All were randomized trials with low or medium risk of bias.DATA EXTRACTION: 2 reviewers independently extracted trial data, assessed risk of bias, and graded strength of evidence.DATA SYNTHESIS: Therapist-led cognitive behavioral therapy, lisdexamfetamine, and second-generation antidepressants (SGAs) decreased binge-eating frequency and increased binge-eating abstinence (relative risk, 4.95 [95% CI, 3.06 to 8.00], 2.61 [CI, 2.04 to 3.33], and 1.67 [CI, 1.24 to 2.26], respectively). Lisdexamfetamine (mean difference [MD], -6.50 [CI, -8.82 to -4.18]) and SGAs (MD, -3.84 [CI, -6.55 to -1.13]) reduced binge-eating-related obsessions and compulsions, and SGAs reduced symptoms of depression (MD, -1.97 [CI, -3.67 to -0.28]). Headache, gastrointestinal upset, sleep disturbance, and sympathetic nervous system arousal occurred more frequently with lisdexamfetamine than placebo (relative risk range, 1.63 to 4.28). Other forms of cognitive behavioral therapy and topiramate also increased abstinence and reduced binge-eating frequency and related psychopathology. Topiramate reduced weight and increased sympathetic nervous system arousal, and lisdexamfetamine reduced weight and appetite.LIMITATIONS: Most study participants were overweight or obese white women aged 20 to 40 years. Many treatments were examined only in single studies. Outcomes were measured inconsistently across trials and rarely assessed beyond end of treatment.CONCLUSION: Cognitive behavioral therapy, lisdexamfetamine, SGAs, and topiramate reduced binge eating and related psychopathology, and lisdexamfetamine and topiramate reduced weight in adults with binge-eating disorder.",0,0,
269,Biomedical and behavioral research in nursing homes: guidelines for ethical investigations,"As nursing homes become increasingly important sites for biomedical and behavioral research, researchers must address the ethical problems of increased vulnerability and the high prevalence of mental and physical disorders in the nursing home population. Obtaining valid informed consent is but one of the many difficult issues that confronts the investigator in the nursing home. Efforts should be made to involve nursing home residents, as well as family and staff members, in the review of research. The benefits and burdens of research protocols should be equitably distributed, and potential conflicts of interest for staff members and physicians should be minimized or their potential adverse impact ameliorated. Appropriate attention to these ethical concerns may facilitate nursing home research while still safeguarding vulnerable residents. We offer proposed guidelines for the ethical conduct of research in nursing homes in an effort to stimulate discussion among investigators, nursing home staff and residents, residents' families, and ethicists.",0,0,
270,Bipolar disorder center for Pennsylvanians: implementing an effectiveness trial to improve treatment for at-risk patients,"OBJECTIVE: Adolescents, elderly persons, African Americans, and rural residents with bipolar disorder are less likely than their middle-aged, white, urban counterparts to be diagnosed, receive adequate treatment, remain in treatment once identified, and have positive outcomes. The Bipolar Disorder Center for Pennsylvanians (BDCP) study was designed to address these disparities. This report highlights the methods used to recruit, screen, and enroll a cohort of difficult-to-recruit individuals with bipolar disorder. METHODS: Study sites included three specialty clinics for bipolar disorder in a university setting and a rural behavioral health clinic. Study operations were standardized, and all study personnel were trained in study procedures. Several strategies were used for recruitment. RESULTS: It was possible to introduce the identical assessment and screening protocol in settings regardless of whether they had a history of implementing research protocols. This protocol was also able to be used across the age spectrum, in urban and rural areas, and in a racially diverse cohort of participants. Across the four sites 515 individuals with bipolar disorder were enrolled as a result of these methods (69 African Americans and 446 non-African Americans). Although clinical characteristics at study entry did not differ appreciably between African Americans and non-African Americans, the pathways into treatment differed significantly. CONCLUSIONS: Rigorous recruitment and assessment procedures can be successfully introduced in different settings and with different patient cohorts, thus facilitating access to high-quality treatment for individuals who frequently do not receive appropriate care for bipolar disorder.",0,0,
271,Books and reading: evidence-based standard of care whose time has come,"Reach Out and Read (ROR) is the only systematically evaluated clinical activity to promote child development in primary care used throughout the United States. The ROR intervention is straightforward: clinicians provide advice about the benefits of reading aloud, as well as directly giving books to high-risk children and parents to take home at each pediatric visit of children aged 6 months to 5 years. ROR builds upon a significant evidence base of the value of reading aloud to young children. The studies evaluating ROR from different sites from subjects from different racial backgrounds and numerous outcome measures are consistently positive. From its initial single site at Boston City Hospital in 1989, to over 4600 clinical sites in 2010, over 30 000 clinicians distributed over 6.2 million books a year to 3.9 million children across the United States. The future efforts for ROR include integrating mental health competencies found in American Academy of Pediatrics guidelines as part of residency and clinician training into the ROR paradigm, quality improvement to ensure fidelity to the intervention, and expanded pediatric clinician involvement in local early childhood/school readiness community efforts. Finally, the most important future goal is the adoption of giving advice about reading aloud and giving developmentally appropriate books to high-risk families as best practice by official bodies.",0,0,
272,Borderline personality disorder in adolescence,"Borderline personality disorder (BPD) is a common and severe mental disorder that is associated with severe functional impairment and a high suicide rate. BPD is usually associated with other psychiatric and personality disorders, high burden on families and carers, continuing resource utilization, and high treatment costs. BPD has been a controversial diagnosis in adolescents, but this is no longer justified. Recent evidence demonstrates that BPD is as reliable and valid among adolescents as it is in adults and that adolescents with BPD can benefit from early intervention. Consequently, adolescent BPD is now recognized in psychiatric classification systems and in national treatment guidelines. This review aims to inform practitioners in the field of adolescent health about the nature of BPD in adolescence and the benefits of early detection and intervention. BPD diagnosis and treatment should be considered part of routine practice in adolescent mental health to improve these individuals' well-being and long-term prognosis.",0,0,
273,Brave New EMR,,0,0,
274,Breaking new ground: challenging existing asthma guidelines,"BACKGROUND: While we have international guidelines and various national guidelines for asthma diagnosis and management, asthma remains poorly controlled in many children and adults. In this paper we review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use, particularly in primary care. DISCUSSION: Clinical practice guidelines based on evidence from randomized controlled trials are considered the most rigorous and accurate. Current evidence-based guidelines are written predominantly from the perspective of the patient with a clear-cut asthma diagnosis, however, and tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. The results of randomized controlled trials, which are designed to establish efficacy of treatment under ideal conditions, may not apply to 'real-world' clinical practice, where patients are unselected, monitoring is less frequent, and effectiveness--the benefit of treatment in routine clinical practice--is the most relevant outcome. Moreover, most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and response to asthma therapy, particularly age, allergic rhinitis, cigarette smoking, adherence, and genetic factors. When these links are recognized, guidelines rarely provide practical recommendations for treatment in these scenarios. Finally, there is some evidence that general practitioners are not convinced of the applicability of asthma guidelines to their practice settings, especially when those writing the guidelines principally work in specialist practice. CONCLUSION: Developing country-specific guidelines or, ideally, local guidelines could provide more practical solutions for asthma care and could account for regional factors that influence patient choice and adherence to therapy. Pragmatic clinical trials and well-designed observational trials are needed in addition to randomized controlled trials to assess real-world effectiveness of therapies, and such evidence needs also to be considered by guideline writers. Finally, practical tools to facilitate the diagnosis and assessment of asthma and factors responsible for poor control, such as associated allergic rhinitis, limited adherence, and smoking behavior, are needed to supplement treatment information provided in clinical practice guidelines for asthma.",0,0,
275,"Breast cancer knowledge, attitudes, and screening behaviors among African American women: the Black cosmetologists promoting health program","BACKGROUND: African American women have higher rates of breast cancer mortality than their white counterparts. Studies have suggested that this is partly caused by discovery of cancer at a later stage, highlighting the importance of encouraging early detection of breast cancer in this population. To guide the creation of a breast cancer education intervention and help focus other health educators' and clinicians' health promotion efforts, this study explored whether a cohort of African American women living in San Diego would demonstrate the possession of adequate baseline knowledge about breast cancer screening and adherence to widely recommended screening guidelines. METHODS: African American women (N = 1,055) from San Diego, California participated in a beauty salon-based survey about breast cancer knowledge, attitudes, and screening practices. Women's ages ranged from 20 to 94 years, with average age of 42.20 (SD = 13.53) years. Thirty-four percent reported completing college and/or some graduate school training, and 52% reported having some college or post high school formal training. Seventy-five percent of the sample reported working outside their home. Participating cosmetologists and their salons were recruited to the study through word-of-mouth referral by highly respected African American community leaders. RESULTS: Salon clients reported low rates of adherence to recommended breast cancer screening guidelines. Of the 1,055 participants, 31% reporting performing breast self-exam every month. Of those participants 40 and older, 57% reported having had a clinical breast exam and 43% reported having had a mammogram in the past year. Knowledge of breast cancer was associated with adherence to screening guidelines. While women recognized the serious health threat that breast cancer poses and that early detection of breast cancer is important, only 30% of women reported feeling well informed about the disease. Many participants demonstrated a lack of basic knowledge about breast cancer. The Health Belief Model postulates that access to such information is an essential element in the progression toward engaging in screening behaviors. CONCLUSION: Data from this study reflect a continuing need for increased breast cancer education for African American women. In light of the considerable mainstream information available related to breast cancer, these data reinforce the need for more breast cancer education programs that are clearly intended to attract the attention of African American women.",0,0,
276,"Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement ""Sepsis Six""","BACKGROUND: Sepsis has a mortality rate of 40 %, which can be halved if the evidence-based ""Sepsis Six"" care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital. METHODS: Factors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity. RESULTS: Five themes were identified as influencing implementation and guided intervention modification. These were:(1) ""knowing what to do and why"" (TDF domains knowledge, social/professional role and identity)"";"" (2) ""risks and benefits"" (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle's effectiveness acting as a lever to implementation"";"" (3) ""working together"" (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier"";"" (4) ""empowerment and support"" (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues' decisions not to implement acting as a barrier"";"" (5) ""staffing levels"" (environmental context and resources), e.g. shortages of doctors at night preventing implementation. The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator""; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions;"" documents and materials). CONCLUSIONS: This work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.",0,0,277
277,Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement “Sepsis Six”,"Background Sepsis has a mortality rate of 40 %, which can be halved if the evidence-based ¡°Sepsis Six¡± care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital.  Methods Factors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity.  Results Five themes were identified as influencing implementation and guided intervention modification. These were:(1) ¡°knowing what to do and why¡± (TDF domains knowledge, social/professional role and identity)""; (2) ¡°risks and benefits¡± (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle¡¯s effectiveness acting as a lever to implementation; (3) ¡°working together¡± (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier; (4) ¡°empowerment and support¡± (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues¡¯ decisions not to implement acting as a barrier; (5) ¡°staffing levels¡± (environmental context and resources), e.g. shortages of doctors at night preventing implementation.  The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions;"" documents and materials).  Conclusions This work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.",0,1,
278,Bridging the science-to-service gap in schizophrenia care in the Netherlands: the Schizophrenia Quality Improvement Collaborative,"OBJECTIVE: Many patients with schizophrenia are not treated in line with evidence-based guidelines. This study examines the large-scale implementation of the National Multidisciplinary Guideline for schizophrenia in the Netherlands. DESIGN: /st> Observational, prospective study, with repeated measurement. SETTING: Thirty mental healthcare teams in different regions of the Netherlands. PARTICIPANTS: Three hundred and fifty-nine clinicians with different professional backgrounds and 1489 patients suffering from schizophrenia. INTERVENTION(S): Six evidence-based interventions for schizophrenia were implemented, in the context of a quality improvement collaborative: assertive community treatment (ACT) or its adapted version functional assertive community treatment (FACT), cognitive behavioural therapy, psycho-education, family interventions, individual placement support and pharmacotherapy. MAIN OUTCOME MEASURE(S): Professional performance, social functioning and relapse rates. RESULTS: Improved professional performance, in line with guidelines. Availability of (F)ACT improved from 23 to 60%. Individual Placement Support improved from 20 to 53%. Complete care plans were composed for 38% of the patients and routine outcome monitoring was introduced in most teams. Social functioning improved slightly (HoNOS mean: from 6.2 to 5.6). Relapse rates did not improve during the course of the study. CONCLUSIONS: An intensive implementation programme can result in an improved delivery of evidence-based care, increased continuity of care and slightly improved outcomes for individuals with schizophrenia. More rigorous research designs have to confirm these findings.",0,1,
279,Brief physician-initiated quit-smoking strategies for clinical oncology settings: a trial coordinated by the Eastern Cooperative Oncology Group,"PURPOSE: Although tobacco use by cancer patients increases the risk of relapse, diminishes treatment efficacy, and worsens quality of life, about one third of patients who smoked before their diagnosis continue to smoke. Because patients have regular contact with oncologists, the efficacy of a physician-based smoking cessation treatment was evaluated. METHODS: Cancer patients (n = 432) were randomly assigned to either usual care or a National Institutes of Health (NIH) physician-based smoking intervention. The primary outcome was 7-day point prevalence abstinence at 6 and 12 months after study entry. RESULTS: At the 6-month follow-up, there was no significant difference in quit rates between the usual care (11.9%) and intervention (14.4%) groups, and there was no significant difference between the usual care (13.6%) and intervention (13.3%) groups at the 12-month follow-up. Patients were more likely to have quit smoking at 6 months if they had head and neck or lung cancer, began smoking after the age of 16, reported at baseline using a cessation self-help guide or treatment in the last 6 months, and showed greater baseline desire to quit. Patients were more likely to have quit smoking at 12 months if they smoked 15 or fewer cigarettes per day, had head and neck or lung cancer, tried a group cessation program, and showed greater baseline desire to quit. Finally, there was greater adherence among physicians to the NIH model for physician smoking treatment for patients in the intervention versus the usual care group. CONCLUSION: While training physicians to provide smoking cessation treatment to cancer patients can enhance physician adherence to clinical practice guidelines, physician smoking cessation interventions fail to yield significant gains in long-term quit rates among cancer patients.",0,0,
280,"British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017","Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy""; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs;"" and recommendations for the management of specific disorders.",0,0,
281,Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme,"BACKGROUND: South Africa recently launched a national antiretroviral treatment programme. This has created an urgent need for nurse-training in antiretroviral treatment (ART) delivery. The PALSA PLUS programme provides guidelines and training for primary health care (PHC) nurses in the management of adult lung diseases and HIV/AIDS, including ART. A process evaluation was undertaken to document the training, explore perceptions regarding the value of the training, and compare the PALSA PLUS training approach (used at intervention sites) with the provincial training model. The evaluation was conducted alongside a randomized controlled trial measuring the effects of the PALSA PLUS nurse-training (Trial reference number ISRCTN24820584). METHODS: Qualitative methods were utilized, including participant observation of training sessions, focus group discussions and interviews. Data were analyzed thematically. RESULTS: Nurse uptake of PALSA PLUS training, with regard not only to ART specific components but also lung health, was high. The ongoing on-site training of all PHC nurses, as opposed to the once-off centralized training provided for ART nurses only at non-intervention clinics, enhanced nurses' experience of support for their work by allowing, not only for ongoing experiential learning, supervision and emotional support, but also for the ongoing managerial review of all those infrastructural and system-level changes required to facilitate health provider behaviour change and guideline implementation. The training of all PHC nurses in PALSA PLUS guideline use, as opposed to ART nurses only, was also perceived to better facilitate the integration of AIDS care within the clinic context. CONCLUSION: PALSA PLUS training successfully engaged all PHC nurses in a comprehensive approach to a range of illnesses affecting both HIV positive and negative patients. PHC nurse-training for integrated systems-based interventions should be prioritized on the ART funding agenda. Training for individual provider behaviour change is nonetheless only one aspect of the ongoing system-wide interventions required to effect lasting improvements in patient care in the context of an over-burdened and under-resourced PHC system.",0,0,
282,Building clinical networks: a developmental evaluation framework,"Background Clinical networks have been designed as a cross-organisational mechanism to plan and deliver health services. With recent concerns about the effectiveness of these structures, it is timely to consider an evidence-informed approach for how they can be developed and evaluated.  Objective To document an evaluation framework for clinical networks by drawing on the network evaluation literature and a 5-year study of clinical networks.  Method We searched literature in three domains: network evaluation, factors that aid or inhibit network development, and on robust methods to measure network characteristics. This material was used to build a framework required for effective developmental evaluation.  Results The framework's architecture identifies three stages of clinical network development"";"" partner selection, network design and network management. Within each stage is evidence about factors that act as facilitators and barriers to network growth. These factors can be used to measure progress via appropriate methods and tools. The framework can provide for network growth and support informed decisions about progress.  Conclusions For the first time in one place a framework incorporating rigorous methods and tools can identify factors known to affect the development of clinical networks. The target user group is internal stakeholders who need to conduct developmental evaluation to inform key decisions along their network's developmental pathway.",0,0,
283,Building Statewide Infrastructure for the Academic Support of Students With Mild Traumatic Brain Injury,"OBJECTIVES: To focus attention on building statewide capacity to support students with mild traumatic brain injury (mTBI)/concussion. METHOD: Consensus-building process with a multidisciplinary group of clinicians, researchers, policy makers, and state Department of Education personnel. RESULTS: The white paper presents the group's consensus on the essential components of a statewide educational infrastructure to support the management of students with mTBI. The nature and recovery process of mTBI are briefly described specifically with respect to its effects on school learning and performance. State and local policy considerations are then emphasized to promote implementation of a consistent process. Five key components to building a statewide infrastructure for students with mTBI are described including (1) definition and training of the interdisciplinary school team, (2) professional development of the school and medical communities, (3) identification, assessment, and progress monitoring protocols, (4) a flexible set of intervention strategies to accommodate students' recovery needs, and (5) systematized protocols for active communication among medical, school, and family team members. The need for a research to guide effective program implementation is stressed. CONCLUSION: This guiding framework strives to assist the development of support structures for recovering students with mTBI to optimize academic outcomes. Until more evidence is available on academic accommodations and other school-based supports, educational systems should follow current best practice guidelines.",0,0,
284,"Building Trust: The History and Ongoing Relationships Amongst DSD Clinicians, Researchers, and Patient Advocacy Groups","Individuals born with differences or disorders of sex development (DSD) have been marginalized by society and the health care system. Standards of care in the mid-20(th) century were based on fixing the child with a DSD, using hormonal and surgical interventions""; these treatments and the diagnoses were almost never disclosed to the child, and sometimes they were not disclosed to the parents. This led to secrecy, shame, and stigma. When these children became adults and demanded access to their medical records, the realization of the depth of secrecy led to the formation of activism groups that shook the medical community. Despite precarious beginnings, advocates, health care professionals, and researchers were able to elicit changes in the standard of care. The 2006 Consensus Statement on Management of Intersex Disorders called for a multidisciplinary approach to care and questioned the evidence for many of the standard procedures. Standard of care moved from a concealment model to a patient-centered paradigm, and funding agencies put resources into determining the future paths of research on DSD. Recognition of the need to address patient priorities led to changing international standards for including patients in research design. Some challenges that remain include: the findings from the Institute of Medicine that sexual and gender minorities experience poor health outcomes; establishing trust across all parties;"" developing a common language and creating venues where individuals can participate in dialogue that addresses personal experiences, research design, clinical practices and intervention strategies.",0,0,
285,Caesarean childbirth. Summary of an NIH consensus statement,,0,0,
286,Can a court order participation in research?,,0,0,
287,Can a rural community-based work-related activity program make a difference for chronic pain-disabled injured workers?,"OBJECTIVE: To assess the effectiveness of a clinical guidelines-informed multidisciplinary work-related activity program, and to improve the physical, psychological and occupational functioning of chronic pain-disabled injured workers. DESIGN: An uncontrolled, repeated-measures, pilot study was conducted. SETTING: The intervention was delivered in a community setting in regional New South Wales. PARTICIPANTS: Participants (n = 30), mean age of 41 years, had a compensable musculoskeletal injury: 60% were male, 63% had back injuries""; the mean time off work was 13 months. INTERVENTION: A cognitive-behavioural, interdisciplinary intervention was delivered using a multi-contributor provider model (a clinical psychologist and physiotherapist from separate practices, working in liaison with the participant's occupational rehabilitation provider and treating doctor). Groups of six participants attended for one half day per week for six weeks. MAIN OUTCOME MEASURES: The outcome measures included: physical functioning, pain intensity and psychological variables, which were assessed pre- and post-program;"" and medical certification and work participation, which was recorded pre-program and at six-month follow up. RESULTS: Significant gains were made in pain intensity, physical and psychological functioning, and medical certification. The mean effect size of the intervention was medium to large (d = 0.70). There was no significant change in employment status at six-month follow up. CONCLUSIONS: The results of this pilot study suggest that independent, rural or community-based practitioners, working collaboratively using an integrated treatment program, can produce positive outcomes for pain-disabled injured workers, and achieve results similar to those reported by metropolitan-based pain clinics.",0,0,
288,"Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial.","Objective. Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations.  Study Setting. Inner-city academic general internal medicine practice.  Study Design. Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 × 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls.  Data Extraction/Collection Methods. Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires.  Principal Findings. During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed.  Conclusions. Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.",1,1,
289,Can hand-held computers improve adherence to guidelines? A (Palm) Pilot study of family doctors in British Columbia,"OBJECTIVE To examine whether Palm Prevention, a free software tool for Palm OS personal digital assistants (PDAs) that provides quick access to preventive guidelines in a patient-specific manner at the point of care, improved adherence to five preventive measures in primary care.  DESIGN Prospective intervention pilot study.  SETTING Vancouver, BC, and surrounding area.  PARTICIPANTS Eight general practitioners.  INTERVENTIONS Each physician used Palm Prevention for five preventive measures during routine preventive health visits with 10 patients (n = 80). Charts of consenting patients were reviewed for documentation of recommended maneuvers.  MAIN OUTCOME MEASURES Rates of adherence to five evidence-based guidelines selected from the Canadian and American task forces on preventive care and incorporated into Palm Prevention.  RESULTS Intervention and control physicians were similar in their familiarity with and use of PDAs, and they recruited similar patients for the study. Intervention and control groups had similar rates of screening for hypertension. Intervention improved adherence to the remaining four guidelines: cervical cancer screening increased 22% (only absolute increases are reported)""; hyperlipidemia screening increased 30%; colorectal cancer screening increased 27%; and prophylaxis with acetylsalicylic acid in high-risk patients increased 38%. Participants were surveyed after the study;"" all reported that they found the software helpful and would continue using Palm Prevention. Usage statistics showed that study participants used the tool outside the trial: users entered between 28 and 68 unique patients into the program during the 2-month intervention.  CONCLUSION This pilot study suggests PDAs are useful in improving preventive care and facilitating translation of knowledge into practice. This was particularly apparent with newer guidelines.",0,1,
290,Can line clinicians master the conceptual complexities of dialectical behavior therapy? An evaluation of a State Department of Mental Health training program,"Dialectical behavior therapy for borderline personality disorder has rapidly attained wide-spread popularity, with one indication being the development of training initiatives by the Department of Mental Health within at least two States in USA. Efficacy data published by the originator of the treatment, Marsha Linehan, and her colleagues, probably accounts at least in part for this popularity. However, the complexity of DBT raises a fundamental question regarding these broader applications: can clinicians of diverse backgrounds acquire a shared and sophisticated understanding of the treatment theory? The clinical utility of a treatment rests heavily upon ease of dissemination (APA, Template for developing guidelines: Interventions for mental disorders and psychosocial aspects of physical disorders. Washington, DC: Author, 1995), and in that regard DBT--a complicated, multifaceted approach--could appear vulnerable. This vulnerability is heightened when institutional adoption involves the collaboration of numerous clinicians, who, despite occupying diverse roles, must nevertheless develop a shared understanding of the treatment. Using a detailed examination of DBT knowledge, we evaluated the conceptual mastery of 109 clinicians trained via a State Department of Mental Health initiative. Performance on the examination correlated specifically with DBT training. Prior education or background in behavior therapy accounted for little variance, indicating that clinicians occupying diverse roles acquired reasonable intellectual mastery over this complex model.",0,0,
291,'Can practice undertaken by patients be increased simply through implementing agreed national guidelines?' An observational study,"OBJECTIVE: To increase autonomous practice time of patients on the stroke unit of a nursing home. INTERVENTION: Nurses stimulated and coached patients with the help of four interventions (muscle strengthening, sitting balance and reach, getting up from a chair, walking) from the evidence-based Clinical Nursing Rehabilitation Stroke Guidelines. DESIGN: An observational study. Practice time of elderly stroke patients in this study was compared with the time observed in our previous study in the same setting. SETTING: Rehabilitation units of a nursing home in the Netherlands. SUBJECTS: Seventeen frail stroke patients, including 8 men, 9 women, with a mean age of 75.8 (SD +/- 9) and 17 subjects with the same characteristics who participated in a previous observational study. MAIN MEASURES: Time spent on therapeutic activities was measured using the Behavioral Mapping method. RESULTS: The time spent on therapeutic activities increased significantly from 103.5 minutes measured in our previous study to 156.5 minutes in this study (Z = 2.86""; P < 0.005;"" d' = 1.09) The mean Barthel Index score was 8.8 (SD +/- 4.1). The patients with more possibilities were more active, resulting in a significant positive Barthel Index-therapy time relationship (r = 0.73, P </= 0.001). CONCLUSIONS: The autonomous practice time of older fragile comorbid stroke patients increased during the weekdays. Patients, stimulated and challenged by nurses, exercise harder and more according to their possibilities. Since this guideline was developed especially for nurses, nurses can stimulate stroke patients to contribute more to autonomous practice and therefore help their recovery.",0,0,
292,Can psychological models bridge the gap between clinical guidelines and clinicians' behaviour? A randomised controlled trial of an intervention to influence dentists' intention to implement evidence-based practice,"OBJECTIVE: The lag between publication of evidence for clinical practice and implementation by clinicians may be decades. Research using psychological models demonstrates that changing intention is very important in changing behaviour. This study examined an intervention (rehearsing alternative actions) to change dentists' intention to implement evidence-based practice (EBP) for third molar (TM) management. DESIGN: Randomised controlled trial / postal. SETTING: Primary care. SUBJECTS AND METHODS: Dentists were randomly selected from the Scottish Dental Practice Board Register, then randomly allocated to intervention or control groups, and sent a questionnaire. The intervention group listed management alternatives to TM extraction prior to their TM extraction intention, and the control group did not. Based on psychological models for reducing a behaviour's frequency (EBP is weighted against TM extraction), prior listing of alternatives should decrease extraction intention. MAIN OUTCOME MEASURES: Intention to extract TMs. RESULTS: A total of 99 dentists - 70 Males, 29 Females""; mean age = 41.42 years (SD = 8.62) participated in the study. The intervention significantly influenced intention to extract TMs, as desired. Despite similar background and knowledge of management alternatives, participants in the intervention group had significantly lower intention to extract: control group mean (SD) = 0.39 (1.99); intervention group mean (SD) = -0.78 (1.89); mean difference (SE) = 1.17 (0.42);"" 95% confidence interval for the difference = 0.34 to 1.99. CONCLUSION: Results suggest this intervention, which successfully influenced a proximal predictor of behaviour pertinent to dental EBP, may result in improved EBP in a service-level trial. Basing implementation interventions and trial methodology on psychological models may effectively bridge the gap between clinical guidelines and practice.",0,1,
293,Can we address depression in vision rehabilitation settings? Professionals' perspectives on the barriers to integrating problem-solving treatment,"PURPOSE: Low vision rehabilitation (LVR) is a pertinent context for integrating early, evidence-based psychological interventions given the high prevalence of untreated depression in adults with vision impairment. This study aims to identify the perceived barriers and facilitators to staff-delivered telephone-based problem-solving treatment for primary care (PST-PC) offered as an integrated component of LVR. METHODS: Qualitative semi-structured interviews, developed using the theoretical domains framework (TDF) and Consolidated Framework for Implementation Research (CFIR), were conducted with 21 LVR professionals and a clinical psychologist involved in the delivery of PST-PC. Barriers and facilitators at the practitioner, client, intervention, and organizational level were identified with thematic analysis using a ""theoretical"" approach. RESULTS: Prominent barriers were a lack of role recognition for PST-PC practitioners (n = 32), unmet client expectation with PST-PC (n = 28), dissatisfaction with telephone delivery (n = 27), and limited organizational awareness of PST-PC (n = 39). Facilitating factors included a recognized need for evidence-based psychological services (n = 28), clients experiencing benefits in early sessions (n = 38), PST-PC promoting practical skills (n = 26), and comprehensive PST-PC training (n = 36). CONCLUSIONS: PST-PC may provide an accessible early intervention for LVR clients with depressive symptoms. Ongoing practitioner training, clinical support, and screening potential LVR clients for treatment suitability are likely to enhance delivery in this setting. Implications for rehabilitation Depression is highly prevalent in adults engaged in low vision rehabilitation (LVR) programs, yet few receive support. Clinical guidelines recommend integrated models of care be offered within rehabilitation settings as early intervention for mild to moderate levels of depressive symptoms. Integrated telephone-based problem-solving treatment for primary care (PST-PC) delivered by trained LVR practitioners is a practical, skills-based model that has potential to increase access to an early psychological intervention in LVR clients with depressive symptoms. LVR clients are often older in age, have multiple comorbid health conditions and a significant level of functional disability, requiring flexibility in the delivery of PST-PC and specialized staff training, and support in working with older and more complex clients.",0,0,
294,"Can we improve adherence to guidelines for the treatment of lower urinary tract infection? A simple, multifaceted intervention in out-of-hours services","OBJECTIVES: To improve antimicrobial prescribing behaviour of general practitioners in large-scale out-of-hours services for uncomplicated lower urinary tract infection (LUTI) in females aged 20-80 years, which is regarded as one of the most prevalent bacterial infections in primary care. METHODS: A quasi-experimental design was used in two regional large-scale out-of-hours services. A simple, multifaceted intervention was offered in a 16 week period in one region (the intervention region). During the two washout periods, at 5 and 17 months, we observed diagnoses and prescriptions. The main outcome measure was the share of appropriate and inappropriate prescriptions. RESULTS: The proportion of patients with LUTI ranged from 1.0% to 2.1%. The relative proportion of appropriate prescriptions in the intervention region increased from 26.9% to 69.4%, but decreased afterwards to 40.8%. CONCLUSIONS: A simple, multifaceted intervention for treatment of LUTI during out-of-hours care may improve the quality of antimicrobial prescribing, although the improvement may not be sustained in the longer term.",0,1,
295,Canadian Contraception Consensus (Part 1 of 4),"OBJECTIVE: To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES: Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods""; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. EVIDENCE: Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse;"" its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index > 25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index > 35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.",0,0,
296,Canadian Contraception Consensus (Part 2 of 4),"OBJECTIVE: To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES: Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods""; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. EVIDENCE: Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse;"" its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index > 25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index > 35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.",0,0,
297,"Canadian guidelines for the evidence-based treatment of tic disorders: behavioural therapy, deep brain stimulation, and transcranial magnetic stimulation","This clinical guideline provides recommendations for nonpharmacological treatments for tic disorders. We conducted a systematic literature search for clinical trials on the treatment of tics. One evidence-based review (including 30 studies) and 3 studies on behavioural interventions, 3 studies on deep brain stimulation (DBS), and 3 studies on transcranial magnetic stimulation (TMS) met our inclusion criteria. Based on this evidence, we have made strong recommendations for the use of habit reversal therapy and exposure and response prevention, preferably embedded within a supportive, psychoeducational program, and with the option to combine either of these approaches with pharmacotherapy. Although evidence exists for the efficacy of DBS, the quality of this evidence is poor and the risks and burdens of the procedure are finely balanced with the perceived benefits. Our recommendation is that this intervention continues to be considered an experimental treatment for severe, medically refractory tics that have imposed severe limitations on quality of life. We recommend that the procedure should only be performed within the context of research studies and by physicians expert in DBS programming and in the management of tics. There is no evidence to support the use of TMS in the treatment of tics. However, the procedure is associated with a low rate of known complications and could continue to be evaluated within research protocols. The recommendations we provide are based on current knowledge, and further studies may result in their revision in future.",0,0,
298,Canadian survey of clinical status at dialysis initiation 1998-1999: a multicenter prospective survey,"AIMS: The current growth in end-stage kidney disease populations has led to increased efforts to understand the impact of status at dialysis initiation on long-term outcomes. Our main objective was to improve the understanding of current Canadian nephrology practice between October 1998 and December 1999. METHODS: Fifteen nephrology centers in 7 provinces participated in a prospective data collection survey. The main outcome of interest was the clinical status at dialysis initiation determined by: residual kidney function, preparedness for chronic dialysis as measured by presence or absence of permanent peritoneal or hemodialysis access, hemoglobin and serum albumin. Uremic symptoms at dialysis initiation were also recorded, however, in some cases these symptom data were obtained retrospectively. RESULTS: Data on 251 patients during 1-month periods were collected. Patients commenced dialysis at mean calculated creatinine clearance levels of approximately 10 ml/min, with an average of 3 symptoms. 35% of patients starting dialysis had been known to nephrologists for less than 3 months. These patients are more likely to commence without permanent access and with lower hemoglobin and albumin levels. Even of those known to nephrologists, only 66% had permanent access in place. CONCLUSIONS: Patients commencing dialysis in Canada appear to be doing so in relative concordance with published guidelines with respect to timing of initiation. Despite an increased awareness of kidney disease, a substantial number of patients continues to commence dialysis without previous care by a nephrologist. Of those who are seen by nephrologists, clinical and laboratory parameters are suboptimal according to current guidelines. This survey serves as an important baseline for future comparisons after the implementation of educational strategies for referring physicians and nephrologists.",0,0,
299,Cancer adolescent pathway in France between 1988 and 1997,"We report an adolescent cancer pathway from referral, through diagnosis and treatment, to follow-up in France. All cases of cancer among 15-19 years, diagnosed from 1988 to 1997, recorded by nine French population-based cancer registries (10% of French population) were included. The management of adolescent cancer by paediatricians was rare. An adolescents' pathway through cancer care can be summarized as first visit to general practitioner, referral to adult oncologist for haematological malignancy and medical or surgical specialists for solid tumours, treatment in adult unit, and follow-up by adult oncologist, adult medical or surgical specialist, or general practitioner. Only 9% of the 15-19 years are entered into a clinical trial (respectively 6% and 3% into adult and paediatric clinical trial). The inclusion rate changes according to the diagnosis, higher for acute lymphoblastic leukaemia (39%), non-Hodgkin's lymphomas (NHL) (27%), and acute non-lymphoblastic leukaemia (20%). Only 4% of adolescent cancers were managed on shared adult/paediatric departments, especially for soft-tissue sarcomas (14.9%), malignant bone tumours (13.4), central nervous system tumours (6.2%), and NHL (4.4%). Whatever the reasons for lack of participation in clinical trials, an ideal model requiring communication and cooperation between all adult and paediatric specialists involved in adolescent cancer treatment should reduce the large gap in access to cooperative groups.",0,0,
300,Cancer education among primary care physicians in an underserved community,"INTRODUCTION: Urban minority groups, such as those living in north Manhattan, are generally underserved with regard to cancer prevention and screening practices. Primary care physicians are in a critical position to counsel their patients on these subjects and to order screening tests for their patients. METHODS: Eighty-four primary care physicians in two intervention communities who received educational visits about cancer screening and prevention were compared with 38 physicians in a nearby community who received no intervention. With pre- and post-test interviews over an 18-month period, the physicians were asked about their attitudes toward, knowledge of (relative to American Cancer Society guidelines), and likelihood of counseling and screening for breast, cervical, colorectal, and prostate cancers. RESULTS: Comparison of the two surveys of physicians indicated no statistically significant differences in knowledge of cancer prevention or screening. At post-test, however, intervention group physicians identified significantly fewer barriers to practice than control physicians (p<0.05). While overall, the educational visits to inner-city primary care physicians did not appear to significantly alter cancer prevention practices, there was a positive dose-response relationship among the subgroup of participants who received three or more project contacts. CONCLUSIONS: We uncovered significant changes in attitude due to academic detailing among urban primary care physicians practicing in north Manhattan. A significant pre-test sensitization effect and small numbers may have masked overall changes in cancer prevention and screening behaviors among physicians due to the intervention.",0,0,
301,Cancer-related and treatment-related fatigue,"Fatigue is a distressing and persistent symptom for patients with gynecological cancer and for survivors. Debilitating cancer-related fatigue (CRF) is produced by both the disease and its treatment. Although awareness and study of CRF have grown in recent years, consistent assessment has not been a priority in routine medical practice. The pathophysiological mechanisms that induce CRF remain unclear, and effective pharmacological interventions have yet to be established. Based on the literature and our own research results, this review focuses on recent progress toward understanding the nature and causes of CRF and on several promising treatment modalities. Given the prevalence and severity of CRF in the gynecological cancer patient population, establishing standardized fatigue measurement and management methods in routine clinical oncology care is of utmost importance. Whether CRF has an underlying inflammatory cause is still hypothetical, however, and no mechanism-driven symptom intervention is currently in clinical use, even though the development of such interventions would provide patients with greater symptom control. Advancing translational and clinical fatigue research will require anatomical pathway studies and well-designed clinical investigations that focus on the development of mechanism-driven interventions based on physiological-behavioral fatigue research, implementation of guidelines for experimental designs, and discovery of biomarkers identifying individuals at high risk for CRF. Validated patient-reported outcomes measures are an essential component of such clinical studies. Because numerous subscales, unidimensional measures, and multidimensional measures exist, clinicians and researchers should consider individual circumstances, good clinical practice, and research goals as guides for choosing the most appropriate fatigue measurement tool. Additionally, education about CRF should be made available to all patients and their caregivers, as accurate and age-appropriate information about conditions like CRF can alleviate much of the stress and anxiety brought on by poor communication about this distressing condition.",0,0,
302,Cardiac drug and psychotropic drug interactions: significance and recommendations,"Understanding cardiac drug interactions with concurrent psychotropic prescriptions is essential for the practicing cardiologist and primary care physician, as well as for the psychiatrist. There has been an explosive use of new drugs in both psychiatry and cardiology without widespread knowledge of their potential interactions. The increasing tendency toward poly-pharmacy, the use of psychotropic medications by cardiologists and primary care physicians caring for cardiac patients, and the growth of the aging population present major challenges for the practitioner. Finally, there is a need to have models/paradigms for predicting potential drug interactions--e.g., the Cytochrome p450 schema. This paper describes a method to identify, understand, and codify the interactions between psychotropic and cardiac drugs, a systematic approach for updating this key database and specific cardiac-psychotropic drug interactions. Specifically, this paper 1) details the interactions, 2) addresses the level of their clinical significance, 3) describes the potential mechanism(s) of the interactions, and 4) offers recommendations to the clinician. Since the majority of the original clinical trials, either for cardiac medications or psychotropic drugs, do not include studies comparing these two drug domains contemporaneously, their interactions often become known only with their combined use in the clinical arena, using the patient as ""guinea pig,"" and through subsequent reporting.",0,0,
303,Cardiac rehabilitation and risk factor management after myocardial infarction. Clinical and economic evaluation,"The increasing scarcity of available, and finite, health care resources, and the increased demands for health care, have made consideration of effectiveness and cost-effectiveness of health care services, such as the secondary prevention of heart disease, an imperative. There is considerable evidence that modification of cigarette smoking, hyperlipidemia, hypertension, and lack of physical activity, either singly or in combination, are effective in reducing the number of clinical events in the secondary prevention of heart disease. Economic evaluation is the comparative analysis of alternative courses of action in terms of both costs and consequences. Data generated in economic evaluations of health care services, such as risk factor modification in the secondary prevention of heart disease, are useful in developing clinical practice guidelines and health policies. Smoking cessation is the most cost-effective intervention for patients with documented heart disease while treatment of hyperlipidemia and referral to cardiac rehabilitation are highly cost-effective per quality-adjusted life year and relatively cost-effective per year of life saved. Risk factor management, provided by a team including cardiovascular specialists and other physicians together with appropriately trained allied health professionals, is the cornerstone of optimal care in both the primary and secondary prevention of heart disease.",0,0,
304,Cardiac Rehabilitation: Unraveling the Complexity of Referral and Current Models of Delivery,"BACKGROUND: Evidence-based guidelines recommend strategies for reducing risk factors for secondary prevention of acute coronary syndromes, yet referral to and completion of programs to deliver this advice are poor. PURPOSE: In this article we describe the complexity of factors that influence referral and delivery of evidence-based cardiac rehabilitation (CR) programs through an Australian context and provide direction for solutions for clinicians and policy makers to consider. The Ecological Approach is used as a framework to synthesize evidence. The approach has 5 categories, the characteristics of which may act as barriers and enablers to the promotion and adoption of health behaviors and includes (a) interpersonal factors, (b) interpersonal factors, (c) institutional factors, (d) community networks, and (e) public policy. CONCLUSIONS: Despite the context of strong evidence for efficacy, this review highlights systematic flaws in the implementation of CR, an important intervention that has been shown to improve patient outcomes and prevent cardiac events. Recommendations from this review include standardization of program delivery, improvement of data capture, use of technological innovations and social networks to facilitate delivery of information and support, and establishment of a cohesive, consistent message through interorganizational collaboration involved in CR. CLINICAL IMPLICATIONS: These avenues provide direction for potential solutions to improve the uptake of CR and secondary prevention.",0,0,
305,Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial),"OBJECTIVE To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment. DESIGN Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system. SETTING Large acute general hospital in the United Kingdom. PARTICIPANTS 600 patients aged over 65 admitted for acute medical care, identified as ""confused"" on admission. INTERVENTIONS Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals""; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers. MAIN OUTCOME MEASURES PRIMARY OUTCOME number of days spent at home over the 90 days after randomisation. SECONDARY OUTCOMES structured non-participant observations to ascertain patients' experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation. RESULTS There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference -12 to 24; P=0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (-9% to 4%), readmission 32% versus 35% (-10% to 5%), and new admission to care home 20% versus 28% (-16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (-6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P=0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P<0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P=0.004), and severe dissatisfaction was reduced (5% v 10%, -10% to 0%;"" P=0.05). CONCLUSIONS Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients' experience and carers' satisfaction might be more appropriate measures of success for frail older people approaching the end of life. TRIAL REGISTRATION Clinical Trials NCT01136148.",0,0,
306,Care of adults with developmental disabilities: Effects of a continuing education course for primary care providers,"OBJECTIVE: To evaluate the effects of an interdisciplinary, guideline-based continuing education course on measures related to the care of adults with developmental disabilities (DD). DESIGN: Before-and-after study with a control group. SETTING: Ontario. PARTICIPANTS: Forty-seven primary care providers (physicians, registered nurses, and nurse practitioners). INTERVENTION: Participants either only received reference material about primary care of people with DD (control group) or participated in a continuing education course on primary care of people with DD in addition to receiving the reference material (intervention group). MAIN OUTCOME MEASURES: Participants reported on 5 key measures related to care of adults with DD: frequency of using guidelines, frequency of performing periodic health examinations, frequency of assessing patients who present with behaviour changes, level of comfort while caring for adults with DD, and knowledge of primary care related to adults with DD. RESULTS: Over time, the intervention group showed significant increases in 4 of the 5 key measures of care compared with the control group: the frequency of guideline use (P < .001), frequency of assessment of patients' behaviour change (P = .03), comfort level in caring for people with DD (P = .01), and knowledge of primary care related to adults with DD (P = .01). CONCLUSION: A continuing education course on primary care of adults with DD is a useful interdisciplinary model to train health professionals who provide primary care services to these patients.",0,0,
307,Care of the menopausal patient: a nurse practitioner's view,"PURPOSE: To evaluate the benefits and risks of hormone therapy (HT) and other treatment options for early postmenopausal women. DATA SOURCES: Published clinical trials, selected peer-reviewed literature, and recent clinical practice guidelines. CONCLUSIONS: Results of the Women's Health Initiative (WHI) studies on HT may not be directly applicable to healthy, early postmenopausal women suffering from hot flushes. HT is the most effective treatment for menopausal symptoms. The benefits of HT in relieving menopausal symptoms are likely to exceed the risks in this population. IMPLICATIONS FOR PRACTICE: The results of the WHI reinforce the importance of individualized care based on a woman's medical history, medical needs, and desired outcomes. Nurse practitioners can help their patients put recent results into perspective. When HT is used, nurse practitioners should consider using lower doses and reevaluate the need for therapy annually.",0,0,
308,CD4 cell count and viral load monitoring in patients undergoing antiretroviral therapy in Uganda: cost effectiveness study,"OBJECTIVE To examine the cost and cost effectiveness of quarterly CD4 cell count and viral load monitoring among patients taking antiretroviral therapy (ART). DESIGN Cost effectiveness study. SETTING A randomised trial in a home based ART programme in Tororo, Uganda. PARTICIPANTS People with HIV who were members of the AIDS Support Organisation and had CD4 cell counts <250 × 10(6) cells/L or World Health Organization stage 3 or 4 disease. MAIN OUTCOME MEASURES Outcomes calculated for the study period and projected 15 years into the future included costs, disability adjusted life years (DALYs), and incremental cost effectiveness ratios (ICER""; $ per DALY averted). Cost inputs were based on the trial and other sources. Clinical inputs derived from the trial; in the base case, we assumed that point estimates reflected true differences even if non-significant. We conducted univariate and multivariate sensitivity analyses. INTERVENTIONS Three monitoring strategies: clinical monitoring with quarterly CD4 cell counts and viral load measurement (clinical/CD4/viral load); clinical monitoring and quarterly CD4 counts (clinical/CD4);"" and clinical monitoring alone. RESULTS With the intention to treat (ITT) results per 100 individuals starting ART, we found that clinical/CD4 monitoring compared with clinical monitoring alone increases costs by $20,458 (£12,780, €14,707) and averts 117.3 DALYs (ICER = $174 per DALY). Clinical/CD4/viral load monitoring compared with clinical/CD4 monitoring adds $142,458, and averts 27.5 DALYs ($5181 per DALY). The superior ICER for clinical/CD4 monitoring is robust to uncertainties in input values, and that strategy is dominant (less expensive and more effective) compared with clinical/CD4/viral load monitoring in one quarter of simulations. If clinical inputs are based on the as treated analysis starting at 90 days (after laboratory monitoring was initiated), then clinical/CD4/viral load monitoring is dominated by other strategies. CONCLUSIONS Based on this trial, compared with clinical monitoring alone, monitoring of routine CD4 cell count is considerably more cost effective than additionally including routine viral load testing in the monitoring strategy and is more cost effective than ART.",0,0,
309,Cervical cancer screening in adolescents: an evidence-based internet education program for practice improvement among advanced practice nurses,"BACKGROUND: The literature reports great variation in the knowledge levels and application of the recent changes of cervical cancer screening guidelines into clinical practice. Evidence-based screening guidelines for the prevention and early detection of cervical cancer offers healthcare providers the opportunity to improve practice patterns among female adolescents by decreasing psychological distress as well as reducing healthcare costs and morbidities associated with over-screening. PURPOSE: The purpose of this pilot intervention study was to determine the effects of a Web-based continuing education unit (CEU) program on advanced practice nurses' (APNs) knowledge of current cervical cancer screening evidence-based recommendations and their application in practice. This paper presents a process improvement project as an example of a way to disseminate updated evidence-based practice guidelines among busy healthcare providers. METHODS: This Web-based CEU program was developed, piloted, and evaluated specifically for APNs. The program addressed their knowledge level of cervical cancer and its relationship with high-risk human papillomavirus. It also addressed the new cervical cancer screening guidelines and the application of those guidelines into clinical practice. FINDINGS: Results of the study indicated that knowledge gaps exist among APNs about cervical cancer screening in adolescents. However, when provided with a CEU educational intervention, APNs' knowledge levels increased and their self-reported clinical practice behaviors changed in accordance with the new cervical cancer screening guidelines. LINKING EVIDENCE TO PRACTICE: Providing convenient and readily accessible up-to-date electronic content that provides CEU enhances the adoption of clinical practice guidelines, thereby decreasing the potential of the morbidities associated with over-screening for cervical cancer in adolescents and young women.",0,0,
310,Challenges and opportunities associated with the introduction of next-generation long-lasting insecticidal nets for malaria control: a case study from Burkina Faso,"Background Reductions in malaria incidence in Africa can largely be attributed to increases in malaria vector control activities""; predominately the use of long-lasting insecticidal nets (LLINs). With insecticide resistance affecting an increasing number of malaria-endemic countries and threatening the effectiveness of conventional LLINs, there is an increasing urgency to implement alternative tools that control these resistant populations. The aim of this study was to identify potential challenges and opportunities for accelerating access to next-generation LLINs in Burkina Faso, a country with areas of high levels of insecticide resistance.  Methods An analytical framework was used to guide the selection of interviewees, data collection and analysis. Semi-structured interviews were carried out with key informants in April 2014 in Burkina Faso. Interviews were conducted in French and English, audio recorded, transcribed and entered into NVivo 10 for data management and analysis. Data were coded according to the framework themes and then analysed to provide a description of the key points and explain patterns in the data.  Results Interviewees reported that the policy architecture in Burkina Faso is characterised by a strong framework of actors that contribute to policymaking and strong national research capacity which indirectly contributes to national policy change via collaboration with internationally led research. Financing significantly impacts the potential adoption, availability and affordability of next-generation LLINs. This confers significant power on international donors that fund vector control. National decisions around which LLINs to procure were restricted to quantity and delivery dates;"" the potential to tackle insecticide resistance was not part of the decision-making process. Furthermore, at the time of the study, there was no World Health Organization (WHO) guidance on where and when next-generation LLINs might positively impact on malaria transmission, severely limiting their adoption, availability and affordability.  Conclusions This study shows that access to next-generation LLINs was severely compromised by the lack of global guidance. In a country like Burkina Faso where WHO recommendations are relatively quickly adopted, a clear WHO recommendation and adequate financing will be key to accelerate access to next-generation LLINs.",0,0,
311,"Changeability, confidence, common sense and corroboration: comprehensive suicide risk assessment","OBJECTIVE: The authors, in collaboration with NSW Health, have recently developed a comprehensive suicide risk assessment framework. The present paper describes key concepts in the assessment of suicide risk by mental health professionals. METHODS: A framework for conducting a comprehensive suicide risk assessment was derived from the literature, incident analysis and clinical experience. The framework underwent a consultation process involving clinicians in NSW area mental health services. The aim was to provide clinicians with a standardized conceptual map for the assessment of suicide risk. A MEDLINE search was conducted for publications dealing with 'suicide' and 'suicide risk assessment' from 1980 to 2002. The recommendations from sentinel event reviews conducted in a NSW area mental health service in the period 1999-2002 were reviewed. The lessons from a visit to a coroner's relatives support group for people who had been bereaved by suicide also informed the development of the guidelines. RESULTS: A framework is proposed for the assessment of suicide risk. The framework promotes a reflective style of practice, encouraging clinicians to evaluate their assessment and its limitations. Risk assessment is always undertaken as part of a full clinical assessment and an evaluation of the person's current predicament and psychosocio-cultural context. The concepts of changeability, assessment confidence, common sense and the importance of corroboration are incorporated in the framework. CONCLUSIONS: Mental health clinicians can be guided by a framework in suicide risk assessment and documentation. The assessment of suicide risk can generate a suicide risk rating for which minimum standards of care can be mandated.",0,0,
312,Changes and challenges: managing ADHD in a fast-paced world,"BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) impairs the lives of both children and adults. Undiagnosed and untreated, ADHD may have serious lifelong consequences. Research has identified diagnostic clues, neurotransmitter pathways, and psychiatric comorbidities related to ADHD, as well as effective pharmacologic, behavioral, and psychosocial interventions. Stimulant agents have been the foundation of ADHD therapy for more than 50 years. Availability of new extended-release (XR or ER) and longer-acting (LA) formulations and novel agents allows for wider and more individualized treatment choices. Side effects of stimulants are generally mild, short lived, and responsive to adjustments in dosage or timing. Outcomes in ADHD treatment can be improved with the use of clear treatment guidelines and tools to aid clinicians in implementing them efficiently and effectively. The Texas Children's Medication Algorithm Project (CMAP) provides a system of algorithm-driven treatment decisions that is evidence based and easy to implement. OBJECTIVE: To (1) review the psychological components of attention, the neurotransmitter pathways associated with ADHD, and the array of therapeutic options for ADHD, with an emphasis on the most recent introductions to the therapeutic armamentarium""; (2) discuss the rare psychiatric and cardiovascular side effects associated with stimulants; (3) review abuse liability, comorbidities, and suggested approaches to these issues;"" and (4) review the development and use of CMAP and offer resources for its implementation in clinical practice. CONCLUSION: The pathophysiology of ADHD is linked to dysfunction of fronto-subcortical networks and dysregulation of dopaminergic, noradrenergic, and nicotinic neurotransmitter systems. An additive effect of multiple genes as well as environmental influences contributes to the clinical picture. Treatment with stimulants and nonstimulants has proven effective in different subgroups, with the effectiveness of specific agents most likely related to the primary neurotransmitter involved. Availability of XR, ER, LA, and transdermal stimulant formulations, as well as alternative nonstimulant agents, offers new options for the pharmacotherapy of ADHD. Major concerns associated with abuse liability of stimulants have been allayed by the availability of ER formulations, which have reduced reinforcing effects associated with short-acting preparations. Medication outcomes in ADHD can be enhanced by the use of evidence-based algorithms such as CMAP. Keys to success are adequate initial assessment and diagnosis, the use of sustained-release products, sufficient dose titration, and the use of clinical rating scales with feedback from caregivers and teachers. Optimal treatment outcomes can be achieved by appropriate pharmacotherapy combined with psychosocial interventions.",0,0,
313,"Changes in insurance physicians' attitudes, self-efficacy, intention, and knowledge and skills regarding the guidelines for depression, following an implementation strategy","INTRODUCTION: To improve guideline adherence by insurance physicians (IPs), an implementation strategy was developed and investigated in a randomized controlled trial. This implementation strategy involved a multifaceted training programme for a group of IPs in applying the guidelines for depression. In this study we report the impact of the implementation strategy on the physicians' attitude, intention, self-efficacy, and knowledge and skills as behavioural determinants of guideline adherence. Any links between these self-reported behavioural determinants and levels of guideline adherence were also determined. METHODS: Just before and 3 months after the implementation of the multifaceted training, a questionnaire designed to measure behavioural determinants on the basis of the ASE (attitude, social norm, self-efficacy) model was completed by the intervention (n = 21) and the control group (n = 19). Items of the questionnaire were grouped to form scales of ASE determinants. Internal consistency of the scales was calculated using Cronbach's alphas. Differences between groups concerning changes in ASE determinants, and the association of these changes with improvements in guideline adherence, were analyzed using analysis of covariance. RESULTS: The internal consistency of the scales of ASE determinants proved to be sufficiently reliable, with Cronbach's alphas of at least 0.70. At follow-up after 3 months, the IPs given the implementation strategy showed significant improvement over the IPs in the control group for all ASE determinants investigated. Changes in knowledge and skills were only weakly associated with improvements in guideline adherence. CONCLUSIONS: The implementation strategy developed for insurance physicians can increase their attitude, intention, self-efficacy, and knowledge and skills when applying the guidelines for depression. These changes in behavioural determinants might indicate positive changes in IPs' behaviour towards the use of the guidelines for depression. However, only changes in knowledge and skills related to the use of the guidelines were associated with improvements in IPs' actual performance when applying the guidelines.",0,0,
314,Changes in lifestyle habits after counselling by nurse practitioners: 1-year results of the Groningen Overweight and Lifestyle study,"OBJECTIVES: The Groningen Overweight and Lifestyle (GOAL) study primarily aims at preventing weight gain by nurse practitioners (NP) guided by a standardized computerized software program. Since favourable changes in physical activity (PA) and diet may improve health independently of weight (loss), insight into effects on lifestyle habits is essential. We examined the 1-year effects of lifestyle counselling by NP on PA and diet, compared with usual care from the general practitioner (GP-UC). DESIGN: A randomized controlled trial. SETTING: Eleven general practice locations in the Netherlands. SUBJECTS: A total of 341 GOAL participants with overweight or obesity and either hypertension or dyslipidaemia, or both, who completed an FFQ and Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) at baseline and after 1 year. RESULTS: After 1 year, the NP group spent 33 min/week more on walking compared with the GP-UC group who spent -5 min/week on walking (P = 0.05). No significant differences were found between the NP and GP-UC groups on the percentage of persons complying with the PA guidelines. In both groups, nutrient intake changed in a favourable direction and participants complied more often with dietary guidelines, but without overall difference between the NP and GP-UC groups. CONCLUSIONS: With the exception of an increase in walking (based on self-reported data) in the NP group, no intervention effects on PA and diet occurred. Positive changes in nutrient intake were seen in both groups.",0,0,
315,Changes in nurse practitioners' knowledge and behaviors following brief training on the healthy eating and activity together (HEAT) guidelines,"INTRODUCTION: Primary care providers, particularly pediatric nurse practitioners, are an integral force involved in tackling the obesity epidemic among youth. The majority of nurse practitioners, however, report low proficiency regarding their ability to adequately prevent and treat pediatric overweight. In response, the National Association of Pediatric Nurse Practitioners (NAPNAP) developed the evidence-based Healthy Eating and Activity Together (HEAT) Clinical Practice Guideline (CPG) to improve provider behavior and efficacy. METHOD: Thirty-five nurse practitioners attending the NAPNAP Annual Conference participated in an intensive 4-hour HEAT CPG training session. Pre-training and post-training data were collected on provider knowledge, practice behaviors, and barriers in relation to the prevention of overweight among youth. RESULTS: Post-training results revealed significant improvements in (a) practitioner knowledge (assessment of patient growth, family history, psychosocial functioning, nutrition, and physical activity)""; (b) practitioners' intent to improve behavior (i.e., increased intent to use behavior modification and counseling aimed at patient and family behavior change);"" and (c) practitioners' report of increased confidence in ability to address barriers. DISCUSSION: Study findings demonstrate preliminary support for the HEAT CPG as an effective tool aimed at helping providers to improve their ability to maintain patients' healthy weight. Future research is needed to verify the effects of HEAT CPG on long-term improvements in care.",0,0,
316,Changes in nursing home residents during an innovation based on the theory of gerotranscendence,"AIMS AND OBJECTIVES: The aim of the present study was to investigate how residents were affected when an intervention based on the theory of gerotranscendence and guidelines derived from the theory was introduced in a nursing home. BACKGROUND: The notion that communication is essential in staff-resident interaction is widely accepted both in theory and practise, as is the notion that communicative behaviour influences patient outcomes. No studies as yet have focused on whether residents are influenced by staff use of guidelines derived from the theory of gerotranscendence. DESIGN: The study was explorative in nature and used a qualitative approach. METHODS: Data were collected through interviews with residents and participant observations""; qualitative content analysis was performed. SAMPLE SIZE: six residents. RESULTS: The study shows that many residents reviewed and thought about their lives, and that this aspect changed during the study period. Some residents' descriptions of their situation revealed that certain changes in social life on the ward had occurred. These changes could be an effect of the intervention. RELEVANCE TO CLINICAL PRACTICE: For nurses working in gerontological care, it is a challenge to get to know and provide the best nursing care and individual treatment for each resident;"" this involves a holistic view helping residents in their ageing process. The use of guidelines derived from the theory of gerotranscendence could help nurses promote positive ageing and constitute one way of treating residents in a more individualized manner.",0,0,
317,Changing acute pain management to improve patient outcomes: an educational approach,"The United States Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines were written to provide a scientific basis for practice. Educational programs designed to promote use of the guidelines may change practice in community hospitals. This article describes the development and implementation of an education program for nurses, physicians, and pharmacists in six community hospitals. Program content addressing the use of continuous quality improvement (CQI) teams, detailed pain histories, application of algorithms and dose calculation is described"";"" direct and indirect outcome measures are reviewed. Six months after the program, all three experimental sites reported use of the AHCPR Guidelines in practice. Nurses reported that assessment and documentation of patients' duration of pain were perceived to be the most important caregiver behaviors providing benefit to patients: Across all respondents' reports of regularly performed activities, the activity performed by the largest proportion was assessing and documenting pain using a 0-10 rating scale.",0,0,
318,Changing clinical behaviour by making guidelines specific,"The problems of getting people to act on evidence based guidelines are widely recognised.1 An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders, and educational outreach.1 The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines. None of the studies used the simplest intervention—that is, changing the wording of the guidelines. We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved.",0,1,
319,"Changing doctors' behaviours: an educational program to disseminate a new clinical pathway for the hospital management of hip fractures in elderly patients in the Lazio Region, Italy","RATIONALE AND AIMS: Concerns with patient safety have increased interest in approaches to improving doctors' performance, yet dissemination of clinical guidelines and conventional continuing medical education have often failed. This study investigated the effects of an educational program based on reflection upon experience on the quality of care for patients with hip fracture in Lazio, Italy. METHODS: Five hospitals participated. The study consisted of the development of a clinical pathway, a preparatory phase and the educational intervention itself, which comprised a course followed by monthly audits with reflection on practice, guided by analysis of patients' charts. Data on the quality of care for patients with hip fracture were collected from the routine information system for the period before and after the intervention. RESULTS: There was a significant increase in the proportion of patients who underwent surgery within 48 hours of admission (from 7% in 2006 to 26.4% in 2007) and a significant reduction in the average length of hospital stay (from 18.8 to 16.4 days). Some process indicators of quality of care were high after the intervention, though non-recommended practices were still routinely used (e.g. urinary catheterization in 72.2% of patients). There were differences in the changes when comparing hospitals. CONCLUSION: An educational intervention that combined the dissemination of a clinical pathway with external auditing geared to reflection upon practice was effective in promoting changes in doctors' behaviours. The persistence of non-recommended practices and the variation among hospitals indicate that multiple factors influence performance and affect the effectiveness of interventions.",0,0,
320,Changing human behavior to prevent disease: the importance of targeting automatic processes.,"Much of the global burden of disease is associated with behaviors—overeating, smoking, excessive alcohol consumption, and physical inactivity—that people recognize as health-harming and yet continue to engage in, even when undesired consequences emerge. To date, interventions aimed at changing such behaviors have largely encouraged people to reflect on their behaviors. These approaches are often ineffectual, which is in keeping with the observation that much human behavior is automatic, cued by environmental stimuli, resulting in actions that are largely unaccompanied by conscious reflection. We propose that interventions targeting these automatic bases of behaviors may be more effective. We discuss specific interventions and suggest ways to determine whether and how interventions that target automatic processes can enhance global efforts to prevent disease.",0,1,
321,Changing minds: Bounded rationality and heuristic processes in exercise-related judgments and choices.,"Theories currently used to understand, predict, and promote physical activity and exercise represent information-processing models of the mind. A fundamental assumption underpinning these theories is that human judgment and decision-making processes are rational. Thus, interventions derived from these models are aimed to enhance ""data input"" (e.g., provide complete, accurate, and compelling information about health benefits) with the expectation that the rational evaluation of these data will result in the desired behavioral ""output."" Given the modest effectiveness of interventions based on these models, we designed 2 experiments testing the validity of the assumption of rationality, focusing specifically on exercise-related judgments and decisions. In Experiment 1, exercise judgments were altered by shifting an arbitrary anchor, whose presence should have had no bearing on these judgments. In Experiment 2, the preference between a target exercise session and an alternative was increased by the mere addition of a third ""decoy"" exercise option. Together, these experiments demonstrate that important motivational variables, including the perceived desirability of exercise, affective attitude, intention, affective forecasts, and exercise choices can be manipulated in a predictable direction without providing any new relevant information, but by merely targeting specific, well-characterized heuristics. Therefore, these data provide evidence that the ""bounded"" nature of human rationality also manifests itself in exercise judgments and decisions. Researchers and exercise practitioners should consider incorporating heuristic processes within dual-process theoretical models of physical activity and exercise behavior. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
322,Changing physician behavior to improve disease prevention,"Physicians often fail to provide nationally recommended preventive services for their patients. Addressing this, we have reviewed selected literature on changing physician behavior using the organizational construct of the ""readiness for change"" transtheoretical model. This model suggests that behavior evolves through stages from precontemplation, to contemplation, to preparation, to initiation, and to maintenance of change. Traditional continuing medical education may affect knowledge and beliefs, but rarely results in behavior change. However, motivational strategies such as practice feedback reports and influential peers can foster stage change. Successful interventions aimed at physicians preparing for change frequently use an office-system approach that targets not only physicians, but office staff and patients as well. Illustrating how the readiness to change model can guide the design and implementation of interventions, we describe strategies being used in a statewide randomized controlled trial to improve cancer prevention counseling and early detection by primary care physicians. The multistage interventions of Partners for Prevention include support from a medical liability carrier, a motivational videotape, a task-delineated office manual, chart flowsheets, patient activation forms, practice feedback reports, a designated prevention coordinator within each practice and regular telephone calls and office visits by project staff.",0,0,
323,Changing physician behavior: what works?,"OBJECTIVES: There are various interventions for guideline implementation in clinical practice, but the effects of these interventions are generally unclear. We conducted a systematic review to identify effective methods of implementing clinical research findings and clinical guidelines to change physician practice patterns, in surgical and general practice. STUDY DESIGN: Systematic review of reviews. METHODS: We searched electronic databases (MEDLINE, EMBASE, and PubMed) for systematic reviews published in English that evaluated the effectiveness of different implementation methods. Two reviewers independently assessed eligibility for inclusion and methodological quality, and extracted relevant data. RESULTS: Fourteen reviews covering a wide range of interventions were identified. The intervention methods used include: audit and feedback, computerized decision support systems, continuing medical education, financial incentives, local opinion leaders, marketing, passive dissemination of information, patient-mediated interventions, reminders, and multifaceted interventions. Active approaches, such as academic detailing, led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active educational methods and multifaceted interventions. CONCLUSIONS: Active forms of continuing medical education and multifaceted interventions were found to be the most effective methods for implementing guidelines into general practice. Additionally, active approaches to changing physician performance were shown to improve practice to a greater extent than traditional passive methods. Further primary research is necessary to evaluate the effectiveness of these methods in a surgical setting.",0,1,
324,Changing physician practice behavior to measure and improve clinical outcomes,"Physician practice behavior often produces poor clinical outcomes in the management of cardiovascular disease risk factors in spite of effective treatments and guidelines. The behavior of 165 physicians in 2 settings (suburban and urban) was studied. After collecting baseline clinical data, including systolic blood pressure and low-density lipoprotein cholesterol, a series of interventions was conducted, including academic detailing. Low-density lipoprotein cholesterol decreased 10.4% in suburban patients with cardiovascular disease in the intervention group (P = .001) and 10.5% in the enhanced intervention group (P = .001). Systolic blood pressure decreased 1.11% (P = .357) in the intervention group and 5.13% in the enhanced intervention group (P < .001). In urban hypertensive patients, systolic blood pressure decreased 5.03% (P = .001) and low-density lipoprotein cholesterol decreased 7.01% (P < .001). Combining urban and suburban data, low-density lipoprotein cholesterol decreased 9.32% (P < .001) and systolic blood pressure decreased 4.00% (P < .001). Providing physicians with their clinical outcomes, reviewing national guidelines, and setting expectations, associated with modest practice systems innovations, can produce significant measurable clinical improvements.",0,0,
325,Changing social relationships,,0,0,
326,Chapter: A review of self-management support for (work-related) musculoskeletal pain disorders.,"The form of the review on self-management interventions for chronic conditions and musculoskeletal disorders (MSDs) within this chapter is narrative. Individual qualitative and quantitative research studies as well as systematic reviews and other reviews of relevance were considered. Four major databases were searched for relevant peer-reviewed literature published in the last 10 years. Publications prior to this period were included in the review if the work was considered seminal in terms of its contribution to the self management knowledge base within the context of interest. The following terms were used as keywords and linked using Boolean operators: self-care, self-management, chronic disease, chronic illness, patient education as topic, patient-centred care, health behaviour, low back pain and musculoskeletal disorders. As the focus of the review was on persons of working age, the limits applied included English language and adults aged 15-64 years. Relevant grey literature and references from key authors in the field were also consulted. We did not formally assess the methodological quality of included studies. The identified peer-reviewed studies were then examined for intervention components that are tightly conceptually linked with self-management and the involvement of chronic conditions, especially MSDs, and excluded otherwise. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
327,Chapter: Behavior economics and treatment engagement.,"Behavior economics is a field that integrates concepts of psychology and economics to explain individuals' decision making. In the past few years, this field has been increasingly incorporated into health care settings to promote healthier lifestyles. Typically, participants are given monetary incentives when a target behavior or goal is objectively verified. In this chapter, we describe this evidence-based treatment usually referred to as contingency management. This chapter is structured in four parts. Section ""Background"" reviews the historical background of incentive-based interventions as applied to substance abuse treatment. Section ""Application of Incentive-Based Intervention to Medicine Targets"" describes the application of these interventions to other medicine targets, such as vaccination, medical screenings, diabetes monitoring, physical activity, and weight loss programs. Section ""Fundamental Elements and Concepts Embedded in Incentive-Based Interventions"" explains fundamental concepts and elements embedded in effective incentive-based interventions, and the final section discusses issues related to the application and dissemination of incentive programs. (PsycINFO Database Record (c) 2017 APA, all rights reserved)",0,0,
328,Chapter: Escape from cognitivism: Exercise as hedonic experience.,"Establishing its societal relevance should be a strategic target for exercise psychology. Progress toward this goal, however, has been slower than anyone in this field would have liked. In this chapter, we argued that, in part, the failure to deliver intervention methods that can reliably and meaningfully increase the level of physical activity may be due to an overly narrow metatheoretical perspective. We illustrated that all major theories in vogue within exercise psychology over the past decades are derivatives of the same (cognitivist) metatheoretical framework. As such, they all exhibit a crucial limitation, namely the relative disregard for the motivational properties of affective constructs, such as core affect, moods, and emotions. Research over the past 15 years has demonstrated that the old adage of ""exercise makes people feel better"" is inaccurate. Thus, the central thrust of this chapter was to underscore the urgent need for the field of exercise psychology to transition to the postcognitivist era. (PsycINFO Database Record (c) 2017 APA, all rights reserved)",0,0,
329,Characteristics of poorly controlled Type 2 diabetes patients in Swiss primary care,"BACKGROUND: Although a variety of treatment guidelines for Type 2 diabetes patients are available, a majority of patients does not achieve recommended targets. We aimed to characterise Type 2 diabetes patients from Swiss primary care who miss HbA1c treatment goals and to reveal factors associated with the poorly controlled HbA1c level. METHODS: Cross-sectional study nested within the cluster randomised controlled Chronic Care for Diabetes study. Type 2 diabetes patients with at least one HbA1c measurement >/= 7.0 % during the last year were recruited from Swiss primary care. Data assessment included diabetes specific and general clinical measures, treatment factors and patient reported outcomes. RESULTS: 326 Type 2 diabetes patients from 30 primary care practices with a mean age 67.1 +/- 10.6 years participated in the study. The patients' findings for HbA1c were 7.7 +/- 1.3 %, for systolic blood pressure 139.1 +/- 17.6 mmHg, for diastolic blood pressure 80.9 +/- 10.5 mmHg and for low density lipoprotein 2.7 +/- 1.1. 93.3 % of the patients suffered from at least one comorbidity and were treated with 4.8 +/- 2.1 different drugs. No determining factor was significantly related to HbA1c in the multiple analysis, but a significant clustering effect of GPs on HbA1c could be found. CONCLUSIONS: Within our sample of patients with poorly controlled Type 2 diabetes, no ""bullet points"" could be pointed out which can be addressed easily by some kind of intervention. Especially within this subgroup of diabetes patients who would benefit the most from appropriate interventions to improve diabetes control, a complex interaction between diabetes control, comorbidities, GPs' treatment and patients' health behaviour seems to exist. So far this interaction is only poorly described and understood.",0,0,
330,Characteristics of successfully implemented telemedical applications,"Background There has been an increased interest in the use of telemedical applications in clinical practice in recent years. Considerable effort has been invested in trials and experimental services. Yet, surprisingly few applications have continued beyond the research and development phase. The aim of this study is to explore characteristics of successfully implemented telemedical applications.  Methods An extensive search of telemedicine literature was conducted in order to identify relevant articles. Following a defined selection process, a small number of articles were identified that described characteristics of successfully implemented telemedical applications. These articles were analysed qualitatively, drawing on central procedures from Grounded Theory (GT), including condensation and categorisation. The analysis resulted in a description of features found to be of importance for a successful implementation of telemedicine. Subsequently, these features were discussed in light of Science and Technology studies (STS) and the concept of 'social negotiation'.  Results Telemedical applications introduced into routine practice are typically characterised by the following six features: 1) local service delivery problems have been clearly stated, 2) telemedicine has been seen as a benefit, 3) telemedicine has been seen as a solution to political and medical issues, 4) there was collaboration between promoters and users, 5) issues regarding organizational and technological arrangements have been addressed, and 6) the future operation of the service has been considered.  Conclusion Our findings support research arguing that technologies are not fixed entities moving from invention through diffusion and into routine use. Rather, it is the interplay between technical and social factors that produces a particular outcome. The success of a technology depends on how this interplay is managed during the process of implementation.",0,0,
331,Child survival in the Third World: a functional analysis of oral rehydration therapy dissemination campaigns,"PIP: Behavior analysts conducted a functional analysis of different intervention strategies employed in 14 oral rehydration therapy (ORT) campaigns in 10 developing countries. The intervention researchers manipulated antecedents, behaviors, and/or consequences to improve diarrhea management. The strategies used radio announcements, posters, and pamphlets to promote behavior change. Only 2 campaigns (Thailand and Egypt) limited their intervention to these antecedents. Only 3 programs manipulated antecedents, behaviors, and consequences. The 1983 campaign in Bangladesh incorporated school instruction to siblings and home visits as part of skill training and provided incentives to trainers (US$30) as its consequences. The 1985 project in the Gambia used health workers to teach mothers at home about ORT and awarded happy baby lottery prizes (rice, sugar, and soap). The skills training component of the 1984 campaign in Honduras involved 1-on-1 instruction. A radio course on breast feeding, school instruction of siblings, and an illustrated health care manual. Its consequences were games and prizes on radio program call in, free calendars, key rings, t-shirts and a trip to Tegucigalpa. The only program limited to a skills training component was the campaign in South India in 1976. The training involved training nurses to instruct mothers about diarrhea management. An obstacle in all the campaigns was that ORT does not outwardly improve diarrhea and vomiting immediately. Those campaigns that had a skills training component were more effective than those that did not. Behavior analysts could contribute to ORT campaigns by developing simple and effective training programs and developing economical and effective mechanisms to evaluate the effectiveness of such campaigns.",0,0,
332,Childhood autism and related conditions,,0,0,
333,Childhood Obesity Screening and Treatment Practices of Pediatric Healthcare Providers,"This study evaluated physicians' childhood obesity screening and treatment practices. A 26-question survey was delivered to pediatric providers in-person or via mail, e-mail, or fax throughout Louisiana. Fifty-seven providers completed the survey, the majority in primary care clinics. Five providers met at least four of seven clinical guidelines, but no provider met all of the guidelines. Whereas 88% of providers screened for obesity, 7% met guidelines for referring patients with obesity to weight management services. Six providers offered interventions that included all recommended components (i.e. dietary, physical activity, and behavioral counseling). One intervention met intensity guidelines (i.e. >25 hours delivered over at least six months). Barriers to offering services included lack of reimbursement and poor compliance by families. Solutions to overcome treatment barriers should be identified to increase the provision of health care services for children with obesity.",0,0,
334,Childhood tonsillectomy: who is referred and what treatment choices are made? Baseline findings from the North of England and Scotland Study of Tonsillectomy and Adenotonsillectomy in Children (NESSTAC),"BACKGROUND: Tonsillectomies are frequently performed, yet variations exist in tonsillectomy rates. Clinicians use guidelines, but complex psychosocial influences on childhood tonsillectomy include anecdotal evidence of parental enthusiasm. Studies indicate that undergoing preferred treatment improves outcome. Despite the enthusiasm with which tonsillectomy is offered and sought, there is little evidence of efficacy. This resulted in a randomised controlled trial to evaluate the cost-effectiveness of (adeno)tonsillectomy in children with recurrent sore throats. OBJECTIVE: To compare characteristics of children entering the randomised trial with those recruited to a parallel, non-randomised study, to establish trends in referral and patient preferences for treatment. DESIGN: Baseline data from a randomised controlled trial with parallel non-randomised preference study, comparing surgical intervention with medical treatment in children aged 4-15 years with recurrent sore throat referred to five secondary care otolaryngology departments located in the north of England or west central Scotland. RESULTS: Centres assessed 1546 children"";"" 21% were not eligible for tonsillectomy. Among older children (8-15 years), girls were significantly more likely to be referred to secondary care. Of 1015 eligible children, 268 (28.2%) agreed to be randomised, while 461 (45.4%) agreed to the parallel, non-randomised preference study, with a strong preference for tonsillectomy. Participants reporting that progress at school had been impeded or with more experience of persistent sore throat were more likely to seek tonsillectomy. Referred boys were more likely than girls to opt for medical treatment. Socio-economic data showed no effect. CONCLUSION: Preference for tonsillectomy reflects educational impact and recent experience, rather than age or socio-economic status.",0,0,
335,Children in taxis: an opportunity for pediatricians and emergency physicians to save lives?,"OBJECTIVE: Child safety devices (infant seats, booster seats, and seat belts) are effective in curbing the risk of injury"";"" however, there remains a pattern of parental nonuse or misuse of safety seats. The aim of this study was to assess the level of knowledge and compliance of parents with children presenting for emergency care of the National Highway and Traffic Association safety seat guidelines in private cars and taxicabs. METHODS: Two hundred forty-two caregivers of children (ages range, 2 weeks to 19 years) presenting for care in the pediatric emergency department of an urban university hospital were approached to complete an interviewer-administered questionnaire, and 225 participated. The questionnaire included knowledge, attitude, and behavior questions on protective equipment for various aged children. RESULTS: Eleven (47.8%) of 23 children 1 year or younger were reported to use infant seats often or always while riding in private cars, compared with 8 (22.2%) of 36 children 1 year or younger were reported to their use while in taxis (P < 0.05). Seventeen (85%) of 20 children older than 8 years were reported to have used seat belts often or always in private cars versus 10 (41.7%) of 24 in taxis (P < 0.01). One hundred fifty-four (99.3%) of 155 subjects knew the National Highway Traffic Safety Administration recommended position for the safety seat for their child. Most parents believed in the efficacy of child safety seats in preventing vehicle injuries and reported they would be more likely to use safety devices if they received information on their use in the emergency department. CONCLUSIONS: Data from this survey show that use of safety seats is lower in taxis than in private automobiles and that this is attributable to the inconvenience of carrying these seats to and from the taxi rather than financial considerations or lack of knowledge about their effectiveness. Strategies should be sought to increase availability of child safety devices in taxicabs. The emergency department, as well as the pediatrician's office or clinic, can be a locus for an educational intervention to parents and caregivers on child passenger safety.",0,0,
336,Children with head injuries,,0,0,
337,Children’s Cognitive Performance and Selective Attention Following Recent Community Violence,"Research has shown robust relationships between community violence and psychopathology, yet relatively little is known about the ways in which community violence may affect cognitive performance and attention. The present study estimates the effects of police-reported community violence on 359 urban children’s performance on a computerized neuropsychological task using a quasi-experimental fixed-effects design. Living in close proximity to a recent violent crime predicted faster but marginally less accurate task performance for the full sample, evolutionarily adaptive patterns of “vigilant” attention (i.e., less attention toward positive stimuli, more attention toward negative stimuli) for children reporting low trait anxiety, and potentially maladaptive patterns of “avoidant” attention for highly anxious children. These results suggest that community violence can directly affect children’s cognitive performance while also having different (and potentially orthogonal) impacts on attention deployment depending on children’s levels of biobehavioral risk. Implications for mental health and sociological research are discussed.",0,0,
338,Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review,"BACKGROUND: Psychostimulants are first line of therapy for paediatric and adolescent AD/HD. The evidence suggests that up to 30% of those prescribed stimulant medications do not show clinically significant outcomes. In addition, many children and adolescents experience side-effects from these medications. As a result, parents are seeking alternate interventions for their children. Complementary and alternative medicine therapies for behavioural disorders such as AD/HD are increasing with as many as 68% of parents having sought help from alternative practitioners, including chiropractors. OBJECTIVE: The review seeks to answer the question of whether chiropractic care can reduce symptoms of inattention, impulsivity and hyperactivity for paediatric and adolescent AD/HD. METHODS: Electronic databases (Cochrane CENTRAL register of Controlled Trials, Cochrane Database of Systematic reviews, MEDLINE, PsycINFO, CINAHL, Scopus, ISI Web of Science, Index to Chiropractic Literature) were searched from inception until July 2009 for English language studies for chiropractic care and AD/HD. Inclusion and exclusion criteria were applied to select studies. All randomised controlled trials were evaluated using the Jadad score and a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines. RESULTS: The search yielded 58 citations of which 22 were intervention studies. Of these, only three studies were identified for paediatric and adolescent AD/HD cohorts. The methodological quality was poor and none of the studies qualified using inclusion criteria. CONCLUSIONS: To date there is insufficient evidence to evaluate the efficacy of chiropractic care for paediatric and adolescent AD/HD. The claim that chiropractic care improves paediatric and adolescent AD/HD, is only supported by low levels of scientific evidence. In the interest of paediatric and adolescent health, if chiropractic care for AD/HD is to continue, more rigorous scientific research needs to be undertaken to examine the efficacy and effectiveness of chiropractic treatment. Adequately-sized RCTs using clinically relevant outcomes and standardised measures to examine the effectiveness of chiropractic care verses no-treatment/placebo control or standard care (pharmacological and psychosocial care) are needed to determine whether chiropractic care is an effective alternative intervention for paediatric and adolescent AD/HD.",0,0,
339,Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question,"In an effort to draw attention to tests and procedures associated with low-value care in headache medicine, the American Headache Society (AHS) joined the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. The AHS president appointed an ad hoc ""Choosing Wisely"" task force of the AHS. The committee surveyed AHS members to develop a candidate list of items for the AHS ""Top 5"" list of low-value care in headache medicine. Through a process of literature review and consensus, the final list of five items was chosen. Draft recommendations went through several rounds of revision and a process of outside review. The AHS Board of Directors approved the final list of ""Five Things."" The five recommendations approved by the AHS Board of Directors are: (1) don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine""; (2) don't perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings; (3) don't recommend surgical deactivation of migraine trigger points outside of a clinical trial; (4) don't prescribe opioid- or butalbital-containing medications as a first-line treatment for recurrent headache disorders;"" and (5) don't recommend prolonged or frequent use of over-the-counter pain medications for headache. We recommend that headache medicine specialists and other physicians who evaluate and treat headache disorders should use this list when discussing care with patients.",0,0,
340,Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question,"OBJECTIVE: We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and patients. METHODS: We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement and perceived high prevalence advanced to a survey of ACR members, who comprise >90% of the US rheumatology workforce. To increase the response rate, a nested random sample of 390 rheumatologists received more intensive survey followup. The samples were combined and weighting procedures were applied to ensure generalizability. Items with high ratings underwent literature review. Final items were then selected and formulated by the task force. RESULTS: One hundred five unique items were proposed and narrowed down to 22 items during the Delphi rounds. A total of 1,052 rheumatologists (17% of those contacted) participated in the member-wide survey, whereas 33% of those in the nested random sample participated"";"" respondent characteristics were similar in both samples. Based on survey results and available scientific evidence, 5 items (relating to antinuclear antibodies, Lyme disease, magnetic resonance imaging, bone absorptiometry, and biologic therapy for rheumatoid arthritis) were selected for inclusion. CONCLUSION: The ACR Top 5 list is intended to promote discussions between physicians and patients about health care practices in rheumatology whose use should be questioned and to assist rheumatologists in providing high-value care.",0,0,
341,Choosing wisely: the American Society for Radiation Oncology's top 5 list,"PURPOSE: To highlight 5 interventions that patients should question, as part of the Choosing Wisely campaign. This initiative, led by the American Board of Internal Medicine Foundation, fosters conversations between physicians and patients about treatments and tests that may be overused, unnecessary, or potentially harmful. METHODS AND MATERIALS: Potential items were initially compiled using an online survey. They were then evaluated and refined by a work group representing the American Society for Radiation Oncology (ASTRO) Clinical Affairs and Quality, Health Policy, and Government Relations Councils. Literature reviews were carried out to support the recommendation and narrative, as well as to provide references for each item. A final list of 5 items was then selected by the ASTRO Board of Directors. RESULTS: ASTRO's 5 recommendations for the Choosing Wisely campaign are the following: (1) Don't initiate whole-breast radiation therapy as a part of breast conservation therapy in women age >/=50 with early-stage invasive breast cancer without considering shorter treatment schedules""; (2) don't initiate management of low-risk prostate cancer without discussing active surveillance; (3) don't routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases; (4) don't routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry;"" and (5) don't routinely use intensity modulated radiation therapy to deliver whole-breast radiation therapy as part of breast conservation therapy. CONCLUSIONS: The ASTRO list for the Choosing Wisely campaign highlights radiation oncology interventions that should be discussed between physicians and patients before treatment is initiated. These 5 items provide opportunities to offer higher quality and less costly care.",0,0,
342,Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system.,"OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model (CCM).  PARTICIPANTS AND METHODS As part of the CCM, 97 primary care physicians at 6 primary care practices in Rochester, MN, referred 639 patients to an on-site diabetes educator between July 1, 2001, and December 31, 2003. On first referral, physicians were centrally randomized to receive a telemedicine intervention (specialty advice and evidence-based messages regarding medication management for cardiovascular risk) or no intervention, keeping outcome assessors and data analysts blinded to group assignment. After each subsequent clinical encounter, endocrinologists reviewed an abstract from the patient's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail. Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes. Outcome measures included diabetes care processes (diabetes test completion), outcomes (metabolic and cardiovascular risk factors, estimated coronary artery disease risk), and patient costs (payer perspective).  RESULTS During the intervention, 951 (70%) of the 1361 endocrinology reviews detected performance gaps and resulted in a message; primary care physicians reported using 49% of messages in patient care. With a mean of 21 months' follow-up, the intervention, compared with control, did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease (adjusted mean difference, -1%;"" 95% confidence interval, -19% to 17%). The intervention group incurred lower costs (P=.02) but not in diabetes-related costs.  CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care.",0,1,
343,Chronic disease health risk behaviours amongst people with a mental illness,"OBJECTIVE: Amongst people with a mental illness, modifiable health risk behaviours contribute substantially to increased chronic disease morbidity and mortality. This study examined the prevalence of and interest in changing such behaviours amongst community mental health service clients in Australia. METHOD: A telephone interview was undertaken with Australian community mental health service clients. Participants reported engagement in four health risk behaviours: tobacco smoking, fruit and vegetable consumption, alcohol consumption, and physical activity. Participants were classified as at risk based upon Australian national guidelines. At-risk participants were asked whether they were considering improving their health risk behaviour within the next month. The association between psychiatric diagnosis and risk, and interest in improving health risk behaviours was examined. RESULTS: Risk prevalence was highest for inadequate vegetable consumption (78.3%), followed by inadequate fruit consumption (60%), smoking (50.7%), physical inactivity (46.8%), short-term alcohol risk (40.3%) and chronic alcohol risk (35.3%). A majority of at-risk participants were considering improving their health risk behaviour for smoking, physical inactivity and inadequate fruit and vegetable consumption (65.1%, 71.1%, and 53.3%, respectively). After adjusting for demographic factors, no diagnostic categories were associated with risk for any behaviour. Those with a diagnosis of depression were more likely to be interested in quitting smoking and increasing physical activity. CONCLUSIONS: Regardless of diagnosis, a high prevalence of chronic disease health risk behaviours was identified, with many participants expressing an interest in improving these behaviours. Such findings reinforce recommendations that preventive care addressing the chronic disease risks of clients be provided routinely by mental health clinicians. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000693729. URL: www.anzctr.org.au/.",0,0,
344,Chronic inflammatory bowel diseases competence network,"Inflammatory bowel diseases (IBD) are intermittently appearing, often chronic diseases mostly affecting young people between 20-30 years of age influencing their quality of life and socioeconomic efficiency. The triggering factors for the development of IBD are not completely understood: besides environmental factors there is clear evidence for additional genetic factors influencing the risk of disease and the pattern of gut inflammation in Crohn's disease. Pathopysiological discoveries are leading to new therapeutic opportunities which are conducted in large clinical studies with main participation of the competence network IBD. The disseminated structure of the network comprising universitary and nonuniversitary hospitals and labs, the self-help-organization DCCV and its vertical cooperation with general practitioners nationwide gives opportunity to describe the diseases from the point of view of the scientist and the physician simultaneously. Therefore the competence network IBD yields the basis for the standardized integration of patient information, for the development of guidelines and the establishment of a quality management system thus leading to an improvement of scientific and clinical research.",0,0,
345,Cigarette Smoking Prevalence Among Adults With HIV Compared With the General Adult Population in the United States,"Background:The negative health effects of cigarette smoking and HIV infection are synergistic.Objective:To compare the prevalence of current cigarette smoking and smoking cessation between adults with HIV receiving medical care and adults in the general population.Design:Nationally representative cross-sectional surveys.Setting:United States.Patients:4217 adults with HIV who participated in the Medical Monitoring Project and 27 731 U.S. adults who participated in the National Health Interview Survey in 2009.Measurements:The main exposure was cigarette smoking. The outcome measures were weighted prevalence of cigarette smoking and quit ratio (ratio of former smokers to the sum of former and current smokers).Results:Of the estimated 419 945 adults with HIV receiving medical care, 42.4% (95% CI, 39.7% to 45.1%) were current cigarette smokers, 20.3% (CI, 18.6% to 22.1%) were former smokers, and 37.3% (CI, 34.9% to 39.6%) had never smoked. Compared with the U.S. adult population, in which an estimated 20.6% of adults smoked cigarettes in 2009, adults with HIV were nearly twice as likely to smoke (adjusted prevalence difference, 17.0 percentage points [CI, 14.0 to 20.1 percentage points]) but were less likely to quit smoking (quit ratio, 32.4% vs. 51.7%). Among adults with HIV, factors independently associated with greater smoking prevalence were older age, non-Hispanic white or non-Hispanic black race, lower educational level, poverty, homelessness, incarceration, substance use, binge alcohol use, depression, and not achieving a suppressed HIV viral load.Limitation:Cross-sectional design with some generalizability limitations.Conclusion:Adults with HIV were more likely to smoke and less likely to quit smoking than the general adult population. Tobacco screening and cessation strategies are important considerations as part of routine HIV care.",0,0,
346,CIOMS' placebo rule and the promotion of negligent medical practice,,0,0,
347,Civil commitment of the anorexic patient,"Involuntary commitment appears to be an infrequently used intervention with anorexic patients, in part because of clinicians' uncertainty about its applicability to this population. In contrast to overtly suicidal patients, anorexic patients typically fail to express an intent to harm themselves, although their actions may result in severe harm. Examination of the language of civil commitment statutes, however, suggests that when the behavior of anorexic patients endangers their lives, they will usually be committable under grave disability standards. This appears to comport with the practices of experts in the treatment of anorexia, and with practices in other countries as well. Involuntary commitment should be used as an approach of last resort, when patients decline voluntary hospitalization and their physical safety is at risk. Moreover, civil commitment should probably also be limited to circumstances in which therapeutic gain is likely from hospitalization. Many severely ill anorexic patients will lack competence to make treatment decisions on their own behalf, allowing involuntary feeding and other procedures to take place, if necessary. Civil commitment is a tool that can legitimately be used in emergent situations with anorexic patients.",0,0,
348,Classifications in the field of mental health,"For the first time in the Ninth Revision of the International Classification of Diseases (ICD-9) the chapter on mental disorders contained short glossary definitions for each category. A number of changes in attitudes and policies at the international and national levels, particularly the reorientation of mental health programmes to include behavioural and psychosocial problems, came at an opportune time and had a positive influence on the development of proposals for the chapter on mental and behavioural disorders in the Tenth Revision (ICD-10). This in turn enabled WHO to undertaken an intensive and extensive assessment of international needs in the classification of mental disorders and, where the situation was not unequivocal, to organize field trials to provide the empirical data necessary for problem solution. The result is a series of compatible classifications of mental and behavioural disorders based on ICD-10. The first, produced mainly as a reference tool for statistical purposes, will be included in ICD-10 with short glossary definitions as was the case for ICD-9. Other versions will be published for practising clinicians (with enhanced glossary definitions followed by diagnostic guidelines) for research (with full definitions, diagnostic guidelines and diagnostic criteria)""; for use in the provision of services to the mentally ill;"" and for use in general health (primary) care. There will also be a multiaxial classification of mental disorders in children to identify the clinical syndrome, resulting disability and environmental factors. It is hoped that these versions tailored to the needs of different groups working in the field of mental health will result in further improvements in communications between those responsible for the provision of services and care.",0,0,
349,Classroom based cognitive behavioural therapy in reducing symptoms of depression in high risk adolescents: pragmatic cluster randomised controlled trial,"OBJECTIVE To compare the effectiveness of classroom based cognitive behavioural therapy with attention control and usual school provision for adolescents at high risk of depression. DESIGN Three arm parallel cluster randomised controlled trial. SETTING Eight UK secondary schools. PARTICIPANTS Adolescents (n=5030) aged 12-16 years in school year groups 8-11. Year groups were randomly assigned on a 1:1:1 ratio to cognitive behavioural therapy, attention control, or usual school provision. Allocation was balanced by school, year, number of students and classes, frequency of lessons, and timetabling. Participants were not blinded to treatment allocation. INTERVENTIONS Cognitive behavioural therapy, attention control, and usual school provision provided in classes to all eligible participants. MAIN OUTCOME MEASURES Outcomes were collected by self completed questionnaire administered by researchers. The primary outcome was symptoms of depression assessed at 12 months by the short mood and feelings questionnaire among those identified at baseline as being at high risk of depression. Secondary outcomes included negative thinking, self worth, and anxiety. Analyses were undertaken on an intention to treat basis and accounted for the clustered nature of the design. RESULTS 1064 (21.2%) adolescents were identified at high risk of depression: 392 in the classroom based cognitive behavioural therapy arm, 374 in the attention control arm, and 298 in the usual school provision arm. At 12 months adjusted mean scores on the short mood and feelings questionnaire did not differ for cognitive behavioural therapy versus attention control (-0.63, 95% confidence interval -1.85 to 0.58, P=0.41) or for cognitive behavioural therapy versus usual school provision (0.97, -0.20 to 2.15, P=0.12). CONCLUSION In adolescents with depressive symptoms, outcomes were similar for attention control, usual school provision, and cognitive behavioural therapy. Classroom based cognitive behavioural therapy programmes may result in increased self awareness and reporting of depressive symptoms but should not be undertaken without further evaluation and research. TRIAL REGISTRATION Current Controlled Trials ISRCTN19083628.",0,0,
350,"Clinical and cost effectiveness of booklet based vestibular rehabilitation for chronic dizziness in primary care: single blind, parallel group, pragmatic, randomised controlled trial","OBJECTIVE To determine the clinical and cost effectiveness of booklet based vestibular rehabilitation with and without telephone support for chronic dizziness, compared with routine care. DESIGN Single blind, parallel group, pragmatic, randomised controlled trial. SETTING 35 general practices across southern England between October 2008 and January 2011. PARTICIPANTS Patients aged 18 years or over with chronic dizziness (mean duration >five years) not attributable to non-vestibular causes (confirmed by general practitioner) and that could be aggravated by head movement (confirmed by patient). INTERVENTIONS Participants randomly allocated to receive routine medical care, booklet based vestibular rehabilitation only, or booklet based vestibular rehabilitation with telephone support. For the booklet approach, participants received self management booklets providing comprehensive advice on undertaking vestibular rehabilitation exercises at home daily for up to 12 weeks and using cognitive behavioural techniques to promote positive beliefs and treatment adherence. Participants receiving telephone support were offered up to three brief sessions of structured support from a vestibular therapist. MAIN OUTCOME MEASURES Vertigo symptom scale-short form and total healthcare costs related to dizziness per quality adjusted life year (QALY). RESULTS Of 337 randomised participants, 276 (82%) completed all clinical measures at the primary endpoint, 12 weeks, and 263 (78%) at one year follow-up. We analysed clinical effectiveness by intention to treat, using analysis of covariance to compare groups after intervention, controlling for baseline symptom scores. At 12 weeks, scores on the vertigo symptom scale in the telephone support group did not differ significantly from those in the routine care group (adjusted mean difference -1.79 (95% confidence interval -3.69 to 0.11), P=0.064). At one year, both intervention groups improved significantly relative to routine care (telephone support -2.52 (-4.52 to -0.51), P=0.014""; booklet only -2.43 (-4.27 to -0.60), P=0.010). Analysis of cost effectiveness acceptability curves showed that both interventions were highly cost effective; at very low QALY values, the booklet only approach was most likely to be cost effective, but the approach with additional telephone support was most likely to be cost effective at QALY values more than £1200 (€1488;"" $1932). Using the booklet approach with telephone support, five (three to 12) patients would need to be treated for one patient to report subjective improvement at one year. CONCLUSIONS Booklet based vestibular rehabilitation for chronic dizziness is a simple and cost effective means of improving patient reported outcomes in primary care. TRIAL REGISTRATION ClinicalTrials.gov NCT00732797.",0,0,
351,Clinical assessment of mothering during infancy,"Using reliable and valid measurements of mothering can enhance clinicians' and researchers' ability to identify problematic patterns that pose risks to the health of mothers and infants during the first postpartum year. A critical review of observational and self-report instruments for measuring components of mothering is presented. Positive indicators of mothering are discussed, and implications for intervention and referral for problematic aspects of mothering are suggested.",0,0,
352,Clinical biochemistry nearer the patient,,0,0,
353,Clinical characteristics associated with the prescribing of SSRI medication in adolescents with major unipolar depression,"Unipolar major depressions (MD) emerge markedly during adolescence. National Institute for Health and Care Excellence (NICE) UK recommends psychological therapies, with accompanying selective serotonin reuptake inhibitors (SSRIs) prescribed in severe cases only. Here, we seek to determine the extent and rationale of SSRI prescribing in adolescent MD before entering a randomised clinical trial. SSRI prescribing, together with their clinical characteristics was determined in 465 adolescent patients with MD prior to receiving a standardised psychological therapy as part of the Improving mood with psychoanalytic and cognitive therapies (IMPACT) clinical trial. Overall, 88 (19 %) had been prescribed antidepressants prior to psychological treatment. The clinical correlates varied by gender: respectively, depression severity in boys and self-harming behaviours in girls. Prescribing also differed between clinical research centres. Medical practitioners consider severity of depression in boys as an indicator for antidepressant prescribing. Self-injury in girls appears to be utilised as a prescribing aid which is inconsistent with past and current revised UK NICE guidelines.",0,0,
354,"Clinical effectiveness of a manual based coping strategy programme (START, STrAtegies for RelaTives) in promoting the mental health of carers of family members with dementia: pragmatic randomised controlled trial","OBJECTIVE To assess whether a manual based coping strategy compared with treatment as usual reduces depression and anxiety symptoms in carers of family members with dementia. DESIGN Randomised, parallel group, superiority trial. SETTING Three mental health community services and one neurological outpatient dementia service in London and Essex, UK. PARTICIPANTS 260 carers of family members with dementia. INTERVENTION A manual based coping intervention comprising eight sessions and delivered by supervised psychology graduates to carers of family members with dementia. The programme consisted of psychoeducation about dementia, carers' stress, and where to get emotional support""; understanding behaviours of the family member being cared for, and behavioural management techniques; changing unhelpful thoughts; promoting acceptance; assertive communication; relaxation; planning for the future; increasing pleasant activities; and maintaining skills learnt. Carers practised these techniques at home, using the manual and relaxation CDs. MAIN OUTCOME MEASURES Affective symptoms (hospital anxiety and depression total score) at four and eight months. Secondary outcomes were depression and anxiety caseness on the hospital anxiety and depression scale; quality of life of both the carer (health status questionnaire, mental health) and the recipient of care (quality of life-Alzheimer's disease); and potentially abusive behaviour by the carer towards the recipient of care (modified conflict tactics scale). RESULTS 260 carers were recruited; 173 were randomised to the intervention and 87 to treatment as usual. Mean total scores on the hospital anxiety and depression scale were lower in the intervention group than in the treatment as usual group over the eight month evaluation period: adjusted difference in means -1.80 points (95% confidence interval -3.29 to -0.31;"" P=0.02) and absolute difference in means -2.0 points. Carers in the intervention group were less likely to have case level depression (odds ratio 0.24, 95% confidence interval 0.07 to 0.76) and there was a non-significant trend towards reduced case level anxiety (0.30, 0.08 to 1.05). Carers' quality of life was higher in the intervention group (difference in means 4.09, 95% confidence interval 0.34 to 7.83) but not for the recipient of care (difference in means 0.59, -0.72 to 1.89). Carers in the intervention group reported less abusive behaviour towards the recipient of care compared with those in the treatment as usual group (odds ratio 0.47, 95% confidence interval 0.18 to 1.23), although this was not significant. CONCLUSIONS A manual based coping strategy was effective in reducing affective symptoms and case level depression in carers of family members with dementia. The carers' quality of life also improved. TRIAL REGISTRATION Current Controlled Trials ISCTRN70017938.",0,0,
355,Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care,"OBJECTIVE To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors. DESIGN Prospective cluster trial randomised by general practice, with 18 month follow-up. SETTING 101 general practices in Trent, England. PARTICIPANTS 2749 women allocated to intervention, 1335 to control. INTERVENTION Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care. MAIN OUTCOME MEASURES Score >or=12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months. RESULTS 4084 eligible women consented and 595 women had a six week EPDS score >or=12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score >or=12. The odds ratio for score >or=12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores >or=12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score >or=12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other. CONCLUSION Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care. TRIAL REGISTRATION ISRCTN92195776.",0,0,
356,Clinical global measures of dementia. Position paper from the International Working Group on Harmonization of Dementia Drug Guidelines,"Following is the report of the committee working on clinical global measures for antidementia drug guidelines. The concepts involved in global scales, the distinctions between change and severity scales, advantages and disadvantages of structured interviews, and anchoring of change scores are discussed, and selected existing clinical global scales are described. In addition, the committee assessed the utility of global scales in clinical trials for antidementia drugs. There was a consensus among the members of the working group on the following: (1) Clinical global scales are interview based"";"" in most cases, they include information obtained from caregivers as well as directly from patients, but they can rely on information from the subject only. (2) Clinicians' global ratings are intended to assess clinically meaningful change based on multidimensional clinical assessment and take into account the clinical heterogeneity of dementia by assessing at least cognition, behavior, and functioning. (3) There are two distinct types of clinical global measures: (a) clinicians' interview-based global severity scales, which generally incorporate classification by stage or severity of illness and (b) clinicians' interview-based global change scales, which incorporate global assessment ratings of clinical change. The committee could not reach a consensus on whether global scales should be required in phase II and phase III clinical trials, or whether other specific assessments such as well-designed activities of daily living, cognition, and behavior measures could, when used in appropriate combinations, replace the global as assessments of clinical meaningfulness.",0,0,
357,Clinical governance in the management of induction of labour,"OBJECTIVE: To determine whether dissemination of explicit guidelines, developed in consensus with stakeholders, for the processes of induction of labour (IOL), results in reduction of variability in clinical practice. DESIGN: A prospective behaviour modification interventional study. PLACE AND DURATION OF STUDY: The study was conducted in the department of Obstetrics and Gynaecology at the Aga Khan University, Karachi, between January 1 and August 31, 2002. SUBJECTS AND METHODS: In a total of 142 conveniently sampled women, undergoing IOL, pre-identified quality assessment indicators were measured. After collection of data from initial 71-women (pre-intervention group) mutually agreed guidelines for clinical practice were disseminated, over a period of time, among consultants, residents and nurses. These indicators were again measured in subsequent 71 women (post-intervention group) to evaluate magnitude of residual non-conformities in these processes. RESULTS: Following behaviour modification interventions, nonconformities in consultants and residents-dependent processes like timely review of patients by consultants (72 vs 1.4%, p value <0.0001), documentation of indication for IOL (66.2 vs 16.9%, p value <0.0001), method of induction for IOL (56.3 vs 28.2%, p value 0.0001), and calculation of Bishop score before IOL (38.0 vs 4.2 %, p value <0.0001) were significantly reduced. CONCLUSION: Dissemination of explicit guidelines developed in consensus with stakeholders significantly reduces variability in clinical practice. Our model can be used for improving quality of care in other areas of obstetric health care.",0,0,
358,Clinical inertia: a common barrier to changing provider prescribing behavior,"BACKGROUND: A cross-sectional content analysis nested within a randomized, controlled trial was conducted to collect information on provider responses to computer alerts regarding guideline recommendations for patients with suboptimal hypertension care. METHODS: Participants were providers who cared for 1,017 patients with uncontrolled hypertension on a single antihypertensive agent within Veterans Affairs primary care clinics. All reasons for action or inaction were sorted into a framework to explain the variation in guideline adaptation. RESULTS: The 184 negative provider responses to computer alerts contained explanations for not changing patient treatment"";"" 76 responses to the alerts were positive, that is, the provider was going to make a change in antihypertensive regimen. The negative responses were categorized as: inertia of practice (66%), lack of agreement with specific guidelines (5%), patient-based factors (17%), environmental factors (10%), and lack of knowledge (2%). Most of the 135 providers classified as inertia of practice indicated, ""Continue current medications and I will discuss at the next visit."" The median number of days until the next visit was 45 days (interquartile range, 29 to 78 days). DISCUSSION: Clinical inertia was the primary reason for failing to engage in otherwise indicated treatment change in a subgroup of patients. A framework was provided as a taxonomy for classification of provider barriers.",0,0,
359,Clinical Judgment Revisited: The Distraction of Quantitative Models,"More than 25 years ago, in a book called Clinical Judgment, each act of patient care was described as having an experimental structure.The “experiments” needed substantial scientific improvement, however, in quality of basic data, taxonomic classification of phenomena, and specifications of clinical reasoning. During the past 2 decades, these improvements have not occurred as extensively as expected because many investigators working in clinical forms of clinical research have not addressed these basic scientific challenges in data, taxonomy, and reasoning. Instead, the investigators have applied quantitative “models,” derived from non-clinical domains, that focus on hard data, randomized trials, Bayes theorem, quantitative decision analysis, and psychometric strategies for clinimetric measurement. Consequently, the main challenges of clinical judgment still remain generally available for basic scientific research by investigative clinicians.",0,0,
360,Clinical practice guideline development manual: a quality-driven approach for translating evidence into action,"BACKGROUND: Guidelines translate best evidence into best practice. A well-crafted guideline promotes quality by reducing health-care variations, improving diagnostic accuracy, promoting effective therapy, and discouraging ineffective-or potentially harmful-interventions. Despite a plethora of published guidelines, methodology is often poorly defined and varies greatly within and among organizations. PURPOSE: This manual describes the principles and practices used successfully by the American Academy of Otolaryngology-Head and Neck Surgery to produce quality-driven, evidence-based guidelines using efficient and transparent methodology for action-ready recommendations with multidisciplinary applicability. The development process, which allows moving from conception to completion in 12 months, emphasizes a logical sequence of key action statements supported by amplifying text, evidence profiles, and recommendation grades that link action to evidence. CONCLUSIONS: As clinical practice guidelines become more prominent as a key metric of quality health care, organizations must develop efficient production strategies that balance rigor and pragmatism. Equally important, clinicians must become savvy in understanding what guidelines are-and are not-and how they are best utilized to improve care. The information in this manual should help clinicians and organizations achieve these goals.",0,0,
361,Clinical Practice Guideline: Otitis Media with Effusion (Update),"OBJECTIVE: This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME. PURPOSE: The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients 12 years old. ACTION STATEMENTS: The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child""; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME.The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child /=4 years old;"" and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.",0,0,
362,Clinical practice guideline: tinnitus,"OBJECTIVE: Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient's quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome. PURPOSE: The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers. ACTION STATEMENTS: The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus""; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (>/= 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (>/= 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status);"" and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.",0,0,
363,Clinical practice guideline: tonsillectomy in children,"OBJECTIVE: Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy. PURPOSE: The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care. RESULTS: The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years""; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain;"" and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3 degrees C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.",0,0,
364,Clinical practice guideline: Tympanostomy tubes in children,"OBJECTIVE: Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. PURPOSE: The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration""; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands;"" avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).",0,0,
365,Clinical practice guidelines for severe Alzheimer's disease,"BACKGROUND: Although severe Alzheimer's disease (AD) represents a prevalent, serious, and costly public health problem, few practice guidelines exist to help physicians manage this disorder. METHODS: A search of English language medical databases was performed from 1996 to the present for articles pertaining to the management of AD. The focus of this review was on studies that included patients with severe disease. Studies were assessed by considering the subjects, trial design, analysis, and results. Recommendations were based on the best available evidence. RESULTS: Severe AD can be defined and diagnosed reliably by using measures of cognition, function, behavior, and global staging. Specific assessments would also include medical status, safety issues, and the health status of the caregiver. Disease-specific management would include treatment with cholinesterase inhibitors and/or memantine. Treatment of neuropsychiatric symptoms begins with nonpharmacologic behavioral and environmental approaches. Severe agitation, aggression, and psychosis that are potentially dangerous to the patient, caregiver, and others in the environment can be treated with atypical antipsychotics, with consideration of their increased risk of cerebrovascular adverse events and mortality. All pharmacologic approaches require careful monitoring and regular periodic reassessments to determine whether ongoing treatment is necessary. CONCLUSIONS: Evidence-based guidelines for the management of severe AD have the potential to improve the quality of life for the patient and their caregiver. More randomized controlled trials aimed specifically at this phase of illness are still urgently required.",0,0,
366,Clinical practice guidelines to improve shared decision-making about assistive device use in home care: a pilot intervention study,"This study examines whether clinical practice guidelines (CPG) for the introduction of assistive devices (ADs) in home care improve shared decision-making about AD use and modify its social-cognitive correlates. Data were collected in an intervention study with quasi-experimental design. Questionnaires were obtained from 116 home nurses and home care workers and their 140 clients with disabilities. Significant differences between intervention and control group revealed that implementation of CPG improved home nurses' and home care workers' self-reported practice: the number of intervention methods they applied increased, and the methods were applied with increased intensity. Nurses' attitudes towards introducing ADs in a shared decision-making process decreased in both intervention group and control group over time. Clients' reports about caregivers' practice showed a minor concurrence with the reports of the caregivers themselves. The complexity of the CPG and a substantial time investment were reported as the main barriers to involving clients in shared decision-making through the experimental CPG. Nevertheless, CPG hold promise for shared decision-making between formal caregivers and community-dwelling persons with disabilities concerning AD use. The findings suggest that these CPG can structure communication between caregiver and client, and can support caregivers in facilitating clients' self-determination concerning coping with their disabilities.",0,0,
367,Clinical Practice Update: Expert Review on Endoscopic Bariatric Therapies,"BACKGROUND & AIMS: Multiple endoscopic bariatric therapies (EBTs) currently are being evaluated or are in clinical use in the United States. EBTs are well positioned to fill an important gap in the management of obesity and metabolic disease. The purpose of this expert review is to update gastroenterologists on these therapies and provide practice advice on how to incorporate them into clinical practice. METHODS: The evidence reviewed in this work is a distillation of comprehensive search of several English-language databases and a manual review of relevant publications (including systematic reviews and meeting abstracts). Best Practice Advice 1: EBTs should be considered in patients with obesity who have been unsuccessful in losing or maintaining weight loss with lifestyle interventions. Best Practice Advice 2: EBTs can be used in patients with severe obesity as a bridge to traditional bariatric surgery. They also can be used as a bridge to allow unrelated interventions that are unable to be performed because of weight limits (ie, orthopedic surgery, organ transplantation). Best Practice Advice 3: Clinicians should use EBTs as part of a structured weight loss program that includes dietary intervention, exercise therapy, and behavior modification, in both the active weight loss phase and the long-term maintenance phase. Best Practice Advice 4: Clinicians should screen all potential EBT candidates with a comprehensive evaluation for medical conditions, comorbidities, and psychosocial or behavioral patterns that contribute to their condition before enrolling patients in a weight loss program that includes EBTs. Best Practice Advice 5: Clinicians incorporating EBTs into their clinical practice should follow up patients prospectively to capture the impact of the EBT program on weight and weight-related comorbidities, and all related adverse outcomes. Poor responders should be identified and offered a detailed evaluation and alternative therapy. Best Practice Advice 6: Clinicians embarking on incorporating EBTs into their clinical practice should have a comprehensive knowledge of the indications, contraindications, risks, benefits, and outcomes of individual EBTs, as well as a practical knowledge of the risks and benefits of alternative therapies for obesity. Best Practice Advice 7: Institutions should establish specific guidelines that are applied consistently across disciplines for granting privileges in EBTs that reflect the necessary knowledge and technical skill a clinician must achieve before being granted privileges to perform these procedures.",0,0,
368,Clinical practice variation in reduced fetal movements,"BACKGROUND: Reduced fetal movements imply a risk pregnancy. This condition is present in a significant proportion of pregnancies, but both the quality of information and that of clinical care is variable. MATERIAL AND METHODS: All delivery units in Eastern Norway and Bergen have registered all consultations for reduced fetal movements, as part of the international collaborative project ""Fetal Movement Intervention Assessment"" (Femina). Out of 23,933 deliveries, 1200 pregnancies were examined. In 1043 pregnancies the mother had spontaneously presented her concern over reduced fetal movements""; these were included in analyses. Results are presented with a 95% confidence interval. RESULTS: Asphyxia, death, growth restriction or preterm birth occurred in 19.6% (16.6-22.6%) of cases, ranging between units from 9.1% to 26.5%. Standard procedures varied extensively;"" ultrasonography was used in 39.0% to 98.6% and Doppler in 4.5% to 74.6% of cases. There was an association between outcomes and the procedures used. Women who waited 24 hours with reduced or absent movements before contacting healthcare had increased risk. Among those with absent movements, 47% (42-52%) had such risk behaviour. INTERPRETATION: There is a need for quality improvements in the information to pregnant women as well as in the clinical management of affected pregnancies. This could have large health benefits. We propose new guidelines for information and management.",0,0,
369,Clinical practice. Later orthodontic complications caused by risk factors observed in the early years of life,"Primary preventive strategies for oral health are an essential public health priority. Paediatricians have frequent contact with families during routine preventive visits in the child's first few years of life and are in an ideal and unique position, to advise families about the prevention of oral diseases in their children. Primary prevention is always recommended in very young children, to promote positive outcomes during childhood and later adulthood. The knowledge paediatricians acquire about orofacial growth may enhance the implementation and eventual success of a preventive programme. In view of the widespread lack of any orthodontic knowledge amongst paediatricians, this paper describes most common and distinctive symptoms appearing frequently in the early stages of a child's development that are easily detectable by clinicians. It is difficult to define preventive strategies to prevent malocclusion owing to its multifactorial origin. There are some recognised behaviours, however, that should be discouraged to allow for ideal craniofacial development and some that require early referral to the orthodontist. The following disorders are easily diagnosed by the paediatrician or parents and represent conditions in which early intervention might be appropriate to prevent future possible orofacial dysfunction: different sucking habits persisting beyond 3 years of age, mouth breathing and significant deviations from established teeth eruption norms. It is suggested that early referral to a paediatric dentist or orthodontist is indicated when any of these conditions are observed. In general, measures to prevent malocclusion should be based on providing good incentives to promote normal growth and development of the face and the elimination of potential interferences that may harm these processes.",0,0,
370,Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of beta-blockers: a randomized trial.,"Background— Although ß-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, they are often underused. We hypothesized that a reminder attached to the echocardiography report would increase the use of ß-blockers for patients with reduced left ventricular ejection fraction.  Methods and Results— We randomized 1546 consecutive patients with a left ventricular ejection fraction <45% found on echocardiography at 1 of 3 laboratories to a reminder for use of ß-blockers or no reminder. Patients were excluded from analysis if they died within 30 days of randomization (n=89), did not receive medications through the Veterans Affairs system after 30 days (n=180), or underwent echocardiography at >1 laboratory (n=6). The primary outcome was a prescription for an oral ß-blocker between 1 and 9 months after randomization. The mean age of the 1271 included patients was 69 years; 60% had a history of heart failure, and 51% were receiving treatment with ß-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent ß-blocker prescription (74%, 458 of 621) compared with those randomized to no reminder (66%, 428 of 650;"" P=0.002). The effect of the reminder was not significantly different for subgroups based on patient location (inpatient versus outpatient) or prior use of ß-blockers.  Conclusions— A reminder attached to the echocardiography report increased the use of ß-blockers in patients with depressed left ventricular systolic function.",1,1,
371,Clinical research in interventional pain management techniques: the clinician's point of view,"Interventional pain management techniques are considered for patients whose pain proves refractory to conventional treatment. According to the evidence-based medicine (EBM) guidelines, the highest level of evidence for efficacy and safety of a treatment is generated in high-quality randomized controlled trials and systematic reviews. A randomized controlled trial is defined as an experiment that determines the influence of an intervention on the natural history of the disease, which means that the comparative group should receive placebo, which is a sham intervention in case of the interventional pain management techniques. The systematic review summarizes in a structured way the results of the available information. When randomized controlled trials are available, observational studies will often be discarded. As new information on a treatment becomes available the perceived value may change, thus determining the survival time of clinical evidence. This survival time is not different when based on randomized or nonrandomized studies. The inclusion criteria are an important component of the randomized controlled trial and are designed to test a treatment in a homogeneous patient population. As interventional pain management techniques are mainly used for the management of spinal pain, it needs to be stressed that there is no gold standard for the diagnosis. This lack of validated standard diagnostic procedures is at the origin of different patient selection criteria, which makes the interpretation of the different randomized controlled trials and the meta-analyses very difficult. Moreover, the extrapolation of randomized controlled trials with carefully selected patient populations to daily practice is a major problem. Randomized controlled trials in interventional pain management techniques often prove to be underpowered, which can be attributed to the difficulty in motivating patients and the referring physicians to participate in a trial where there is 50% chance of receiving a placebo/sham for intractable pain. Furthermore, the validity of sham intervention as a reflection of the natural course of the disease is questioned. It is stated that any new technique should prove to be at least equally effective as the best available treatment option, which offers the possibility of comparing two groups, both receiving active treatment. The reference treatment may be pharmacological or a rehabilitation program (cognitive behavioral) in which case blinding becomes a problem. It has been demonstrated that large observational studies with a cohort or case-control design do not systematically overestimate the magnitude of the associations between exposure and outcome as compared with the results of randomized controlled trials. There is an urgent need for guidelines on performing prospective cohort trials that should be designed to confirm or refute the anecdotal findings from retrospective studies.",0,0,
372,Clinical risk management in psychiatry,"This paper deals with suicide and violence to others, which constitute the topics of greatest current concern in risk management in the mental health services. Most of the psychiatric claims managed by the Risk Management Foundation of the Harvard Medical Institutions over a twelve year period involved cases in which suicide, attempted suicide, or violence to self or others occurred.'",0,0,
373,Clinical risk prediction for pre-eclampsia in nulliparous women: development of model in international prospective cohort,"OBJECTIVES To develop a predictive model for pre-eclampsia based on clinical risk factors for nulliparous women and to identify a subgroup at increased risk, in whom specialist referral might be indicated. DESIGN Prospective multicentre cohort. SETTING Five centres in Auckland, New Zealand""; Adelaide, Australia; Manchester and London, United Kingdom;"" and Cork, Republic of Ireland. PARTICIPANTS 3572 ""healthy"" nulliparous women with a singleton pregnancy from a large international study"";"" data on pregnancy outcome were available for 3529 (99%). MAIN OUTCOME MEASURE Pre-eclampsia defined as ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg, or both, on at least two occasions four hours apart after 20 weeks' gestation but before the onset of labour, or postpartum, with either proteinuria or any multisystem complication. Preterm pre-eclampsia was defined as women with pre-eclampsia delivered before 37(+0) weeks' gestation. In the stepwise logistic regression the comparison group was women without pre-eclampsia. RESULTS Of the 3529 women, 186 (5.3%) developed pre-eclampsia, including 47 (1.3%) with preterm pre-eclampsia. Clinical risk factors at 14-16 weeks' gestation were age, mean arterial blood pressure, body mass index (BMI), family history of pre-eclampsia, family history of coronary heart disease, maternal birth weight, and vaginal bleeding for at least five days. Factors associated with reduced risk were a previous single miscarriage with the same partner, taking at least 12 months to conceive, high intake of fruit, cigarette smoking, and alcohol use in the first trimester. The area under the receiver operating characteristics curve (AUC), under internal validation, was 0.71. Addition of uterine artery Doppler indices did not improve performance (internal validation AUC 0.71). A framework for specialist referral was developed based on a probability of pre-eclampsia generated by the model of at least 15% or an abnormal uterine artery Doppler waveform in a subset of women with single risk factors. Nine per cent of nulliparous women would be referred for a specialist opinion, of whom 21% would develop pre-eclampsia. The relative risk for developing pre-eclampsia and preterm pre-eclampsia in women referred to a specialist compared with standard care was 5.5 and 12.2, respectively. CONCLUSIONS The ability to predict pre-eclampsia in healthy nulliparous women using clinical phenotype is modest and requires external validation in other populations. If validated, it could provide a personalised clinical risk profile for nulliparous women to which biomarkers could be added. Trial registration ACTRN12607000551493.",0,0,
374,Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat.,"Objective:To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat  Design:Unblinded, cluster randomised pretest-post-test trial  Setting:142 general practices in Norway  Participants:72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection.  Interventions:Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants  Main outcome measures:Changes in rates of use of antibiotics, laboratory tests, and telephone consultations  Results:Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practicesin the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures  Conclusions:Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice",0,1,
375,Cluster randomized trial of a multifaceted primary care decision-support intervention for inherited breast cancer risk.,"Background. GPs are increasingly expected to meet the needs of patients concerned about their risk of inherited breast cancer, but may lack skills or confidence to use complex management guidelines. We developed an evidence-based, multifaceted intervention intended to promote confidence and skills in this area.  Objective. To evaluate the effectiveness of the intervention in improving GP confidence in managing patients concerned about genetic risk of breast cancer.  Methods.  Design. Cluster randomized controlled trial.  Setting. General practices in the Grampian region of Scotland.  Subjects. GPs and the patients they referred for genetic counselling for risk of breast cancer.  Main outcome measures. GPs’ self-reported confidence in four activities related to genetics""; rates of referral of patients at elevated genetic risk;"" and referred patients’ understanding of cancer risk factors.  Results. No statistically significant differences were observed between intervention and control arms in the primary or secondary outcomes. A possible effect of the intervention on the proportion of referred patients who were at elevated risk could not be discounted. Only a small proportion of intervention GPs attended the educational session, were aware or the software, or made use of it in practice.  Conclusions. No convincing evidence of the effectiveness of the intervention was found, probably reflecting barriers to its use in routine practice.",0,1,
376,Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA Patient Aligned Care Teams to the needs of women Veterans,"Background The Veterans Health Administration (VA) has undertaken a major initiative to transform care through implementation of Patient Aligned Care Teams (PACTs). Based on the patient-centered medical home (PCMH) concept, PACT aims to improve access, continuity, coordination, and comprehensiveness using team-based care that is patient-driven and patient-centered. However, how VA should adapt PACT to meet the needs of special populations, such as women Veterans (WVs), was not considered in initial implementation guidance. WVs¡¯ numerical minority in VA healthcare settings (approximately 7¨C8 % of users) creates logistical challenges to delivering gender-sensitive comprehensive care. The main goal of this study is to test an evidence-based quality improvement approach (EBQI) to tailoring PACT to meet the needs of WVs, incorporating comprehensive primary care services and gender-specific care in gender-sensitive environments, thereby accelerating achievement of PACT tenets for women (Women¡¯s Health (WH)-PACT).  Methods/design EBQI is a systematic approach to developing a multilevel research-clinical partnership that engages senior organizational leaders and local quality improvement (QI) teams in adapting and implementing new care models in the context of prior evidence and local practice conditions, with researchers providing technical support, formative feedback, and practice facilitation. In a 12-site cluster randomized trial, we will evaluate WH-PACT model achievement using patient, provider, staff, and practice surveys, in addition to analyses of secondary administrative and chart-based data. We will explore impacts of receipt of WH-PACT care on quality of chronic disease care and prevention, health status, patient satisfaction and experience of care, provider experience, utilization, and costs. Using mixed methods, we will assess pre-post practice contexts""; document EBQI activities undertaken in participating facilities and their relationship to provider/staff and team actions/attitudes; document WH-PACT implementation;"" and examine barriers/facilitators to EBQI-supported WH-PACT implementation through a combination of semi-structured interviews and monthly formative progress narratives and administrative data.  Discussion Lack of gender-sensitive comprehensive care has demonstrated consequences for the technical quality and ratings of care among WVs and may contribute to decisions to continue use or seek care elsewhere under the US Affordable Care Act. We hypothesize that tailoring PACT implementation through EBQI may improve the experience and quality of care at many levels.",0,1,
377,Cluster randomized trials for pharmacy practice research,"Introduction Cluster randomized trials (CRTs) are now the gold standard in health services research, including pharmacy-based interventions. Studies of behaviour, epidemiology, lifestyle modifications, educational programs, and health care models are utilizing the strengths of cluster randomized analyses. Methodology The key property of CRTs is the unit of randomization (clusters), which may be different from the unit of analysis (individual). Subject sample size and, ideally, the number of clusters is determined by the relationship of between-cluster and within-cluster variability. The correlation among participants recruited from the same cluster is known as the intraclass correlation coefficient (ICC). Generally, having more clusters with smaller ICC values will lead to smaller sample sizes. When selecting clusters, stratification before randomization may be useful in decreasing imbalances between study arms. Participant recruitment methods can differ from other types of randomized trials, as blinding a behavioural intervention cannot always be done. When to use CRTs can yield results that are relevant for making ""real world"" decisions. CRTs are often used in non-therapeutic intervention studies (e.g. change in practice guidelines). The advantages of CRT design in pharmacy research have been avoiding contamination and the generalizability of the results. A large CRT that studied physician-pharmacist collaborative management of hypertension is used in this manuscript as a CRT example. The trial, entitled Collaboration Among Pharmacists and physicians To Improve Outcomes Now (CAPTION), was implemented in primary care offices in the United States for hypertensive patients. Limitations CRT design limitations include the need for a large number of clusters, high costs, increased training, increased monitoring, and statistical complexity.",0,0,
378,"Cluster-randomized, controlled trial of computer-based decision support for selecting long-term anti-thrombotic therapy after acute ischaemic stroke.","Background: Identifying the appropriate long-term anti-thrombotic therapy following acute ischaemic stroke is a challenging area in which computer-based decision support may provide assistance.  Aim: To evaluate the influence on prescribing practice of a computer-based decision support system (CDSS) that provided patient-specific estimates of the expected ischaemic and haemorrhagic vascular event rates under each potential anti-thrombotic therapy.  Design: Cluster-randomized controlled trial.  Methods: We recruited patients who presented for a first investigation of ischaemic stroke or TIA symptoms, excluding those with a poor prognosis or major contraindication to anticoagulation. After observation of routine prescribing practice (6 months) in each hospital, centres were randomized for 6 months to either control (routine practice observed) or intervention (practice observed while the CDSS provided patient-specific information). We compared, between control and intervention centres, the risk reduction (estimated by the CDSS) in ischaemic and haemorrhagic vascular events achieved by long-term anti-thrombotic therapy, and the proportions of subjects prescribed the optimal therapy identified by the CDSS.  Results: Sixteen hospitals recruited 1952 subjects. When the CDSS provided information, the mean relative risk reduction attained by prescribing increased by 2.7 percentage units (95%CI -0.3 to 5.7) and the odds ratio for the optimal therapy being prescribed was 1.32 (0.83 to 1.80). Some 55% (5/9) of clinicians believed the CDSS had influenced their prescribing.  Conclusions: Cluster-randomized trials provide excellent frameworks for evaluating novel clinical management methods. Our CDSS was feasible to implement and acceptable to clinicians, but did not substantially influence prescribing practice for anti-thrombotic drugs after acute ischaemic stroke.",1,1,
379,COACH trial: a randomized controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers: rationale and design,"BACKGROUND: Despite well-publicized guidelines on the appropriate management of cardiovascular disease (CVD) and type 2 diabetes, implementation of risk-reducing practices remains poor. This paper describes the rationale and design of a randomized controlled clinical trial evaluating the effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner (NP)/community health worker (CHW) teams versus enhanced usual care in improving the proportion of patients in urban community health centers who achieve goal levels recommended by national guidelines for lipids, blood pressure, HbA1c and prescription of appropriate medications. METHODS: The COACH (Community Outreach and Cardiovascular Health) trial is a randomized controlled trial in which patients at federally-qualified community health centers were randomly assigned to one of two groups: comprehensive intensive management of CVD risk factors for one year by a NP/CHW team or an enhanced usual care control group. RESULTS: A total of 3899 patients were assessed for eligibility and 525 were randomized. Groups were comparable at baseline on sociodemographic and clinical characteristics with the exception of statistically significant differences in total cholesterol and hemoglobin A1c. CONCLUSIONS: This study is a novel amalgam of multilevel interdisciplinary strategies to translate highly efficacious therapies to low-income federally-funded health centers that care for patients who carry a disproportionate burden of CVD, type 2 diabetes and uncontrolled CVD risk factors. The impact of such a community clinic-based intervention is potentially enormous.",0,0,
380,Code of practice for the clinical assessment of licensed medicinal products in general practice,"KIE: A code of practice for the clinical assessment of licensed drugs by physicians in general practice has been developed jointly by the British Medical Association, the Royal Society of General Practitioners, and the Association of the British Pharmaceutical Industry. The new code, reproduced in full here, outlines the reasons drug assessments outside hospitals are needed""; defines the roles of pharmaceutical firms, ethics committees, and investigators; lists items that must be included in research protocols;"" and offers guidelines on confidentiality, publication of results, and remuneration.",0,0,
381,Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis,"Background: Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia. Purpose: To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia. Data Sources: Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening. Study Selection: Randomized, controlled trials assessing the efficacy of face-to-face, multimodal CBT-i compared with inactive comparators on overnight sleep in adults with chronic insomnia. Studies of insomnia comorbid with medical, sleep, or psychiatric disorders were excluded. Data Extraction: Study characteristics, quality, and data were assessed independently by 2 reviewers. Main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE%). Data Synthesis: Among 292 citations and 91 full-text articles reviewed, 20 studies (1162 participants [64% female"";"" mean age, 56 years]) were included. Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, ?0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%). Changes seemed to be sustained at later time points. No adverse outcomes were reported. Limitation: Narrow inclusion criteria limited applicability to patients with comorbid insomnia and other sleep problems, and accuracy of estimates at later time points was less clear. Conclusion: CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes. Primary Funding Source: None. (PROSPERO registration number: CRD42012002863)",0,0,
382,Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women,"Context The prevalence of posttraumatic stress disorder (PTSD) is elevated among women who have served in the military, but no prior study has evaluated treatment for PTSD in this population. Prior research suggests that cognitive behavioral therapy is a particularly effective treatment for PTSD.  Objective To compare prolonged exposure, a type of cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for the treatment of PTSD.  Design, Setting, and Participants A randomized controlled trial of female veterans (n=277) and active-duty personnel (n=7) with PTSD recruited from 9 VA medical centers, 2 VA readjustment counseling centers, and 1 military hospital from August 2002 through October 2005.  Intervention Participants were randomly assigned to receive prolonged exposure (n = 141) or present-centered therapy (n = 143), delivered according to standard protocols in 10 weekly 90-minute sessions.  Main Outcome Measures Posttraumatic stress disorder symptom severity was the primary outcome. Comorbid symptoms, functioning, and quality of life were secondary outcomes. Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up.  Results Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27""; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37;"" P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment.  Conclusions Prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings.",0,0,
383,Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults,"Context Insomnia is a common condition in older adults and is associated with a number of adverse medical, social, and psychological consequences. Previous research has suggested beneficial outcomes of both psychological and pharmacological treatments, but blinded placebo-controlled trials comparing the effects of these treatments are lacking.  Objective To examine short- and long-term clinical efficacy of cognitive behavioral therapy (CBT) and pharmacological treatment in older adults experiencing chronic primary insomnia.  Design, Setting, and Participants A randomized, double-blinded, placebo-controlled trial of 46 adults (mean age, 60.8 y""; 22 women) with chronic primary insomnia conducted between January 2004 and December 2005 in a single Norwegian university-based outpatient clinic for adults and elderly patients.  Intervention CBT (sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and relaxation; n = 18), sleep medication (7.5-mg zopiclone each night; n = 16), or placebo medication (n = 12). All treatment duration was 6 weeks, and the 2 active treatments were followed up at 6 months.  Main Outcome Measures Ambulant clinical polysomnographic data and sleep diaries were used to determine total wake time, total sleep time, sleep efficiency, and slow-wave sleep (only assessed using polysomnography) on all 3 assessment points.  Results CBT resulted in improved short- and long-term outcomes compared with zopiclone on 3 out of 4 outcome measures. For most outcomes, zopiclone did not differ from placebo. Participants receiving CBT improved their sleep efficiency from 81.4% at pretreatment to 90.1% at 6-month follow-up compared with a decrease from 82.3% to 81.9% in the zopiclone group. Participants in the CBT group spent much more time in slow-wave sleep (stages 3 and 4) compared with those in other groups, and spent less time awake during the night. Total sleep time was similar in all 3 groups;"" at 6 months, patients receiving CBT had better sleep efficiency using polysomnography than those taking zopiclone.  Conclusion These results suggest that interventions based on CBT are superior to zopiclone treatment both in short- and long-term management of insomnia in older adults.",0,0,
384,Cognitive debiasing 2: impediments to and strategies for change,"In a companion paper, we proposed that cognitive debiasing is a skill essential in developing sound clinical reasoning to mitigate the incidence of diagnostic failure. We reviewed the origins of cognitive biases and some proposed mechanisms for how debiasing processes might work. In this paper, we first outline a general schema of how cognitive change occurs and the constraints that may apply. We review a variety of individual factors, many of them biases themselves, which may be impediments to change. We then examine the major strategies that have been developed in the social sciences and in medicine to achieve cognitive and affective debiasing, including the important concept of forcing functions. The abundance and rich variety of approaches that exist in the literature and in individual clinical domains illustrate the difficulties inherent in achieving cognitive change, and also the need for such interventions. Ongoing cognitive debiasing is arguably the most important feature of the critical thinker and the well-calibrated mind. We outline three groups of suggested interventions going forward: educational strategies, workplace strategies and forcing functions. We stress the importance of ambient and contextual influences on the quality of individual decision making and the need to address factors known to impair calibration of the decision maker. We also emphasise the importance of introducing these concepts and corollary development of training in critical thinking in the undergraduate level in medical education.",0,1,
385,Cognitive debiasing through sparklines in clinical data displays,"Sparklines, embedded contextual information graphics, can help reduce diagnostic errors by highlighting trends in data, simplifying cognitive tasks and providing context for decision making. Examples applied to heparin induced thrombocytopenia, cardiac catheterization and pediatric viral illness illustrate the concept. Sparklines are ideal in situations where the limited textual data representations obfuscate interpretation, the graphic aids interpretation of the data, and the graphic guides decision making.",0,1,
386,Cognitive-behavioral therapy for insomnia in patients with cancer,"Sleep-wake disturbances, particularly insomnia, are among the most prevalent and distressing symptoms experienced by patients with cancer. As a result of extensive interdisciplinary research conducted since 2000, cognitive-behavioral therapy now is considered the standard of care for the treatment of insomnia in the general population and also has been upgraded to ""likely to be effective"" in the Oncology Nursing Society Putting Evidence Into Practice weight of evidence category. Cognitive-behavioral therapy is a multicomponent psychological and behavioral treatment designed to eliminate the perpetuating factors of insomnia. The most frequently used strategies are stimulus control, sleep restriction and relaxation therapies, paradoxical intention, sleep hygiene, and cognitive restructuring. Although this insomnia treatment recommendation has been well publicized, the nursing literature has not effectively translated the theories and principles of cognitive-behavioral therapy into practical guidelines or considerations for use by oncology staff nurses and advanced practitioners. This article attempts to demystify cognitive-behavioral therapy and provide nurses at different levels of practice a foundation from which to evaluate and potentially deliver this promising insomnia intervention.",0,0,
387,"Cognitive-Behavioral Therapy, Imipramine, or Their Combination for Panic Disorder","Context Panic disorder (PD) may be treated with drugs, psychosocial intervention, or both, but the relative and combined efficacies have not been evaluated in an unbiased fashion.  Objective To evaluate whether drug and psychosocial therapies for PD are each more effective than placebo, whether one treatment is more effective than the other, and whether combined therapy is more effective than either therapy alone.  Design and Setting Randomized, double-blind, placebo-controlled clinical trial conducted in 4 anxiety research clinics from May 1991 to April 1998.  Patients A total of 312 patients with PD were included in the analysis.  Interventions Patients were randomly assigned to receive imipramine, up to 300 mg/d, only (n=83)""; cognitive-behavioral therapy (CBT) only (n=77); placebo only (n=24); CBT plus imipramine (n=65); or CBT plus placebo (n=63). Patients were treated weekly for 3 months (acute phase); responders were then seen monthly for 6 months (maintenance phase) and then followed up for 6 months after treatment discontinuation.  Main Outcome Measures Treatment response based on the Panic Disorder Severity Scale (PDSS) and the Clinical Global Impression Scale (CGI) by treatment group.  Results Both imipramine and CBT were significantly superior to placebo for the acute treatment phase as assessed by the PDSS (response rates for the intent-to-treat [ITT] analysis, 45.8%, 48.7%, and 21.7%; P=.05 and P=.03, respectively), but were not significantly different for the CGI (48.2%, 53.9%, and 37.5%, respectively). After 6 months of maintenance, imipramine and CBT were significantly more effective than placebo for both the PDSS (response rates, 37.8%, 39.5%, and 13.0%, respectively; P=.02 for both) and the CGI (37.8%, 42.1%, and 13.0%, respectively). Among responders, imipramine produced a response of higher quality. The acute response rate for the combined treatment was 60.3% for the PDSS and 64.1% for the CGI; neither was significantly different from the other groups. The 6-month maintenance response rate for combined therapy was 57.1% for the PDSS (P=.04 vs CBT alone and P=.03 vs imipramine alone) and 56.3% for the CGI (P=.03 vs imipramine alone), but not significantly better than CBT plus placebo in either analysis. Six months after treatment discontinuation, in the ITT analysis CGI response rates were 41.0% for CBT plus placebo, 31.9% for CBT alone, 19.7% for imipramine alone, 13% for placebo, and 26.3% for CBT combined with imipramine.  Conclusions Combining imipramine and CBT appeared to confer limited advantage acutely but more substantial advantage by the end of maintenance. Each treatment worked well immediately following treatment and during maintenance;"" CBT appeared durable in follow-up.",0,0,
388,Collaborative care for depressed patients with chronic medical conditions: a randomized trial in Puerto Rico,"OBJECTIVE: This study examined whether a collaborative care model for depression would improve clinical and functional outcomes for depressed patients with chronic general medical conditions in primary care practices in Puerto Rico. METHODS: A total of 179 primary care patients with major depression and chronic general medical conditions were randomly assigned to receive collaborative care or usual care. The collaborative care intervention involved enhanced collaboration among physicians, mental health specialists, and care managers paired with depression-specific treatment guidelines, patient education, and follow-up. In usual care, study personnel informed the patient and provider of the diagnosis and encouraged patients to discuss treatment options with their provider. Depression severity was assessed with the Hopkins Symptom Checklist"";"" social functioning was assessed with the 36-item Short Form. RESULTS: Compared with usual care, collaborative care significantly reduced depressive symptoms and improved social functioning in the six months after randomization. Integration of collaborative care in primary care practices considerably increased depressed patients' use of mental health services. CONCLUSIONS: Collaborative care significantly improved clinical symptoms and functional status of depressed patients with coexisting chronic general medical conditions receiving treatment for depression in primary care practices in Puerto Rico. These findings highlight the promise of the collaborative care model for strengthening the relationship between mental health and primary care services in Puerto Rico.",0,0,
389,Collaborative management to achieve treatment guidelines. Impact on depression in primary care,"OBJECTIVE: To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of ""usual care"" by the primary care physician. DESIGN: A randomized controlled trial among primary care patients with major depression or minor depression. PATIENTS: Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression. INTERVENTIONS: Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials. MAIN OUTCOME MEASURES: Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms. RESULTS: In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%""; P < .01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P < .03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < .01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls (P < .01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < .004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P < .001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%;"" P < .02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time. CONCLUSION: A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression.",0,0,
390,Collaborative practice improvement for childhood obesity in rural clinics: the Healthy Eating Active Living Telehealth Community of Practice (HEALTH COP),"This study assessed the impact of participation in a virtual quality improvement (QI) learning network on adherence to clinical guidelines for childhood obesity prevention in rural clinics. A total of 7 primary care clinics in rural California included in the Healthy Eating Active Living TeleHealth Community of Practice and 288 children seen in these clinics for well-child care participated in this prospective observational pre-post study. Clinics participated in a virtual QI learning network over 9 months to implement best practices and to exchange strategies for improvement. Following the intervention, documentation of weight assessment and counseling increased significantly. Children who received care from clinicians who led the implementation of the intervention at their clinic showed significant improvements in nutrition and physical activity. Virtual QI learning networks in geographically dispersed clinics can significantly increase clinicians' adherence to guidelines for childhood obesity and improve access to recommended care for rural and underserved children.",0,0,
391,Collective action for implementation: a realist evaluation of organisational collaboration in healthcare,"Background Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation.  Methods A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds.  Results The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations¡¯ architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that ¡®what¡¯s in it for me¡¯ resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation.  Conclusions These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation.",0,0,
392,"Colonoscopy uptake for high-risk individuals with a family history of colorectal neoplasia: A multicenter, randomized trial of tailored counseling versus standard information","BACKGROUND: Colonoscopic screening is recommended for first-degree relatives of patients diagnosed with colorectal cancer (CRC) or colorectal adenomatous polyps (CAP) before the age of 60 years. This has the potential to reduce CRC-related morbidity and mortality, but uptake is currently inadequate. METHODS: The aim of the study was to compare the effectiveness of standard information versus a nurse-led tailored intervention designed to promote uptake of colonoscopy screening by siblings of CRC or CAP patients. A randomized controlled trial was conducted. Digestive surgeons and gastroenterologists recruited index patients who developed CRC or CAP before the age of 60 years. All index patients received standard screening information for their siblings, in keeping with current guidelines. Centrally computerized randomization of index patients resulted in allocating all their siblings to the same group, intervention or control. The tailored intervention targeted the index patient first, to help them convey information to their siblings. The nurse then provided the siblings with tailored information based on their answers to a self-questionnaire which explored health behaviors, derived from psychosocial models of prevention. Then the siblings were given a personalized information leaflet to hand to their regular physician. The primary endpoint was the rate of documented colonoscopy performed in siblings within 1 year after diagnosis of the index patient. The intent-to-treat analysis included siblings who refused to participate in the study. Statistical analysis was adjusted for intrafamilial correlation. RESULTS: A total of 304 siblings of 125 index patients were included: 160 in the intervention group and 144 in the control group. The rate of colonoscopy uptake among siblings was 56.3% in the intervention group and 35.4% in the control group (P = 0.0027). The respective rates after exclusion of refusals were 69.2% and 37.0% (P < 0.0001). More lesions were detected in the intervention group (1 invasive cancer and 11 advanced adenomas vs 5 advanced adenomas"";"" P = 0.022). CONCLUSIONS: This study demonstrates the effectiveness of a nurse-led tailored intervention designed to promote colonoscopy screening uptake by siblings of patients diagnosed with CRC or CAP before age 60 years. Such tailored interventions that also involve physicians should help to reduce CRC-related mortality.",0,0,
393,Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force,"Background: Trials have shown efficacy of rigorous diet and physical activity promotion programs to reduce diabetes incidence and improve glycemic measures in adults at increased risk for type 2 diabetes. Purpose: To evaluate diet and physical activity promotion programs for persons at increased risk for type 2 diabetes, primarily to reduce diabetes risk and decrease body weight and glycemia. Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, CAB Abstracts, Global Health, and Ovid Health- STAR from 1991 through 27 February 2015, with no language restriction. Study Selection: 8 researchers screened articles for singlegroup or comparative studies of combined diet and physical activity promotion programs with at least 2 sessions over at least 3 months in participants at increased risk for type 2 diabetes. Data Extraction: 7 researchers extracted data on study design""; participant, intervention, and outcome descriptions;"" and results and assessed study quality. Data Synthesis: 53 studies (30 of diet and physical activity promotion programs vs. usual care, 13 of more intensive vs. less intensive programs, and 13 of single programs) evaluated 66 programs. Compared with usual care, diet and physical activity promotion programs reduced type 2 diabetes incidence (risk ratio [RR], 0.59 [95% CI, 0.52 to 0.66]) (16 studies), decreased body weight (net change,-2.2% [CI,-2.9% to-1.4%]) (24 studies) and fasting blood glucose level (net change, -0.12 mmol/L [-2.2 mg/dL] [CI, -0.20 to -0.05 mmol/L {-3.6 to -0.9 mg/ dL}]) (17 studies), and improved other cardiometabolic risk factors. Evidence for clinical events was limited. More intensive programs were more effective. Limitations: Wide variation in diet and physical activity promotion programs limited identification of features most relevant to effectiveness. Evidence on clinical outcomes and in children was sparse. Conclusion: Combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardiometabolic risk factors in persons at increased risk. More intensive programs are more effective.",0,0,
394,Combining intensive practice nurse counselling or brief general practitioner advice with varenicline for smoking cessation in primary care: study protocol of a pragmatic randomized controlled trial,"INTRODUCTION: Combining behavioural support and pharmacotherapy is most effective for smoking cessation and recommended in clinical guidelines. Despite that smoking cessation assistance from the general practitioner can be effective, dissemination of clinical practice guidelines and efforts on upskilling has not lead to the routine provision of smoking cessation advice among general practitioners. Intensive counselling from the practice nurse could contribute to better smoking cessation rates in primary care. However, the effectiveness of intensive counselling from a practice nurse versus usual care from a general practitioner in combination with varenicline is still unknown. MATERIALS AND METHODS: A pragmatic randomized controlled trial was conducted comparing: (a) intensive individual counselling delivered by a practice nurse and (b) brief advice delivered by a general practitioner"";"" both groups received 12-weeks of open-label varenicline. A minimum of 272 adult daily smoking participants were recruited and treated in their routine primary care setting. The primary outcome was defined as prolonged abstinence from weeks 9 to 26, biochemically validated by exhaled carbon monoxide. Data was analysed blinded according to the intention-to-treat principle and participants with missing data on their smoking status at follow-up were counted as smokers. Secondary outcomes included: one-year prolonged abstinence, short-term incremental cost-effectiveness, medication adherence, and baseline predictors of successful smoking cessation. DISCUSSION: This trial is the first to provide scientific evidence on the effectiveness, cost-effectiveness, and potential mechanisms of action of intensive practice nurse counselling combined with varenicline under real-life conditions. This paper explains the methodology of the trial and discusses the pragmatic and/or explanatory design aspects. TRIAL REGISTRATION: Dutch Trial Register NTR3067.",0,0,
395,Comfort First: an evaluation of a procedural pain management programme for children with cancer,"BACKGROUND: The Comfort First Program (CFP) provides children and their caregivers with early procedural pain management intervention to reduce procedural pain and distress. This study evaluated whether the CFP was meeting its goals and effectively implementing the Royal Australasian College of Physicians paediatric pain management guidelines. METHODS: The study was conducted as a single-site cross-sectional audit. One hundred and thirty-five patients (mean age 7.7 years) receiving treatment at the Royal Children's Hospital, Melbourne, Children's Cancer Centre Day Oncology Unit were observed. Procedural aspects related to the treatment room, carer and staff behaviour, child distress and use of pharmacologic and nonpharmacologic interventions were recorded using an audit tool developed for the study. RESULTS: The procedure room was regularly quiet and prepared before the child entered. Median procedure duration was 8 min. Median procedure wait time was 54 min. At least one carer was typically present during procedures. Comfort First (CF) clinicians were more likely to be present in procedures with a significantly distressed child. Carers, nurses and CF clinicians generally displayed comfort-promoting behaviour. Topical anaesthetic was regularly utilised. Nonpharmacologic supports were frequently used, particularly distraction. Patients under 8 years of age were significantly more likely to receive nonpharmacologic supports and have a carer and CF clinician present. Age was a significant predictor of distress, with higher distress rates in younger children. CONCLUSIONS: The CFP was found to be effectively implementing procedural pain guidelines. Regular audit is recommended to ensure adherence to pain management standards.",0,0,
396,Coming to grips with challenging behavior: a cluster randomized controlled trial on the effects of a multidisciplinary care program for challenging behavior in dementia,"OBJECTIVES: The Grip on Challenging Behavior care program was developed using the current guidelines and models on managing challenging behavior in dementia in nursing homes. It was hypothesized that the use of the care program would lead to a decrease in challenging behavior and in the prescription of psychoactive drugs without increase in use of restraints. DESIGN: A randomized controlled trial was undertaken using a stepped-wedge design to implement the care program and to evaluate the effects. An assessment of challenging behavior and psychoactive medication was undertaken every 4 months on all participating units followed by the introduction of the care program in a group of 3 to 4 units. A total of 6 time assessments took place over 20 months. SETTING: Seventeen dementia special care units of different nursing homes. PARTICIPANTS: A total of 659 residents of dementia special care units. All residents with dementia on the unit were included. Units were assigned by random allocation software to 1 of 5 groups with different starting points for the implementation of the care program. INTERVENTION: A care program consisting of various assessment procedures and tools, which ensure a multidisciplinary approach and which structure the process of managing challenging behavior in dementia. MEASUREMENTS: Challenging behavior was measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory. Research assistants (blinded for intervention status of the unit) interviewed nurses on the units about challenging behavior. Data on psychoactive drugs and restraints were retrieved from resident charts. RESULTS: A total of 2292 assessments took place involving 659 residents (1126 control measurements, 1166 intervention measurements). The group of residents who remained in the intervention condition compared with the group in the control condition differed significantly in the CMAI change scores between successive assessments [-2.4 CMAI points, 95% confidence interval (CI) -4.3 to -0.6]. No significant effects were found for the control-to-intervention group compared with the group who remained in the control group (0.0 CMAI points, 95% CI -2.3 to 2.4). Significant effects were found on 5 of the 12 Neuropsychiatric Inventory items and on the use of antipsychotics (odds ratio 0.54, 95% CI 0.37- 0.80) and antidepressants (odds ratio 0.65, 95% CI 0.44-0.94). No effect on use of restraints was observed. CONCLUSIONS: The Grip on Challenging behavior program was able to diminish some forms of challenging behavior and the use of psychoactive drugs.",0,0,
397,Communicating with pediatricians: developing social work practice in primary care,"While social work models of interdisciplinary collaboration suggest that communication is important, the research literature on social worker-physician collaboration infrequently considers work with pediatricians or practice outside the hospital setting. A cross-sectional survey was sent to a stratified random sample of social workers to assess their communication satisfaction with pediatricians. The study found that social workers in health settings were more satisfied than those in mental health settings. The implications of this finding for the development of colocated, collaborative care models are discussed.",0,0,
398,"Communication style and exercise compliance in physiotherapy (CONNECT): a cluster randomized controlled trial to test a theory-based intervention to increase chronic low back pain patients' adherence to physiotherapists' recommendations: study rationale, design, and methods","BACKGROUND: Physical activity and exercise therapy are among the accepted clinical rehabilitation guidelines and are recommended self-management strategies for chronic low back pain. However, many back pain sufferers do not adhere to their physiotherapist's recommendations. Poor patient adherence may decrease the effectiveness of advice and home-based rehabilitation exercises. According to self-determination theory, support from health care practitioners can promote patients' autonomous motivation and greater long-term behavioral persistence (e.g., adherence to physiotherapists' recommendations). The aim of this trial is to assess the effect of an intervention designed to increase physiotherapists' autonomy-supportive communication on low back pain patients' adherence to physical activity and exercise therapy recommendations. METHODS/DESIGN: This study will be a single-blinded cluster randomized controlled trial. Outpatient physiotherapy centers (N =12) in Dublin, Ireland (population = 1.25 million) will be randomly assigned using a computer-generated algorithm to either the experimental or control arm. Physiotherapists in the experimental arm (two hospitals and four primary care clinics) will attend eight hours of communication skills training. Training will include handouts, workbooks, video examples, role-play, and discussion designed to teach physiotherapists how to communicate in a manner that promotes autonomous patient motivation. Physiotherapists in the waitlist control arm (two hospitals and four primary care clinics) will not receive this training. Participants (N = 292) with chronic low back pain will complete assessments at baseline, as well as 1 week, 4 weeks, 12 weeks, and 24 weeks after their first physiotherapy appointment. Primary outcomes will include adherence to physiotherapy recommendations, as well as low back pain, function, and well-being. Participants will be blinded to treatment allocation, as they will not be told if their physiotherapist has received the communication skills training. Outcome assessors will also be blinded.We will use linear mixed modeling to test between arm differences both in the mean levels and the rates of change of the outcome variables. We will employ structural equation modeling to examine the process of change, including hypothesized mediation effects. DISCUSSION: This trial will be the first to test the effect of a self-determination theory-based communication skills training program for physiotherapists on their low back pain patients' adherence to rehabilitation recommendations.",0,0,
399,Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study,"OBJECTIVE To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint. DESIGN Cost effectiveness study alongside a single blind randomised controlled trial. SETTING Memory clinic, day clinic of a geriatrics department, and participants' homes. Patients 135 patients aged > or =65 with mild to moderate dementia living in the community and their primary care givers. INTERVENTION 10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision. MAIN OUTCOME MEASURES Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures. RESULTS The intervention cost 1183 euros (848 pounds sterling, $1738) (95% confidence interval 1128 euros (808 pounds sterling, $1657) to 1239 euros (888 pounds sterling, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were 1748 euros (1279 pounds sterling, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9). CONCLUSIONS Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.",0,0,
400,"Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers","BACKGROUND: Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes, the implementation of risk-reducing practices remains poor. This report describes the results of a randomized, controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker (NP/CHW) teams versus enhanced usual care (EUC) to improve lipids, blood pressure, glycated hemoglobin (HbA1c), and patient perceptions of the quality of their chronic illness care in patients in urban community health centers. METHODS AND RESULTS: A total of 525 patients with documented cardiovascular disease, type 2 diabetes, hypercholesterolemia, or hypertension and levels of LDL cholesterol, blood pressure, or HbA1c that exceeded goals established by national guidelines were randomly assigned to NP/CHW (n=261) or EUC (n=264) groups. The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control. Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol (difference, 19.7 mg/dL), LDL cholesterol (difference,15.9 mg/dL), triglycerides (difference, 16.3 mg/dL), systolic blood pressure (difference, 6.2 mm Hg), diastolic blood pressure (difference, 3.1 mm Hg), HbA1c (difference, 0.5%), and perceptions of the quality of their chronic illness care (difference, 1.2 points). CONCLUSIONS: An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients.",0,0,
401,Community-based care for the management of type 2 diabetes: an evidence-based analysis,"UNLABELLED: In June 2008, the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project, an evidence-based review of the literature surrounding strategies for successful management and treatment of diabetes. This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry's newly released Diabetes Strategy.After an initial review of the strategy and consultation with experts, the secretariat identified five key areas in which evidence was needed. Evidence-based analyses have been prepared for each of these five areas: insulin pumps, behavioural interventions, bariatric surgery, home telemonitoring, and community based care. For each area, an economic analysis was completed where appropriate and is described in a separate report.To review these titles within the Diabetes Strategy Evidence series, please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM: Summary of Evidence-Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics: An Evidence-Based AnalysisBehavioural Interventions for Type 2 Diabetes: An Evidence-Based AnalysisBARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY: An Evidence-Based SummaryCommunity-Based Care for the Management of Type 2 Diabetes: An Evidence-Based AnalysisHome Telemonitoring for Type 2 Diabetes: An Evidence-Based AnalysisApplication of the Ontario Diabetes Economic Model (ODEM) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE: The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care. CLINICAL NEED: TARGET POPULATION AND CONDITION Diabetes (i.e. diabetes mellitus) is a highly prevalent chronic metabolic disorder that interferes with the body's ability to produce or effectively use insulin. The majority (90%) of diabetes patients have type 2 diabetes. (1) Based on the United Kingdom Prospective Diabetes Study (UKPDS), intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics. While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines, factors associated with glycemic control are less well studied, one of which is the provider(s) of care. Multidisciplinary approaches to care may be particularly important for diabetes management. According guidelines from the Canadian Diabetes Association (CDA), the diabetes health care team should be multi-and interdisciplinary. Presently in Ontario, the core diabetes health care team consists of at least a family physician and/or diabetes specialist, and diabetes educators (registered nurse and registered dietician). Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management. Several systematic reviews and meta-analyses have examined multidisciplinary care programs, but these have either been limited to a specific component of multidisciplinary care (e.g. intensified education programs), or were conducted as part of a broader disease management program, of which not all were multidisciplinary in nature. Most reviews also do not clearly define the intervention(s) of interest, making the evaluation of such multidisciplinary community programs challenging. EVIDENCE-BASED ANALYSIS METHODS: RESEARCH QUESTIONS: What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse, registered dietician and physician (primary care and/or specialist) for the management of type 2 diabetes compared to usual care? [Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care? [Henceforth referred to as Model 2] INCLUSION CRITERIA: English language full-reportsPublished between January 1, 2000 and September 28, 2008Randomized controlled trials (RCTs), systematic reviews and meta-analysesType 2 diabetic adult population (>/=18 years of age)Total sample size >/=30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines (of which at least one must be a specialist in diabetes) with integrated communication between the care providers.Compared to usual care (defined as health care provision by non-specialist(s) in diabetes, such as primary care providers""; may include referral to other health care professionals/services as necessary)>/=6 months follow-up EXCLUSION CRITERIA: Studies where discrete results on diabetes cannot be abstractedPredominantly home-based interventionsInpatient-based interventions OUTCOMES OF INTEREST: The primary outcomes for this review were glycosylated hemoglobin (rHbA1c) levels and systolic blood pressure (SBP). SEARCH STRATEGY: A literature search was performed on September 28, 2008 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published between January 1, 2000 and September 28, 2008. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low or very low according to GRADE methodology. Given the high clinical heterogeneity of the articles that met the inclusion criteria, specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario, models of care that were commonly reported in the literature, as well as suggestions from an Expert Advisory Panel Meeting held on January 21, 2009. SUMMARY OF FINDINGS: The initial search yielded 2,116 unique citations, from which 22 RCTs trials and nine systematic reviews published were identified as meeting the eligibility criteria. Of these, five studies focused on care provided by at least a nurse, dietician, and physician (primary care and/or specialist) model of care (Model 1; see Table ES 1), while three studies focused on care provided by at least a pharmacist and primary care physician (Model 2;"" see Table ES 2). Based on moderate quality evidence, specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinically significant reduction in HbA1c of 1.0% compared with usual care. The effects of this model on SBP, however, are uncertain compared with usual care, based on very-low quality evidence. Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinically significant reduction in both HbA1c of 1.05% (based on high quality evidence) and SBP of 7.13 mm Hg (based on moderate quality evidence) compared to usual care. For both models, the evidence does not suggest a preferred setting of care delivery (i.e., primary care vs. hospital outpatient clinic vs. community clinic). Table ES1:Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1OutcomeEstimate of effect(95% CI)Heterogeneity I(2)(p-value)GRADEGlycosylated Hemoglobin (HbA1c [%])-1.00 [-1.27, -0.73]4% (p=0.37)Moderate-quality Subgroup: Moderate-to-High Quality-0.91 [-1.19, -0.62]0% (p=0.74)Systolic Blood Pressure (mm Hg)-2.04 [-13.80, 9.72]89% (p=0.002)Very-low quality*Mean change from baseline to follow-up between intervention and control groupsTable ES2:Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2OutcomeEstimate of effect(95% CI)Heterogeneity I(2)(p-value)GRADEGlycosylated Hemoglobin (HbA1c [%])-1.05 [-1.57, -0.52]0% (p=0.75)High-qualitySystolic Blood Pressure (mm Hg)-7.13 [-11.78, -2.48]46% (p=0.17)Moderate quality*Mean change from baseline to follow-up between intervention and control groups.",0,0,
402,Community-based knowledge transfer and exchange: Helping community-based organizations link research to action,"Background Community-based organizations (CBOs) are important stakeholders in health systems and are increasingly called upon to use research evidence to inform their advocacy, program planning, and service delivery efforts. CBOs increasingly turn to community-based research (CBR) given its participatory focus and emphasis on linking research to action. In order to further facilitate the use of research evidence by CBOs, we have developed a strategy for community-based knowledge transfer and exchange (KTE) that helps CBOs more effectively link research evidence to action. We developed the strategy by: outlining the primary characteristics of CBOs and why they are important stakeholders in health systems""; describing the concepts and methods for CBR and for KTE; comparing the efforts of CBR to link research evidence to action to those discussed in the KTE literature; and using the comparison to develop a framework for community-based KTE that builds on both the strengths of CBR and existing KTE frameworks.  Discussion We find that CBR is particularly effective at fostering a climate for using research evidence and producing research evidence relevant to CBOs through community participation. However, CBOs are not always as engaged in activities to link research evidence to action on a larger scale or to evaluate these efforts. Therefore, our strategy for community-based KTE focuses on: an expanded model of 'linkage and exchange' (i.e., producers and users of researchers engaging in a process of asking and answering questions together); a greater emphasis on both producing and disseminating systematic reviews that address topics of interest to CBOs; developing a large-scale evidence service consisting of both 'push' efforts and efforts to facilitate 'pull' that highlight actionable messages from community relevant systematic reviews in a user-friendly way;"" and rigorous evaluations of efforts for linking research evidence to action.  Summary Through this type of strategy, use of research evidence for CBO advocacy, program planning, and service delivery efforts can be better facilitated and continually refined through ongoing evaluations of its impact.",0,0,
403,Community-based primary care: improving and assessing diabetes management,"Morbidity and mortality associated with diabetes make it a prime target for quality improvement research. Quality gaps and racial/gender disparities persist throughout this population of patients necessitating a sustainable improvement in the clinical management of diabetes. The authors of this study sought (1) to provide a population perspective on diabetes management, and (2) to reinforce evidence-based clinical guidelines through a Web-based educational module.The project also aimed to gain insight into working remotely with a community of rural physicians. This longitudinal pre-post intervention study involved 18 internal medicine physicians and included 3 points of medical record data abstraction over 24 months. A Web-based educational module was introduced after the baseline data abstraction. This module contained chapters on clinical education, practice tools, and self-assessment. The results showed a sustained improvement in most clinical outcomes and demonstrated the effectiveness of using Web-based mediums to reinforce clinical guidelines and change physician behavior.",0,0,
404,Community-Implemented Trauma Therapy for Former Child Soldiers in Northern Uganda,"Context The psychological rehabilitation of former child soldiers and their successful reintegration into postconflict society present challenges. Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers.  Objective To assess the efficacy of a community-based intervention targeting symptoms of posttraumatic stress disorder (PTSD) in formerly abducted individuals.  Design, Setting, and Participants Randomized controlled trial recruiting 85 former child soldiers with PTSD from a population-based survey of 1113 Northern Ugandans aged 12 to 25 years, conducted between November 2007 and October 2009 in camps for internally displaced persons. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD and trauma-related feelings of guilt were measured using the Clinician-Administered PTSD Scale. The respective sections of the Mini International Neuropsychiatric Interview were used to assess depression and suicide risk, and a locally adapted scale was used to measure perceived stigmatization. Symptoms of PTSD, depression, and related impairment were assessed before treatment and at 3 months, 6 months, and 12 months postintervention.  Intervention Treatments were carried out in 8 sessions by trained local lay therapists, directly in the communities.  Main Outcome Measures Change in PTSD severity, assessed over a 1-year period after treatment. Secondary outcome measures were depression symptoms, severity of suicidal ideation, feelings of guilt, and perceived stigmatization.  Results PTSD symptom severity (range, 0-148) was significantly more improved in the narrative exposure therapy group than in the academic catch-up (mean change difference, ?14.06 [95% confidence interval, ?27.19 to ?0.92]) and waiting-list (mean change difference, ?13.04 [95% confidence interval, ?26.79 to 0.72]) groups. Contrast analyses of the time ¡Á treatment interaction of the mixed-effects model on PTSD symptom change over time revealed a superiority of narrative exposure therapy compared with academic catch-up (F1,234.1 = 5.21, P = .02) and wait-listing (F1,228.3 = 5.28, P = .02). Narrative exposure therapy produced a larger within-treatment effect size (Cohen d = 1.80) than academic catch-up (d = 0.83) and wait-listing (d = 0.81).  Conclusion Among former Ugandan child soldiers, short-term trauma-focused treatment compared either with an academic catch-up program including supportive counseling or with wait-listing resulted in greater reduction of PTSD symptoms.",0,0,
405,"Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County, 1970-2010","Importance  Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated the effect of risk factor improvements on reductions in morbidity and mortality.  Objective  To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community.  Design, Setting, and Participants  Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22?444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages.  Interventions  Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians.  Main Outcomes and Measures  Resident participation""; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age.  Results  More than 150?000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7% (95% CI, 21.6%-27.7%) from 18.3% to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed?-?expected [O?-?E], 11.3%; 95% CI, 5.5%-17.7%; P?<?.001), 1996-2000; these differences later disappeared when Maine’s overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006 (O?-?E, -17 discharges/1000 residents; 95% CI -20.1 to -13.9; P?<?.001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010 (O?-?E, -60.4 deaths/100?000; 95% CI, -97.9 to -22.8; P?<?.001, and -41.6/100?000; 95% CI, -77.3 to -5.8;"" P?=?.005, respectively).  Conclusions and Relevance  Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county’s population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.",0,0,
406,Comparative Benefits and Harms of Second-Generation Antidepressants for Treating Major Depressive Disorder,"Background:Second-generation antidepressants dominate the management of major depressive disorder (MDD), but evidence on the comparative benefits and harms of these agents is contradictory.Purpose:To compare the benefits and harms of second-generation antidepressants for treating MDD in adults.Data Sources:English-language studies from PubMed, Embase, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to August 2011 and reference lists of pertinent review articles and gray literature.Study Selection:2 independent reviewers identified randomized trials of at least 6 weeks' duration to evaluate efficacy and observational studies with at least 1000 participants to assess harm.Data Extraction:Reviewers abstracted data about study design and conduct, participants, and interventions and outcomes and rated study quality. A senior reviewer checked and confirmed extracted data and quality ratings.Data Synthesis:Meta-analyses and mixed-treatment comparisons of response to treatment and weighted mean differences were conducted on specific scales to rate depression. On the basis of 234 studies, no clinically relevant differences in efficacy or effectiveness were detected for the treatment of acute, continuation, and maintenance phases of MDD. No differences in efficacy were seen in patients with accompanying symptoms or in subgroups based on age, sex, ethnicity, or comorbid conditions. Individual drugs differed in onset of action, adverse events, and some measures of health-related quality of life.Limitations:Most trials were conducted in highly selected populations. Publication bias might affect the estimates of some comparisons. Mixed-treatment comparisons cannot conclusively exclude differences in efficacy. Evidence within subgroups was limited.Conclusion:Current evidence does not warrant recommending a particular second-generation antidepressant on the basis of differences in efficacy. Differences in onset of action and adverse events may be considered when choosing a medication.",0,0,
407,Comparative Benefits and Harms of Second-Generation Antidepressants: Background Paper for the American College of Physicians,"Background:Second-generation antidepressants dominate the management of major depressive disorder, dysthymia, and subsyndromal depression. Evidence on the comparative benefits and harms is still accruing.Purpose:To compare the benefits and harms of second-generation antidepressants (bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine) for the treatment of depressive disorders in adults.Data Sources:MEDLINE, EMBASE, PsychLit, Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts from 1980 to April 2007, limited to English-language articles. Reference lists of pertinent review articles were manually searched and the Center for Drug Evaluation and Research database was explored to identify unpublished research.Study Selection:Abstracts and full-text articles were independently reviewed by 2 persons. Six previous good- or fair-quality systematic reviews or meta-analyses were included, as were 155 good- or fair-quality double-blind, placebo-controlled, or head-to-head randomized, controlled trials of at least 6 weeks' duration. For harms, 35 observational studies with at least 100 participants and follow-up of at least 12 weeks were also included.Data Extraction:Using a standard protocol, investigators abstracted data on study design and quality-related details, funding, settings, patients, and outcomes.Data Synthesis:If data were sufficient, meta-analyses of head-to-head trials were conducted to determine the relative benefit of response to treatment and the weighted mean differences on specific depression rating scales. If sufficient evidence was not available, adjusted indirect comparisons were conducted by using meta-regressions and network meta-analyses. Second-generation antidepressants did not substantially differ in efficacy or effectiveness for the treatment of major depressive disorder on the basis of 203 studies"";"" however, the incidence of specific adverse events and the onset of action differed. The evidence is insufficient to draw conclusions about the comparative efficacy, effectiveness, or harms of these agents for the treatment of dysthymia and subsyndromal depression.Limitation:Adjusted indirect comparisons have methodological limitations and cannot conclusively rule out differences in efficacy.Conclusion:Current evidence does not warrant the choice of one second-generation antidepressant over another on the basis of differences in efficacy and effectiveness. Other differences with respect to onset of action and adverse events may be relevant for the choice of a medication.",0,0,
408,Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy,"BACKGROUND: We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL). OBJECTIVE: We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback. DESIGN: Four-year cluster randomized controlled trial. PARTICIPANTS: Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening. INTERVENTIONS: Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports. MAIN MEASURES: PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months""; and changes in patient cancer screening rates over 24 months. KEY RESULTS: There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups;"" however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge. CONCLUSION: Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.",0,1,
409,Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis,"BackgroundThe question of which antipsychotic drug should be preferred for the treatment of schizophrenia is controversial, and conventional pairwise meta-analyses cannot provide a hierarchy based on the randomised evidence. We aimed to integrate the available evidence to create hierarchies of the comparative efficacy, risk of all-cause discontinuation, and major side-effects of antipsychotic drugs."";"" BackgroundThe question of which antipsychotic drug should be preferred for the treatment of schizophrenia is controversial, and conventional pairwise meta-analyses cannot provide a hierarchy based on the randomised evidence. We aimed to integrate the available evidence to create hierarchies of the comparative efficacy, risk of all-cause discontinuation, and major side-effects of antipsychotic drugs.",0,0,
410,Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis,"OBJECTIVE To evaluate the relative efficacy of the World Health Organization 2005 campaign (WHO-5) and other interventions to promote hand hygiene among healthcare workers in hospital settings and to summarize associated information on use of resources. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, Embase, CINAHL, NHS Economic Evaluation Database, NHS Centre for Reviews and Dissemination, Cochrane Library, and the EPOC register (December 2009 to February 2014)""; studies selected by the same search terms in previous systematic reviews (1980-2009). REVIEW METHODS Included studies were randomised controlled trials, non-randomised trials, controlled before-after trials, and interrupted time series studies implementing an intervention to improve compliance with hand hygiene among healthcare workers in hospital settings and measuring compliance or appropriate proxies that met predefined quality inclusion criteria. When studies had not used appropriate analytical methods, primary data were re-analysed. Random effects and network meta-analyses were performed on studies reporting directly observed compliance with hand hygiene when they were considered sufficiently homogeneous with regard to interventions and participants. Information on resources required for interventions was extracted and graded into three levels. RESULTS Of 3639 studies retrieved, 41 met the inclusion criteria (six randomised controlled trials, 32 interrupted time series, one non-randomised trial, and two controlled before-after studies). Meta-analysis of two randomised controlled trials showed the addition of goal setting to WHO-5 was associated with improved compliance (pooled odds ratio 1.35, 95% confidence interval 1.04 to 1.76; I(2)=81%). Of 22 pairwise comparisons from interrupted time series, 18 showed stepwise increases in compliance with hand hygiene, and all but four showed a trend for increasing compliance after the intervention. Network meta-analysis indicated considerable uncertainty in the relative effectiveness of interventions, but nonetheless provided evidence that WHO-5 is effective and that compliance can be further improved by adding interventions including goal setting, reward incentives, and accountability. Nineteen studies reported clinical outcomes; data from these were consistent with clinically important reductions in rates of infection resulting from improved hand hygiene for some but not all important hospital pathogens. Reported costs of interventions ranged from $225 to $4669 (£146-£3035;"" €204-€4229) per 1000 bed days. CONCLUSION Promotion of hand hygiene with WHO-5 is effective at increasing compliance in healthcare workers. Addition of goal setting, reward incentives, and accountability strategies can lead to further improvements. Reporting of resources required for such interventions remains inadequate.",0,1,
411,Comparing cost effects of two quality strategies to improve test ordering in primary care: a randomized trial,"OBJECTIVE: To determine the costs and cost reductions of an innovative strategy aimed at improving test ordering routines of primary care physicians, compared with a traditional strategy. DESIGN: Multicenter randomized controlled trial with randomization at the local primary care physicians group level. SETTING: Primary care: local primary care physicians groups in five regions of the Netherlands with diagnostic centers. STUDY PARTICIPANTS: Twenty-seven existing local primary care physicians groups, including 194 primary care physicians. INTERVENTION: The test ordering strategy was developed systematically, and combined feedback, education on guidelines, and quality improvement sessions in small groups. In regular quality meetings in local groups, primary care physicians discussed each others' test ordering behavior, related it to guidelines, and made individual and/or group plans for change. Thirteen groups engaged in the entire strategy (complete intervention arm), while 14 groups received feedback only (feedback arm). MAIN OUTCOME MEASURE: Running costs, development costs, and research costs were calculated for the intervention period per primary care physician per 6 months. The mean costs of tests ordered per primary care physician per 6 months were assessed at baseline and follow-up. RESULTS: The new strategy was found to cost 702.00, while the feedback strategy cost 58.00. When including running costs only, the intervention was found to cost 554.70, compared with 17.10 per primary care physician per 6 months in the feedback arm. When excluding opportunity costs for the physicians' time spent, the intervention was found to cost 92.70 per physician per 6 months in the complete intervention arm. The mean costs reduction that physicians in that arm achieved by reducing unnecessary tests was 144 larger per physician per 6 months than the physicians in the feedback arm (P = 0.048). CONCLUSION: On the basis of our findings, including the expected non-monetary benefits, we recommend further long-term effect and cost-effect studies on the implementation of the quality strategy.",0,1,
412,Comparing the efficacy of staff versus housestaff instruction in an intervention to improve hypertension management,"PURPOSE: To determine whether a resident physician can be as effective as a faculty opinion leader in changing physicians' compliance with a hypertension practice guideline. METHOD: At a general internal medicine clinic associated with an internal medicine residency program, sequential charts were reviewed for patients with uncontrolled or new-onset hypertension who were seen routinely during a two-week period. Subsequently, 23 providers were randomly assigned to an academic intervention to implement a hypertension practice guideline led by a single second-year resident instructor (RI), and 21 providers were assigned to the same intervention led by a single staff internist (SI) with an interest in hypertension. The intervention involved academic detailing, chart audit with feedback, and behavior reinforcement. Six weeks later, the chart audit was repeated to assess the change in practice patterns among providers taught by the RI compared with those taught by the SI. RESULTS: Overall, management consistent with the practice guideline improved from 32% (51/157) to 45% (56/123) (p < .01) after the intervention. This change was due to improvement in the care provided by providers from the SI-led intervention: 28% (17/60) to 57% (26/46) (p < .003). Providers from the RI-led intervention showed no improvement: 35% (34/97) to 39% (30/77) (p = NS). CONCLUSIONS: This intervention was effective in improving providers' compliance with a hypertension practice guideline, but only when led by a faculty opinion leader. A resident instructor using the same format was unable to change the providers' behaviors.",1,1,
413,Comparison of strategies to reduce meticillin-resistant Staphylococcus aureus rates in surgical patients: a controlled multicentre intervention trial.,"Objective To compare the effect of two strategies (enhanced hand hygiene vs meticillin-resistant Staphylococcus aureus (MRSA) screening and decolonisation) alone and in combination on MRSA rates in surgical wards.  Design Prospective, controlled, interventional cohort study, with 6-month baseline, 12-month intervention and 6-month washout phases.  Setting 33 surgical wards of 10 hospitals in nine countries in Europe and Israel.  Participants All patients admitted to the enrolled wards for more than 24 h.  Interventions The two strategies compared were (1) enhanced hand hygiene promotion and (2) universal MRSA screening with contact precautions and decolonisation (intranasal mupirocin and chlorhexidine bathing) of MRSA carriers. Four hospitals were assigned to each intervention and two hospitals combined both strategies, using targeted MRSA screening.  Outcome measures Monthly rates of MRSA clinical cultures per 100 susceptible patients (primary outcome) and MRSA infections per 100 admissions (secondary outcome). Planned subgroup analysis for clean surgery wards was performed.  Results After adjusting for clustering and potential confounders, neither strategy when used alone was associated with significant changes in MRSA rates. Combining both strategies was associated with a reduction in the rate of MRSA clinical cultures of 12% per month (adjusted incidence rate ratios (aIRR) 0.88, 95% CI 0.79 to 0.98). In clean surgery wards, strategy 2 (MRSA screening, contact precautions and decolonisation) was associated with decreasing rates of MRSA clinical cultures (15% monthly decrease, aIRR 0.85, 95% CI 0.74 to 0.97) and MRSA infections (17% monthly decrease, aIRR 0.83, 95% CI 0.69 to 0.99).  Conclusions In surgical wards with relatively low MRSA prevalence, a combination of enhanced standard and MRSA-specific infection control approaches was required to reduce MRSA rates. Implementation of single interventions was not effective, except in clean surgery wards where MRSA screening coupled with contact precautions and decolonisation was associated with significant reductions in MRSA clinical culture and infection rates.",0,1,
414,Comparison of the instructional efficacy of Internet-based CME with live interactive CME workshops: a randomized controlled trial,"CONTEXT: Despite evidence that a variety of continuing medical education (CME) techniques can foster physician behavioral change, there have been no randomized trials comparing performance outcomes for physicians participating in Internet-based CME with physicians participating in a live CME intervention using approaches documented to be effective. OBJECTIVE: To determine if Internet-based CME can produce changes comparable to those produced via live, small-group, interactive CME with respect to physician knowledge and behaviors that have an impact on patient care. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted from August 2001 to July 2002. Participants were 97 primary care physicians drawn from 21 practice sites in Houston, Tex, including 7 community health centers and 14 private group practices. A control group of 18 physicians from these same sites received no intervention. INTERVENTIONS: Physicians were randomly assigned to an Internet-based CME intervention that could be completed in multiple sessions over 2 weeks, or to a single live, small-group, interactive CME workshop. Both incorporated similar multifaceted instructional approaches demonstrated to be effective in live settings. Content was based on the National Institutes of Health National Cholesterol Education Program--Adult Treatment Panel III guidelines. MAIN OUTCOME MEASURES: Knowledge was assessed immediately before the intervention, immediately after the intervention, and 12 weeks later. The percentage of high-risk patients who had appropriate lipid panel screening and pharmacotherapeutic treatment according to guidelines was documented with chart audits conducted over a 5-month period before intervention and a 5-month period after intervention. RESULTS: Both interventions produced similar and significant immediate and 12-week knowledge gains, representing large increases in percentage of items correct (pretest to posttest: 31.0% [95% confidence interval {CI}, 27.0%-35.0%]""; pretest to 12 weeks: 36.4% [95% CI, 32.2%-40.6%]; P or =93%) with no significant postintervention change. However, the Internet-based intervention was associated with a significant increase in the percentage of high-risk patients treated with pharmacotherapeutics according to guidelines (preintervention, 85.3%; postintervention, 90.3%;"" P = .04). CONCLUSIONS: Appropriately designed, evidence-based online CME can produce objectively measured changes in behavior as well as sustained gains in knowledge that are comparable or superior to those realized from effective live activities.",1,1,
415,Comparison of three methods of recalling patients for influenza vaccination.,"Despite recommendations supporting annual influenza vaccination for people aged 65 years or older, vaccination rates remain low. Several studies have evaluated the effect of sending mailed reminders, but few have compared alternative ways of reminding patients to receive the vaccine. In a randomized trial of 939 patients aged 65 years or older in four family practices carried out between Oct. 23 and Dec. 31, 1984, we compared three ways of reminding elderly patients to receive the vaccine: personal reminder by the physician, telephone reminder by the nurse and reminder by letter. The vaccination rates for the three groups were 22.9%, 37% and 35.1% respectively. No reminder was issued to a control group, and the rate was 9.8%. Some patients could not be reached by telephone, and some did not see the physician during the specified time. Among the patients whom the nurse actually contacted, the vaccination rate was 43.5%"";"" the rate for patients whom the doctor actually saw was 45.1%. Overall, a telephone reminder by the nurse was the most effective method, and at an hourly salary of $16 or less this method would also be the most cost-effective. The reminders used in this study were automatically generated from a computerized medical record system. The study shows how a computerized system can be used to identify patients for whom preventive procedures are due.",0,1,
416,"Competence network ""community acquired pneumonia"" (CAPNETZ). A first interim report","Community acquired pneumonia (CAP) is a disease with high morbidity and mortality in Germany. However, no reliable data are available about spectrum and resistance of pathogens, course of the disease, evidence based guidelines for treatment, and pathogen-host interactions. The German Ministry of Education and Research recognized these deficits and therefore decided to fund CAPNETZ, a network of competence for community acquired pneumonia. CAPNETZ integrates components of health research as well as clinical and basic research (horizontal network) on one hand and supports cooperation among general practitioners, community hospitals and universities (vertical network). Since October 2002, 1547 patients with CAP have been recruited within the network. First results indicate, that new observations made in terms of symptoms, spectrum of pathogens involved, and treatment modalities will impact on the formulation of new guidelines for the management of community acquired pneumonia.",0,0,
417,Competency development in new registered nurse graduates: closing the gap between education and practice,"The gap between a new registered nurse graduate's education for practice and actual practice requirements of new registered nurses has long been an accepted fact in nursing. This article describes the development of an intervention from the academic side of the gap to improve the competency of nursing students before graduation. The intervention is noteworthy because it was developed collaboratively between academia and practice. The three-pronged intervention included development of learning modules based on the top 10 high-risk, high-volume patient conditions""; faculty and staff educator development in learning strategies to enhance competency development;"" and sharing of products with the 84 schools of nursing in Texas.",0,0,
418,Complementary therapy in allergic rhinitis,"The term complementary/alternative medicine (CAM) refers to those therapeutic and diagnostic approaches different from conventional allopathic medicine. CAM may encompass homeopathy, acupuncture, phytotherapy, antioxidant therapy, and numerous holistic or behavioral techniques. Allergists and physicians of all disciplines are confronted with patients using CAM treatments, making it imperative that they become familiar with the scientific literature surrounding them. Given the high prevalence of allergic diseases and associated costs of CAM treatments, proof of CAM therapies is needed to establish appropriate guidelines for their use. Efficacy of CAM modalities should be established with randomized, double-blind, placebo-controlled trials, including adverse-effects monitoring. Of all the CAM therapies examined to treat allergic rhinitis, some herbal therapies and antioxidants demonstrate a trend toward some clinical efficacy. Researchers have yet to determine how to integrate these CAM modalities into the general treatment paradigm of allergic rhinitis.",0,0,
419,Complex pharmaceutical care intervention in pulmonary care: part A. The process and pharmacists' professional satisfaction,"OBJECTIVE: In the IPMP study (Interventions on the principle of Pulmonary Medication Profiles), tailored pharmaceutical care interventions were provided to pulmonary patients selected because of drug use that deviates from Dutch guidelines. The aims were to solve drug-related problems and to improve patients' drug use. This article describes the pharmaceutical care process tailored to the individual problems of patients in the intervention arm of a randomized controlled trial and defines the package of care. METHODS: After a preliminary selection of the patients with the help of the algorithmic IPMP computer instrument, instructed Dutch community pharmacists had structured consultations with patients (aged 13-70 years) in the intervention arm to identify behaviour and specific problems with their medication. Based on this identification process, a tailored intervention was constructed that could comprise one or more of six pharmaceutical care modules. Modules were clustered in sets describing the complete programme of care provided to one patient. If necessary, pharmacists consulted the patients' physicians to improve the prescribed therapy. After the interventions, medication changes were evaluated with the patients. The prescribed medication and the refill rate were monitored in the pharmacy computer during 1 year. All activities and results were extensively monitored and documented. MAIN OUTCOME MEASURE: Process description, i.e. number of provided pharmaceutical care modules and medication changes. Pharmacists' satisfaction. RESULTS: Tailored interventions were provided to 199 patients at risk of sub-optimal drug therapy. In all 813 pharmaceutical care modules were performed and documented, and clustered in four different programmes. In addition to education and motivation to adhere to prescribed medication for all 199 patients, a medication change was suggested in 124 cases. Patients and physicians agreed upon a change in 94 cases. Device change was agreed upon in 58 of 64 cases, often simultaneously with medication change. Pharmacists consulted physicians concerning 100 patients. Pharmacists reported satisfaction with the pharmaceutical care approach. CONCLUSION: Because of the extensive documentation, interventions could be described completely. Pharmacists observed a better drug use after educating patients or by solving their drug-related problems. In collaboration with physicians drug treatment could be improved.",0,0,420
420,Complex pharmaceutical care intervention in pulmonary care: part A. The process and pharmacists' professional satisfaction. ,"In the IPMP study (Interventions on the principle of Pulmonary Medication Profiles), tailored pharmaceutical care interventions were provided to pulmonary patients selected because of drug use that deviates from Dutch guidelines. The aims were to solve drug-related problems and to improve patients' drug use. This article describes the pharmaceutical care process tailored to the individual problems of patients in the intervention arm of a randomized controlled trial and defines the package of care.After a preliminary selection of the patients with the help of the algorithmic IPMP computer instrument, instructed Dutch community pharmacists had structured consultations with patients (aged 13-70 years) in the intervention arm to identify behaviour and specific problems with their medication. Based on this identification process, a tailored intervention was constructed that could comprise one or more of six pharmaceutical care modules. Modules were clustered in sets describing the complete programme of care provided to one patient. If necessary, pharmacists consulted the patients' physicians to improve the prescribed therapy. After the interventions, medication changes were evaluated with the patients. The prescribed medication and the refill rate were monitored in the pharmacy computer during 1 year. All activities and results were extensively monitored and documented.Process description, i.e. number of provided pharmaceutical care modules and medication changes. Pharmacists' satisfaction.Tailored interventions were provided to 199 patients at risk of sub-optimal drug therapy. In all 813 pharmaceutical care modules were performed and documented, and clustered in four different programmes. In addition to education and motivation to adhere to prescribed medication for all 199 patients, a medication change was suggested in 124 cases. Patients and physicians agreed upon a change in 94 cases. Device change was agreed upon in 58 of 64 cases, often simultaneously with medication change. Pharmacists consulted physicians concerning 100 patients. Pharmacists reported satisfaction with the pharmaceutical care approach.Because of the extensive documentation, interventions could be described completely. Pharmacists observed a better drug use after educating patients or by solving their drug-related problems. In collaboration with physicians drug treatment could be improved.",0,1,
421,Complexities of fall prevention in clinical settings: a commentary,"Falls and associated injury and mortality are of increasing concern among aging Americans. Effective fall risk management is a complicated process requiring involvement by both health care professionals and older adults for three related actions: (a) early screening to detect risk factors""; (b) prescription of tailored interventions; and (c) implementation of, adherence to, and compliance with the intervention by the older adult. Early detection of fall risk can prevent future falls;"" however, uptake of evidence-based screening and assessment protocols in the clinical setting has been limited. A variety of practice guidelines and financial incentives are available to health care professionals to facilitate adoption. Yet, there remains a gap between recommended practices and current clinical activities. This commentary addresses the complexities of fall prevention practices and offers solutions that can facilitate adoption by clinical practices. Toward this end, this commentary will present two models (i.e., a clinical approach and a financial incentive approach) to summarize current clinical recommendations and practice guidelines for fall risk management in clinical settings. The various drivers to encourage adoption of evidence-based fall risk management strategies will be described. In this context, we will discuss how understanding the different system wide practice improvement initiatives and factors that drive action in physician groups, can facilitate adoption and implementation of fall risk management behaviors by clinicians. Additional efforts are needed to explore and assess similar initiatives to adopt and implement fall risk management practices at different entry points into the system (e.g., community settings, patients, caregivers).",0,0,
422,Compliance with biopsy recommendations of a prostate cancer risk calculator,"UNLABELLED: Study Type - Diagnostic (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? So far, few publications have shown that a prediction model influences the behaviour of both physicians and patients. To our knowledge, it was unknown whether urologists and patients are compliant with the recommendations of a prostate cancer risk calculator and their reasons for non-compliance. Recommendations of the European Randomized study of Screening for Prostate Cancer risk calculator (ERSPC RC) about the need of a prostate biopsy were followed in most patients. In most cases of non-compliance with 'no biopsy' recommendations, a PSA level >/= 3 ng/mL was decisive to opt for biopsy. Before implementation of the ERSPC RC in urological practices at a large scale, it is important to obtain insight into the use of guidelines that might counteract the adoption of the use of the RC as a result of opposing recommendations. OBJECTIVES: To assess both urologist and patient compliance with a 'no biopsy' or 'biopsy' recommendation of the European Randomized study of Screening for Prostate Cancer (ERSPC) Risk Calculator (RC), as well as their reasons for non-compliance. To assess determinants of patient compliance. PATIENTS AND METHODS: The ERSPC RC calculates the probability on a positive sextant prostate biopsy (P(posb) ) using serum prostate-specific antigen (PSA) level, outcomes of digital rectal examination and transrectal ultrasonography, and ultrasonographically assessed prostate volume. A biopsy was recommended if P(posb) >/=20%. Between 2008 and 2011, eight urologists from five Dutch hospitals included 443 patients (aged 55-75 years) after a PSA test with no previous biopsy. Urologists calculated the P(posb) using the RC in the presence of patients and completed a questionnaire about compliance. Patients completed a questionnaire about prostate cancer knowledge, attitude towards prostate biopsy, self-rated health (12-Item Short Form Health Survey), anxiety (State Trait Anxiety Inventory-6, Memorial Anxiety Scale for Prostate Cancer) and decision-making measures (Decisional Conflict Scale). RESULTS: Both urologists and patients complied with the RC recommendation in 368 of 443 (83%) cases. If a biopsy was recommended, almost all patients (96%""; 257/269) complied, although 63 of the 174 (36%) patients were biopsied against the recommendation of the RC. Compliers with a 'no biopsy' recommendation had a lower mean P(posb) than non-compliers (9% vs 14%; P /= 3 ng/mL) (78%; 49/63) and patients because they wanted certainty (60%;"" 38/63). CONCLUSIONS: Recommendations of the ERSPC RC on prostate biopsy were followed in most patients. The RC hence may be a promising tool for supporting clinical decision-making.",0,0,
423,Compliance with the Adult Treatment Panel III guidelines for hyperlipidemia in a resident-run ambulatory clinic: a retrospective data analysis,"BACKGROUND: One in every six adults (16.3% of the U.S. adult population) has high total cholesterol levels, and they are at double the risk of heart disease compared with people with optimal levels. OBJECTIVE: To evaluate compliance of internal medicine residents with the latest National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines in treating patients with hyperlipidemia. DESIGN: Retrospective observational study. SETTING: Ambulatory Clinic, Saint Vincent Hospital, Worcester, Massachusetts. PATIENTS: Patients with a diagnosis of hyperlipidemia who attended the clinic during a 1-ear period, from December 2009 to November 2010. MEASUREMENTS: A review of medical records was conducted to evaluate residents' compliance with the NCEP-ATP III guidelines for LDL cholesterol and non-HDL cholesterol management. RESULTS: Seven hundred seventy charts were reviewed. Only 212 (27.5%) met the inclusion criteria. Analysis of data revealed better compliance with drug therapy (44%-77%) and therapeutic lifestyle changes (44%-83%) when compared with follow-up recommendations (22%-31%). An increase in compliance also was noted in all areas of intervention when patients had an abnormal lipid profile. LIMITATIONS: Compliance was assessed on the basis of electronic medical record documentation alone and hence we may be underestimating compliance with therapeutic lifestyle changes and follow-up recommendations. CONCLUSION: Compliance among internal medicine residents in the diagnosis, treatment and follow-up of patients with hyperlipidemia according to NCEP-ATP III guidelines was suboptimal and needs improvement.",0,0,
424,Comprehensive asthma management for underserved children,"In response to the ‘asthma epidemic’, local organisations in San Francisco formed the Yes We Can Urban Asthma Partnership, which uses a comprehensive medical/social model for paediatric asthma care. The Yes We Can Urban Asthma Partnership reaches out to high‐risk children in different clinical settings: urgent visits, the hospital, a comprehensive specialty asthma clinic, and through an expanded community health worker programme. This article highlights the initial development, implementation, and evaluation of the success of this innovative management programme to address the problem of paediatric asthma in underserved urban areas.",0,1,
425,Computed critiquing integrated into daily clinical practice affects physicians' behavior--a randomized clinical trial with AsthmaCritic,"OBJECTIVE: We developed AsthmaCritic, a non-inquisitive critiquing system integrated with the general practitioners' electronic medical records. The system is based on the guidelines for asthma and chronic obstructive pulmonary disease (COPD) as issued by the Dutch College of General Practitioners. This paper assesses the effect of AsthmaCritic on monitoring and treatment of asthma and COPD by Dutch general practitioners in daily practice. METHODS: A randomized clinical trial in 32 practices (40 Dutch general practitioners) using electronic patient records. An intervention group was given the use of AsthmaCritic, a control group continued working in the usual manner. Both groups had the disposal of the asthma and COPD guidelines routinely distributed by the Dutch College of General Practitioners. We measured the average number of contacts, FEV 1 (forced expiratory volume), and peak-flow measurements per asthma/COPD patient per practice"";"" and, the average number of antihistamine, cromoglycate, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice. RESULTS: The number of contacts increased in the age group of 12-39 years. The number of FEV1 , peak-flow measurements, and the ratio of coded measurements increased, whereas the number of cromoglycate prescriptions decreased in the age group of 12-39 years. CONCLUSIONS: Our study shows that the guideline-based critiquing system AsthmaCritic changed the manner in which the physicians monitored their patients and, to a lesser extent, their treatment behavior. In addition, the physicians changed their data-recording habits.",0,1,
426,Computed tomography of the body: when should it be used?,,0,0,
427,Computer reminders for Chlamydia screening in general practice: a randomized controlled trial.,"Background: Chlamydia notifications are increasing in Australia, and the use of a computer alert prompting general practitioners to test young women is a potential way to increase opportunistic chlamydia testing. The aim of this trial was to determine the effectiveness of a computer alert in general practice on chlamydia testing in young women.  Methods: In 2006, clinics (n = 68) in Melbourne, Australia were cluster randomized into 2 groups: the intervention group received a computerized alert advising the general practitioner to discuss chlamydia testing with their patient which popped up when the medical record of a 16- to 24-year-old woman was opened""; the control group received no alert. The outcome was whether or not that patient received a chlamydia test at the level of a single consultation with an eligible patient. A mixed effects logistic regression model adjusting for clustering was used to assess the impact of the alert on the proportion of women tested for chlamydia during the trial period.  Results: Testing increased from 8.3% (95% confidence interval (CI): 6.8, 9.8) to 12.2% (95% CI: 9.1, 15.3) (P < 0.01) in the intervention group, and from 8.8% (95% CI: 6.8, 10.7) to 10.6% (95% CI: 8.5, 12.7) (P < 0.01) in the control group. Overall, the intervention group had a 27% (OR = 1.3;"" 95% CI: 1.1, 1.4) greater increase in testing.  Conclusion: The results of this study suggest that alerts alone may not be sufficient to get chlamydia testing levels up sufficiently high enough to have an impact on the burden of chlamydia in the population but that they could be included as part of a more complex intervention.",0,1,
428,Computer reminders to implement preventive care guidelines for hospitalized patients.,"Background:  Hospitalizations are an opportunity to provide preventive care.  Objective:  To determine if computer reminders, which we have shown to be effective in our ambulatory care setting, increase the provision of inpatient preventive care.  Methods:  Randomized, controlled trial on the general medicine inpatient service of an urban, university-affiliated public hospital. Study subjects were 78 house staff rotating on the 6 general medicine services. The intervention was reminders to physicians printed on daily rounds reports about preventive care for which their patients were eligible, and suggested orders for preventive care provided through the physicians' workstations. The preventive care guidelines were derived from the US Preventive Care Task Force recommendations. Compliance with preventive care guidelines and house staff attitudes toward providing preventive care to hospitalized patients were the main outcome measures.  Results:  No significant differences were seen between intervention and control physicians in compliance with preventive care guidelines in the aggregate or when individual preventive care actions were analyzed. This was true even though most physicians endorsed providing most kinds of preventive care for hospitalized patients.  Conclusions:  Despite past success in increasing preventive care in the outpatient setting, we were unable, using a moderately intensive intervention, to increase the provision of preventive care during hospitalizations. The physicians providing care during the hospitalization were not the patients' primary care physicians, which proved to be an important barrier. More intensive interventions, or more direct linkages between inpatient and outpatient care providers, may be required to overcome this resistance.Arch Intern Med. 1996"";""156:1551-1556",0,1,
429,Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior.,"Background Appropriate hand hygiene among health care workers is the most important infection prevention measure"";"" however, compliance is generally low. Gain-framed messages (ie, messages that emphasize the benefits of hand hygiene rather than the risks of noncompliance) may be most effective, but have not been tested.  Methods The study was conducted in a 27-bed neonatal intensive care unit. We performed an interrupted time series analysis of objectively measured hand disinfection events. We used electronic devices in hand alcohol dispensers, which continuously documented the frequency of hand disinfection events. In addition, hand hygiene compliance before and after the intervention period were directly observed.  Results The negative trend in hand hygiene events per patient-day before the intervention (decrease by 2.3 [standard error, 0.5] per week) changed to a significant positive trend (increase of 1.5 [0.5] per week) after the intervention (P < .001). The direct observations confirmed these results, showing a significant improvement in hand hygiene compliance from 193 of 303 (63.6%) observed hand hygiene events at pretest to 201 of 281 (71.5%) at posttest.  Conclusions We conclude that gain-framed messages concerning hand hygiene presented on screen savers may improve hand hygiene compliance.",1,1,
430,Computer-administered clinical rating scales. A review,"While clinician-administered symptom rating scales are the most commonly used outcome measures in pharmaceutical research, error variance due to poor inter-rater reliability increases the risk of type II errors in multi-center clinical trials. Such error variance could obscure true differences between active drug and placebo, or between two comparator compounds. Computer-administered versions of symptom rating scales originally designed to be administered by trained clinicians offer a solution to this problem. This paper reviews the empirical data on the reliability, validity and equivalence of computer-administered rating scales. Computer-administered versions of clinician-administered scales are now available for the assessment of depression, anxiety, obsessive-compulsive disorder, and social phobia. Validation studies support the reliability, validity and equivalence of these scales. Patient reaction has been positive, with patients generally more honest with and often preferring the computer for assessing sensitive areas such as suicide, alcohol or drug abuse, sexual behavior, or HIV related symptoms. Applications using Interactive Voice Response (IVR) technology facilitate longitudinal monitoring of patients without requiring office visits to collect data, increase the accessibility of information to the clinician, and the quality of patient care through more informed decision making. When used in accordance with established ethical guidelines, computers offer a reliable, inexpensive, accessible, and time-efficient means of assessing psychiatric symptoms.",0,0,
431,Computer-based decision support for pediatric asthma management: description and feasibility of the Stop Asthma Clinical System,"Clinical guidelines can assist in the management of asthma. Decision support systems (DSSs) can enhance adherence to clinical guidelines but tend not to provide clinicians with cues for behavioral change strategies to promote patient self-management. The Stop Asthma Clinical System (SACS) is a DSS designed for this purpose. To assess feasibility, seven clinicians used SACS to guide well visits with 26 predominantly persistent pediatric asthma patients. Data were collected via survey and in-depth semi-structured interviews. SACS improved assessment of asthma severity and control, classification of and intervention in medicine and environmental trigger management problems, and development of an action plan (all p < 0.05). Clinician-patient communication was enhanced. The primary challenge was that SACS increased clinic visit time. SACS can enhance clinician behavior to improve patient asthma self-management, but more studies are indicated to mitigate temporal constraints and evaluate impact on clinician and patient communication and behavior as well as clinical outcomes.",0,0,
432,Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.,"Objective: To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency.  Design: Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units.  Measurement: The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses""; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information.  Results: The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0);"" and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units—relative risk 1.2 (1.0, 1.4).  Conclusions: Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.",1,1,
433,Computerized community cholesterol control (4C): meeting the challenge of secondary prevention.,"Background: Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity to close these gaps.   Objectives: To study the impact of computerized intervention on secondary prevention of CAD[1].   Methods: The CDSS[2] was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization.   Results: Follow-up was available for 7448 patients with CAD (median 19.8 months, range 6–36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment recommended to lower lipid level. A significant decrease in low density lipoprotein levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 ± 34.2 vs. 124.3 ± 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001).   Conclusions: This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.",0,1,
434,Computerized decision support based on a clinical practice guideline improves compliance with care standards,"PURPOSE: Clinical guidelines are designed to assist in the management of specific diseases""; however, these guidelines are often neglected in the delivery of care. The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having, at the patient visit, a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient's electronic medical record. SUBJECTS AND METHODS: In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed;"" data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care. RESULTS: Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group. CONCLUSION: Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care.",0,1,
435,"Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.","Study objective Emergency physicians prescribe several discharge medications that require dosage adjustment for patients with renal disease. The hypothesis for this research was that decision support in a computerized physician order entry system would reduce the rate of excessive medication dosing for patients with renal impairment.  Methods This was a randomized, controlled trial in an academic emergency department (ED), in which computerized physician order entry was used to write all prescriptions for patients being discharged from the ED. The sample included 42 physicians who were randomized to the intervention (21 physicians) or control (21 physicians) group. The intervention was decision support that provided dosing recommendations for targeted medications for patients aged 18 years and older when the patient's estimated creatinine clearance level was below the threshold for dosage adjustment. The primary outcome was the proportion of targeted medications that were excessively dosed.  Results For 2,783 (46%) of the 6,015 patient visits, the decision support had sufficient information to estimate the patient's creatinine clearance level. The average age of these patients was 46 years, 1,768 (64%) were women, and 1,523 (55%) were black. Decision support was provided 73 times to physicians in the intervention group, who excessively dosed 31 (43%) prescriptions. In comparison, control physicians excessively dosed a significantly larger proportion of medications: 34 of 46, 74% (effect size=31%; 95% confidence interval 14% to 49%;"" P=.001).  Conclusion Emergency physicians often prescribed excessive doses of medications that require dosage adjustment for renal impairment. Computerized physician order entry with decision support significantly reduced excessive dosing of targeted medications.",1,1,
436,"Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial.","OBJECTIVES: To evaluate the effectiveness of computer-assisted decision support in reducing potentially inappropriate prescribing to older adults.  DESIGN: Randomized, controlled trial.  SETTING: An academic emergency department (ED) in Indianapolis, Indiana, where computerized physican order entry was used to write all medication prescriptions.  PARTICIPANTS: Sixty-three emergency physicians were randomized to the intervention (32 physicians) or control (31 physicians) group.  INTERVENTION: Decision support that advised against use of nine potentially inappropriate medications and recommended safer substitute therapies.  MEASUREMENTS: The primary outcome was the proportion of ED visits by seniors that resulted in one or more prescriptions for an inappropriate medication. The main secondary outcomes were the proportions of medications prescribed that were inappropriate and intervention physicians' reasons for rejecting the decision support.  RESULTS: The average age of the patients was 74, two-thirds were female, and just over half were African American. Decision support was provided 114 times to intervention physicians, who accepted 49 (43%) of the recommendations. Intervention physicians prescribed one or more inappropriate medications during 2.6% of ED visits by seniors, compared with 3.9% of visits managed by control physicians (P=.02;"" odds ratio=0.55, 95% confidence interval=0.34–0.89). The proportion of all prescribed medications that were inappropriate significantly decreased from 5.4% to 3.4%. The most common reason for rejecting decision support was that the patient had no prior problems with the medication.  CONCLUSION: Computerized physican order entry with decision support significantly reduced prescribing of potentially inappropriate medications for seniors. This approach might be used in other efforts to improve ED care.Trial Registration: Clinical trials.gov Identifier: NCT00297869.",1,1,
437,Computerized reminders to encourage cervical screening in family practice.,"In a randomized trial three ways of increasing rates of cervical screening were compared for women attending a family medicine center. Working from computerized medical records, 1,587 women aged 18 to 35 years who were overdue for a screening test were included in the study. In a control group, no formal method was used to encourage patients to attend for screening, and 13.7 percent obtained a test within the trial year. In one intervention group the physician was issued a message identifying those women visiting the center for a routine appointment who were due for screening"";"" 16.1 percent were screened. Sending a letter to patients in a second group yielded a 25.9 percent compliance rate. In a third group the practice nurse called patients on the telephone to advise them to obtain the test, and 20.0 percent complied. Reminders issued to the physician provide a low-cost, opportunistic approach to reach women who happen to visit the practice, but this approach should be supplemented by telephoning or sending a letter to those women who do not attend regularly.",0,1,
438,Conducting research in community-based care facilities: ethical and regulatory implications,"Successful research in community-based care settings requires collaboration between facility staff and researchers. The ethical conduct of research involves respect for persons, beneficence, and justice. Research must comply with specific federal regulations and state laws. Interviews with 15 community-based care facility administrators revealed differences in understanding how research is regulated and the influence that research might have when a facility provides access to researchers. A Facility Bill of Rights describes principles related to the ethical conduct of research and questions to consider when deciding whether to provide researchers with access to a facility.",0,0,
439,Confidentiality and research,,0,0,
440,Congenital rubella syndrome burden in Morocco: a rapid retrospective assessment,"BackgroundWHO recommends that countries considering introduction of rubella vaccine into their immunisation programme assess their burden of congenital rubella syndrome, to determine whether vaccination is warranted. However, few guidelines exist for such assessments in developing countries. We retrospectively estimated the burden of congenital rubella syndrome in Morocco, and assessed our methods of rapid case finding."";"" BackgroundWHO recommends that countries considering introduction of rubella vaccine into their immunisation programme assess their burden of congenital rubella syndrome, to determine whether vaccination is warranted. However, few guidelines exist for such assessments in developing countries. We retrospectively estimated the burden of congenital rubella syndrome in Morocco, and assessed our methods of rapid case finding.",0,0,
441,Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders,"BACKGROUND: For patients with psychiatric illnesses remaining refractory to 'standard' therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups. METHODS: To expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments. FINDINGS: The proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered 'established' in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients. INTERPRETATION: This consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.",0,0,
442,Consensus statement on panic disorder from the International Consensus Group on Depression and Anxiety,"OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in panic disorder and guide clinical practice with recommendations for appropriate pharmacotherapy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Four faculty invited by the chairman also participated: David S. Baldwin, Johan A. den Boer, Siegfried Kasper, and M. Katherine Shear. EVIDENCE: The consensus statement is based on the 6 review papers that are published in this supplement and on the scientific literature relevant to these issues. CONSENSUS PROCESS: There were group meetings held during a 2-day period. On day 1, the group discussed each review paper and the chairman and discussant (Dr. Kasper) identified key issues for further debate. On day 2, the group discussed these key issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chairman and approved by all attendees. CONCLUSIONS: The consensus statement provides standard definitions for response and remission and identifies appropriate strategy for the management of panic disorder in a primary care setting. Serotonin selective reuptake inhibitors are recommended as drugs of first choice with a treatment period of 12 to 24 months. Pharmacotherapy should be discontinued slowly over a period of 4 to 6 months.",0,0,
443,Conservation of resources theory and research use in health systems,"Background Health systems face challenges in using research evidence to improve policy and practice. These challenges are particularly evident in small and poorly resourced health systems, which are often in locations (in Canada and globally) with poorer health status. Although organizational resources have been acknowledged as important in understanding research use resource theories have not been a focus of knowledge translation (KT) research. What resources, broadly defined, are required for KT and how does their presence or absence influence research use?  In this paper, we consider conservation of resources (COR) theory as a theoretical basis for understanding the capacity to use research evidence in health systems. Three components of COR theory are examined in the context of KT. First, resources are required for research uptake. Second, threat of resource loss fosters resistance to research use. Third, resources can be optimized, even in resource-challenged environments, to build capacity for KT.  Methods A scan of the KT literature examined organizational resources needed for research use. A multiple case study approach examined the three components of COR theory outlined above. The multiple case study consisted of a document review and key informant interviews with research team members, including government decision-makers and health practitioners through a retrospective analysis of four previously conducted applied health research studies in a resource-challenged region.  Results The literature scan identified organizational resources that influence research use. The multiple case study supported these findings, contributed to the development of a taxonomy of organizational resources, and revealed how fears concerning resource loss can affect research use. Some resources were found to compensate for other resource deficits. Resource needs differed at various stages in the research use process.  Conclusions COR theory contributes to understanding the role of resources in research use, resistance to research use, and potential strategies to enhance research use. Resources (and a lack of them) may account for the observed disparities in research uptake across health systems. This paper offers a theoretical foundation to guide further examination of the COR-KT ideas and necessary supports for research use in resource-challenged environments.",0,0,
444,Consultation training of nurses for cardiovascular prevention - a randomized study of 2 years duration,"The aim of this study was to increase patients' adherence to the treatment of hypertension through the consultation training of nurses. Thirty-three nurses were included in the study. In the intervention group (IG), 19 nurses took part in a 3-day residential training course on the Stages of Change model, Motivational Interviewing and guidelines for cardiovascular prevention, and recruited 153 patients. Sixteen nurses in the control group (CG) recruited 59 patients. A decrease in systolic and diastolic blood pressure and total cholesterol was noticed in both groups over the 2 years. Heart rate (p = 0.027), body mass index (p = 0.019), weight (p = 0.0001), waist (p = 0.041), low-density lipoprotein-cholesterol (p = 0.0001), the waist-hip ratio (p = 0.024), and perceived stress (p = 0.001) decreased to any great extent only in the IG. After 2 years, 52.6% of the patients in the IG (p = 0.13) reached the target of </= 140/90 mmHg in blood pressure compared with 39.2% in the CG. For self-reported physical activity, there was a significant (p = 0.021) difference between the groups. The beneficial effects of the consultation training on patients' weight parameters, physical activity, perceived stress and the proportion of patients who achieved blood pressure control emphasize consultation training and the use of behavioural models in motivating patients to adhere to treatment.",0,0,
445,Consumer satisfaction among patients and their general practitioners about involving nurse specialists in primary care for patients with urinary incontinence,"BACKGROUND: Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs). METHODS: Patients' satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self-completed questionnaire. GPs' views on the involvement of nurse specialists were measured in a structured telephone interview. RESULTS: The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1-10), vs. 6.7 for care-as-usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2. CONCLUSIONS: Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI-specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.",0,0,
446,"Contemporary challenges in education for the caring professions: education for nursing, midwifery, and health visiting",,0,0,
447,Contemporary perspectives in tobacco cessation: what oncologists need to know,"Within the last 5 years there has been a large outgrowth of smoking cessation research, largely encouraged by the release of the 1996 Clinical Practice Guidelines for Treating Tobacco Use and Dependence. These federal guidelines published by the Agency for Healthcare Policy and Research offered comprehensive empirical evidence that tobacco cessation interventions are effective and encouraged routine implementation within medical settings. Since that time, numerous studies in tobacco cessation have augmented the state of knowledge regarding successful smoking intervention modalities. Unfortunately, approximately one-third of cancer-related deaths continue to be attributed to smoking behaviors. It is imperative that health care providers encourage and participate in the smoking cessation efforts of their patients and family members. This article provides a review of the current literature in smoking cessation and describes first-line therapies with proven effectiveness in tobacco cessation. Clinicians are encouraged to consistently screen for tobacco use and provide brief interventions utilizing behavioral counseling and pharmacotherapies to treat their patients' tobacco dependence.",0,0,
448,Contingency management to induce exercise among college students.,"Objective: The effects of contingency management to induce physical activity levels were examined in seven non-obese physically inactive undergraduate students by providing monetary payments using a multiple baseline, changing-criterion procedure. Methods: Participants attended a baseline phase, a subsequent intervention phase consisting of three exercise sessions per week for 4 weeks, and a follow-up session 2 weeks post intervention. A total of $145 was available for attendance and exercise contingency payments. Results: Results indicate that all participants significantly increased exercise during intervention from inactivity at baseline to exercising three 30-minute sessions per week. Participants maintained some gains during follow-up. Limitations: The study employed a small and homogenous sample size and required participants to exercise in a lab setting thus limiting external validity. Conclusions: These findings suggest that incentive-based interventions are an effective and viable means for inducing exercise. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
449,Continued driving habits of patients diagnosed with excessive daytime sleepiness,"OBJECTIVE: Description of driving behaviour of patients with excessive daytime sleepiness (EDS) and the influence on their driving of diagnosis, therapy, legal guidelines and advices. DESIGN: Inventory based on questionnaires. SETTING: Centre for Sleep and Wake Disorders, The Hague, the Netherlands. METHODS: All patients with EDS who were in a stable condition for at least 6 months after therapy were sent a questionnaire (n = 138). The questions concerned actual driving behaviour, EDS and the effects of diagnosis, therapy and advice given by the Centre. RESULTS: The response was 67% (n = 92). Eighteen patients had never driven a car. Eighteen of the other 74 patients quit driving or drove less. Fifty-six patients did not change their behaviour or drove even more. There was little effect on driving behaviour of diagnosis, therapy and advice to stop driving. CONCLUSION: Patients with EDS often participate as drivers in modern traffic. Legal guidelines and advice given by physicians have only little influence on this behaviour. As general measures seem to be ineffective, approaches tailored to the individual patient may lead to more acceptable results.",0,0,
450,Controlled trial of an audit facilitatorin diagnosis and treatment of childhood asthma in general practice.,"Objective: To test whether an audit facilitator could alter the pattern of diagnosis and treatment of childhood asthma.  Design: Randomised stratified controlled trial.  Setting: 12 general practices in Tayside.  Subjects: 3373 children aged 1-15 inclusive who had symptoms suggestive of asthma or possible asthma drawn from a systematic review of 10 725 general practice case records.  Intervention: Children were targeted for a clinical review by their general practitioner or practice nurses.  Main outcome measures: Asthma related consultations, precriptions, hospital attendances, and health service costs 12 months before and after study.  Results: Compared with controls (n=1563) the intervention group (n=1585) had more practice initiated consultations for asthma (relative risk 2.18 (95% confidence interval 1.74 to 2.73)), new diagnoses of asthma (2.83 (2.26 to 3.54)), and past diagnoses reaffirmed (1.30 (1.08 to 1.58)), and they were more frequently prescribed inhaled cromoglycate (1.52 (1.02 to 2.25)). Hospital inpatient day rates fell from 152 to 122 in the intervention group and rose from 69 to 117 in the control group between the year before and the year after study. Total primary care costs rose from pounds sterling30118 to pounds sterling37243 in the intervention group and fell from pounds sterling29131 to pounds sterling27990 in the control group. Hospital care cost fell in the intervention group from pounds sterling25406 to pounds sterling20727 and rose in the control group from pounds sterling12699 to pounds sterling19650.  Conclusion: An audit facilitator can favourably influence the pattern of diagnosis and treatment of childhood asthma in general practice. This may have an impact on health service costs.",0,1,
451,Controlling conflicts of interest in the doctor-patient relationship: lessons from Moore v. Regents of the University of California,,0,0,
452,Cooperation between the occupational health insurance and physicians practicing occupational dermatology: optimization potential in quality assurance,"BACKGROUND: Quality assurance is a task of the medical profession, but it is also a duty of the occupational health insurance (OHI). Data on the interaction quality between physicians practicing occupational dermatology and the OHI are limited. MATERIAL AND METHODS: An online survey was performed in 854 German members of the Working Group on Occupational and Environmental Dermatology in October 2013. Items included demographic data, a judgment on the cooperation between the dermatologists and OHI companies, an economic grading of the current compensation scheme, and prioritization of optimization tasks. RESULTS: 182 members (21.3 % of the invited population) participated in the survey. The cooperation with the OHI companies was judged as ""very good"" by 10.8 %, as ""good"" by 56.7 %, as ""satisfactory"" by 24.2 %, as ""sufficient"" by 7.0 % and as ""inadequate"" by 1.3 %. 93.4 % of the interviewed mentioned problems and improvement potentials in the cooperation of their practice or clinic with OHI companies. Main points of criticisms were reimbursement (44.7 %), followed by impairments of the treatment options (36.5 %) and the delay or scope of the treatment in the dermatologist's procedure (29.4 %). CONCLUSIONS: While most physicians practicing occupational dermatology give a positive judgment of their cooperation with OHI companies, quality optimization potentials exist regarding the reimbursement of dermatological services, especially regarding time-intensive counselling in the prevention of occupational skin diseases, in the enablement of diagnostic and therapeutic procedures according to current guidelines and in a timely preventive intervention to use the therapeutic window before chronification of skin diseases may occur.",0,0,
453,Core outcome measures for opioid abuse liability laboratory assessment studies in humans: IMMPACT recommendations,"A critical component in development of opioid analgesics is assessment of their abuse liability (AL). Standardization of approaches and measures used in assessing AL have the potential to facilitate comparisons across studies, research laboratories, and drugs. The goal of this report is to provide consensus recommendations regarding core outcome measures for assessing the abuse potential of opioid medications in humans in a controlled laboratory setting. Although many of the recommended measures are appropriate for assessing the AL of medications from other drug classes, the focus here is on opioid medications because they present unique risks from both physiological (e.g., respiratory depression, physical dependence) and public health (e.g., individuals in pain) perspectives. A brief historical perspective on AL testing is provided, and those measures that can be considered primary and secondary outcomes and possible additional outcomes in AL assessment are then discussed. These outcome measures include the following: subjective effects (some of which comprise the primary outcome measures, including drug liking""; physiological responses; drug self-administration behavior;"" and cognitive and psychomotor performance. Before presenting recommendations for standardized approaches and measures to be used in AL assessments, the appropriateness of using these measures in clinical trials with patients in pain is discussed.",0,0,
454,Coronary heart disease multiple risk factor reduction. Providers' perspectives,"BACKGROUND: Although primary care physicians understand the importance of preventive services for patients with multiple risk factors (MRF) for coronary heart disease, physician intervention is limited. This study investigated (1) physicians' views of challenges faced in managing patients with MRF""; (2) the counseling and management methods they utilize; and (3) possible strategies to enhance MRF intervention in the primary care setting. METHODS: Two focus groups were conducted with primary care physicians from varying settings to gain insight into these issues noted above. Each group was co-facilitated by a physician and a behavioral scientist using a previously developed semistructured interview guide. The group discussions were tape recorded and subsequently transcribed. Transcripts were analyzed using the constant comparative method for analysis. RESULTS: Physicians are challenged by knowledge limitations (contribution of individual risk factors to overall risk); limited support (guidelines, materials, and staff);"" and logistic difficulties (organizational issues, time limitations). Their approach to MRF management tends to be highly individualized with an initial preference for lifestyle change interventions rather than prescription of medications with some qualifying circumstances. Physicians favored a serial rather than a parallel approach to MRF intervention, starting with behaviors that the patient perceives as a priority. Proposed solutions to current challenges emphasize physician education and the development of innovative approaches that include physician assistance and a team approach. CONCLUSIONS: Physicians are aware of and sensitive to the complexity of MRF management for their patients and themselves. However, future MRF interventions will require nonphysician staff involvement and increased systems support.",0,0,
455,"Coronary risk factor management in primary practice in Shibuya, Tokyo","OBJECTIVES: Many large-scale clinical trials have confirmed that coronary risk factors such as hypertension, hyperlipidemia and diabetes mellitus predict a higher incidence of cardiovascular events and that control of these risk factors reduces the incidence. However, the actual management of such risk factors and the resultant improvement of the cardiovascular events in primary practice remains unclear. The Heart Care Network Shibuya, a voluntary study group of regional primary physicians, surveyed the management of coronary risk factors and the clinical outcomes. METHODS: Behavioral patterns of the coronary risk factor was investigated in the management and resultant changes of the risk factors in 209 outpatients (mean age 65.6 +/- 11.2 years) with more than one of hypertension, hyperlipidemia, diabetes mellitus or prior myocardial infarction for 1 year. RESULTS: Prescriptions of anti-hypertensive (from 1.3 +/- 0.8 to 1.4 +/- 0.8 drugs per patient) and antihyperlipidemia drugs (from 0.70 +/- 0.4 to 0.73 +/- 0.4 drugs per patient) did not significantly increase. Patient education for diet (93% to 97%, p = 0.077), exercise (69% to 81%, p < 0.05) and nonsmoking (66% to 86%, p < 0.05) significantly increased after 1 year. Blood pressure decreased from 142 +/- 16/81 +/- 10 to 138 +/- 78/78 +/- 9 mmHg (p < 0.05), serum total cholesterol level decreased from 215 +/- 39 to 203 +/- 39 mg/dl (p < 0.05). As a result, more patients attained the treatment goals recommended in the guidelines by the Japanese Society of Hypertension (34.6% to 46.8%) and Japan Atherosclerosis Society (40.2% to 49.5%), respectively. However, none of blood hemoglobin A1c level, body mass index or smokers significantly changed. CONCLUSIONS: Regional practitioners attempted to control all coronary risk factors. Hypertension and hyperlipidemia, which are relatively more dependent on the medical management, improved. In contrast, diabetes mellitus, obesity or smoking, which require life style changes, did not improve. The main issue in the risk factor management is how physicians act rather than specific actions.",0,0,
456,Cost consequences of implementing an electronic decision support system for ordering laboratory tests in primary care: evidence from a controlled prospective study in the Netherlands,"BACKGROUND: The economic consequences of interventions to promote rational, evidence-based use of laboratory tests by physicians are not yet fully understood. We evaluated the cost consequences of a computer-based, guideline-driven decision-support system (CDSS) for ordering blood tests in primary care. METHODS: We installed the CDSS in 118 practices [159 general practitioners (GPs)] throughout The Netherlands and calculated the costs of the intervention in this group. During a period of 6 months before and 6 months after installation of the CDSS, the test-ordering behavior of 87 (109 GPs) of these 118 study practices was studied and the results were compared with those of a nonhistorical control group that did not receive the CDSS. In addition the costs of laboratory requests were calculated for both groups. RESULTS: Total intervention costs, comprising development costs and installation costs, amounted to 79,000 euro (670 euro per practice). Whereas the introduction of the CDSS did not affect the number of order forms submitted to the laboratories, it did reduce the number of blood tests per order form. As a result, the CDSS yielded mean savings on the costs of laboratory requests of 847 euro per practice per 6 months. CONCLUSIONS: This study demonstrates that providing electronic decision support for ordering blood tests in primary care represents an economically promising concept. Savings on laboratory costs are achievable and not offset by disproportionally high intervention costs.",1,1,
457,Cost effectiveness of a clinical decision support system based on the recommendations of the European Society of Cardiology and other societies for the management of hypercholesterolemia: report of a cluster-randomized trial.,"Introduction and objectives To assess the cost effectiveness of a clinical decision support system (CDSS) based on the recommendations of the European Society of Cardiology and other societies for Hypercholesterolemia Management (ESCHM).  Study design and perspective A cluster-randomized, unblinded, pragmatic trial was conducted. To assess the impact in effectiveness and costs of a CDSS implementing an adapted version of the ESCHM recommendations, a parallel comparison with a usual care group was carried out over 1 year. The recruitment period started in April 2000 and ended 1 year later. Effectiveness was defined as the achievement of the low-density lipoprotein-cholesterol (LDL-C) reduction goals in patients with initial cardiovascular risk (CVR) >20% over 10 years (the goals being LDL-C <115 mg/dL for patients with coronary heart disease [CHD], or LDL-C <130 mg/dL for patients without CHD), or keeping CVR <20% at study end in patients with initial CVR <20%. The costs of treatments, visits, and laboratory assessments were estimated from the social perspective (year of costing 2002).  Methods The ESCHM guidelines adapted by a steering committee included therapeutic recommendations directed to achieve LDL-C objectives in a cost-effective manner. To promote healthy cardiovascular lifestyles, items such as table cloths and magnets for the refrigerator (with relevant promotional messages) were distributed to intervention practices. All study physicians recorded the patients’ data in a specific-purpose application installed on their computer. In the case of intervention physicians, the CDSS was installed as an additional module of this application and they were requested to use it but were otherwise free to adopt or ignore the recommendations. Adherence to the guideline was monitored by the CDSS. Patients with hypercholesterolemia were selected from 44 general practices in Spain, mainly in the Catalonia region.  Main outcome measures and results 2221 patients were included in the study (1161 in usual care group and 1060 in the intervention group). The intervention was shown to be as effective as usual care, both in an unadjusted analysis and after adjusting for absolute CVR and previous treatment with lipid-lowering drugs (LLDs) [odds ratio (OR) 1.02; 95% CI 0.58, 1.77]. The intervention had no impact on lipid profiles. Intervention patients were prescribed LLDs less frequently than usual care patients (OR = 0.37; 95% CI 0.26, 0.52;"" p = 0.0001), particularly when CVR was low. This induced important savings in treatments (p = 0.0001) and total costs (p = 0.001), which were estimated as 24.9% and 20.8%, respectively. The intervention increased the number of laboratory analyses. The recommendations issued by the CDSS were accepted in 71.3% of the visits.  Discussion and conclusions The CDSS based on the recommendations of the ESCHM did not modify the effectiveness of usual care but induced considerable savings.",0,1,
458,Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial,"OBJECTIVE To assess whether the START (STrAtegies for RelatTives) intervention added to treatment as usual is cost effective compared with usual treatment alone. DESIGN Cost effectiveness analysis nested within a pragmatic randomised controlled trial. SETTING Three mental health and one neurological outpatient dementia service in London and Essex, UK. PARTICIPANTS Family carers of people with dementia. INTERVENTION Eight session, manual based, coping intervention delivered by supervised psychology graduates to family carers of people with dementia added to usual treatment, compared with usual treatment alone. PRIMARY OUTCOME MEASURES Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score (HADS-T) of affective symptoms and quality adjusted life years (QALYs) in cost effectiveness analyses over eight months from baseline. RESULTS Of the 260 participants recruited to the study, 173 were randomised to the START intervention, and 87 to usual treatment alone. Mean HADS-T scores were lower in the intervention group than the usual treatment group over the 8 month evaluation period (mean difference -1.79 (95% CI -3.32 to -0.33)), indicating better outcomes associated with the START intervention. There was a small improvement in health related quality of life as measured by QALYs (0.03 (-0.01 to 0.08)). Costs were no different between the intervention and usual treatment groups (£252 (-28 to 565) higher for START group). The cost effectiveness calculations suggested that START had a greater than 99% chance of being cost effective compared with usual treatment alone at a willingness to pay threshold of £30,000 per QALY gained, and a high probability of cost effectiveness on the HADS-T measure. CONCLUSIONS The manual based coping intervention START, when added to treatment as usual, was cost effective compared with treatment as usual alone by reference to both outcome measures (affective symptoms for family carers, and carer based QALYs). TRIAL REGISTRATION ISCTRN 70017938.",0,0,
459,Cost effectiveness of strategies to combat neuropsychiatric conditions in sub-Saharan Africa and South East Asia: mathematical modelling study,"OBJECTIVE To assess the comparative costs and effects of interventions to combat five neuropsychiatric conditions (schizophrenia, bipolar disorder, depression, epilepsy, and heavy alcohol use). DESIGN Cost effectiveness analysis based on an epidemiological model. SETTING Two epidemiologically defined World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE)""; and countries in South East Asia with high adult and high child mortality (SearD). DATA SOURCES Published studies, costing databases. MAIN OUTCOME MEASURES Cost per capita and cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005. RESULTS Across 44 assessed intervention strategies for the five neuropsychiatric conditions, cost effectiveness values differed by as much as two orders of magnitude (from $Int100-250 to $Int10,000-25,000 for a year of healthy life gained). In both sub-regions, inpatient based treatment of schizophrenia with newer antipsychotic drugs was the most costly and least cost effective strategy. The most cost effective strategies in the African sub-region related to population based alcohol control, while in the South East Asian sub-region the most cost effective intervention was drug treatment of epilepsy in primary care. The cumulative cost per capita of the most cost effective set of interventions covering all five conditions was estimated at $Int4.90-5.70. This package comprises interventions for epilepsy (older first line antiepileptic drugs); depression (generically produced newer antidepressants and psychosocial treatment); bipolar disorder (mood stabiliser drug lithium); schizophrenia (neuroleptic antipsychotic drugs and psychosocial treatment);"" and heavy alcohol use (increased taxation and its enforcement, reduced access, and, in the African sub-region, advertising bans and brief advice to heavy drinkers in primary care). CONCLUSIONS Reallocation of resources to cost effective intervention strategies would increase health gain, save money and help implement much needed expansion of services for neuropsychiatric conditions in low resource settings.",0,0,
460,Cost effectiveness of strategies to combat vision and hearing loss in sub-Saharan Africa and South East Asia: mathematical modelling study,"OBJECTIVE To determine the relative costs, effects, and cost effectiveness of selected interventions to control cataract, trachoma, refractive error, hearing loss, meningitis and chronic otitis media. DESIGN Cost effectiveness analysis of or combined strategies for controlling vision and hearing loss by means of a lifetime population model. SETTING Two World Health Organization sub-regions of the world where vision and hearing loss are major burdens: sub-Saharan Africa and South East Asia. DATA SOURCES Biological and behavioural parameters from clinical and observational studies and population based surveys. Intervention effects and resource inputs based on published reports, expert opinion, and the WHO-CHOICE database. MAIN OUTCOME MEASURES Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005. RESULTS Treatment of chronic otitis media, extracapsular cataract surgery, trichiasis surgery, treatment for meningitis, and annual screening of schoolchildren for refractive error are among the most cost effective interventions to control hearing and vision impairment, with the cost per DALY averted <$Int285 in both regions. Screening of both schoolchildren (annually) and adults (every five years) for hearing loss costs around $Int1000 per DALY averted. These interventions can be considered highly cost effective. Mass treatment with azithromycin to control trachoma can be considered cost effective in the African but not the South East Asian sub-region. CONCLUSIONS Vision and hearing impairment control interventions are generally cost effective. To decide whether substantial investments in these interventions is warranted, this finding should be considered in relation to the economic attractiveness of other, existing or new, interventions in health.",0,0,
461,Cost-effectiveness of a nurse-based intervention (AIMS) to improve adherence among HIV-infected patients: design of a multi-centre randomised controlled trial.,"Background Non-adherence to HIV-treatment can have a negative impact on patients’ treatment success rates, quality of life, infectiousness, and life expectancy. Few adherence interventions have shown positive effects on adherence and/or virologic outcomes. The theory- and evidence-based Adherence Improving self-Management Strategy (AIMS) is an intervention that has been demonstrated to improve adherence and viral suppression rates in a randomised controlled trial. However, evidence of its cost-effectiveness is lacking. Following a recent review suggesting that cost-effectiveness evaluations of adherence interventions for chronic diseases are rare, and that the methodology of such evaluations is poorly described in the literature, this manuscript presents the study protocol for a multi-centre trial evaluating the effectiveness and cost-effectiveness of AIMS among a heterogeneous sample of patients.  Methods/design The study uses a multi-centre randomised controlled trial design to compare the AIMS intervention to usual care from a societal perspective. Embedded in this RCT is a trial-based and model-based economic evaluation. A planned number of 230 HIV-infected patients are randomised to receive either AIMS or usual care. The relevant outcomes include changes in adherence, plasma viral load, quality of life, and societal costs. The time horizon for the trial-based economic evaluation is 12–15 months. Costs and effects are extrapolated to a lifetime horizon for the model-based economic evaluation.  Discussion The present multicentre RCT is designed to provide sound methodological evidence regarding the effectiveness and cost-effectiveness of a nurse-based counselling intervention (AIMS) to support treatment adherence among a large and heterogeneous sample of HIV-infected patients in the Netherlands. The objective of the current paper is to describe the trial protocol in sufficient detail to allow full evaluation of the quality of the study design. It is anticipated that, if proven cost-effective, AIMS can contribute to improved evidence-based counselling guidelines for HIV-nurses and other health care professionals.",0,1,
462,Cost-effectiveness of alternative strategies for the initial medical management of non-ST elevation acute coronary syndrome: systematic review and decision-analytical modelling,"OBJECTIVES: To identify and prioritise key areas of clinical uncertainty regarding the medical management of non-ST elevation acute coronary syndrome (ACS) in current UK practice. DATA SOURCES: Electronic databases. Consultations with clinical advisors. Postal survey of cardiologists. REVIEW METHODS: Potential areas of important uncertainty were identified and 'decision problems' prioritised. A systematic literature review was carried out using standard methods. The constructed decision model consisted of a short-term phase that applied the results of the systematic review and a long-term phase that included relevant information from a UK observational study to extrapolate estimated costs and effects. Sensitivity analyses were undertaken to examine the dependence of the results on baseline parameters, using alternative data sources. Expected value of information analysis was undertaken to estimate the expected value of perfect information associated with the decision problem. This provided an upper bound on the monetary value associated with additional research in the area. RESULTS: Seven current areas of clinical uncertainty (decision problems) in the drug treatment of unstable angina patients were identified. The agents concerned were clopidogrel, low molecular weight heparin, hirudin and intravenous glycoprotein antagonists (GPAs). Twelve published clinical guidelines for unstable angina or non-ST elevation ACS were identified, but few contained recommendations about the specified decision problems. The postal survey of clinicians showed that the greatest disagreement existed for the use of small molecule GPAs, and the greatest uncertainty existed for decisions relating to the use of abciximab (a large molecule GPA). Overall, decision problems concerning the GPA class of drugs were considered to be the highest priority for further study. Selected papers describing the clinical efficacy of treatment were divided into three groups, each representing an alternative strategy. The strategy involving the use of GPAs as part of the initial medical management of all non-ST elevation ACS was the optimal choice, with an incremental cost-effectiveness ratio (ICER) of 5738 pounds per quality-adjusted life-year (QALY) compared with no use of GPAs. Stochastic analysis showed that if the health service is willing to pay 10,000 pounds per additional QALY, the probability of this strategy being cost-effective was around 82%, increasing to 95% at a threshold of 50,000 pounds per QALY. A sensitivity analysis including an additional strategy of using GPAs as part of initial medical management only in patients at particular high risk (as defined by age, ST depression or diabetes) showed that this additional strategy was yet more cost-effective, with an ICER of 3996 pounds per QALY compared with no treatment with GPA. Value of information analysis suggested that there was considerable merit in additional research to reduce the level of uncertainty in the optimal decision. At a threshold of 10,000 pounds per QALY, the maximum potential value of such research in the base case was calculated as 12.7 million pounds per annum for the UK as a whole. Taking account of the greater uncertainty in the sensitivity analyses including clopidogrel, this figure was increased to approximately 50 million pounds. CONCLUSIONS: This study suggests the use of GPAs in all non-ST elevation ACS patients as part of their initial medical management. Sensitivity analysis showed that virtually all of the benefit could be realised by treating only high-risk patients. Further clarification of the optimum role of GPAs in the UK NHS depends on the availability of further high-quality observational and trial data. Value of information analysis derived from the model suggests that a relatively large investment in such research may be worthwhile. Further research should focus on the identification of the characteristics of patients who benefit most from GPAs as part of medical management, the comparison of GPAs with clopidogrel as an adjunct to standard care, follow-up cohort studies of the costs and outcomes of high-risk non-ST elevation ACS over several years, and exploring how clinicians' decisions combine a normative evidence-based decision model with their own personal behavioural perspective.",0,0,
463,Cost-effectiveness of cognitive-behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial,"BACKGROUND: Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication. AIMS: To assess the cost-effectiveness of cognitive-behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone. METHOD: Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs). RESULTS: The mean cost of CBT per participant was pound910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was pound14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of pound20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups. CONCLUSIONS: The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT.",0,0,
464,Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review,"Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.",0,0,
465,Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States,"Background:The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear.Objective:To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID.Design:Empirically calibrated dynamic compartmental model.Data Sources:Published literature and expert opinion.Target Population:Adult U.S. PWID.Time Horizon:20 years and lifetime.Intervention:PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage.Outcome Measures:Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.Results of Base-Case Analysis:PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years.Results of Sensitivity Analysis:Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence.Limitation:Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited.Conclusion:PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained.",0,0,
466,Cost-effectiveness of Practice-Initiated Quality Improvement for Depression,"Context Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.  Objective To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.  Design Group-level randomized controlled trial conducted June 1996 to July 1999.  Setting Forty-six primary care clinics in 6 community-based managed care organizations.  Participants One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.  Interventions Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds""; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.  Main Outcome Measures Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.  Results Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P = .35) and $485 (13%) in QI-therapy (P = .28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy;"" and patients had 25 (P = .19) and 47 (P = .01) fewer days with depression burden and were employed 17.9 (P = .07) and 20.9 (P = .03) more days during the study period.  Conclusions Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.",0,0,
467,Costs associated with implementation of computer-assisted clinical decision support system for antenatal and delivery care: case study of Kassena-Nankana district of northern Ghana,"OBJECTIVE: This study analyzed cost of implementing computer-assisted Clinical Decision Support System (CDSS) in selected health care centres in Ghana. METHODS: A descriptive cross sectional study was conducted in the Kassena-Nankana district (KND). CDSS was deployed in selected health centres in KND as an intervention to manage patients attending antenatal clinics and the labour ward. The CDSS users were mainly nurses who were trained. Activities and associated costs involved in the implementation of CDSS (pre-intervention and intervention) were collected for the period between 2009-2013 from the provider perspective. The ingredients approach was used for the cost analysis. Costs were grouped into personnel, trainings, overheads (recurrent costs) and equipment costs (capital cost). We calculated cost without annualizing capital cost to represent financial cost and cost with annualizing capital costs to represent economic cost. RESULTS: Twenty-two trained CDSS users (at least 2 users per health centre) participated in the study. Between April 2012 and March 2013, users managed 5,595 antenatal clients and 872 labour clients using the CDSS. We observed a decrease in the proportion of complications during delivery (pre-intervention 10.74% versus post-intervention 9.64%) and a reduction in the number of maternal deaths (pre-intervention 4 deaths versus post-intervention 1 death). The overall financial cost of CDSS implementation was US$23,316, approximately US$1,060 per CDSS user trained. Of the total cost of implementation, 48% (US$11,272) was pre-intervention cost and intervention cost was 52% (US$12,044). Equipment costs accounted for the largest proportion of financial cost: 34% (US$7,917). When economic cost was considered, total cost of implementation was US$17,128-lower than the financial cost by 26.5%. CONCLUSIONS: The study provides useful information in the implementation of CDSS at health facilities to enhance health workers' adherence to practice guidelines and taking accurate decisions to improve maternal health care.",0,0,
468,"Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba, Peru and Bolivia?","OBJECTIVES: To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis"";"" and to understand the contextual factors which impede or facilitate its success. METHODS: Twenty-six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six-month periods pre- and post-intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals' clinical behaviour after the introduction of clinical audit. RESULTS: We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients' attitudes towards illness. CONCLUSIONS: Clinical audit may drive improvements in the quality of clinical care in resource-poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.",0,0,
469,Counseling African Americans to Control Hypertension (CAATCH) trial: a multi-level intervention to improve blood pressure control in hypertensive blacks,"Despite strong evidence of effective interventions targeted at blood pressure (BP) control, there is little evidence on the translation of these approaches to routine clinical practice in care of hypertensive blacks. The goal of this study is to evaluate the effectiveness of a multilevel, multicomponent, evidence-based intervention compared with usual care in improving BP control among hypertensive blacks who receive care in community health centers. The primary outcomes are BP control rate at 12 months and maintenance of intervention 1 year after the trial. The secondary outcomes are within-patient change in BP from baseline to 12 months and cost-effectiveness of the intervention. Counseling African Americans to Control Hypertension (CAATCH) is a group randomized clinical trial with 2 conditions: intervention condition and usual care. Thirty community health centers were randomly assigned equally to the intervention condition group (n=15) or the usual care group (n=15). The intervention comprises 3 components targeted at patients (interactive computerized hypertension education, home BP monitoring, and monthly behavioral counseling on lifestyle modification) and 2 components targeted at physicians (monthly case rounds based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, chart audit and provision of feedback on clinical performance and patients' home BP readings). All outcomes are assessed at quarterly study visits for 1 year. Chart review is conducted at 24 months to evaluate maintenance of intervention effects and sustainability of the intervention. Poor BP control is one of the major reasons for the mortality gap between blacks and whites. Findings from this study, if successful, will provide salient information needed for translation and dissemination of evidence-based interventions targeted at BP control into clinical practice for this high-risk population.",0,0,
470,Counseling African Americans to Control Hypertension: cluster-randomized clinical trial main effects,"BACKGROUND: Data are limited on the implementation of evidence-based multilevel interventions targeted at blood pressure (BP) control in hypertensive blacks who receive care in low-resource primary care practices. METHODS AND RESULTS: Counseling African Americans to Control Hypertension is a cluster-randomized clinical trial in which 30 community health centers were randomly assigned to the intervention condition (IC) or usual care (UC). Patients at the IC sites received patient education, home BP monitoring, and monthly lifestyle counseling, whereas physicians attended monthly hypertension case rounds and received feedback on their patients' home BP readings and chart audits. Patients and physicians at the UC sites received printed patient education material and hypertension treatment guidelines, respectively. The primary outcome was BP control, and secondary outcomes were mean changes in systolic and diastolic BPs at 12 months, assessed with an automated BP device. A total of 1059 patients (mean age, 56 years""; 28% men, 59% obese, and 36% with diabetes mellitus) were enrolled. The BP control rate was similar in both groups (IC=49.3% versus UC=44.5%; odds ratio, 1.21 [95% confidence interval, 0.90-1.63]; P=0.21). In prespecified subgroup analyses, the intervention was associated with greater BP control in patients without diabetes mellitus (IC=54.0% versus UC=44.7%; odds ratio, 1.45 [confidence interval, 1.02-2.06]); and small-sized community health centers (IC=51.1% versus UC=39.6%;"" odds ratio, 1.45 [confidence interval, 1.04-2.45]). CONCLUSIONS: A practice-based, multicomponent intervention was no better than UC in improving BP control among hypertensive blacks. Future research on the implementation of behavioral modification strategies for hypertension control in low-resource settings should focus on the development of more efficient and tailored interventions in this high-risk population. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00233220.",0,0,
471,"Creating a sustainable, interprofessional-team training program: initial results","PURPOSE/OBJECTIVES: The purpose of this program evaluation was to explore whether incorporating deliberate learning concepts, through the use of simulated patient scenarios to teach interprofessional collaboration skills to a healthcare team on one acute-care hospital unit, would improve the resuscitation response in the first 5 minutes on that unit. DESIGN/SETTING: This was a pilot program evaluation utilizing a unit-based, clinical nurse specialist in the deployment of an interprofessional educational program involving simulation on an acute medical floor in a large tertiary-care hospital. SAMPLE: Eighty-four staff members participated in 17 simulations. The sample included first-year internal-medicine residents, registered nurses, respiratory therapists, and patient care technicians. METHODS: This was a program evaluation that used the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) (Classroom slides: TeamSTEPPS essentials""; http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructo r/essentials/slessentials.html#s3) during the presimulation/postsimulation sessions to assess the participants' perceptions of teamwork. Expected intervention behaviors were collected through observations of participants in the simulations and compared with the American Heart Association guidelines (Circulation 2010;122:S685-S670, S235-S337). Common perceptions of participants regarding the experience were obtained through open-ended evaluation questions. RESULTS: Fifty-three participants completed the pre- and post-T-TPQ. Mean scores in the leadership category of T-TPQ decreased significantly (P = .003) from the pretest (median, 2.167) to the T-TPQ posttest (median, 2.566). Only 35% of the groups administered a defibrillation during the ventricular fibrillation simulation scenario, and only 1 group delivered this shock within the American Heart Association's recommended time frame of 2 minutes (Circulation 2010;""122:S235-S337). CONCLUSION: A single resuscitation simulation was not enough interventional dosage for staff to improve the resuscitation process. A longitudinal study should be conducted to determine the effectiveness of the program after staff members have repeated the program multiple times. IMPLICATIONS: A unit-based quality-improvement simulation training program could help improve the first-5-minute response and resuscitation skills of staff by increasing the frequency of unit-based training overseen by the unit's clinical nurse specialist.",0,0,
472,Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study,"Background The built environment in acute care settings is a new focus in patient safety research, with few studies focusing primarily on the design of ward environments and the location and choice of material objects such as light fittings and hand-washing basins.  Methods We report on an interventionist video-reflexive ethnographic (VRE) study that explored how clinicians used the built environment to achieve safe communication in an intensive care unit (ICU) in a metropolitan Sydney hospital. We conducted 40 semistructured interviews, 5 weeks of observation and four reflexive focus groups with a total of 87 participants (including medical, nursing, allied health and clerical staff).  Results We found that the accessibility of staff and patients in the open spaces of the ICU was both a safety feature and a safety risk, enabling safe communication flow, but also allowing potentially unsafe interruptions. Staff managed interruptions while allowing for a safe degree of accessibility by creating temporary protected spaces, using physical markers such as curtains, tape and signs as well as behavioural cues, movement and the development of policies restricting activities at certain areas. Furthermore, clinicians were able to use the VRE method to gain insight into their own practices and problems, and to develop meaningful solutions for other problematic spaces.  Conclusions ICU staff enable safe communication in their wards by creating temporary spaces that are both ‘connected’ and ‘protected’. The flexibility of these ‘soft’ strategies is especially well suited to the fast-paced clinical context of intensive care.",0,0,
473,"Crisis intervention: A handbook of immediate person-to-person help., 4th ed.","Furnishes a framework for providing immediate problem-solving assistance to persons in crisis. As a handbook it presents core knowledge as well as methods tailored to particular circumstances. The book is intended for caregivers whose work involves regular or occasional crisis intervention efforts. It is maintained that the techniques are applicable in crisis centers, hotlines, Internet-based services, victim assistance programs, college counseling centers, hospitals, schools, correctional facilities, children and youth programs, and other social service agencies. Users of the concepts include counselors, social workers, psychologists, nurses, physicians, clergy, correctional officers, parole and probation officers, and lay volunteers. Each chapter ends with study questions. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
474,Cueing prenatal providers effects on discussions of intimate partner violence,"BACKGROUND: Intimate partner violence (IPV) during pregnancy poses a significant health risk to the mother and developing fetus. Practice guidelines recommend that prenatal providers screen for and counsel their patients about IPV, yet many physicians express reluctance or discomfort regarding such discussions. The Health in Pregnancy (HIP) computer program was designed to improve prenatal providers' counseling about behavioral risks. METHODS: English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the five participating clinics in the San Francisco area, were randomized in parallel groups in a controlled trial (June 2006-present"";"" data analyzed June 2007). Participants reporting one or more risks were randomized to intervention or control in stratified blocks. Providers received summary ""cueing sheets"" alerting them to their patient's risk(s) and suggesting counseling statements. RESULTS: Thirteen percent (37/286) of the sample reported current IPV. Provider cueing resulted in 85% of the IPV-intervention group reporting discussions with their provider, compared to 23.5% of the control group (p<0.001). CONCLUSIONS: IPV discussions were influenced strongly by cueing providers. Provider cueing is an effective and appropriate adjunct to routine risk counseling in prenatal care.",0,0,
475,Cultivation of a learning culture in general practice: an educational intervention,"BACKGROUND: Increasing challenges are faced in primary care, including the increase in chronic disease and its management in the community. This paper describes an educational initiative developed to help local general practitioners (GPs) and primary care teams manage chronic conditions and address referral behaviour. The purpose of this study was to evaluate the initiative through the exploration of the experiences of the participants and providers. METHODS: A variety of methods was used to collect data for the evaluation. These included feedback from participants in the form of workshop evaluation questionnaires, semi-structured interviews of both participants and presenters and focus groups involving participants. RESULTS: Following analysis of the data, five themes were identified across all the methods used. This paper focuses on the key themes of 'practice change' and 'referral behaviour' as they relate to the specific aims and objectives of the initiative. The data indicated that participants had identified actual changes in practice following their participation in the educational initiative, including changes in individual practice and prescribing behaviour as well as in the provision of healthcare in the community. Changes identified in referral behaviour were evident in feedback from both participants and presenters in secondary care. Participants indicated proposed changes, including an anticipated reduction in referrals for dermatology with greater management of conditions in primary care, as well as a greater awareness of indications for early referral. The use of guidelines in aiding referral decisions was identified and the content and information required from referral letters was also a key area. CONCLUSION: The evaluation of this educational initiative has identified changes in practice in primary care and demonstrates how educational interventions can support and enhance future developments in primary care.",0,0,
476,Culturally tailored interventions of chronic disease targeting Korean Americans: a systematic review,"OBJECTIVE: Because little is known about promising interventions to prevent and control chronic disease in Korean Americans, we conducted a systematic literature review to investigate: (1) theoretical frameworks and strategies employed by interventions targeting Korean Americans""; (2) cultural factors considered by these interventions;"" and (3) the extent of their success in engaging Korean participants and improving their health. DESIGN: Following the PRISMA guidelines, PubMed, PsycInfo, and Web of Science were searched to identify primary research articles evaluating interventions to prevent or control chronic disease, tailored to Korean Americans, and published from 1980 through 2011. Of 238 articles identified, 21 articles describing16 unique intervention tests met inclusion criteria. These interventions targeted cancer (10), hypertension (2), diabetes (1), mental health (1), tobacco cessation (1), and general health (1). RESULTS: All included studies were published since 2000, reflecting the relatively recent establishment of intervention research with Korean Americans. All 16 programs delivered linguistically appropriate messages and education. The 11 programs that realized significant intervention effects also provided or coordinated social support from culturally relevant and well-trained lay health workers, nurses, or family members during an intervention and/or follow-up period. CONCLUSIONS: Culturally matched and linguistically appropriate messages and education may not be enough to prevent or control chronic disease among immigrant Korean Americans. Culturally sensitive and committed social support should be provided to catalyze behavioral changes and sustain the effect of the interventions.",0,0,
477,"Current management of transitional feeding issues in preterm neonates born in Queensland, Australia","BACKGROUND: Many preterm neonates display difficulty establishing suck-feeding competence in the weeks following birth. Ineffective management of transitional feeding issues may cause patient complications, and can contribute to increased length of stay. AIMS: Given that many neonatal nurseries appear to vary in their neonatal feeding management practices, the aim of this study was to investigate and document the routine level of support and intervention currently provided for preterm neonates with transitional feeding issues across the various level II (special care) nurseries (SCNs) in Queensland, Australia. METHODS: A questionnaire was mailed to all Queensland SCNs in 2005 (n=36). The questionnaire contained a series of closed-choice and short-answer questions designed to obtain information from each SCN regarding their current practices for managing transitional feeding issues in preterm neonates. Results were confirmed during a follow-up phone call. RESULTS: Responses were obtained from 29 SCNs (80.6%). None of these nurseries reported having any formal, written policies regarding the management of transitional feeding issues in preterm neonates. Wide variations were reported in relation to the suck-feeding assessments and interventions used by staff within the various SCNs. Of the 29 nurseries, 4 (13.8%) reported using checklists or assessments to judge readiness for suck-feeds, and 5 (17.2%) reported using pulse oximetry to judge tolerance of suck-feeding attempts. Eighteen SCNs (62.1%) reported offering some form of active intervention to assist neonates with transitional feeding issues, with the most common intervention techniques reported being non-nutritive sucking during tube feeds, pre-feeding oral stimulation, and actively pacing suck-feeds. Twenty-two SCNs (75.4%) reported having access to a lactation consultant to assist mothers with breastfeeding issues. CONCLUSIONS: Differences were reported in the routine management of transitional feeding issues in preterm neonates across the various SCNs in Queensland. It is suggested that evidence based guidelines need to be developed, and that, in order to do this, further research studies are required to determine current best practice, as well as to answer remaining questions.",0,0,
478,Current patterns and future directions in the treatment of insomnia,"BACKGROUND: Despite the high prevalence and the high burden associated with chronic insomnia, it remains largely unrecognized and often inadequately treated by physicians. METHODS: A review was undertaken of the literature on barriers to both acute and chronic treatment of insomnia, as well as recent trials of pharmacologic and nonpharmacologic agents for insomnia. RESULTS: Obstacles to appropriate treatment of the condition include outdated insomnia management guidelines, which have contributed to US Food and Drug Administration restrictions on longer-term prescription of hypnotic agents""; lack of research demonstrating the benefit of treating insomnia;"" and fears of tolerance and withdrawal effects of long-term use of hypnotic agents, as well as an absence of longer-term, randomized, controlled, double-blind trials of existing agents used to treat insomnia. CONCLUSIONS: There is evidence that improved sleep may improve outcome in some medical and psychiatric illnesses. Both behavioral and pharmacologic therapies have shown efficacy in chronic insomnia. In addition, a recent 6-month, randomized, controlled study has demonstrated that at least one agent may be safe and effective in longer-term use.",0,0,
479,Curtailing laboratory test ordering in a managed care setting through redesign of a computerized order form,"OBJECTIVE: To increase appropriate use of blood tests for folic acid and vitamin B12 ordered by primary care physicians in a managed care organization in Israel through redesign of a computerized order form. STUDY DESIGN: Pre-post intervention. METHODS: A new version of the computerized order form was launched. Utilization patterns were calculated for tests of vitamin B12, folic acid, and ferritin, which were previously grouped together. Concomitant utilization patterns for tests of hemoglobin and iron were evaluated as controls. RESULTS: Tests ordered for the 3 targets decreased by 31% to 41% relative to the preintervention month, with a further decrease to 36% to 53% the following month. Negligible changes in utilization patterns were observed for the controls (-2% to 3%) during the postintervention period. CONCLUSIONS: Simple restructuring of a computerized order form significantly reduced the number of laboratory tests suspected of being unnecessary or redundant. When overutilization of laboratory resources is suspected, managers should evaluate the efficiency of the organization's current ordering procedures before implementing resource-intensive interventions.",1,1,
480,Cutaneous malignant lymphomas: update 2006,"Cutaneous lymphomas represent a unique group of lymphomas and are the second most frequent extranodal lymphomas. As with other neoplasias, the pathogenesis is based mainly on a stepwise accumulation of mutations of suppressor genes and oncogenes caused by genetic, environmental or infectious factors. The diagnostic work-up includes clinical, histological, imaging and hematological investigations and in many cases immunohistochemical and molecular biological analyses. The current WHO/EORTC classification of cutaneous lymphomas differentiates ""mature T-cell and NK-cell lymphomas"", ""mature B-cell lymphomas"" and ""immature hematopoietic malignancies"", their variants and subgroups. It is compatible with the WHO classification for neoplasias of the hematopoietic and lymphoid tissue and respects the organ-specific peculiarities of primary cutaneous lymphomas. The assignment of the various types of cutaneous lymphomas into prognostic categories (pre-lymphomatous ""abortive"" disorders""; definite malignant lymphomas of low-grade malignancy;"" definite malignant lymphomas of high-grade malignancy) provides essential information on the biological behavior and allows an appropriate planning of the therapeutic strategy, which may be topical or systemic and aggressive or non-aggressive. Besides the classical options for therapy, there are new and ""experimental"" strategies, the efficacy of which has to be studied in clinical trials.",0,0,
481,Daily co-trimoxazole prophylaxis in severely immunosuppressed HIV-infected adults in Africa started on combination antiretroviral therapy: an observational analysis of the DART cohort,"BackgroundCo-trimoxazole prophylaxis can reduce mortality from untreated HIV infection in Africa""; whether benefits occur alongside combination antiretroviral therapy (ART) is unclear. We estimated the effect of prophylaxis after ART initiation in adults.; BackgroundCo-trimoxazole prophylaxis can reduce mortality from untreated HIV infection in Africa;"" whether benefits occur alongside combination antiretroviral therapy (ART) is unclear. We estimated the effect of prophylaxis after ART initiation in adults.",0,0,
482,Decision aid for patients considering total knee arthroplasty with preference report for surgeons: a pilot randomized controlled trial,"BACKGROUND: To evaluate feasibility and potential effectiveness of a patient decision aid (PtDA) for patients and a preference report for surgeons to reduce wait times and improve decision quality in patients with osteoarthritis considering total knee replacement. METHODS: A prospective two-arm pilot randomized controlled trial. Patients with osteoarthritis were eligible if they understood English and were referred for surgical consultation about an initial total knee arthroplasty at a Canadian orthopaedic joint assessment clinic. Patients were randomized to the PtDA intervention or usual education. The intervention was an osteoarthritis PtDA for patients and a one-page preference report summarizing patients' clinical and decisional data for their surgeon. The main feasibility outcomes were rates of recruitment and questionnaire completion""; the preliminary effectiveness outcomes were wait times and decision quality. RESULTS: Of 180 patients eligible for surgical consultation, 142 (79%) were recruited and randomized to the PtDA intervention (n = 71) or usual education (n = 71). Data collection yielded a 93% questionnaire completion rate with less than 1% missing items. After one year, 13% of patients remained on the surgical wait list. The median time from referral to being off the wait list (censored using survival analysis techniques) was 33.4 weeks for the PtDA group (n = 69, 95% CI: 26.0, 41.4) and 33.0 weeks for usual education (n = 71, 95% CI: 26.1, 39.9). Patients exposed to the PtDA had higher decision quality based on knowledge (71% versus 47%; p < 0.0001) and quality decision being an informed choice that is consistent with their values for option outcomes (56.4% versus 25.0%;"" p < 0.001). CONCLUSIONS: Recruitment of patients with osteoarthritis considering surgery and data collection were feasible. As some patients remained on the surgical waiting list after one year, follow-up should be extended to two years. Patients exposed to the PtDA achieved higher decision quality compared to those receiving usual education but there was no difference in wait for surgery. TRIALS REGISTRATION: ClinicalTrials.Gov NCT00743951.",0,0,
483,Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion,"Chronic low back pain (CLBP) is one of the main causes of disability in the western world with a huge economic burden to society. As yet, no specific underlying anatomic cause has been identified for CLBP. Imaging often reveals degenerative findings of the disc or facet joints of one or more lumbar motion segments. These findings, however, can also be observed in asymptomatic people. It has been suggested that pain in degenerated discs may be caused by the ingrowth of nerve fibers into tears or clefts of the annulus fibrosus or nucleus pulposus, and by reported high levels of pro-inflammatory mediators. As this so-called discogenic pain is often exacerbated by mechanical loading, the concept of relieving pain by spinal fusion to stabilise a painful spinal segment, has been developed. For some patients lumbar spinal fusion indeed is beneficial, but its results are highly variable and hard to predict for the individual patient. To identify those CLBP patients who will benefit from fusion, many surgeons rely on tests that are assumed to predict the outcome of spinal fusion. The three most commonly used prognostic tests in daily practice are immobilization in a lumbosacral orthosis, provocative discography and trial immobilization by temporary external transpedicular fixation. Aiming for consensus on the indications for lumbar fusion and in order to improve its results by better patient selection, it is essential to know the role and value of these prognostic tests for CLBP patients in clinical practice. The overall aims of the present thesis were: 1) to evaluate whether there is consensus among spine surgeons regarding the use and appreciation of prognostic tests for lumbar spinal fusion""; 2) to verify whether a thoracolumbosacral orthosisis (TLSO) truly minimises lumbosacral motion; 3) to verify whether a TLSO can predict the clinical outcome of fusion for CLBP; 4) to assess whether provocative discography of adjacent segments actually predicts the long-term clinical outcome fusion; 5) to determine the incidence of postdiscography discitis, and whether there is a need for routine antibiotic prophylaxis; 6) to assess whether temporary external transpedicular fixation (TETF) can help to predict the outcome of spinal fusion;"" 7) to determine the prognostic accuracy of the most commonly used tests in clinical practice to predict the outcome of fusion for CLBP. The results of a national survey among spine surgeons in the Netherlands were presented in Study I. The surgeons were questioned about their opinion on prognostic factors and about the use of predictive tests for lumbar fusion in CLBP patients. The comments were compared with findings from the prevailing literature. The survey revealed a considerable lack of uniformity in the use and appreciation of predictive tests. Prognostic factors known from the literature were not consistently incorporated in the surgeons' decision making process either. This heterogeneity in strategy is most probably caused by the lack of sound scientific evidence for current predictive tests and it was concluded that currently there is not enough consensus among spine surgeons in the Netherlands to create national guidelines for surgical decision making in CLBP. In Study II, the hypothesized working mechanism of a pantaloon cast (i.e., minimisation of lumbosacral joint mobility) was studied. In patients who were admitted for a temporary external transpedicular fixation test (TETF), infrared light markers were rigidly attached to the protruding ends of Steinman pins that were fixed in two spinal levels. In this way three-dimensional motion between these levels could be analysed opto-electronically. During dynamic test conditions such as walking, a plaster cast, either with or without unilateral hip fixation, did not significantly decrease lumbosacral joint motion. Although not substantiated by sound scientific support, lumbosacral orthoses or pantaloon casts are often used in everyday practice as a predictor for the outcome of fusion. A systematic review of the literature supplemented with a prospective cohort study was performed (Study III) in order to assess the value of a pantaloon cast in surgical decision-making. It appeared that only in CLBP patients with no prior spine surgery, a pantaloon cast test with substantial pain relief suggests a favorable outcome of lumbar fusion compared to conservative treatment. In patients with prior spine surgery the test is of no value. It is believed by many spine surgeons that provocative discography, unlike plain radiographs or magnetic resonance imaging, is a physiologic test that can truly determine whether a disc is painful and relevant in a patient's pain syndrome, irrespective of the morphology of the disc. It has been suggested that in order to achieve a successful clinical outcome of lumbar fusion, suspect discs should be painful and adjacent control discs should elicit no pain on provocative discography. For this reason, a cohort of patients in whom the decision to perform lumbar fusion was based on an external fixation (TETF) trial, was analysed retrospectively in Study IV. The results of preoperative discography of solely the levels adjacent to the fusion were compared with the clinical results after spinal fusion. It appeared that in this select group of patients the discographic status of discs adjacent to a lumbar fusion did not have any effect on the clinical outcome. The most feared complication of lumbar discography is discitis. Although low in incidence, this is a serious complication for a diagnostic procedure and prevention by the use of prophylactic antibiotics has been advocated. In search for clinical guidelines, the risk of postdiscography discitis was assessed in Study V by means of a systematic literature review and a cohort of 200 consecutive patients. Without the use of prophylactic antibiotics, an overall incidence of postdiscography discitis of 0.25% was found. To prove that antibiotics would actually prevent discitis, a randomised trial of 9,000 patients would be needed to reach significance. Given the possible adverse effects of antibiotics, it was concluded that the routine use of prophylactic antibiotics in lumbar discography is not indicated. In Study VI, the middle- and long-term results of external fixation (TETF) as a test to predict the clinical outcome of lumbar fusion were studied in a group of back pain patients for whom there was doubt about the indication for surgery. The test included a placebo trial, in which the patients were unaware whether the lumbar segmental levels were fixed or dynamised. Using strict and objective criteria of pain reduction on a visual analogue scale, the TETF test failed to predict clinical outcome of fusion in this select group of patients. Pin track infection and nerve root irritation were registered as complications of this invasive test. It was concluded that in chronic low back pain patients with a doubtful indication for fusion, TETF is not recommended as a supplemental tool for surgical decision-making. In Study VII, a systematic literature review was performed regarding the prognostic accuracy of tests that are currently used in clinical practice and that are presumed to predict the outcome of lumbar spinal fusion for CLBP. The tests of interest were magnetic resonance imaging (MRI), TLSO immobilisation, TETF, provocative discography and facet joint infiltration. Only 10 studies reporting on three different index tests (discography, TLSO immobilisation and TETF) that truly reported on test qualifiers, such as sensitivity, specificity and likelihood ratios, could be selected. It appeared that the accuracy of all prognostic tests was low, which confirmed that in many clinical practices patients are scheduled for fusion on the basis of tests, of which the accuracy is insufficient or at best unknown. As the overall methodological quality of included studies was poor, higher quality trials that include negatively tested as well as positively tested patients for fusion, will be needed. It was concluded that at present, best evidence does not support the use of any prognostic test in clinical practice. No subset of patients with low back pain could be identified, for whom spinal fusion is a reliable and effective treatment. In literature, several studies have reported that cognitive behavioural therapy or intensive exercise programs have treatment results similar to those of spinal fusion, but with considerably less complications, morbidity and costs. As the findings of the present thesis show that the currently used tests do not improve the results of fusion by better patient selection, these tests should not be recommended for surgical decision making in standard care. Moreover, spinal fusion should not be proposed as a standard treatment for chronic low back pain. Causality of nonspecific spinal pain is complex and CLBP should not be regarded as a diagnosis, but rather as a symptom in patients with different stages of impairment and disability. Patients should be evaluated in a multidisciplinary setting or Spine Centre according to the so-called biopsychosocial model, which aims to identify underlying psychosocial factors as well as biological factors. Treatment should occur in a stepwise fashion starting with the least invasive treatment. The current approach of CLBP, in which emphasis is laid on self-management and empowerment of patients to take an active course of treatment in order to prevent long-term disability and chronicity, is recommended.",0,0,
484,Declaration of Helsinki,Recommendations guiding physicians in biomedical research involving human subjects.,0,0,
485,Decree No. 93-1155 of 17 May 1993 promulgating the Code of Medical Ethics.,,0,0,
486,Default options in the ICU: widely used but insufficiently understood,"Purpose of review Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology.  Recent findings Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking.  Summary Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.  Keywords: behavioral economics, choice behavior, communication, critical care, decision making",0,1,
487,Default settings of computerized physician order entry system order sets drive ordering habits.,"Background: Computerized physician order entry (CPOE) systems are quickly becoming ubiquitous, and groups of orders (“order sets”) to allow for easy order input are a common feature. This provides a streamlined mechanism to view, modify, and place groups of related orders. This often serves as an electronic equivalent of a specialty requisition. A characteristic, of these order sets is that specific orders can be predetermined to be “preselected” or “defaulted-on” whenever the order set is used while others are “optional” or “defaulted-off” (though there is typically the option is to “deselect” defaulted-on tests in a given situation). While it seems intuitive that the defaults in an order set are often accepted, additional study is required to understand the impact of these “default” settings in an order set on ordering habits. This study set out to quantify the effect of changing the default settings of an order set.  Methods: For quality improvement purposes, order sets dealing with transfusions were recently reviewed and modified to improve monitoring of outcome. Initially, the order for posttransfusion hematocrits and platelet count had the default setting changed from “optional” to “preselected.” The default settings for platelet count was later changed back to “optional,” allowing for a natural experiment to study the effect of the default selections of an order set on clinician ordering habits.  Results: Posttransfusion hematocrit values were ordered for 8.3% of red cell transfusions when the default order set selection was “off” and for 57.4% of transfusions when the default selection was “preselected” (P < 0.0001). Posttransfusion platelet counts were ordered for 7.0% of platelet transfusions when the initial default order set selection was “optional,” increased to 59.4% when the default was changed to “preselected” (P < 0.0001), and then decreased to 7.5% when the default selection was returned to “optional.” The posttransfusion platelet count rates during the two “optional” periods: 7.0% versus 7.5% – were not statistically different (P = 0.620).  Discussion: Default settings in CPOE order sets can significantly influence physician selection of laboratory tests. Careful consideration by all stakeholders, including clinicians and pathologists, should be obtained when establishing default settings in order sets.",1,1,
488,Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment,"Context How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate.  Objective To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment.  Design, Setting, and Participants Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003.  Main Outcome Measures Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior).  Results A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. “Assurance behavior” such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums.  Conclusion Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.",0,0,
489,Defining optimal treatment with cholinesterase inhibitors in Alzheimer's disease,"Despite growing recognition that Alzheimer's disease (AD) represents a global public health and social care crisis, diagnosis is frequently slow and many patients still receive no treatment at all. Of those who do receive treatment, many remain on lower than recommended doses. The Alzheimer's disease International Global Charter promotes awareness and understanding of AD, stressing the importance of optimal treatment. However, the definition of ""optimal treatment"" is unclear. Since cholinesterase inhibitors became available nearly 20 years ago, clinicians have developed a variety of protocols on the basis of clinical experiences. This review considers what is optimal for several aspects of cholinesterase inhibitor therapy, taking into account initiation strategies, dosages, modes of drug delivery (e.g., oral vs. transdermal), and treatment durations. Regardless of management approach, individuals with AD, their families, and caregivers have a right to a timely diagnosis and access to best available treatment.",0,0,
490,Delivery of well-child care: a look inside the door,"OBJECTIVE: To describe the delivery of well-child care and its components""; to compare that delivery with recommendations in Bright Futures; and to compare delivery of well-child care for children with special health care needs with that for children without special needs. METHODS: Over a 10-week period, 2 medical students observed and documented characteristics of well-child care visits by general pediatricians and midlevel pediatric providers. Parents completed a demographic questionnaire and a screener for children with special health care needs. RESULTS: A total of 483 visits by 43 pediatricians and 9 midlevel providers with patients from 0 to 19 years of age were observed. Adjusted mean visit duration was 20.3 minutes; 38.9% of visits began with an open-ended question about parent/child concerns. A mean of 7.2 health supervision/anticipatory guidance topics were addressed per visit. Clinicians addressed a mean of 42% of Bright Futures-recommended age-specific health supervision/anticipatory guidance topics. Topics addressed less frequently than recommended included family support, parental well-being, behavior/discipline, physical activity, media screen time, risk reduction/substance use, puberty/sex, social-peer interactions, and violence. Shorter visits were associated with asking about parent/child concerns and with addressing greater proportions of recommended health supervision/anticipatory guidance topics. Well-child care visits with children with special health care needs were 36% longer than those with children without special needs and addressed similar numbers of age-specific health supervision/anticipatory guidance topics. More time was spent with children with special health care needs addressing health supervision/anticipatory guidance topics, other conditions (usually their chronic condition), and testing, prescriptions, and referrals. CONCLUSIONS: Utilizing direct observation of visits with pediatric clinicians, we found that solicitation of parent/child concerns occurred less frequently than recommended. Fewer than half of recommended visit-specific health supervision/anticipatory guidance topics were addressed, and there was little congruence with some Bright Futures age group-specific recommendations. Notably, both solicitation of patient/parent concerns and greater adherence to health supervision/anticipatory guidance recommendations were associated with shorter visits. Well-child care visits with children with special health care needs were longer than those with children without special needs;"" more time was spent addressing similar numbers of health supervision/anticipatory guidance topics as well as their chronic conditions.",0,0,
491,Demand management for planned care: a realist synthesis.," The task of matching fluctuating demand with available capacity is one of the basic challenges in all large-scale service industries. It is a particularly pressing concern in modern health-care systems, as increasing demand (ageing populations, availability of new treatments, increased patient knowledge, etc.) meets stagnating supply (capacity and funding restrictions on staff and services, etc.). As a consequence, a very large portfolio of demand management strategies has developed based on quite different assumptions about the source of the problem and about the means of its resolution. This report presents a substantial review of the effectiveness of main strategies designed to alleviate demand pressures in the area of planned care. The study commences with an overview of the key ideas about the genesis of demand and capacity problems for health services. Many different diagnoses were uncovered: fluctuating demand meeting stationary capacity""; turf protection between different providers; social rather than clinical pressures on referral decisions; self-propelling diagnostic cascades; supplier-induced demand; demographic pressures on treatment; and the informed patient and demand inflation. We then conducted a review of the key ideas (programme theories) underlying interventions designed to address demand imbalance. We discovered that there was no close alignment between purported problems and advocated solutions. Demand management interventions take their starting point in seeking reforms at the levels of strategic decision-making, organisational re-engineering, procedural modifications and behavioural change. In mapping the ideas for reform, we also noted a tendency for programme theories to become 'whole-system' models; over time policy-makers have advocated the need for concerted action on all of these fronts. The remainder and core of the report contains a realist synthesis of the empirical evidence on the effectiveness on a spanning subset of four major demand management interventions: referral management centres (RMCs); using general practitioners with special interests (GPwSIs) at the interface between primary and secondary care; general practitioner (GP) direct access to clinical tests; and referral guidelines. In all cases we encountered a chequered pattern of success and failure. The primary literature is replete with accounts of unanticipated problems and unintended effects. These programmes 'work' only in highly circumscribed conditions. To give brief examples, we found that the success of RMCs depends crucially on the balance of control in their governance structures; GPwSIs influence demand only after close negotiations on an agreed and intermediate case mix; significant efficiencies are created by direct GP access to tests mainly when there is low diagnostic yield and high 'rule-out' rates;"" and referral guidelines are more likely to work when implemented by staff with responsibility for their creation. The report concludes that there is no 'preferred intervention' that has the capacity to outperform all others. Instead, the review found many, diverse, hard-won, local and adaptive solutions. Whatever the starting point, success in demand management depends on synchronising a complex array of strategic, organisational, procedural and motivational changes. The final chapter offers practitioners some guidance on how they might 'think through' all of the interdependencies, which bring demand and capacity into equilibrium. A close analysis of the implementation of different configurations of demand management interventions in different local contexts using mixed methods would be valuable to understand the processes through which such interventions are tailored to local circumstances. There is also scope for further evidence synthesis. The substitution theory is ubiquitous in health and social care and a realist synthesis to compare the fortunes of different practitioners placed at different professional boundaries (e.g. nurses/doctors, dentists/dental care practitioners, radiologists/radiographers and so on) would be valuable to identify the contexts and mechanisms through which substitution, support or short-circuit occurs. The National Institute for Health Research Health Services and Delivery Research programme.",0,0,
492,Dementia care management: going new ways in ambulant dementia care within a GP-based randomized controlled intervention trial,"BACKGROUND: Increasing prevalence of dementia is a major challenge for the German healthcare system. The study DelpHi-MV (""Dementia: life- and person-centered help in Mecklenburg-Western Pomerania"") aims to implement and evaluate an innovative subsidiary support system for persons with dementia (PwDs) living at home and their caregivers. METHODS: DelpHi-MV is a GP-based cluster randomized controlled intervention trial. DelpHi-Intervention aims to provide ""optimum care"" by integrating multi-professional and multimodal strategies to individualize and optimize treatment of dementia within the framework of the established healthcare and social service system. The intervention is conducted by Dementia Care Managers (DCMs)--nurses with dementia-specific training--at the people's homes. Based on German guidelines for evidence-based diagnoses and treatment of dementia, a comprehensive set of 95 interventio--modules--the ""DelpHi-Standard""--was defined. Each module consists of predefined trigger condition(s), a subsequent intervention task, as well as at least one criterion for its completion. The intervention begins with a comprehensive assessment of the care situation, needs, and resources. The DCM develops and implements an intervention plan tailored to the individual conditions in close cooperation with the GP. EXPECTED RESULTS AND CONCLUSIONS: We expect statistically significant differences between control and intervention group in primary outcomes (quality of life, behavioral and psychological symptoms of dementia, pharmacotherapy, caregiver burden). Results can provide evidence for the effectiveness and efficacy of dementia care management according to the ""Delphi-Standard""--prerequisites for implementing this concept into routine healthcare.",0,0,
493,Depression,,0,0,
494,Design and dissemination of the MOVE! Weight-Management Program for Veterans,"BACKGROUND: Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight management as a high priority in early 2001. PROGRAM DESIGN: The MOVE! Weight-Management Program for Veterans was developed on the basis of published guidelines from the National Institutes of Health and other organizations. Testing of program feasibility occurred at 17 VHA sites, and the program was refined during early implementation throughout 2005. DISSEMINATION: MOVE! was disseminated nationally in January 2006. Local program coordinators and physician champions were named, and toolkits, online training, marketing materials, and ongoing field support were provided. EVALUATION: MOVE! has been implemented at nearly all VHA medical centers. By June 2008, more than 100,000 patients had participated in MOVE! during more than 500,000 visits. An evaluation based on an established framework is under way. CONCLUSION: MOVE! is an example of the large-scale translation of research into practice. It has the potential to reduce the burden of disease from obesity and related conditions.",0,0,
495,Design and evaluation of a computer reminder system to improve prescribing behaviour of GPs,"OBJECTIVE: To evaluate the implementation of a decision support system with reactive computer reminders to improve drug prescribing behaviour. METHODS: A clustered RCT with an incomplete block design was carried out in the south of the Netherlands: 25 GPs received reminders on antibiotics and asthma/COPD prescriptions, 28 GPs received reminders on cholesterol prescriptions. Prescribing guidelines were integrated into the GP information system, which was installed in the GPs practices of the intervention group. When the computer program was in use, a reminder popped up if the GP deviated from the guidelines during prescribing. PRIMARY OUTCOME: prescription according to the guidelines as a percentage of total prescriptions of a specific drug. Furthermore, an evaluation on the user-friendliness of the CRS in the GP's practice was carried out through questionnaires and interviews. RESULTS: Presently analyses are being carried out. Preliminary results indicate that the CRS study supported our expectations. In general, there seems to be a reduction in the numbers of prescriptions according to the advices of the computerised guidelines not to prescribe certain drugs. Final analysis will be performed shortly. In general, the Computer Reminder System was perceived as stable and user friendly. CONCLUSION: We created a stable and user friendly Computer Reminder System which was adjusted to the needs and demands of GPs. Preliminary results regarding the effectiveness of the system seem to indicate that the implementation of a Computer Reminder System with reactive reminders improves drug prescribing behaviour.",0,1,
496,Design and implementation of training to improve management of pediatric overweight,"INTRODUCTION: Clinicians report a low proficiency in treating overweight children and using behavioral management strategies. This paper documents the design and implementation of a training program to improve clinicians' skills in the assessment and behavioral management of pediatric overweight. METHODS: Two one-hour CME trainings were designed using published guidelines, research findings, and expert committee recommendations. The trainings were provided to clinicians of a managed care pediatric department, utilizing novel screening and counseling tools, and interactive exercises. Surveys and focus groups were conducted 3 and 6 months post intervention to examine clinician attitudes and practices regarding the screening and counseling tools. RESULTS: Post intervention, the majority of clinicians agreed that the clinical practice guidelines (Pediatric Obesity Practice Resource) and BMI-for-age percentile provided useful information for clinical practice. Clinicians reported an increased utilization of the recommended screening tools and changes in office practices to implement these tools. They offered suggestions to improve the ease of use of the tools and to overcome perceived clinician and/or patient barriers. DISCUSSION: A brief, cost effective, multi-faceted training and provision of counseling tools were perceived as helpful to clinical practice. Useful lessons were learned about tool design and ways to fit tools into practice. Training the entire health care team is advantageous to the adoption of new tools and practices.",0,0,
497,Design and methods of the Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen SignificantlY) study: An investigator-blinded randomized controlled trial of education and feedback intervention to reduce inappropriate echocardiograms,"BACKGROUND: Appropriate use criteria (AUC) for transthoracic echocardiography (TTE) were developed to address concerns regarding inappropriate use of TTE. A previous pilot study suggests that an educational and feedback intervention can reduce inappropriate TTEs ordered by physicians in training. It is unknown if this type of intervention will be effective when targeted at attending level physicians in a variety of clinical settings. AIMS: The aim of this international, multicenter study is to evaluate the hypothesis that an AUC-based educational and feedback intervention will reduce the proportion of inappropriate echocardiograms ordered by attending physicians in the ambulatory environment. METHODS: In an ongoing multicentered, investigator-blinded, randomized controlled trial across Canada and the United States, cardiologists and primary care physicians practicing in the ambulatory setting will be enrolled. The intervention arm will receive (1) a lecture outlining the AUC and most recent available evidence highlighting appropriate use of TTE, (2) access to the American Society of Echocardiography mobile phone app, and (3) individualized feedback reports e-mailed monthly summarizing TTE ordering behavior including information on inappropriate TTEs and brief explanations of the inappropriate designation. The control group will receive no education on TTE appropriate use and order TTEs as usual practice. CONCLUSIONS: The Echo WISELY (Will Inappropriate Scenarios for Echocardiography Lessen Significantly in an education RCT) study is the first multicenter randomized trial of an AUC-based educational intervention. The study will examine whether an education and feedback intervention will reduce the rate of outpatient inappropriate TTEs ordered by attending level cardiologists and primary care physicians (www.clinicaltrials.gov identifier NCT02038101).",0,0,
498,Design factors for success or failure of guideline-based decision support systems: an hypothesis involving case complexity,"Computer-based decision support systems (CDSSs) are currently mostly reminder systems. However, the effectiveness of such systems to modify physician behavior is not always observed. We assume that this approach is appropriate when physicians think they know how to prescribe and consider they don't need to be helped, i.e. for simple clinical cases. On the opposite, on-demand approaches allowing for flexibility in the interpretation of patient conditions are more appropriate for more complex cases, e.g. in chronic disease management. ASTI is a CDSS operating in two modes, a critiquing mode working as a reminder-based system and a user-initiated guiding mode. Using a clinical case complexity score, a pre/post-intervention experiment with 10 GPs and 15 cases of hypertensive patients has been performed. Preliminary results tend to indicate that reminder-based interaction is appropriate for simple cases and that physicians are willing to use on-demand systems as clinical situations become complex, making both modes complementary.",1,1,
499,Design of high reliability organizations in health care,"To improve safety performance, many healthcare organizations have sought to emulate high reliability organizations from industries such as nuclear power, chemical processing, and military operations.We outline high reliability design principles for healthcare organizations including both the formal structures and the informal practices that complement those structures. A stage model of organizational structures and practices, moving from local autonomy to formal controls to open inquiry to deep self-understanding, is used to illustrate typical challenges and design possibilities at each stage. We suggest how organizations can use the concepts and examples presented to increase their capacity to self-design for safety and reliability.",0,1,
500,"Design of the Balance@Work project: systematic development, evaluation and implementation of an occupational health guideline aimed at the prevention of weight gain among employees","BACKGROUND: Occupational health professionals may play an important role in preventive health promotion activities for employees. However, due to a lack of knowledge and evidence- and practice based methods and strategies, interventions are hardly being implemented by occupational physicians to date. The aim of the Balance@Work project is to develop, evaluate, and implement an occupational health guideline aimed at the prevention of weight gain among employees. METHODS: Following the guideline development protocol of the Netherlands Society of Occupational Medicine and the Intervention Mapping protocol, the guideline was developed based on literature, interviews with relevant stakeholders, and consensus among an expert group. The guideline consists of an individual and an environmental component. The individual component includes recommendations for occupational physicians on how to promote physical activity and healthy dietary behavior based on principles of motivational interviewing. The environmental component contains an obesogenic environment assessment tool. The guideline is evaluated in a randomised controlled trial among 20 occupational physicians. Occupational physicians in the intervention group apply the guideline to eligible workers during 6 months. Occupational physicians in the control group provide care as usual. Measurements take place at baseline and 6, 12, and 18 months thereafter. Primary outcome measures include waist circumference, daily physical activity and dietary behavior. Secondary outcome measures include sedentary behavior, determinants of behavior change, body weight and body mass index, cardiovascular disease risk profile, and quality of life. Additionally, productivity, absenteeism, and cost-effectiveness are assessed. DISCUSSION: Improving workers' daily physical activity and dietary behavior may prevent weight gain and subsequently improve workers' health, increase productivity, and reduce absenteeism. After an effect- and process evaluation the guideline will be adjusted and, after authorisation, published. Together with several implementation aids, the published guideline will be disseminated broadly by the Netherlands Society of Occupational Medicine. TRIAL REGISTRATION: ISRCTN73545254/NTR1190.",0,0,
501,"Design, implementation, and evaluation of a knowledge translation intervention to increase organ donation after cardiocirculatory death in Canada: a study protocol","Background A shortage of transplantable organs is a global problem. There are two types of organ donation: living and deceased. Deceased organ donation can occur following neurological determination of death (NDD) or cardiocirculatory death. Donation after cardiocirculatory death (DCD) accounts for the largest increments in deceased organ donation worldwide. Variations in the use of DCD exist, however, within Canada and worldwide. Reasons for these discrepancies are largely unknown. The purpose of this study is to develop, implement, and evaluate a theory-based knowledge translation intervention to provide practical guidance about how to increase the numbers of DCD organ donors without reducing the numbers of standard NDD donors.  Methods We will use a mixed method three-step approach. In step one, we will conduct semi-structured interviews, informed by the Theoretical Domains Framework, to identify and describe stakeholders¡¯ beliefs and attitudes about DCD and their perceptions of the multi-level factors that influence DCD. We will identify: determinants of the evidence-practice gap""; specific behavioural changes and/or process changes needed to increase DCD; specific group(s) of clinicians or organizations (e.g., provincial donor organizations) in need of behaviour change;"" and specific targets for interventions. In step two, using the principles of intervention mapping, we will develop a theory-based knowledge translation intervention that encompasses behavior change techniques to overcome the identified barriers and enhance the enablers to DCD. In step three, we will roll out the intervention in hospitals across the 10 Canadian provinces and evaluate its effectiveness using a multiple interrupted time series design.  Discussion We will adopt a behavioural approach to define and test novel, theory-based, and ethically-acceptable knowledge translation strategies to increase the numbers of available DCD organ donors in Canada. If successful, this study will ultimately lead to more transplantations, reducing patient morbidity and mortality at a population-level.",0,0,
502,Designing a patient-centered personal health record to promote preventive care,"BACKGROUND: Evidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential. METHODS: Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR) designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases. RESULTS: The IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources--selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices). Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results, automatically issue patient reminders for overdue services, prompt clinicians about needed services, and formulate personalized prevention plans. CONCLUSIONS: The IPHR demonstrates that a patient-centered personal health record that interfaces with the electronic medical record can give patients a high level of individualized guidance and be successfully adopted by busy primary care practices. Further study and refinement are necessary to make information systems even more patient-centered and to demonstrate their impact on care. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00589173.",0,0,
503,Designing a valid randomized pragmatic primary care implementation trial: the my own health report (MOHR) project,"Background There is a pressing need for greater attention to patient-centered health behavior and psychosocial issues in primary care, and for practical tools, study designs and results of clinical and policy relevance. Our goal is to design a scientifically rigorous and valid pragmatic trial to test whether primary care practices can systematically implement the collection of patient-reported information and provide patients needed advice, goal setting, and counseling in response.  Methods This manuscript reports on the iterative design of the My Own Health Report (MOHR) study, a cluster randomized delayed intervention trial. Nine pairs of diverse primary care practices will be randomized to early or delayed intervention four months later. The intervention consists of fielding the MOHR assessment ¨C addresses 10 domains of health behaviors and psychosocial issues ¨C and subsequent provision of needed counseling and support for patients presenting for wellness or chronic care. As a pragmatic participatory trial, stakeholder groups including practice partners and patients have been engaged throughout the study design to account for local resources and characteristics. Participatory tasks include identifying MOHR assessment content, refining the study design, providing input on outcomes measures, and designing the implementation workflow. Study outcomes include the intervention reach (percent of patients offered and completing the MOHR assessment), effectiveness (patients reporting being asked about topics, setting change goals, and receiving assistance in early versus delayed intervention practices), contextual factors influencing outcomes, and intervention costs.  Discussion The MOHR study shows how a participatory design can be used to promote the consistent collection and use of patient-reported health behavior and psychosocial assessments in a broad range of primary care settings. While pragmatic in nature, the study design will allow valid comparisons to answer the posed research question, and findings will be broadly generalizable to a range of primary care settings. Per the pragmatic explanatory continuum indicator summary (PRECIS) framework, the study design is substantially more pragmatic than other published trials. The methods and findings should be of interest to researchers, practitioners, and policy makers attempting to make healthcare more patient-centered and relevant.",0,1,
504,Detection and management of alcohol use disorders in German primary care influenced by non-clinical factors,"AIMS: The primary objective was to assess the proportion of detected and correctly referred patients in German primary care. The secondary objective was to identify patient and practitioner characteristics that predict detection and correct referral. METHODS: In this clustered cross-sectional survey in German primary care, 3003 patients were consecutively invited to participate, and were asked to fill in a standardized health questionnaire. They were then screened for problematic alcohol consumption using the Alcohol Use Disorders Identification Test. The physicians recorded their assessment of the presence of any alcohol use disorder and documented the treatment course of all identified patients for 3 months. RESULTS: Correctly identified problem drinkers were 38.6% in a per-protocol analysis and 33.6% using a worst-case scenario. Referral behaviour of physicians was in conformity with current practice guidelines in 64.6% of the documented cases and 27.0% in a worst-case scenario. Several patient (e.g. sex, age) and practitioner characteristics (e.g. age), which influence the diagnosis and referral of patients, could be identified. CONCLUSIONS: There is a clear need to increase the special diagnostic and therapeutic skills of general practitioners so that they may be able to indicate and perform secondary prevention. Further research should focus on the likely effects of the implementation of these diagnostic and management tools.",0,0,
505,Detection of lymphocytotoxic antibodies in relatives of patients with type I diabetes,"Concentrations of lymphocytotoxic antibodies were measured in serum samples from 19 patients recently diagnosed as having type I diabetes and 43 healthy relatives (33 consanguineous and 10 non-consanguineous). The specificity of the reaction was tested at 15 degrees C and 37 degrees C against T lymphocytes and purified helper/inducer and cytotoxic/suppressor subsets. The concentrations of lymphocytotoxic antibodies in each of the three test groups were significantly higher than those in controls (type I patients, p less than 0.005""; consanguineous relatives, p less than 0.001;"" and non-consanguineous relatives, p less than 0.002). The frequency of detection of the antibodies was also greater in each of the study groups (p less than 0.01, p less than 0.01, and p less than 0.05, respectively). Cytotoxicity affected both subsets at 15 degrees C but only cytotoxic/suppressor cells at 37 degrees C. The findings of lymphocytotoxic antibodies in healthy relatives of type I diabetics, irrespective of consanguinity, suggests that an environmental agent such as a virus is at least partially responsible for this lymphocytotoxic effect. Furthermore, the residual cytotoxic/suppressor cell killing at 37 degrees C could explain the defect of suppressor cells observed in these patients.",0,0,
506,Determinants of college students' health-promoting lifestyles,"This descriptive study of 151 university students in Boston, Massachusetts, was undertaken to determine the relationships of their perceived health status, sex, grade point average, and health and nonhealth majors to their health-promoting lifestyles, using the Health Promoting Lifestyle Profile (HPLP) II, based on Pender's model. Students' perceived health status was significantly predictive of total HPLP II, exercise, stress management, and spiritual growth. College women practiced significantly better nutrition, interpersonal relationships, health responsibility, and total HPLP II than men. The whole sample scored lower in stress management than any previous group studied. Male students, those reporting poor health, and all students are targeted for intervention and research in their deficient areas. Guidelines for nursing practice are derived from the HPLP II questionnaire. These clinically significant findings may guide nurse practitioners to intervene in the health awareness and practices of college students.",0,0,
507,Determinants of successful clinical networks: the conceptual framework and study protocol,"Background Clinical networks are increasingly being viewed as an important strategy for increasing evidence-based practice and improving models of care, but success is variable and characteristics of networks with high impact are uncertain. This study takes advantage of the variability in the functioning and outcomes of networks supported by the Australian New South Wales (NSW) Agency for Clinical Innovation's non-mandatory model of clinical networks to investigate the factors that contribute to the success of clinical networks.  Methods/Design The objective of this retrospective study is to examine the association between external support, organisational and program factors, and indicators of success among 19 clinical networks over a three-year period (2006-2008). The outcomes (health impact, system impact, programs implemented, engagement, user perception, and financial leverage) and explanatory factors will be collected using a web-based survey, interviews, and record review. An independent expert panel will provide judgements about the impact or extent of each network's initiatives on health and system impacts. The ratings of the expert panel will be the outcome used in multivariable analyses. Following the rating of network success, a qualitative study will be conducted to provide a more in-depth examination of the most successful networks.  Discussion This is the first study to combine quantitative and qualitative methods to examine the factors that contribute to the success of clinical networks and, more generally, is the largest study of clinical networks undertaken. The adaptation of expert panel methods to rate the impacts of networks is the methodological innovation of this study. The proposed project will identify the conditions that should be established or encouraged by agencies developing clinical networks and will be of immediate use in forming strategies and programs to maximise the effectiveness of such networks.",0,0,
508,Developing a managed clinical network in palliative care: a realistic evaluation,"BACKGROUND: The attainment of evidence-based practice is at the fore of the international practice development agenda. It is therefore imperative that robust evaluation methodologies are available to scrutinise new approaches to service development. OBJECTIVES: This paper reflects on the merits and challenges of realistic evaluation design in the establishment of a new managed clinical network (MCN) approach to implementing a guideline concerned with the care of individuals with cancer-related pain. DESIGN AND METHODS: There were three evaluation points scrutinising three versions of the MCN approach to care. At each stage, steps were taken to identify the context, mechanisms and outcomes associated with the version of the model under scrutiny. Findings from patient-centred case studies fed into realistic evaluation interviews with the management group. SETTING: A rural primary care setting in Scotland. PARTICIPANTS: Three older men, their families, and the doctors and nurses providing direct care participated, along with 13 members of the network management group. RESULTS: The investigation highlighted the level of practitioner effort required to introduce the MCN approach to care. Progress was much slower than anticipated, at times frustrated by inexperience in change management and unfamiliarity with leading practice development projects and supporting practitioner learning. Issues to do with the age appropriateness of the evidence base in relation to the care of frail older people were also apparent. The professional group that experienced most role change were district nurses and community pharmacists. CONCLUSION: The collaborative approach nurtured by the realistic evaluation framework was found particularly helpful and there was consensus that the evaluation had become integral to the intervention itself. There were a number of methodological challenges and a need to limit the depth of 'realistic unravelling'. However, as a formative approach, in the messy world of interdisciplinary practice development, realistic evaluation proved a worthy design.",0,0,
509,Developing a pain assessment tool for use by nurses in an adult intensive care unit,"Critically ill patients are particularly vulnerable to pain, patient's citing it as their second greatest ICU stressor. Pain has also been identified as a complicating factor in critical illness. Despite this, pain management is often not considered a priority by the ICU team. Effective management can only be achieved with accurate pain assessment. However, this is difficult in the critically ill as patients are often unable to communicate verbally due to the presence of endotracheal/tracheostomy tubes, sedation and paralysing agents. Nurses therefore rely on behavioural and physiological indicators in establishing the presence of pain. However, as these also occur in situations and conditions not associated with pain there is a need for a systematic, objective assessment tool. Such a tool, consisting of a numerical and verbal rating scale to facilitate documentation and audit, was developed as a result of ongoing adjustment and evaluation. The tool scores the patient's pain by incorporating behavioural and physiological indicators and is used in conjunction with the Glasgow Coma Score and the modified Sheffield Sedation Scale to achieve a comprehensive neurological assessment. As movement and intervention may exacerbate pain, assessment is carried out at rest and during procedures such as suctioning and manual handling. As an aid to pain assessment and management a flow chart and a clinical guideline have also been introduced. Although preliminary evaluation established the effectiveness of the tool as a means of estimating and recording pain levels in individual patients, it was evident that there has been no change to the way in which pain is managed. To address this issue, the level of nurses understanding regarding pain management has been ascertained and teaching sessions delivered to increase the profile of pain management in the unit.",0,0,
510,Developing a science of clinical utility in diagnostic classification systems field study strategies for ICD-11 mental and behavioral disorders,"The World Health Organization (WHO) Department of Mental Health and Substance Abuse has developed a systematic program of field studies to evaluate and improve the clinical utility of the proposed diagnostic guidelines for mental and behavioral disorders in the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11). The clinical utility of a diagnostic classification is critical to its function as the interface between health encounters and health information, and to making the ICD-11 be a more effective tool for helping the WHO's 194 member countries, including the United States, reduce the global disease burden of mental disorders. This article describes the WHO's efforts to develop a science of clinical utility in regard to one of the two major classification systems for mental disorders. We present the rationale and methodologies for an integrated and complementary set of field study strategies, including large international surveys, formative field studies of the structure of clinicians' conceptualization of mental disorders, case-controlled field studies using experimental methodologies to evaluate the impact of proposed changes to the diagnostic guidelines on clinicians' diagnostic decision making, and ecological implementation field studies of clinical utility in the global settings in which the guidelines will ultimately be implemented. The results of these studies have already been used in making decisions about the structure and content of ICD-11. If clinical utility is indeed among the highest aims of diagnostic systems for mental disorders, as their developers routinely claim, future revision efforts should continue to build on these efforts. (PsycINFO Database Record",0,0,
511,Developing an intervention to promote young people's participation in asthma review consultations with practice nurses,"AIM: The article is a report of a study to develop an evidence-based pre-consultation guide for young people to use prior to an asthma review with a practice nurse. BACKGROUND: The participation of young people aged 13-19 in consultations with health professionals can be limited by the lack of opportunity to learn the appropriate skills in triadic consultations. Evidence-based interventions to promote participation of adults in consultations have been developed but young people's needs have not been specifically addressed. DESIGN: Multiple methods design informed by guidelines for the development of complex interventions. METHODS: A pre-consultation guide for young people was developed in 2007 by application of a model of health behaviour change, development of criteria by an expert panel and in consultation with young people using a nominal group technique. RESULTS: The concepts of the Health Action Process Approach model were applied to the development of criteria underpinning the pre-consultation guide. In the nominal groups young people agreed that they had different needs to other children and adults. The consensus was that the preconsultation guide should include disease-specific information, realistic photographs rather than Clip Art, consistent styles of fonts, bullet points and colours, short words and mature language. Statements and example questions written by young people were included in the evidence-based guide. CONCLUSION: Young people's views can contribute to the development of interventions designed to promote communication in consultations with nurses. There is potential for this approach to be used to develop interventions in primary and secondary care of a range of long-term conditions.",0,0,
512,Developing guidelines for community child health staff and examining the referral pathways and outcomes of care in the support of emotionally and behaviourally disturbed children,"The East Sussex Public Health Commissioners had enquired whether referral guidelines were needed to ensure that the children with the greatest concerns achieved support from the Child and Adolescent Mental Health Services (CAMHS). Community child health doctors and nurses recorded all contacts with children with emotional and behavioural difficulties (EBD) over a one month period. Data on presenting difficulties and on intervention pathways were recorded. The same children were reviewed five months later and the outcome was measured by clinical assessment and by support offered. The work showed that child health staff were managing cases both through single advisory sessions and through planned on-going support. Additionally, the use of the three tier pathways recommended by the Department of Health was demonstrated. Analysis of recorded data was used to describe referral pathways and to give guidance on the characteristics of children who needed referral to CAMHS.",0,0,
513,Developing guidelines for smoking cessation interventions for pregnant adolescents,"More than 400,000 deaths a year in the United States are attributed to active and passive tobacco smoke exposure. Healthy People 2000 objectives target a reduction in the tobacco use of high-risk populations such as youth and pregnant women. This article describes guidelines for health professionals to address smoking cessation when working with pregnant adolescents and teen mothers who smoke."";"" PIP: This article examines essential components of smoking cessation and health promotion interventions for pregnant and parenting adolescents. It also describes guidelines for health care professionals to address smoking cessation when working with pregnant adolescents and teen mothers who smoke. Both pregnancy and tobacco use are increasing among adolescents in the US. Evidence clearly indicates that cigarette smoking among pregnant adolescents is even higher than the national rate. Such a habit among pregnant teenagers presents an immediate risk to the fetus, plus an extended risk for establishment of entrenched smoking patterns for the teen. Cessation of smoking during pregnancy can have a profound effect in reducing infant mortality. To this effect, it is suggested that health care practitioners can have a positive influence on the health of the mothers, infants and children by encouraging and supporting smoking cessation efforts in young mothers. The practitioner is in a special position to provide this counseling during health supervision visits. Overall, the guidelines for intervention presented in this article can be used for school-based clinics with pregnant students and can be implemented easily in private practices or hospital-based clinics.",0,0,
514,Developing Internet-based health interventions: a guide for public health researchers and practitioners,"BACKGROUND: Researchers and practitioners interested in developing online health interventions most often rely on Web-based and print resources to guide them through the process of online intervention development. Although useful for understanding many aspects of best practices for website development, missing from these resources are concrete examples of experiences in online intervention development for health apps from the perspective of those conducting online health interventions. OBJECTIVE: This study aims to serve as a series of case studies in the development of online health interventions to provide insights for researchers and practitioners who are considering technology-based interventional or programmatic approaches. METHODS: A convenience sample of six study coordinators and five principal investigators at a large, US-based land grant university were interviewed about the process of developing online interventions in the areas of alcohol policy, adolescent health, medication adherence, and human immunodeficiency virus prevention in transgender persons and in men who have sex with men. Participants were asked questions that broadly addressed each of the four phases of the User-Centered Design Process Map from the US Department of Health and Human Services' Research-Based Web Design & Usability Guidelines. Interviews were audio recorded and transcribed. Qualitative codes were developed using line-by-line open coding for all transcripts, and all transcripts were coded independently by at least 2 authors. Differences among coders were resolved with discussion. RESULTS: We identified the following seven themes: (1) hire a strong (or at least the right) research team, (2) take time to plan before beginning the design process, (3) recognize that vendors and researchers have differing values, objectives, and language, (4) develop a detailed contract, (5) document all decisions and development activities, (6) use a content management system, and (7) allow extra time for testing and debugging your intervention. Each of these areas is discussed in detail, with supporting quotations from principal investigators and study coordinators. CONCLUSIONS: The values held by members of each participating organization involved in the development of the online intervention or program, as well as the objectives that are trying to be met with the website, must be considered. These defined values and objectives should prompt an open and explicit discussion about the scope of work, budget, and other needs from the perspectives of each organization. Because of the complexity of developing online interventions, researchers and practitioners should become familiar with the process and how it may differ from the development and implementation of in-person interventions or programs. To assist with this, the intervention team should consider expanding the team to include experts in computer science or learning technologies, as well as taking advantage of institutional resources that will be needed for successful completion of the project. Finally, we describe the tradeoff between funds available for online intervention or program development and the complexity of the project.",0,0,
515,Developing leadership capacity for guideline use: a pilot cluster randomized control trial,"SIGNIFICANCE: The importance of leadership to influence nurses' use of clinical guidelines has been well documented. However, little is known about how to develop and evaluate leadership interventions for guideline use. PURPOSE: The purpose of this study was to pilot a leadership intervention designed to influence nurses' use of guideline recommendations when caring for patients with diabetic foot ulcers in home care nursing. This paper reports on the feasibility of implementing the study protocol, the trial findings related to nursing process outcomes, and leadership behaviors. METHODS: A mixed methods pilot study was conducted with a post-only cluster randomized controlled trial and descriptive qualitative interviews. Four units were randomized to control or experimental groups. Clinical and management leadership teams participated in a 12-week leadership intervention (workshop, teleconferences). Participants received summarized chart audit data, identified goals for change, and created a team leadership action. Criteria to assess feasibility of the protocol included: design, intervention, measures, and data collection procedures. For the trial, chart audits compared differences in nursing process outcomes. PRIMARY OUTCOME: 8-item nursing assessments score. Secondary outcome: 5-item score of nursing care based on goals for change identified by intervention participants. Qualitative interviews described leadership behaviors that influenced guideline use. RESULTS: Conducting this pilot showed some aspects of the study protocol were feasible, while others require further development. Trial findings observed no significant difference in the primary outcome. A significant increase was observed in the 5-item score chosen by intervention participants (p = 0.02). In the experimental group more relations-oriented leadership behaviors, audit and feedback and reminders were described as leadership strategies. CONCLUSIONS: Findings suggest that a leadership intervention has the potential to influence nurses' use of guideline recommendations, but further work is required to refine the intervention and outcome measures. A taxonomy of leadership behaviors is proposed to inform future research.",0,0,
516,Developing measures of quality for the emergency department management of pediatric suicide-related behaviors,"OBJECTIVE: Given the public health importance of suicide-related behaviors and the corresponding gap in the performance measurement literature, we sought to identify key candidate process indicators (quality of care measures) and structural measures (organizational resources and attributes) important for emergency department (ED) management of pediatric suicide-related behaviors. METHODS: We reviewed nationally endorsed guidelines and published research to establish an inventory of measures. Next, we surveyed expert pediatric ED clinicians to assess the level of agreement on the relevance (to patient care) and variability (across hospitals) of 42 candidate process indicators and whether 10 hospital and regional structural measures might impact these processes. RESULTS: Twenty-three clinicians from 14 pediatric tertiary-care hospitals responded (93% of hospitals contacted). Candidate process indicators identified as both most relevant to patient care (>/=87% agreed or strongly agreed) and most variable across hospitals (>/=78% agreed or strongly agreed) were wait time for medical assessment""; referral to crisis intervention worker/program; mental health, psychosocial, or risk assessment requested; any inpatient admission; psychiatric inpatient admission; postdischarge treatment plan; wait time for first follow-up appointment; follow-up obtained; and type of follow-up obtained. Key hospital and regional structural measures (>/=87% agreed or strongly agreed) were specialist staffing and type of specialist staffing in or available to the ED; regional policies, protocols, or procedures;"" and inpatient psychiatric services. CONCLUSIONS: This study highlighted candidate performance measures for the ED management of pediatric suicide-related behaviors. The 9 candidate process indicators (covering triage, assessment, admission, discharge, and follow-up) and 4 hospital and regional structural measures merit further development.",0,0,
517,Developing team leadership to facilitate guideline utilization: planning and evaluating a 3-month intervention strategy,"BACKGROUND: Research describes leadership as important to guideline use. Yet interventions to develop current and future leaders for this purpose are not well understood. AIM: To describe the planning and evaluation of a leadership intervention to facilitate nurses' use of guideline recommendations for diabetic foot ulcers in home health care. METHOD: Planning the intervention involved a synthesis of theory and research (qualitative interviews and chart audits). One workshop and three follow-up teleconferences were delivered at two sites to nurse managers and clinical leaders (n=15) responsible for 180 staff nurses. Evaluation involved workshop surveys and interviews. RESULTS: Highest rated intervention components (four-point scale) were: identification of target indicators (mean 3.7), and development of a team leadership action plan (mean 3.5). Pre-workshop barriers assessment rated lowest (mean 2.9). Three months later participants indicated their leadership performance had changed as a result of the intervention, being more engaged with staff and clear about implementation goals. CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT: Creating a team leadership action plan to operationalize leadership behaviours can help in delivery of evidence-informed care. Access to clinical data and understanding team leadership knowledge and skills prior to formal training will assist nursing management in tailoring intervention strategies to identify needs and gaps.",0,0,
518,Developing the protocol for the evaluation of the health foundation's' engaging with quality initiative'–an emergent approach,"In 2004 a UK charity, The Health Foundation, established the 'Engaging with Quality Initiative' to explore and evaluate the benefits of engaging clinicians in quality improvement in healthcare. Eight projects run by professional bodies or specialist societies were commissioned in various areas of acute care. A developmental approach to the initiative was adopted, accompanied by a two level evaluation: eight project self-evaluations and a related external evaluation. This paper describes how the protocol for the external evaluation was developed. The challenges faced included large variation between and within the projects (in approach, scope and context, and in understanding of quality improvement), the need to support the project teams in their self-evaluations while retaining a necessary objectivity, and the difficulty of evaluating the moving target created by the developmental approach adopted in the initiative. An initial period to develop the evaluation protocol proved invaluable in helping us to explore these issues.",0,0,
519,Development and implementation of a medical oncology quality improvement tool for a regional community oncology network: the Fox Chase Cancer Center Partners initiative,"Fox Chase Cancer Center Partners (FCCCP) is a community hospital/academic partnership consisting of 25 hospitals in the Delaware Valley. Originally created in 1986, FCCCP promotes quality community cancer care through education, quality assurance, and access to clinical trial research. An important aspect of quality assurance is a yearly medical oncology audit that benchmarks quality indicators and guidelines and provides a roadmap for quality improvement initiatives in the community oncology clinical office setting. Each year, the FCCCP team and the Partner Medical Oncologists build disease site- and stage-specific indicators based on National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Concordance with multiple indicators is assessed on 20 charts from each community practice. A report for each FCCCP medical oncology practice summarizes documentation, screening recommendations, new drug use, and research trends in a particular disease site. Descriptive statistics reflect indicators met, number of new cases seen per year, number of disease site cases from tumor registry information, and clinical trial accrual total. Education and documentation tools are provided to physicians and oncology office nursing staff. The FCCCP Clinical Operations Team, consisting of medical oncologists and oncology-certified nurses, has conducted quality audits in medical oncology offices for 7 years using NCCN-derived indicators. Successful audits comprising gastric, colorectal, and breast cancer have been the focus of recent evaluations. For the 2005 stage II/III breast cancer evaluation, mean compliance per parameter was 88%, with 15 of 16 practices achieving mean compliance greater than 80%. A large-scale quality assurance audit in a community cancer partner network is feasible. Recent evaluation of localized breast cancer shows high compliance with guidelines and identifies areas for focused education. Partnership between academic and community oncologists produces a quality review process that is broadly applicable and adaptable to changing medical knowledge.",0,0,
520,Development and implementation of a program to assess medical patients’ need for venous thromboembolism prophylaxis,"Purpose. The development and implementation of a program to assess medical patients’ need for venous thromboembolism (VTE) prophylaxis are described.  Summary. The pharmacy services, medicine, and information services departments at Hartford Hospital collaborated to institute a program to improve VTE prophylaxis in medical patients. After baseline VTE prophylaxis compliance was assessed, the departments developed an intervention consisting of a message to be displayed to providers using the institution’s computerized prescriber-order-entry (CPOE) system as a reminder to assess the current patient for VTE risk factors and the need for VTE prophylaxis. The message was displayed when a patient met predefined criteria for VTE risk factors. The message would not continue to be displayed once either mechanical or pharmacologic VTE prophylaxis was an active order on the patient’s medication profile. Extensive education about the program was provided to hospital staff, pharmacists, physicians, nurse practitioners, physician assistants, and nurses. The program was implemented in March 2007 on a pilot medical floor. To measure the impact of the program, a retrospective chart review was conducted using the risk-assessment tool developed. The VTE prophylaxis compliance rate post-implementation was 93%, compared with 49% preimplementation of the program ( p < 0.001). Before the program, only 25% of patients with a contraindication to pharmacologic therapy received mechanical prophylaxis, compared with 100% after program implementation.  Conclusion. Use of message alerts through a CPOE system and an interdisciplinary team approach to assess patients’ risk for VTE appeared to improve the use of VTE prophylaxis in medical patients.",0,1,
521,Development and implementation of nonpharmacologic protocols for the management of patients with Alzheimer's disease and their families in a multiracial primary care setting,"PURPOSE: Most patients and families with dementia are cared for in primary care clinics. These clinics are seldom designed to provide the necessary comprehensive care. The purpose of this article is to describe nonpharmacologic protocols for the management of patients with Alzheimer's disease and their families that are administered as part of a multifaceted care-management intervention program in a multiracial primary care clinic. DESIGN & METHODS: The nonpharmacologic component for the integrated program of collaborative care was developed based on a literature review and previous clinical experience. The care is coordinated by a geriatric nurse practitioner who meets with patients, families, and the primary care physicians. The nonpharmacologic protocols included general educational guidelines about Alzheimer's disease. Specific protocols to treat the common behavioral disturbances associated with Alzheimer's disease also were developed. A major component of the intervention is a monthly psychoeducational support group for caregivers. RESULTS: The intervention has been well accepted by patients, families, and physicians. Approximately one-half of the treatment group has participated in the support group regularly. IMPLICATIONS: The integration of behavioral interventions and team care within the primary care environment has been successful.",0,0,
522,Development and testing of a caring-based intervention for older adults with heart failure,"The clinical and cost burdens of heart failure (HF) continue to rise, creating an immediate need for cost-effective interventions geared toward improving health outcomes. This article describes the development and testing of a caring-based nursing intervention for older adults with advanced HF who have been recently discharged from acute care. The developmental process and components of the intervention are presented. A methodology for testing the intervention is also introduced. Through a phased development process including research, this intervention can be refined and used to guide clinicians, administrators, and policymakers in the provision of high-quality care to older adults with HF.",0,0,
523,Development of a behaviour change intervention: a case study on the practical application of theory,"BACKGROUND: Use of theory in implementation of complex interventions is widely recommended. A complex trial intervention, to enhance self-management support for people with osteoarthritis (OA) in primary care, needed to be implemented in the Managing Osteoarthritis in Consultations (MOSAICS) trial. One component of the trial intervention was delivery by general practitioners (GPs) of an enhanced consultation for patients with OA. The aim of our case study is to describe the systematic selection and use of theory to develop a behaviour change intervention to implement GP delivery of the enhanced consultation. METHODS: The development of the behaviour change intervention was guided by four theoretical models/frameworks: i) an implementation of change model to guide overall approach, ii) the Theoretical Domains Framework (TDF) to identify relevant determinants of change, iii) a model for the selection of behaviour change techniques to address identified determinants of behaviour change, and iv) the principles of adult learning. Methods and measures to evaluate impact of the behaviour change intervention were identified. RESULTS: The behaviour change intervention presented the GPs with a well-defined proposal for change""; addressed seven of the TDF domains (e.g., knowledge, skills, motivation and goals); incorporated ten behaviour change techniques (e.g., information provision, skills rehearsal, persuasive communication);"" and was delivered in workshops that valued the expertise and professional values of GPs. The workshops used a mixture of interactive and didactic sessions, were facilitated by opinion leaders, and utilised 'context-bound communication skills training.' Methods and measures selected to evaluate the behaviour change intervention included: appraisal of satisfaction with workshops, GP report of intention to practise and an assessment of video-recorded consultations of GPs with patients with OA. CONCLUSIONS: A stepped approach to the development of a behaviour change intervention, with the utilisation of theoretical frameworks to identify determinants of change matched with behaviour change techniques, has enabled a systematic and theory-driven development of an intervention designed to enhance consultations by GPs for patients with OA. The success of the behaviour change intervention in practice will be evaluated in the context of the MOSAICS trial as a whole, and will inform understanding of practice level and patient outcomes in the trial.",0,0,
524,Development of a complex intervention for secondary prevention of coronary heart disease in primary care using the UK Medical Research Council framework,"OBJECTIVE: To apply the UK Medical Research Council (MRC) framework for development and evaluation of trials of complex interventions to a primary healthcare intervention to promote secondary prevention of coronary heart disease. STUDY DESIGN: Case report of intervention development. METHODS: First, literature relating to secondary prevention and lifestyle change was reviewed. Second, a preliminary intervention was modeled, based on literature findings and focus group interviews with patients (n = 23) and staff (n = 29) from 4 general practices. Participants' experiences of and attitudes toward key intervention components were explored. Third, the preliminary intervention was pilot-tested in 4 general practices. After delivery of the pilot intervention, practitioners evaluated the training sessions, and qualitative data relating to experiences of the intervention were collected using semistructured interviews with staff (n = 10) and patient focus groups (n = 17). RESULTS: Literature review identified 3 intervention components: a structured recall system, practitioner training, and patient information. Initial qualitative data identified variations in recall system design, training requirements (medication prescribing, facilitating behavior change), and information appropriate to the prospective study participants. Identifying detailed structures within intervention components clarified how the intervention could be tailored to individual practice, practitioner, and patient needs while preserving the theoretical functions of the components. Findings from the pilot phase informed further modeling of the intervention, reducing administrative time, increasing practical content of training, and omitting unhelpful patient information. CONCLUSION: Application of the MRC framework helped to determine the feasibility and development of a complex intervention for primary care research.",0,0,
525,Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice,"Background Poorly controlled type 2 diabetes mellitus (T2DM) can be seen as failure to meet recommended targets for management of key risk factors including glycaemic control, blood pressure and lipids. Poor control of risk factors is associated with significant morbidity, mortality and healthcare costs. Failure to intensify medications for patients with poor control of T2DM when indicated is called clinical inertia and is one contributory factor to poor control of T2DM. We aimed to develop a theory and evidence-based complex intervention to improve appropriate prescribing and medication intensification in poorly controlled T2DM in Irish general practice.  Methods The first stage of the Medical Research Council Framework for developing and evaluating complex interventions was utilised. To identify current evidence, we performed a systematic review to examine the effectiveness of interventions targeting patients with poorly controlled T2DM in community settings. The Behaviour Change Wheel theoretical approach was used to identify suitable intervention functions. Workshops, simulation, collaborations with academic partners and observation of physicians were utilised to operationalise the intervention functions and design the elements of the complex intervention.  Results Our systematic review highlighted that professional-based interventions, potentially through clinical decision support systems, could address poorly controlled T2DM. Appropriate intensification of anti-glycaemic and cardiovascular medications, by general practitioners (GPs), for adults with poorly controlled T2DM was identified as the key behaviour to address clinical inertia. Psychological capability was the key driver of the behaviour, which needed to change, suggesting five key intervention functions (education, training, enablement, environmental restructuring and incentivisation) and nine key behaviour change techniques, which were operationalised into a complex intervention. The intervention has three components: (a) a training program/academic detailing of target GPs, (b) a remote finder tool to help GPs identify patients with poor control of T2DM in their practice and (c) A web-based clinical decision support system.  Conclusions This paper describes a multifaceted process including an exploration of current evidence and a thorough theoretical understanding of the predictors of the behaviour resulting in the design of a complex intervention to promote the implementation of evidence-based guidelines, through appropriate prescribing and medication intensification in poorly controlled T2DM.",0,1,
526,Development of a minimization instrument for allocation of a hospital-level performance improvement intervention to reduce waiting times in Ontario emergency departments,"Background Rigorous evaluation of an intervention requires that its allocation be unbiased with respect to confounders""; this is especially difficult in complex, system-wide healthcare interventions. We developed a short survey instrument to identify factors for a minimization algorithm for the allocation of a hospital-level intervention to reduce emergency department (ED) waiting times in Ontario, Canada.  Methods Potential confounders influencing the intervention's success were identified by literature review, and grouped by healthcare setting specific change stages. An international multi-disciplinary (clinical, administrative, decision maker, management) panel evaluated these factors in a two-stage modified-delphi and nominal group process based on four domains: change readiness, evidence base, face validity, and clarity of definition.  Results An original set of 33 factors were identified from the literature. The panel reduced the list to 12 in the first round survey. In the second survey, experts scored each factor according to the four domains; summary scores and consensus discussion resulted in the final selection and measurement of four hospital-level factors to be used in the minimization algorithm: improved patient flow as a hospital's leadership priority; physicians' receptiveness to organizational change; efficiency of bed management;"" and physician incentives supporting the change goal.  Conclusion We developed a simple tool designed to gather data from senior hospital administrators on factors likely to affect the success of a hospital patient flow improvement intervention. A minimization algorithm will ensure balanced allocation of the intervention with respect to these factors in study hospitals.",0,1,
527,Development of a tool to measure clinical competence in occupational therapy: a pilot study?,"Clinical competence is generally defined as a combination of knowledge, skill and professional behaviour. It is typically assessed using written tests, direct observation, chart audit, client satisfaction surveys and supervisor ratings. This paper describes the development and evaluation of a chart-stimulated recall (CSR) measure that combines the methods of chart audit and clinician interview to assess the clinical competence of practicing occupational therapists. The CSR tool was developed using the Canadian Guidelines for Client-Centred Practice and taps global domains of competence: use of theory, assessment, program planning, intervention, discharge planning, follow-up, program evaluation, clinical reasoning and professional behaviours. This pilot study involved two independent raters/interviewers who assessed twelve occupational therapy clinicians on two occasions using a random sample of client cases/records on each occasion Results indicate that the CSR tool is not only reliable and valid, but also sufficiently generic to be used in a variety of practice settings as a global measure of on-the-job performance.",0,0,
528,"Development of an exercise program for older adults: pre-exercise testing, exercise prescription and program maintenance","Health care practitioners have the technical skills, frequency of contact and credibility with older adults to use exercise as a health-promoting and disease-preventing intervention. This article acquaints the clinician with how to develop an exercise program specifically for older adults. The health-promotion and disease-prevention outcomes of exercise in older adults, including an explanation of the three stages of exercise programming for older adults, are also reviewed. Stage one is labeled pre-exercise testing and discusses assessment protocols for aerobic capacity, body composition, flexibility and strength. Guidelines for who should and should not exercise are also explored. The second stage of exercise programming is exercise prescription. An explanation of how to develop a beginning level of training and guidelines for how to set goals based on the initial pre-exercise testing are presented. Program maintenance is the third stage"";"" this includes suggestions for designing an exercise program that increases program compliance, reduces attrition and prevents relapses to non-exercise behaviors.",0,0,
529,Development of an ICF-based clinical practice guideline for the assessment of function in head and neck cancer,"BACKGROUND: Functional outcome following head and neck cancer is not regularly assessed in a standardized way in clinical practice. Clinical trials assessing functional outcome apply many different instruments. Therefore, results are not always comparable and have limited clinical implications. Aim of this study was the identification, interdisciplinary evaluation, and recommendation of functional outcome instruments for use in clinical practice and clinical trials in patients with HNC. MATERIAL: Preparatory studies came up with a shortlist of outcome instruments on the basis of previously determined criteria. An interdisciplinary expert group evaluated these instruments and decided on which ones can be recommended for use in 3 application areas: screening, therapy evaluation/planning, and clinical trials. Decision making health professionals included physicians (ENT and maxillofacial surgeons, radiotherapists, oncologists), medical psychologists, speech and language therapists, physiotherapists, and social workers. RESULTS: 98 instruments were presented at the consensus conference. Altogether 21 participants recommended for each of the 3 application areas a basic set of measures for the evaluation of impairment in 6 functional domains: follow-up therapy monitoring, pain, ingestion, voice/speaking, other organic problems, and psychosocial problems. CONCLUSION: A multi-professional expert's pool discussed and adopted recommendations for the use of functional outcome instruments in clinical praxis and/or in research. The re-commended instruments are now available for use in clinical routine.",0,0,
530,Development of clinical practice guidelines for the nursing care of people undergoing percutaneous coronary interventions: An Australian & New Zealand collaboration,"AIM: This paper describes the development of nursing practice guidelines for percutaneous coronary intervention (PCI). BACKGROUND: Clinical practice guidelines (CPGs) supporting PCI nursing care are limited. METHOD: The National Health and Medical Research Council's (NH&MRC) health and medical practice development guidelines were used for the guideline development process. A panel of experts (clinicians and consumers) attended a consensus conference to review existing evidence. Subsequently, nurses' opinions were identified via an online survey. This was followed by a modified Delphi method was used to refine a draft set of guidelines over two rounds. RESULTS: The consensus conference was attended by 41 participants (39 cardiovascular nurses and 2 consumer representatives). Eight additional members joined the panel for the modified Delphi rounds with 27 participants completing the online survey. The final guideline document consisted of 75 recommendations. Endorsement was then sought from key peak cardiovascular bodies in Australia and New Zealand. DISCUSSION/CONCLUSION: Inconclusive evidence precludes definitive recommendations. Therefore, consultation and consensus are important in developing guidelines to achieve standardised nursing care and monitoring of outcomes. IMPLICATIONS FOR PRACTICE: Nurses play a crucial role in PCI care, yet currently there are limited guidelines to inform practice. This paper describes the method developing clinical practice guideline and deriving consensus.",0,0,
531,Development of geriatric competencies for emergency medicine residents using an expert consensus process,"BACKGROUND: The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. OBJECTIVES: The objective was to develop a consensus document, ""Geriatric Competencies for Emergency Medicine Residents,"" by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. METHODS: This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. RESULTS: In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease""; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care;"" and effect of comorbid conditions. CONCLUSIONS: The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.",0,0,
532,"Development, implementation, and evaluation of a community pharmacy-based asthma care model","BACKGROUND Pharmacists are uniquely placed in the healthcare system to address critical issues in asthma management in the community. Various programs have shown the benefits of a pharmacist-led asthma care program""; however, no such programs have previously been evaluated in Australia.  OBJECTIVE To measure the impact of a specialized asthma service provided through community pharmacies in terms of objective patient clinical, humanistic, and economic outcomes.  METHODS A parallel controlled design, where 52 intervention patients and 50 control patients with asthma were recruited in 2 distinct locations, was used. In the intervention area, pharmacists were trained and delivered an asthma care model, with 3 follow-up visits over 6 months. This model was evaluated based on clinical, humanistic, and economic outcomes compared between and within groups.  RESULTS There was a significant reduction in asthma severity in the intervention group, 2.6 ± 0.5 to 1.6 ± 0.7 (mean ± SD;"" p < 0.001) versus the control group, 2.3 ± 0.7 to 2.4 ± 0.5. In the intervention group, peak flow indices improved from 82.7% ± 8.2% at baseline to 87.4% ± 8.9% (p < 0.001) at the final visit, and there was a significant reduction in the defined daily dose of albuterol used by patients, from 374.8 ± 314.8 µg at baseline to 198.4 ± 196.9 µg at the final visit (p < 0.015). There was also a statistically significant improvement in perceived control of asthma and asthma-related knowledge scores in the intervention group compared with the control group between baseline and the final visit. Annual savings of $132.84(AU) in medication costs per patient and $100,801.20 for the whole group, based on overall severity reduction, were demonstrated.  CONCLUSIONS Based on the results of this study, it appears that a specialized asthma care model offers community pharmacists an opportunity to contribute toward improving asthma management in the Australian community.",0,1,
533,Diabetes in rural towns: effectiveness of continuing education and feedback for healthcare providers in altering diabetes outcomes at a population level: protocol for a cluster randomised controlled trial,"BACKGROUND: Type 2 diabetes is one of the fastest growing chronic diseases internationally. The health complications associated with type 2 diabetes can be prevented, delayed, or improved via early diagnosis and effective management. This research aims to examine the impact of a primarily web-based educational intervention on the diabetes care provided by general practitioners (GPs) in rural areas, and subsequent patient outcomes. A population-level approach to outcome assessment is used, via whole-town de-identified pathology records. METHODS/DESIGN: The study uses a cluster randomised controlled trial with rural communities as the unit of analysis. Towns from four Australian states were selected and matched on factors including rurality, population size, proportion of the population who were Indigenous Australians, and socio-economic status. Eleven pairs of towns from two states were suitable for the trial, and one town from each pair was randomised to the experimental group. GPs in the towns allocated to the experimental group are offered an intervention package comprising education on best practice diabetes care via an on-line active learning module, a moderated discussion forum, access to targeted and specialist advice through an on-line request form, and town-based performance feedback on diabetes monitoring and outcomes. The package is offered via repeated direct mail. DISCUSSION: The benefits of the outcomes of the trial are described along with the challenges and limitations associated with the methodology. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12611000553976.",0,0,
534,Diabetes mellitus--refractory obesity,,0,0,
535,Diabetes nurse case management and motivational interviewing for change (DYNAMIC): study design and baseline characteristics in the Chronic Care Model for type 2 diabetes,"BACKGROUND: Despite evidence that diabetes is costly and devastating, the health care system is poorly equipped to meet the challenges of chronic disease care. The Penn State Institute of Diabetes & Obesity is evaluating a model of managing type 2 DM which includes nurse case management (NCM) and motivational interviewing (MI) to foster behavior change. The primary care intervention is designed to improve patients' self care and to reduce clinical inertia through provider use of standardized clinical guidelines to achieve better diabetes outcomes. METHODS: This RCT tests the efficacy of an enhanced NCM intervention on type 2 DM (n=549) patient outcomes mediated by changes in self-care behavior and diabetes management. Outcome measures include: (a) effect on clinical parameters such as HbA1c (<7), BP (<130/80), and LDL (<100), depression scores and weight""; (b) process measures such as complication screening; (c) patient psychological and behavioral outcomes as measured by emotional distress (PAID), diabetes-specific quality of life (ADDQoL), patient satisfaction (DTSQ), self-care activities (SDSCA); and (d) physician satisfaction and cost-effectiveness of the intervention. CONCLUSIONS: Baseline includes (mean) age=58; BMI=34.4; 57% females;"" 47% Caucasian, and 39% Hispanic. Patients had elevated HbA1c (8.4), BP (137/77) and LDL (114). Overall, patients were depressed (CES-D=21.6) and had an extremely negative quality of life (ADDQoL=-1.58). We believe that enhanced NCM will both improve self-care and reduce emotional distress for patients with diabetes. If proven effective, enhanced NCM may be translated to other chronic illnesses.",0,0,
536,Diabetes Translation Research: Where Are We and Where Do We Want To Be?,"Translation research transforms currently available knowledge into useful measures for everyday clinical and public health practice. We review the progress in diabetes translation research and identify future challenges and opportunities in this field. Several promising interventions to optimize implementation of efficacious diabetes treatments are available. Many of these interventions, singly or in combination, need to be more formally tested in larger randomized or quasi-experimental practical trials using outcomes of special interest to patients (for example, patient satisfaction and quality of life) and policymakers (for example, cost and cost-effectiveness). The long-term outcomes (such as morbidity, mortality, quality of life, and costs) of strategies aimed at improving diabetes care must be assessed. Translation research also needs to incorporate ways of studying complex systems of care. The challenges and opportunities offered by translation research are tremendous.",0,0,
537,Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD),"OBJECTIVE: The objective of this NIH Consensus Statement is to inform the biomedical research and clinical practice communities of the results of the NIH Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD). The statement provides state-of-the-art information regarding effective treatments for ADHD and presents the conclusions and recommendations of the consensus panel regarding these issues. In addition, the statement identifies those areas of study that deserve further investigation. Upon completion of this educational activity, the reader should possess a clear working clinical knowledge of the state of the art regarding this topic. The target audience of clinicians for this statement includes, but is not limited to, psychiatrists, family practitioners, pediatricians, internists, neurologists psychologists, and behavioral medicine specialists. PARTICIPANTS: Participants were a non-Federal, nonadvocate, 13-member panel representing the fields of psychology, psychiatry, neurology, pediatrics, epidemiology, biostatistics, education and the public. In addition, 31 experts from these same fields presented data to the panel and a conference audience of 1215. EVIDENCE: The literature was searched through Medline and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience. CONSENSUS PROCESS: The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately following its release at the conference and was updated with the panel's final revisions. CONCLUSIONS: Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short and long-term treatment. Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder. Further research is needed on the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult forms. Studies, (primarily short term, approximately three months) including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer term studies with drugs and behavioral modalities and their combination. Although trials are underway, conclusive recommendations concerning treatment for the long term cannot be made presently. There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants. (ABSTRACT",0,0,
538,Diagnosis of pulmonary embolism,,0,0,
539,Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging,"Purpose:To review evidence on the diagnostic accuracy of clinical information and imaging for patients with low back pain in primary care settings.Data Source:MEDLINE search (January 1966 to September 2001) for articles and reviews relevant to the accuracy of the clinical and radiographic examination of patients with low back pain.Study Selection:The authors reviewed abstracts and selected articles for review on the basis of a combined judgment. Data on the clinical examination were based primarily on recent systematic reviews""; data on imaging tests were based primarily on original articles.Data Extraction:Diagnostic results were extracted by one or the other author. Quality of methods was evaluated informally. Major potential biases were identified, but neither quantitative data extraction nor scoring was done.Data Synthesis:Formal meta-analysis was not used because the diagnostic hardware and software, gold standards, and patient selection methods were heterogeneous and the number of studies was small. Sensitivity for cancer was highest for magnetic resonance imaging (0.83 to 0.93) and radionuclide scanning (0.74 to 0.98);"" specificity was highest for magnetic resonance imaging (0.9 to 0.97) and radiography (0.95 to 0.99). Magnetic resonance imaging was the most sensitive (0.96) and specific (0.92) test for infection. The sensitivity and specificity of magnetic resonance imaging for herniated discs were slightly higher than those for computed tomography but very similar for the diagnosis of spinal stenosis.Conclusions:The data suggest a diagnostic strategy similar to the 1994 Agency for Health Care Policy and Research guidelines. For adults younger than 50 years of age with no signs or symptoms of systemic disease, symptomatic therapy without imaging is appropriate. For patients 50 years of age and older or those whose findings suggest systemic disease, plain radiography and simple laboratory tests can almost completely rule out underlying systemic diseases. Advanced imaging should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected.",0,0,
540,"Dietary treatment of hypercholesterolemia: do dietitians do it better? A randomized, controlled trial","PURPOSE: Current guidelines of the National Cholesterol Education Program (NCEP) recommend initial dietary counseling by physicians for most patients with hypercholesterolemia"";"" referral to a registered dietitian and lipid-lowering drugs are recommended only for patients who remain hypercholesterolemic. We evaluated the incremental value of detailed nutritional counseling by dietitians when added to general nutritional advice provided by physicians. SUBJECTS AND METHODS: Hypercholesterolemic patients detected during a cholesterol screening project were randomly assigned to receive dietary counseling by a physician only (70 patients) or by a physician and a registered dietitian (66 patients). Patients were observed for 1 year to determine compliance with NCEP guidelines. RESULTS: At 3 months, the mean (+/- SD) decrease in the serum low-density lipoprotein (LDL) cholesterol level was 7% +/- 11% in the physician group and 12% +/- 10% in the dietitian group (P <0.004). A decrease of 10% or more in the LDL cholesterol level was seen in 25 patients (36%) in the physician group and 43 patients (65%) in the dietitian group (P <0.001). Only 40 (29%) of the patients in both groups achieved their NCEP target goals at 3 months. The majority of these were low-risk patients with an LDL cholesterol target goal of 160 mg/dL. At 12 months, both groups lost about half of the beneficial effects on LDL cholesterol levels, and the difference between the two groups diminished. CONCLUSIONS: The short-term reduction in LDL cholesterol level achieved after counseling by dietitians is superior to that achieved by physicians. However, long-term compliance remains inadequate. For patients at high risk, consideration should be given to a more aggressive dietary approach and possibly earlier introduction of lipid-lowering medications.",0,0,
541,"Different indications, warnings and precautions, and contraindications for the same drug--an international comparison of prescribing information for commonly used psychiatric drugs","PURPOSE: We aim to derive an internationally applicable data set to improve prescription safety of psychiatric drugs. METHODS: We performed an in-depth analysis of the concordance of prescribing information of 10 key psychiatric drugs across four major drug markets with regard to indications, warnings and precautions, and contraindications. RESULTS: The individual prescribing information covered on average 71.4 +/- 30.3% of all named indications, 59.5 +/- 17.1% of all potential warnings and precautions and 70.1 +/- 24.4% of all applicable contraindications. CONCLUSION: This substantial variation in key prescribing information across countries highlights the need for a better international cooperation and standardization of prescribing information.",0,0,
542,Differentiating normal speech dysfluency from stuttering in children,"The concept of stuttering refers to a lack of fluency or a hesitancy of a speech pattern. The incidence is reported to be 1% worldwide with a greater incidence of males to females (3:1). Theories of causation are briefly identified including a genetic predisposition and neurological factors. In the process of acquiring speech skills, preschool children normally pass through a transitional stage of speech dysfluency. This fact may impede recognition of early stuttering behavior, can be emotionally painful for the child and may interfere with psychological development. The health care provider is in a key position to provide early diagnosis and intervention to the child who presents with early stuttering. In order to do so, the health care provider must possess the knowledge and skill to differentiate normal developmental dysfluency from early stuttering. Factors that differentiate these speech patterns are identified along with guidelines for referral. Current treatment modalities employed by speech pathologists are described. Practical interventions to offer parents in order to promote the child's speech fluency and decrease speaker anxiety are summarized.",0,0,
543,Difficulties implementing a mental health guideline: an exploratory investigation using psychological theory,"BACKGROUND: Evaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method. While implementation depends on clinicians and managers changing a variety of behaviours, psychological theories of behaviour and behaviour change are seldom used to try to understand difficulties in implementation or to develop interventions to overcome them. OBJECTIVES: This study applied psychological theory to examine explanations for difficulties in implementation. It used a theoretical framework derived from an interdisciplinary consensus exercise to code interviews across 11 theoretical domains. The focus of the study was a National Institute for Health and Clinical Excellence's Schizophrenia guideline recommendation that family intervention should be offered to the families of people with schizophrenia. METHODS: Participants were recruited from community mental health teams from three United Kingdom National Health Service (NHS) Trusts""; 20 members (social workers, nurses, team managers, psychologists, and psychiatrists) participated. Semi-structured interviews were audio-taped and transcribed. Interview questions were based on the theoretical domains and addressed respondents' knowledge, attitudes and opinions regarding the guideline. Two researchers independently coded the transcript segments from each interview that were related to each theoretical domain. A score of 1 indicated that the transcript segments relating to the domain did not appear to contain description of difficulties in implementation of the family therapy guidelines;"" similarly a score of 0.5 indicated possible difficulties and a score of 0 indicated definite difficulties. RESULTS: Coding respondents' answers to questions related to the three domains 'beliefs about consequences,' 'social/professional role and identity,' and 'motivation' produced the three highest total scores indicating that factors relating to these domains were unlikely to constitute difficulties in implementation. 'Environmental context and resources' was the lowest scoring domain, with 'Emotion' scoring the second lowest, suggesting that these were likely to be areas for considering intervention. The two main resources identified as problems were time and training. The emotions that appeared to potentially influence the offer of family therapy were self-doubt and fear. CONCLUSION: This exploratory study demonstrates an approach to developing a theoretical understanding of implementation difficulties.",0,0,
544,"Digitalisation of medicines: artefact, architecture and time",,0,0,
545,Dimension of Time in Illness: An Objective View,,0,0,
546,Disability Associated With Psychiatric Comorbidity and Health Status in Bosnian Refugees Living in Croatia,"Context The relationship between psychiatric symptoms and disability in refugee survivors of mass violence is not known.  Objective To determine if risk factors, such as demographics, trauma, health status, and psychiatric illness, are associated with disability in Bosnian refugees.  Design, Setting, and Participants Cross-sectional survey conducted in 1996 of Bosnian refugee adults living in a camp established by the Croatian government near the city of Vara?din. One adult aged 18 years or older was randomly selected from each of 573 camp families""; 534 (93%) agreed to participate (mean age, 50 years; 41% male).  Main Outcome Measures Culturally validated measures for depression and posttraumatic stress disorder (ptsd) included the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire, respectively. Disability measures included the Medical Outcomes Study Short-Form 20, a physical functioning scale based on World Health Organization criteria, and self-reports of socioeconomic activity, levels of physical energy, and perceived health status.  Results Respondents reported a mean (sd) of 6.5 (4.7) unduplicated trauma events; 18% (n=95) had experienced 1 or more torture events. While 55.2% reported no psychiatric symptoms, 39.2% and 26.3% reported symptoms that meet dsm-iv criteria for depression and ptsd, respectively; 20.6% reported symptoms comorbid for both disorders. a total of 25.5% reported having a disability. Refugees who reported symptoms comorbid for both depression and ptsd were associated with an increased risk for disability compared with asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95% confidence interval ¦Ö, 3.05-8.26; adjusted or, 2.06;"" 95% ci, 1.10-3.86). Older age, cumulative trauma, and chronic medical illness were also associated with disability.  Conclusions In a population of Bosnian refugees who had recently fled from the war in Bosnia and Herzegovina, psychiatric comorbidity was associated with disability independent of the effects of age, trauma, and health status.",0,0,
547,Discerning patterns of human immunodeficiency virus risk in healthy young adults,"Previous research has questioned the effectiveness of existing methods to identify individuals at high risk for contracting and transmitting human immunodeficiency virus and other sexually transmitted diseases. Thus, new approaches are needed to provide these individuals with risk-reduction strategies. We review our research on young adults' sexual decision making by using theories and methods from social and cognitive sciences. Four patterns of condom use and associated levels of risks and beliefs were identified. These patterns suggest value in targeting intervention strategies to individuals at different levels of risk. The findings also imply that the monogamous population may be at higher risk for infection than they realize. Primary-care physicians are the first line of contact for many individuals in the health care system and may be in the best position to screen for at-risk individuals. Given the time demands and other barriers, easy-to-use, evidence-based guidelines for such screening are needed. We propose such guidelines for primary-care physicians to use in identifying an individual's risk, from which custom-tailored intervention strategies can be developed.",0,0,
548,Discharge of professional employees: protecting against dismissal for acts within a professional code of ethics,,0,0,
549,Discontinuing cholinesterase inhibitors: results of a survey of Canadian dementia experts,"BACKGROUND: Cholinesterase inhibitors (ChEIs) are being used for increasingly long periods of time, even in patients with severe Alzheimer's disease. Because there is little data to help clinicians to decide on when it is safe and appropriate to discontinue ChEIs after long-term use, practices may vary widely. METHODS: An internet-based survey was undertaken of Canadian dementia experts (geriatric psychiatrists, neurologists, geriatricians) involved in clinical trial research. Recommendations for ChEI discontinuation were determined based on responses to questions dealing with patient/caregiver preference, administrative considerations, effectiveness, and adverse events. RESULTS: There was reasonable consensus that ChEIs should be discontinued based on patient and caregiver preference, and in the presence of severe bothersome adverse events. There was much less consensus on issues related to effectiveness - in particular, what constitutes greater than expected decline. There was a general reluctance to rely on any single measure of cognition, function and/or behavior, and in particular, the MMSE was seen as unhelpful for making decisions about discontinuation. CONCLUSION: Recommendations for discontinuing ChEIs after long-term use from a survey of dementia experts are presented. Ideally, clinical practice guidelines based on controlled discontinuation trials are needed.",0,0,
550,Discussing randomised clinical trials of cancer therapy: evaluation of a Cancer Research UK training programme,"OBJECTIVE: To evaluate a training intervention aimed at improving healthcare professionals' communication with cancer patients about randomised clinical trials. DESIGN: Before and after evaluation of training programme. SETTING: Members of the National Cancer Research Network, Scottish Trials Network, and the Welsh Cancer Trials Network. PARTICIPANTS: 101 healthcare professionals (33 clinicians and 68 research nurses). INTERVENTION: Four modules delivered by a trained facilitator using videotapes and interactive exercises to cover general issues about discussing randomised clinical trials with patients, problems specific to adjuvant trials, trials with palliation as the goal, and trials where patients had a strong preference for one treatment arm. MAIN OUTCOME MEASURES: Before and after the intervention, participants were videotaped discussing a trial with an actor portraying a patient. These consultations were assessed for presence of information required by good clinical practice guidelines. The actor patients gave an assessment after each interview. Participants reported their self confidence about key aspects of trial discussion. RESULTS: Analysis of the videotaped consultations showed that, after intervention, significantly more participants displayed key communication behaviours such as explaining randomisation (69 v 81, odds ratio 2.33, P = 0.033), checking patients' understanding (11 v 31, odds ratio 3.22, P = 0.002), and discussing standard treatment (73 v 88, odds ratio 4.75, P = 0.005) and side effects (69 v 85, odds ratio 3.29, P = 0.006). Participants' self confidence increased significantly (P < 0.001) across all areas. Actor patients' ratings of participants' communication showed significant improvements for 12/15 key items. CONCLUSION: This intensive 8 hour intervention significantly improved participants' confidence and competence when communicating about randomised clinical trials.",0,0,
551,Discussion of sexual risk behavior in HIV care is infrequent and appears ineffectual: a mixed methods study,"Consensus guidelines in HIV care call for clinicians to provide a brief sexual risk behavioral intervention in each visit. Studies based on participant reports find this occurs infrequently, but studies based on direct observation of clinical encounters are lacking. We conducted a mixed method study that used audio recordings of 116 routine outpatient visits by 58 different patients with HIV, in five different practice sites. Transcripts of the visits were coded and analyzed using a quantitative system. In addition, we conducted a qualitative analysis of the dialogue segments in which sexual risk behaviors arose as a topic. Discussion of sexual risk behavior occurred in 10 visits, and was generally quite brief. Two visits featured substantial counseling about sexual risk reduction"";"" two others included substantial discussion which was not evidently directed at the patient's changing behavior. Cues suggesting a need or opportunity for such discussion that physicians did not follow up on occurred in seven additional visits. Interactions about sexual risk had less patient engagement than interactions about other health behaviors. Physicians seldom provide sexual risk reduction counseling in HIV care, even where specific indications are present.",0,0,
552,Diseases of the alimentary system. Jaundice,,0,0,
553,Dissemination of effectiveness and outcomes research,"Effectiveness and outcomes research seeks to improve patients' health outcomes by improving the quality of the health care they receive. Dissemination of the findings of such research is a necessary step in that process. This paper reviews what is known about designing and disseminating effective information packages aimed at health care providers (mainly physicians), where effectiveness means promoting behavior change on the part of practitioners that leads to better patient care. Practice-relevant research information is delivered to providers through publication of results from randomized clinical trials, dissemination of consensus recommendations, development and use of computer-based aids to clinical decision making, and provision of continuing medical education. Each of these areas offers numerous examples of the exceedingly modest behavioral response that can be expected from the mere provision of information. The literature also offers some principles that may improve the chances for success, including the desirability of techniques that involve face-to-face interaction, promoting the active involvement of the learner, repeating the message, making recommendations explicit and relevant to clinical practice, and making use of opinion leaders and peer influence. Little basic research has been done on providers' motivations and actual decision-making processes. Research aimed at furthering a behavioral science of providers could yield new insights on effective dissemination strategies as well.",0,1,
554,Dissemination of Evidence-Based Antipsychotic Prescribing Guidelines to Nursing Homes: A Cluster Randomized Trial,"OBJECTIVES: To evaluate the effectiveness of efforts to translate and disseminate evidence-based guidelines about atypical antipsychotic use to nursing homes (NHs). DESIGN: Three-arm, cluster randomized trial. SETTING: NHs. PARTICIPANTS: NHs in the state of Connecticut. MEASUREMENTS: Evidence-based guidelines for atypical antipsychotic prescribing were translated into a toolkit targeting NH stakeholders, and 42 NHs were recruited and randomized to one of three toolkit dissemination strategies: mailed toolkit delivery (minimal intensity)""; mailed toolkit delivery with quarterly audit and feedback reports about facility-level antipsychotic prescribing (moderate intensity);"" and in-person toolkit delivery with academic detailing, on-site behavioral management training, and quarterly audit and feedback reports (high intensity). Outcomes were evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. RESULTS: Toolkit awareness of 30% (7/23) of leadership of low-intensity NHs, 54% (19/35) of moderate-intensity NHs, and 82% (18/22) of high-intensity NHs reflected adoption and implementation of the intervention. Highest levels of use and knowledge among direct care staff were reported in high-intensity NHs. Antipsychotic prescribing levels declined during the study period, but there were no statistically significant differences between study arms or from secular trends. CONCLUSION: RE-AIM indicators suggest some success in disseminating the toolkit and differences in reach, adoption, and implementation according to dissemination strategy but no measurable effect on antipsychotic prescribing trends. Further dissemination to external stakeholders such as psychiatry consultants and hospitals may be needed to influence antipsychotic prescribing for NH residents.",0,1,
555,Do decision support systems influence variation in prescription?,"BACKGROUND: Translating scientific evidence into daily practice is problematic. All kinds of intervention strategies, using educational and/or directive strategies, aimed at modifying behavior, have evolved, but have been found only partially successful. In this article the focus is on (computerized) decision support systems (DSSs). DSSs intervene in physicians' daily routine, as opposed to interventions that aim at influencing knowledge in order to change behavior. We examined whether general practitioners (GPs) are prescribing in accordance with the advice given by the DSS and whether there is less variation in prescription when the DSS is used. METHODS: Data were used from the Second Dutch National Survey of General Practice (DNSGP2), collected in 2001. A total of 82 diagnoses, 749811 contacts, 133 physicians, and 85 practices was included in the analyses. GPs using the DSS daily were compared to GPs who do not use the DSS. Multilevel analyses were used to analyse the data. Two outcome measures were chosen: whether prescription was in accordance with the advice of the DSS or not, and a measure of concentration, the Herfindahl-Hirschman Index (HHI). RESULTS: GPs who use the DSS daily prescribe more according to the advice given in the DSS than GPs who do not use the DSS. Contradictory to our expectation there was no significant difference between the HHIs for both groups: variation in prescription was comparable. CONCLUSION: We studied the use of a DSS for drug prescribing in general practice in the Netherlands. The DSS is based on guidelines developed by the Dutch College of General Practitioners and implemented in the Electronic Medical Systems of the GPs. GPs using the DSS more often prescribe in accordance with the advice given in the DSS compared to GPs not using the DSS. This finding, however, did not mean that variation is lower"";"" variation is the same for GPs using and for GPs not using a DSS. Implications of the study are that DSSs can be used to implement guidelines, but that it should not be expected that variation is limited.",0,1,
556,Do Health Reforms Impact Cost Consciousness of Health Care Professionals? Results from a Nation-Wide Survey in the Balkans,"BACKGROUND: Serbia, as the largest market of the Western Balkans, has entered socioeconomic transition with substantial delay compared to most of Eastern Europe. Its health system reform efforts were bold during the past 15 years, but their results were inconsistent in various areas. The two waves of global recession that hit Balkan economies ultimately reflected to the financial situation of healthcare. Serious difficulties in providing accessible medical care to the citizens became a reality. A large part of the unbearable expenses actually belongs to the overt prescription of pharmaceuticals and various laboratory and imaging diagnostic procedures requested by physicians. Therefore, a broad national survey was conducted at all levels of the healthcare system hierarchy to distinguish the ability of cost containment strategies to reshape clinician's mindsets and decision-making in practice. AIMS: Assessment of healthcare professionals' judgment on economic consequences of prescribed medical interventions and evaluation of responsiveness of healthcare professionals to policy measures targeted at increasing cost-consciousness. STUDY DESIGN: Cross-sectional study. METHODS: A nationwide cross-sectional survey was conducted through a hierarchy of medical facilities across diverse geographical regions before and after policy action, from January 2010 to April 2013. In the middle of the observed period, the National Health Insurance Fund (RFZO) adopted severe cost-containment measures. Independently, pharmacoeconomic guidelines targeted at prescribers were disseminated. Administration in large hospitals and community pharmacies was forced to restrict access to high budget-impact medical care. Economic Awareness of Healthcare Professionals Questionnaire-29 (EAHPQ-29), developed in Serbian language, was used in face-to-face interviews. The questionnaire documented clinician's attitudes on: Clinical-Decision-Making-between-Alternative-Interventions (CDMAI), Quality-of-Health-Care (QHC), and Cost-Containment-Policy (CCP). The authors randomly and anonymously recruited 2000 healthcare experts, with a total of 1487 responding""; after eliminating incomplete surveys, 649 participants were considered before and 651 after policy intervention. RESULTS: Dentists (1.195+/-0.560) had a higher mean CDMAI score compared to physicians (1.017+/-0.453). The surgical group compared to the internist group had a higher total EAHPQ-29 score, CCP score and CDMAI score. Policy intervention had a statistically significant negative impact on the QHC score (F=4.958; df=1;"" p=0.027). There was no substantial impact of policy interventions on professional behavior and judgment with regard to the CDMAI, CCP, and total EAHPQ-29 scores. CONCLUSION: Although cost savings were forcibly imposed in practice, the effects on clinical decision-making were modest. Clinicians' perceptions of quality of medical care were explained in a less effective manner due to the severely constrained resources allocated to the providers. This pioneering effort in the Balkans exposes the inefficiency of current policies to expand clinicians' cost consciousness.",0,0,
557,Do knowledge brokers facilitate implementation of the stroke guideline in clinical practice?,"BACKGROUND: The implementation of clinical practice guidelines in rehabilitation practice is often troublesome and incomplete. An intervention to enhance the implementation of guidelines is the knowledge transfer program built around the activities of a knowledge broker (KB).This study investigates the use of KBs to implement guideline recommendations for intensive therapy and physical activity for patients post-stroke in 22 stroke units in hospitals and rehabilitation centers in The Netherlands. METHODS/DESIGN: This study includes a quantitative evaluation with a non controlled pre-post intervention design and a mixed methods process evaluation. From each stroke unit, enterprising nurses and therapists will be recruited and trained as KB. The KB will work for one year on the implementation of the guideline recommendations in their team. To evaluate the effectiveness of the KB, a questionnaire will be administered to patients, health professionals and KBs at baseline (T0) and after one year (T1). Furthermore, semi structured interviews with 5 KBs will be performed at T1.The primary outcome of this implementation project will be the support health professionals give patients to exercise and be physically active, as reported by patients and health professionals themselves. The support immediately after the intervention is compared with the support at the start of the intervention.Additionally we will explore the influence of socio-demographic characteristics of health professionals and determinants identified in the Theory of Planned Behavior (intention, attitude, subjective norm and perceived behavioral control) on the change of supportive behavior of health professionals. Finally, KBs will complete a questionnaire on their own psychological and social demographic characteristics and on organizational conditions needed for health-care improvement such as time, workforce, sponsoring and support from management. DISCUSSION: With this study we will gain insight in when and why knowledge brokers seem to be effective. Also we will identify determinants that predict which health professionals are susceptible to change their behavior. This study will provide guidance how to implement guidelines and will help to improve stroke rehabilitation services.",0,0,
558,Do nurses have a different physical health profile? A systematic review of experimental and observational studies on nurses' physical health,"AIM: To review the evidence on nurses' health systematically. BACKGROUND: Nurses are one of the most important resources of a health system. They are subjected to biological, socio-economic, cultural and health system factors that determine their health. Although mental and physical health problems seem to prevail among nurses, literature is often contradictory. The literature on health styles, health behaviours and self perceived health of nurses is also unclear. DESIGN: Systematic review of experimental and observational studies on nurses' health. METHODS: Forty-three databases searched. 2692 references identified as of potential interest"";"" 187 studies included. Only the results from studies on physical health are presented. No meta-analysis was possible. The Scottish Intercollegiate Guidelines Network system was used to rate evidence. RESULTS: Nurses were at greater risk of musculoskeletal injuries and more prone to blood-borne pathogens infections than other health care workers. They were at greater risk of breast cancer than other female health care workers. Nurses in hospitals were more at risk of tuberculosis. They did not have excess risk of cancer in general, Hodgkin's disease, stomach, colon, rectum, pancreatic, ovary, kidney, brain or thyroid cancer or of lymphosarcoma. They have a higher prevalence of occupational allergies than clerical workers. DISCUSSION: Nurses suffer more from musculoskeletal disorders which is consistent with the nature of nursing work. They are at greater risk of acquiring tuberculosis, particularly if they work in pulmonary, medicine or Human Immunodeficiency Virus wards which might be due to repeated contact with infected patients. Nurses are also more prone to blood-borne pathogens infections which might be explained by exposure while working. The proneness to occupational allergies can be explained by exposure to a series of chemical agents. RELEVANCE TO CLINICAL PRACTICE: Without sound knowledge on nurses' health and it is not possible to develop specific occupational health programmes.",0,0,
559,Do pediatricians apply the 2009 NASPGHAN-ESPGHAN guidelines for the diagnosis and management of gastroesophageal reflux after being trained?,"BACKGROUND: According to a recent survey, the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines are poorly adhered to by European primary care pediatricians. The main issue raised from the survey was the prescription of unnecessary acid suppressive medications, especially in infants. No inquiry into the reasons was made. The primary objective of the present study was to assess the applicability of the guidelines in European primary care pediatricians undergoing specific trainings. METHODS: One hundred pediatricians involved in the previous survey agreed to participate and were randomly divided into 2 groups: one group was trained in the guidelines through an online podcast and the other group was trained through a synopsis. During the following 3 months, each involved pediatrician was asked to enroll every consecutive infant, child, or adolescent with suggestive reflux symptoms. For every enrolled patient, pediatricians filled in a report concerning their diagnostic and therapeutic choices. RESULTS: A total of 382 patients (boys/girls 186/196, infants/children/adolescents 194/123/65) were enrolled by pediatricians. Infants with unexplained crying and/or distressed behavior who were prescribed proton-pump inhibitors were 3.7% compared with 45.2% of the survey data obtained before the training (P < 0.05). Infants with uncomplicated recurrent regurgitation and vomiting who were prescribed proton-pump inhibitors were 4.5% against 37.1% of the baseline survey data (P < 0.05). The overall rate of children managed in full compliance with the guidelines was 46.1% after the training compared with 1.8% before the training (P < 0.05). No significant differences were seen between pediatricians from podcast and synopsis group. CONCLUSIONS: The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition gastroesophageal reflux guidelines have good applicability, despite that they are presently poorly adhered to by European primary care pediatricians. Simple, inexpensive trainings were proven to be effective in increasing adherence by pediatricians. The increase in compliance clearly favors the role of continuous medical education through simple educational tools and subsequent assessment of practice.",0,1,
560,Do polypills lead to neglect of lifestyle risk factors? Findings from an individual participant data meta-analysis among 3140 patients at high risk of cardiovascular disease,"AIM: The aim of this study was to investigate whether polypill-based care for the prevention of cardiovascular disease (CVD) is associated with a change in lifestyle risk factors when compared with usual care, among patients with CVD or high calculated cardiovascular risk. METHODS: We conducted an individual participant data meta-analysis of three trials including patients from Australia, England, India, Ireland, the Netherlands and New Zealand that compared a strategy using a polypill containing aspirin, statin and antihypertensive therapy with usual care in patients with a prior CVD event or who were at high risk of their first event. Analyses investigated any differential effect on anthropometric measures and self-reported lifestyle behaviours. RESULTS: Among 3140 patients (75% male, mean age 62 years and 76% with a prior CVD event) there was no difference in lifestyle risk factors in those randomised to polypill-based care compared with usual care over a median of 15 months, either across all participants combined, or in a range of subgroups. Furthermore, narrow confidence intervals (CIs) excluded any major effect"";"" for example differences between the groups in body mass index was -0.1 (95% CI -0.2 to 0.1) kg/m(2), in weekly duration of moderate intensity physical activity was -2 (-26 to 23) minutes and the proportion of smokers was 16% vs 17% (RR 0.98, 0.84 to 1.15) at the end of trial. DISCUSSION: This analysis allays concern that polypill-based care may lead to neglect of lifestyle risk factors, at least among high-risk patients. Maximally effective preventive approaches should address lifestyle factors alongside pharmaceutical interventions, as recommended by major international guidelines.",0,0,
561,Documentation-based clinical decision support to improve antibiotic prescribing for acute respiratory infections in primary care: a cluster randomised controlled trial,"Background and objective Clinical guidelines discourage antibiotic prescribing for many acute respiratory infections (ARIs), especially for non-antibiotic appropriate diagnoses. Electronic health record (EHR)-based clinical decision support has the potential to improve antibiotic prescribing for ARIs. Methods We randomly assigned 27 primary care clinics to receive an EHR-integrated, documentation based clinical decision support system for the care of patients with ARIs - the ARI Smart Form - or to offer usual care. The primary outcome was the antibiotic prescribing rate for ARIs in an intent-to-intervene analysis based on administrative diagnoses. Results During the intervention period, patients made 21 961 ARI visits to study clinics. Intervention clinicians used the ARI Smart Form in 6% of 11 954 ARI visits. The antibiotic prescribing rate in the intervention clinics was 39% versus 43% in the control clinics (odds ratio (OR), 0.8""; 95% confidence interval (CI), 0.6_1.2, adjusted for clustering by clinic). For antibiotic appropriate ARI diagnoses, the antibiotic prescribing rate was 54% in the intervention clinics and 59% in the control clinics (OR, 0.8; 95% CI, 0.5_1.3). For non-antibiotic appropriate diagnoses, the antibiotic prescribing rate was 32% in the intervention clinics and 34% in the control clinics (OR, 0.9; 95% CI, 0.6_1.4). When the ARI Smart Form was used, based on diagnoses entered on the form, the antibiotic prescribing rate was 49% overall, 88% for antibiotic appropriate diagnoses and 27% for non-antibiotic appropriate diagnoses. In an as-used analysis, the ARI Smart Form was associated with a lower antibiotic prescribing rate for acute bronchitis (OR, 0.5;"" 95% CI, 0.3_0.8). Conclusions The ARI Smart Form neither reduced overall antibiotic prescribing nor significantly improved the appropriateness of antibiotic prescribing for ARIs, but it was not widely used. When used, the ARI Smart Form may improve diagnostic accuracy compared to administrative diagnoses and may reduce antibiotic prescribing for certain diagnoses.",0,1,
562,Does a joint development and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/post study with concurrent control group and a randomised trial,"BACKGROUND: It is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing. METHODS: The study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group. A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugs. The main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations. RESULTS: Significant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement. CONCLUSION: Disseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change.",0,0,563
563,Does a joint development and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/post study with concurrent control group and a randomised trial.,"Background It is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing.  Methods The study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group.  A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugs  The main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations.  Results Significant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement.  Conclusion Disseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change.",0,1,
564,Does methadone maintenance treatment based on the new national guidelines work in a primary care setting?,"BACKGROUND: General practitioners (GPs) are being encouraged to treat more drug users but there are few studies to demonstrate the effectiveness of primary care treatment. AIM: To determine whether patients retained on methadone maintenance treatment for one year in a modern British primary care setting, with prescribing protocols based on the new national guidelines, can achieve similar harm reduction outcomes to those demonstrated in other settings, using objective outcome measures where available. DESIGN OF STUDY: Longitudinal cohort study. SETTING: The Primary Care Clinic for Drug Dependence, Sheffield. METHOD: The intervention consisted of a methadone maintenance treatment provided by GPs with prescribing protocols based on the 1999 national guidelines. The first 96 eligible consenting patients entering treatment were recruited"";"" 65 completed the study. Outcome measures were current drug use, HIV risk-taking behaviour, social functioning, criminal activity, and mental and physical health, supplemented by urinalysis and criminal record data. RESULTS: Frequency of heroin use was reduced from a mean of 3.02 episodes per day (standard deviation [SD] = 1.73) to a mean of 0.22 episodes per day (SD = 0.54), (chi 2 = 79.48, degrees of freedom [df] = 2, P < 0.001), confirmed by urinalysis. Mean numbers of convictions and cautions were reduced by 62% (z = 3.378, P < 0.001) for all crime. HIV risk-taking behaviour, social functioning, and physical and psychological wellbeing all showed significant improvements. CONCLUSION: Patients retained on methadone maintenance treatment for one year in a primary care setting can achieve improvements on a range of harm reduction outcomes similar to those shown by studies in other, often more highly structured programmes.",0,0,
565,Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials,"BACKGROUND: The efficacy of antidepressant medication has been shown empirically to be overestimated due to publication bias, but this has only been inferred statistically with regard to psychological treatment for depression. We assessed directly the extent of study publication bias in trials examining the efficacy of psychological treatment for depression. METHODS AND FINDINGS: We identified US National Institutes of Health grants awarded to fund randomized clinical trials comparing psychological treatment to control conditions or other treatments in patients diagnosed with major depressive disorder for the period 1972-2008, and we determined whether those grants led to publications. For studies that were not published, data were requested from investigators and included in the meta-analyses. Thirteen (23.6%) of the 55 funded grants that began trials did not result in publications, and two others never started. Among comparisons to control conditions, adding unpublished studies (Hedges' g = 0.20""; CI95% -0.11~0.51; k = 6) to published studies (g = 0.52; 0.37~0.68; k = 20) reduced the psychotherapy effect size point estimate (g = 0.39;"" 0.08~0.70) by 25%. Moreover, these findings may overestimate the ""true"" effect of psychological treatment for depression as outcome reporting bias could not be examined quantitatively. CONCLUSION: The efficacy of psychological interventions for depression has been overestimated in the published literature, just as it has been for pharmacotherapy. Both are efficacious but not to the extent that the published literature would suggest. Funding agencies and journals should archive both original protocols and raw data from treatment trials to allow the detection and correction of outcome reporting bias. Clinicians, guidelines developers, and decision makers should be aware that the published literature overestimates the effects of the predominant treatments for depression.",0,0,
566,Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review,"BACKGROUND: Adolescence and young adulthood are important developmental periods. Screening for health compromising behaviours and mental health disorders during routine primary care visits has the potential to assist clinicians to identify areas of concern and provide appropriate interventions. The objective of this systematic review is to investigate whether screening and subsequent interventions for multiple health compromising behaviours and mental health disorders in primary care settings improves the health outcomes of young people. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in Medline, PsycINFO, Scopus and Cochrane Library databases (Prospero registration number CRD42013005828) using search terms representing four thematic concepts: primary care, young people, screening, and mental health and health compromising behaviour. To be eligible for inclusion, studies had to: include a measure of health outcome""; include at least 75 % of participants aged under 25 years; use a screening tool that assessed more than one health domain;"" and be conducted within a primary care setting. Risk of bias was assessed using the Quality Rating Scale. RESULTS: From 5051 articles identified, nine studies fulfilled the inclusion criteria and were reviewed: two randomised controlled trials (RCTs), one pilot RCT, two clustered RCTs, one randomised study with multiple intervention groups and no control group, one cluster RCT with two active arms, one longitudinal study and one pre-post study. Seven studies, including two RCTs and one clustered RCT, found positive changes in substance use, diet, sexual health or risky sexual behaviour, alcohol-related risky behaviour, social stress, stress management, helmet use, sleep and exercise. Of only two studies reporting on harms, one reported a negative health outcome of increased alcohol use. CONCLUSIONS: There is some evidence that the use of screening and intervention with young people for mental health disorder or health compromising behaviours in clinical settings improves health outcomes. Along with other evidence that young people value discussions of health risks with their providers, these discussions should be part of the routine primary care of young people. Further quality studies are needed to strengthen this evidence.",0,0,
567,Does shared care help in the treatment of depression?,"INTRODUCTION: shared or Collaborative Care in the treatment of Depression is an evidence based intervention which has been shown to be more effective than ordinary general Practitioner care in the treatment of Depression, however, it is not yet Government policy in the United Kingdom. We aimed to bring together in one place all the studies which have been carried out, up till mid 2009, in order to demonstrate the evidence that shared collaborative care has important advantages in terms both of depression outcomes and cost benefits, in order to argue for the adoption of this approach in the United Kingdom and n Europe. METHODS: we carried out a literature search using PUBMED in order to identify and describe all trials, systematic reviews and Metanalyses which have been carried out on shared care until mid 2009. We also described a shared care service for depression which some of us had been involved in developing and working in in Luton in the late 1990's. We have excluded papers which describe trials which have not yet been carried out, and instead focussed on the trials which have reported. RESULTS: it has been demonstrated in numerous recent studies that shared care in the treatment of depression, which includes the training of General Practitoners in the treatment of depression, and the provision in Primary Care of a Nurse specialist or another professional who will impart psycho-education, ensure concordance with medication, and may provide psychotherapy, leads to both improved treatment outcomes and increased doctor and patient satisfaction, as well providing some cost-benefits, despite somewhat increased immediate costs. This is the case in both adult and adolescent patients, while in the case of diabetic patients depression is improved, despite the lack of improvement in glycaemic control. The shared care intervention continues to be useful in the case of patients with resistant depressive symptoms, though a longer input will be necessary in such cases. Patients with subthreshold depression will not benefit as much, and patients expressed more satisfaction when psychological interventions were offered. It is also the case that collaborative or shared care is effective in treating depression in the elderly. This is shown by studies which include older patients who also suffer from multiple health conditions, arthritis, diabetes, anxiety and PTSD, the poorer, those with suicidal ideation, and also in Ethnic Minorities. DISCUSSION: The results described above are mostly based on studies carried out in the USA, but similar studies have been reported from the United Kingdom, and are consistent with the experience of the service in Luton which we describe. From these results it would seem important that shared, collaborative care, with primary and secondary care doctors (General Practitioners and Psychiatrists) working as part of a single team, with the help of mental health practitioners attached to primary care, but with easy access to secondary care is a productive way of optimising the treatment of depression. In the UK, however, it has not yet been possible to develop such a service for the whole population. This is becausein the UK, General Practice is managed by Primary Care Trusts, while Secondary Care, including Psychiatry, is managed by Mental Health Trusts. This has led the National Institute of Health and Clinical Excellence, and indeed local commissioners of care to focus on a Stepped Model for the treatment of depression, with one key issue being access (or referral) to secondary care, and discharge back to primary care, with a group of Mental Health workers focussing on the facilitation (or gate-keeping) of these processes, rather than focussing on actually optimising outcomes of care. CONCLUSION: the evidence argues for the development of collaborative care between primary and secondary care for the treatment of Depression. This will require common medication guidelines across both Primary and Secondary Care, easy access so that General Practitioners can receive advice from Psychiatrists about patients, and the use of Mental Health Professionals to provide patients with psycho-education, support of concordance with treatment, and psychotherapy. It may be that, in order for this to be achieved, services may need to be re-structured, to allow easy communication between professionals.",0,0,
568,"Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations","BACKGROUND: Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched. DATA SOURCES: Databases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015). REVIEW METHODS: Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately under International Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines. OBJECTIVES: To review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom. RESULTS: From 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW""; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) -0.61, 95% confidence interval (CI) -0.96 to -0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted across all of the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD -0.04 95% CI -0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use;"" and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW. LIMITATION: Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure. CONCLUSIONS: Overall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012003343. FUNDING: The National Institute for Health Research Health Technology Assessment programme.",0,0,
569,Dominant inheritance of intracranial berry aneurysm,,0,0,
570,Dressings for venous leg ulcers: systematic review and meta-analysis,"OBJECTIVE To review the evidence of effectiveness of dressings applied to venous leg ulcers. DESIGN Systematic review and meta-analysis. DATA SOURCES Hand searches of journals and searches of electronic databases, conference proceedings, and bibliographies up to April 2006""; contacts with dressing manufacturers for unpublished studies. STUDIES REVIEWED All randomised controlled trials that evaluated dressings applied to venous leg ulcers were eligible for inclusion. Data from eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Methodological quality was assessed independently by two reviewers. RESULTS The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials;"" relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings. CONCLUSIONS The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.",0,0,
571,"Driving simulators for occupational therapy screening, assessment, and intervention","Simulation technology provides safe, objective, and repeatable performance measures pertaining to operational (e.g., avoiding a collision) or tactical (e.g., lane maintenance) driver behaviors. Many occupational therapy researchers and others are using driving simulators to test a variety of applications across diverse populations. A growing body of literature provides support for associations between simulated driving and actual on-road driving. One limitation of simulator technology is the occurrence of simulator sickness, but management strategies exist to curtail or mitigate its onset. Based on the literature review and a consensus process, five consensus statements are presented to support the use of driving simulation technology among occupational therapy practitioners. The evidence suggests that by using driving simulators occupational therapy practitioners may detect underlying impairments in driving performance, identify driving errors in at-risk drivers""; differentiate between driving performance of impaired and healthy controls groups; show driving errors with absolute and relative validity compared to on-road studies; and mitigate the onset of simulator sickness. Much progress has been made among occupational therapy researchers and practitioners in the use of driving simulation technology;"" however, empirical support is needed to further justify the use of driving simulators in clinical practice settings as a valid, reliable, clinical useful, and cost effective tool for driving assessment and intervention.",0,0,
572,Drug formularies in hospitals,,0,0,
573,Drug rechallenge and patients' rights,"Challenging a hypersensitive patient with a potentially harmful drug is most important to the development of medical knowledge. However, it does not always serve the interest of the particular patient. In order to protect the interest of an individual patient, one must abstain from challenge unless it is vital to the health of the particular patient at the time and has no substitute. Patients' rights demand the establishment of limitations and guidelines for the procedure of rechallenge in all its aspects. An approach which will bring physicians closer to a solution, which will protect the patient from uncontrolled decisions and from unnecessary risks, is suggested.",0,0,
574,Drug use and the role of patients and prescribers,"In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.""; PIP: In the effort to improve rational drug use in local or national settings, especially in developing countries, the behavior of prescribers and users is the subject of the least research. The effectiveness of drugs depends on a complex set of factors involved in the situation of prescription and acquisition. One aspect that needs examination is the information given to prescribers by drug advertisers and detailers, a deficiency being addressed by an international network of prescribers. In many countries, the largest outlet for drugs is the private sector pharmacies, where drugs are often dispensed without prescription. A simple inexpensive way of researching prescription behavior is to use fictitious tracers to follow case management of given conditions, such as infant diarrhea. There are many factors involved in prescribing;"" the process must be studied with an epidemiologic approach, i.e., by description, analysis, intervention and evaluation. Standard treatment schedules, essential drugs lists, targeted intervention with treatment guidelines should be audited by local therapeutic committees. Drug information should also be scientifically evaluated by the same analytical principles. The experimental method of group randomization is suggested as a feasible choice for developing countries. In this technique groups of physicians are observed or interviewed, and quantitative outcome data are collected. Behavior of individual users is best studied by combining anthropological and biomedical approaches, from the case-study perspective. An example of a problem amenable to this approach is the possible use of shorter courses of antibiotic treatment to lessen the risk of development of resistant organisms.",0,0,
575,DRUGS system enhancing adherence of Chinese surgeons to antibiotic use guidelines during perioperative period,"OBJECTIVE: Irrational use of antimicrobial agents for preventing postoperative SSIs is a common phenomenon in China, which results in more bacterial resistance, higher hospital infection rates, extra costs of antimicrobial agents. The aim of the study is to evaluate the effect of Drug Rational Usage Guidelines System (DRUGS) on the surgeon's prescription behavior of antimicrobial agents. METHODS: 10 common surgical operations which included 1543 cases (where 778 cases using paper-based guidelines and 765 cases using DRUGS) were selected and their demographic and clinical data were collected. The selected operations include thyroid resection, breast mass resection, myomectomy, etc. The evaluation criteria were antibiotic administrative categories, the time of initial dose, duration of administration, length of stay, the costs of antibiotics, SSIs and drug adverse reactions(ADR). RESULTS: The antimicrobial agents were mostly administrated within 0.5 h to 2 h before incision, 656 patients (85.75%) were intervened with DRUGS and 256 (32.90%) with paper-based guidelines according to the protocol. For the clean wounds incision, 547 patients (91.62%) were within 24 h of withdrawal antibiotics with using paper-based guidelines versus 91 (14.79%) with using DRUGS. A total of 19 kinds of antibiotics were used in the 1543 cases. The leading three on the list of frequency were piperacillin and sulbactam sodium, cefathiamidine and cefoperazone. While after the intervention, the list of frequency changed to cefazolin, cefathiamidine, cefoperazone. The average hospital stay was (7.00+/-4.31)d with paper-based guidelines and (2.54+/-1.57)d with DRUGS, respectively. The average cost of antibiotics was yen(3481.36+/-2584.46) with paper-based guidelines and yen(1693.39+/-1478.27) with DRUGS, respectively. However, there were no significant differences in the incidence of SSIs and ADR between two groups. CONCLUSION: In this study, the increased availability of antibiotic guidelines at the time of drug ordering, combined with DRUGS, was associated with an enhanced surgeon adherence to guidelines.",0,0,
576,Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial,"CONTEXT: Prostate cancer screening with prostate-specific antigen (PSA) is frequently performed, counter to clinical practice guidelines. BACKGROUND: It was hypothesized that an e-mail-based intervention termed ""spaced education"" could reduce clinicians' inappropriate screening for prostate cancer. DESIGN: The study was conducted as an RCT. SETTING/PARTICIPANTS: The study involved 95 primary care clinicians in eight Veterans Affairs medical centers from January 2007 to February 2009. INTERVENTION: Participants were randomized into two cohorts: spaced education clinicians received four isomorphic cycles of nine e-mails over 36 weeks (zero to two e-mails per week), whereas control clinicians received no intervention. Each e-mail presented a clinical scenario and asked whether it was appropriate to obtain a PSA test. Participants received immediate feedback after submitting their answers. MAIN OUTCOME MEASURES: The primary outcome was the number and percentage of inappropriate PSA screening tests ordered. Inappropriate testing was defined as use of PSA for prostate cancer screening in patients aged >76 or <40 years. Appropriateness of screening was dichotomized based on patient age at time of screening. Patients with PSA testing for non-screening reasons were excluded using a validated protocol. Logistic regression with adjustment for patient clustering by clinician was performed. Analyses were conducted in 2009. RESULTS: During the intervention period (Weeks 1-36), clinicians receiving spaced education e-mails ordered significantly fewer inappropriate PSA screening tests than control clinicians (10.5% vs 14.2%, p=0.041). Over the 72-week period following the intervention (Weeks 37-108), spaced education clinicians continued to order fewer inappropriate tests compared to controls (7.8% vs 13.1%, respectively, p=0.011), representing a 40% relative reduction in inappropriate screening. CONCLUSIONS: Spaced education durably improves the prostate cancer screening behaviors of clinicians and represents a promising new methodology to improve patient care across healthcare systems.",1,1,
577,Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study,"OBJECTIVES To evaluate whether happiness can spread from person to person and whether niches of happiness form within social networks. DESIGN Longitudinal social network analysis. SETTING Framingham Heart Study social network. PARTICIPANTS 4739 individuals followed from 1983 to 2003. MAIN OUTCOME MEASURES Happiness measured with validated four item scale"";"" broad array of attributes of social networks and diverse social ties. RESULTS Clusters of happy and unhappy people are visible in the network, and the relationship between people's happiness extends up to three degrees of separation (for example, to the friends of one's friends' friends). People who are surrounded by many happy people and those who are central in the network are more likely to become happy in the future. Longitudinal statistical models suggest that clusters of happiness result from the spread of happiness and not just a tendency for people to associate with similar individuals. A friend who lives within a mile (about 1.6 km) and who becomes happy increases the probability that a person is happy by 25% (95% confidence interval 1% to 57%). Similar effects are seen in coresident spouses (8%, 0.2% to 16%), siblings who live within a mile (14%, 1% to 28%), and next door neighbours (34%, 7% to 70%). Effects are not seen between coworkers. The effect decays with time and with geographical separation. CONCLUSIONS People's happiness depends on the happiness of others with whom they are connected. This provides further justification for seeing happiness, like health, as a collective phenomenon.",0,0,
578,"Dyslipidemia in primary care--prevalence, recognition, treatment and control: data from the German Metabolic and Cardiovascular Risk Project (GEMCAS)","BACKGROUND: Current guidelines from the European Society of Cardiology (ESC) define low thresholds for the diagnosis of dyslipidemia using total cholesterol (TC) and LDL-cholesterol (LDL-C) to guide treatment. Although being mainly a prevention tool, its thresholds are difficult to meet in clinical practice, especially primary care. METHODS: In a nationwide study with 1,511 primary care physicians and 35,869 patients we determined the prevalence of dyslipidemia, its recognition, treatment, and control rates. Diagnosis of dyslipidemia was based on TC and LDL-C. Basic descriptive statistics and prevalence rate ratios, as well as 95% confidence intervals were calculated. RESULTS: Dyslipidemia was highly frequent in primary care (76% overall). 48.6% of male and 39.9% of female patients with dyslipidemia was diagnosed by the physicians. Life style intervention did however control dyslipidemia in about 10% of patients only. A higher proportion (34.1% of male and 26.7% female) was controlled when receiving pharmacotherapy. The chance to be diagnosed and subsequently controlled using pharmacotherapy was higher in male (PRR 1.15""; 95%CI 1.12-1.17), in patients with concomitant cardiovascular risk factors, in patients with hypertension (PRR 1.20; 95%CI 1.05-1.37) and cardiovascular disease (PRR 1.46; 95%CI 1.29-1.64), previous myocardial infarction (PRR 1.32; 95%CI 1.19-1.47), and if patients knew to be hypertensive (PRR 1.18; 95%CI 1.04-1.34) or knew about their prior myocardial infarction (PRR 1.17;"" 95%CI 1.23-1.53). CONCLUSION: Thresholds of the ESC seem to be difficult to meet. A simple call for more aggressive treatment or higher patient compliance is apparently not enough to enhance the proportion of controlled patients. A shift towards a multifactorial treatment considering lifestyle interventions and pharmacotherapy to reduce weight and lipids may be the only way in a population where just to be normal is certainly not ideal.",0,0,
579,Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial,"BackgroundThrombolysis with intravenous alteplase is the only approved treatment for acute ischaemic stroke. After alteplase-induced recanalisation, reocclusion occurs in 14?34% of patients, probably because of platelet activation. Early administration of antiplatelet therapy after alteplase could reduce the risk of reocclusion and improve outcome. We compared the effects of early addition of intravenous aspirin to alteplase with standard alteplase without aspirin."";"" BackgroundThrombolysis with intravenous alteplase is the only approved treatment for acute ischaemic stroke. After alteplase-induced recanalisation, reocclusion occurs in 14?34% of patients, probably because of platelet activation. Early administration of antiplatelet therapy after alteplase could reduce the risk of reocclusion and improve outcome. We compared the effects of early addition of intravenous aspirin to alteplase with standard alteplase without aspirin.",0,0,
580,"Early coverage, access, utilization, and health effects of the affordable care act medicaid expansions: A quasi-experimental study","Background In 2014, only 26 states and D.C. chose to implement the Affordable Care Act (ACA) Medicaid expansions for low-income adults. Objective To estimate whether the state Medicaid expansions were associated with changes in insurance coverage, access to and utilization of health care, and self-reported health. Design Comparison of outcomes before and after the expansions in states that did and did not expand Medicaid. Setting U.S. Participants Citizens aged 19¨C64 with family incomes below 138% of the Federal Poverty Level in the 2010¨C2014 National Health Interview Surveys. Measurements Health insurance coverage (private, Medicaid, uninsured)""; health insurance better than last year; visits with doctors in general practice and with specialists; hospitalizations and ED visits; skipped or delayed medical care; usual source of care; diagnoses of diabetes, high cholesterol, and hypertension; self-reported health; and depression. Results In the second half of 2014, low-income adults in expansion states experienced increased health insurance (7.4 percentage points; 95% CI, ?11.3 to ?3.4) and Medicaid (10.5 percentage points; 95% CI, 6.5 to 14.5) coverage, and increased quality of insurance coverage compared to a year ago (7.1 percentage points; 95% CI, 2.7 to 11.5) when compared to adults in states that did not expand Medicaid. Medicaid expansions were associated with increased visits with doctors in general practice (6.6 percentage points; 95% CI, 1.3 to 12.0), overnight hospital stays (2.4 percentage points; 95% CI, 0.7 to 4.2), and rates of diagnosis of diabetes (5.2 percentage points; 95% CI, 2.4 to 8.1) and high cholesterol (5.7 percentage points; 95% CI, 2.0 to 9.4); changes in other outcomes were not statistically significant. Limitations Observational study may be susceptible to unmeasured confounders; relies on self-reported data;"" limited post-ACA timeframe provides information on short-term changes only. Conclusions The ACA Medicaid expansions were associated with higher rates of insurance coverage, improved quality of coverage, increased utilization of some types of health care, and higher rates of diagnosis of chronic health conditions for low-income adults.",0,0,
581,Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial,"OBJECTIVE To determine whether cognitive therapy is effective in preventing the worsening of emerging psychotic symptoms experienced by help seeking young people deemed to be at risk for serious conditions such as schizophrenia. DESIGN Multisite single blind randomised controlled trial. SETTING Diverse services at five UK sites. PARTICIPANTS 288 participants aged 14-35 years (mean 20.74, SD 4.34 years) at high risk of psychosis: 144 were assigned to cognitive therapy plus monitoring of mental state and 144 to monitoring of mental state only. Participants were followed-up for a minimum of 12 months and a maximum of 24 months. INTERVENTION Cognitive therapy (up to 26 (mean 9.1) sessions over six months) plus monitoring of mental state compared with monitoring of mental state only. MAIN OUTCOME MEASURES Primary outcome was scores on the comprehensive assessment of at risk mental states (CAARMS), which provides a dichotomous transition to psychosis score and ordinal scores for severity of psychotic symptoms and distress. Secondary outcomes included emotional dysfunction and quality of life. RESULTS Transition to psychosis based on intention to treat was analysed using discrete time survival models. Overall, the prevalence of transition was lower than expected (23/288"";"" 8%), with no significant difference between the two groups (proportional odds ratio 0.73, 95% confidence interval 0.32 to 1.68). Changes in severity of symptoms and distress, as well as secondary outcomes, were analysed using random effects regression (analysis of covariance) adjusted for site and baseline symptoms. Distress from psychotic symptoms did not differ (estimated difference at 12 months -3.00, 95% confidence interval -6.95 to 0.94) but their severity was significantly reduced in the group assigned to cognitive therapy (estimated between group effect size at 12 months -3.67, -6.71 to -0.64, P=0.018). CONCLUSIONS Cognitive therapy plus monitoring did not significantly reduce transition to psychosis or symptom related distress but reduced the severity of psychotic symptoms in young people at high risk. Most participants in both groups improved over time. The results have important implications for the at risk mental state concept. TRIAL REGISTRATION Current Controlled Trials ISRCTN56283883.",0,0,
582,Early detection of autism spectrum disorders: screening between 12 and 24 months of age,"PURPOSE: The purpose of this article is to present nurse practitioners (NPs) with information on screening for autism spectrum disorders (ASDs) in children between 12 and 24 months of age. Recommendations are also provided for appropriate referrals and initiation of early intervention (EI). DATA SOURCES: Review of published literature about ASD. CONCLUSIONS: Children with ASD exhibit impaired social interaction, verbal and nonverbal communication deficits, and repetitive, restricted, and stereotyped patterns of behavior or interests. Studies show that these children benefit from beginning intensive EI as soon as possible. IMPLICATIONS FOR PRACTICE: Early detection enables children with suspected ASD to be evaluated by specialists and entered into treatment programs at the earliest possible opportunity. Because of the importance of early diagnosis of ASD, it is critical that NPs use established screening instruments to maximize time and increase the reliability of the assessment.",0,0,
583,"Early photography, goitre, and James Inglis",,0,0,
584,Early training in tackling patient obesity: a systematic review of nurse education,"OBJECTIVES: This systematic review aims to identify studies that have assessed educational interventions in undergraduate nurse training regarding obesity, and to investigate the interventions' effectiveness. BACKGROUND: Obesity is a prominent global issue and nurses have an increased role in weight management with patients. The literature has identified various theory-based behaviour change techniques that successfully assist weight management in patients. Thus, training nurses in obesity-related behaviour change techniques is appropriate in preparing them for their future professional role. However, effectiveness of these educational interventions has not yet been assessed. METHODS: The Centre for Reviews and Dissemination guidelines informed this systematic review. Four databases were systematically searched and articles were assessed against inclusion criteria. Data extraction and quality appraisal forms were developed and completed to identify salient features within the articles. RESULTS: Eight studies met inclusion criteria. Only two included both baseline and outcome measures, one of which was a randomised controlled trial. Additionally, only one study included an explicitly identified behaviour change technique. Interventions were delivered through a range of methods, however, quality appraisal indicated that all of the studies had poor methodologies and had high risks of bias. CONCLUSIONS: Studies in this area of research are sparse and are not methodologically robust. Therefore, it is not possible to identify effective educational interventions for nursing students on weight management. IMPLICATIONS: More robust research is needed to investigate how nurses can be trained to facilitate weight management. Greater transparency of intervention descriptions, particularly around what behaviour change techniques were taught, would allow for replication and appropriate evaluation. Until then, it is not known if current teaching adequately equips nurses to manage obese and overweight patients.",0,0,
585,Early treatment of migraine attacks with triptans: a strategy to enhance outcomes and patient satisfaction?,"Treating migraine attacks early with triptans may be more effective than late triptan administration. However, in published studies, the definition of 'early' varied (in terms of time, pain intensity or presence of allodynia) or was unclear. Therefore, clear clinical indications have not been established. Appropriately designed trials to address this issue remain a priority. Early triptan treatment may also have disadvantages, including inadvertent treatment of tension-type headaches and danger of medication overuse. At present, only those migraineurs with rapid pain worsening, high pain recurrence rate and clinical indications of allodynia should be encouraged to take triptans as quickly as possible. This recommendation implies a requirement for patient education and the need to carefully tailor treatment to individual needs.",0,0,
586,Eating disorders in children and adolescents: pharmacological therapies,"Anorexia nervosa and bulimia nervosa do exist in childhood, frequently have their onset in adolescence, and can result in serious medical and psychiatric sequelae that impede physical, emotional, and behavioral development. Although we use the same Diagnostic and Statistical Manual of Mental Disorders-Version 4 [DSM-IV] definitions to diagnose eating disorders in children, adolescents, and adults, these disorders may be expressed somewhat differently in younger populations, requiring assessment and treatment procedures that are tailored to their developmental needs. Significant advances have been made in recent years in our understanding of treatments for eating disorders in adults, and specifically pharmacological treatments for these disorders. Multiple double-blind, placebo-controlled studies have documented the short-term efficacy of antidepressant medications in bulimia nervosa. While the usefulness of pharmacological treatments for the acute treatment of anorexia nervosa is less clear, recent evidence suggests a role for medication in the relapse-prevention stage of the illness. The majority of the medication trials for the eating disorders have been conducted with adults, and the literature on the pharmacological treatment of children and adolescents with these disorders is very limited. This review article summarizes the current literature on the role of medication in the treatment of anorexia nervosa and bulimia nervosa, with particular emphasis on studies conducted in child and adolescent populations.",0,0,
587,"Eating disorders in the context of preconception care: fertility specialists' knowledge, attitudes, and clinical practices","OBJECTIVE(S): To gauge fertility specialists' knowledge, clinical practices, and training needs in regard to eating disorders. DESIGN: Cross-sectional study. SETTINGS: Fertility clinics. PARTICIPANTS: Eighty Australian and New Zealand fertility specialists who were members of the Fertility Society of Australia. INTERVENTION(S): None. MAIN OUTCOME MEASURES(S): Responses to an anonymously completed online questionnaire. RESULT(S): Approximately 54% of doctors correctly identified the body mass index relevant to anorexia nervosa, and 30% identified menstrual disturbances for anorexia, while 63.8% of doctors incorrectly nominated maladaptive weight control behaviors as a characteristic of binge eating disorder. While clinicians (83.7%) agreed it was important to screen for eating disorders during preconception assessments, 35% routinely screened for eating disorders and 8.8% indicated that their clinics had clinical practice guidelines for management of eating disorders. A minority of participants (13.8%) felt satisfied with their level of university training in eating disorders, 37.5% of doctors felt confident in their ability to recognize symptoms of an eating disorder, and 96.2% indicated a need for further education and clinical guidelines. On most items examined, knowledge and clinical practices regarding eating disorders did not differ according to doctor gender or years of clinical experience working as a fertility specialist. CONCLUSION(S): Knowledge about eating disorders in the context of fertility treatment is important. This study highlights the uncertainty among fertility specialists in detecting features of eating disorders. The findings point to the importance of further education and training, including the development of clinical guidelines specific to fertility health care providers.",0,0,
588,Economic analyses of the Be Fit Be Well program: a weight loss program for community health centers,"BACKGROUND: The U.S. Preventive Services Task Force has released new guidelines on obesity, urging primary care physicians to provide obese patients with intensive, multi-component behavioral interventions. However, there are few studies of weight loss in real world nonacademic primary care, and even fewer in largely racial/ethnic minority, low-income samples. OBJECTIVE: To evaluate the recruitment, intervention and replications costs of a 2-year, moderate intensity weight loss and blood pressure control intervention. DESIGN: A comprehensive cost analysis was conducted, associated with a weight loss and hypertension management program delivered in three community health centers as part of a pragmatic randomized trial. PARTICIPANTS: Three hundred and sixty-five high risk, low-income, inner city, minority (71 % were Black/African American and 13 % were Hispanic) patients who were both hypertensive and obese. MAIN MEASURES: Measures included total recruitment costs and intervention costs, cost per participant, and incremental costs per unit reduction in weight and blood pressure. KEY RESULTS: Recruitment and intervention costs were estimated $2,359 per participant for the 2-year program. Compared to the control intervention, the cost per additional kilogram lost was $2,204 /kg, and for blood pressure, $621 /mmHg. Sensitivity analyses suggest that if the program was offered to a larger sample and minor modifications were made, the cost per participant could be reduced to the levels of many commercially available products. CONCLUSIONS: The costs associated with the Be Fit Be Well program were found to be significantly more expensive than many commercially available products, and much higher than the amount that the Centers for Medicare and Medicaid reimburse physicians for obesity counseling. However, given the serious and costly health consequences associated with obesity in high risk, multimorbid and socioeconomically disadvantaged patients, the resources needed to provide interventions like those described here may still prove to be cost-effective with respect to producing long-term behavior change.",0,0,
589,Economic evaluation of implementation strategies in health care,"Economic evaluations can inform decisions about the efficiency and allocation of resources to implementation strategies¡ªstrategies explicitly designed to inform care providers and patients about the best available research evidence and to enhance its use in their practices. These strategies are increasingly popular in health care, especially in light of growing concerns about quality of care and limits on resources. But such concerns have hardly motivated health authorities and other decision-makers to spend on some form of economic evaluation in their assessments of implementation strategies. This editorial addresses the importance of economic evaluation in the context of implementation science¡ªparticularly, how these analyses can be most efficiently incorporated into decision-making processes about implementation strategies.",0,0,
590,Economic implications of evidence-based prescribing for hypertension: can better care cost less?,"Context Deviation from evidence-based guidelines in hypertension treatment is common, but its economic impact has not been rigorously studied. Suboptimal prescribing patterns contribute to the high cost of medications for elderly patients as well as the difficulty in providing affordable prescription drug benefits for older Americans.  Objective To calculate the potential savings from the perspective of health care payers that would result from increased adherence to evidence-based recommendations for managing hypertension in patients older than 65 years.  Design Comparative analysis of medications prescribed vs potential regimens suggested by evidence-based guidelines tailored to each patient's medical history, with calculation of the costs of both the actual and the evidence-based regimens.  Setting and Patients A total of 133 624 patients being treated for hypertension during 2001 who were enrolled in a large state pharmaceutical assistance program that provides prescription drug insurance for elderly persons.  Main Outcome Measure Cost difference between medications actually prescribed and regimens suggested by evidence-based guidelines.  Results The patients studied filled more than 2.05 million prescriptions for antihypertensive medications in 2001, at an annual program cost of $48.5 million ($363 per patient). We identified 815 316 prescriptions (40%) for which an alternative regimen appeared more appropriate according to evidence-based recommendations. Such changes would have reduced the costs to payers in 2001 by $11.6 million (nearly a quarter of program spending on antihypertensive medications), as well as being more clinically appropriate overall. Replacement of calcium channel blockers resulted in the largest potential savings. Use of pricing limits similar to those in the Medicaid program would have resulted in even larger potential savings of $20.5 million (42% of program costs).  Conclusions Adherence to evidence-based prescribing guidelines for hypertension could result in substantial savings in prescription costs for elderly patients with hypertension that would amount to savings of about $1.2 billion nationally. Identification of similar areas in which prescribing can be improved will be critical for the affordability of prescription drug benefit programs.",0,0,
591,Editorial: Paroxysmal tachycardia in children,,0,0,
592,Editorial: research guidelines,,0,0,
593,Educational and organizational interventions to improve the management of depression in primary care: a systematic review,"CONTEXT: Depression is commonly encountered in primary care settings yet is often missed or suboptimally managed. A number of organizational and educational strategies to improve management of depression have been proposed. The clinical effectiveness and cost-effectiveness of these strategies have not yet been subjected to systematic review. OBJECTIVE: To systematically evaluate the effectiveness of organizational and educational interventions to improve the management of depression in primary care settings. DATA SOURCES: We searched electronic medical and psychological databases from inception to March 2003 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane Controlled Trials Register, United Kingdom National Health Service Economic Evaluations Database, Cochrane Depression Anxiety and Neurosis Group register, and Cochrane Effective Professional and Organisational Change Group specialist register)""; conducted correspondence with authors;"" and used reference lists. Search terms were related to depression, primary care, and all guidelines and organizational and educational interventions. STUDY SELECTION: We selected 36 studies, including 29 randomized controlled trials and nonrandomized controlled clinical trials, 5 controlled before-and-after studies, and 2 interrupted time-series studies. Outcomes relating to management and outcome of depression were sought. DATA EXTRACTION: Methodological details and outcomes were extracted and checked by 2 reviewers. Summary relative risks were, where possible, calculated from original data and attempts were made to correct for unit of analysis error. DATA SYNTHESIS: A narrative synthesis was conducted. Twenty-one studies with positive results were found. Strategies effective in improving patient outcome generally were those with complex interventions that incorporated clinician education, an enhanced role of the nurse (nurse case management), and a greater degree of integration between primary and secondary care (consultation-liaison). Telephone medication counseling delivered by practice nurses or trained counselors was also effective. Simple guideline implementation and educational strategies were generally ineffective. CONCLUSIONS: There is substantial potential to improve the management of depression in primary care. Commonly used guidelines and educational strategies are likely to be ineffective. The implementation of the findings from this research will require substantial investment in primary care services and a major shift in the organization and provision of care.",0,0,
594,Educational Intervention in Primary Care Residents' Knowledge and Performance of Hepatitis B Vaccination in Patients with Diabetes Mellitus,"OBJECTIVES: Although guidelines recommend hepatitis B virus (HBV) immunization for adults with diabetes mellitus (DM), vaccination rates remain low. Our aim was to evaluate knowledge and practice regarding HBV and to assess the effectiveness of a multifaceted educational program. METHODS: Primary care residents (n = 244) at three academic institutions were surveyed about various aspects of HBV. Residents at one training program were then randomly assigned to an educational intervention (E) (n = 20) and control group (C) (n = 19). The E group received a focused didactic lecture and periodic e-mail reminders with immediate feedback. We compared knowledge scores before and after the intervention. Chart audits were conducted to evaluate the residents' behavior. RESULTS: A total of 103 (42%) residents responded to the survey. The survey indicated that residents lacked the necessary knowledge and risk assessment skills concerning HBV in patients with DM. In the controlled trial of the E intervention, both groups had similar baseline knowledge scores. The E group had a significant increase in the immediate postintervention knowledge scores from a mean of 29% at baseline to 70% (P < 0.001) that was sustained 6 months postintervention (65%"";"" P < 0.001). In the C group, 6-month postintervention scores were not different from baseline (38% vs 29%). No significant differences were observed in documentation skills. CONCLUSIONS: A combined educational program was effective in enhancing knowledge about HBV and vaccination in DM but had limited influence on physicians' practice. Further study incorporating system changes along with educational initiatives is required to improve clinical practice.",0,1,
595,Educational interventions for general practitioners to identify and manage depression as a suicide risk factor in young people: a systematic review and meta-analysis protocol,"BACKGROUND: Suicide is a major public health problem and globally is the second leading cause of death in young adults. Globally, there are 164,000 suicides per year in young people under 25 years. Depression is a strong risk factor for suicide. Evidence shows that 45% of those completing suicide, including young adults, contact their general practitioner rather than a mental health professional in the month before their death. Further evidence indicates that risk factors or early warning signs of suicide in young people go undetected and untreated by general practitioners. Healthcare-based suicide prevention interventions targeted at general practitioners are designed to increase identification of at-risk young people. The rationale of this type of intervention is that early identification and improved clinical management of at-risk individuals will reduce morbidity and mortality. This systematic review will synthesise evidence on the effectiveness of education interventions for general practitioners in identifying and managing depression as a suicide risk factor in young people. METHODS/DESIGN: We shall conduct a systematic review and meta-analysis following the Cochrane Handbook for Systematic Reviews of Interventions guidelines and conform to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. Electronic databases will be systematically searched for randomised controlled trials and quasi-experimental studies investigating the effectiveness of interventions for general practitioners in identifying and managing depression as a suicide risk factor in young people in comparison to any other intervention, no intervention, usual care or waiting list. Grey literature will be searched by screening trial registers. Only studies published in English will be included. No date restrictions will be applied. Two authors will independently screen titles and abstracts of potential studies. The primary outcome is identification and management of depression. Secondary outcomes are suicidal ideation, suicide attempts, deliberate self-harm, knowledge of suicide risk factors and suicide-related behaviours, attitudes towards suicide risk and suicide-related behaviours, confidence in dealing with suicide risk factors and suicide-related behaviour. DISCUSSION: Our study will inform the development of future education interventions and provide feasibility and acceptability evidence, to help general practitioners identify and manage suicidal behaviour in young people. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number: CRD42014009110.",0,0,
596,Educational interventions to improve prescription and dispensing of antibiotics: a systematic review,"BACKGROUND: Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings. METHODS: We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011. RESULTS: We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes""; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others;"" only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively. CONCLUSION: The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.",0,0,
597,Educational visiting and hypnosedative prescribing in general practice,"Public concern about the prescription of hypnosedative drugs (mostly benzodiazepines) led to a controlled trial of an educational intervention to promote rational prescribing by general practitioners (GPs). This paper describes the educational intervention and its process evaluation. In urban and rural New South Wales 137 GPs were visited in office hours by a GP or pharmacist who had undergone communication skills training. Material offered to GPs included relaxation tapes and a booklet of problem-orientated management guidelines. The interview had three stages: rapport was established, then educational material was introduced and finally the visitor sought the doctor's agreement to review five patients on long-term benzodiazepines. The visits were well received. Several measures were composed to reflect doctors' motivation and interest in non-drug management"";"" there was virtually no correlation between any of these process measures and the trial outcome: a change in prescribing behaviour. Self-rating of benzodiazepine prescribing greatly underestimated actual self-reported incidents of prescribing. We interpret this as a reminder that we do not always do what we mean to do, and that we do not always do what we think we do.",0,0,
598,Effect of a computerized body mass index prompt on diagnosis and treatment of adult obesity.,"Background: In obese adults, physicians often fail to identify obesity and recommend treatments for it. We sought to determine whether a computerized body mass index (BMI) chart prompt would increase the likelihood that patients of family physicians would be diagnosed with obesity and referred for obesity treatment. Methods: A total of 846 obese patients of 37 family physicians were randomly assigned to either have a patient’s BMI chart prompt placed in their electronic medical record (intervention group) or not have a BMI prompt (comparison group) placed in the record. We then examined patient medical records for evidence of an obesity diagnosis and referral for specific obesity treatments. We also measured whether the presence of comorbidities in obese patients influenced the likelihood of diagnoses and treatments by the physicians. Results: Obese patients of physicians who had a BMI chart prompt in their medical records were significantly more likely than obese patients of physicians who did not receive a BMI chart prompt to receive a diagnosis of obesity (16.6% versus 10.7%"";"" P=.016). Patients of physicians who were provided with a BMI chart prompt were also more likely than patients of physicians who did not get a chart prompt to receive a referral for diet treatment (14.0% versus 7.3%, P=.002) and exercise (12.1% versus 7.1%, P=.016). Of the obesity comorbidities, only obstructive sleep apnea (OSA) was a predictor of a patient being diagnosed with obesity (OR=.49, 95% CI=0.281, 0.869, P=.014). Conclusions: Inclusion of a computerized BMI chart prompt increased the likelihood that physicians would diagnose obesity in obese patients and refer them for treatment.",0,1,
599,Effect of a minimal pharmacy intervention on improvement of adherence to asthma guidelines.,"Objective To study the effectiveness of a minimal intervention strategy to improve adherence to paediatric asthma guidelines.  Design and setting A group of pharmacists was encouraged to discuss essential elements of asthma care with the general practitioners they normally worked with. Adherence to guidelines was evaluated by studying prescriptions for children with asthma. We compared the treatment of children registered at pharmacies which participated in the study (intervention group) with a control group of children registered at other, non-participating pharmacies (reference group) and with the results of an earlier study.  Main outcome measures The numbers of children who had no short-acting betamimetics, no inhaled corticosteroids while on long-acting betamimetics, and more than one type of inhaler.  Results The number of children who had no shortacting betamimetics was significantly lower in the intervention group (176/1447 vs 534/3527""; p<0.01) and fewer children had no inhaled corticosteroid although on long-acting betamimetics (6/219 vs 41/477; p=0.03). The number of children who had more than one type of inhaler was equal in both groups (5.1%), but this was significantly lower compared with the earlier study (119/2311 vs 239/3217;"" p<0.01).  Conclusions The assistance of pharmacists with adherence to paediatric asthma guidelines is beneficial. Pharmacists should be involved actively in the care of children with asthma.",0,1,
600,Effect of a Web-Based Guided Self-help Intervention for Prevention of Major Depression in Adults With Subthreshold Depression,"Importance  Evidence-based treatments for major depressive disorder (MDD) are not very successful in improving functional and health outcomes. Attention has increasingly been focused on the prevention of MDD.  Objective  To evaluate the effectiveness of a web-based guided self-help intervention for the prevention of MDD.  Design, Setting, and Participants  Two-group randomized clinical trial conducted between March 1, 2013, and March 4, 2015. Participants were recruited in Germany from the general population via a large statutory health insurance company (ie, insurance funded by joint employer-employee contributions). Participants included 406 self-selected adults with subthreshold depression (Centre for Epidemiologic Studies Depression Scale score ¡Ý16, no current MDD according to Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition, Text Revision] criteria).  Interventions  All participants had unrestricted access to usual care (visits to the primary care clinician) and were randomized to either a web-based guided self-help intervention (cognitive-behavioral and problem-solving therapy supported by an online trainer""; n?=?202) or a web-based psychoeducation program (n?=?204).  Main Outcomes and Measures  The primary outcome was time to onset of MDD in the intervention group relative to the control group over a 12-month follow-up period as assessed by blinded diagnostic raters using the telephone-administered Structured Clinical Interview for DSM-IV Axis Disorders at 6- and 12-month follow-up, covering the period to the previous assessment.  Results  Among 406 randomized patients (mean age, 45 years; 73.9% women), 335 (82%) completed the telephone follow-up at 12 months. Fifty-five participants (27%) in the intervention group experienced MDD compared with 84 participants (41%) in the control group. Cox regression analyses controlling for baseline depressive symptom severity revealed a hazard ratio of 0.59 (95% CI, 0.42-0.82;"" P?=?.002) at 12-month follow-up. The number needed to treat to avoid 1 new case of MDD was 5.9 (95% CI, 3.9-14.6).  Conclusions and Relevance  Among patients with subthreshold depression, the use of a web-based guided self-help intervention compared with enhanced usual care reduced the incidence of MDD over 12 months. Further research is needed to understand whether the effects are generalizable to both first onset of depression and depression recurrence as well as efficacy without the use of an online trainer.",0,0,
601,Effect of an educational program (PEGASE) on cardiovascular risk in hypercholesterolaemic patients,"BACKGROUND: Many studies have demonstrated a gap between guidelines for the prevention of cardiovascular disease (CVD) and their implementation in clinical practice. AIM: The PEGASE education program has been devised with an aim to improve the management of patients at high risk of CVD. METHODS: In a multicentre study carried out from 2001-2004 in France, 96 participating physicians were randomized into a ""trained"" group, which included 398 ""educated"" patients, and a ""non-trained"" group, which included 242 ""non-educated"" patients. Educated patients received six hospital-based educational sessions, four collective and two individual. Framingham score, smoking, lipid levels, glycaemia, blood pressure, dietary intake and drug compliance, as well as quality of life, were evaluated at baseline (M0) and 6 months (M6). The primary endpoint of the study was the efficacy of the PEGASE program in reducing global CVD risk in high-risk patients. RESULTS: The Framingham score was calculated for 473 patients. The Framingham score improved significantly at M6 vs M0 in the educated group (13.0 +/- 8.21 vs 13.6 +/- 8.48, d = -0.658, p = 0.016), but not in the non-educated group (12.5 +/- 8.19 vs 12.4 +/- 7.81, d = +0.064, p = 0.836)"";"" the mean change between the two groups did not reach significance. Quality of life, LDL-c level and diet scores improved in the ""educated"" group only. CONCLUSIONS: The PEGASE education program improved risk factors for CVD, although global assessment by Framingham score was not significantly different between groups. This program, aimed at meeting needs and expectations of patients and physicians, was easily implemented in all hospital centres.",0,0,
602,Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial.,"Importance Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback. However, most antimicrobial use occurs in outpatients with acute respiratory tract infections (ARTIs).  Objective To evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric outpatients.  Design Cluster randomized trial of outpatient antimicrobial stewardship comparing prescribing between intervention and control practices using a common electronic health record. After excluding children with chronic medical conditions, antibiotic allergies, and prior antibiotic use, we estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance from 20 months before the intervention to 12 months afterward (October 2008–June 2011).  Setting and Participants A network of 25 pediatric primary care practices in Pennsylvania and New Jersey""; 18 practices (162 clinicians) participated.  Interventions One 1-hour on-site clinician education session (June 2010) followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice.  Main Outcomes and Measures Rates of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention.  Results Broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% (absolute difference, 12.5%) among intervention practices vs from 28.4% to 22.6% (absolute difference, 5.8%) in controls (difference of differences [DOD], 6.7%; P = .01 for differences in trajectories). Off-guideline prescribing for children with pneumonia decreased from 15.7% to 4.2% among intervention practices compared with 17.1% to 16.3% in controls (DOD, 10.7%; P < .001) and for acute sinusitis from 38.9% to 18.8% in intervention practices and from 40.0% to 33.9% in controls (DOD, 14.0%; P = .12). Off-guideline prescribing was uncommon at baseline and changed little for streptococcal pharyngitis (intervention, from 4.4% to 3.4%; control, from 5.6% to 3.5%; DOD, -1.1%; P = .82) and for viral infections (intervention, from 7.9% to 7.7%; control, from 6.4% to 4.5%; DOD, -1.7%;"" P = .93).  Conclusions and Relevance In this large pediatric primary care network, clinician education coupled with audit and feedback, compared with usual practice, improved adherence to prescribing guidelines for common bacterial ARTIs, and the intervention did not affect antibiotic prescribing for viral infections. Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship.",0,1,
603,Effect of anaemia and cardiovascular disease on surgical mortality and morbidity,"BackgroundGuidelines have been offered on haemoglobin thresholds for blood transfusion in surgical patients. However, good evidence is lacking on the haemoglobin concentrations at which the risk of death or serious morbidity begins to rise and at which transfusion is indicated."";"" BackgroundGuidelines have been offered on haemoglobin thresholds for blood transfusion in surgical patients. However, good evidence is lacking on the haemoglobin concentrations at which the risk of death or serious morbidity begins to rise and at which transfusion is indicated.",0,0,
604,Effect of audit and feedback with peer review on general practitioners' prescribing and test ordering performance: a cluster-randomized controlled trial,"BACKGROUND: Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting. METHODS: We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis. RESULTS: Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements. CONCLUSIONS: Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands. TRIAL REGISTRATION: This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007.",0,1,
605,"Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial.","Background Radiological tests are often used by general practitioners (GPs). These tests can be overused and contribute little to clinical management. We aimed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists' guidelines on lumbar spine and knee radiographs.  Methods We assessed audit and feedback, and educational reminder messages in six radiology departments and 244 general practices that they served. The study was a before-and-after, pragmatic, cluster randomised controlled trial with a 2·2 factorial design. A random subset of GP patients' records were examined for concordance with the guidelines. The main outcome measure was number of radiograph requests per 1000 patients per year. Analysis was by intention to treat.  Findings The effect of educational reminder messages (ie, the change in request rate after intervention) was an absolute change of -1·53 (95% CI -2·5 to -0·57) for lumbar spine and of -1·61 (-2·6 to -0·62) for knee radiographs, both relative reductions of about 20%. The effect of audit and feedback was an absolute change of -0·07 (-1·3 to 0·9) for lumbar spine of 0·04 (-0·95 to 1·03) for knee radiograph requests, both relative reductions of about 1%. Concordance between groups did not differ significantly.  Interpretation 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals. Any department of radiology that handles referrals from primary care could deliver this intervention to good effect.",1,1,
606,Effect of Behavior Modification on Outcome in Early- to Moderate-Stage Chronic Kidney Disease: A Cluster-Randomized Trial,"OBJECTIVES: Owing to recent changes in our understanding of the underlying cause of chronic kidney disease (CKD), the importance of lifestyle modification for preventing the progression of kidney dysfunction and complications has become obvious. In addition, effective cooperation between general physicians (GPs) and nephrologists is essential to ensure a better care system for CKD treatment. In this cluster-randomized study, we studied the effect of behavior modification on the outcome of early- to moderate-stage CKD. DESIGN: Stratified open cluster-randomized trial. SETTING: A total of 489 GPs belonging to 49 local medical associations (clusters) in Japan. PARTICIPANTS: A total of 2,379 patients (1,195 in group A (standard intervention) and 1,184 in group B (advanced intervention)) aged between 40 and 74 years, who had CKD and were under consultation with GPs. INTERVENTION: All patients were managed in accordance with the current CKD guidelines. The group B clusters received three additional interventions: patients received both educational intervention for lifestyle modification and a CKD status letter, attempting to prevent their withdrawal from treatment, and the group B GPs received data sheets to facilitate reducing the gap between target and practice. MAIN OUTCOME MEASURE: The primary outcome measures were 1) the non-adherence rate of accepting continuous medical follow-up of the patients, 2) the collaboration rate between GPs and nephrologists, and 3) the progression of CKD. RESULTS: The rate of discontinuous clinical visits was significantly lower in group B (16.2% in group A vs. 11.5% in group B, p = 0.01). Significantly higher referral and co-treatment rates were observed in group B (p<0.01). The average eGFR deterioration rate tended to be lower in group B (group A: 2.6+/-5.8 ml/min/1.73 m2/year, group B: 2.4+/-5.1 ml/min/1.73 m2/year, p = 0.07). A significant difference in eGFR deterioration rate was observed in subjects with Stage 3 CKD (group A: 2.4+/-5.9 ml/min/1.73 m2/year, group B: 1.9+/-4.4 ml/min/1.73 m2/year, p = 0.03). CONCLUSION: Our care system achieved behavior modification of CKD patients, namely, significantly lower discontinuous clinical visits, and behavior modification of both GPs and nephrologists, namely significantly higher referral and co-treatment rates, resulting in the retardation of CKD progression, especially in patients with proteinuric Stage 3 CKD. TRIAL REGISTRATION: The University Hospital Medical Information Network clinical trials registry UMIN000001159.",0,0,
607,Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial,"IMPORTANCE: Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. OBJECTIVE: To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. INTERVENTIONS: Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments""; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records;"" peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of ""top performers"" (those with the lowest inappropriate prescribing rates). MAIN OUTCOMES AND MEASURES: Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. RESULTS: There were 14,753 visits (mean patient age, 47 years""; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, -11.0%) for control practices; from 22.1% to 6.1% (absolute difference, -16.0%) for suggested alternatives (difference in differences, -5.0% [95% CI, -7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, -18.1%) for accountable justification (difference in differences, -7.0% [95% CI, -9.1% to -2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, -16.3%) for peer comparison (difference in differences, -5.2% [95% CI, -6.9% to -1.6%];"" P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions. CONCLUSIONS AND RELEVANCE: Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01454947.",1,1,
608,Effect of Clinical Decision-Support Systems: a systematic review,"BACKGROUND: Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking.PURPOSE: To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation.DATA SOURCES: MEDLINE, CINAHL, PsycINFO, and Web of Science through January 2011.STUDY SELECTION: Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings""; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes.DATA EXTRACTION: Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality.DATA SYNTHESIS: 148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n= 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n= 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n= 46;"" OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects.LIMITATIONS: Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded.CONCLUSION: Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers.",0,1,
609,Effect of computer-assisted European Best Practice Guideline implementation on adherence and target attainment: ORAMA results.,"Background: The success of guidelines depends largely on effective implementation and uptake in clinical practice. The Optimal Renal Anemia Management Assessment (ORAMA) study investigated the impact of European Best Practice Guideline (EBPG) prompting on patient outcomes. Methods: ORAMA was a prospective, international, multicenter, cluster-randomized study. Fifty-three centers in eight European countries enrolled patients with chronic kidney disease stage V receiving chronic dialysis. Patients were either anemic (hemoglobin [Hb] <11 g/dL [110 g/L]) or treated with erythropoiesis stimulating agents and/or iron supplementation. Centers were randomized to two groups, with or without access to a computerized clinical decision support (CDS) system. In a post hoc analysis,patients were further subdivided into adherence or non-adherence of investigators to the EBPG regardless of CDS usage. Primary endpoint was the proportion of patients with Hb >11 g/ dL (110 g/L), reflecting hematological targets in the revised EPBG. Results: In this population of 599 dialysis patients, hematological targets did not differ in the presence or absence of a CDS system. There was a general shift towards improved patient distribution by Hb categories while the width of the distribution curves remained unchanged. The proportion of patients with Hb >11 g/dL (110 g/L) was higher among adherers (79% and 84% with or without CDS use, respectively) than non-adherers (59% and 57%, respectively). Conclusions: ORAMA is the first international study to show that adherence to EBPG improved attainment of anemia indices. The availability of a CDS system did not affect anemia management.",0,1,
610,Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial.,"Abstract Objective: To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care.  Design: A before and after pragmatic cluster randomised controlled trial utilising a two by two incomplete block design.  Setting: 60 general practices in north east England.  Participants: General practitioners and practice nurses in the study practices and their patients aged 18 or over with angina or asthma.  Main outcome measures: Adherence to the guidelines, based on review of case notes and patient reported generic and condition specific outcome measures.  Results: The computerised decision support system had no significant effect on consultation rates, process of care measures (including prescribing), or any patient reported outcomes for either condition. Levels of use of the software were low.  Conclusions: No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care. This was probably due to low levels of use of the software, despite the system being optimised as far as was technically possible. Even if the technical problems of producing a system that fully supports the management of chronic disease were solved, there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex, multiple conditions.",0,1,
611,Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials,"BackgroundTreatment with daily aspirin for 5 years or longer reduces subsequent risk of colorectal cancer. Several lines of evidence suggest that aspirin might also reduce risk of other cancers, particularly of the gastrointestinal tract, but proof in man is lacking. We studied deaths due to cancer during and after randomised trials of daily aspirin versus control done originally for prevention of vascular events."";"" BackgroundTreatment with daily aspirin for 5 years or longer reduces subsequent risk of colorectal cancer. Several lines of evidence suggest that aspirin might also reduce risk of other cancers, particularly of the gastrointestinal tract, but proof in man is lacking. We studied deaths due to cancer during and after randomised trials of daily aspirin versus control done originally for prevention of vascular events.",0,0,
612,Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: systematic review and meta-analysis,"OBJECTIVE To assess the impact of exercise referral schemes on physical activity and health outcomes. Design Systematic review and meta-analysis. DATA SOURCES Medline, Embase, PsycINFO, Cochrane Library, ISI Web of Science, SPORTDiscus, and ongoing trial registries up to October 2009. We also checked study references. Study selection Design: randomised controlled trials or non-randomised controlled (cluster or individual) studies published in peer review journals. POPULATION sedentary individuals with or without medical diagnosis. Exercise referral schemes defined as: clear referrals by primary care professionals to third party service providers to increase physical activity or exercise, physical activity or exercise programmes tailored to individuals, and initial assessment and monitoring throughout programmes. Comparators: usual care, no intervention, or alternative exercise referral schemes. RESULTS Eight randomised controlled trials met the inclusion criteria, comparing exercise referral schemes with usual care (six trials), alternative physical activity intervention (two), and an exercise referral scheme plus a self determination theory intervention (one). Compared with usual care, follow-up data for exercise referral schemes showed an increased number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week (pooled relative risk 1.16, 95% confidence intervals 1.03 to 1.30) and a reduced level of depression (pooled standardised mean difference -0.82, -1.28 to -0.35). Evidence of a between group difference in physical activity of moderate or vigorous intensity or in other health outcomes was inconsistent at follow-up. We did not find any difference in outcomes between exercise referral schemes and the other two comparator groups. None of the included trials separately reported outcomes in individuals with specific medical diagnoses. Substantial heterogeneity in the quality and nature of the exercise referral schemes across studies might have contributed to the inconsistency in outcome findings. Conclusions Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.",0,0,
613,"Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels","Importance  Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established.  Objective  To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk.  Design, Setting, and Participants  Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25?627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not.  Interventions  Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation.  Main Outcomes and Measures  Change in LDL-C level at 12 months.  Results  Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL (95% CI, 30.1-37.1""; baseline, 160.1 mg/dL; 12 months, 126.4 mg/dL); those in physician incentives achieved a mean reduction of 27.9 mg/dL (95% CI, 24.9-31.0; baseline, 159.9 mg/dL; 12 months, 132.0 mg/dL); those in patient incentives achieved a mean reduction of 25.1 mg/dL (95% CI, 21.6-28.5; baseline, 160.6 mg/dL; 12 months, 135.5 mg/dL); and those in the control group achieved a mean reduction of 25.1 mg/dL (95% CI, 21.7-28.5; baseline, 161.5 mg/dL; 12 months, 136.4 mg/dL; P?<?.001 for comparison of all 4 groups). Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dL; 95% CI, 3.8-13.3;"" P?=?.002).  Conclusions and Relevance  In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value.",0,0,
614,"Effect of financial incentives to physicians, patients, or both on lipid levels: A randomized clinical trial.","Importance: Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established. Objective: To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk. Design, Setting, and Participants: Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25 627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not. Interventions: Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation. Main Outcomes and Measures: Change in LDL-C level at 12 months. Results: Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5mg/dL""; 95%CI, 3.8-13.3;"" P = .002). For comparison of all 4 groups, P < .001. Conclusions and Relevance: In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
615,Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial,"Context Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients.  Objective To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis.  Design, Setting, and Participants Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (¡Ý60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline.  Intervention Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care).  Main Outcome Measures Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months.  Results In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]""; between-group difference, ?0.53; 95% confidence interval [CI], ?0.92 to ?0.14; P = .009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, ?0.59; 95% CI, ?1.00 to ?0.19; P = .004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, ?0.26; 95% CI, ?0.41 to ?0.10;"" P = .002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months.  Conclusions In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.",0,0,
616,Effect of inhibitors of the renin-angiotensin system and other antihypertensive drugs on renal outcomes: systematic review and meta-analysis,"BackgroundA consensus has emerged that angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-II receptor blockers (ARBs) have specific renoprotective effects. Guidelines specify that these are the drugs of choice for the treatment of hypertension in patients with renal disease. We sought to determine to what extent this consensus is supported by the available evidence."";"" BackgroundA consensus has emerged that angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-II receptor blockers (ARBs) have specific renoprotective effects. Guidelines specify that these are the drugs of choice for the treatment of hypertension in patients with renal disease. We sought to determine to what extent this consensus is supported by the available evidence.",0,0,
617,Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial,"OBJECTIVE: To evaluate the cost effectiveness, cost utility, and cost-benefit of an integrated care programme compared with usual care for sick listed patients with chronic low back pain. DESIGN: Economic evaluation alongside a randomised controlled trial with 12 months' follow-up. SETTING: Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals) in the Netherlands, 2005-9. PARTICIPANTS: 134 adults aged 18-65 sick listed because of chronic low back pain: 66 were randomised to integrated care and 68 to usual care. INTERVENTIONS: Integrated care consisted of a workplace intervention based on participatory ergonomics, with involvement of a supervisor, and a graded activity programme based on cognitive behavioural principles. Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines. MAIN OUTCOME MEASURES: The primary outcome was duration until sustainable return to work. The secondary outcome was quality adjusted life years (QALYs), measured using EuroQol. RESULTS: Total costs in the integrated care group ( pound13 165, SD pound13 600) were significantly lower than in the usual care group ( pound18 475, SD pound13 616). Cost effectiveness planes and acceptability curves showed that integrated care was cost effective compared with usual care for return to work and QALYs gained. The cost-benefit analyses showed that every pound1 invested in integrated care would return an estimated pound26. The net societal benefit of integrated care compared with usual care was pound5744. CONCLUSIONS: Implementation of an integrated care programme for patients sick listed with chronic low back pain has a large potential to significantly reduce societal costs, increase effectiveness of care, improve quality of life, and improve function on a broad scale. Integrated care therefore has large gains for patients and society as well as for employers.",0,0,
618,Effect of interactive group discussion among physicians to promote rational prescribing,"This study assessed the effect of an educational intervention (interactive group discussion) on the prescribing behaviour of 51 general physicians from the north-west of Tabriz. Prescriptions were analysed pre-intervention and post-intervention (control and intervention groups) using a proforma with 8 indicators of correct prescribing. The mean number of drugs per prescription pre-intervention was 3.82. The percentage of prescriptions with antibiotics, corticosteroids and injections were 40.8%, 25.9% and 58.0%, respectively. Following the intervention there were slight but not significant changes in the indicators in both intervention and control groups compared with pre-intervention results.",0,0,
619,"Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: active for Life Year 5 (AFLY5) school based cluster randomised controlled trial","OBJECTIVE To investigate the effectiveness of a school based intervention to increase physical activity, reduce sedentary behaviour, and increase fruit and vegetable consumption in children. DESIGN Cluster randomised controlled trial. SETTING 60 primary schools in the south west of England. PARTICIPANTS Primary school children who were in school year 4 (age 8-9 years) at recruitment and baseline assessment, in year 5 during the intervention, and at the end of year 5 (age 9-10) at follow-up assessment. INTERVENTION The Active for Life Year 5 (AFLY5) intervention consisted of teacher training, provision of lesson and child-parent interactive homework plans, all materials required for lessons and homework, and written materials for school newsletters and parents. The intervention was delivered when children were in school year 5 (age 9-10 years). Schools allocated to control received standard teaching. MAIN OUTCOME MEASURES The pre-specified primary outcomes were accelerometer assessed minutes of moderate to vigorous physical activity per day, accelerometer assessed minutes of sedentary behaviour per day, and reported daily consumption of servings of fruit and vegetables. RESULTS 60 schools with more than 2221 children were recruited"";"" valid data were available for fruit and vegetable consumption for 2121 children, for accelerometer assessed physical activity and sedentary behaviour for 1252 children, and for secondary outcomes for between 1825 and 2212 children for the main analyses. None of the three primary outcomes differed between children in schools allocated to the AFLY5 intervention and those allocated to the control group. The difference in means comparing the intervention group with the control group was -1.35 (95% confidence interval -5.29 to 2.59) minutes per day for moderate to vigorous physical activity, -0.11 (-9.71 to 9.49) minutes per day for sedentary behaviour, and 0.08 (-0.12 to 0.28) servings per day for fruit and vegetable consumption. The intervention was effective for three out of nine of the secondary outcomes after multiple testing was taken into account: self reported time spent in screen viewing at the weekend (-21 (-37 to -4) minutes per day), self reported servings of snacks per day (-0.22 (-0.38 to -0.05)), and servings of high energy drinks per day (-0.26 (-0.43 to -0.10)) were all reduced. Results from a series of sensitivity analyses testing different assumptions about missing data and from per protocol analyses produced similar results. CONCLUSION The findings suggest that the AFLY5 school based intervention is not effective at increasing levels of physical activity, decreasing sedentary behaviour, and increasing fruit and vegetable consumption in primary school children. Change in these activities may require more intensive behavioural interventions with children or upstream interventions at the family and societal level, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services. Trial registration Current Controlled Trials ISRCTN50133740.",0,0,
620,Effect of offering different levels of support and free nicotine replacement therapy via an English national telephone quitline: randomised controlled trial,"OBJECTIVE To compare the effects of free nicotine replacement therapy or proactive telephone counselling in addition to standard smoking cessation support offered through a telephone quitline. DESIGN Parallel group, 2 × 2 factorial, randomised controlled trial. SETTING National quitline, England. PARTICIPANTS 2591 non-pregnant smokers aged 16 or more residing in England who called the quitline between February 2009 and February 2010 and agreed to set a quit date: 648 were each randomised to standard support, proactive support, or proactive support with nicotine replacement therapy, and 647 were randomised to standard support with nicotine replacement therapy. INTERVENTIONS Two interventions were offered in addition to standard support: six weeks' nicotine replacement therapy, provided free, and proactive counselling sessions (repeat telephone calls from, and interaction with, cessation advisors). MAIN OUTCOME MEASURES The primary outcome was self reported smoking cessation for six or more months after the quit date. The secondary outcome was cessation validated by exhaled carbon monoxide measured at six or more months. RESULTS At six months, 17.7% (n = 229) of those offered nicotine replacement therapy reported smoking cessation compared with 20.1% (n = 261) not offered such therapy (odds ratio 0.85, 95% confidence interval 0.70 to 1.04), and 18.2% (n = 236) offered proactive counselling reported smoking cessation compared with 19.6% (n = 254) offered standard support (0.91, 0.75 to 1.11). Data validated by carbon monoxide readings changed the findings for nicotine replacement therapy only, with smoking cessation validated in 6.6% (85/1295) of those offered nicotine replacement therapy compared with 9.4% (122/1296) not offered such therapy (0.67, 0.50 to 0.90). CONCLUSIONS Offering free nicotine replacement therapy or additional (proactive) counselling to standard helpline support had no additional effect on smoking cessation. TRIAL REGISTRATION ClinicalTrials.gov NCT00775944.",0,0,
621,Effect of patient-specific ratings vs conventional guidelines on investigation decisions in angina: Appropriateness of Referral and Investigation in Angina (ARIA) Trial,"BACKGROUND: Conventional guidelines have limited effect on changing physicians' test ordering. We sought to determine the effect of patient-specific ratings vs conventional guidelines on appropriate investigation of angina. METHODS: Randomized controlled trial of 145 physicians receiving patient-specific ratings (online prompt stating whether the specific vignette was considered appropriate or inappropriate for investigation, with access to detailed information on how the ratings were derived) and 147 physicians receiving conventional guidelines from the American Heart Association and the European Society of Cardiology. Physicians made recommendations on 12 Web-based patient vignettes before and on 12 vignettes after these interventions. The outcome was the proportion of appropriate investigative decisions as defined by 2 independent expert panels. RESULTS: Decisions for exercise electrocardiography were more appropriate with patient-specific ratings (819/1491 [55%]) compared with conventional guidelines (648/1488 [44%]) (odds ratio [OR], 1.57""; 95% confidence interval [CI], 1.36-1.82). The effect was stronger for angiography (1274/1595 [80%] with patient-specific ratings compared with 1009/1576 [64%] with conventional guidelines [OR, 2.24; 95% CI, 1.90-2.62]). Within-arm comparisons confirmed that conventional guidelines had no effect but that patient-specific ratings significantly changed physicians' decisions toward appropriate recommendations for exercise electrocardiography (55% vs 42%; OR, 2.62; 95% CI, 2.14-3.22) and for angiography (80% vs 65%; OR, 2.10;"" 95% CI, 1.79-2.47). These effects were robust to physician specialty (cardiologists and general practitioners) and to vignette characteristics, including older age, female sex, and nonwhite race/ethnicity. CONCLUSION: Patient-specific ratings, unlike conventional guidelines, changed physician testing behavior and have the potential to reduce practice variations and to increase the appropriate use of investigation.",1,1,
622,Effect of physician recommendation and patient adherence on rates of colorectal cancer testing.,"This study explored: (1) patient characteristics associated with physician recommendation for colorectal cancer (CRC) screening and patient adherence to recommendation, and (2) the combined effect of recommendation and adherence on CRC testing, broadly defined. Data were from the 1999 MA BRFSS and a call-back survey of 869 BRFSS participants, age 50 and older. Logistic regression was used to identify correlates of recommendation, adherence, and testing. Patient–physician factors were positively associated with recommendation, adherence and testing. Inadequate health insurance was negatively associated with recommendation (OR = 0.45, 95% CI = 0.27–0.78) and testing (OR = 0.64, 95% CI = 0.38–1.1). Men were not more likely to be recommended (OR = 1.1, 95% CI = 0.78–1.5), but were more likely to adhere (OR = 1.9, 95% CI = 1.2–2.0) and to be tested (OR = 1.4, 95% CI = 1.0–1.9). There were gender differences in recommendation when considering health and risk factor measures. Research is needed to understand differences in recommendation and adherence. Greater encouragement and follow-through may be needed for groups less likely to adhere.",0,1,
623,Effect of self-efficacy and social support on adherence to antihypertensive drugs,"STUDY OBJECTIVE: To determine the relationship between poor adherence and self-efficacy or social support after a pharmacist intervention. DESIGN: Post-hoc analysis of data from two randomized controlled trials of physician-pharmacist collaborative interventions (6 and 9 mo, respectively) to improve blood pressure control. SETTING: Eleven university-affiliated primary care clinics. PATIENTS: Five hundred eighty-four patients (aged 21-85 yrs) with uncontrolled primary hypertension""; 296 were in the intervention group and 288 were in the control group. INTERVENTION: Pharmacists provided intensified hypertension management and drug adherence counseling to patients in the intervention group. MEASUREMENTS AND MAIN RESULTS: Social support and self-efficacy questionnaires were administered at baseline and end-of-study visits. Patient adherence was monitored by using the Morisky self-reported adherence questionnaire. Self-reported adherence scores improved significantly in the control group (p=0.0053) but not in the intervention group; however, adherence at baseline in both groups was high. There were small, but significant, improvements in self-efficacy (p<0.04) and social support (p<0.05) scores in the intervention group but not the control group at the end of the study. Social support and, to a lesser extent, self-efficacy improved as a function of duration of study participation (9-mo vs 6-mo intervention), regardless of whether the patient received the intervention. Blood pressure control in both groups improved significantly at the end of the study; however, mean blood pressure was significantly lower in the intervention group (129.7/76.6 mm Hg) compared with the control group (140.8/78.9 mm Hg;"" p<0.0001 for systolic, p=0.032 for diastolic). CONCLUSION: Social support and self-efficacy improved significantly in the intervention group at the end of the pharmacist intervention. Drug adherence was correlated with self-efficacy even though drug adherence did not improve significantly in the intervention group. The fact that social support and self-efficacy improved as a function of duration of study participation suggests that participation in a research study may have had a positive influence on these measures. Even though the changes in social support, self-efficacy, and drug adherence were modest, there was significantly better blood pressure control in the intervention group compared with the control group. These findings indicate that changes in drug adherence, self-efficacy, or social support probably played a minor role in the blood pressure outcomes in these studies.",0,0,
624,Effect of telecare management on pain and depression in patients with cancer: a randomized trial,"Context Pain and depression are 2 of the most prevalent and treatable cancer-related symptoms, yet they frequently go unrecognized, undertreated, or both.  Objective To determine whether centralized telephone-based care management coupled with automated symptom monitoring can improve depression and pain in patients with cancer.  Design, Setting, and Patients Randomized controlled trial conducted in 16 community-based urban and rural oncology practices involved in the Indiana Cancer Pain and Depression (INCPAD) trial. Recruitment occurred from March 2006 through August 2008 and follow-up concluded in August 2009. The participating patients had depression (Patient Health Questionnaire-9 score ¡Ý10), cancer-related pain (Brief Pain Inventory [BPI] worst pain score ¡Ý6), or both.  Intervention The 202 patients randomly assigned to receive the intervention and 203 to receive usual care were stratified by symptom type. Patients in the intervention group received centralized telecare management by a nurse-physician specialist team coupled with automated home-based symptom monitoring by interactive voice recording or Internet.  Main Outcome Measures Blinded assessment at baseline and at months 1, 3, 6, and 12 for depression (20-item Hopkins Symptom Checklist [HSCL-20]) and pain (BPI) severity.  Results Of the 405 participants enrolled in the study, 131 had depression only, 96 had pain only, and 178 had both depression and pain. Of the 274 patients with pain, 137 patients in the intervention group had greater improvements in BPI pain severity over the 12 months of the trial whether measured as a continuous severity score or as a categorical pain responder (¡Ý30% decrease in BPI) than the 137 patients in the usual-care group (P < .001 for both). Similarly, of the 309 patients with depression, the 154 patients in the intervention group had greater improvements in HSCL-20 depression severity over the 12 months of the trial whether measured as a continuous severity score or as a categorical depression responder (¡Ý 50% decrease in HSCL) than the 155 patients in the usual care group (P < .001 for both). The standardized effect size for between-group differences at 3 and 12 months was 0.67 (95% confidence interval [CI], 0.33-1.02) and 0.39 (95% CI, 0.01-0.77) for pain, and 0.42 (95% CI, 0.16-0.69) and 0.41 (95% CI, 0.08-0.72) for depression.  Conclusion Centralized telecare management coupled with automated symptom monitoring resulted in improved pain and depression outcomes in cancer patients receiving care in geographically dispersed urban and rural oncology practices.",0,0,
625,"Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial","OBJECTIVE To assess the effect of second generation, home based telehealth on health related quality of life, anxiety, and depressive symptoms over 12 months in patients with long term conditions. DESIGN A study of patient reported outcomes (the Whole Systems Demonstrator telehealth questionnaire study""; baseline n=1573) was nested in a pragmatic, cluster randomised trial of telehealth (the Whole Systems Demonstrator telehealth trial, n=3230). General practice was the unit of randomisation, and telehealth was compared with usual care. Data were collected at baseline, four months (short term), and 12 months (long term). Primary intention to treat analyses tested treatment effectiveness; multilevel models controlled for clustering by general practice and a range of covariates. Analyses were conducted for 759 participants who completed questionnaire measures at all three time points (complete case cohort) and 1201 who completed the baseline assessment plus at least one other assessment (available case cohort). Secondary per protocol analyses tested treatment efficacy and included 633 and 1108 participants in the complete case and available case cohorts, respectively. SETTING Provision of primary and secondary care via general practices, specialist nurses, and hospital clinics in three diverse regions of England (Cornwall, Kent, and Newham), with established integrated health and social care systems. PARTICIPANTS Patients with chronic obstructive pulmonary disease (COPD), diabetes, or heart failure recruited between May 2008 and December 2009. MAIN OUTCOME MEASURES Generic, health related quality of life (assessed by physical and mental health component scores of the SF-12, and the EQ-5D), anxiety (assessed by the six item Brief State-Trait Anxiety Inventory), and depressive symptoms (assessed by the 10 item Centre for Epidemiological Studies Depression Scale). RESULTS In the intention to treat analyses, differences between treatment groups were small and non-significant for all outcomes in the complete case (0.480 ≤ P ≤ 0.904) or available case (0.181 ≤ P ≤ 0.905) cohorts. The magnitude of differences between trial arms did not reach the trial defined, minimal clinically important difference (0.3 standardised mean difference) for any outcome in either cohort at four or 12 months. Per protocol analyses replicated the primary analyses; the main effect of trial arm (telehealth v usual care) was non-significant for any outcome (complete case cohort 0.273 ≤ P ≤ 0.761;"" available case cohort 0.145 ≤ P ≤ 0.696). CONCLUSIONS Second generation, home based telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only. Telehealth did not improve quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months. The findings suggest that concerns about potentially deleterious effect of telehealth are unfounded for most patients. TRIAL REGISTRATION ISRCTN43002091.",0,0,
626,Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study,"OBJECTIVE To determine the effects over one year of contacting patients by telephone one month or three months after being discharged from an emergency department for deliberate self poisoning compared with usual treatment. DESIGN Multicentre, randomised controlled trial. SETTING 13 emergency departments in the north of France. PARTICIPANTS 605 people discharged from an emergency department after attempted suicide by deliberate self poisoning. INTERVENTION The intervention consisted of contacting patients by telephone at one month or three months after discharge from an emergency department for attempted suicide to evaluate the success of recommended treatment or to adjust treatment. Control patients received treatment as usual, in most cases referral back to their general practitioner. MAIN OUTCOME MEASURES The primary outcome measures were proportion of participants who reattempted suicide, number of deaths by suicide, and losses to follow-up at 13 months' follow-up. Secondary outcome measures were types and number of contacts with health care. RESULTS On an intention to treat basis, the three groups did not differ significantly for further suicide attempts, deaths by suicide, or losses to follow-up: contact at one month (intervention 23% (34/147) v controls 30% (93/312), difference 7%, 95% confidence interval - 2% to 15%), three months (25% (36/146) v 30%, difference 5%, - 4% to 14%). Participants contacted at one month were less likely at follow-up to report having reattempted suicide (12% v 22% in control group, difference 10%, 2% to 18%). CONCLUSION Contacting people by telephone one month after being discharged from an emergency department for deliberate self poisoning may help reduce the number of reattempted suicides over one year.",0,0,
627,"Effect of training on adoption of cancer prevention nutrition-related activities by primary care practices: results of a randomized, controlled study","OBJECTIVE: The National Cancer Institute (NCI) developed a manual to guide primary care practices in structuring their office environment and routine visits so as to enhance nutrition screening, advice/referral, and follow-up for cancer prevention. The adoption of the manual's recommendations by primary care practices was evaluated by examining two strategies: physician training on how to implement the manual's recommendations versus simple mailing of the manual. This article reports on the results of a randomized controlled trial to evaluate the effectiveness of these two strategies. DESIGN: A three-arm, randomized, controlled study. SETTING: Free-standing primary care physician practices in Pennsylvania and New Jersey. INTERVENTION: Each study practice was randomly assigned to one of three groups. The training group practices were invited to send one member from their practice of their choosing to a 3-hour ""train-a-trainer"" workshop, the manual-only-group practices were mailed the nutrition manual, and the control group practices received no intervention. For training group practices, training was provided in the four major components of the nutrition manual: how to organize the office environment to support cancer prevention nutrition-related activities""; how to screen patient adherence to the NCI dietary guidelines; how to provide dietary advice/referral;"" and how to implement a patient follow-up system to support patients in making changes in their nutrition-related behaviors. MEASUREMENTS: The primary outcomes of the study were derived from two evaluation instruments. The observation instrument documented the tools and procedures recommended by the nutrition manual and adopted in patient charts and the office environment. The in-person structured interview evaluated the physician and staff's self-reported nutrition-related activities reflecting the nutrition manual's recommendations. Data from these two instruments were used to construct four adherence scores corresponding to the areas: office organization, nutrition screening, nutrition advice/referral, and patient follow-up. MAIN RESULTS: The adoption of the manual's recommendations was highest among the practices in the training group as reflected by their higher adherence scores. They organized their office ( P =.005) and screened their patients regarding their eating habits ( P =.046) significantly more closely to the recommendations of the nutrition manual than practices in the manual-only group. However, despite being the highest in compliance, the training group practices were only 54.9% adherent to the manual's recommendations regarding nutrition advice/referral, and 28.5% adherent to its recommendations on office organization, 23.5% adherent to its recommendations on nutrition screening, and 14.6% adherent to its patient follow-up recommendations. CONCLUSIONS: Primary care practices exposed to the nutrition manual in a training session adopted more of the manual's recommendations. Specifically, practices invited to training were more likely to perform nutrition screening and to structure their office environment to be conducive to providing nutrition-related services for cancer prevention. The impact of the training was moderate and not statistically significant for nutrition advice/referral or patient follow-up, which are important in achieving long-term dietary changes in patients. The overall low adherence scores to nutrition-related activities demonstrates that there is plenty of room for improvement among the practices in the training group.",0,0,
628,Effect of varying the number and location of alcohol-based hand rub dispensers on usage in a general inpatient medical unit.,"We sequentially increased the number of wall-mounted alcohol-based hand rub dispensers in a small medical unit to evaluate effects on hand hygiene performance. Above a certain point, addition of more dispensers did not increase hand hygiene frequency, which appeared to be influenced more by location than by total number of dispensers.",1,1,
629,Effect of written and computerized decision support aids for the U.S. Agency for Health Care Policy and Research depression guidelines on the evaluation of hypothetical clinical scenarious.,"Objective.The objective of this study was to compare the effects of written and computerized decision support aids (DSAs) based on U.S. Agency for Health Care Policy and Research depression guidelines.Methods.Fifty-six internal medicine residents were randomized to evaluate clinical scenarios using either a written or a computerized DSA after first assessing scenarios without a DSA. The paired difference between aided and unaided scores was determined for diagnostic accuracy, treatment selection, severity and subtype classification, antipsychotic use, and mental health consultations.Results.Diagnostic accuracy with the written DSA increased from 64% to 73%, and with the computerized DSA decreased from 67% to 64% (P = 0.0065). Residents using the computerized DSA (vs. no DSA) requested fewer consultations (65% vs. 52%, P = 0.028). In post hoc analysis, the written DSA increased sensitivity (66% to 89%, P < 0.001) and the computerized DSA improved specificity (66% to 86%, P = 0.0020) but reduced sensitivity (67% to 49%, P = 0.011).Conclusions.A written DSA improved diagnostic accuracy, whereas a computerized DSA did not. However, the computerized DSA improved specificity and reduced mental health consultations.",0,1,
630,"Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial","OBJECTIVE To determine if a complex nursing and midwifery intervention in hospital labour assessment units would increase the likelihood of spontaneous vaginal birth and improve other maternal and neonatal outcomes. DESIGN Multicentre, randomised controlled trial with prognostic stratification by hospital. SETTING 20 North American and UK hospitals. PARTICIPANTS 5002 nulliparous women experiencing contractions but not in active labour""; 2501 were allocated to structured care and 2501 to usual care. INTERVENTIONS Usual nursing or midwifery care or a minimum of one hour of care by a nurse or midwife trained in structured care, consisting of a formalised approach to assessment of and interventions for maternal emotional state, pain, and fetal position. MAIN OUTCOME MEASURES Primary outcome was spontaneous vaginal birth. Other outcomes included intrapartum interventions, women's views of their care, and indicators of maternal and fetal health during hospital stay and 6-8 weeks after discharge. RESULTS Outcome data were obtained for 4996 women. The rate of spontaneous vaginal birth was 64.0% (n=1597) in the structured care group and 61.3% (n=1533) in the usual care group (odds ratio 1.12, 95% confidence interval 0.96 to 1.27). Fewer women allocated to structured care (n=403, 19.5%) rated staff helpfulness as less than very helpful than those allocated to usual care (n=544, 26.4%); odds ratio 0.67, 98.75% confidence interval 0.50 to 0.85. Fewer women allocated to structured care (n=233, 11.3%) were disappointed with the amount of attention received from staff than those allocated to usual care (n=407, 19.7%);"" odds ratio 0.51, 98.75% confidence interval 0.32 to 0.70. None of the other results met prespecified levels of statistical significance. CONCLUSION A structured approach to care in hospital labour assessment units increased satisfaction with care and was suggestive of a modest increase in the likelihood of spontaneous vaginal birth. Further study to strengthen the intervention is warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN16315180.",0,0,
631,Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation,"BackgroundEvidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance""; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda.; BackgroundEvidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance;"" P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda.",0,0,
632,Effective weight management practice: a review of the lifestyle intervention evidence,"OBJECTIVES: Despite the existence of guidelines for obesity management, uncertainty remains as to what interventions comprise effective practice. This uncertainty could act as a barrier to busy health care professionals, who may lack the time and expertize to fully appraise the huge amount of literature that is published each year on obesity management. Therefore, the objectives of this review were to synthesize the available evidence, determine most effective and most promising practices for obesity management in adults, using an established methodology, and present this information according to its quality. EVIDENCE ACQUISITION: This synthesis review was conducted from January 2009. A detailed search of relevant databases was conducted to September 2010. Most effective and promising practices were defined using the Canadian Best Practice Initiative Methodology Background Paper, with systematic reviews (with/without meta analysis) as the most rigorous methodology for developing recommendations that were deemed most effective (level 1), and non-systematic reviews for developing recommendations deemed as most promising (level 2). Literature was reviewed and classified across these two levels of rigor, and supplemented with primary studies to further refine recommendations. RESULTS: Evidence from systematic reviews and meta-analyses was classified into three intervention themes or areas of context, in which more specific most effective and/or promising practice recommendations could be nested. These intervention themes were (1) targeted multi-component interventions for weight management, (2) dietary manipulation strategies and (3) delivery of weight management interventions, including health professional roles and method of delivery. Specific recommendations accompanied each theme. CONCLUSIONS: This review highlights the value of multi-component interventions that are delivered over the longer term, and reinforces the role of health care professionals. The findings will help to inform evidence-based practice for health care practitioners involved in obesity management and prevention.",0,0,
633,Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study,"OBJECTIVE To estimate the potential cost effectiveness of a population-wide risk factor reduction programme aimed at preventing cardiovascular disease. DESIGN Economic modelling analysis. SETTING England and Wales. Population Entire population. Model Spreadsheet model to quantify the reduction in cardiovascular disease over a decade, assuming the benefits apply consistently for men and women across age and risk groups. MAIN OUTCOME MEASURES Cardiovascular events avoided, quality adjusted life years gained, and savings in healthcare costs for a given effectiveness""; estimates of how much it would be worth spending to achieve a specific outcome. RESULTS A programme across the entire population of England and Wales (about 50 million people) that reduced cardiovascular events by just 1% would result in savings to the health service worth at least £30m (€34m;"" $48m) a year compared with no additional intervention. Reducing mean cholesterol concentrations or blood pressure levels in the population by 5% (as already achieved by similar interventions in some other countries) would result in annual savings worth at least £80m to £100m. Legislation or other measures to reduce dietary salt intake by 3 g/day (current mean intake approximately 8.5 g/day) would prevent approximately 30,000 cardiovascular events, with savings worth at least £40m a year. Legislation to reduce intake of industrial trans fatty acid by approximately 0.5% of total energy content might gain around 570,000 life years and generate NHS savings worth at least £230m a year. CONCLUSIONS Any intervention that achieved even a modest population-wide reduction in any major cardiovascular risk factor would produce a net cost saving to the NHS, as well as improving health. Given the conservative assumptions used in this model, the true benefits would probably be greater.",0,0,
634,Effectiveness and cost-effectiveness of an exposure-based return-to-work programme for patients on sick leave due to common mental disorders: design of a cluster-randomized controlled trial,"BACKGROUND: To reduce the duration of sick leave and loss of productivity due to common mental disorders (CMDs), we developed a return-to-work programme to be provided by occupational physicians (OPs) based on the principles of exposure in vivo (RTW-E programme). This study evaluates this programme's effectiveness and cost-effectiveness by comparing it with care as usual (CAU). The three research questions we have are: 1) Is an RTW-E programme more effective in reducing the sick leave of employees with common mental disorders, compared with care as usual? 2) Is an RTW-E programme more effective in reducing sick leave for employees with anxiety disorders compared with employees with other common mental disorders? 3) From a societal perspective, is an RTW-E programme cost-effective compared with care as usual? METHODS/DESIGN: This study was designed as a pragmatic cluster-randomized controlled trial with a one-year follow-up and randomization on the level of OPs. We aimed for 60 OPs in order to include 200 patients. Patients in the intervention group received the RTW-E programme. Patients in the control group received care as usual. Eligible patients had been on sick leave due to common mental disorders for at least two weeks and no longer than eight weeks. As primary outcome measures, we calculated the time until full return to work and the duration of sick leave. Secondary outcome measures were time until partial return to work, prevalence rate of sick leave at 3, 6, 9, and 12 months' follow-up, and scores of symptoms of distress, anxiety, depression, somatization, and fatigue""; work capacity; perceived working conditions; self-efficacy for return to work; coping behaviour; avoidance behaviour; patient satisfaction;"" and work adaptations. As process measures, we used indices of compliance with the intervention in the intervention group and employee-supervisor communication in both groups. Economic costs were calculated from a societal perspective. The total costs consisted of the costs of consuming health care, costs of production loss due to sick leave and reduced productivity, and out-of-pocket costs of patients for travelling to their OP. DISCUSSION: The results will be published in 2009. The strengths and weaknesses of the study protocol are discussed. TRIAL REGISTRATION: ISRCTN72643128.",0,0,
635,Effectiveness and cost-effectiveness of knowledge transfer and behavior modification interventions in type 2 diabetes mellitus patients—the INDICA study: a cluster randomized controlled trial,"Background Type 2 diabetes mellitus is a chronic disease whose health outcomes are related to patients and healthcare professionals¡¯ decision-making. The Diabetes Intervention study in the Canary Islands (INDICA study) aims to evaluate the effectiveness and cost-effectiveness of educational interventions supported by new technology decision tools for type 2 diabetes patients and primary care professionals in the Canary Islands.  Methods/design The INDICA study is an open, community-based, multicenter, clinical controlled trial with random allocation by clusters to one of three interventions or to usual care. The setting is primary care where physicians and nurses are invited to participate. Patients with diabetes diagnosis, 18¨C65 years of age, and regular users of mobile phone were randomly selected. Patients with severe comorbidities were excluded. The clusters are primary healthcare practices with enough professionals and available places to provide the intervention. The calculated sample size was 2,300 patients.  Patients in group 1 are receiving an educational group program of eight sessions every 3 months led by trained nurses and monitored by means of logs and a web-based platform and tailored semi-automated SMS for continuous support. Primary care professionals in group 2 are receiving a short educational program to update their diabetes knowledge, which includes a decision support tool embedded into the electronic clinical record and a monthly feedback report of patients¡¯ results. Group 3 is receiving a combination of the interventions for patients and professionals.  The primary endpoint is the change in HbA1c in 2 years. Secondary endpoints are cardiovascular risk factors, macrovascular and microvascular diabetes complications, quality of life, psychological outcomes, diabetes knowledge, and healthcare utilization. Data is being collected from interviews, questionnaires, clinical examinations, and records. Generalized linear mixed models with repeated time measurements will be used to analyze changes in outcomes.  The cost-effectiveness analysis, from the healthcare services perspective, involves direct medical costs per quality-adjusted life year gained and two periods, a ¡®within-trial¡¯ period and a lifetime Markov model. Deterministic and probabilistic sensitivity analyses are planned.  Discussion This ongoing trial aims to set up the implementation of evidence-based programs in the clinical setting for chronic patients.",0,0,
636,Effectiveness and efficiency under competition: the Cochrane test,,0,0,
637,Effectiveness of a behavioural intervention to prevent excessive weight gain during infancy (The Baby Milk Trial): study protocol for a randomised controlled trial,"BACKGROUND: Infancy is a period of rapid growth and habit formation and hence could be a critical period for obesity prevention. Excess weight gain during infancy is associated with later obesity and formula-fed babies are more likely to gain excess weight compared to breastfed babies. The primary trial outcome is a change in the weight standard deviation score from birth to 1 year. METHODS/DESIGN: We will recruit 650 to 700 parents who introduce formula-milk feeds within 14 weeks of their baby's birth to a single (assessor) blind, parallel group, individually randomised controlled trial. The focus of the intervention is the caregiver (usually the mother), and the focus of the primary outcome is the infant. The intervention group will receive the behavioural intervention, which aims to reduce formula-milk intake, promote responsive feeding and healthy weaning, and prevent excessive weight gain during infancy. The intervention is based on Social Cognitive Theory and action planning ('implementation intentions'). It consists of three components: (1) a motivational component to strengthen parents' motivation to follow the Baby Milk feeding guidelines, (2) an action planning component to help translate motivation into action, and (3) a coping planning component to help parents deal with difficult situations. It will be delivered by trained facilitators (research nurses) over 6 months through three face-to-face contacts, two telephone contacts and written materials. The control group will have the same number of contacts with facilitators, and general issues about feeding will be discussed. Anthropometric outcomes will be measured by trained research staff, blind to group allocation, at baseline, 6 months and 12 months following standard operating procedures. Validated questionnaires will assess milk intake, temperament, appetite, sleep, maternal quality of life and maternal psychological factors. A 4-day food diary will be completed at 8 months. DISCUSSION: The results of the trial will help to inform infant feeding guidelines and to understand the links between infant feeding, behaviour, appetite and growth. TRIAL REGISTRATION: ISRTCN20814693 . Registration date 13 January 2011.",0,0,
638,Effectiveness of a combined strategy to improve therapeutic compliance and degree of control among patients with hypercholesterolaemia: a randomised clinical trial,"BACKGROUND: In subjects with hypercholesterolaemia, cholesterol values remain above guideline levels. One of the limiting factors to the achievement of goals in such patients is therapeutic non-adherence. The aim of this study is to assess the effectiveness of an intervention designed to improve control of hypercholesterolaemic patients, consisting of a combined strategy that would include the delivery of printed information, treatment-compliance check cards and the dispatch of text messages as complementary measures in support of the intervention at the general practitioner's practice. METHODS/DESIGN: A randomised, parallel-group clinical trial will be conducted at the family medicine outpatient facilities of eight health centres in three of Spain's Autonomous Regions (Comunidades Autonomas), covering a total of 358 subjects aged 18 years or over with diagnosis of hypercholesterolaemia. Patients in the intervention group will be supplied with printed material with information on the disease and its management, mobile-telephone text messages with guideline summaries, reminders of forthcoming appointments and/or arrangements for making new appointments in the event of non-attendance, and self-report cards to check compliance with recommendations. Both groups -intervention and control- will receive routine recommendations from their physicians in accordance with current European clinical practice guidelines for hypercholesterolaemia and cardiovascular risk management. As regards the measurements to be made, the main variable is the proportion of subjects who attain the low density lipoprotein cholesterol levels set as a target across a follow-up period of 24 months. The secondary variables are as follows: adherence to recommendations on lifestyle and adherence to drug treatment""; variation in lipid profiles and cardiovascular risk levels; appearance of cardiovascular events; physical activity; food consumption; smoking habit; anthropometric measures; blood pressure; health problems; use of hypolipidaemic agents; socio-demographic data; beliefs and expectations about preventive recommendations;"" and degree of satisfaction with the combined strategy. DISCUSSION: Should this intervention prove effective, a recommendation could be issued on the application of this combined strategy to subjects with hypercholesterolaemia. It is a simple, relatively inexpensive intervention. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02314663.",0,0,
639,Effectiveness of a prospective physician self-audit transfusion-monitoring system.,"BACKGROUND: The purpose of this study was to search for a more effective transfusion‐monitoring system than the existing system of retrospective peer review. STUDY DESIGN AND METHODS: This research used a study‐control, preintervention and postintervention design, to evaluate the effectiveness of a prospective physician self‐audit transfusion‐monitoring system that functioned without the direct involvement of transfusion service physicians. This research also evaluated the effectiveness of issuing to physicians a memo with transfusion guidelines. Three process indicators were used to assess physician behavior at various stages of the blood‐ordering process: 1) the number of crossmatches ordered per admission, 2) the transfusion‐to‐ crossmatch ratio, and 3) the number of blood units returned to the laboratory after physician self‐auditing. The study used two outcome indicators to reflect overall blood utilization: 1) the percentage of patients who received red cell transfusions and 2) the number of blood units transfused per recipient each month. RESULTS: The prospective physician self‐audit system implemented at the study hospital did not reverse physician transfusion decisions, and the process of issuing to physicians a memo with transfusion guidelines at the control hospital failed to reduce blood usage. However, a transient reduction in blood utilization was observed at the study hospital. CONCLUSION: The reduction was hypothesized to be due to a Hawthorne effect, in which observed behavior is affected by the subject's awareness of the research study.",0,1,
640,Effectiveness of academic detailing to optimize medication prescribing behaviour of family physicians,"PURPOSE: To synthesize current knowledge about the effectiveness and the magnitude of the effect, of Academic Detailing (AD), as a stand-alone intervention, at modifying drug prescription behavior of Family Physicians (FPs) in primary care settings. METHODS: A search of MEDLINE, EMBASE, CENTRAL, and Web of Science databases of all English language articles between January 1983 and July 2010 was conducted. We hand-searched the bibliographies of articles retrieved from the electronic search to identify additional studies. Inclusion criteria were: full-length articles describing original research""; randomized controlled trial (RCT), or observational study design with a control group; studies of AD delivered to FPs; AD as a stand-alone intervention; drug prescription as the target behavior. Data extraction was done independently by two reviewers. Outcomes evaluated were: the difference in relative change in prescription rate between the intervention and control groups; the difference in absolute change in prescription rate between the intervention and control groups;"" and effect size, calculated as the standardized mean difference. RESULTS: 11 RCTs and 4 observational studies were included. Five RCTS described results showing effectiveness, while 2 RCTs reported a positive effect on some of the target drugs. Two observational studies found AD to be effective, while 2 did not. The median difference in relative change among the studies reviewed was 21% (interquartile range 43.75%) for RCTs, and 9% (interquartile range 8.5%) for observational studies. The median effect size among the studies reviewed was - 0.09 (interquartile range 2.73). CONCLUSION: This systematic review demonstrates that AD can be effective at optimizing prescription of medications by FPs. Although variable, the magnitude of the effect is moderate in the majority of studies. This systematic review also provides evidence supportive of the use of AD as a strategy to promote evidence based prescription of medications or incorporation of clinical guidelines into clinical practice. This article is open to POST-PUBLICATION REVIEW. Registered readers (see ""For Readers"") may comment by clicking on ABSTRACT on the issue's contents page.",0,0,
641,Effectiveness of an audible reminder on hand hygiene adherence,"Multimodal interventions aim to improve health care workers’ adherence to hand hygiene guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interventions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the transmission of epidemic infections to or from health care environments.  Methods An electronic motion sensor–triggered audible hand hygiene reminder was installed at hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to measure the adherence of hospital visitors and staff to hand hygiene guidelines.  Results Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P = .341).  Conclusions The electronic motion sensor–triggered audible reminder immediately and significantly improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control epidemic infections.",0,1,
642,Effectiveness of an electronic medical record clinical quality alert prepared by off-line data analysis,,0,1,
643,Effectiveness of an information technology intervention to improve prophylactic antibacterial use in the postoperative period.,"Background A 2005 report from the Centers for Medicare and Medicaid Services and the Centers for Disease Control Surgical Infection Prevention program indicated that only 41% of prophylactic antibacterials were correctly stopped within 24 h of the end of surgery. Electronic order sets have shown promise as a means of integrating guideline information with electronic order entry systems and facilitating safer, more effective care.  Objective The aim was to study the effectiveness of a computer-based antibacterial order set on increasing the proportion of patients who have antibacterial wound prophylaxis discontinued in the appropriate time frame.  Design The authors conducted a quasi-experimental interrupted time-series analysis over an 8-month study period with the implementation of a computer-based order system designed to prevent excessive duration of surgical prophylaxis antibacterials.  Measurement The primary outcome was the proportion of surgeries with antibacterials discontinued in the appropriate time frame. Additionally, we evaluated the percent of surgeries after implementation of the electronic intervention with chart documentation of infection among surgeries where the prescriber indicated the reason for antibacterial therapy was treatment.  Results The computer-based order intervention significantly improved the proportion of surgeries with timely discontinuation of antibacterials from 38.8% to 55.7% (p<0.001) in the intervention hospital, while the control hospital remained at 56–57% (p=0.006 for the difference between treated and control hospitals). In surgeries after intervention implementation where a prescriber indicated the reason for antibacterial therapy was treatment, the prevalence of chart documented infection was only 14%.  Conclusions A computer-based electronic order set intervention increased timely discontinuation of postoperative antibacterials.",0,1,
644,Effectiveness of an Intervention to Enhance Occupational Physicians' Guideline Adherence on Sickness Absence Duration in Workers with Common Mental Disorders: A Cluster-Randomized Controlled Trial,"Purpose Evidence-based guidelines in occupational health care improve the quality of care and may reduce sickness absence duration. Notwithstanding that, guideline adherence of occupational physicians (OPs) is limited. Based on the literature on guideline implementation, an intervention was developed that was shown to effectively improve self-reported adherence in OPs. The aim of present study was to evaluate whether this intervention leads to earlier return to work (RTW) in workers with common mental disorders (CMD). Methods In a two-armed cluster randomized controlled trial, 66 OPs were randomized. The trial included 3379 workers, with 1493 in the intervention group and 1886 in the control group. The outcome measures were: time to full RTW, time to first RTW, and total hours of sickness absence. Cox regression analyses and generalized linear mixed model analyses were used for the evaluations. Results The median time to RTW was 154 days among the 3228 workers with CMD. No significant differences occurred in (time to) full RTW between intervention and control group HR 0.96 (95% CI 0.81-1.15) nor for first RTW HR 0.96 (95% CI 0.80-1.15). The mean total hours of sickness absence was 478 h in the intervention group and 483 h in the control group. Conclusions The intervention to enhance OPs' guideline adherence did not lead to earlier RTW in workers with CMD guided by the OPs. Possible explanations are the remaining external barriers for guideline use, and that perceived guideline adherence might not represent actual guideline adherence and improved care.Trail registration: ISRCTN86605310.",0,1,
645,Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners,"We describe training in CBT techniques for 20 palliative care practitioners delivered as 12 days' equivalent teaching plus skills-building supervision over a six month period. Audiotapes of trainees' interactions with patients during their usual work were rated using a specially devised 'Cognitive First Aid' rating scale (CFARS). The CFARS was highly internally consistent (Cronbach's Alpha 0.93) and inter-rater reliability was high. Trainees showed significant gain in CBT skills competency over six months (p=0.001). After initial training, half the trainees were randomised to discontinue supervision"";"" their measured CBT skill dropped as did their self-reported confidence when reassessed six months later, whereas those who continued in supervision gained further skill and maintained confidence (p=0.007). Palliative care practitioners can be trained in CBT skills by a simple and brief training course and supportive, skills-building supervision. These skills are compatible with national guidelines on delivery of psychological support to patients at all stages of cancer. Supervision is necessary to ensure maintenance of skills and confidence to use them.",0,0,
646,Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review for a Clinical Practice Guideline,"Background: The effectiveness of the 5 U.S. Food and Drug Administration¨Capproved pharmacologic therapies for dementias in achieving clinically relevant improvements is unclear. Purpose: To review the evidence for the effectiveness of cholinesterase inhibitors (donepezil, galantamine, rivastigmine, and tacrine) and the neuropeptide-modifying agent memantine in achieving clinically relevant improvements, primarily in cognition, global function, behavior, and quality of life, for patients with dementia. Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE, PREMEDLINE, EMBASE, Allied and Complementary Medicine Database, CINAHL, AgeLine, and PsycINFO from January 1986 through November 2006. Study Selection: English-language randomized, controlled trials were included in the review if they evaluated pharmacologic agents for adults with a diagnosis of dementia, did not use a crossover design, and had a quality score of at least 3 on the Jadad scale. Data Extraction: Data were extracted on study characteristics and outcomes, including adverse events. Effect sizes were calculated and data were combined when appropriate. Data Synthesis: 96 publications representing 59 unique studies were eligible for this review. Both cholinesterase inhibitors and memantine had consistent effects in the domains of cognition and global assessment, but summary estimates showed small effect sizes. Outcomes in the domains of behavior and quality of life were evaluated less frequently and showed less consistent effects. Most studies were of short duration (6 months), which limited their ability to detect delay in onset or progression of dementia. Three studies directly compared different cholinesterase inhibitors and found no differences in cognition and behavior. Limitations: Limitations of available studies included short duration, inclusion of only patients with mild to moderate Alzheimer disease, poor reporting of adverse events, lack of clear definitions for statistical significance, limited evaluation of behavior and quality-of-life outcomes, and limited direct comparison of different treatments. Conclusions: Treatment of dementia with cholinesterase inhibitors and memantine can result in statistically significant but clinically marginal improvement in measures of cognition and global assessment of dementia.",0,0,
647,Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial,"CONTEXT: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. OBJECTIVE: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. DESIGN, SETTING, AND PATIENTS: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n = 84) or augmented usual care (n = 69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. INTERVENTION: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. MAIN OUTCOME MEASURES: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. RESULTS: Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%""; P = .002) and antidepressants (45.2% vs 27.5%; P = .03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P = .01) and at 18 months (mean difference, -5.4; P = .01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months;"" at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. CONCLUSIONS: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00246896.",0,0,
648,Effectiveness of computer assisted instruction in increasing the rate of universal precautions related behaviours.,"Background: With widespread noncompliance to universal precautions well established, an experimental study was designed to compare the rate of universal precautions-related behaviors between nurses who participate in computer-assisted instruction. This study also explored the relationship between rates of universal precautions-related behaviors and subjects' demographic and experiential characteristics and history of occupational blood-borne exposure.  Methods: Data were collected by using a questionnaire to elicit information as to subjects' demographic and experiential characteristics and history of occupational blood-borne exposure. The Universal Precautions Assessment Tool was used to gather data on rates of universal precautions-related behaviors on two groups of registered nurses with 30 subjects per group.  Results: By using analysis of variance, the null hypothesis was rejected. The intervention used in this study did increase universal precautions-related behaviors. Multiple regression was used to analyze the research question and none of the variables were significant. Forty (67.8%) subjects reported receiving a needlestick or cut caused by a needle or sharp that was actually or potentially contaminated with blood or body fluids. Of these exposures, one one patient was known to be HIV antibody positive.  Conclusion: Replication studies using computer-assisted instruction interventions are needed as are studies aimed at exploring other potentially effective interventions.",0,1,
649,Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study,"BackgroundNon-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community."";"" BackgroundNon-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community.",0,0,
650,Effectiveness of eye protection in the metal working industry,,0,0,
651,Effectiveness of guideline-based care by occupational physicians on the return-to-work of workers with common mental disorders: design of a cluster-randomised controlled trial,"BACKGROUND: Sickness absence due to common mental disorders (such as depression, anxiety disorder, adjustment disorder) is a problem in many Western countries. Long-term sickness absence leads to substantial societal and financial costs. In workers with common mental disorders, sickness absence costs are much higher than medical costs. In the Netherlands, a practice guideline was developed that promotes an activating approach of the occupational physician to establish faster return-to-work by enhancing the problem-solving capacity of workers, especially in relation to their work environment. Studies on this guideline indicate a promising association between guideline adherence and a shortened sick leave duration, but also minimal adherence to the guideline by occupational physicians. Therefore, this study evaluates the effect of guideline-based care on the full return-to-work of workers who are sick listed due to common mental disorders. METHODS/DESIGN: This is a two-armed cluster-randomised controlled trial with randomisation at the occupational physician level. During one year, occupational physicians in the intervention group receive innovative training to improve their guideline-based care whereas occupational physicians in the control group provide care as usual. A total of 232 workers, sick listed due to common mental disorders and counselled by participating occupational physicians, will be included. Data are collected via the registration system of the occupational health service, and by questionnaires at baseline and at 3, 6 and 12 months. The primary outcome is time to full return-to-work. Secondary outcomes are partial return-to-work, total number of sick leave days, symptoms, and workability. Personal and work characteristics are the prognostic measures. Additional measures are coping, self-efficacy, remoralization, personal experiences, satisfaction with consultations with the occupational physician and with contact with the supervisor, experiences and behaviour of the supervisor, and the extent of guideline adherence. DISCUSSION: If the results show that guideline-based care in fact leads to faster and sustainable return-to-work, this study will contribute to lowering personal, societal and financial costs. TRIAL REGISTRATION: ISRCTN86605310.",0,0,
652,"Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial.","Objective To assess the the effect of medical nutrition therapy (MNT) provided by dietitians on medical and clinical outcomes for adults with non–insulin-dependent diabetes mellitus (NIDDM), and to compare MNT administered according to practice guidelines nutrition care (PGC) to MNT administered with basic nutrition care (BC).  Design A prospective, randomized, controlled clinical trial of two levels of MNT on metabolic control in persons newly diagnosed with or currently under treatment for NIDDM was conducted at diabetes centers in three states (Minnesota, Florida, and Colorado). BC consisted of a single visit with a dietitian""; PGC involved an initial visit with a dietitian followed by two visits during the first 6 weeks of the study period. Data were collected at entry to the study and at 3 and 6 months.  Subjects Results are reported for 179 men and women aged 38 to 76 years: 85 assigned randomly to BC and 94 to PGC. This represents 72% of the 247 subjects enrolled. An additional 62 adults with NIDDM at one site who had no contact with a dietitian were identified as a nonrandom comparison group.  Outcomes Medical outcome measures included fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), and serum lipid levels. Clinical outcomes included weight, body mass index, waist-to-hip ratio, and changes in medical therapy.  Statistical analyses Initial analysis of the discrete variables was done using the ?2 statistic with Yates' correction. Initial analysis of continuous variables was done by analysis of variance. The changes in variables between time periods were analyzed by paired t test, and comparisons between groups were analyzed using a t test for independent groups.  Results At 6 months, PGC resulted in significant improvements in blood glucose control as indicated by FPG and HbA1c levels and BC resulted in significant improvements in HbA1c level. Participants assigned to the PGC group had a mean FPG level at 6 months that was 10.5% lower than the level at entry, and those in the BC group had a 5.3% lower value. Among subjects who had diabetes for longer than 6 months, those who received PGC had a significantly better HbA1c level at 3 months compared with those receiving BC. The comparison group showed no improvement in glycemic control over a comparable 6 months. PGC subjects had significant improvements in cholesterol values at 6 months, and subjects in both the PGC and the BC groups had significant weight loss.  Conclusions MNT provided by dietitians resulted in significant improvements in medical and clinical outcomes in both the BC and PGC groups and is beneficial to persons with NIDDM. Persons with a duration of diabetes longer than 6 months tended to do better with PGC than with BC. Because of the upward trend in glucose levels after 3 months, ongoing MNT by dietitians is important for long-term metabolic control. J Am Diet Assoc. 1995;"" 95:1009-1017.",0,1,
653,Effectiveness of Motivational Interviewing in improving lipid level in patients with dyslipidemia assisted by general practitioners: Dislip-EM study protocol,"BACKGROUND: The non-pharmacological approach to cholesterol control in patients with hyperlipidemia is based on the promotion of a healthy diet and physical activity. Thus, to help patients change their habits, it is essential to identify the most effective approach. Many efforts have been devoted to explain changes in or adherence to specific health behaviors. Such efforts have resulted in the development of theories that have been applied in prevention campaigns, and that include brief advice and counseling services. Within this context, Motivational Interviewing has proven to be effective in changing health behaviors in specific cases. However, more robust evidence is needed on the effectiveness of Motivational Interviewing in treating chronic pathologies -such as dyslipidemia- in patients assisted by general practitioners. This article describes a protocol to assess the effectiveness of MI as compared with general practice (brief advice), with the aim of improving lipid level control in patients with dyslipidemia assisted by a general practitioner. METHODS/DESIGN: An open, two-arm parallel, multicentre, cluster, controlled, randomized, clinical trial will be performed. A total of 48-50 general practitioners from 35 public primary care centers in Spain will be randomized and will recruit 436 patients with dyslipidemia. They will perform an intervention based either on Motivational Interviewing or on the usual brief advice. After an initial assessment, follow-ups will be performed at 2, 4, 8 and 12 months. Primary outcomes are lipid levels (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) and cardiovascular risk. The study will assess the degree of dietary and physical activity improvement, weight loss in overweight patients, and adherence to treatment guidelines. DISCUSSION: Motivational interview skills constitute the primary strategies GPs use to treat their patients. Having economical, simple, effective and applicable techniques is essential for primary care professionals to help their patients change their lifestyle and improve their health. This study will provide scientific evidence on the effectiveness of Motivational interviewing, and will be performed under strict control over the data collected, ensuring the maintenance of therapeutic integrity. TRIALS REGISTRATION: ClinicalTrials.gov (NCT01282190).",0,0,
654,Effectiveness of motivational interviewing in patients with dyslipidemia: a randomized cluster trial,"BACKGROUND: It is known that making people change their habits is challenging. It is crucial to identify the most effective approach that general practitioners (GPs) should use to help their patients change unhealthy habits. The objective this study was to assess the efficacy of a multifactorial intervention based on Motivational Interviewing performed by general practitioners to enhance lipid levels in patients with dyslipidemia, as compared to standard care. METHODS: A multicenter, controlled, randomized, cluster, two-parallel arm trial with a 12-month follow-up conducted in 25 community health centers of the Spanish. 38 GPs and 227 primary care patients with uncontrolled dyslipidemia were included in the trial. GPs performed an intervention based either on Motivational Interviewing (MI) or standard practice. Lipid levels were measured, and the control degree was analyzed based on the criteria of clinical guidelines. RESULTS: 107 were assigned to the Experimental Group (EG) and 120 to the Control Group (CG). An overall improvement was achieved in total cholesterol levels (Mean Difference -MD- = -19.60""; 95 % CI: -15.33 at -23.87 mg/dl; p < 0.001), LDL-cholesterol levels (MD = -13.78; 95 % CI: -9.77 at -17.79 mg/dl; p < 0.001) and triglycerides (MD = -19.14; CI 95 %: -11.29 at -26.99 mg/dl; p < 0.001). No differences were found between the two groups. However, when we assessed the degree of lipid control by combining cholesterol <200 mg/dl and LDL-cholesterol < 130 mg/dl parameters, it was observed that a higher percentage of patients achieved target figures in the EG versus CG (13.1 % vs. 5.0 %; adjusted OR = 5.77, 95 % CI: 1.67-19.91). CONCLUSION: A Motivational Interviewing-based approach conducted by Primary Care physicians aimed at patients with dyslipidemia, achieved a significant reduction in all lipid parameters, cardiovascular risk, weight reduction and the adherence to the Mediterranean diet, similar to that obtained with the usual intervention and superior in the proportion of patients achieving combined lipid control goals and the level of physical exercise. TRIAL REGISTRATION: the trial is registered in ClinicalTrials.gov ( NCT01282190 ;"" January 21, 2011).",0,0,
655,Effectiveness of multicomponent interventions in primary healthcare settings to promote continuous smoking cessation in adults: a systematic review,"OBJECTIVE: The objective of the present review is to evaluate multicomponent/complex primary care (PC) interventions for their effectiveness in continuous smoking abstinence by adult smokers. DESIGN: A systematic review of randomised and non-randomised controlled trials was undertaken. ELIGIBILITY CRITERIA FOR INCLUDED STUDIES: Selected studies met the following criteria: evaluated effects of a multicomponent/complex intervention (with 2 or more intervention components) in achieving at least 6-month abstinence in adult smokers who visited a PC, biochemical confirmation of abstinence, intention-to-treat analysis and results published in English/Spanish. METHODS: We followed PRISMA statement to report the review. We searched the following data sources: MEDLINE, Web of Science, Scopus (from inception to February 2014), 3 key journals and a tobacco research bulletin. The Scottish Intercollegiate Guidelines Network checklists were used to evaluate methodological quality. Data selection, evaluation and extraction were done independently, using a paired review approach. Owing to the heterogeneity of interventions in the studies included, a meta-analysis was not conducted. RESULTS: Of 1147 references identified, 9 studies were selected (10,204 participants, up to 48 months of follow-up, acceptable methodological quality). Methodologies used were mainly individual or group sessions, telephone conversations, brochures or quit-smoking kits, medications and economic incentives for doctors and no-cost medications for smokers. Complex interventions achieved long-term continuous abstinence ranging from 7% to 40%. Behavioural interventions were effective and had a dose-response effect. Both nicotine replacement and bupropion therapy were safe and effective, with no observed differences. CONCLUSIONS: Multicomponent/complex interventions in PC are effective and safe, appearing to achieve greater long-term continuous smoking cessation than usual care and counselling alone. Selected studies were heterogeneous and some had significant losses to follow-up. Our results show that smoking interventions should include more than one component and a strong follow-up of the patient to maximise results.",0,0,
656,Effectiveness of nursing interventions in people with personality disorders,"BACKGROUND: Nurses usually provide care for people with personality disorders on a day-to-day basis. Consequently, it is important to establish how effective nursing interventions are for those with personality disorders, both in terms of general management and more specific therapeutic approaches. These are also issues of current political and professional debate. The crucial question, however, for planners, providers and commissioners of services is, What research evidence is there about effectiveness? There is also a need to determine what further research is necessary to evaluate programmes for managing or modifying behaviours. AIM: The aim of this paper is to report on a systematic review of the literature on the effectiveness of nursing interventions in people with personality disorders, whether delivered by nurses alone or in combination with other health care professionals. METHOD: The review was conducted according to the United Kingdom National Health Service Centre for Reviews and Dissemination guidelines. Literature was identified from electronic database searching, footnote chasing, hand searching of journals and contact with authors of studies. Narrative synthesis was undertaken in relation to study design, participants, and type of intervention. FINDINGS: Eighteen separate studies were included in the review: four randomized controlled trials, four non-randomized controlled trials, seven before-and-after studies and three case studies. CONCLUSIONS: There is a weak evidence-base for what constitutes effective nursing intervention with people with personality disorders. There is stronger evidence from mixed disciplines intervention studies than from nursing only intervention studies. Studies of interventions based on psychological approaches show greater improvements in outcomes than nursing management studies.",0,0,
657,Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial.,"Context It is not known whether patient outcomes are enhanced by effective pharmacist-patient interactions.  Objective To assess the effectiveness of a pharmaceutical care program for patients with asthma or chronic obstructive pulmonary disease (COPD).  Design, Setting, and Participants Randomized controlled trial conducted at 36 community drugstores in Indianapolis, Ind. We enrolled 1113 participants with active COPD or asthma from July 1998 to December 1999. Outcomes were assessed in 947 (85.1%) participants at 6 months and 898 (80.7%) at 12 months.  Interventions The pharmaceutical care program (n = 447) provided pharmacists with recent patient-specific clinical data (peak expiratory flow rates [PEFRs], emergency department [ED] visits, hospitalizations, and medication compliance), training, customized patient educational materials, and resources to facilitate program implementation. The PEFR monitoring control group (n = 363) received a peak flow meter, instructions about its use, and monthly calls to elicit PEFRs. However, PEFR data were not provided to the pharmacist. Patients in the usual care group (n = 303) received neither peak flow meters nor instructions in their use""; during monthly telephone interviews, PEFR rates were not elicited. Pharmacists in both control groups had a training session but received no components of the pharmaceutical care intervention.  Main Outcome Measures Peak expiratory flow rates, breathing-related ED or hospital visits, health-related quality of life (HRQOL), medication compliance, and patient satisfaction.  Results At 12 months, patients receiving pharmaceutical care had significantly higher peak flow rates than the usual care group (P = .02) but not than PEFR monitoring controls (P = .28). There were no significant between-group differences in medication compliance or HRQOL. Asthma patients receiving pharmaceutical care had significantly more breathing-related ED or hospital visits than the usual care group (odds ratio, 2.16; 95% confidence interval, 1.76-2.63;"" P<.001). Patients receiving pharmaceutical care were more satisfied with their pharmacist than the usual care group (P = .03) and the PEFR monitoring group (P = .001) and were more satisfied with their health care than the usual care group at 6 months only (P = .01). Despite ample opportunities to implement the program, pharmacists accessed patient-specific data only about half of the time and documented actions about half of the time that records were accessed.  Conclusions This pharmaceutical care program increased patients' PEFRs compared with usual care but provided little benefit compared with peak flow monitoring alone. Pharmaceutical care increased patient satisfaction but also increased the amount of breathing-related medical care sought.",0,1,
658,Effectiveness of physical therapy for patients with neck pain: an individualized approach using a clinical decision-making algorithm,"Objective: The purpose of this study was to determine the effectiveness of an individualized physical therapy intervention in treating neck pain based on a clinical reasoning algorithm. Treatment effectiveness was examined by assessing changes in impairment, physical performance, and disability in response to intervention.  Design: One treatment group of 30 patients with neck pain completed physical therapy treatment. The control group of convenience was formed by a cohort group of 27 subjects who also had neck pain but did not receive treatment for various reasons. There were no significant differences between groups in demographic data and the initial test scores of the outcome measures. A quasi-experimental, nonequivalent, pretest-posttest control group design was used. A physical therapist rendered an eclectic intervention to the treatment group based on a clinical decision-making algorithm. Treatment outcome measures included the following five dependent variables: cervical range of motion, numeric pain rating, timed weighted overhead endurance, the supine capital flexion endurance test, and the Patient Specific Functional Scale. Both the treatment and control groups completed the initial and follow-up examinations, with an average duration of 4 wk between tests.  Results: Five mixed analyses of variance with follow-up tests showed a significant difference for all outcome measures in the treatment group compared with the control group. After an average 4 wk of physical therapy intervention, patients in the treatment group demonstrated statistically significant increases of cervical range of motion, decrease of pain, increases of physical performance measures, and decreases in the level of disability. The control group showed no differences in all five outcome variables between the initial and follow-up test scores.  Conclusions: This study delineated algorithm-based clinical reasoning strategies for evaluating and treating patients with cervical pain. The algorithm can help clinicians classify patients with cervical pain into clinical patterns and provides pattern-specific guidelines for physical therapy interventions. An organized and specific physical therapy program was effective in improving the status of patients with neck pain.",0,1,
659,Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials,"OBJECTIVE To evaluate the effectiveness of physiotherapy exercise after elective primary total knee arthroplasty in patients with osteoarthritis. DESIGN Systematic review. DATA SOURCES Database searches: AMED, CINAHL, Embase, King's Fund, Medline, Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. Review methods Randomised controlled trials were reviewed if they included a physiotherapy exercise intervention compared with usual or standard physiotherapy care, or compared two types of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis. OUTCOME MEASURES Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardised effect sizes, and tests for heterogeneity. RESULTS Six trials were identified, five of which were suitable for inclusion in meta-analyses. There was a small to moderate standardised effect size (0.33, 95% confidence interval 0.07 to 0.58) in favour of functional exercise for function three to four months postoperatively. There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (-1 to 4.3) for quality of life in favour of functional exercise three to four months postoperatively. Benefits of treatment were no longer evident at one year. CONCLUSIONS Interventions including physiotherapy functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty. Effect sizes are small to moderate, with no long term benefit.",0,0,
660,Effectiveness of provider incentives for anaemia reduction in rural China: a cluster randomised trial,"OBJECTIVES To test the impact of provider performance pay for anaemia reduction in rural China. DESIGN A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment. SETTING 72 randomly selected rural primary schools across northwest China. PARTICIPANTS 3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study. INTERVENTIONS Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia""; (b) a subsidy arm, in which principals received information and unconditional subsidies;"" and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point). MAIN OUTCOME MEASURES Student haemoglobin concentrations. RESULTS Mean student haemoglobin concentration rose by 1.5 g/L (95% CI -1.1 to 4.1) in information schools, 0.8 g/L (-1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools. CONCLUSIONS Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical. TRIAL REGISTRATION NUMBER ISRCTN76158086.",0,0,
661,Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial,"OBJECTIVE To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in primary care. The hypothesis was that more intensive intervention would result in a greater reduction in hazardous or harmful drinking. DESIGN Pragmatic cluster randomised controlled trial. SETTING Primary care practices in the north east and south east of England and in London. PARTICIPANTS 3562 patients aged 18 or more routinely presenting in primary care, of whom 2991 (84.0%) were eligible to enter the trial: 900 (30.1%) screened positive for hazardous or harmful drinking and 756 (84.0%) received a brief intervention. The sample was predominantly male (62%) and white (92%), and 34% were current smokers. INTERVENTIONS Practices were randomised to three interventions, each of which built on the previous one: a patient information leaflet control group, five minutes of structured brief advice, and 20 minutes of brief lifestyle counselling. Delivery of the patient leaflet and brief advice occurred directly after screening and brief lifestyle counselling in a subsequent consultation. MAIN OUTCOME MEASURES The primary outcome was patients' self reported hazardous or harmful drinking status as measured by the alcohol use disorders identification test (AUDIT) at six months. A negative AUDIT result (score <8) indicated non-hazardous or non-harmful drinking. Secondary outcomes were a negative AUDIT result at 12 months, experience of alcohol related problems (alcohol problems questionnaire), health utility (EQ-5D), service utilisation, and patients' motivation to change drinking behaviour (readiness to change) as measured by a modified readiness ruler. RESULTS Patient follow-up rates were 83% at six months (n=644) and 79% at 12 months (n=617). At both time points an intention to treat analysis found no significant differences in AUDIT negative status between the three interventions. Compared with the patient information leaflet group, the odds ratio of having a negative AUDIT result for brief advice was 0.85 (95% confidence interval 0.52 to 1.39) and for brief lifestyle counselling was 0.78 (0.48 to 1.25). A per protocol analysis confirmed these findings. CONCLUSIONS All patients received simple feedback on their screening outcome. Beyond this input, however, evidence that brief advice or brief lifestyle counselling provided important additional benefit in reducing hazardous or harmful drinking compared with the patient information leaflet was lacking. TRIAL REGISTRATION Current Controlled Trials ISRCTN06145674.",0,0,
662,Effectiveness of screening and treatment for depression in ambulatory indigent patients,"OBJECTIVE: To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians. DESIGN: Two-group randomized trial (N = 33 intervention, N = 28 usual care) with baseline, 6-month, and 12-month outcome measurements. SETTING: Internal Medicine Residency Clinic. PATIENTS: Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line. INTERVENTION: Resident physicians were educated to follow AHCPR (AHRQ"";"" Agency for Healthcare Research and Quality) guidelines for diagnosis and treatment of depression in a primary care setting. For the intervention group patients, a screening nurse advised residents regarding the positive screen, handed them a standardized protocol outline, and attempted to arrange behavioral care. The patients in the usual care group were provided the results of the screen by the screening nurse before their visit with the resident, and advised to seek care for their symptoms. MAIN RESULTS: Results for the primary outcome of depression symptoms measured with the Beck Depression Inventory (BDI) demonstrated that intervention was successful in reducing symptoms relative to usual care (difference = -4.9 BDI points, P =.05, 95% confidence interval [CI], -9.8 to -0.005 effect size = -0.41). During the 12-month follow-up, 70% of intervention patients were treated for depression (of these, 91% with antidepressants), while 15% of usual care patients were treated with antidepressants for depression. Another 18% of the usual care group had depression noted, but no treatment was identified. BDI differences between intervention and control groups were similar at the 6- and 12-month measures. Quality of life and costs were also measured, but differences between the groups were not significant in this regard. CONCLUSION: Screening and treatment for depression by resident physicians was successful in reducing symptoms relative to usual care in an indigent population. Almost twice as many intervention patients as usual care controls demonstrated a substantial reduction (10 BDI points) in symptoms related to depression.",0,0,
663,"Effectiveness of strategies to disseminate and implement clinical guidelines for the management of impacted and unerupted third molars in primary dental care, a cluster randomised controlled trial","OBJECTIVE: To investigate the effectiveness and cost-effectiveness of different guideline implementation strategies, using the Scottish Intercollegiate Guidelines Network (SIGN) Guideline 42 ""Management of unerupted and impacted third molar teeth"" (published 2000) as a model. DESIGN: A pragmatic, cluster RCT (2x2 factorial design). SUBJECTS: Sixty-three dental practices across Scotland. Clinical records of all 16-24-year-old patients over two, four-month periods in 1999 (pre-intervention) and 2000 (post-intervention) were searched by a clinical researcher blind to the intervention group. Data were also gathered on the costs of the interventions. INTERVENTIONS: Group 1 received a copy of SIGN 42 Guideline and had an opportunity to attend a postgraduate education course (PGEC). In addition to this, group 2 received audit and feedback (A and F). Group 3 received a computer aided learning (CAL) package. Group 4 received A and F and CAL. PRINCIPAL OUTCOME MEASUREMENT: The proportion of patients whose treatment complied with the guideline. RESULTS: The weighted t-test for A and F versus no A and F (P=0.62) and CAL versus no CAL (P=0.76) were not statistically significant. Given the effectiveness results (no difference) the cost effectiveness calculation became a cost-minimisation calculation. The minimum cost intervention in the trial consisted of providing general dental practitioners (GDPs) with guidelines and the option of attending PGEC courses. Routine data which subsequently became available showed a Scotland-wide fall in extractions prior to data collection. CONCLUSION: In an environment in which pre-intervention compliance was unexpectedly high, neither CAL nor A and F increased the dentists' compliance with the SIGN guideline compared with mailing of the guideline and the opportunity to attend a postgraduate course. The cost of the CAL arm of the trial was greater than the A and F arm. Further work is required to understand dental professionals' behaviour in response to guideline implementation strategies.",0,1,
664,"Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial","BackgroundDeep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke."";"" BackgroundDeep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke.",0,0,
665,Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial,"OBJECTIVE To test whether a drug review and symptom self management and lifestyle advice intervention by community pharmacists could reduce hospital admissions or mortality in heart failure patients. DESIGN Randomised controlled trial. SETTING Home based intervention in heart failure patients. PARTICIPANTS 293 patients diagnosed with heart failure were included (149 intervention, 144 control) after an emergency admission. INTERVENTION Two home visits by one of 17 community pharmacists within two and eight weeks of discharge. Pharmacists reviewed drugs and gave symptom self management and lifestyle advice. Controls received usual care. MAIN OUTCOME MEASURES The primary outcome was total hospital readmissions at six months. Secondary outcomes included mortality and quality of life (Minnesota living with heart failure questionnaire and EQ-5D). RESULTS Primary outcome data were available for 291 participants (99%). 136 (91%) intervention patients received one or two visits. 134 admissions occurred in the intervention group compared with 112 in the control group (rate ratio=1.15, 95% confidence interval 0.89 to 1.48""; P=0.28, Poisson model). 30 intervention patients died compared with 24 controls (hazard ratio=1.18, 0.69 to 2.03; P=0.54). Although EQ-5D scores favoured the intervention group, Minnesota living with heart failure questionnaire scores favoured controls;"" neither difference was statistically significant. CONCLUSION This community pharmacist intervention did not lead to reductions in hospital admissions in contrast to those found in trials of specialist nurse led interventions in heart failure. Given that heart failure accounts for 5% of hospital admissions, these results present a problem for policy makers who are faced with a shortage of specialist provision and have hoped that skilled community pharmacists could produce the same benefits. TRIAL REGISTRATION NUMBER ISRCTN59427925.",0,0,
666,Effects of a behaviour independent financial incentive on prescribing behaviour of general practitioners,"RATIONALE AND OBJECTIVES: It is difficult to keep control over prescribing behaviour in general practice. The purpose of this study was to assess the initial effects of a behaviour independent financial incentive on the volume of drug prescribing of general practitioners (GPs). DESIGN: 2-Year Controlled Before After study with an intervention region and a concurrent control region. SETTING AND PARTICIPANTS: GPs in two regions in the Netherlands (n = 119 and n = 118). INTERVENTION: A financial incentive for prescribing according to local guidelines on specific drugs or drug categories. The financial incentive consisted of a non-recurrent, behaviour-independent allowance. MAIN OUTCOME MEASURE: Change in the number of prescriptions for 10 targeted drugs or drug groups. RESULTS: Significant changes were seen only in three types of antibiotics and in recommended gastric medicines. In almost all cases, effects were temporary. CONCLUSION: Behaviour independent financial incentives can be a help in changing prescription behaviour of GPs, but effects are small-scale and temporary.",0,0,
667,Effects of a clinician referral and exercise program for men who have completed active treatment for prostate cancer: A multicenter cluster randomized controlled trial (ENGAGE),"BACKGROUND: The purpose of this study was to determine the efficacy of a clinician referral and exercise program in improving exercise levels and quality of life for men with prostate cancer. METHODS: This was a multicenter cluster randomized controlled trial in Melbourne, Australia comprising 15 clinicians: 8 clinicians were randomized to refer eligible participants (n = 54) to a 12-week exercise program comprising 2 supervised gym sessions and 1 home-based session per week, and 7 clinicians were randomized to follow usual care (n = 93). The primary outcome was self-reported physical activity""; the secondary outcomes were quality of life, anxiety, and symptoms of depression. RESULTS: A significant intervention effect was observed for vigorous-intensity exercise (effect size: Cohen's d, 0.46; 95% confidence interval [CI], 0.09-0.82; P = .010) but not for combined moderate and vigorous exercise levels (effect size: d, 0.08; 95% CI, -0.28 to 0.45; P = .48). Significant intervention effects were also observed for meeting exercise guidelines (>/=150 min/wk; odds ratio, 3.9; 95% CI, 1.9-7.8; P = .002); positive intervention effects were observed in the intervention group for cognitive functioning (effect size: d, 0.34; 95% CI, -0.02 to 0.70; P = .06) and depression symptoms (effect size: d, -0.35; 95% CI, -0.71 to 0.02;"" P = .06). Eighty percent of participants reported that the clinician's referral influenced their decision to participate in the exercise program. CONCLUSIONS: The clinician referral and 12-week exercise program significantly improved vigorous exercise levels and had a positive impact on mental health outcomes for men living with prostate cancer. Further research is needed to determine the sustainability of the exercise program and its generalizability to other cancer populations.",0,0,
668,Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial,"BackgroundBlood pressure is an important determinant of the risks of macrovascular and microvascular complications of type 2 diabetes, and guidelines recommend intensive lowering of blood pressure for diabetic patients with hypertension. We assessed the effects of the routine administration of an angiotensin converting enzyme (ACE) inhibitor-diuretic combination on serious vascular events in patients with diabetes, irrespective of initial blood pressure levels or the use of other blood pressure lowering drugs."";"" BackgroundBlood pressure is an important determinant of the risks of macrovascular and microvascular complications of type 2 diabetes, and guidelines recommend intensive lowering of blood pressure for diabetic patients with hypertension. We assessed the effects of the routine administration of an angiotensin converting enzyme (ACE) inhibitor-diuretic combination on serious vascular events in patients with diabetes, irrespective of initial blood pressure levels or the use of other blood pressure lowering drugs.",0,0,
669,"Effects of a multifaceted intervention on cardiovascular risk factors in high-risk hypertensive patients: the ESCAPE trial, a pragmatic cluster randomized trial in general practice","BACKGROUND: Several observational studies on hypertensive patients have shown a gap between therapeutic targets recommended in guidelines and those achieved in daily practice. The ESCAPE trial aimed to determine whether a multifaceted intervention focused on general practitioners (GPs), could increase significantly the proportion of hypertensive patients at high risk in primary prevention who achieved all their recommended therapeutic targets. METHODS: A pragmatic, cluster randomized trial involving 257 GPs randomized by region. The GPs in the intervention group had a one-day training session and were given an electronic blood pressure measurement device and a short recommendation leaflet. Along with usual follow-up, they focused one consultation on hypertension and other cardiovascular risk factors every six months for two years. They also received feedback at baseline and at one year on their patients' clinical and biological parameters. Main outcome measures were change in the proportion of patients achieving all their therapeutic targets and each individual therapeutic target at two years, and quality of life. RESULTS: 1,832 high-risk hypertensive patients were included. After two years, the proportion of patients achieving all their therapeutic targets increased significantly in both groups, but significantly more in the intervention group: OR (odds-ratio) 1.89, (95% confidence interval (CI) 1.09 to 3.27, P = 0.02). Significantly more patients achieved their blood pressure targets in the intervention group than in the usual care group: OR 2.03 (95% CI 1.44 to 2.88, P < 0.0001). Systolic and diastolic blood pressures decreased significantly more in the intervention group than in the usual care group, by 4.8 mmHg and 1.9 mmHg, respectively (P < 0.0001 for both). There were no significant difference changes in physical and mental quality of life between groups. CONCLUSION: An easy-to-perform, multifaceted intervention targeting only GPs increased significantly the proportion of high-risk hypertensive patients in primary prevention achieving their recommended therapeutic targets. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov, number NCT00348855.",0,0,
670,Effects of a Short Course of Eszopiclone on Continuous Positive Airway Pressure Adherence,"Background:Adherence to short-term continuous positive airway pressure (CPAP) may predict long-term use. Unfortunately, initial CPAP intolerance may lead to poor adherence or abandonment of therapy.Objective:To determine whether a short course of eszopiclone at the onset of therapy improves long-term CPAP adherence more than placebo in adults with obstructive sleep apnea.Design:Parallel randomized, placebo-controlled trial from March 2007 to December 2008. Randomization, maintained and concealed centrally by pharmacy personnel, was computer-generated using fixed blocks of 10. Referring physicians, investigators, and patients were blinded to the treatment assignment until after the final data were collected. (ClinicalTrials.gov registration number: NCT00612157)Setting:Academic sleep disorder center.Patients:160 adults (mean age, 45.7 years [SD, 7.3]""; mean apneaa€¡°hypopnea index, 36.9 events/h [SD, 23]) with newly diagnosed obstructive sleep apnea initiating CPAP.Intervention:Eszopiclone, 3 mg (n? = 76), or matching placebo (n? = 78) for the first 14 nights of CPAP.Measurements:Use of CPAP was measured weekly for 24 weeks. Adherence to CPAP (primary outcome) and the rate of CPAP discontinuation and improvements in symptoms (secondary outcomes) were compared. Follow-up at 1, 3, and 6 months was completed by 150, 136, and 120 patients, respectively.Results:Patients in the eszopiclone group used CPAP for 20.8% more nights (95% CI, 7.2% to 34.4%; P? = 0.003), 1.3 more hours per night for all nights (CI, 0.4 to 2.2 hours; P? = 0.005), and 1.1 more hours per night of CPAP use (CI, 0.2 to 2.1 hours; P? = 0.019). The hazard ratio for discontinuation of CPAP was 1.90 (CI, 1.1 to 3.4; P? = 0.033) times higher in the placebo group. Side effects were reported in 7.1% of patients and did not differ between groups.Limitations:Patients had severe obstructive sleep apnea treated at a specialized sleep center with frequent follow-up;"" results may not be generalizable to different settings. Patients' tolerance to CPAP and their reasons for discontinuation were not assessed.Conclusion:Compared with placebo, a short course of eszopiclone during the first 2 weeks of CPAP improved adherence and led to fewer patients discontinuing therapy.Primary Funding Source:Sepracor.",0,0,
671,Effects of an automated electronic reminder in changing the antiplatelet drug-prescribing behavior among Italian general practitioners in diabetic patients: an intervention trial,"OBJECTIVE—To evaluate whether an electronic reminder integrated into a routine computer system increases the use of antiplatelet drugs for diabetic patients among Italian general practitioners (GPs).  RESEARCH DESIGN AND METHODS—A randomized controlled trial was carried out among 300 GPs and their patients selected from the Health Search Database. Among these, 150 GPs (intervention group) received instructions to activate an electronic reminder plus a letter summarizing the beneficial effects of antiplatelet drugs in diabetic patients with at least one additional cardiovascular risk factor (“high risk”), whereas the other 150 GPs (control group) received only the letter. The electronic reminder, integrated into a standard software system for the management of the daily clinical practice, was displayed when every participating GP opened the medical record of diabetic patients aged =30 years. Only high-risk diabetic patients were included in the analysis. Patients were considered under antiplatelet treatment if they received two or more prescriptions at baseline and during the follow-up.  RESULTS—We selected 15,343 high-risk diabetic patients, 7,313 belonging to GPs of the control group and 8,030 belonging to GPs of the intervention group. Overall, 1,672 patients (22.9%) of the control group and 1,886 (23.5%) patients of the intervention group received antiplatelet drugs at baseline (P = N.S.). At the end of the follow-up, the number of treated patients was significantly increased in the intervention group (odds ratio 1.99, 95% CI 1.79–2.22) versus the control group. The effect of the electronic reminder was more relevant among those patients with one or more cardiovascular risk factors but without previous cardiovascular diseases (CVDs), compared with those with CVDs.  CONCLUSIONS—These findings provide evidence for the effect of an electronic reminder in affecting the prescriptive behavior of GPs.",1,1,
672,Effects of an evidence service on community-based AIDS service organizations' use of research evidence: A protocol for a randomized controlled trial,"Background To support the use of research evidence by community-based organizations (CBOs) we have developed 'Synthesized HIV/AIDS Research Evidence' (SHARE), which is an evidence service for those working in the HIV sector. SHARE consists of several components: an online searchable database of HIV-relevant systematic reviews (retrievable based on a taxonomy of topics related to HIV/AIDS and open text search)""; periodic email updates; access to user-friendly summaries;"" and peer relevance assessments. Our objective is to evaluate whether this 'full serve' evidence service increases the use of research evidence by CBOs as compared to a 'self-serve' evidence service.  Methods/design We will conduct a two-arm randomized controlled trial (RCT), along with a follow-up qualitative process study to explore the findings in greater depth. All CBOs affiliated with Canadian AIDS Society (n = 120) will be invited to participate and will be randomized to receive either the 'full-serve' version of SHARE or the 'self-serve' version (a listing of relevant systematic reviews with links to records on PubMed and worksheets that help CBOs find and use research evidence) using a simple randomized design. All management and staff from each organization will be provided access to the version of SHARE that their organization is allocated to. The trial duration will be 10 months (two-month baseline period, six-month intervention period, and two month crossover period), the primary outcome measure will be the mean number of logins/month/organization (averaged across the number of users from each organization) between baseline and the end of the intervention period. The secondary outcome will be intention to use research evidence as measured by a survey administered to one key decision maker from each organization. For the qualitative study, one key organizational decision maker from 15 organizations in each trial arm (n = 30) will be purposively sampled. One-on-one semi-structured interviews will be conducted by telephone on their views about and their experiences with the evidence service they received, how helpful it was in their work, why it was helpful (or not helpful), what aspects were most and least helpful and why, and recommendations for next steps.  Discussion To our knowledge, this will be the first RCT to evaluate the effects of an evidence service specifically designed to support CBOs in finding and using research evidence.",0,0,
673,Effects of an evidence service on health-system policy makers' use of research evidence: A protocol for a randomised controlled trial,"Background Health-system policy makers need timely access to synthesised research evidence to inform the policy-making process. No efforts to address this need have been evaluated using an experimental quantitative design. We developed an evidence service that draws inputs from Health Systems Evidence, which is a database of policy-relevant systematic reviews. The reviews have been (a) categorised by topic and type of review""; (b) coded by the last year searches for studies were conducted and by the countries in which included studies were conducted; (c) rated for quality;"" and (d) linked to available user-friendly summaries, scientific abstracts, and full-text reports. Our goal is to evaluate whether a ""full-serve"" evidence service increases the use of synthesized research evidence by policy analysts and advisors in the Ontario Ministry of Health and Long-Term Care (MOHLTC) as compared to a ""self-serve"" evidence service.  Methods/design We will conduct a two-arm randomized controlled trial (RCT), along with a follow-up qualitative process study in order to explore the findings in greater depth. For the RCT, all policy analysts and policy advisors (n = 168) in a single division of the MOHLTC will be invited to participate. Using a stratified randomized design, participants will be randomized to receive either the ""full-serve"" evidence service (database access, monthly e-mail alerts, and full-text article availability) or the ""self-serve"" evidence service (database access only). The trial duration will be ten months (two-month baseline period, six-month intervention period, and two month cross-over period). The primary outcome will be the mean number of site visits/month/user between baseline and the end of the intervention period. The secondary outcome will be participants' intention to use research evidence. For the qualitative study, 15 participants from each trial arm (n = 30) will be purposively sampled. One-on-one semi-structured interviews will be conducted by telephone on their views about and their experiences with the evidence service they received, how helpful it was in their work, why it was helpful (or not helpful), what aspects were most and least helpful and why, and recommendations for next steps.  Discussion To our knowledge, this will be the first RCT to evaluate the effects of an evidence service specifically designed to support health-system policy makers in finding and using research evidence.",0,0,
674,Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics.,"To study the effects of computer-generated reminders for influenza vaccination of patients at high risk of pulmonary disease during the winter, we selected 4555 such patients from a population of 15,000 adults who participated in a three-year randomized trial of preventive-care reminders. The physicians who received the reminders vaccinated eligible patients twice as often as did the control physicians (P = 0.0001). There was a linear increase in the incidence of influenza in our area during the three winters under study (from 1000 to 33,451 to 71,075 cases per year), and we modeled the percentage of patients with hospitalizations, emergency room visits with chest radiography, and blood gas determinations as a logistic function of this increase. The difference in linear trends between the patients in the intervention group (whose physicians received reminders) and those in the control group was significant for emergency room visits (P less than 0.05), hospitalizations (P less than 0.01), and blood gas determinations (P less than 0.001). The most likely explanation for the difference is the greater use of influenza vaccine in the intervention group.",0,1,
675,Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care--a cluster randomised study,"BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention. METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention. RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal. CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.",1,1,
676,Effects of computerized guidelines for managing heart disease in primary care,"BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care). OBJECTIVE: To assess the effects of computer-based cardiac care suggestions. DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists. SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease. INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines. RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients. CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.",1,1,
677,Effects of general practitioner training and family support services on the care of home-dwelling dementia patients--results of a controlled cluster-randomized study,"BACKGROUND: More than 90% of dementia patients are cared for by their general practitioners, who are decisively involved in the diagnosis, therapy and recommendation of support services. OBJECTIVE: To test whether special training of general practitioners alters the care of dementia patients through their systematic recommendation of caregiver counseling and support groups. METHOD: 129 general practitioners enrolled 390 dementia patients and their informal caregivers in a prospective, three-arm cluster-randomized 2-year study. Arm A constituted usual care, in Arm B and C support groups and caregiver counseling (in Arm B one year after baseline, in Arm C at baseline) were recommended by the general practitioners. The general practitioners received arm-specific training. Diagnostic and therapeutic behavior of physicians was recorded at baseline. Informal caregivers were questioned in follow-up after 2 years about the utilization of support services. RESULTS: The diagnostic behavior of the general practitioners conforms to relevant guidelines. The procedure in newly-diagnosed patients does not differ from previously diagnosed patients with the exception of the rate of referral to a specialist. About one-third of the newly-diagnosed dementia patients are given an anti-dementia drug. The utilization of support groups and counseling increased five- and fourfold, respectively. Utilization of other support services remained low (< 10%), with the exception of home nursing and institutional short-term nursing. CONCLUSION: Trained general practitioners usually act in conformity with guidelines with respect to diagnosing dementia, and partly in conformity with the guidelines with respect to recommended drug therapy. Recommendations of support services for informal caregivers by the general practitioner are successful. They result in a marked increase in the utilization rate for the recommended services compared to offers which are not recommended by the general practitioner. TRIAL REGISTRATION: ISRCTN68329593.",0,0,
678,Effects of interactive voice response self-monitoring on natural resolution of drinking problems: Utilization and behavioral economic factors.,"Objective: Most problem drinkers do not seek help, and many recover on their own. A randomized controlled trial evaluated whether supportive interactive voice response (IVR) self-monitoring facilitated such ""natural"" resolutions. Based on behavioral economics, effects on drinking outcomes were hypothesized to vary with drinkers' baseline ""time horizons,"" reflecting preferences among commodities of different value available over different delays and with their IVR utilization. Method: Recently resolved untreated problem drinkers were randomized to a 24-week IVR self-monitoring program (n = 87) or an assessment-only control condition (n = 98). Baseline interviews assessed outcome predictors including behavioral economic measures of reward preferences (delay discounting, pre-resolution monetary allocation to alcohol vs. savings). Six-month outcomes were categorized as resolved abstinent, resolved nonabstinent, unresolved, or missing. Complier average causal effect (CACE) models examined IVR self-monitoring effects. Results: IVR self-monitoring compliers (>=70% scheduled calls completed) were older and had greater pre-resolution drinking control and lower discounting than noncompliers (<70%). A CACE model interaction showed that observed compliers in the IVR group with shorter time horizons (expressed by greater pre-resolution spending on alcohol than savings) were more likely to attain moderation than abstinent resolutions compared with predicted compliers in the control group with shorter time horizons and with all noncompliers. Intention-to-treat analytical models revealed no IVR-related effects. More balanced spending on savings versus alcohol predicted moderation in both approaches. Conclusions: IVR interventions should consider factors affecting IVR utilization and drinking outcomes, including person-specific behavioral economic variables. CACE models provide tools to evaluate interventions involving extended participation. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
679,Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial.,"Determined whether mortality and recurrent infarction are reduced by treatment of depression and low perceived social support (LPSS) with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after myocardial infarction (MI). A randomized clinical trial was conducted in 2481 MI patients. LPSS was determined by the ENRICHD Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention. CBT was initiated at a median of 17 days after the index MI, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the Hamilton Rating Scale for Depression or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks. Improvement in psychosocial outcomes at 6 months favored treatment: mean change in HRSD score, -10.1 in the depression and psychosocial intervention group vs -8.4 in the depression and usual care group"";"" mean change in ESSI score, 5.1 in the LPSS and psychosocial intervention group vs 3.4 in the LPSS and usual care group. After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care and psychosocial intervention.",0,0,
680,Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials,"BackgroundFew evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection."";"" BackgroundFew evidence-based treatment guidelines for tendinopathy exist. We undertook a systematic review of randomised trials to establish clinical efficacy and risk of adverse events for treatment by injection.",0,0,
681,Efficacy and safety of sucrose for procedural pain relief in preterm and term neonates,"BACKGROUND: Preterm and acutely ill term neonates who are hospitalized in a neonatal intensive care unit are subjected to multiple frequent invasive and painful procedures aimed at improving their outcome. Although several trials to determine the efficacy of sucrose for managing procedural pain in preterm and acutely ill term neonates have been developed, these have generally lacked methodological rigor and have not provided clinicians with clear practice guidelines. OBJECTIVES: To compare the efficacy and safety of three interventions for relieving procedural pain associated with heel lances in preterm and term neonates, and to explore the influence of contextual factors including sex, severity of illness, and prior painful procedures on pain responses. METHODS: In a randomized controlled trial, 190 neonates were stratified by gestational age and then randomized to receive (a) sucrose and nonnutritive sucking (n = 64), (b) sucrose alone (n = 62), or (c) sterile water and nonnutritive sucking (control) (n = 64) to evaluate the efficacy (pain response as measured using the Premature Infant Pain Profile) (Stevens, Johnson, Petryshen, & Taddio, 1996) and safety (adverse events) following a scheduled heel lance during the first week of life. Stratification was used to control for the effects of age on pain response. RESULTS: Significant differences in pain response existed among treatment groups (F = 22.49, p <.001), with the lowest mean Premature Infant Pain Profile scores in the sucrose and nonnutritive sucking group. Efficacy of sucrose following a heel lance was not affected by severity of illness, postnatal age, or number of painful procedures. Intervention group and sex explained 12% of the variance in Premature Infant Pain Profile scores. Few adverse events occurred (n = 6), and none of them required medical or nursing interventions. CONCLUSIONS: The combination of sucrose and nonnutritive sucking is the most efficacious intervention for single heel lances. Research on the effects of gestational age on the efficacy and safety of repeated doses of sucrose is required.",0,0,
682,Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial,"BackgroundEarly mobilisation after stroke is thought to contribute to the effects of stroke-unit care""; however, the intervention is poorly defined and not underpinned by strong evidence. We aimed to compare the effectiveness of frequent, higher dose, very early mobilisation with usual care after stroke.; BackgroundEarly mobilisation after stroke is thought to contribute to the effects of stroke-unit care;"" however, the intervention is poorly defined and not underpinned by strong evidence. We aimed to compare the effectiveness of frequent, higher dose, very early mobilisation with usual care after stroke.",0,0,
683,Efficacy of a cognitive and behavioural psychotherapy applied by primary care psychologists in patients with mixed anxiety-depressive disorder: a research protocol,"BACKGROUND: In contrast with the recommendations of clinical practice guidelines, the most common treatment for anxiety and depressive disorders in primary care is pharmacological. The aim of this study is to assess the efficacy of a cognitive-behavioural psychological intervention, delivered by primary care psychologists in patients with mixed anxiety-depressive disorder compared to usual care. METHODS/DESIGN: This is an open-label, multicentre, randomized, and controlled study with two parallel groups. A random sample of 246 patients will be recruited with mild-to-moderate mixed anxiety-depressive disorder, from the target population on the lists of 41 primary care doctors. Patients will be randomly assigned to the intervention group, who will receive standardised cognitive-behavioural therapy delivered by psychologists together with usual care, or to a control group, who will receive usual care alone. The cognitive-behavioural therapy intervention is composed of eight individual 60-minute face-to face sessions conducted in eight consecutive weeks. A follow-up session will be conducted over the telephone, for reinforcement or referral as appropriate, 6 months after the intervention, as required. The primary outcome variable will be the change in scores on the Short Form-36 General Health Survey. We will also measure the change in the frequency and intensity of anxiety symptoms (State-Trait Anxiety Inventory) and depression (Beck Depression Inventory) at baseline, and 3, 6 and 12 months later. Additionally, we will collect information on the use of drugs and health care services. DISCUSSION: The aim of this study is to assess the efficacy of a primary care-based cognitive-behavioural psychological intervention in patients with mixed anxiety-depressive disorder. The international scientific evidence has demonstrated the need for psychologists in primary care. However, given the differences between health policies and health services, it is important to test the effect of these psychological interventions in our geographical setting. TRIAL REGISTRATION: NCT01907035 (July 22, 2013).",0,0,
684,Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: a randomized controlled trial,"BACKGROUND: Many strategies have been evaluated to improve the prevention and control of cardiovascular (CVD) risk factors. Nursing telephonic and tele-counseling individualized lifestyle educational programs have been found to improve blood pressure control and adherence to lifestyle recommendation. This study tested the efficacy of a nurse-led reminder program through email (NRP-e) to improve CVD risk factors among hypertensive adults. METHODS: All participants received usual CVD prevention and a guideline-based educational program. Subjects in the NRP-e group also received weekly email alerts and phone calls from a nurse care manager for 6 months. Emails contained a reminder program on the need for adherence with a healthy lifestyle based upon current guidelines. Follow-up visits were scheduled at 1, 3 and 6 months after enrollment""; randomization was made centrally and blood samples were evaluated into a single laboratory. RESULTS: The final sample consisted of 98 (control) and 100 (NRP-e) subjects (mean age 59.0 +/- 14.5 years;"" 51.0% males). After 6 months, the following CVD risk factors significantly improved in both groups: body mass index, alcohol and fruit consumption, cigarette smoking, adherence to therapy hours, systolic and diastolic blood pressure, fasting blood glucose, low-density lipoproteins (LDL) and total cholesterol, triglycerides, and physical activity. In the NRP-e group, however, the prevalence of several behaviors or conditions at risk decreased significantly more than in the control group: obesity (-16%), low fruit consumption (-24%), uncontrolled hypertension (-61%), LDL (-56%), and total cholesterol (-40%). CONCLUSIONS: The NRP-e improved a range of CVD risk factors. The program had low costs, required only an average of <20 min per day in addition to normal practice, and may deserve further evaluation for the inclusion among existing care management approaches.",0,0,
685,Efficacy of a self-help manual in increasing resilience in carers of adults with depression in Thailand,"Caring for a person with a mental illness can have adverse effects on caregivers""; however, little is known about how best to help such caregivers. The aim of the present study was to examine the efficacy of a cognitive behaviour therapy-guided self-help manual in increasing resilience in caregivers of individuals with depression, in comparison to caregivers who receive routine support only. A randomized, controlled trial was conducted, following CONSORT guidelines, with 54 caregivers allocated to parallel intervention (self-help manual) (n = 27) or control (standard support) (n = 27) groups. Resilience was assessed at baseline, post-test (week 8), and follow up (week 12). Intention-to-treat analyses were undertaken. Repeated-measures ANOVA indicated a significant difference in resilience scores between the three time points, showing a large effect. Pairwise comparisons between intervention and control groups indicated resilience to be significantly different between baseline and post-test, and between baseline and follow up, but not between post-test and follow up. Overall, the intervention group showed a slightly greater increase in resilience over time than the control group;"" however, the time-group interaction was not significant. Guided self-help is helpful in improving caregivers' resilience and could be used as an adjunct to the limited support provided to carers by mental health nurses and other clinicians.",0,0,
686,Efficacy of an evidence-based clinical decision support in primary care practices,"Importance  There is consensus that incorporating clinical decision support into electronic health records will improve quality of care, contain costs, and reduce overtreatment, but this potential has yet to be demonstrated in clinical trials.  Objective  To assess the influence of a customized evidence-based clinical decision support tool on the management of respiratory tract infections and on the effectiveness of integrating evidence at the point of care.  Design, Setting, and Participants  In a randomized clinical trial, we implemented 2 well-validated integrated clinical prediction rules, namely, the Walsh rule for streptococcal pharyngitis and the Heckerling rule for pneumonia.  Interventions and Main Outcomes and Measures  The intervention group had access to the integrated clinical prediction rule tool and chose whether to complete risk score calculators, order medications, and generate progress notes to assist with complex decision making at the point of care.  Results  The intervention group completed the integrated clinical prediction rule tool in 57.5% of visits. Providers in the intervention group were significantly less likely to order antibiotics than the control group (age-adjusted relative risk, 0.74""; 95% CI, 0.60-0.92). The absolute risk of the intervention was 9.2%, and the number needed to treat was 10.8. The intervention group was significantly less likely to order rapid streptococcal tests compared with the control group (relative risk, 0.75; 95% CI, 0.58-0.97;"" P?=?.03).  Conclusions and Relevance  The integrated clinical prediction rule process for integrating complex evidence-based clinical decision report tools is of relevant importance for national initiatives, such as Meaningful Use.",0,1,
687,Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial,"OBJECTIVE To investigate the efficacy of a programme of manual therapy and exercise treatment compared with placebo treatment delivered by physiotherapists for people with chronic rotator cuff disease. DESIGN Randomised, participant and single assessor blinded, placebo controlled trial. SETTING Metropolitan region of Melbourne, Victoria, Australia. PARTICIPANTS 120 participants with chronic (>3 months) rotator cuff disease recruited through medical practitioners and from the community. INTERVENTIONS The active treatment comprised a manual therapy and home exercise programme""; the placebo treatment comprised inactive ultrasound therapy and application of an inert gel. Participants in both groups received 10 sessions of individual standardised treatment over 10 weeks. For the following 12 weeks, the active group continued the home exercise programme and the placebo group received no treatment. MAIN OUTCOME MEASURES The primary outcomes were pain and function measured by the shoulder pain and disability index, average pain on movement measured on an 11 point numerical rating scale, and participants' perceived global rating of overall change. RESULTS 112 (93%) participants completed the 22 week trial. At 11 weeks no difference was found between groups for change in shoulder pain and disability index (3.6, 95% confidence interval -2.1 to 9.4) or change in pain (0.7, -0.1 to 1.5);"" both groups showed significant improvements. More participants in the active group reported a successful outcome (defined as ""much better""), although the difference was not statistically significant: 42% (24/57) of active participants and 30% (18/61) of placebo participants (relative risk 1.43, 0.87 to 2.34). The active group showed a significantly greater improvement in shoulder pain and disability index than did the placebo group at 22 weeks (between group difference 7.1, 0.3 to 13.9), although no significant difference existed between groups for change in pain (0.9, -0.03 to 1.7) or for the percentage of participants reporting a successful treatment outcome (relative risk 1.39, 0.94 to 2.03). Several secondary outcomes favoured the active group, including shoulder pain and disability index function score, muscle strength, interference with activity, and quality of life. CONCLUSION A standardised programme of manual therapy and home exercise did not confer additional immediate benefits for pain and function compared with a realistic placebo treatment that controlled for therapists' contact in middle aged to older adults with chronic rotator cuff disease. However, greater improvements were apparent at follow-up, particularly in shoulder function and strength, suggesting that benefits with active treatment take longer to manifest. TRIAL REGISTRATION Clinical trials NCT00415441.",0,0,
688,Efficiency of guidelines and educational program: a training process for the diagnosis of low back pain,"BACKGROUND: The Italian National Health Plan has included low back pain (LBP) among the pathologies for which clinical guidelines should be created and disseminated. A change in the clinical behaviour of doctors requires forms of intervention whose efficiency is not fully known. OBJECTIVES: This study proposes to evaluate the efficacy of a multifaceted intervention, including educational materials, lectures, workshops and local consensus processes, in order to modify the General Practitioners' (GP) clinical treatment of LBP. METHODS: Changes in diagnostic capacity have been evaluated through a controlled (before/after) trial based on the frequency of etiological diagnoses of LBP, the testing of clinical knowledge with multiple choice tests, and on priorities given in confronting problems of treatment of LBP by the three GP's groups that had voluntarily adhered to the study. RESULTS: A statistically significant increase of diagnostic capacity (the frequency of exact responses in the multiple choice test) was achieved. There was also a shifting of priorities in confronting problems in the treatment of LBP, from the diagnosis as a primary issue before intervening, to communication with the patient. CONCLUSIONS: Within the Italian context, the study also confirms the efficiency of a multifaceted intervention based on a training process aimed at modifying the clinical behaviour of the GP with respect to LBP.",0,0,
689,EHRA research network surveys: 6 years of EP wires activity,"Clinical practice should follow guidelines and recommendations mainly based on the results of controlled trials, which are often conducted in selected populations and special conditions, whereas clinical practice may be influenced by factors different from controlled scientific studies. Hence, the real-world setting is better assessed by the observational registries enrolling patients for longer periods of time. However, this may be difficult, expensive, and time-consuming. In 2009, the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA) has instigated a series of surveys covering the controversial issues in clinical electrophysiology (EP). With this in mind, an EHRA EP research network has been created, which included EP centres in Europe among which the surveys on 'hot topic' were circulated. This review summarizes the overall experience conducting EP wires over the past 6 years, categorizing and assessing the topics regarding clinical EP, and evaluating the acceptance and feedback from the responding centres, in order to improve participation in the surveys and better address the research needs and aspirations of the European EP community.",0,0,
690,Electronic alerts to prevent venous thromboembolism among hospitalized patients,"BACKGROUND Prophylaxis against deep-vein thrombosis in hospitalized patients remains underused. We hypothesized that the use of a computer-alert program to encourage prophylaxis might reduce the frequency of deep-vein thrombosis among high-risk hospitalized patients.  METHODS We developed a computer program linked to the patient database to identify consecutive hospitalized patients at risk for deep-vein thrombosis in the absence of prophylaxis. The program used medical-record numbers to randomly assign 1255 eligible patients to an intervention group, in which the responsible physician was alerted to a patient's risk of deep-vein thrombosis, and 1251 patients to a control group, in which no alert was issued. The physician was required to acknowledge the alert and could then withhold or order prophylaxis, including graduated compression stockings, pneumatic compression boots, unfractionated heparin, low-molecular-weight heparin, or warfarin. The primary end point was clinically diagnosed, objectively confirmed deep-vein thrombosis or pulmonary embolism at 90 days.  RESULTS More patients in the intervention group than in the control group received mechanical prophylaxis (10.0 percent vs. 1.5 percent, P<0.001) or pharmacologic prophylaxis (23.6 percent vs. 13.0 percent, P<0.001). The primary end point occurred in 61 patients (4.9 percent) in the intervention group, as compared with 103 (8.2 percent) in the control group""; the Kaplan–Meier estimates of the likelihood of freedom from deep-vein thrombosis or pulmonary embolism at 90 days were 94.1 percent (95 percent confidence interval, 92.5 to 95.4 percent) and 90.6 percent (95 percent confidence interval, 88.7 to 92.2 percent), respectively (P<0.001). The computer alert reduced the risk of deep-vein thrombosis or pulmonary embolism at 90 days by 41 percent (hazard ratio, 0.59; 95 percent confidence interval, 0.43 to 0.81;"" P=0.001).  CONCLUSIONS The institution of a computer-alert program increased physicians' use of prophylaxis and markedly reduced the rates of deep-vein thrombosis and pulmonary embolism among hospitalized patients at risk.",1,1,
691,Electronic alerts versus on-demand decision support to improve dyslipidemia treatment: a cluster randomized controlled trial,"BACKGROUND: Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system. However, randomized trials comparing these methods in a clinical setting are lacking. We studied the effect of both alerting and on-demand decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners. METHODS AND RESULTS: In a clustered randomized trial design, 38 Dutch general practices (77 physicians) and 87,886 of their patients (39,433 men 18 to 70 years of age and 48,453 women 18 to 75 years of age) who used the ELIAS electronic health record participated. Each practice was assigned to receive alerts, on-demand support, or no intervention. We measured the percentage of patients screened and treated after 12 months of follow-up. In the alerting group, 65% of the patients requiring screening were screened (relative risk versus control=1.76""; 95% confidence interval, 1.41 to 2.20) compared with 35% of patients in the on-demand group (relative risk versus control=1.28; 95% confidence interval, 0.98 to 1.68) and 25% of patients in the control group. In the alerting group, 66% of patients requiring treatment were treated (relative risk versus control=1.40; 95% confidence interval, 1.15 to 1.70) compared with 40% of patients (relative risk versus control=1.19;"" 95% confidence interval, 0.94 to 1.50) in the on-demand group and 36% of patients in the control group. CONCLUSIONS: The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners.",1,1,
692,Electronic antibiotic stewardship–reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting.,"Objectives Antibiotic stewardship is important, but the ideal strategy for providing stewardship in a hospital setting is unknown. A practical, sustainable and transferable strategy is needed. This study evaluates the impact of a novel computerized antimicrobial approval system on antibiotic-prescribing behaviour in a hospital. Effects on drug consumption, antibiotic resistance patterns of local bacteria and patient outcomes were monitored.  Methods The study was conducted at a tertiary referral teaching hospital in Melbourne, Australia. The system was deployed in January 2005 and guided the use of 28 restricted antimicrobials. Data were collected over 7 years: 5 years before and 2 years after deployment. Uptake of the system was evaluated using an in-built audit trail. Drug utilization was prospectively monitored using pharmacy data (as defined daily doses per 1000 bed-days) and analysed via time-series analysis with segmental linear regression. Antibiograms of local bacteria were prospectively evaluated. In-hospital mortality and length of stay for patients with Gram-negative bacteraemia were also reported.  Results Between 250 and 300 approvals were registered per month during 2006. The gradients in the use of third- and fourth-generation cephalosporins (+0.52, -0.05, -0.39""; P < 0.01), glycopeptides (+0.27, -0.53; P = 0.09), carbapenems (+0.12, -0.24; P = 0.21), aminoglycosides (+0.15, -0.27; P < 0.01) and quinolones (+0.76, +0.11;"" P = 0.08) all fell after deployment, while extended-spectrum penicillin use increased. Trends in increased susceptibility of Staphylococcusaureus to methicillin and improved susceptibility of Pseudomonas spp. to many antibiotics were observed. No increase in adverse outcomes for patients with Gram-negative bacteraemia was observed.  Conclusions The system was successfully adopted and significant changes in antimicrobial usage were demonstrated.",0,1,
693,Electronic e-isotretinoin prescription chart: improving physicians' adherence to isotretinoin prescription guidelines,"Oral isotretinoin is a highly effective treatment for refractory nodulocystic acne. However, it can be associated with serious adverse effects such as teratogenicity and hepatitis. Inadequate cumulative dosing may also result in reduced therapeutic efficacy and higher disease relapse. A preliminary audit had previously revealed a poor and inconsistent adherence to local isotretinoin prescribing guidelines by physicians. To achieve greater than 90% adherence to isotretinoin guidelines for all acne patients prescribed systemic isotretinoin at the National Skin Centre, Singapore, key areas and the reasons for non-adherence were identified. A specifically designed 'one-stop' electronic isotretinoin chart was launched within the electronic medical records (EMR) system to address important safety areas"";"" namely, informed patient consent, pregnancy testing, baseline laboratory tests, and automatic calculation of cumulative and target doses of isotretinoin. Physician adherence to prescribing guidelines improved from a baseline of 50-60% to greater than 90% (range 95-100%) for 30 consecutive months post intervention. The e-isotretinoin chart has resulted in significant improvement in physicians' adherence to isotretinoin prescription guidelines and highlights the utility of EMR technology in influencing safe prescribing behaviour among doctors.",0,1,
694,Electronic health record decision support and quality of care for children with ADHD.,"OBJECTIVES: The objective of this study was to assess the effect of electronic health record (EHR) decision support on physician management and documentation of care for children with attention-deficit/hyperactivity disorder (ADHD).  METHODS: This study involved 79 general pediatricians in 12 pediatric primary care practices that use the same EHR who were caring for 412 children who were aged 5 to 18 years and had a previous diagnosis of ADHD. We conducted a cluster randomized trial of EHR-based decision support that included (1) clinician reminders to assess ADHD symptoms every 3 to 6 months and (2) an ADHD note template with structured fields for symptoms, treatment effectiveness, and adverse effects. The main outcome measures were (1) proportion of children with visits during the 6-month study period in which ADHD was assessed and (2) quality of documentation of ADHD assessment. Generalized estimating equations were used to control for the clustering by providers.  RESULTS: Children at intervention sites were more likely to have had a visit during the study period in which their ADHD was assessed. The ADHD template was used at 32% of visits at which patients were scheduled specifically for ADHD assessment, and its use was associated with improved documentation of symptoms, treatment effectiveness, and treatment adverse effects.  CONCLUSIONS: EHR-based decision support improved the likelihood that children with ADHD had visits for as well as care related to managing this condition. Better understanding of how to optimize provider use of the decision support and templates could promote additional improvements in care.",0,1,
695,Electronic health record feedback to improve antibiotic prescribing for acute respiratory infections,"Objective: To examine whether the Acute Respiratory Infection (ARI) Quality Dashboard, an electronic health record (EHR)–based feedback system, changed antibiotic prescribing. Study Design: Cluster randomized, controlled trial. Methods: We randomly assigned 27 primary care practices to receive the ARI Quality Dashboard or usual care. The primary outcome was the intent-to-intervene antibiotic prescribing rate for ARI visits. We also compared antibiotic prescribing between ARI Quality Dashboard users and nonusers. Results: During the 9-month intervention, there was no difference between intervention and control practices in antibiotic prescribing for all ARI visits (47% vs 47%""; P = .87), antibioticappropriate ARI visits (65% vs 64%; P = .68), or non–antibiotic-appropriate ARI visits (38% vs 40%; P = .70). Among the 258 intervention clinicians, 72 (28%) used the ARI Quality Dashboard at least once. These clinicians had a lower overall ARI antibiotic prescribing rate (42% vs 50% for nonusers; P = .02). This difference was due to less antibiotic prescribing for non–antibiotic-appropriate ARIs (32% vs 43%; P = .004), including nonstreptococcal pharyngitis (31% vs 41%; P = .01) and nonspecific upper respiratory infections (19% vs 34%; P = .01). Conclusions: The ARI Quality Dashboard was not associated with an overall change in antibiotic prescribing for ARIs, although when used, it was associated with improved antibiotic prescribing. EHR-based quality reporting, as part of “meaningful use,” may not improve care in the absence of other changes to primary care practice. (Am J Manag Care. 2010;""16(12 Spec No.):e311-e319)",0,1,
696,Electronic health record-based decision support to improve asthma care: a cluster-randomized trial.,"OBJECTIVE: Asthma continues to be 1 of the most common chronic diseases of childhood and affects 
6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting. METHODS: We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratified for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of office-based spirometry. RESULTS: Increases in the number of prescriptions for controller medications, over time, was 6% greater (P  .006) and 3% greater for spirometry (P  .04) in the intervention urban practices. Filing an up-todate asthma care plan improved 14% (P  .03) and spirometry improved 6% (P  .003) in the suburban practices with the intervention. CONCLUSION: In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines. Pediatrics 2010;""125:e770–e777",1,1,
697,Electronic health records for intervention research: a cluster randomized trial to reduce antibiotic prescribing in primary care (eCRT Study),"PURPOSE This study aimed to implement a point-of-care cluster randomized trial using electronic health records. We evaluated the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in primary care.  METHODS Family practices from England and Scotland participating in the Clinical Practice Research Datalink (CPRD) were included in the trial""; 53 family practices were allocated to intervention and 51 practices were allocated to usual care. Patients aged 18 to 59 years consulting for respiratory tract infections were eligible. The intervention was through remotely installed, computer-delivered decision support tools accessed during the consultations. Control practices provided usual care. The primary outcome was the proportion of consultations for respiratory tract infections with an antibiotic prescribed based on electronic health records. Family practice-specific proportions were included in a cluster-level analysis.  RESULTS Data were analyzed for 603,409 patients: 317,717 at intervention practices and 285,692 at control practices. Use of the intervention was less than anticipated, varying among practices. There was a reduction in proportion of consultations with antibiotics prescribed of 1.85% (95% CI, 0.10%–3.59%, P = .038) and in the rate of antibiotic prescribing for respiratory tract infections (9.69%;"" 95% CI, 0.75%–18.63%, fewer prescriptions per 1,000 patient-years, P = .034). There were no adverse events.  CONCLUSIONS Cluster randomized trials may be implemented efficiently in large samples from routine care settings by using primary care electronic health records. Future studies should develop and test multicomponent methods for remotely delivered intervention.",0,1,
698,Electronic human immunodeficiency virus (HIV) clinical reminder system improves adherence to practice guidelines among the University of Washington HIV study cohort.,"We conducted a prospective study of an electronic clinical reminder system in an academic medical center-based human immunodeficiency virus (HIV) specialty clinic. Published performance indicators were used to examine adherence to HIV practice guidelines before and after its implementation for 1204 patients. More than 90% of patients received CD4 cell count and HIV type 1 (HIV-1) RNA level monitoring every 3–6 months during both time periods, and ∼80% of patients with a CD4 cell count nadir of <350 cells/mm3 received highly active antiretroviral therapy. Patients were significantly more likely to receive prophylaxis against Mycobacterium avium complex (hazard ratio, 3.84""; 95% confidence interval [CI], 1.58–9.31; P =.003), to undergo annual cervical carcinoma screening (OR, 2.09; 95% CI, 1.04–4.16; P =.04), and to undergo serological screening for Toxoplasma gondii (odds ratio [OR], 1.86; 95% CI, 1.05–3.27; P =.03) and syphilis infection (OR, 3.71; 95% CI, 2.37–5.81;"" P <.0001). HIV clinical reminders delivered at the time that HIV care is provided were associated with more timely initiation of recommended practices.",0,1,
699,Electronic Laboratory Medicine ordering with evidence-based Order sets in primary care (ELMO study): protocol for a cluster randomised trial,"Background Laboratory testing is an important clinical act with a valuable role in screening, diagnosis, management and monitoring of diseases or therapies. However, inappropriate laboratory test ordering is frequent, burdening health care spending and negatively influencing quality of care. Inappropriate tests may also result in false-positive results and potentially cause excessive downstream activities. Clinical decision support systems (CDSSs) have shown promising results to influence the test-ordering behaviour of physicians and to improve appropriateness. Order sets, a form of CDSS where a limited set of evidence-based tests are proposed for a series of indications, integrated in a computerised physician order entry (CPOE) have been shown to be effective in reducing the volume of ordered laboratory tests but convincing evidence that they influence appropriateness is lacking. The aim of this study is to evaluate the effect of order sets on the quality and quantity of laboratory test orders by physicians. We also aim to evaluate the effect of order sets on diagnostic error and explore the effect on downstream or cascade activities.  Methods We will conduct a cluster randomised controlled trial in Belgian primary care practices. The study is powered to measure two outcomes. We will primarily measure the influence of our CDSS on the appropriateness of laboratory test ordering. Additionally, we will also measure the influence on diagnostic error. We will also explore the effects of our intervention on cascade activities due to altered results of inappropriate tests.  Discussion We have designed a study that should be able to demonstrate whether the CDSS aimed at diagnostic testing is not only able to influence appropriateness but also safe with respect to diagnostic error. These findings will influence a lager, nationwide implementation of this CDSS.  Trial registration ClinicalTrials.gov, NCT02950142.",0,0,
700,Electronic medical records to increase the clinical treatment of tobacco dependence: a systematic review,"CONTEXT: The expanded use of electronic medical records (EMRs) may provide an opportunity to increase the use and impact of clinical guidelines to promote tobacco-cessation treatment in primary care settings. The objective of this systematic review is to evaluate the evidence for such an effect. EVIDENCE ACQUISITION: After a systematic search of the English-language literature regarding an EMR effect on either smoking cessation or clinician behavior, relevant articles were abstracted and findings summarized from both observational studies and RCTs. EVIDENCE SYNTHESIS: Of ten identified studies of EMRs and tobacco, only two RCTs were found. Adding tobacco status as a vital sign resulted in an increase in some clinical guideline recommended actions, particularly documentation of smoking status. There was insufficient evidence to quantify the effect of an EMR on changes in patient smoking behaviors. CONCLUSIONS: While the use of EMRs to prompt or provide feedback on the clinical treatment of tobacco dependence demonstrates some promising results, substantial additional research is needed to understand the effects of EMRs on provider and patient behavior.",0,1,
701,Electronic prescribing increases uptake of clinical pharmacologists' recommendations in the hospital setting. ,"AIMS To determine whether electronic prescribing facilitates the uptake of clinical pharmacologists’ recommendations for improving drug safety in medical inpatients. METHODS Electronic case records and prescription charts (either electronic or paper) of 502 patients hospitalized on medical wards in a large Swiss teaching hospital between January 2009 and January 2010 were studied by four junior and four senior clinical pharmacologists. Drug-related problems were identified and interventions proposed. The implementation and time delays of these proposed interventions were compared between the patients for whom paper drug charts were used and the patients for whom electronic drug charts were used. RESULTS One hundred and fifty-eight drug-related problems in 109 hospital admissions were identified and 145 recommendations were made, of which 51% were implemented. Admissions with an electronic prescription chart (n = 90) were found to have 2.74 times higher odds for implementation of the change than those with a paper prescription chart (n = 53) (95% confidence interval 1.2, 6.3, P = 0.018, adjusted for any dependency introduced by patient, ward or clinical team"";"" follow-up for two cases missing). The time delay between recommendations being made and their implementation (if any) was minimal (median 1 day) and did not differ between the two groups. CONCLUSIONS Electronic prescribing in this hospital setting was associated with increased implementation of clinical pharmacologists’ recommendations for improving drug safety when compared with",0,1,
702,"Electronically distributed, computer-generated, individualized feedback enhances the use of a computerized practice guideline","Clinical guidelines have been developed to assist with the management of patient care"";"" however, these guidelines are frequently neglected in clinical practice. Computer-generated reminders enhance guideline use, but these systems often fail to achieve high rates of guideline utilization. This study was designed to test the hypothesis that computer-generated, individualized feedback regarding adherence to care guidelines will significantly improve clinician compliance with guideline recommendations presented through a computer-assisted management protocol. Half of the 45 primary care clinicians employed at a primary care clinic affiliated with an academic medical center, were randomized to receive a biweekly electronic mail message consisting of a computer-generated report summarizing his/her response to care guideline recommendations for the diabetic patients seen during the previous 2 weeks. Clinician compliance with guideline recommendations was the primary outcome measure. This study demonstrated that the intervention significantly increased clinician compliance with the guideline recommendations without incurring high maintenance expenses. Median compliance among the intervention group was 35% versus 6.1% among the control group (p < 0.01). Electronically distributed, computer-generated, individualized feedback regarding clinician use of care guideline recommendations is an effective way to enhance compliance with a care guideline.",0,1,
703,Email for clinical communication between healthcare professionals,"BACKGROUND: Email is one of the most widely used methods of communication, but its use in healthcare is still uncommon. Where email communication has been utilised in health care, its purposes have included clinical communication between healthcare professionals, but the effects of using email in this way are not well known. We updated a 2012 review of the use of email for two-way clinical communication between healthcare professionals. OBJECTIVES: To assess the effects of email for clinical communication between healthcare professionals on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information. SEARCH METHODS: We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9 2013), MEDLINE (OvidSP) (1946 to August 2013), EMBASE (OvidSP) (1974 to August 2013), PsycINFO (1967 to August 2013), CINAHL (EbscoHOST) (1982 to August 2013), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched November 2013). We used additional search methods: examining reference lists and contacting authors. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised trials, controlled before and after studies, and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information in the form of: 1) unsecured email, 2) secure email, or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information and have reported all measures as per the study report. MAIN RESULTS: The previous version of this review included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment versus usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement or osteoporosis medication, or both) when compared with usual care. The evidence for its impact on patient behaviours or actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively (patients had a higher calcium intake), and two found no difference between the two groups. The study did not assess health service outcomes or harms.No new studies were identified for this update. AUTHORS' CONCLUSIONS: Only one study was identified for inclusion, providing insufficient evidence for guiding clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research should aim to utilise high-quality study designs that use the most recent developments in information technology, with consideration of the complexity of email as an intervention.",0,0,
704,Email for clinical communication between healthcare professionals,"BACKGROUND: Email is a popular and commonly-used method of communication, but its use in healthcare is not routine. Where email communication has been utilised in health care, its purposes have included use for clinical communication between healthcare professionals, but the effects of using email in this way are not known. This review assesses the use of email for two-way clinical communication between healthcare professionals. OBJECTIVES: To assess the effects of healthcare professionals using email to communicate clinical information, on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information. SEARCH METHODS: We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information, and that took the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information. We report all measures as per the study report. MAIN RESULTS: We included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment with usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement and/or osteoporosis medication) when compared with usual care. The evidence for its impact on patient behaviours/actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively: patients had a higher calcium intake, and two found no difference between the two groups. The study did not assess primary health service outcomes or harms. AUTHORS' CONCLUSIONS: As only one study was identified for inclusion, the results are inadequate to inform clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research needs to use high-quality study designs that take advantage of the most recent developments in information technology, with consideration of the complexity of email as an intervention, and costs.",0,0,703
705,Emergency mental health nursing for self-harming refugees and asylum seekers,"This article describes the structure and function of emergency mental health nursing practice for self-harming refugees and asylum seekers on Temporary Protection Visas. Emergency nurses working in accident and emergency departments or as part of crisis intervention teams will see self-harming refugees and asylum seekers at the very point of their distress. This clinical paper is intended to support nurses in their practice should they encounter an adult asylum seeker needing emergency mental health care. Practical strategies are highlighted to help mental health nurses assess, care, and comfort refugees and asylum seekers in this predicament. Mental health nurses should, where possible, work closely with asylum seekers, their support workers, and accredited interpreters and translators to ensure the appropriate use of language when dealing with mental and emotional health issues without further isolating the asylum seeker from appropriate services. To help strengthen continuity and integration of mental health supports for refugees and asylum seekers, well-resourced care must be experienced as coherent and connected. A coherent, interdisciplinary and team-orientated approach will synthesize different viewpoints to shape clinical practice and create workable solutions in local situations.",0,0,
706,Empowering patients or general practitioners? A randomised clinical trial to improve quality in reproductive health care in Belgium,"BACKGROUND: Evidence-based clinical guidelines on contraceptive use were developed and distributed among all Flemish general practitioners (GPs) in Belgium. OBJECTIVES: To evaluate the effectiveness of two strategies for implementing a guideline on oral contraceptives in order to enhance the quality of the first contraception consultation in general practice, by either empowering patients or by introducing a computer decision support system (CDSS). METHOD: A random sample of 45 GPs was distributed among three study groups. One group was visited by an 'empowered patient', one group's electronic medical record was supplemented with a CDSS, and one group served as the control group. Simulated patients (SPs) assessed the performance of GPs in daily practice before and after the interventions, using a validated 48-point checklist. RESULTS: The baseline mean score of the 43 GPs was 26.16 (SD = 5.76). The SPs received sufficient information about correct pill usage, but not concerning factors associated with pill failure and drug interaction. After the intervention, the GPs' mean score was 26.39 (SD = 6.86). Only the intervention group with the 'empowered patient' scored significantly better (29.92 [SD = 7.11]). The computer group and control group scored lower (24.36 [SD = 6.60] and 24.82 [SD = 5.65], respectively). CONCLUSION: Developing and distributing an evidence-based guideline did not change GPs' behaviour. However, empowering patients to participate more proactively significantly improved GPs' performance during a contraception consultation. A CDSS did not.",0,0,
707,Encouraging post-stroke patients to be active seems possible: results of an intervention study with knowledge brokers,"PURPOSE: Although physical activity and exercise for stroke patients is highly recommended for fast recovery, patients in hospitals and rehabilitation centres are insufficiently encouraged to be physically active. In this study, we investigated the impact of knowledge brokers (KBs), enterprising nurses and therapists, on health professionals' (HP) performance to encourage stroke inpatients to be physically active. METHOD: This multicenter intervention study used a pre-post test design. Two or three KBs were trained in each stroke unit of 12 hospitals and 10 rehabilitation centres in The Netherlands. Questionnaires were completed by patients and HPs before and after the KB-intervention. The primary outcome was encouragement given by HPs to their patients to be physically active, as reported by patients and HPs. RESULTS: After the KB-intervention, many more patients (48%""; N=217) reported at least some encouragement by HPs to be physically active than before (26%;"" N=243, p<0.000). HPs (N=288) on an average reported encouraging patients more often after the intervention, but this difference was significant only for occupational therapists and KBs. CONCLUSIONS: Based on patient's reports of HP behaviour, the KB-intervention appears effective since more patients felt encouraged to be physically active after the intervention compared to before. Replication of this study in an experimental design is needed to allow causal inferences. Implications for rehabilitation We advise rehabilitation teams to make use of knowledge brokers (KBs), since the KB-intervention was shown to increase the encouragement felt by stroke patients to be physically active. It seems worthwhile to involve physicians, nurses and patients' families more frequently in efforts to encourage stroke patients to be physically active.",0,0,
708,Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial,"BACKGROUND: Evidence-based clinical practice guidelines may improve treatment quality, but the uptake of guideline recommendations is often incomplete and slow. Recently new low back pain guidelines are being launched in Denmark. The guidelines are considered to reduce personal and public costs. The aim of this study is to evaluate whether a complex, multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy. METHODS/DESIGN: In a two-armed cluster randomised trial, 100 general practices (clusters) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included. Practices are randomly allocated 1:1 to a simple or a complex implementation strategy. Intervention practices will receive a complex implementation strategy, including guideline facilitator visits, stratification tools, and quality reports on low back pain treatment. Primary outcome is referral to secondary care. Secondary outcomes are pain, physical function, health-related quality of life, patient satisfaction with care and treatment outcome, employment status, and sick leave. Primary and secondary outcomes pertain to the patient level. Assessments of outcomes are blinded and follow the intention-to-treat principle. Additionally, a process assessment will evaluate the degree to which the intervention elements will be delivered as planned, as well as measure changes in beliefs and behaviours among general practitioners and patients. DISCUSSION: This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice, and will provide insight on essential elements to include in future implementation strategies in general practice. TRIAL REGISTRATION: Registered as NCT01699256 on ClinicalTrials.gov.",0,0,
709,Enhanced physician adherence to antibiotic use guidelines through increased availability of guidelines at the time of drug ordering in hospital setting.,"Purpose Some studies have shown that making practice guidelines accessible to physicians when they are making clinical decisions could improve prescribing practices. The aim of the study was to assess the benefit of impact on physician adherence of the intervention that consisted of embedding previously paper-based antibiotic guidelines in the computerized physician drug order entry system of a teaching hospital in order to make these guidelines available to physician at the time of antibiotic ordering. Before the intervention, these guidelines were available in booklet form in all the wards of the hospital.  Methods Adherence to guidelines was evaluated in 471 consecutive antibiotic orders for pneumonia, 104 just before and 367 just after the intervention. The evaluation criteria were: the choice of the antibiotic relative to the context of acquisition of pneumonia, the daily dose, the planned duration of treatment. Evaluation of antibiotic orders was performed at the initiation of antibiotic treatment.  Results The intervention was followed by a significant decrease in the proportion of antibiotic orders containing at least one criterion of non-conformity to the guidelines, respectively, 33% after vs. 51% (p?<?0.001) before the intervention. Proportion of non-conform orders decreased in the post- vs. pre-intervention period for the daily dosage of antibiotics, respectively, 12.2% vs. 26.9% (p?<?0.001), for the planned duration of treatment, respectively, 7.3% vs. 18.3% (p?<?0.001), whereas for the choice of antibiotics relative to the context of acquisition of pneumonia, the improvement failed to reach statistical significance, respectively, 18.2% vs. 25% (p?=?0.12).  Conclusion In this study, the increased availability of antibiotic guidelines at the time of drug ordering, combined with a periodical reinforcement educational round, was associated with an enhanced physician adherence to these guidelines. Copyright © 2010 John Wiley & Sons, Ltd.",1,1,
710,Enhancing access to alcohol use disorder pharmacotherapy and treatment in primary care settings: ADaPT-PC,"Background Only 7.8 % of individuals meeting diagnostic criteria for alcohol use disorder (AUD) receive treatment in a given year. Most individuals with AUDs are identified in primary care (PC) settings and referred to substance use disorders (SUD) clinics"";"" however, only a minority of those referred attend treatment services. Safe and effective pharmacological treatments for AUD exist, but they are rarely prescribed by PC providers. The objective of this study is to refine, implement, and evaluate an intervention to integrate pharmacological AUD treatment options into PC settings. This paper provides a detailed description of the intervention design and the evaluation components.  Methods/design Three large Veterans Health Administration (VHA) facilities are participating in the intervention. The intervention targets stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local SUD providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive external facilitation. PC providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification. Veterans with AUD diagnoses receive educational information in the mail just prior to a scheduled PC visit. Effectiveness of the intervention will be evaluated through an interrupted time series with matched controls to monitor change in facility level AUD pharmacotherapy prescribing rates. Following Stetler¡¯s four-phase formative evaluation (FE) strategy, FE methods include (1) developmental FE (pre-implementation interviews with champions, PC providers, and Veterans), (2) implementation-focused FE (tracking attendance at facilitation meetings, academic detailing efforts by local champions, and patient dashboard utilization), (3) progress-focused FE (tracking rates of AUD pharmacotherapy prescribing and rates of referral to PCMHI and SUD specialty care), and (4) interpretive FE (post-implementation interviews with champions and PC providers). Analysis of FE data will be guided by the Consolidated Framework for Implementation Research (CFIR).  Discussion If demonstrated to be successful, this implementation strategy will provide a replicable, feasible, and relative low-cost method for integrating AUD treatment services into PC settings, thereby increasing access to AUD treatment.",0,0,
711,Enhancing evidence-based diabetes and chronic disease control among local health departments: a multi-phase dissemination study with a stepped-wedge cluster randomized trial component,"Background The rates of diabetes and prediabetes in the USA are growing, significantly impacting the quality and length of life of those diagnosed and financially burdening society. Premature death and disability can be prevented through implementation of evidence-based programs and policies (EBPPs). Local health departments (LHDs) are uniquely positioned to implement diabetes control EBPPs because of their knowledge of, and focus on, community-level needs, contexts, and resources. There is a significant gap, however, between known diabetes control EBPPs and actual diabetes control activities conducted by LHDs. The purpose of this study is to determine how best to support the use of evidence-based public health for diabetes (and related chronic diseases) control among local-level public health practitioners.  Methods/design This paper describes the methods for a two-phase study with a stepped-wedge cluster randomized trial that will evaluate dissemination strategies to increase the uptake of public health knowledge and EBPPs for diabetes control among LHDs. Phase 1 includes development of measures to assess practitioner views on and organizational supports for evidence-based public health, data collection using a national online survey of LHD chronic disease practitioners, and a needs assessment of factors influencing the uptake of diabetes control EBPPs among LHDs within one state in the USA. Phase 2 involves conducting a stepped-wedge cluster randomized trial to assess effectiveness of dissemination strategies with local-level practitioners at LHDs to enhance capacity and organizational support for evidence-based diabetes prevention and control. Twelve LHDs will be selected and randomly assigned to one of the three groups that cross over from usual practice to receive the intervention (dissemination) strategies at 8-month intervals"";"" the intervention duration for groups ranges from 8 to 24 months. Intervention (dissemination) strategies may include multi-day in-person workshops, electronic information exchange methods, technical assistance through a knowledge broker, and organizational changes to support evidence-based public health approaches. Evaluation methods comprise surveys at baseline and the three crossover time points, abstraction of local-level diabetes and chronic disease control program plans and progress reports, and social network analysis to understand the relationships and contextual issues that influence EBPP adoption.",0,1,
712,Enhancing mammography referral in primary care,"Background.This 1-year randomized trial tested the efficacy of behavioral techniques for increasing mammography referrals by primary care physicians in small, community practices.  Methods.Sixty-one practices were randomly assigned to one of three conditions: (1) education-only control, (2) education plus cue enhancement using mammography chart stickers, and (3) education plus cue enhancement plus feedback and token rewards. Quarterly chart audits of a defined sample (N= 11,716) of women patients 50 years of age or older were conducted to document mammography referrals, completions, and compliance.  Results.Referral and completion rates increased from baseline to first quarter and gradually declined thereafter. Overall, these rates were higher in the cuing conditions than in the control condition. In contrast, compliance rates in both experimental conditions increased over the year while remaining static in the control condition, demonstrating a strong and continuing effect for cue enhancement. Compliance increases were greatest for physicians who were older, nonwhite, with a second speciality, in solo practice, not members of the AMA, not residency trained, and not board certified.  Conclusions.Chart stickers can significantly increase mammography utilization in small, community practices. These practices are an efficient route to reaching large numbers of older women in need of mammography screening.",1,1,
713,Enhancing the African bioethics initiative,"BACKGROUND: Medical ethics has existed since the time of Hippocrates. However, formal training in bioethics did not become established until a few decades ago. Bioethics has gained a strong foothold in health sciences in the developed world, especially in Europe and North America. The situation is quite different in many developing countries. In most African countries, bioethics - as established and practiced today in the west- is either non-existent or is rudimentary. DISCUSSION: Though bioethics has come of age in the developed and some developing countries, it is still largely ""foreign"" to most African countries. In some parts of Africa, some bioethics conferences have been held in the past decade to create research ethics awareness and ensure conformity to international guidelines for research with human participants. This idea has arisen in recognition of the genuine need to develop capacity for reviewing the ethics of research in Africa. It is also a condition required by external sponsors of collaborative research in Africa. The awareness and interest that these conferences have aroused need to be further strengthened and extended beyond research ethics to clinical practice. By and large, bioethics education in schools that train doctors and other health care providers is the hook that anchors both research ethics and clinical ethics. SUMMARY: This communication reviews the current situation of bioethics in Africa as it applies to research ethics workshops and proposes that in spite of the present efforts to integrate ethics into biomedical research in Africa, much still needs to be done to accomplish this. A more comprehensive approach to bioethics with an all-inclusive benefit is to incorporate formal ethics education into health training institutions in Africa.",0,0,
714,Enhancing the algorithm for developmental-behavioral surveillance and screening in children 0 to 5 years,"OBJECTIVE: To determine if the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm is adequate or if revisions are needed. METHODS: A comprehensive literature search was conducted to investigate a clinician's ability to perform developmental-behavioral surveillance in children 0 to 5 years. RESULTS: Even when a broad-band developmental screen is typical, pediatricians should refer when they confidently suspect a delay but be far more suspicious about children who seem asymptomatic. Periodic screening enhances surveillance by improving early detection and early intervention (EI) eligibility rates. Nevertheless, children with concerning screens are not consistently referred and interlinked to EI. Once referred, approximately half are deemed EI-ineligible, even though they typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, clinicians struggle with tracking at-risk children. CONCLUSION: Revisions are needed to optimize early detection, prevention, and monitoring. Greater emphasis is needed on developmental-behavioral promotion and referral care coordination.",0,0,
715,Enhancing the quality of antibiotic prescribing in primary care: qualitative evaluation of a blended learning intervention,"BACKGROUND: The Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial. METHODS: Semi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis. RESULTS: The majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data. CONCLUSION: Participants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program. TRIAL REGISTRATION: Current Controlled Trials ISRCTN63355948.",0,0,
716,Epidemiology for the uninitiated. Aetiology of disease--selection of controls,,0,0,
717,"Epidemiology of Alzheimer's presenile dementia in Scotland, 1974-88","OBJECTIVE To describe the epidemiology of presenile Alzheimer's disease in Scotland from 1974 to 1988. DESIGN Retrospective review of hospital records of patients aged less than 73 years admitted to psychiatric hospital with various diagnoses of dementia. Diagnoses were classified by National Institute for Communicative Disorders and Stroke and Alzheimer's Disease and Related Disorders Association Criteria and the Hachinski score. Completeness of the study sample was evaluated by scrutiny of neurology outpatient and general hospital records. SETTING All general psychiatric hospitals in Scotland. SUBJECTS All patients with onset of dementia aged 40-64. MAIN OUTCOME MEASURES Probable and broad Alzheimer's disease, sex of patient, age at onset. RESULTS 5874 psychiatric hospital records, 129 neurology outpatient records, and 89 records from non-psychiatric hospitals were examined. 317 patients met criteria for probable Alzheimer's disease, 569 met criteria for broad Alzheimer's disease, and 267 met those for multi-infarct dementia. Minimal incidences per 100,000 population aged 40-64 years were 22.6 (95% confidence interval, 20.2 to 25.2) and 40.5 (38.9 to 42.3) per 100,000 for probable and broad Alzheimer's disease. In the 1981 census year the annual incidence of probable Alzheimer's disease was 1.6 (1.0 to 2.6). Women were at greater risk with incidence rates for probable Alzheimer's disease of 28.2 (24.5 to 32.4) per 100,000 compared with 16.5 (13.8 to 19.8) per 100,000 for men. The incidence per 100,000 for multi-infarct dementia was greater in men (25.1, 23.3 to 27.1) than women (13.4, 12.1 to 14.8). CONCLUSION Female sex seems to be positively associated with development of Alzheimer's disease before age 65 years.",0,0,
718,Epilepsy and employment,,0,0,
719,"Erratum to: Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies",,0,0,
720,ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction-a guide for fertility staff,"STUDY QUESTION: Based on the best available evidence in the literature, what is the optimal management of routine psychosocial care at infertility and medically assisted reproduction (MAR) clinics? SUMMARY ANSWER: Using the structured methodology of the Manual for the European Society of Human Reproduction and Embryology (ESHRE) Guideline Development, 120 recommendations were formulated that answered the 12 key questions on optimal management of routine psychosocial care by all fertility staff. WHAT IS ALREADY KNOWN: The 2002 ESHRE Guidelines for counselling in infertility has been a reference point for best psychosocial care in infertility for years, but this guideline needed updating and did not focus on routine psychosocial care that can be delivered by all fertility staff. STUDY, DESIGN, SIZE, DURATION: This guideline was produced by a group of experts in the field according to the 12-step process described in the ESHRE Manual for Guideline Development. After scoping the guideline and listing a set of 12 key questions in PICO (Patient, Intervention, Comparison and Outcome) format, thorough systematic searches of the literature were conducted"";"" evidence from papers published until April 2014 was collected, evaluated for quality and analysed. A summary of evidence was written in a reply to each of the key questions and used as the basis for recommendations, which were defined by consensus within the guideline development group (GDG). Patient and additional clinical input was collected during the scoping and the review phase of the guideline development. PARTICIPANTS/MATERIALS, SETTING, METHODS: The guideline group, comprising psychologists, two medical doctors, a midwife, a patient representative and a methodological expert, met three times to discuss evidence and reach consensus on the recommendations. MAIN RESULTS AND THE ROLE OF CHANCE THE GUIDELINE PROVIDES: 120 recommendations that aim at guiding fertility clinic staff in providing optimal evidence-based routine psychosocial care to patients dealing with infertility and MAR. The guideline is written in two sections. The first section describes patients' preferences regarding the psychosocial care they would like to receive at clinics and how this care is associated with their well-being. The second section of the guideline provides information about the psychosocial needs patients experience across their treatment pathway (before, during and after treatment) and how fertility clinic staff can detect and address these. Needs refer to conditions assumed necessary for patients to have a healthy experience of the fertility treatment. Needs can be behavioural (lifestyle, exercise, nutrition and compliance), relational (relationship with partner if there is one, family friends and larger network, and work), emotional (well-being, e.g. anxiety, depression and quality of life) and cognitive (treatment concerns and knowledge). LIMITATIONS, REASONS FOR CAUTION: We identified many areas in care for which robust evidence was lacking. Gaps in evidence were addressed by formulating good practice points, based on the expert opinion of the GDG, but it is critical for such recommendations to be empirically validated. WIDER IMPLICATIONS OF THE FINDINGS: The evidence presented in this guideline shows that providing routine psychosocial care is associated with or has potential to reduce stress and concerns about medical procedures and improve lifestyle outcomes, fertility-related knowledge, patient well-being and compliance with treatment. As only 45 (36.0%) of the 125 recommendations were based on high-quality evidence, the guideline group formulated recommendations to guide future research with the aim of increasing the body of evidence.",0,0,
721,Essential elements of an early intervention service for psychosis: the opinions of expert clinicians,"BACKGROUND: Early intervention teams attempt to improve outcome in schizophrenia through earlier detection and the provision of phase-specific treatments. Whilst the number of early intervention teams is growing, there is a lack of clarity over their essential structural and functional elements. METHODS: A 'Delphi' exercise was carried out to identify how far there was consensus on the essential elements of early intervention teams in a group of 21 UK expert clinicians. Using published guidelines, an initial list was constructed containing 151 elements from ten categories of team structure and function. RESULTS: Overall there was expert consensus on the importance of 136 (90%) of these elements. Of the items on which there was consensus, 106 (70.2%) were rated essential, meaning that in their absence the functioning of the team would be severely impaired. CONCLUSION: This degree of consensus over essential elements suggests that it is reasonable to define a model for UK early intervention teams, from which a measure of fidelity could be derived.",0,0,
722,Essentials of research ethics for healthcare professionals,"Whether conducted in a university or the healthcare field, research with human subjects gives rise to a multitude of ethical questions for healthcare professionals. While engaging in ongoing professional development on how to conduct research ethically, both clinicians and scientists need to expand their knowledge to provide answers to the following questions: Which ethical theories serve as a foundation for ethical principles in research ethics? What ethical principles should a researcher respect when conducting research with human subjects? What does it mean to conduct research ethically? What ethical dilemmas are encountered by a researcher in conducting research? This paper provides a review of ethical theories, and the ethical basis of guidelines developed and used to guide human subject research. Ethical behaviors and the personal responsibility of the researcher conducting research with human subjects are discussed along with the ethical considerations in research designs and methods.",0,0,
723,Establishing translational and clinical cancer research collaborations between high- and low-income countries,"Both infectious and noninfectious related malignancies are a growing problem in low- and middle-income countries (LMIC). It is difficult to extrapolate data and guidelines regarding cancer care from high-income countries (HIC) to cancer patients in LMIC. Due to the rise in noncommunicable cancer rates, there is a widening gap between the need for evidence-based treatments for cancer control plans and existing research capabilities. Surgeons frequently provide all surgical and medical oncology treatments for patients in LMIC for diseases, such as breast, gastric, cervical, and colorectal cancers. Surgical oncology clinical and translational research collaborations, however, are lacking. There are several successful consortiums that focus on HIV- and infectious-related malignancies. These collaborations can be used as an example for future surgical research efforts. The Memorial Sloan Kettering Cancer Center-Nigerian collaboration that is concentrating on colorectal cancer is used as an example of how to initiate a research collaboration that can build research infrastructure and provide the necessary data to generate realistic treatment guidelines. The need for expanded surgical oncology research and the growing population of patients with noninfectious-related malignancies in LMIC has created a unique opportunity for surgeons to initiate and lead clinical and translational research collaborations between HIC and LMIC.",0,0,
724,Ethical aerobics: ACHRE's flight from responsibility,"The President's Advisory Committee on Human Radiation Experiments (ACHRE) was charged to perform a comprehensive ethical evaluation of US government‐funded radiation experiments. In these experiments, several hundred thousand people were used as experimental subjects in several thousand experiments. This paper reviews ACHRE's Final Report, issued in October 1995. ACHRE recommended no apology or compensation to the vast majority of victims. Their rationale for this decision was plagued with inconsistencies. Whenever facts could not be recontextualized to reduce the apparent misconduct of the government‐funded researchers, ACHRE constructed ethical loopholes to avoid judgment of the perpetrators. We critique ACHRE's recommendations by a careful analysis of their own records and transcripts. We. provide an accurate history of informed consent standards in human subject research, in contrast to ACHRE's inconsistent history. We also give a detailed review of ACHRE's erroneous risk analysis in two representative groups of experiments.",0,0,
725,Ethical and institutional review board issues,"IRBs provide an important role in the protection of research subjects/patients. Research investigators have an inherent potential conflict of interest as health care professionals"";"" as physicians, they are dedicated to promoting the welfare of individual patients, whereas as researchers, they seek knowledge that can be generalized and is applicable to persons other than the individual patient under study. The second goal may be in conflict with the first. IRBs have the paramount responsibility of protecting the rights and welfare of human research subjects. Although the IRB system is not perfect, conscientious IRBs reassure the public that the rights and welfare of human subjects are seriously considered by people who do not have a vested interest in the outcome of the research. By exercising their responsibilities, IRBs promote the protection of human subjects. IRB approval provides a significant affirmation of the scientific and ethical qualities of research, and therefore offers important validation to research and research investigators. IRBs, acting in accordance with the guiding principles of the Belmont Report and within the regulatory guidelines of 45.CFR.46, are intended to provide balance between society's interest in advancing scientific knowledge and the mandate to protect the rights and welfare of human subjects.",0,0,
726,Ethical and legal risks associated with archival research,"Mental health facilities and practitioners commonly permit resarchers to have direct access to patients' records for the purposes of archival research without the informed consent of patient-participants. Typically these researchers have access to all information in such records as long as they agree to maintain confidentiality and remove any identifying data from subsequent research reports. Changes in the American Psychological Association's Ethical Principles (American Psychological Association, 1992) raise ethical and legal issues that require consideration by practitioners, researchers, and facility Institutional Review Boards. This article addresses these issues and provides recommendations for changes in ethical standards as well as alternative avenues for conducting research using archival mental health records.",0,0,
727,Ethical complications of clinical therapeutic research on children,"Usual discussion by ethicists and physicians of the ethical implications of research on children with catastrophic disease, and the guidelines established by the Federal Government for this research, rest on applying general moral principles to problems. Whatever the merits of this approach for establishing policy, it does not adequately reflect the life situation of patients and the complexity of a single regimen which is simultaneously both therapeutic and research oriented. Also, the issues become more complex when there is disagreement among the parents about a course of treatment. It is our contention that such cases are properly resolved by considering the degree of paternalism to be exercised by the clinician-researcher."";"" KIE: Much of the discussion of ethical issues in therapeutic research on children is based on the application of general moral principles to categories of problems. The authors believe that this approach does not adequately address the complexity of a treatment regimen for catastrophically ill children which is both therapeutic and research oriented. Using a case study to illustrate the potential complications of such a situation, they argue that medical paternalism is justified in therapeutic research on children even if it diminishes the patient's autonomy, on the grounds that the best interests of the patient must take precedence over preservation of complete autonomy.",0,0,
728,Ethical considerations for research on human subjects,,0,0,
729,"Ethical considerations in the recruitment of research subjects from hospitalized, cardiovascular patient populations","Cardiovascular research nurses play important roles in ensuring that subject recruitment is conducted in an ethically defensible manner. However, these nurses encounter many ethical challenges in the course of research. Sole reliance on regulatory mechanisms such as institutional review board oversight and adherence to legal requirements does not necessarily ensure human subjects' protection or the scientific integrity of researchers (J Law Med Ethics. 2002"";""30:411-419). Therefore, this article discusses 3 additional ethical considerations associated with recruiting hospitalized cardiovascular patients for research studies. These include (a) the role of the family and patient-delegated ""gatekeepers,"" (b) the effect of transient and subtle mental status changes upon the consent process, and (c) the effect of conflicting patient priorities. This content is illustrated using the authors' experiences recruiting hospitalized coronary artery bypass graft surgical patients for a research study.",0,0,
730,Ethical dilemmas in qualitative research: how do we respect autonomy?,"This essay brings the concept of nursing research into light and in particular examines the principle of 'respect for autonomy', its relationship and limitations in the field of research on human subjects during qualitative research. This essay will also identify how ethical dilemmas, involving respect for autonomy, can develop during research and a systematical method of critical ethical analysis will be presented to demonstrate how nurse researchers can resolve such issues, if and when they arise. It is necessary to focus on one facet of the research process to illustrate the 'depth' of consideration required to ensure that such research is of the highest quality.",0,0,
731,Ethical genetic research on human subjects,"Since the Nuremberg trials and the Nazi doctors trial following World War II, international ethics protocols have emerged designed to protect human subjects from the atrocities of medical experimentation that were literally routine under the Nazis. Some of the apparent ""lessons"" from the Nazi period have been encapsulated in the Declaration of Helsinki, perhaps the leading medical ethics protocol. This paper argues that these protocols have not been notably conducive to human welfare or to the protection of human rights in the field of human genetics research. The paper proposes new protocols and a new approach to the ethics of research on human subjects.",0,0,
732,Ethical issues in the management of chronic nonmalignant pain,"Chronic pain represents a challenge to patients, families, employers, and the physicians who care for these individuals. Opioids remain the mainstay of the analgesic medications for the treatment of both acute and chronic pain. Controlled release preparations of morphine, oxycodone, fentanyl and long acting opioid agents such as methadone and levorphanol have been medically and ethically accepted in managing chronic cancer pain. However, the continued use of these medications for patients with chronic noncancer pain has been fiercely debated. This article attempts to reconcile the medical and ethical dilemma of using opioid medications for chronic noncancer pain. Growing clinical experience in the field of pain medicine has helped to clarify: (1) the misunderstanding of addiction, physical dependence and analgesic tolerance, (2) the misconception that chronic opioid therapy inevitably causes personality changes, depression, and impairment of cognitive and physical function, (3) the lack of information on the correct use of opioid analgesics with regard to titration and management of related side effects. The behavioral management of pain patients undergoing chronic opioid therapy is also discussed. A protocol for optimal patient management is proposed. Particular emphasis is given to the consent form, behavioral contracting, and the consequences of noncompliance. The importance of psychologic evaluation before a long-term opioid trial, to minimize future complications, is stressed. Although most patients on the opioid regimen do well, special attention must be given to patients with current addiction, a past history of addiction, or current misuse of opioid medications. Pharmacologic and conservative interventions are often warranted in those patients with significant behavioral problems. If such strategies fail, and chronic opioid therapy is deemed necessary, some treatment guidelines are offered.",0,0,
733,Ethical regulations for innovative surgery: the last frontier?,"BACKGROUND: There are no clear federal regulations governing innovative surgery, even though general guidelines regulating research with human subjects do exist. We hypothesized that US surgeons are unaware of Department of Health and Human Services regulations, rarely seek IRB review, generally oppose outside regulation of innovative surgery, and are uncertain what constitutes innovation and research. These circumstances, if true, would pose a significant ethical problem and present potential harm to patients as unwitting subjects of research. STUDY DESIGN: In a pilot study we reviewed 527 issues of US surgical and medical journals, selecting 59 articles published between 1992 and 2000, that described innovative surgery. Corresponding authors from university hospitals (71%) and other facilities (29%) were sent an anonymous questionnaire. RESULTS: The survey was conducted between November 2000 and May 2001. Twenty-one questionnaires were returned, completed with responses, constituting a 35% overall response rate. Fourteen authors confirmed their work was research, yet only six had sought prior IRB review. The majority of authors (15 of 21) did not submit their protocol to IRB. Only seven authors had mentioned the innovative nature of the procedure in the informed consent form. Seven authors claimed familiarity with Office for Human Research Protections definitions of research and human subject. Two-thirds of the respondents stated that government regulations for the protection of human subjects of innovative surgery would not be appropriate. CONCLUSIONS: The current system of definitions, ethical theories, and voluntary professional guidelines may be inadequate to meet the challenge of surgical innovation. Further research is proposed to examine the adequacy of the existing guidelines.",0,0,
734,Ethical requirements that must be met before the introduction of new procedures,"For orthopaedic care of patients to continue to improve, new approaches, both diagnostic and therapeutic, must be continually developed. To verify that a new approach actually provides improved outcomes, these innovations must be subjected to rigorous scientific study. However, because outcomes of clinical interventions only can be studied in human subjects, these studies must not only meet scientific criteria, they also must meet strict ethical criteria. The Declaration of Helsinki, a document prepared by the World Medical Association that originally was written in 1964, revised substantially in 1975, and most recently revised in 1996, provides guidelines for such studies. In addition to satisfying ethical requirements, clinical investigators also face various complex issues that must be dealt with in the performance of clinical research studies. One of the most difficult issues is the conflict between a physician's concern for the well-being of his or her patients and the need for protocol driven trials. No matter how enthusiastic surgeons may be about a new therapeutic approach, they must recognize that they are responsible to scientifically validate their innovative approach with a well controlled clinical trial using valid functional outcome measures.",0,0,
735,Ethical review of health promotion program evaluation proposals,"Some policies state that program evaluation falls within the domain of administrative research that does not require review by an ethics review board. We propose that some health promotion program evaluations include at least one element of research and can be distinguished from quality assurance. Although American and Canadian evaluation societies provide important guidelines and standards for evaluation practitioners, processes for accountability to the public are provided by research ethics boards. The field of health promotion is, by its nature, replete with challenges to existing research ethics boards. Given the dearth of published literature on the ethics of health promotion evaluation or practice, the field could benefit from the open debate that reviews of proposals would encourage.",0,0,
736,Ethics committees and achievement of good clinical practice,"Local ethics committees (institutional review boards, or similar bodies) were established during the last decades at (bio)medical research institutions worldwide to serve as review bodies of the proposed research projects (inclusive protocols of clinical trials), and also to monitor if the ethical principles, including the requirements of good practice (clinical, laboratory, and scientific) are respected and fulfilled during the conduct of research projects. Existing pluralism of the philosophical background on which contemporary bioethics theories are developed is questioning seriously the ancient traditions of Hippocratic, non-utilitarian medical ethics, trying to promote more utilitarian and secular approaches. Individual physicians, or researchers, as well as the ethics committee itself, are faced today with complicated ethical dilemmas, that frequently have to be solved in the atmosphere of considerable social, collegiate, economical, and time pressures, and sometimes without helpful guidance of appropriate legislation. An interesting possibility of how to overcome some of the pitfalls of the ethics review process is to express a common ethical responsibility for the research project or trial protocol in a statement of most (or all) parties involved (such as the principal investigator, sponsor, ethics committee, the patient, ""society'). Such an approach has proven helpful in enhancing concrete deliberations of ethics committees-established in Slovakia since 1991 according to the requirements of the national guidelines issued by the Slovak Ministry of Health.",0,0,
737,Ethics committees and paediatric research: a personal viewpoint,"Surveillance of clinical research involving child subjects, or tissues taken from them, continues to become more formalized and sophisticated. Many doctors and most paediatricians can be expected to be offered the opportunity to serve on paediatric Institutional Ethics Committees (IEC) at some stage of their professional lives. Fearless and independent Ethics Committees have considerable influence on both the design and implementation of clinical research, and on the topics of allowable research in which infants and children will be involved. The composition of IECs generally is designed to give a balance of sexes, professional backgrounds, and institutional and non-institutional affiliations. In addition to these now well established compositional guidelines, IECs adjudicating on paediatric research have a pragmatic requirement for three extra specific roles: those of in loco parentis, in loco infanti, and the special role of nursing staff. These roles and the ethical basis for them are defined. Further, the in loco parentis role is ethnically complex, and an IEC considering this role should be clear about its implications. Paediatric research projects involve not only specific risks inherent to the project in question, but also more general risks inherent in any clinical research intervention endeavour itself. Paediatric IECs should act in a mode of encouragement, rather than purely as 'doctor watchers', and should insist ab initio on the publication of results as a condition of permission to undertake the research in question. One particularly effective form of ethical audit is the national and international peer review that follows such publication of paediatric research. This report discusses these special themes in the evolving context of greater surveillance of paediatric research.",0,0,
738,Ethics committees in Italy: a survey on a sample of oncologists,"AIMS AND BACKGROUND: The mission of physicians and the purpose of clinical research may give rise to a conflict between medical ethics and human rights. All the recommendations, directives and laws regarding experimental interventions require a formal protocol, approval from an ethics committee (EC), and written informed consent from potential participants. In Italy new guidelines on handling submissions to EC were published in 1998. One year later, there was a feeling among people involved in EC activities that the immediate impact of the new rules (ie, decentralization and emphasis on pharmacological aspects of the studies) was negative. A prospective study was launched to evaluate oncologists' opinions on Italian EC functioning. METHODS AND STUDY DESIGN: A questionnaire was administered twice to 110 oncologists involved in two multicenter trials. Nine questions were included regarding the following aspects: presence of an EC at hospital level, personal experience with an EC, average time required for the evaluation of proposals submitted, and level of satisfaction with important functions of the EC. RESULTS: Responses were received from 93 (first survey) and 69 (second survey) clinicians. In both surveys clinicians reported they were satisfied with the scientific and ethical aspects of EC functioning but dissatisfied with educational activities and training as well as bureaucratic and clerical requirements. At the second survey, the mean time required for evaluation after the submission of a study protocol was about 2.4 months and the level of dissatisfaction was still high for some critical aspects such as bureaucracy (44%) and educational activities and training (64%). Analysis of the change over time documented small differences (from -8% to +7%) in all aspects evaluated. CONCLUSIONS: Despite the limitations of the present study, ie, the small sample size and the intrinsic characteristics of the Italian setting, the findings add empirical evidence regarding the functioning of local EC and clinical researchers' opinions. This experience confirms that empirical studies on medical ethics are feasible and may produce useful information to facilitate the implementation of EC in the medical and lay community.",0,0,
739,"Ethics of innovative surgery: US surgeons' definitions, knowledge, and attitudes","BACKGROUND: Innovative surgery is not clearly defined, nor is it formally regulated by governing bodies as is the development of drugs and medical devices. This unclear status and the subsequent questionable applicability of existing federal guidelines for human subject research pose an ethical concern. To clarify its position, we solicited US surgeons' definitions of, opinions toward, and attitudes about innovative surgery. Surgeons were also invited to self-report knowledge about current federal regulations guiding human subject research and rules for informed consent for and IRB review of clinical research. STUDY DESIGN: A group of US surgeons received a 46-item questionnaire addressing the definition of innovative surgery versus those for research and practice, regulations for human subject research, need for specific informed consent, and IRB review of surgical innovations. RESULTS: A total of 665 responses were used in the content analysis. Respondents expressed a fairly prudent stance when judging hypothetical innovative scenarios. Hallmarks for experimentation and clinical research as modes of innovation were defined more clearly for the surgical situation. CONCLUSIONS: Defining criteria exist that prompt added scrutiny and previous review of surgical innovations. Some forms of innovation clearly fall under the current regulations for human subject research"";"" others might not fully meet the definition but could still require some additional oversight.",0,0,
740,Ethics of randomized clinical trials and the 'ALARA' approach,"A balanced discussion on the ethics of randomized clinical trials should not be based on a single ethical aspect such as respect for the patient's autonomy. Rather, the analysis should consider the four ethical principles--respect for autonomy, non-maleficence, beneficence, and justice--as applicable to all groups of persons concerned. We present the ethical benefits and costs of the present practice of randomized clinical trials for four groups: patients involved in clinical trials, patients not involved in trials, participating physicians and society. The ALARA (As Low As Reasonably Achievable) approach is then introduced and practical measures to achieve a positive balance between ethical benefits and costs of randomized trials are proposed.",0,0,
741,Ethics of research in relation to human subjects/patients,,0,0,
742,"Ethics of research with psychiatric patients: principles, problems and the primary responsibilities of researchers","In this paper some of the general issues surrounding recently published guidelines for the practice of research ethics committees are outlined, concentrating in particular on the difficulties raised by research with psychiatric patients. Research is distinguished from ordinary clinical practice by the intention to advance knowledge. So defined, research with psychiatric patients should be governed by the same four principles as research with any other group--knowledge, necessity, benefit and consent. In applying these principles, however, particularly the principle of consent, many acute difficulties are raised by psychiatric patients. A number of proposals for addressing these difficulties are discussed. It is suggested that, notwithstanding the value of published guidelines, and the help that may be available from research ethics committees, the primary responsibility for maintaining high standards of practice in research rests with research workers themselves.",0,0,
743,"EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries","AIM: The aim of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III) survey was to determine whether the Joint European Societies' guidelines on cardiovascular prevention are being followed in everyday clinical practice and to describe the lifestyle, risk factor and therapeutic management in patients with coronary heart disease (CHD) in Europe. METHODS: The EUROASPIRE III survey was carried out in 2006-2007 in 76 centres from selected geographical areas in 22 countries in Europe. Consecutive patients, with a clinical diagnosis of CHD, were identified retrospectively and then followed up, interviewed and examined at least 6 months after their coronary event. RESULTS: Thirteen thousand nine hundred and thirty-five medical records (27% women) were reviewed and 8966 patients were interviewed. At interview, 17% of patients smoked cigarettes, 35% were obese and 53% centrally obese, 56% had a blood pressure >or=140/90 mmHg (>or=130/80 in people with diabetes mellitus), 51% had a serum total cholesterol >or=4.5 mmol/l and 25% reported a history of diabetes of whom 10% had a fasting plasma glucose less than 6.1 mmol/l and 35% a glycated haemoglobin A1c less than 6.5%. The use of cardioprotective medication was: antiplatelets 91%""; beta-blockers 80%; angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 71%;"" calcium channel blockers 25% and statins 78%. CONCLUSION: The EUROASPIRE III survey shows that large proportions of coronary patients do not achieve the lifestyle, risk factor and therapeutic targets for cardiovascular disease prevention. Wide variations in risk factor prevalences and the use of cardioprotective drug therapies exist between countries. There is still considerable potential throughout Europe to raise standards of preventive care in order to reduce the risk of recurrent disease and death in patients with CHD.",0,0,
744,"EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries","AIMS: To determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice of secondary prevention and to describe the lifestyle, risk factor and therapeutic management of coronary patients across Europe. METHODS AND RESULTS: EUROASPIRE IV was a cross-sectional study undertaken at 78 centres from 24 European countries. Patients /= 6 months later. A total of 16,426 medical records were reviewed and 7998 patients (24.4% females) interviewed. At interview, 16.0% of patients smoked cigarettes, and 48.6% of those smoking at the time of the event were persistent smokers. Little or no physical activity was reported by 59.9%""; 37.6% were obese (BMI >/= 30 kg/m(2)) and 58.2% centrally obese (waist circumference >/= 102 cm in men or >/=88 cm in women); 42.7% had blood pressure >/= 140/90 mmHg (>/=140/80 in people with diabetes); 80.5% had low-density lipoprotein cholesterol >/= 1.8 mmol/l and 26.8% reported having diabetes. Cardioprotective medication was: anti-platelets 93.8%; beta-blockers 82.6%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75.1%;"" and statins 85.7%. Of the patients 50.7% were advised to participate in a cardiac rehabilitation programme and 81.3% of those advised attended at least one-half of the sessions. CONCLUSION: A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Less than one-half of the coronary patients access cardiac prevention and rehabilitation programmes. All coronary and vascular patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control and adherence with cardioprotective medications.",0,0,
745,Evaluating an educational intervention to improve the treatment of asthma in four European countries. Drug Education Project Group,"In the international Drug Education Project, a new educational program for peer groups of doctors was developed and tested to improve the treatment of asthma patients in The Netherlands, Norway, Sweden, and Slovakia. Individualized feedback on prescribing and the underlying decision strategy was presented and discussed within the group of doctors, in relation to existing guidelines. In a parallel, randomized controlled design the effect on competence and actual prescribing was tested. Results were related to national guidelines. In general, the program improved the doctors' attitudes as well as some of their prescribing behavior. The proportion of patients treated with inhaled corticosteroids significantly improved in The Netherlands (effect size 1.27), and the proportion of oral corticosteroid use for exacerbation treatment increased both in The Netherlands and in Norway (effect sizes 1.99 and 0.87, respectively). Overall attitudes of Dutch and Norwegian doctors also improved significantly (effect sizes 1.06 and 0.87, respectively), as did both knowledge (effect size 1.06) and attitudes (effect size 1.49) concerning exacerbation treatment in Slovakia. In Sweden no significant improvements could be measured. Conclusively, improvements in asthma treatment are possible with an educational program based on self-learning in small peer groups, although effects in one health care setting may not occur in another health care setting. Possible explaining factors may be different attitudes to and experiences with guidelines as well as with continuing medical education programs, and differences in the opportunities for change, including prevailing trends in prescribing behavior.",0,0,
746,"Evaluating informatics applications--some alternative approaches: theory, social interactionism, and call for methodological pluralism","A review of evaluation literature concerning CDSSs indicates that randomized controlled clinical trials (RCTs) are the 'gold standard' for evaluation. While this approach is excellent for studying system or clinical performance, it is not well suited to answering questions concerning whether systems will be used or how they will be used. Because lack of use of CDSS has been of concern for some years, other evaluation research designs are needed to address those issues. This paper critiques RCT and experimental evaluation approaches and presents alternative approaches to evaluation that address questions outside the scope of the usual RCT and experimental designs. A wide range of literature is summarized to illustrate the value of evaluations that take into account social, organizational, professional, and other contextual considerations. Many of these studies go beyond the usual measures of systems performance or physicians' behavior by focusing on 'fit' of the system with other aspects of professional and organizational life. Because there is little explicit theory that informs many evaluations, the paper then reviews CDSS evaluations informed by social science theories. Lastly, it proposes a theoretical social science base of social interactionism. An example of such an approach is given. It involves a CDSS in psychiatry and is based on Kaplan's 4Cs, which focus on communication, control, care, and context. Although the example is a CDSS, the evaluation approach also is useful for clinical guideline implementation and other medical informatics applications. Similarly, although the discussion is about social interactionism, the more important point is the need to broaden evaluation through a variety of methods and approaches that investigate social, cultural, organizational, cognitive, and other contextual concerns. Methodological pluralism and a variety of research questions can increase understanding of many influences concerning informatics applications development and deployment.",0,0,
747,"Evaluating the effectiveness of a clinical practice change intervention in increasing clinician provision of preventive care in a network of community-based mental health services: a study protocol of a non-randomized, multiple baseline trial","BACKGROUND: People with a mental illness experience substantial disparities in health, including increased rates of morbidity and mortality caused by potentially preventable chronic diseases. One contributing factor to such disparity is a higher prevalence of modifiable health risk behaviors, such as smoking, inadequate fruit and vegetable intake, harmful alcohol consumption, and inadequate physical activity. Evidence supports the effectiveness of preventive care in reducing such risks, and guidelines recommend that preventive care addressing such risks be incorporated into routine clinical care. Although community-based mental health services represent an important potential setting for ensuring that people with a mental illness receive such care, research suggests its delivery is currently sub-optimal. A study will be undertaken to evaluate the effectiveness of a clinical practice change intervention in increasing the routine provision of preventive care by clinicians in community mental health settings. METHODS/DESIGN: A two-group multiple baseline design will be utilized to assess the effectiveness of a multi-strategic intervention implemented over 12 months in increasing clinician provision of preventive care. The intervention will be implemented sequentially across the two groups of community mental health services to increase provision of client assessment, brief advice, and referral for four health risk behaviors (smoking, inadequate fruit and vegetable consumption, harmful alcohol consumption, and inadequate physical activity). Outcome measures of interest will be collected via repeated cross-sectional computer-assisted telephone interviews undertaken on a weekly basis for 36 months with community mental health clients. DISCUSSION: This study is the first to assess the effectiveness of a multi-strategic clinical practice change intervention in increasing routine clinician provision of preventive care for chronic disease behavioral risk factors within a network of community mental health services. The results will inform future policy and practice regarding the ability of clinicians within mental health settings to improve preventive care provision as a result of such interventions. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000693729.",0,0,
748,Evaluating the effectiveness of educational interventions to prevent delirium,"The aim of this study was to combine knowledge about how clinicians learn with a review of educational interventions to prevent delirium in hospitalised patients. The primary aim was to evaluate the effectiveness of approaches to delirium education. A detailed search of educational and medical databases was undertaken. The type of intervention used was classified according to the PRECEED model of Green and colleagues, using factors relevant to behaviour change in health promotion. The effectiveness of the intervention was determined by assessing changes in staff performance and patient outcomes. Nineteen studies of variable design and quality were identified. Studies using predisposing, enabling and reinforcing strategies together were more often effective in producing changes in staff behaviour and patient outcomes. Education and guidelines used together or in combination have little effect. When strategies to enable and reinforce changes in clinical practice are used together with education sessions, outcomes for patients are more positive.",0,0,
749,Evaluating the stage of change model to a cervical cancer screening intervention among Ohio Appalachian women,"Cervical cancer incidence and mortality rates are disproportionally high among women living in Appalachia Ohio. This study used the Transtheoretical Model to examine screening barriers before and after a lay health advisor (LHA) intervention (2005-2009) to increase cervical cancer screening rates. Ohio Appalachian women (n = 90) who were in need of a Pap test, based on risk-appropriate guidelines, were randomized to a 10-month LHA intervention and received two in-person visits, two phone calls, and four mailed postcards targeted to the participant's stage of change. Findings revealed that 63% had forward stage movement 10 months after the intervention. The most frequently reported screening barriers were time constraints, forgetting to make an appointment, and cost. Women who reported the following barriers-doctor not recommending the test""; being unable to afford the test;"" and being embarrassed, nervous, or afraid of getting a Pap test-were less likely to be in the action stage. Understanding the stages of change related to Pap testing and reported barriers among this underserved population may help inform researchers and clinicians of this population's readiness for change and how to set realistic intervention goals.",0,0,
750,Evaluating the uptake and effects of the computerized decision support system NHGDoc on quality of primary care: protocol for a large-scale cluster randomized controlled trial,"BACKGROUND: Computerized decision support systems (CDSSs) are increasingly used to improve quality of care. There is evidence for moderate to large effects from randomized controlled trials (RCTs), but evidence on their effectiveness when implemented at a national level is lacking. In the Netherlands, the Dutch College of General Practitioners (NHG) initiated their successful guideline program already 30 years ago. NHGDoc, a CDSS based on these NHG guidelines, covering multiple disease areas for general practice, was developed in 2006 with the aim to improve quality of primary care. In this paper, a protocol is presented to evaluate the uptake and effects of NHGDoc. METHODS: A cluster RCT will be conducted among 120 general practices in the Netherlands. Eligible general practices will be randomized to receive either the regular NHGDoc decision support modules (control arm) or the regular modules plus an additional module on heart failure (intervention arm). The heart failure module consists of patient-specific alerts concerning the treatment of patients with heart failure. The effect evaluation will focus on performance indicators (e.g., prescription behavior) as well as on patient outcomes (e.g., hospital admissions) relevant in the domain of heart failure. Additionally, a process evaluation will be conducted to gain insight into the barriers and facilitators that affect the uptake and impact of NHGDoc. DISCUSSION: Results of this study will provide insight in the uptake and impact of a multiple-domain covering CDSS for primary care implemented by a national guideline organization to improve the quality of primary care. Whereas the trial focuses on a specific domain of care-heart failure-conclusions of this study will shed light on the functioning of CDSSs covering multiple disease areas for primary care, particularly as this study also explores the factors contributing to the system's uptake and effectiveness. TRIAL REGISTRATION: Clinical trials NCT01773057.",0,0,
751,Evaluating training methods for transporting contingency management to therapists,"The effects of three increasingly intensive training methods on therapist use, knowledge, and implementation adherence of contingency management (CM) with substance abusing adolescents were evaluated. Ten public sector substance abuse or mental health provider organizations were randomized to one of three training conditions: workshop and resources (WS+), WS+and computer assisted training (WS+/CAT), or WS+/CAT and supervisory support (WS+/CAT/SS). Across conditions, 161 therapists participated in the training experiences, and measures were obtained at baseline and 2-month intervals for 12 months following workshop participation. Across training conditions, therapists reported increased CM use, knowledge, and implementation adherence through the 12-month follow-up. The findings show that community-based practitioners are amenable to the adoption of evidence-based treatments when provided access to useful resources. Moreover, high quality workshops in combination with resource access can increase knowledge of the evidence-based treatment and might enhance intervention adherence to a level needed to improve youth outcomes.",0,0,
752,Evaluation of a complex intervention for changing professional behaviour: the Evidence Based Out Reach (EBOR) Trial,"OBJECTIVES: To identify the effect of a complex intervention (educational outreach visits by pharmacists) designed to change general practitioners' (GPs') prescribing on each step of a hypothesised pathway of change leading to the final primary trial outcome of change in prescribing. METHOD: The study was undertaken in six health authorities in the North of England and six in London. We described three steps leading to this outcome: the general practices agreeing to participate""; GPs in each practice attending the outreach visit conducted by the pharmacists;"" and the GPs' prescribing practice being influenced by these visits. The outcomes of each step were assessed using a combination of quantitative and qualitative methods. RESULTS: Of the 102 practices randomly selected, 75 (73.5%) agreed to participate. The odds of all the doctors attending the outreach meeting in small practices (i.e. 1-2 partners) was 6.7 (95% CI: 4.4-23.5) compared with other practices (i.e. > 3 partners). Although the pharmacists reported that they had established a good rapport at 100 (72%) first visits and had agreed management plans for 110 (79%) of these visits, they were confident that the practice was likely to alter its prescribing in only 41% of these visits. Pharmacists' and GPs' satisfaction with the outreach visits did not necessarily lead to prescribing changes after the practice visit, and the GPs' knowledge of the guidelines promoted by the pharmacists did not necessarily translate into changes in clinical practice. The main barriers to the implementation of guidelines identified by the pharmacists at the follow-up visits were organisational difficulties, the GPs' scepticism of the evidence presented to them and the doctors' lack of interest in changing their prescribing behaviour. CONCLUSIONS: Although our study is limited by a post hoc rather than a pre hoc design, it provides a pragmatic approach to understanding the factors influencing the pathway of change in prescribing behaviour in response to academic outreach visits.",0,0,
753,Evaluation of a decision support system for pressure ulcer prevention and management: preliminary findings,"A decision support system for prevention and management of pressure ulcers was developed based on AHCPR guidelines and other sources. The system was implemented for 21 weeks on a 20-bed clinical care unit. Fifteen nurses on that unit volunteered as subjects of the intervention to see whether use of the system would have a positive effect on their knowledge about pressure ulcers and on their decision-making skills related to this topic. A similar care unit was used as a control. In addition, the system was evaluated by experts for its instructional adequacy, and by end users for their satisfaction with the system. Preliminary results show no effect on knowledge about pressure ulcers and no effect on clinical decision making skills. The system was rated positively for instructional adequacy, and positively for user satisfaction. User interviews related to satisfaction supplemented the quantitative findings. A discussion of the issues of conducting experiments like this in today's clinical environment is included.",0,1,
754,Evaluation of a dental public health program for old-age pensioners in Denmark,"A high priority is given to improvements in the oral health of the elderly in Scandinavia. In 1987 a Danish municipality established a dental public health care program for old-age pensioners. All 67-year-old citizens were offered school-based preventive and curative care using guidelines and principles established by the Danish Municipal Dental Service for children. Care was provided free of charge. Citizens not wishing to obtain care through the public system could do so from private dental practitioners. Reimbursement for care obtained from the private system was provided by the National Health Insurance and the municipality. The purpose of this study was to evaluate the outcome of the program after three years of operation. A follow-up design was used and data were collected by interviews and clinical registrations. At baseline and follow-up 216 (71%) and 235 (77%) pensioners, respectively, were interviewed about their self-assessments of dental health, dental knowledge, attitudes, and behavior. Clinical data were collected only for the elderly who participated in the public program, and included 194 persons at baseline and 187 at follow-up. These data included information on tooth loss, dental caries, periodontal health, and presence and function of removable dentures. At the follow-up, 86 percent of all respondents had regular dental visits of at least once a year compared to 46 percent at baseline"";"" 75 percent participated in the public program and 11 percent obtained care from private practitioners. At the end of the intervention period, fewer elderly reported symptoms of poor oral health or impaired function of dentures.(ABSTRACT TRUNCATED AT 250 WORDS)",0,0,
755,Evaluation of a diabetes specialist-guided primary care diabetes treatment program,"PURPOSE: An initial pilot program demonstrated promising results in improvements in glycosylated hemoglobin (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP) and prompted us to test these findings in a controlled trial. The purpose of the Diabetes-focused, Algorithm-directed care, Midlevel practitioner-administered, Electronically coached, Treatment (DAMET-2) program clinical trial was to investigate the benefits of a novel program for disseminating guidance in the treatment of diabetes from a central specialist clinic to primary care centers with access to midlevel provider services. DATA SOURCES: DAMET-2 included standardized treatment algorithms and education disseminated through computer-assisted and traditional methods associated with distance medicine. Two primary care practices were selected and subjects with diagnosed type 2 diabetes > or =6 months, > or =18 years of age with one or more cardiovascular risk factors (identified by chart review) were eligible for inclusion. Midlevel practitioners for subjects in the experimental group (N = 34) received training in American Diabetes Association treatment algorithms, had telephone consultations at 2- to 4-week intervals and bimonthly visits with diabetes specialists, and received treatment guidance within 24 h from remote diabetes specialists. Weekly diabetes clinics were made available to subjects in the experimental group. After 12 months, the last available subject data were extracted from the subjects' charts and compared to 12-month chart data from a control group (N = 101) that did not receive additional study services. CONCLUSIONS: Mean HbA(1c) values decreased from baseline by 0.46% in the active treatment group versus 0.06% in the control group""; however, reductions in HbA(1c) did not achieve statistical significance potentially because of the small sample size of the experimental group. Mean SBP values were significantly reduced in both groups;"" however, LDL-C was only significantly reduced in the control group, where more aggressive use of statins may have had an effect. IMPLICATIONS FOR PRACTICE: Despite the inconsistencies in risk factor reduction from the pilot program, the DAMET-2 program provided insights regarding the importance of electronic records and provider notifications, patient adherence, prioritization of provider resources by risk factor level among patients, and access to self-management education.",0,0,
756,Evaluation of a knowledge transfer scheme to improve policy making and practices in health promotion and disease prevention setting in French regions: a realist study protocol,"Background Evidence-based decision-making and practice are pivotal in public health. However, barriers do persist and they relate to evidence properties, organisations and contexts. To address these major knowledge transfer (KT) issues, we need to rethink how knowledge is produced and used, to enhance our understanding of decision-making processes, logics and mechanisms and to examine the ability of public health services to integrate research findings into their decisions and operations. This article presents a realist evaluation protocol to assess a KT scheme in prevention policy and practice at local level in France.  Methods/design This study is a comparative multiple case study, using a realist approach, to assess a KT scheme in regional health agencies (ARS) and regional non-profit organisations for health education and promotion (IREPS), by analysing the configurations contexts/mechanisms/outcomes of it. The KT scheme assessed is designed for the use of six reviews of systematic reviews concerning the following themes: nutrition, alcohol, tobacco smoking, physical activity, emotional and sexual life and psychosocial skills. It combines the following activities: supporting the access to and the adaptation of scientific and usable evidences""; strengthening professionals’ skills to analyse, adopt and use the evidences in the course of their practices and their decision-making process;"" facilitating the use of evidence in the organisations and processes. RAMESE II reporting standards for realist evaluations was used.  Discussion The aims of this study are to experiment and characterise the factors related to the scheme’s ability to enable public health stakeholders to address the challenges of KT and to integrate scientific knowledge into policy and practice. We will use the realist approach in order to document the parameters of successful KT strategies in the specific contexts of preventive health services in France, while seeking to determine the transferability of such strategies.",0,0,
757,Evaluation of a novel individualised communication-skills training intervention to improve doctors' confidence and skills in end-of-life communication,"BACKGROUND: We developed a novel individualised training program regarding end-of-life communication, designed to be time effective for busy junior-doctors working in hospital settings. AIM: We aimed to pilot this brief individualised training program with junior-doctors to explore its acceptability, feasibility and effect on the doctors' confidence, communication skills, attitudes towards psychosocial care and burnout. DESIGN: The content of the training intervention was informed by a systematic literature review and evidence-based clinical practice guidelines regarding end-of-life communication. The intervention was based on sound educational principles and involved three one-hour teaching sessions over a three-week period, including two individual sessions with an expert facilitator and simulated patient/caregiver. In addition, participants received written and audiovisual take-home learning materials. PARTICIPANTS were videotaped consulting with a simulated patient/caregiver pre/post training to assess the impact of the course on their communication behaviours. PARTICIPANTS completed de-identified questionnaires pre/post training, including self-assessed confidence, attitudes to psychosocial care, and the Maslach Burnout inventory. PARTICIPANTS: PARTICIPANTS included 22 junior-doctors from a large teaching hospital in Sydney, Australia. RESULTS: All participants reported that the training was useful, had been helpful for their communication with patients and that they would recommend the training to others. Significant improvements were found in participants' communication skills (in seven out of 21 specific and all three global communication behaviours assessed, range P=0.02 to <0.001), confidence in communicating about relevant topics (P<0.001), attitudes towards psychosocial care (P=0.03) and sense of personal accomplishment (P=0.043). There were no overall differences in participants' burnout levels. CONCLUSION: This intervention shows promise and warrants further formal evaluation.",0,0,
758,Evaluation of a physician-focused educational intervention on medicaid children with asthma,"BACKGROUND: The 1990 Omnibus Budget Reconciliation Act mandated drug utilization review in response to inappropriate drug use. In the Pennsylvania Medicaid program, pediatric asthma is associated with high healthcare utilization and cost. OBJECTIVE: To determine the effects of a physician-focused educational intervention on asthma drug use and healthcare utilization. METHODS: Pre- and postintervention comparison design was used in children 5-18 years of age who were enrolled in the Pennsylvania Medicaid fee-for-service program from July 1, 1998, to March 31, 1999 (preintervention), and July 1, 1999, to March 31, 2000 (postintervention). The intervention packet included patients' drug profiles, medical history, monograph with national asthma management guidelines, and patient education materials to physicians. Main outcome measures are changes in asthma drug utilization among high-users of short-acting beta(2)-agonists (SAB). RESULTS: The intervention focused on 2 asthma drug use criteria: (1) high-use of quick-relief medication and (2) use of salmeterol without the availability of a quick-relief medication. The intervention reduced quick-relief medication use by 26% among patients with higher use without significant changes in long-term control drugs. In addition, 82% of the recipients evaluated had a positive change in salmeterol utilization as either having an SAB inhaler added after the intervention or salmeterol discontinued after the intervention. There was no significant change in asthma-related emergency department visits or hospitalizations. CONCLUSIONS: Although the physician responders agreed on the usefulness of the educational materials, the results suggest that the intervention had limited success in improving the pharmacologic management and no effect on the health outcomes. We believe that mailed educational materials to physicians can be effective to change prescribing behavior"";"" however, a more multifaceted intervention may be necessary to improve health outcomes.",0,0,
759,Evaluation of a tailored intervention to improve management of overweight and obesity in primary care: study protocol of a cluster randomised controlled trial,"BACKGROUND: In the UK around 22% of men and 24% of women are obese, and there are varying but worrying levels in other European countries. Obesity is a chronic condition that carries an important health risk. National guidelines, for use in England, on the management of people who are overweight or obese have been published by the National Institute for Health and Clinical Excellence (NICE, 2006). NICE recommendations for primary care teams are: determine the degree of overweight and obesity""; assess lifestyle, comorbidities and willingness to change; offer multicomponent management of overweight and obesity; referral to external services when appropriate. This study investigates a tailored intervention to improve the implementation of these recommendations by primary care teams. METHODS/DESIGN: The study is a cluster randomised controlled trial. Primary care teams will be recruited from the East Midlands of England, and randomised into two study arms: 1) the study group, in which primary care teams are offered a set of tailored interventions to help implement the NICE guidelines for overweight and obesity;"" or 2) the control group in which primary care teams continue to practice usual care. The primary outcome is the proportion of overweight or obese patients for whom the primary care team adheres to the NICE guidelines. Secondary outcomes include the proportion of patients with a record of lifestyle assessment, referral to external weight loss services, the proportion of obese patients who lose weight during the intervention period, and the mean weight change over the same period. DISCUSSION: Although often recommended, the methods of tailoring implementation interventions to account for the determinants of practice are not well developed. This study is part of a programme of studies seeking to develop the methods of tailored implementation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07457585. Registered 09/08/2013. Randomisation commenced 30/08/2013.",0,0,
760,Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial,"BACKGROUND: The gap between the level of care recommended by evidence-based clinical practice guidelines and the actual care delivered to patients in practice has been well established. The Canadian Diabetes Association (CDA) created an implementation strategy to improve the implementation of its 2008 guidelines. This study will evaluate the impact of the strategy to improve cardiovascular disease (CVD) screening, prevention and treatment for people with diabetes. DESIGN: A pragmatic cluster-randomized trial will be conducted to evaluate the CDA's CVD Toolkit. All family physicians in Ontario, Canada were randomly allocated to receive the Toolkit, which includes several printed educational materials targeting CVD screening, prevention and treatment, either in spring 2009 (intervention arm) or in spring 2010 (control arm). Randomization occurred at the level of the practice. Forty family physicians from each arm will be recruited to participate, and the medical records for 20 of their diabetic patients at high risk for CVD will be retrospectively reviewed. Outcome measures will be assessed for each patient between July 2009 and March 2010. The primary outcome will be that the patient is receiving a statin. Secondary outcomes will include 1) the receipt of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 2) various intermediate measures (A1c, blood pressure, LDL-cholesterol, total-/HDL-cholesterol ratio, body mass index and waist circumference), and 3) clinical inertia (the failure to change therapy in response to an abnormal A1c, blood pressure or cholesterol reading). The analysis will be carried out using multilevel hierarchical logistic regression models to account for the clustered nature of the data. The group assignment will be a physician-level variable. In addition, a process evaluation study with six focus groups of family physicians will assess the acceptability of the CDA's Toolkit and will explore factors contributing to any change or lack of change in behaviour, from the perspectives of family physicians. DISCUSSION: Printed educational materials for physicians have been shown to exert small-to-moderate changes in patient care. The CDA's CVD Toolkit is an example of a practice guideline implementation strategy that can be disseminated to a wide audience relatively inexpensively, and so demonstrating its effectiveness at improving diabetes care could have important consequences for guideline developers, policy makers and clinicians.",0,0,
761,Evaluation of Abnormal Mammography Results and Palpable Breast Abnormalities,"Background:Because approximately 1 in 10 women with a breast lump or abnormal mammography result will have breast cancer, a series of decisions must be taken by a primary care practitioner to exclude or establish a diagnosis of breast cancer among these women.Purpose:To determine the most accurate and least invasive means to evaluate an abnormal mammography result and a palpable breast abnormality.Data Source:MEDLINE search (January 1966 to March 2003) for articles and reviews describing the accuracy of clinical examination, biopsy procedures, and radiographic examination for patients with abnormal mammography results or palpable breast abnormalities.Study Selection:The authors reviewed abstracts and selected articles that provided relevant primary data. Studies were included if 1) mammography, fine-needle aspiration biopsy, or core-needle biopsy was performed before a definitive diagnosis was obtained""; 2) the study sample included 100 or more women;"" and 3) breast cancer status was determined from histopathology review of excisional biopsy specimens, from linkage with a state cancer registry or the Surveillance, Epidemiology, and End Results program, or from clinical follow-up of 95% or more of the study sample.Data Extraction:One investigator abstracted results. Methods were evaluated for major potential biases, but methodologic scoring was not performed.Data Synthesis:Likelihood ratios for first screening mammography were 0.1 for the Breast Imaging Reporting and Data System (BI-RADS) assessment category negative or benign finding, 1.2 for probably benign finding, 7 for need additional imaging evaluation, 125 for suspicious abnormality, and 2200 for highly suggestive of malignancy. For fine-needle aspiration biopsy of a palpable lump performed by formally trained physicians, the likelihood ratio was infinity for an assessment of malignant, 2.6 for atypical/suspicious, and 0.02 for benign. When diagnostic mammography was used to evaluate a palpable lump or nonpalpable breast abnormality, the positive likelihood ratios were 5.6 and 9.4, and the negative likelihood ratios were 0.15 and 0.19, respectively.Conclusions:Women whose screening mammography results are interpreted as suspicious abnormality or highly suggestive of malignancy have a high risk for breast cancer and should undergo core-needle biopsy or needle localization with surgical biopsy. Women whose screening mammography results are interpreted as need additional imaging evaluation have a moderate risk for breast cancer and should undergo diagnostic mammography or ultrasonography to decide whether a nonpalpable breast lesion should be biopsied. Women whose screening mammography results are interpreted as probably benign finding have a low risk for breast cancer and can undergo follow-up mammography in 6 months. Either fine-needle aspiration biopsy or ultrasonography is recommended as the first diagnostic test of a palpable breast abnormality to distinguish simple cysts from solid masses. Fine-needle aspiration biopsy also allows characterization of a solid mass. Diagnostic mammography does not help determine whether a palpable breast mass should be biopsied and should not affect the decision to perform a biopsy.",0,0,
762,Evaluation of an informative leaflet on AIDS/HIV infection aimed at primary health care professionals in Catalonia,"OBJECTIVE: To assess primary care professionals' understanding and acceptance of a periodic information leaflet on HIV/AIDS. DESIGN: Crossover. SETTING: Primary care teams from the Institut Catala de la Salut. PARTICIPANTS: A random sample of 300 doctors, qualified nurses and social workers. INTERVENTION: A self-administered, anonymous questionnaire returned by normal post. MEASUREMENTS AND MAIN RESULTS: Questions covered the following thematic areas: clinical care of people infected by HIV/AIDS and requests for diagnostic tests for infection, perception of skills in the promotion of changes in patients' sexual behaviour and drug use, providing psychological support and guidelines for integrating HIV+ children in schools and information on social resources. 60% knew the publication. Thematic areas which aroused most interest were: psychological support for people affected, prevention of HIV infection in the health environment, clinical advice and diagnosis. 77% had received requests for diagnostic tests and 88% had attended infected people. CONCLUSIONS: In spite of the low reply rate (50%) and relative variability among the professionals and the health regions they came from, this first assessment enabled us to identify specific educational needs in the care and prevention of HIV/AIDS infection in the primary care framework and also to improve the distribution methods we used.",0,0,
763,Evaluation of an Internet-based decision-support system for applying the ATS/CDC guidelines for tuberculosis preventive therapy.,"Preventive therapy for patients infected with tuberculosis (TB) remains an important component of TB control. To guide physicians in applying preventive therapy, the American Thoracic Society and Centers for Disease Control (ATS/CDC) developed guidelines based on PPD reactivity and on pretest probability of infection. The guidelines have become complex, and many clinicians find them challenging to apply. The authors developed a computerized decision-support system to assist clinicians in applying the ATS/CDC guidelines. This tool, published on the World Wide Web using hypertext markup language, delivers patient-specific recommendations based on physician-delivered patient-specific information. Four local TB experts derived eight TB infection scenarios and validated the web-based tool, which was tested for effectiveness using general internal medicine residents, randomly divided into two groups. Group A (n = 12) used the web-based tool and group B (n = 17) used pre-existing understanding of the guidelines and/or written resources to determine the need for preventive therapy in the case scenarios. Group A correctly used therapy in 92/96 possible cases (95.8%), group B in only 77/136 (56.6%) (p < 0.001). Group A required a mean of three mouse-clicks and 1.5 minutes per scenario to reach their choices, and they rated the web-based tool both intuitive and effective. These data demonstrate that a computer-based decision-support system for applying TB treatment guidelines can be delivered over the Internet and provide an efficient and effective resource for clinicians.",0,1,
764,Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial.,"Objectives: To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk, blood pressure, and prescribing of cardiovascular drugs in hypertensive patients.  Design: Cluster randomised controlled trial.  Setting: 27 general practices in Avon.  Participants: 614 patients aged between 60 and 79 years with high blood pressure.  Interventions: Patients were randomised to computer based clinical decision support system plus cardiovascular risk chart""; cardiovascular risk chart alone;"" or usual care.  Main outcome measures: Percentage of patients in each group with a five year cardiovascular risk=10%, systolic blood pressure, diastolic blood pressure, prescribing of cardiovascular drugs.  Results: Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10% than patients receiving usual care. Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk=10% than chart only patients, odds ratio 2.3 (95% confidence interval 1.1 to 4.8). The chart only group had significantly lower systolic blood pressure compared with the usual care group (difference in means-4.6 mm Hg (95% confidence interval-8.4 to-0.8). Reduction of diastolic blood pressure did not differ between the three groups. The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups.  Conclusions: The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended. Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure.",1,1,
765,Evaluation of internet-based clinical decision support systems.,"Background: Scientifically based clinical guidelines have become increasingly used to educate physicians and improve quality of care. While individual guidelines are potentially useful, repeated studies have shown that guidelines are ineffective in changing physician behavior. The Internet has evolved as a potentially useful tool for guideline education, dissemination, and implementation because of its open standards and its ability to provide concise, relevant clinical information at the location and time of need.  Objective: Our objective was to develop and test decision support systems (DSS) based on clinical guidelines which could be delivered over the Internet for two disease models: asthma and tuberculosis (TB) preventive therapy.  Methods: Using open standards of HTML and CGI, we developed an acute asthma severity assessment DSS and a preventative tuberculosis treatment DSS based on content from national guidelines that are recognized as standards of care. Both DSS's are published on the Internet and operate through a decision algorithm developed from the parent guidelines with clinical information provided by the user at the point of clinical care. We tested the effectiveness of each DSS in influencing physician decisions using clinical scenario testing.  Results: We first validated the asthma algorithm by comparing asthma experts' decisions with the decisions reached by nonpulmonary nurses using the computerized DSS. Using the DSS, nurses scored the same as experts (89% vs. 88%""; p = NS). Using the same scenario test instrument, we next compared internal medicine residents using the DSS with residents using a printed version of the National Asthma Education Program-2 guidelines. Residents using the computerized DSS scored significantly better than residents using the paper-based guidelines (92% vs. 84%; p <0.002). We similarly compared residents using the computerized TB DSS to residents using a printed reference card; the residents using the computerized DSS scored significantly better (95.8% vs. 56.6% correct;"" p<0.001).  Conclusions: Previous work has shown that guidelines disseminated through traditional educational interventions have minimal impact on physician behavior. Although computerized DSS have been effective in altering physician behavior, many of these systems are not widely available. We have developed two clinical DSS's based on national guidelines and published them on the Internet. Both systems improved physician compliance with national guidelines when tested in clinical scenarios. By providing information that is coupled to relevant activity, we expect that these widely available DSS's will serve as effective educational tools to positively impact physician behavior.",0,1,
766,Evaluation of studies investigating the effectiveness of pharmacists' clinical services,"A quantitative evaluation of randomized trials of counseling, education, and other clinical services provided by pharmacists was performed. Data sources were MEDLINE and the bibliographies of published articles. Pharmacists' services were categorized as counseling of patients, counseling of physicians, counseling of both patients and physicians, and patient care. The outcomes extracted were measures of patient behavior, disease, symptoms, and patient knowledge. Thirty-two trials met the inclusion criteria. The pharmacists were specified as clinical pharmacists in 24 trials and as community pharmacists in 2. In six unblinded trials of patient counseling, the outcomes favored the counseled patients over control patients in every trial, and the effects were statistically significant in five trials (the outcome was medication adherence in these five trials). In seven trials of counseling of both patients and their physicians, patient outcomes were significantly better in the intervention group in six trials, four of which were single blind. Two trials in which patients were randomized to either physician counseling or control groups yielded inconsistent results. In one trial in which physicians were randomized to receive counseling from pharmacists, the proportion of prescriptions meeting guidelines was higher in the counseling group than in the control group. Four trials of patient care by pharmacists were inconclusive. These trials demonstrated that counseling of patients and their physicians by pharmacists can improve patient outcomes. The evidence that counseling of patients alone improved patient outcomes was good, though weaker because of suboptimal trial design.",0,0,
767,"Evaluation of Talking Parents, Healthy Teens, a new worksite based parenting programme to promote parent-adolescent communication about sexual health: randomised controlled trial","OBJECTIVE To evaluate a worksite based parenting programme-Talking Parents, Healthy Teens-designed to help parents learn to address sexual health with their adolescent children. DESIGN Randomised controlled trial (April 2002-December 2005). SETTING 13 worksites in southern California. PARTICIPANTS 569 parents completed baseline surveys at work, gave permission for confidential surveys to be posted to their adolescent children, and were randomised to intervention or control groups. Parents and adolescents completed follow-up surveys at one week, three months, and nine months after the programme. INTERVENTION Talking Parents, Healthy Teens consists of eight weekly one hour sessions at worksites for parents of adolescent children in 6th-10th grade (about ages 11-16 years). MAIN OUTCOME MEASURES Parent-adolescent communication about a list of sexual topics""; whether parent taught adolescent how to use a condom; ability to communicate with parent/adolescent about sex; openness of parent-adolescent communication about sex. RESULTS Differences between intervention and control groups were significant for the mean number of new sexual topics that parents and adolescents reported discussing between baseline and each follow-up (P<0.001 for each); intervention parents were less likely than controls to discuss no new topics (8% v 29%, 95% confidence interval for difference 16% to 24%) and more likely to discuss seven or more new topics (38% v 8%, 19% to 41%) at nine months. Some differences increased after completion of the programme: at one week after the programme, 18% of adolescents in the intervention group and 3% in the control group (6% to 30%) said that their parents had reviewed how to use a condom since baseline (P<0.001);"" this grew to 29% v 5% (13% to 36%) at nine months (P<0.001). Compared with controls at nine months, parents and adolescents in the intervention group reported greater ability to communicate with each other about sex (P<0.001) and more openness in communication about sex (P<0.001). CONCLUSIONS A worksite based programme can have substantial effects on communication between parents and adolescents about sexual health. TRIAL REGISTRATION Clinical Trials NCT00465010.",0,0,
768,Evaluation of two school smoking education programmes under normal classroom conditions,"OBJECTIVES To assess the effectiveness of two school based smoking education projects in delaying onset of smoking behaviour and in improving health knowledge, beliefs, and values. DESIGN Cluster randomised controlled trial of two projects taught under normal classroom conditions. Schools were allocated to one of four groups to receive the family smoking education project (FSE)""; the smoking and me project (SAM); both projects in sequence (FSE/SAM);"" or no intervention at all. SETTING 39 schools in Wales and England matched for size and catchment profile. SUBJECTS All first year pupils in the schools were included and were assessed on three occasions (4538 before teaching (1988), 3930 immediately after teaching (1989), 3786 at one year follow up (1990)). MAIN OUTCOME MEASURES Self reported smoking behaviour (backed by saliva sample) and change in relevant health knowledge, beliefs, and values. RESULTS No consistent significant differences in smoking behaviour, health knowledge, beliefs, or values were found between the four groups. For never smokers at baseline the rate of remaining never smokers in 1990 was 74% (594/804) in the control group, 65% (455/704) in the FSE group, 70% (440/625) in the SAM group, and 69% (549/791) in the FSE/SAM group (chi 2adj = 6.1, df = 3, p = 0.1). Knowledge about effects of smoking rose in all groups from a mean score of 5.4 in 1988 to 6.4 in 1989 and 6.5 in 1990. CONCLUSIONS More comprehensive interventions than school health education alone will be needed to reduce teenage smoking. Other measures including further restrictions on access to cigarettes and on the promotion of tobacco products need to be considered. Further research will be needed to develop effective school based health education projects, which should be formally field tested under normal conditions before widespread dissemination.",0,0,
769,Evidence-based behavioral medicine: what is it and how do we achieve it?,"The goal of evidence-based medicine is ultimately to improve patient outcomes and quality of care. Systematic reviews of the available published evidence are required to identify interventions that lead to improvements in behavior, health, and well-being. Authoritative literature reviews depend on the quality of published research and research reports. The Consolidated Standards for Reporting Trials (CONSORT) Statement (www.consort-statement.org) was developed to improve the design and reporting of interventions involving randomized clinical trials (RCTs) in medical journals. We describe the 22 CONSORT guidelines and explain their application to behavioral medicine research and to evidence-based practice. Additional behavioral medicine-specific guidelines (e.g., treatment adherence) are also presented. Use of these guidelines by clinicians, educators, policymakers, and researchers who design, report, and evaluate or review RCTs will strengthen the research itself and accelerate efforts to apply behavioral medicine research to improve the processes and outcomes of behavioral medicine practice.",0,0,
770,Evidence-based care of older people with suspected cognitive impairment in general practice: protocol for the IRIS cluster randomised trial,"BACKGROUND: Dementia is a common and complex condition. Evidence-based guidelines for the management of people with dementia in general practice exist"";"" however, detection, diagnosis and disclosure of dementia have been identified as potential evidence-practice gaps. Interventions to implement guidelines into practice have had varying success. The use of theory in designing implementation interventions has been limited, but is advocated because of its potential to yield more effective interventions and aid understanding of factors modifying the magnitude of intervention effects across trials. This protocol describes methods of a randomised trial that tests a theory-informed implementation intervention that, if effective, may provide benefits for patients with dementia and their carers. AIMS: This trial aims to estimate the effectiveness of a theory-informed intervention to increase GPs' (in Victoria, Australia) adherence to a clinical guideline for the detection, diagnosis, and management of dementia in general practice, compared with providing GPs with a printed copy of the guideline. Primary objectives include testing if the intervention is effective in increasing the percentage of patients with suspected cognitive impairment who receive care consistent with two key guideline recommendations: receipt of a i) formal cognitive assessment, and ii) depression assessment using a validated scale (primary outcomes for the trial). METHODS: The design is a parallel cluster randomised trial, with clusters being general practices. We aim to recruit 60 practices per group. Practices will be randomised to the intervention and control groups using restricted randomisation. Patients meeting the inclusion criteria, and GPs' detection and diagnosis behaviours directed toward these patients, will be identified and measured via an electronic search of the medical records nine months after the start of the intervention. Practitioners in the control group will receive a printed copy of the guideline. In addition to receipt of the printed guideline, practitioners in the intervention group will be invited to participate in an interactive, opinion leader-led, educational face-to-face workshop. The theory-informed intervention aims to address identified barriers to and enablers of implementation of recommendations. Researchers responsible for identifying the cohort of patients with suspected cognitive impairment, and their detection and diagnosis outcomes, will be blind to group allocation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12611001032943 (date registered 28 September, 2011).",0,0,
771,Evidence-based guidelines for teaching patient-centered interviewing,"In a rare study of effectiveness of an interviewing method, we previously reported a randomized controlled trial demonstrating that training in a step-by-step patient-centered interviewing method improved residents' knowledge, attitudes, and skills and had a consistently positive effect on trained residents' patients. For those who wish to use this evidence-based patient-centered method as a template for their own teaching, we describe here for the first time our training program--and propose that the training can be adapted for students, physicians, nurse practitioners, physician assistants, and other new learners as well. Training was skills-oriented and experiential, fostered positive attitudes towards patient-centered interviewing, and used a learner-centered approach which paid special attention to the teacher-resident relationship and to the resident's self-awareness. Skills training was guided by a newly identified patient-centered interviewing method that described the step-by-step use of specific behaviors.",0,0,
772,Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology,"The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.",0,0,
773,Evidence-based health care for children: what are we missing?,"With the enactment of comprehensive health reform, reimbursement for a variety of health care services will likely depend on evidence to support that provision. Understanding what constitutes ""evidence"" will have a profound effect on the range of clinical care provided. A too-narrow definition may have a considerable impact on pediatric care in particular: much of current child health care requires consideration of a broader body of evidence than is usually relied upon when developing clinical guidelines. This is especially true for care that addresses behavioral and developmental problems. The current standard for evaluating evidence uses study design as a proxy for the quality of evidence"";"" it may therefore inadvertently exclude many important findings and fail to support further relevant research. The project described here yielded a new, broader framework for evaluating clinical practice, one that should be of value to both clinicians and policymakers.",0,0,
774,Evidence-based medicine and headache patient management by general practitioners in Italy,"The study explores the awareness of technical terms used in evidence-based medicine (EBM) and manner of treating patients with migraine among a random sample of 500 general practitioners (GPs). A mailed questionnaire included questions on GPs' demographics and practice characteristics""; awareness of EBM; sources of information about migraine and EBM;"" and patient's treatment behaviour. Only 27.2% of GPs agreed that clinical trials are needed to evaluate the efficacy of treatments and this awareness was higher in those who learned about migraine from scientific journals or continuing education courses and who attended courses on EBM. For two-thirds of GPs, disability is equivalent to illness diagnosis, and this behaviour was more prevalent in those who agreed that clinical trials are needed to evaluate the efficacy of preventive or curative treatments of migraine and that the clinical approach to migraine required an evaluation of clinical effectiveness, in those who treated a lower number of headache patients, who were older, and in those who did not use guidelines. The majority (93.1%) of GPs indicated that it is important to integrate clinical practice and the best available evidence, and this behaviour was significantly more frequent in those who agreed that the clinical approach to migraine required a clinical effectiveness evaluation, that clinical trials are needed to evaluate the efficacy of preventive or curative treatments of migraine, and in those who attended courses on EBM. Training and continuing educational programmes on EBM and guidelines on treatments of headache for GPs are strongly needed.",0,0,
775,Evidence-based medicine and women: do the principles and practice of EBM further women's health?,"Clinicians and policy makers the world over are embracing evidence-based medicine (EBM). The promise of EBM is to use summaries of research evidence to determine which healthcare interventions are effective and which are not, so that patients may benefit from effective interventions and be protected from useless or harmful ones. EBM provides an ostensibly rational objective means of deciding whether or not an intervention should be provided on the basis of its effectiveness, in theory leading to fair and effective healthcare for all. In this paper I closely examine these claims from the perspective of healthcare for women, using relevant examples. I argue that the current processes of evidence-based medicine contain a number of biases against women. These biases occur in the production of research that informs evidence-based medicine, in the methods used to analyse and synthesise the evidence, and in the application of EBM through the use of guidelines. Finally, the biomedical model of health that underpins most of the medical research used by EBM ignores the social and political context which contributes so much to the ill-health of women.",0,0,
776,Evidence-based medicine. Interpreting studies and setting policy,"The ascendancy of EBM has been accompanied by a greater awareness of its shortcomings. It is increasingly evident from the cost, length, and difficulty of performing RCTs that studies cannot be launched to address every question in medicine. Good evidence is often lacking in medicine. Epistomologists question the very notions of evidence and the suitability of current study designs and measurement tools to research the salient issues of concern to patients and others concerned with quality. Lack of evidence of effectiveness does not prove ineffectiveness, yet, in reaction to EBM, insurance companies and government often make this inference to justify decisions to withhold coverage or research support. The unbridled enthusiasm for the evidence-based practice guideline of the early 1990s has been tempered by a more mature understanding of its limitations. Not many practice guidelines are developed well, and the implementation of flawed guidelines can cause harm. The seven-step process outlined earlier is slow, laborious, and expensive (sometimes costing hundreds of thousands of dollars). Moreover, there is little evidence that either the rigor of the methods or the guidelines themselves have a meaningful effect on practice behavior or patient outcomes. To the most cynical observers, the only consistent beneficiaries of guidelines are payers, who use guidelines with considerable success in reducing costs, lengths of stay, and utilization rates. Even ardent advocates of guidelines acknowledge the evidence that disseminating reviews and recommendations, by itself, fails to motivate clinicians to increase delivery of effective interventions and to abandon ineffective ones. This absence of response has stimulated a closer look at the barriers to behavior change and the design of thoughtful implementation strategies that begin with, but reach beyond, simple guidelines. Tools such as reminder systems, standing orders, academic detailing, peer review and audit, feedback, and health system changes recognize that knowing what to do is only one piece of an increasingly complex puzzle. The competitive marketplace of managed health care has added new economic influences on clinician behavior but is also fueling private-sector interest in good research. Patients, clinicians, and policy makers will continue to seek better data concerning what works in medicine and what does not.",0,0,
777,Examination of the analytic quality of behavioral health randomized clinical trials,"Adoption of evidence-based practice (EBP) policy has implications for clinicians and researchers alike. In fields that have already adopted EBP, evidence-based practice guidelines derive from systematic reviews of research evidence. Ultimately, such guidelines serve as tools used by practitioners. Systematic reviews of treatment efficacy and effectiveness reserve their strongest endorsements for treatments that are supported by high-quality randomized clinical trials (RCTs). It is unknown how well RCTs reported in behavioral science journals fare compared to quality standards set forth in fields that pioneered the evidence-based movement. We compared analytic quality features of all behavioral health RCTs (n = 73) published in three leading behavioral journals and two leading medical journals between January 2000 and July 2003. A behavioral health trial was operationalized as one employing a behavioral treatment modality to prevent or treat an acute or chronic physical disease or condition. Findings revealed areas of weakness in analytic aspects of the behavioral health RCTs reported in both sets of journals. Weaknesses were more pronounced in behavioral journals. The authors offer recommendations for improving the analytic quality of behavioral health RCTs to ensure that evidence about behavioral treatments is highly weighted in systematic reviews.",0,0,
778,Examining clinical judgment in an adaptive intervention design: The fast track program,"Although clinical judgment is often used in assessment and treatment planning, rarely has research examined its reliability, validity, or impact in practice settings. This study tailored the frequency of home visits in a prevention program for aggressive- disruptive children (n = 410"";"" 56% minority) on the basis of 2 kinds of clinical judgment: ratings of parental functioning using a standardized multi-item scale and global assessments of family need for services. Stronger reliability and better concurrent and predictive validity emerged for the 1st kind of clinical judgment than for the 2nd. Exploratory analyses suggested that using ratings of parental functioning to tailor treatment recommendations improved the impact of the intervention by the end of 3rd grade but using more global assessments of family need did not.",0,0,
779,Exceptional deliveries: home births as ethical anomalies in American obstetrics,"Interest in home birth appears to be growing among American women, and most obstetricians can expect to encounter patients who are considering home birth. In 2011, the American College of Obstetricians and Gynecologists (ACOG) issued an opinion statement intended to guide obstetricians in responding to such patients. In this article, I examine the ACOG statement in light of the historical and contemporary clinical realities surrounding home birth in the United States, an examination guided in part by my own experiences as an obstetrician in home-birth-friendly and home-birth-unfriendly medical milieus. Comparison with other guidelines indicates that ACOG treats home birth as an ethical exception: comparable evidence leads to strikingly different recommendations in the case of home birth and the case of trial of labor following a prior cesarean"";"" and ACOG treats other controversial issues that involve similar ethical questions quite differently. By casting the provision of information as not just the primary but the sole ethical responsibility of the obstetrician, ACOG statement obviates obstetricians' responsibilities to provide appropriate clinical care and to make the safest possible clinical environment for those mothers who choose home birth and for their newborns. What, on its face, seems to be a statement of respect for women's autonomy, implicitly authorizes behaviors that unethically restrain truly autonomous choices. Obstetricians need not attend home births, I argue. Our ethical duties do, however, oblige us (1) to refer clients to skilled clinicians who will attend home birth, (2) to continue respectful antenatal care for those women choosing home birth, (3) to provide appropriate consultation to home birth attendants, and (4) to ensure that transfers of care are smooth and nonpunitive.",0,0,
780,"Exercise referral: the public health panacea for physical activity promotion? A critical perspective of exercise referral schemes"";"" their development and evaluation","This review critically explores the development, impact and evaluation of exercise referral schemes (ERS) in the UK. A rapid expansion in the use of such ERSs has been recorded throughout leisure and primary care settings, but the evidence underpinning their implementation has been sparse and predominantly limited to randomized control trial (RCT) research design. Consequently, understanding of exercise referral as a 'real world' intervention has been limited. Considering the increasing importance being placed on evidence-based practice and clinical effectiveness, it is no longer sufficient for service providers of exercise referral to ignore the need to evaluate schemes. The guidelines on evaluation provided by the National Quality Assurance Framework for Exercise Referral are limited, hence practitioners are often unsure of the best measures to use when assessing effectiveness. Predominantly, exercise professionals focus on the collection of physiological data but tend to ignore relevant psychological and environmental parameters. Also, few UK studies have followed participants up in the long term, to see if physical activity behaviour is sustained over time. Here, evidence from two on-going, large-scale (n = 1600/annum) evaluation studies of exercise referral schemes, based in urban localities in the northwest of England, are described. A participatory action research framework for evaluation was utilized and incorporated multi-method research approaches for the assessment of both ERS participants and health professionals involved in intervention delivery. This framework is an appropriate methodology for the evaluation and development of complex interventions, and here incorporates case study, focus groups, interviews and survey questionnaires. Included was a 12-month tracking study of a cohort of exercise referral participants (n = 342), which measured leisure-time physical activity levels (Godin leisure time score), at baseline (entry to exercise referral) and at 3 monthly intervals thereafter. Adherence to the ERS was approximately 35-45%, with the older participants more likely to complete. Physiological changes during the ERS, although statistically significant, were not of a magnitude to convey any real health benefit to an individual's health status. Although small in scale, physiological changes were all in a positive direction (e.g. reduction in blood pressure) and, if maintained over time, could bring about population-level benefits in health. Participants referred from cardiac and practice nurses had higher levels of adherence than participants referred by general practitioners. Scheme B showed that the participants who adhered (n = 103) until the end of the ERS (12 weeks) were able to sustain a small increase in physical activity at the end of 12 months (increase of 21 min moderate activity/week compared with baseline). In conclusion, this research shows that the process of exercise referral benefits certain segments of the population, but not necessarily all.",0,0,
781,"Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs","Background: An extensive literature supports expanded HIV screening in the United States. However, the question of whom to test and how frequently remains controversial. Objective: To inform the design of HIV screening programs by identifying combinations of screening frequency and HIV prevalence and incidence at which screening is cost-effective. Design: Cost-effectiveness analysis linking simulation models of HIV screening to published reports of HIV transmission risk, with and without antiretroviral therapy. Data Sources: Published randomized trials, observational cohorts, national cost and service utilization surveys, the Red Book, and previous modeling results. Target Population: U.S. communities with low to moderate HIV prevalence (0.05% to 1.0%) and annual incidence (0.0084% to 0.12%). Time Horizon: Lifetime. Perspective: Societal. Interventions: One-time and increasingly frequent voluntary HIV screening of all adults using a same-day rapid test. Outcome Measures: HIV infections detected, secondary transmissions averted, quality-adjusted survival, lifetime medical costs, and societal cost-effectiveness, reported in discounted 2004 dollars per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: Under moderately favorable assumptions regarding the effect of HIV patient care on secondary transmission, routine HIV screening in a population with HIV prevalence of 1.0% and annual incidence of 0.12% had incremental cost-effectiveness ratios of $30 800/QALY (one-time screening), $32 300/QALY (screening every 5 years), and $55 500/QALY (screening every 3 years). In settings with HIV prevalence of 0.10% and annual incidence of 0.014%, one-time screening produced cost-effectiveness ratios of $60 700/QALY. Results of Sensitivity Analysis: The cost-effectiveness of screening policies varied within a narrow range as assumptions about the effect of screening on secondary transmission varied from favorable to unfavorable. Assuming moderately favorable effects of antiretroviral therapy on transmission, cost-effectiveness ratios remained below $50 000/QALY in settings with HIV prevalence as low as 0.20% for routine HIV screening on a one-time basis and at prevalences as low as 0.45% and annual incidences as low as 0.0075% for screening every 5 years. Limitations: This analysis does not address the difficulty of determining the prevalence and incidence of undetected HIV infection in a given patient population. Conclusions: Routine, rapid HIV testing is recommended for all adults except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.2%.",0,0,
782,Expanding the Use of Continuous Sedation Until Death: Moving Beyond the Last Resort for the Terminally Ill,"As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a ""last resort,"" and a position statement from the American Academy of Hospice and Palliative Medicine describe it as ""an intervention reserved for extreme situations."" Accordingly, patients must progress to unremitting pain and suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of ""last resort.""",0,0,
783,Experience-based design: from redesigning the system around the patient to co-designing services with the patient,"Involving patients in service improvement and listening and responding to what they say has played a key part in the redesign of healthcare processes over the past five years and more. Patients and users have attended stakeholder events, participated in discovery interviews, completed surveys, mapped healthcare processes and even designed new hospitals with healthcare staff. However, to date efforts have not necessarily focused on the patient’s experience, beyond asking what was good and what was not. Questions were not asked to find out details of what the experience was or should be like (“experience” being different from “attitudes”) and the information then systematically used to co-design services with patients. Knowledge of the experience, held only by the patient, is unique and precious. In this paper, attention is drawn to the burgeoning discipline of the design sciences and experience-based design, in which the traditional view of the user as a passive recipient of a product or service has begun to give way to the new view of users as integral to the improvement and innovation process.",0,0,
784,Expert Panel vs Decision-Analysis Recommendations for Postdischarge Coronary Angiography After Myocardial Infarction,"Context Expert panels and decision-analytic techniques are increasingly used to determine the appropriateness of medical interventions, but these 2 approaches use different methods to process evidence.  Objective To compare expert panel appropriateness ratings of coronary angiography after myocardial infarction (from the time of hospital discharge to 12 weeks after infarction) with the health gains and cost-effectiveness predicted by a decision-analytic model.  Design Comparison of the degree of importance of the clinical variables considered in expert panel appropriateness ratings vs a previously published decision-analytic model. Identification of 36 clinical scenarios from the expert panel that could be simulated by the decision-analytic model.  Main Outcome Measures Appropriateness score and appropriateness classification (expert panel) vs gain in quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (decision-analytic model).  Results The most important clinical variables were similar in the 2 approaches, with the exercise tolerance test result exerting the greatest leverage on strength of recommendation for angiography. Among the expert panel clinical scenarios considered to be appropriate for coronary angiography that could be simulated in the decision-analysis model, the median (interquartile range) health gain and incremental cost-effectiveness ratio were 0.59 (0.41-0.76) QALYs and $27,000 ($23,000-$35,000) per QALY gained, respectively. Among the clinical scenarios that expert panels considered inappropriate, the corresponding medians (interquartile ranges) were 0.24 (0.19-0.34) QALYs and $54,000 ($36,000-$58,000) per QALY gained. The Spearman rank correlation between appropriateness score and QALY gain was 0.58 (P<.001) and between appropriateness score and estimated incremental cost-effectiveness ratios was ?0.66 (P<.001).  Conclusions For the 36 expert panel scenarios that could be simulated by the decision-analytic model, there was moderate to good agreement between the appropriateness score and both the health gain and the incremental cost-effectiveness ratio of coronary angiography compared with no angiography in the convalescent phase of acute myocardial infarction, but several scenarios judged as inappropriate by the expert panel approach had cost-effectiveness ratios comparable with many generally recommended medical interventions. Formal synthesis of expert judgment and decision modeling is warranted in future efforts at guideline development.",0,0,
785,Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial,"BACKGROUND: There is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the 'black box' of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses' hand hygiene compliance. METHODS: A process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities"";"" another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses' hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses' experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses' hand hygiene compliance and thereby better understand trial effects. RESULTS: Both strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses' hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components 'social influence' (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and 'leadership' (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses' hand hygiene compliance. CONCLUSION: This study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects. TRIAL REGISTRATION: The study is registered in ClinicalTrials.gov, dossier number: NCT00548015.",0,1,
786,Explaining variation in GP referral rates for x-rays for back pain,"BACKGROUND: Despite the availability of clinical guidelines for the management of low back pain (LBP), there continues to be wide variation in general practitioners' (GPs') referral rates for lumbar spine x-ray (LSX). This study aims to explain variation in GPs' referral rates for LSX from their accounts of the management of patients with low back pain. METHODS: Qualitative, semi-structured interviews with 29 GPs with high and low referral rates for LSX in North East England. Thematic analysis used constant comparative techniques. RESULTS: Common and divergent themes were identified among high- and low-users of LSX. Themes that were similar in both groups included an awareness of current guidelines for the use of LSX for patients with LBP and the pressure from patients and institutional factors to order a LSX. Differentiating themes for the high-user group included: a belief that LSX provides reassurance to patients that can outweigh risks, pessimism about the management options for LBP, and a belief that denying LSX would adversely affect doctor-patient relationships. Two specific differentiating themes are considered in more depth: GPs' awareness of their use of lumbar spine radiology relative to others, and the perceived risks associated with LSX radiation. CONCLUSION: Several key factors differentiate the accounts of GPs who have high and low rates of referral for LSX, even though they are aware of clinical guideline recommendations. Intervention studies that aim to increase adherence to guideline recommendations on the use of LSX by changing the ordering behaviour of practitioners in primary care should focus on these factors.",0,0,
787,Explaining variations in prescribing costs across England,"OBJECTIVE To derive a predictive model for national prescribing behaviour in terms of basic morbidity and demographic factors. DESIGN 24 demographic, morbidity, and practice factors were entered into a multiple regression analysis to determine the net ingredient cost per patient. SETTING The 90 family health service authorities in England for 1989. RESULTS For net ingredient cost per patient only two demographic factors (numbers of pensioners and the mobility of the registered population measured by list inflation) and two morbidity related factors (standardised mortality ratios and numbers of prepayment certificates issued) significantly contributed to a multiple regression model. This model explained 81% of the variation in net ingredient cost per registered patient between family health services authorities. The model also enabled a weighting factor of 4.6 (95% confidence interval 3.2 to 6.7) to be derived for the net ingredient cost for elderly patients (compared with the existing prescribing unit factor of 3). CONCLUSIONS The model shows that variations in prescribing costs essentially reflect demand. It also suggests that the current prescribing unit value of 3 for patients aged 65 or more underestimates the extra costs of prescribing for elderly patients.",0,0,
788,Exploratory analysis of patients' motivations to quit smoking and participate in smoking cessation classes,"BACKGROUND AND OBJECTIVES: Significant research has evaluated the impacts of smoking, the impacts of exposure to secondhand smoke, the effectiveness of a variety of social and individual interventions for smoking cessation, and the frequency at which physicians discuss smoking cessation with their patients. Little research has addressed barriers to physician-initiated discussion and intervention related to smoking cessation, especially pertaining to resident physicians treating low-income patients. The existing research indicates that physicians have low expectations regarding patients' desires to quit smoking and often wait to discuss smoking cessation with patients until the patient broaches the subject. The purpose of this pilot was to identify trends in smoking, desire for smoking cessation, and desire to participate in smoking cessation classes at the family practice clinic. METHODS: Patients completed a survey eliciting demographic information, smoking behavior, presence of chronic illness, desire to quit smoking, and reasons for wanting to quit smoking. RESULTS: Higher rates of smoking and lower rates of desired cessation were identified. However, among patients contemplating smoking cessation, a relatively high number desired cessation classes. Higher numbers of failed quit attempts were predictive of increases odds of both wanting to quit and desire for cessation classes. Other predictors of cessation desire and class participation are discussed. CONCLUSIONS: Based on the current research, physicians are encouraged to follow practice guidelines, asking all patients about smoking behavior and assisting in their efforts to quit, especially those who have previously been unsuccessful in the past.",0,0,
789,Exploring nurses' and patients' perspectives of limit setting in a forensic mental health setting,"Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals""; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced);"" and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting.",0,0,
790,Exploring the feasibility of Conjoint Analysis as a tool for prioritizing innovations for implementation,"Background In an era of scarce and competing priorities for implementation, choosing what to implement is a key decision point for many behavioural change projects. The values and attitudes of the professionals and managers involved inevitably impact the priority attached to decision options. Reliably capturing such values is challenging.  Methods This paper presents an approach for capturing and incorporating professional values into the prioritization of healthcare innovations being considered for adoption. Conjoint Analysis (CA) was used in a single UK Primary Care Trust to measure the priorities of healthcare professionals working with women with postnatal depression. Rating-based CA data was gathered using a questionnaire and then mapped onto 12 interventions being considered as a means of improving the management of postnatal depression.  Results The ¡®impact on patient care¡¯ and the ¡®quality of supporting evidence¡¯ associated with the potential innovations were the most influential in shaping priorities. Professionals were least influenced by whether an innovation was an existing national or local priority, or whether current practice in the Trust was meeting minimum standards. Ranking the 12 innovations by the preferences of potential adopters revealed ¡®guided self help¡¯ was the top priority for implementation and ¡®screening questions for post natal depression¡¯ the least. When other factors were considered (such as the presence of routine data or planned implementation activity elsewhere in the Trust), the project team chose to combine the eight related treatments and implement these as a single innovation referred to as ¡®psychological therapies¡¯.  Conclusions Using Conjoint Analysis to prioritise potential innovation implementation options is a feasible means of capturing the utility of stakeholders and thus increasing the chances of an innovation being adopted. There are some practical barriers to overcome such as increasing response rates to conjoint surveys before routine and unevaluated use of this technique should be considered.",0,1,
791,Exploring the gap between knowledge and behavior: a qualitative study of clinician action following an educational intervention,"PURPOSE: Many medical education interventions improve clinicians' knowledge but fail to change behavior. The authors exposed this knowledge-behavior gap through standardized clinical interactions, thus allowing in-depth exploration of the contributing factors. METHOD: A typical evidence-based educational intervention in one clinical domain (early signs of autism) was administered to family medicine residents at the University of Toronto in 2001-02, and change in knowledge was assessed through a multiple-choice test. Six to eight weeks later, participants' relevant knowledge was documented, and their clinical behavior was observed during four interactions with standardized patients. Factors producing a knowledge-behavior discrepancy were then explored using semistructured interviews, which were audiotaped, transcribed, and analyzed using grounded theory methods. RESULTS: Half of participants demonstrated varying degrees of knowledge-behavior gap. Eight main rationalizations (relationships, patient agenda, knowledge deficit, clinical style, means to an end, ideals, autism stigma, and systems barriers) were used to justify choices of clinical behavior, and the same rationalizations were used to justify opposite choices of behavior. Two conditions that promote clinical action based on knowledge (level of certainty and sense of urgency) were identified. CONCLUSION: The knowledge-behavior gap was exposed and factors reported to influence clinicians' decisions about whether to implement new knowledge were elicited. That identical rationalizations were used to justify opposite behaviors implies these factors may not be behavioral determinants. Sense of urgency and level of certainty promote clinical action based on knowledge"";"" focusing on these may increase the impact of education on practice.",0,0,
792,Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study,"Objective Hospital electronic prescribing (ePrescribing) systems offer a wide range of patient safety benefits. Like other hospital health information technology interventions, however, they may also introduce new areas of risk. Despite recent advances in identifying these risks, the development and use of ePrescribing systems is still leading to numerous unintended consequences, which may undermine improvement and threaten patient safety. These negative consequences need to be analysed in the design, implementation and use of these systems. We therefore aimed to understand the roots of these reported threats and identify candidate avoidance/mitigation strategies.  Methods We analysed a longitudinal, qualitative study of the implementation and adoption of ePrescribing systems in six English hospitals, each being conceptualised as a case study. Data included semistructured interviews, observations of implementation meetings and system use, and a collection of relevant documents. We analysed data first within and then across the case studies.  Results Our dataset included 214 interviews, 24 observations and 18 documents. We developed a taxonomy of factors underlying unintended safety threats in: (1) suboptimal system design, including lack of support for complex medication administration regimens, lack of effective integration between different systems, and lack of effective automated decision support tools""; (2) inappropriate use of systems—in particular, too much reliance on the system and introduction of workarounds;"" and (3) suboptimal implementation strategies resulting from partial roll-outs/dual systems and lack of appropriate training. We have identified a number of system and organisational strategies that could potentially avoid or reduce these risks.  Conclusions Imperfections in the design, implementation and use of ePrescribing systems can give rise to unintended consequences, including safety threats. Hospitals and suppliers need to implement short- and long-term strategies in terms of the technology and organisation to minimise the unintended safety risks.",0,0,
793,"External validity of randomised controlled trials: ""to whom do the results of this trial apply?""","In making treatment decisions, doctors and patients must take into account relevant randomised controlled trials (RCTs) and systematic reviews. Relevance depends on external validity (or generalisability)--ie, whether the results can be reasonably applied to a definable group of patients in a particular clinical setting in routine practice. There is concern among clinicians that external validity is often poor, particularly for some pharmaceutical industry trials, a perception that has led to underuse of treatments that are effective. Yet researchers, funding agencies, ethics committees, the pharmaceutical industry, medical journals, and governmental regulators alike all neglect external validity, leaving clinicians to make judgments. However, reporting of the determinants of external validity in trial publications and systematic reviews is usually inadequate. This review discusses those determinants, presents a checklist for clinicians, and makes recommendations for greater consideration of external validity in the design and reporting of RCTs.",0,0,
794,Facilitating patients' diabetes self-management: a primary care intervention framework,A quality primary care framework for diabetes self-management (DSM) is presented on the basis of prevalent office setting changes. Recent DSM research and literature are reviewed concerning (a) patients' DSM perceptions and office visit experiences and (b) more effective office-based DSM programs. This quality primary care framework enables nurse clinicians to more consistently assess and integrate individual patient factors using typically limited clinic resources into office visits to optimize DSM patient outcomes.,0,0,
795,Factorial Surveys: Using Vignettes to Study Professional Judgement.,"Decision making is becoming an increasingly central feature of social work practice, yet there is limited research on the topic. Experimental methods of investigating decision making tend to be constrained by practical and ethical difficulties, whilst questions about validity and generalizability surround ethnographic and other descriptive methods. It is argued here that the factorial survey addresses these methodological difficulties as a research design to study the way that professionals make decisions in real life. In this research design, true-to-life vignettes (case scenarios or paper cases) are presented to social workers or other staff to make a judgement about a familiar type of scenario. The randomized factors within the vignettes, combined with the randomization of the selection of vignettes for each decision maker, give the factorial survey a unique capability to investigate the effect of multiple factors in complex decisions, unlike the more common factorial experiment. The method is explained, and prospects and issues for the development of this research design to study professional judgement within social work are discussed. The factorial survey has potential as a method for rigorous study of the impact of client, family and context factors on decisions by social work and social care staff. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
796,Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study,"BACKGROUND: Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts. Educational outreach into practices, alongside other measures, such as audit and feedback, have the potential to enable GP prescribing to become more evidence based. High GP prescribing costs are associated with GPs who see drug company representatives""; tend to end consultations with prescriptions;"" and 'try out' new drugs on an 'ad hoc basis' and use this as evidence of the drug's effect. An educational intervention called 'reflective practice' was developed to meet these and other educational needs. The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice. OBJECTIVES: The study investigated the following: (i) Is it feasible for GPs to attend the sessions included in the educational intervention? (ii) Is the intervention acceptable to the participants and the session facilitators? (iii) What are the barriers to the group educational processes, and how can these be overcome? METHODS: Four practices were recruited in South West England, all of them experiencing problems with prescribing appropriateness and cost. Reflective practice sessions (including a video-taped scenario) were run in each of these practices and qualitative methods were used to explore the complex attitudes and behaviour of the participants. A researcher observed and audio-taped sessions in each practice. At the end of the programme, a sample of doctors and all the facilitators were interviewed about their experiences. The recorded data were transcribed and analysed using standard qualitative methods. RESULTS: The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions. Elsewhere, doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality. Facilitators came from a broad range of professional backgrounds. While knowledge of prescribed drug management issues was important, the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory. The video-taped scenario was found to be useful to set the scene for the discussion. Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion. Reaching a consensus on management of common conditions was sometimes difficult, partly because the use of the term 'best buy' implies economic pressures, rather than benefits to patients, and partly because of the value with which GPs regard the concept of clinical autonomy. 'Reflective Practice' appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence. CONCLUSION: The study indicates the importance of preparing the practice adequately, including providing protected time for all GPs to attend the educational intervention. Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness. Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized. We have also identified the skill profile of the facilitator role. Our study indicates a need for a clearer understanding of GPs' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment. The intervention is now ripe for further development, perhaps by integrating it with other interventions to change professional behaviour. The improved intervention should then be evaluated in a randomized controlled trial.",0,0,
797,Factors associated with nursing interventions to reduce incontinence in hospitalized older adults,"INTRODUCTION: The problem of incontinence in hospitalized elderly patients is rarely documented, and there is little research that determines why nurses choose to help or not help with this problem. Are hospital-based acute care nurses' attitudes and beliefs about incontinence associated with the perceived opportunity to assist the patient with the problem? What do hospital nurses know about causes and interventions relative to incontinence? METHODS: Two vignettes, one describing a patient with stress incontinence and one describing a patient with urge incontinence, were created. Questions measuring variables of a help-giving model were developed, and nurses were asked to mark on a Likert-type scale when answering each question. RESULTS: One hundred-fifty respondents returned completed questionnaires along with three nurse experts. Many hospital nurses believed incontinence was temporary and part of being old. As a group they had a more positive attitude toward intervening for urge incontinence and believed the physician and their nurse manager expected them to assist the patient with urge incontinence. Respondents tended to believe the patient was least likely to expect help. Respondents were evenly divided about opportunity to provide assistance for stress or urge incontinence. Less than half of the nurses correctly listed causes and interventions for stress or urge incontinence. CONCLUSIONS: Other clinical problems perceived as more pressing and lack of knowledge concerning appropriate helping measures affect nurses' perceptions of opportunity to intervene when elderly hospital patients are incontinent. Assessment and intervention are essential to quality nursing care. Undergraduate nursing education and ongoing staff education about incontinence are crucial if assessments and interventions are to be correct. Patients, as health care consumers, have to be more educated about incontinence and choose to have the problem addressed during hospitalization. The Agency for Health Care Policy and Research Clinical Practice Guidelines is a major recommended reference.",0,0,
798,Factors Associated With Poor Mental Health Among Guatemalan Refugees Living in Mexico 20 Years After Civil Conflict,"Context From 1981 to 2001, 46 000 refugees who fled the 36-year civil conflict in Guatemala for Chiapas, Mexico were under the protection of the United Nations High Commissioner for Refugees.  Objectives To estimate the prevalence of mental illness and factors associated with poor mental health of underserved Guatemalan refugee communities located in Chiapas, Mexico, since 1981 and to assess need for mental health services.  Design, Setting, and Participants Cross-sectional survey of 183 households in 5 Mayan refugee camps in Chiapas representing an estimated 1546 residents (adults and children) conducted November-December 2000.  Main Outcome Measures Symptom criteria of Posttraumatic Stress Disorder (PTSD), anxiety, and depression as measured by the Harvard Trauma Questionnaire and Hopkins Symptom Checklist-25 (Hopkins-25).  Results One adult (aged =16 years) per household (n = 170 respondents) who agreed to participate was included in the analysis, representing an estimated 93% of households. All respondents reported experiencing at least 1 traumatic event with a mean of 8.3 traumatic events per individual. Of the respondents, 20 (11.8%) had all symptom criteria for PTSD. Of the 160 who completed the Hopkins Symptom Checklist-25, 87 (54.4%) had anxiety symptoms and 62 (38.8%) had symptoms of depression. Witnessing the disappearance of family members (adjusted odds ratio [AOR], 4.58""; 95% confidence interval [CI], 1.35-15.50), being close to death (AOR, 4.19, 95% CI, 1.03-17.00), or living with 9 to 15 persons in the same home (AOR, 3.69; 95% CI, 1.19-11.39) were associated with symptoms of PTSD. There was a protective factor found for lacking sufficient food (AOR, 0.08; 95% CI, 0.01-0.59). Elevated anxiety symptoms were associated with witnessing a massacre (AOR, 10.63; 95% CI, 4.31-26.22), being wounded (AOR, 3.22; 95% CI, 0.95-10.89), and experiencing 7 to 12 traumatic events (AOR, 2.67; 95% CI, 1.14-6.27) and 13 to 19 traumatic events (AOR, 2.26; 95% CI, 0.65-7.89). Elevated symptoms of depression were associated with being a woman (AOR, 3.64; 95% CI, 1.47-9.04), being widowed (AOR, 27.55; 95% CI, 2.54-299.27), being married (AOR, 1.93; 95% CI, 0.59-6.33), witnessing disappearances (AOR, 2.68; 95% CI, 1.16-6.19), experiencing 7 to 12 traumatic events (AOR, 1.57; 95% CI, 0.64-3.88), or experiencing 13 to 19 traumatic events (AOR, 7.44;"" 95% CI, 2.18-25.37).  Conclusion Psychiatric morbidity related to human rights violations, traumatic events, and refugee status was common among Guatemalan refugees surveyed 20 years after the Guatemalan civil conflict.",0,0,
799,Failure of computerized treatment suggestions to improve health outcomes of outpatients with uncomplicated hypertension: results of a randomized controlled trial.,"Study Objective. To assess the effects of evidence-based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system.  Design. Randomized controlled trial with a 2 times 2 factorial design of physician and pharmacist interventions, which resulted in four groups of patients: physician intervention only, pharmacist intervention only, intervention by physician and pharmacist, and intervention by neither physician nor pharmacist (control).  Setting. Academic primary care internal medicine practice.  Subjects. Seven hundred twelve patients with uncomplicated hypertension.  Measurements and Main Results. Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions. The primary end point was generic health-related quality of life. Secondary end points were symptom profile and side effects from antihypertensive drugs, number of emergency department visits and hospitalizations, blood pressure measurements, patient satisfaction with physicians and pharmacists, drug therapy compliance, and health care charges. In the control group, implementation of care changes in accordance with treatment suggestions was observed in 26% of patients. In the intervention groups, compliance with suggestions was poor, with treatment suggestions implemented in 25% of patients for whom suggestions were displayed only to pharmacists, 29% of those for whom suggestions were displayed only to physicians, and 35% of the group for whom both physicians and pharmacists received suggestions (p=0.13). Intergroup differences were neither statistically significant nor clinically relevant for generic health-related quality of life, symptom and side-effect profiles, number of emergency department visits and hospitalizations, blood pressure measurements, charges, or drug therapy compliance.  Conclusion. Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension.",0,1,
800,Fall prevention in acute care hospitals: a randomized trial.,"Context Falls cause injury and death for persons of all ages, but risk of falls increases markedly with age. Hospitalization further increases risk, yet no evidence exists to support short-stay hospital-based fall prevention strategies to reduce patient falls.  Objective To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient falls in hospitals.  Design, Setting, and Patients Cluster randomized study conducted January 1, 2009, through June 30, 2009, comparing patient fall rates in 4 urban US hospitals in units that received usual care (4 units and 5104 patients) or the intervention (4 units and 5160 patients).  Intervention The FPTK integrated existing communication and workflow patterns into the HIT application. Based on a valid fall risk assessment scale completed by a nurse, the FPTK software tailored fall prevention interventions to address patients' specific determinants of fall risk. The FPTK produced bed posters composed of brief text with an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders.  Main Outcome Measures The primary outcome was patient falls per 1000 patient-days adjusted for site and patient care unit. A secondary outcome was fall-related injuries.  Results During the 6-month intervention period, the number of patients with falls differed between control (n = 87) and intervention (n = 67) units (P=.02). Site-adjusted fall rates were significantly higher in control units (4.18 [95% confidence interval {CI}, 3.45-5.06] per 1000 patient-days) than in intervention units (3.15 [95% CI, 2.54-3.90] per 1000 patient-days""; P = .04). The FPTK was found to be particularly effective with patients aged 65 years or older (adjusted rate difference, 2.08 [95% CI, 0.61-3.56] per 1000 patient-days;"" P = .003). No significant effect was noted in fall-related injuries.  Conclusion The use of a fall prevention tool kit in hospital units compared with usual care significantly reduced rate of falls.",0,1,
801,Family members' requests to extend physiologic support after declaration of brain death: a case series analysis and proposed guidelines for clinical management,"We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients' ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS's advice and recommendations generally promoted ""reasonable accommodation"" of the requests, balancing compassion for grieving families with other ethical and moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finite-goal accommodation, a ""reasonable accommodation"" strategy proved effective in balancing stakeholders' interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the ""reasonable accommodation"" approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases.",0,0,
802,Family-based interventions to increase physical activity in children: a meta-analysis and realist synthesis protocol,"INTRODUCTION: Despite the established relationship between physical activity and health, data suggest that many children are insufficiently active, and that levels decline into adolescence. Engaging the family in interventions may increase and maintain children's physical activity levels at the critical juncture before secondary school. Synthesis of existing evidence will inform future studies, but the heterogeneity in target populations recruited, behaviour change techniques and intervention strategies employed, and measurement conducted, may require a multifaceted review method. The primary objective of this work will therefore be to synthesis evidence from intervention studies that explicitly engage the family unit to increase children's physical activity using an innovative dual meta-analysis and realist approach. METHODS AND ANALYSIS: Peer-reviewed studies will be independently screened by two authors for inclusion based on (1) including 'healthy' participants aged 5-12 years"";"" (2) having a substantive intervention aim of increasing physical activity, by engaging the family and (3) reporting on physical activity. Duplicate data extraction and quality assessment will be conducted using a specially designed proforma and the Effective Public Health Practice Project Quality Assessment Tool respectively. STATA software will be used to compute effect sizes for meta-analyses, with subgroup analyses conducted to identify moderating characteristics. Realist syntheses will be conducted according to RAMESES quality and publication guidelines, including development of a programme theory and evidence mapping. DISSEMINATION: This review will be the first to use the framework of a traditional review to conduct a dual meta-analysis and realist synthesis, examining interventions that engage the family to increase physical activity in children. The results will be disseminated through peer-reviewed publications, conferences, formal presentations to policy makers and practitioners and informal meetings. Evidence generated from this synthesis will also be used to inform the development of theory-driven, evidence-based interventions aimed at engaging the family to increase physical activity levels in children. PROTOCOL REGISTRATION: International Prospective Register for Systematic Reviews (PROSPERO): number CRD42013005780.",0,0,
803,Family-member DOTS and community DOTS for tuberculosis control in Nepal: cluster-randomised controlled trial,"BackgroundA key component of the DOTS strategy for tuberculosis control (short-course chemotherapy following WHO guidelines) is direct observation of treatment. WHO technical guidelines recommend that health workers should undertake this part of the strategy, but will also accept direct observation of treatment in the community""; WHO does not think that a family member should undertake this role. Supporting evidence for these recommendations is not available. The Nepal national tuberculosis programme asked us to develop and test a strategy of direct observation of treatment for the hill districts of Nepal, where direct observation of treatment by health workers is not feasible. We aimed to assess the success rates of two DOTS strategies developed for such areas.; BackgroundA key component of the DOTS strategy for tuberculosis control (short-course chemotherapy following WHO guidelines) is direct observation of treatment. WHO technical guidelines recommend that health workers should undertake this part of the strategy, but will also accept direct observation of treatment in the community;"" WHO does not think that a family member should undertake this role. Supporting evidence for these recommendations is not available. The Nepal national tuberculosis programme asked us to develop and test a strategy of direct observation of treatment for the hill districts of Nepal, where direct observation of treatment by health workers is not feasible. We aimed to assess the success rates of two DOTS strategies developed for such areas.",0,0,
804,Fast tracking the design of theory-based KT interventions through a consensus process,"BACKGROUND: Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains. METHODS: Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention. RESULTS: Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences)""; availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge);"" and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors. CONCLUSIONS: A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.",0,0,
805,Feasibility and acceptability of two incentive-based implementation strategies for mental health therapists implementing cognitive-behavioral therapy: a pilot study to inform a randomized controlled trial,"Background Informed by our prior work indicating that therapists do not feel recognized or rewarded for implementation of evidence-based practices, we tested the feasibility and acceptability of two incentive-based implementation strategies that seek to improve therapist adherence to cognitive-behavioral therapy for youth, an evidence-based practice.  Methods This study was conducted over 6 weeks in two community mental health agencies with therapists (n?=?11) and leaders (n?=?4). Therapists were randomized to receive either a financial or social incentive if they achieved a predetermined criterion on adherence to cognitive-behavioral therapy. In the first intervention period (block 1""; 2 weeks), therapists received the reward they were initially randomized to if they achieved criterion. In the second intervention period (block 2;"" 2 weeks), therapists received both rewards if they achieved criterion. Therapists recorded 41 sessions across 15 unique clients over the project period. Primary outcomes included feasibility and acceptability. Feasibility was assessed quantitatively. Fifteen semi-structured interviews were conducted with therapists and leaders to assess acceptability. Difference in therapist adherence by condition was examined as an exploratory outcome. Adherence ratings were ascertained using an established and validated observational coding system of cognitive-behavioral therapy.  Results Both implementation strategies were feasible and acceptable—however, modifications to study design for the larger trial will be necessary based on participant feedback. With respect to our exploratory analysis, we found a trend suggesting the financial reward may have had a more robust effect on therapist adherence than the social reward.  Conclusions Incentive-based implementation strategies can be feasibly administered in community mental health agencies with good acceptability, although iterative pilot work is essential. Larger, fully powered trials are needed to compare the effectiveness of implementation strategies to incentivize and enhance therapists’ adherence to evidence-based practices such as cognitive-behavioral therapy.",1,1,
806,Feasibility and impact of a computerised clinical decision support system on investigation and initial management of new onset chest pain: a mixed methods study,"BACKGROUND: Clinical decision support systems (CDSS) can modify clinician behaviour, yet the factors influencing their effect remain poorly understood. This study assesses the feasibility and acceptability of a CDSS supporting diagnostic and treatment decisions for patients with suspected stable angina. METHODS: Intervention The Optimising Management of Angina (OMA) programme includes a CDSS guiding investigation and medication decisions for clinicians managing patients with new onset stable angina, based on English national guidelines, introduced through an educational intervention. Design and participants A mixed methods study i. A study of outcomes among patients presenting with suspected angina in three chest pain clinics in England before and after introduction of the OMA programme. ii. Observations of clinic processes, interviews and a focus group with health professionals at two chest pain clinics after delivery of the OMA programme. OUTCOMES: Medication and cardiovascular imaging investigations undertaken within six months of presentation, and concordance of these with the recommendations of the CDSS. Thematic analysis of qualitative data to understand how the CDSS was used. RESULTS: Data were analysed for 285 patients attending chest pain clinics: 106 before and 179 after delivery of the OMA programme. 40 consultations were observed, 5 clinicians interviewed, and a focus group held after the intervention. The proportion of patients appropriate for diagnostic investigation who received one was 50 % (95 CI 34-66 %) of those before OMA and 59 % (95 CI 48-70 %) of those after OMA. Despite high use of the CDSS (84 % of consultations), observations and interviews revealed difficulty with data entry into the CDSS, and structural and practical barriers to its use. In the majority of cases the CDSS was not used to guide real-time decision making, only being consulted after the patient had left the room. CONCLUSIONS: The OMA CDSS for the management of chest pain is not feasible in its current form. The CDSS was not used to support decisions about the care of individual patients. A range of barriers to the use of the CDSS were identified, some are easily removed, such as insufficient capture of cardiovascular risk, while others are more deeply embedded in current practice, such as unavailability of some investigations or no prescribing privileges for nurses.",0,1,
807,Feasibility of conducting a randomized controlled trial of telemental health with children diagnosed with attention-deficit/hyperactivity disorder in underserved communities,"OBJECTIVE: Telemental health (TMH), the use of videoteleconferencing to provide care that is usually delivered in person, is increasingly used to rectify disparities in access to care. Few studies, however, have been conducted to demonstrate the effectiveness of TMH as a service delivery model. The Children's Attention-Deficit/Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) is a randomized clinical trial (RCT) of TMH conducted in multiple underserved communities. This article reports on the feasibility of conducting an effectiveness trial of TMH with children. METHODS: The CATTS trial used videoteleconferencing to provide guideline-based care and secure web sites to coordinate key aspects of trial implementation, such as participant recruitment and retention, intervention fidelity, and completion of assessments. RESULTS: The CATTS trial engaged seven communities and 150 primary care providers as partners in the study, and enrolled 223 children 5.5-12.9 years old. The intervention group completed an average of 5.3 of 6.0 planned sessions and 96% of controls completed a TMH consultation. Both groups completed an average of 4.8 of the 5.0 assessments. Clinicians demonstrated high fidelity to their treatment protocols. Minor technical difficulties did not interfere with providing care. CONCLUSIONS: The CATTS trial demonstrated the feasibility of conducting an RCT of TMH with children living in multiple underserved communities. Telecommunications technologies can facilitate the coordination of research activities across sites and clinicians. Future trials should work closely with study partners to ensure referral of a representative study sample. Further trials are needed to help establish the effectiveness of TMH as a service delivery model. TRIAL REGISTRATION: http://clinicaltrials.gov/show/NCT00830700 .",0,0,
808,Feasibility study of a communication and education asthma intervention for general practitioners in Australia,"The Physician Asthma Care Education (PACE) program significantly improved asthma prescribing and communication behaviours of primary care paediatricians in the USA. We tested the feasibility and acceptability of a modified PACE program with Australian general practitioners (GP) and measured its impact on self-reported consulting behaviours in a pilot study. Recruitment took place through a local GP division. Twenty-five GP completed two PACE Australia workshops, which incorporated paediatric asthma management consistent with Australian asthma guidelines and focussed on effective communication strategies. Program feasibility, usefulness and perceived benefit were measured by questionnaires before the workshop and 1 month later, and an evaluation questionnaire after each workshop. GP were universally enthusiastic and supportive of the workshops. The most useful elements they reported were communication skills, case studies, device demonstrations and the toolkit provided. GP self reports of the perceived helpfulness of the key communication strategies and their confidence in their application and reported frequency of use increased significantly after the workshops. The PACE program shows promise in improving the way in which Australian GP manage asthma consultations, particularly with regard to doctor-patient communication. The impact ofthe modified PACE Australia program on the processes and outcomes ofGP care ofchildren with asthma is now being measured in a randomised controlled trial.",0,0,
809,"Feasibility, accuracy, and clinical effect of point-of-care Xpert MTB/RIF testing for tuberculosis in primary-care settings in Africa: a multicentre, randomised, controlled trial","BackgroundThe Xpert MTB/RIF test for tuberculosis is being rolled out in many countries, but evidence is lacking regarding its implementation outside laboratories, ability to inform same-day treatment decisions at the point of care, and clinical effect on tuberculosis-related morbidity. We aimed to assess the feasibility, accuracy, and clinical effect of point-of-care Xpert MTB/RIF testing at primary-care health-care facilities in southern Africa."";"" BackgroundThe Xpert MTB/RIF test for tuberculosis is being rolled out in many countries, but evidence is lacking regarding its implementation outside laboratories, ability to inform same-day treatment decisions at the point of care, and clinical effect on tuberculosis-related morbidity. We aimed to assess the feasibility, accuracy, and clinical effect of point-of-care Xpert MTB/RIF testing at primary-care health-care facilities in southern Africa.",0,0,
810,Feedback as a strategy to change behaviour: the devil is in the details,"BACKGROUND: Performance feedback is one of a number of strategies used to improve clinical practice among students and clinicians. OBJECTIVES: The aims of this paper were to examine conceptual underpinnings and essential components for audit and feedback strategies, to assess the extent to which recently published audit and feedback interventions include these components and to recommend future directions for feedback to improve its educational and behavioural impact. METHODS: Based on the actionable feedback model, we examined the presence of four theoretical constructs--timeliness, individualization, lack of punitiveness and customizability--in studies published during 2009-2010 which included a feedback intervention. RESULTS: There was wide variation in the definition, implementation and outcomes of 'feedback' interventions, making it difficult to compare across studies. None of the studies we reviewed included all of the components of the actionable feedback model. CONCLUSIONS: Feedback interventions reported to date, even when results are positive, often fail to include concepts of behaviour change. This may partially explain the large variation in approaches and in results of such interventions and presents major challenges for replicating any given intervention. If feedback processes are to be successfully used and disseminated and implemented widely, some standardization and certainly more clarity is needed in the specific action steps taken to apply behavioural theory to practice.",0,1,
811,Fibromyalgia treatment update,"PURPOSE OF REVIEW: Fibromyalgia is a common chronic pain disorder characterized by complex symptomatology and few consistently effective treatments. The purpose of this review is to highlight the recent literature from April 2005 through September 2006 involving treatment options. RECENT FINDINGS: Prior evidence suggests that medication and self-management approaches to care can improve symptoms, function and well-being in this patient population. Recent studies examining the efficacy of two serotonin and norepinephrine-reuptake inhibitors--duloxetine and milnacipran--and the anticonvulsant pregabalin are encouraging. Studies evaluating different forms of exercise continue to support the belief that increased physical activity is an essential component of any treatment plan for the patient with fibromyalgia. Three studies added to the understanding of treatment adherence. Finally, three studies evaluating the efficacy of acupuncture in the treatment of fibromyalgia showed conflicting results, but added to the knowledge needed for clinicians to have substantive conversations with patients. SUMMARY: Recent studies support the recommendation of a multimodal approach to treatment involving individualized, evidence-based pharmacotherapy and self-management. Treatment goals should include the improvement of symptoms, primarily pain and sleep, and the promotion of positive health behaviors with the aim of improving physical function and emotional well-being.",0,0,
812,Financial incentives for smoking cessation in pregnancy: randomised controlled trial,"OBJECTIVE To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit. DESIGN Phase II therapeutic exploratory single centre, individually randomised controlled parallel group superiority trial. SETTING One large health board area with a materially deprived, inner city population in the west of Scotland, United Kingdom. PARTICIPANTS 612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control. INTERVENTIONS The control group received routine care, which was the offer of a face to face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date""; then another £50 if at four weeks' post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks' gestation. MAIN OUTCOME MEASURE The primary outcome was cotinine verified cessation at 34-38 weeks' gestation through saliva (<14.2 ng/mL) or urine (<44.7 ng/mL). Secondary outcomes included birth weight, engagement, and self reported quit at four weeks. RESULTS Recruitment was extended from 12 to 15 months to achieve the target sample size. Follow-up continued until September 2013. Of the 306 women randomised, three controls opted out soon after enrolment; these women did not want their data to be used, leaving 306 intervention and 303 control group participants in the intention to treat analysis. No harms of financial incentives were documented. Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%). The relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval 1.73 to 4.01) P<0.001. The absolute risk difference was 14.0% (95% confidence interval 8.2% to 19.7%). The number needed to treat (where financial incentives need to be offered to achieve one extra quitter in late pregnancy) was 7.2 (95% confidence interval 5.1 to 12.2). The mean birth weight was 3140 g (SD 600 g) in the incentives group and 3120 (SD 590) g in the control group (P=0.67). CONCLUSION This phase II randomised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy;"" as this was only a single centre trial, incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom. TRIAL REGISTRATION Current Controlled Trials ISRCTN87508788.",0,0,
813,FIRE (facilitating implementation of research evidence): a study protocol,"Background Research evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids.  Objectives This study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice""; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation;"" and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community.  Setting and sample Four European countries, each with six long-term nursing care sites (total 24 sites) for people aged 60 years and over with documented urinary incontinence  Methods and design Pragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances.",0,0,
814,"First on-line survey of an international multidisciplinary working group (MightyMedic) on current practice in diagnosis, therapy and follow-up of dyslipidemias","The MightyMedic (Multidisciplinary International Group for Hemapheresis TherapY and MEtabolic DIsturbances Contrast) Working Group has been founded in 2013. The leading idea was to establish an international network of interdisciplinary nature aimed at working to cross national borders research projects, clinical trials, educational initiatives (meetings, workshops, summer schools) in the field of metabolic diseases, namely hyperlipidemias, and diabetes, preventive cardiology, and atherosclerosis. Therapeutic apheresis, its indications and techniques, is a parallel field of investigation. The first on-line survey of the Group has been completed in the first half of 2014. The survey included # 24 Centers in Italy, Germany, Greece, UK, Sweden, Japan and USA. Relevant data have been collected on current practice in diagnosis, therapy and follow-up of dyslipidemias. 240 subjects with hyperlipidemia and treated with lipoprotein apheresis have been reported in the survey, but a large percentage of patients (35%) who could benefit from this therapeutic option are still treated by conventional drug approach. Genetic molecular diagnosis is performed in only 33% of patients while Lipoprotein(a) (Lp(a)) is included in cardiovascular disease risk assessment in 71% of participating Centers. New detailed investigations and prospective multicenter studies are needed to evaluate changes induced by the impact of updated indications and strategies, as well as new treatment options, targeting standardization of therapeutic and diagnostic approaches.",0,0,
815,First-episode psychosis: a window of opportunity for best practices,"Patients experiencing a first psychotic episode or early stages of psychosis present with key diagnostic issues for clinicians. At the time of first-episode psychosis presentation, it is crucial that clinicians select the most effective treatment option as immediate intervention offers the best chance for containing the illness. During this period, selecting the best treatment option is also important because functional impairment occurs most rapidly during this early period, which can alter the patient's future prognosis, level of necessary treatment, and affect morbidity. Although research has shown a decrease in brain gray matter for those who develop psychosis along with signs of functional impairment, many patients with psychosis remain untreated for extended periods of time and do not visit a clinician because of denial, fear of stigma, a failure to recognize the problem, or complexities of their care system. Prior studies have shown that when psychosis is left untreated, the patient outcome is worse than for a patient treated earlier in the course of illness. There is a range of treatment options for psychosis treatment, including use of first-generation or second-generation antipsychotic medication. Clinicians should note that both drug types are associated with certain side effects, such as tardive dyskinesia and weight gain, respectively. For both medication types, doses should be lower for patients with a first psychotic episode than for patients with chronic psychosis. Lastly, patients may present with various comorbidities, such as substance abuse, that also may affect treatment. This expert roundtable supplement will address the diagnosis and treatment selection for first-episode psychosis as well as comorbidities related to the condition. The use of first- or second-generation antipsychotics for psychosis treatment, dosing guidelines, and the antipsychotic side-effect profile will also be addressed.",0,0,
816,Format change of a laboratory test order form affects physician behavior,"PURPOSE: Our study was designed to find whether a change in physician ordering of laboratory testing could be obtained by the simple strategy of changing the set-up of the check-box laboratory order form that is embedded in a computerized medical record. METHODS: This prospective intervention study was undertaken in Maccabi Healthcare Services, a Preferred Provider Organization that has used a computerized medical record since 1992. We examined data from 865 primary healthcare physicians over 3 years. In May 2005 we changed the order form and reduced the number of tests that can be ordered using a check-box form from 51 to 26. Twenty-seven tests were removed from the form and two tests were added. The total number of laboratory test orders and the median rate of test orders per visit to physician during each of the study periods were calculated separately for each test. RESULTS: Tests that were added to the computerized laboratory order form showed an increase of 60.7% in the first year and a further 90% increase in the following year. For the unchanged tests the percentage changes over the same periods were +18.4% and -22.4%. For the deleted tests the change was -27% and -19.2% for the respective years. CONCLUSIONS: Changes in format of laboratory test order forms can change physician test ordering and may be useful together with other interventions to improve appropriateness of laboratory testing. A thoughtfully built test ordering form can reinforce clinical guidelines for the performance of some preventive testing and follow-up.",1,1,
817,Formative evaluation of practice changes for managing depression within a Shared Care model in primary care,"Aim To investigate the implementation and initial impact of the Physician Integrated Network (PIN) mental health indicators, which are specific to screening and managing follow-up for depression, in three primary care practices with Shared Mental Health Care in Manitoba. BACKGROUND: Manitoba Health undertook a primary care renewal initiative in 2006 called the PIN, which included the development of mental health indicators specific to screening and managing follow-up for depression. These indicators were implemented in three PIN group practice sites in Manitoba, which are also part of Shared Mental Health Care. METHODS: The design was a non-experimental longitudinal design. A formative evaluation investigated the implementation and initial impact of the mental health indicators using mixed methods (document review, survey, and interview). Quantitative data was explored using descriptive and comparative statistics and a content and theme analysis of the qualitative interviews was conducted. Survey responses were received from 32 out of 36 physicians from the three sites. Interviews were conducted with 15 providers. Findings This evaluation illustrated providers' perceived attitudes, knowledge, skills, and behaviours related to recognizing and treating depression and expanded our understanding of primary care processes related to managing depression related to the implementation of a new initiative. Depression is viewed as an important problem in primary care practice that is time consuming to diagnose, manage and treat and requires further investigation. Implementation of the PIN mental health indicators was variable across sites and providers. There was an increase in use of the indicators across time and a general sentiment that benefits of screening outweigh the costs"";"" however, the benefit of screening for depression remains unclear. Consistent with current guidelines, a question the findings of this evaluation suggests is whether there are more effective ways of having an impact on depression within primary care than screening.",0,0,
818,Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science,"Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.  Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.  Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.  Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.",0,0,
819,Founder and Recurrent CDH1 Mutations in Families With Hereditary Diffuse Gastric Cancer,"Context Hereditary diffuse gastric cancer is caused by germline mutations in the epithelial cadherin (CDH1) gene and is characterized by an increased risk for diffuse gastric cancer and lobular breast cancer.  Objective To determine whether recurring germline CDH1 mutations occurred due to independent mutational events or common ancestry.  Design, Setting, and Patients Thirty-eight families diagnosed clinically with hereditary diffuse gastric cancer were accrued between November 2004 and January 2006 and were analyzed for CDH1 mutations as part of an ongoing study at the British Columbia Cancer Agency. Twenty-six families had at least 2 gastric cancer cases with 1 case of diffuse gastric cancer in a person younger than 50 years"";"" 12 families had either a single case of diffuse gastric cancer diagnosed in a person younger than 35 years or multiple cases of diffuse gastric cancer diagnosed in persons older than 50 years.  Main Outcome Measures Classification of family members as carriers or noncarriers of CDH1 mutations. Haplotype analysis to assess recurring mutations for common ancestry was performed on 7 families from this study and 7 previously reported families with the same mutations.  Results Thirteen mutations (6 novel) were identified in 15 of the 38 families (40% detection rate). The 1137G>A splicing mutation and the 1901C>T (A634V) missense/splicing mutation occurred on common haplotypes in 2 families but on different haplotypes in a third family. The 2195G>A (R732Q) missense/splicing mutation occurred in 2 families on different haplotypes. The 2064-2065delTG mutation occurred on a common haplotype in 2 families. Two families from this study plus 2 additional families carrying the novel 2398delC mutation shared a common haplotype, suggesting a founder effect. All 4 families originate from the southeast coast of Newfoundland. Due to concentrations of lobular breast cancer cases, 2 branches of this family had been diagnosed as having hereditary breast cancer and were tested for BRCA mutations. Within these 4 families, the cumulative risk by age 75 years in mutation carriers for clinically detected gastric cancer was 40% (95% confidence interval [CI], 12%-91%) for males and 63% (95% CI, 19%-99%) for females and the risk for breast cancer in female mutation carriers was 52% (95% CI, 29%-94%).  Conclusions Recurrent CDH1 mutations in families with hereditary diffuse gastric cancer are due to both independent mutational events and common ancestry. The presence of a founder mutation from Newfoundland is strongly supported.",0,0,
820,Framework for direct observation of performance and safety in healthcare,,0,0,
821,Framework for pharmacy services quality improvement--a bridge to cross the quality chasm. Part I. The opportunity and the tool,"OBJECTIVE: To review the literature on the subject of quality improvement principles and methods applied to pharmacy services and to describe a framework for current and future efforts in pharmacy services quality improvement and effective drug therapy management. BACKGROUND: The Academy of Managed Care Pharmacy produced the Catalog of Pharmacy Quality Indicators in 1997, followed by the Summary of National Pharmacy Quality Measures in February 1999. In April 2002, AMCP introduced Pharmacy's Framework for Drug Therapy Management in the 21st Century. The Framework documents include a self-assessment tool that details more than 250 specific ""components"" that describe tasks, behaviors, skills, functions, duties, and responsibilities that contribute to meeting customer expectations for effective drug therapy management. FINDINGS: There are many opportunities for quality improvement in clinical, service, and cost outcomes related to drug therapy management. These may include patient safety""; incidence of medical errors; adverse drug events; patient adherence to therapy; attainment of target goals of blood pressure, glucose, and lipid levels; risk reduction for adverse cardiac events and osteoporotic-related fractures; patient satisfaction; risk of hospitalization or mortality;"" and cost of care. Health care practitioners can measure improvements in health care quality in several ways including (a) a better patient outcome at the same cost, (b) the same patient outcome at lower cost, (c) a better patient outcome at lower cost, or (d) a significantly better patient outcome at moderately higher cost. Measurement makes effective management possible. A framework of component factors (e.g., tasks) is necessary to facilitate changes in the key processes and critical factors that will help individual practitioners and health care systems meet customer expectations in regard to drug therapy, thus improving these outcomes. CONCLUSIONS: Quality improvement in health care services in the United States will be made in incremental changes that rely on a structure-process-outcome model. The structure is provided by evidence created from controlled randomized trials and other studies of care and system outcomes that are based on the scientific method. The process portion is created by the application of evidence in the form of clinical practice guidelines, clinical practice models, and self-assessment tools such as Pharmacy's Framework for Drug Therapy Management. Incremental changes in structure and process will result in the desirable outcome of meeting customer needs for more effective drug therapy and disease management.",0,0,
822,Framing options as choice or opportunity: does the frame influence decisions?,"Objective. Health professionals must enable patients to make informed decisions about health care choices through unbiased presentation of all options. This study examined whether presenting the decision as “opportunity” rather than “choice” biased individuals’ preferences in the context of trial participation for cancer treatment. Methods. Self-selecting healthy women (N = 124) were randomly assigned to the following decision frames: opportunity to take part in the trial (opt-in), opportunity to be removed from the trial (opt-out), and choice to have standard treatment or take part in the trial (choice). The computer-based task required women to make a hypothetical choice about a real-world cancer treatment trial. The software presented the framed scenario, recorded initial preference, presented comprehensive and balanced information, traced participants’ use of information during decision making, and recorded final decision. A posttask paper questionnaire assessed perceived risk, attitudes, subjective norm, perceived behavioral control, and satisfaction with decision. Results. Framing influenced women’s immediate preferences. Opportunity frames, whether opt-in or opt-out, introduced a bias as they discouraged women from choosing standard treatment. Using the choice frame avoided this bias. The opt-out opportunity frame also affected women’s perceived social norm"";"" women felt that others endorsed the trial option. The framing bias was not present once participants had had the opportunity to view detailed information on the options within a patient decision aid format. There were no group differences in information acquisition and final decisions. Sixteen percent changed their initial preference after receiving full information. Conclusions. A “choice” frame, where all treatment options are explicit, is less likely to bias preferences. Presentation of full information in parallel, option-by-attribute format is likely to “de-bias” the decision frame. Tailoring of information to initial preferences would be ill-advised as preferences may change following detailed information.",0,1,
823,Fraud and misconduct in clinical research,,0,0,
824,Fraud and misconduct in clinical research: is it prejudicial to patient safety?,,0,0,
825,From clinical evidence to everyday practice: implementing findings from a cost-effectiveness analysis for endoscopic injection therapy for upper-gastrointestinal bleeding,"BACKGROUND: A previous upper-gastrointestinal bleeding trial showed that patients treated with repeated fibrin glue injection for upper-gastrointestinal bleeding have significantly less rebleeding than those treated with polidocanol. OBJECTIVE: To analyse the cost and effectiveness of repeated fibrin glue injection and to investigate whether these results change physicians' attitudes. DESIGN: A retrospective random sample of five hospitals from the previous study, collection of cost identification, and follow-up data on 320 patients (155 in the polidocanol group, 165 in the fibrin glue group). METHODS: An incremental cost-effectiveness analysis and comparison of outcomes was performed using chi-squared tests and Kaplan-Meier survival analysis. A survey was carried out using a questionnaire in the five hospitals on local guidelines for management of ulcer bleeding, and its results were analysed qualitatively. The measure of effectiveness is the number of prevented rebleedings. Further variables were length of hospital stay and length of intensive care unit (ICU) stay. RESULTS: The cost for the prevention of one additional rebleeding by repeated fibrin glue treatment amounts to 14,316 +/- 4981 euros (incremental cost-effectiveness ratio). There were no significant differences in length of stays in ICU or in hospital. The physicians did not change their management plans for patients with upper-gastrointestinal bleeding. In a survey, it was seen that other factors, such as local guidelines, attitudes towards new treatment options, and ease of handling of drugs, are more important than a result of a single study for a behavioural change of the doctors. CONCLUSIONS: The study was not designed prospectively to address a pharmacoeconomic question. As relevant variables (e.g. length of ICU stay) could not be reliably ascertained retrospectively, this may lead to biased estimates of the incremental cost-effectiveness ratio.",0,0,
826,From evidence to expertise: concordance in the topical management of psoriasis,"Vulgar psoriasis is an inflammatory cutaneous-systemic disease, chronic and intermittent. Its etiology is not defined, and it has a higher risk of comorbidities which affect the patients' quality of life. The objectives of this trial were establishing the concordance between Guia de Practica Clinica (GPC) of the plaque psoriasis pharmacological treatment and the clinical practice of a group of Mexican dermatologists, experts in the psoriasis topical treatment"";"" as well as weighing up the interest and knowledge of quality of life and adherence to treatment. A Delphi questionnaire was applied to 30 experts to explore their therapeutic behavior and attitudes toward the assessment of quality of life and treatment adherence. A meeting was held with a subgroup of 10 dermatologists to analyze the results. A second questionnaire was responded to distinguish the decisions taken for topical treatment in institutional and private practice, as well as other items unexplored in the first questionnaire. After analyzing the questionnaires results, it was clear that the data published in the Guia de Practica Clinica and the prescriptive attitude of the experts are consistent with respect to the topical treatment for plaque psoriasis. There is also agreement on the attitude about drug prescriptions between the physicians in the private and institutional medical care, although in the private practice it is more common to use vitamin D analogues and corticosteroids and the salicylic acid replaces corticosteroids in the institutions.",0,0,
827,From hypertension control to global cardiovascular risk management: an educational intervention in a cluster-randomised controlled trial,"BACKGROUND: Guidelines on hypertension management recommend adjusting therapeutic efforts in accordance with global cardiovascular risk (CVR) rather than by blood pressure levels alone. However, this paradigm change has not yet arrived in German General Practice. We have evaluated the effect of an educational outreach visit with general practitioners (GPs), encouraging them to consider CVR in treatment decisions for patients with hypertension. METHODS: Prospective cluster-randomised trial comprising 3443 patients with known hypertension treated by 87 GPs. Practices were randomly assigned to complex (A) or simple (B) intervention. Both groups received a guideline by mail"";"" group A also received complex peer intervention promoting the concept of global CVR. Clinical data were collected at baseline and 6-9 months after intervention. Main outcome was improvement of calculated CVR in the predefined subpopulation of patients with a high CVR (10-year mortality >/=5%), but no manifest cardiovascular disease. RESULTS: Adjusted for baseline the follow-up CVR were 13.1% (95% CI 12.6%-13.6%) (A) and 12.6% (95% CI 12.2%-13.1%) (B) with a group difference (A vs. B) of 0.5% (-0.2%-1.1%), p = 0.179. The group difference was -0.05% in patients of GPs familiar with global CVR and 1.1% in patients of GPs not familiar with with global CVR. However, this effect modification was not significant (p = 0.165). Pooled over groups, the absolute CVR reduction from baseline was 1.0%, p < 0.001. The ICC was 0.026 (p = 0.002). Hypertension control (BP <140/90 mmHg) improved in the same subpopulation from 38.1 to 45.9% in the complex intervention group, and from 35.6 to 46.5% in the simple intervention group, with adjusted follow-up control rates of 46.7% (95% CI 40.4%-53.1%) (A) and 46.9% (95% CI 40.3%-53.5% (B) and an adjusted odds ratio (A vs B) of 0.99 (95% CI 0.68-1.45), p = 0.966. CONCLUSIONS: Our complex educational intervention, including a clinical outreach visit, had no significant effect on CVR of patients with known hypertension at high risk compared to a simple postal intervention. TRIAL REGISTRATION: ISRCTN44478543 .",0,0,
828,From interdisciplinary to integrated care of the child with autism: the essential role for a code of ethics,"To address the developmental deficits of children with autism, several disciplines have come to the forefront within intervention programs. These are speech-pathologists, psychologists/counselors, occupational-therapists/physical-therapists, special-education consultants, behavior analysts, and physicians/medical personnel. As the field of autism therapy moves toward a more comprehensive, holistic and interdisciplinary model, the complexity of an interdisciplinary service delivery model could pose significant challenges. The difficulty of carrying out this approach could lead to sub-par programs being established. With integration among the disciplines a necessity, the ethical principles and language common to all the contributing disciplines is argued as the appropriate integrating force. An outline of these principles and a draft code of ethics are offered to introduce high standards and expectations for all participating in such a program.",0,0,
829,From protocol to practice: translating the clinical data into clinical practice,"Clinicians must be prepared to treat individual patients based on evidence-based risk assessments. However, ethnic minorities, the elderly, and women have been underrepresented in large-scale studies, so data to support clinical decisions for patients in these groups may be lacking. One notable example is the Framingham Heart Study, with a study population consisting of a nearly homogeneous population from one small American town. Clearly, future studies must include more representative samples from these populations. Meanwhile, the Adult Treatment Panel III guidelines should be applied across the board.",0,0,
830,From specialist care to self directed treatment,,0,0,
831,Functional Recovery after Myocardial Infarction in Men: The Independent Effects of Social Class,"Background:Social class has been repeatedly associated with cardiovascular-related illness and death, but no studies have examined the effect of social class on recovery from myocardial infarction. Moreover, few studies have simultaneously evaluated a broad array of demographic, clinical, and psychosocial factors that may influence health outcomes after myocardial infarction.Objective:To determine whether social class remains independently associated with functional recovery after myocardial infarction, even after controlling for clinical, demographic, and psychosocial factors known to influence outcomes after infarction.Design:Analysis of prospective data from a multicenter, randomized, double-blind clinical trial.Setting:25 hospitals or clinical settings in the United States and Canada that participated in the Beta Blocker Heart Attack Trial, including the Health Insurance Plan substudy.Patients:2145 men 29 to 69 years of age who were hospitalized with acute myocardial infarction and were recruited into the Beta Blocker Heart Attack Trial.Measurements:The primary outcome was change in New York Heart Association functional class between baseline assessment and 12 months after infarction, dichotomized as improved or not improved (that is, no change, decline in at least one category, or death).Results:Social class maintained its independent effect on improved functional status, even after controlling for pertinent prognostic factors. Persons of high social class were significantly more likely than persons of low or middle social class to have improved functional status 1 year after infarction. Certain clinical, demographic, and psychosocial features were related to recovery, but the effect of social class could not be explained by these additional features.Conclusions:Social class has a substantial influence on recovery from myocardial infarction and may explain differences in clinical outcomes.",0,0,
832,Functional Somatic Syndromes,"The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease""; the expectation that one's condition is likely to worsen; the “sick role,” including the effects of litigation and compensation;"" and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.",0,0,
833,Gastroesophageal reflux disease,"Heartburn on 2 or more days a week warrants medical attention, as patients are likely to suffer from gastroesophageal reflux disease (GERD). Chronic GERD can lead to the development of complications including erosive esophagitis, stricture formation, and Barrett's esophagus, which increases the risk of esophageal adenocarcinoma. A trial with a proton pump inhibitor (PPI) is the quickest and most cost-effective way to diagnose GERD, and is at least as sensitive as 24-hour intra-esophageal pH monitoring. As PPIs only bind to actively secreting proton pumps, they should be dosed 30 to 60 minutes before a meal. Despite these recommendations, a recent survey of over 1000 US primary care physicians found that 36% instructed their patients to take a PPI with or after a meal or did not specify the timing of dosing. The patients who will have the best response to surgical therapy for GERD are those who had clearly documented acid reflux with typical symptoms, and who have responded to PPI treatment. Unfortunately, the same survey found that most physicians recommend antireflux surgery for patients in whom medical therapy has failed.",0,0,
834,General practice fundholding,,0,0,
835,General practice trainees' information searching strategies for clinical queries encountered in daily practice,"BACKGROUND: Earlier studies have shown that clinical queries are common among doctors. Data on the information-seeking behaviour of general practice (GP) trainees are scarce though, and numbers studied are small. OBJECTIVE: The objective of this study was to determine how often and how GP trainees search for answers to clinical queries encountered in daily clinical practice. METHODS: Third-year GP trainees kept logs on all patient contacts for eight consecutive practice days. Information was obtained on patient contacts (description), clinical queries (frequency, type), seeking behaviour (frequency, moment, reason not to search, resources used, duration of search) and answers (frequency, impact). Descriptive analyses were performed"";"" frequencies and percentages were computed. We calculated the number of clinical queries per patient, the number of searches per query and the number of answers per search. RESULTS: Seventy-six trainees reported 1533 clinical queries about 7300 patients presenting 7619 complaints [mean of 0.2 queries per patient, standard deviation (SD) 0.1]. For most of the queries trainees pursued an answer (mean of 0.8 per query, SD 0.2), mostly during consultation (61% of searches), and frequently retrieved answers (mean of 0.8 per search, SD 0.17) they reported to improve clinical decision making in 26%. Most common resources were colleagues or supervisors (28%), and national GP guidelines (26%). The median duration of a search was 4 minutes (interquartile range 3). CONCLUSION: GP trainees have one clinical query per five patients. They often attempted to find answers and reported to succeed in most of the searches, primarily by consulting supervisors or colleagues and national GP guidelines.",0,0,
836,General practitioner views on the determinants of test ordering: a theory-based qualitative approach to the development of an intervention to improve immunoglobulin requests in primary care,"BACKGROUND: Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between general practitioners (GPs). This study aims to explore GP's views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in primary care. METHODS: Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or University Hospital Kerry in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample of GPs (stratified by GP requesting patterns) was generated from this list. GPs were purposively sampled based on the criteria of location (urban/rural)""; length of time qualified;"" and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software and analysed using the framework analysis method. Emerging themes were mapped to the theoretical domains framework (TDF), which outlines 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to identify potential intervention strategies. RESULTS: Sixteen GPs were interviewed (ten males and six females). Findings suggest that intervention strategies should specifically target the key barriers to effective test ordering, while considering the context of primary care practice. Seven domains from the TDF were perceived to influence immunoglobulin test ordering behaviours and were identified as 'mechanisms for change' (knowledge, environmental context and resources, social/professional role and identity, beliefs about capabilities, beliefs about consequences, memory, attention and decision-making processes and behavioural regulation). Using these TDF domains, seven BCTs emerged as feasible 'intervention content' for targeting GPs' ordering behaviour. These included instructions on how to effectively request the test (how to perform behaviour), information on GPs' use of the test (feedback on behaviour), information about patient consequences resulting from not doing the test (information about health consequences), laboratory/consultant-based advice/education (credible source), altering the test ordering form (restructuring the physical environment), providing guidelines (prompts/cues) and adding interpretive comments to the results (adding objects to the environment). These BCTs aligned to four intervention functions: education, persuasion, environmental restructuring and enablement. CONCLUSIONS: This study has effectively applied behaviour change theory to identify feasible strategies for improving immunoglobulin test use in primary care using the TDF, 'behaviour change wheel' and BCT taxonomy. The identified BCTs will form the basis of a theory-based intervention to improve the use of immunoglobulin tests among GPs. Future research will involve the development and evaluation of this intervention.",0,0,
837,General practitioners' reasons for the failure of a randomized controlled trial (The TIGER Trial) to implement epilepsy guidelines in primary care,"PURPOSE: To explore reasons for the failure of a randomized controlled trial to influence implementation of epilepsy guidelines in primary care, and to generate theory about likely contexts in which guidelines would lead to changes in clinician behavior. METHODS: Qualitative study based on focus groups and a single in-depth interview. Participants included 47 primary health care staff selected from a purposive sample of 13 urban and rural general practices. RESULTS: The key reason for the lack of implementation of the Scottish Intercollegiate Guidelines Network epilepsy guideline was an established pattern of general practitioner behavior, supported by practice staff, with which there was little perceived need to change. Secondary to this was a lack of knowledge of the existence and/or content of the guideline and perceived difficulties in implementing them in practice stemming from resource constraints and possible patient resistance. The individual behavior of clinicians was therefore rooted in wider service structures and policies. CONCLUSIONS: Guidelines may be more likely to be implemented where there are perceived problems with current service delivery. Attempts to facilitate the implementation of guidelines could also focus on areas where there is already a perceived need for guidance or a disruption in one of the underlying variables that maintain the health professional's role and practice. They may also be more likely where initiatives are focused more widely than individual physician behavior and are more broadly directed toward redesigning the wider care delivery systems by incorporating other providers to provide care coordination, enhancing patient self-management, and using information technology tools.",0,0,
838,General practitioners' uptake of clinical practice guidelines: a qualitative study,"OBJECTIVE: To explain recent rapid audited change in the uptake of locally implemented, evidence-based clinical guidelines for asthma and angina in primary care. METHODS: A case study of primary care in two matched, adjacent districts in Northern England, focusing on a stratified random sample of 49 general practitioners (GPs) from eight primary care groups. Data were collected from three cycles of mainly qualitative interviews carried out at six-monthly intervals, before and after the dissemination of local guidelines and after audit data were gathered. Interviews examined attitudes, awareness and impact of locally disseminated asthma and angina guidelines and the subsequent audit. Audit data on guideline uptake were also available from a parallel study. RESULTS: The rapid increase in guideline uptake observed in both intervention and control groups was not explained by individual practitioners or practice factors. The findings are attributed to GPs' awareness of policies for evidence-based medicine, of new health service institutions and of the clinical governance activities of primary care groups. Behaviour change reflects GPs' decisions about what to record in case notes as well as their clinical decisions, so that findings may reflect changing perceptions about accountability rather than about preferred treatment regimes. CONCLUSIONS: Guideline production and dissemination is best seen in the broader context of policy change. Studies of guideline implementation should report before and after data and incorporate significant qualitative components in order to identify important contextual factors.",0,0,
839,General surgeon's antibiotic stewardship: Climbing the Rogers Diffusion of Innovation Curve-Prospective Cohort Study,"INTRODUCTION: The primary aim of this study was to establish concordance of general surgeon's prescribing practice with local IV-oral antibiotic guidelines. The secondary aim was to evaluate the effect of introducing educational antibiotic measures. The Rogers Diffusion of Innovation Model was used to explore the adoption of antibiotic stewardship practices. METHODS: In this prospective, cohort study, data was collected on 100 pre and 100 post awareness intervention programme patients. The educational intervention comprised raising awareness of a) the guidelines b) pre-intervention results c) introducing an IV-oral antibiotic prompt sheet. The concordance with local guidelines was compared between pre- and post-intervention groups using Fisher's Exact Test or Pearson's Chi Test (SPSS Statistics V22). RESULTS: The concordance of general surgical doctors with local IV-oral antibiotic guidelines was poor and did not improve significantly following the awareness intervention programme. There was no uptake of the antibiotic prompt sheet. There was a trend towards increase in the number of patients switched from IV to oral antibiotics at 48-72 h and significant increase (p < 0.05) in number of patients with clearly documented intention to review IV antibiotics. CONCLUSION: Antibiotic governance measures failed to inspire even an initial group of innovators to use the antibiotic prompt sheets. It appears educational measures are effective in improving prescribing behavior and intent amongst a group of early adopters, but this fails to reach a critical mass. In order to improve antibiotic governance and embark upon the Rogers Diffusion of Innovation Curve, more must be done to engage general surgical doctors in timely, judicious antibiotic prescribing.",0,0,
840,Genetic evaluation of oocyte donors: recipient couple preferences and outcome of testing,"OBJECTIVE: To report preferences of recipient couples for genetic testing of their oocyte donors. DESIGN: Observational report of results from a genetic testing-options form implemented as part of routine care. SETTING: Private practice. PATIENT(S): Recipients and oocyte donors. INTERVENTION(S): Recipient couples completed a form before screening of their oocyte donor that outlined required screening and recommended tests that the couple could accept or decline. Couples were given information about carrier frequency, risk to their child if results were abnormal, and cost. MAIN OUTCOME MEASURE(S): Percentage of couples accepting optional testing. RESULT(S): Of the 63 couples with data available from their first testing-options form, 42 (67%) accepted and 21 (33%) declined fragile X testing, whereas 34 (54%) accepted and 29 (46%) declined karyotyping. When asked whether they would accept additional testing of their donor if it was recommended by a genetic counselor, 15 (24%) said that they would accept additional testing regardless of cost, 35 (56%) declined, and 13 (20%) indicated that their decision would depend on the cost. In many cases, history was elicited by the genetic counselor or test results were obtained that influenced further testing, decisions to proceed, or provided information important for the child. CONCLUSION(S): Recipient couples sometimes chose to decline tests that we recommended but did not require, despite the relatively low cost of this testing compared with the total cost of the oocyte donation cycle.",0,0,
841,Genetic testing for children and adolescents. Who decides?,"In the future there is likely to be a large array of DNA-based tests to diagnose single-gene disorders and to identify predispositions to genetically influenced disorders. This article focuses on ethical, legal, and psychological implications of testing healthy children and adolescents for such disorders. Testing may offer medical or psychological benefits but may harm parent-child bonds or the child's self-concept. Clinicians may encounter situations where they must weigh the child's or adolescent's wishes against wishes of parents. We examine the legal history and current status of minors as health care consumers""; psychosocial research on their maturity to make choices; impact of testing on intrafamilial relationships; views of national commissions on appropriate ages of assent and full informed consent; ethical and legal requirements for competence in children and adolescents;"" and disclosure of genetic information. We propose guidelines for predictive genetic testing and counseling of children and discuss risks and benefits of testing.",0,0,
842,Genetics support to primary care practitioners - a demonstration project,"Primary care practitioners need to be supported by specialist genetics services to enable them to cope effectively with the expanding relevance of genetics to their patients. Genetic counselors could be effective in such a role. This exploratory project set out to improve the Primary-Tertiary interface through piloting such a service to general practice for 1 year. Tailored genetic educational outreach was delivered by a genetic counselor to ten randomly selected general practices in central England for 12 months. A range of services were provided to the practices these included facilitated genetic update sessions, a responsive advice service and referral guidelines. The service was evaluated through pre and post intervention questionnaires and via seven semi-structured interviews. This article presents a description of the development and delivery of this service and also reports on the experiences of a sample of the participants. Participants reported positive attitudes to the service and said that they had gained knowledge and confidence, as well as recognized limitations and gaps in their current knowledge. The consistent link with a specialist genetics service provided by a genetic counselor had a positive impact during the project and participants have continued to utilize the genetic counselor for advice and support with genetic patient issues since the project was completed. This is the first example of this model of service provision. Further research, utilizing a larger sample and other measures of behavioral change needs to be carried out to assess whether this model should be adopted on a wider basis.",0,0,
843,German translation of Suicidal Patient Observation Chart (SPOC) - an instrument for practice,"Nursing of suicidal in-patients is a complex and responsible task. A direct and immediate intensive caring and therapeutic supervision, also known as special observation is still recommended in guidelines (DGPPN, 2012) and maybe one of the most used interventions in the caring of suicidal patients in inpatient settings. It involves many kinds to develop the relationship between the observer and the patient. The original SPOC was developed in Sweden with the aim to increase the quality of a systematically documentation during the supervision of suicidal patients. It is an instrument to ensure systematic documentation of observational behavior or noticeable mood during acute suicidal crisis, for example feelings like ""worried, anxious"" or other possible influencing factors like ""sudden mood variation"". By this means the SPOC can ensure the process of systematic documentation of special observation and increase its quality, i. e. who documented what at what time. Furthermore SPOC can facilitate a better communication of the observation process to the multidisciplinary team and to the patient as well. The SPOC includes the 28 items and covers 24 separate observation periods. The aim of this paper is to constitute the translation process from the English to the German SPOC version. The translation process followed a five step model. In the first step the English version was translated from two German native speakers. In the second step, the first two translation results where discussed by the Expert group (authors) and a new version was developed. In the third step the first german version was translated back (two English native Speakers) into English. The fourth step was taken, to review the results by the expert groups (authors) and set up the so called ""pre version"". The last step includes the proof of content validity by 52 nurses. The proof was able to identify a few misunderstandings and helped to enhance the tool in its final version. With the translation, the German-speaking nursing practice in psychiatry has a tool that can be used by psychiatric nurses regarding their complex interventions to be undertaken in this special group of patients.",0,0,
844,Gestational diabetes and hypertensive disorders of pregnancy as vascular risk signals: an overview and grading of the evidence,"The occurrence of common pregnancy-related medical disorders identifies women at high risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, and preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the 2-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance surveillance of vascular risk factors in these women after pregnancy is underappreciated by the women themselves and their physicians. Although a prudent diet and physically active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low"";"" qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.",0,0,
845,Getting the Most Out of Financial Incentives for Weight Loss,,0,0,
846,Global initiatives to enhance cancer care in areas of limited resources: what ASCO members are doing and how you can become involved,"Cancer is the leading cause of death worldwide. In 2008, 7.6 million deaths were attributable to cancer, representing 13% of all deaths. It is estimated that approximately 30% of cancer deaths are attributable to the five leading behavioral and dietary risks. These include high body mass index, low fruit and vegetable intake, lack of physical activity, and tobacco and alcohol use. A number of viral infections, such as hepatitis B and C and HPV, are responsible for approximately 20% of cancer deaths. Approximately 70% of cancer deaths occurred in low- and middle-income countries. Because of the increased numbers of elderly individuals and improved control of comorbidity, deaths from cancer worldwide are projected to continue rising, with an estimated 13.1 million deaths in 2030. To meet this need, the American Society of Clinical Oncology (ASCO) has evolved into a truly international organization. Over one-third of ASCO members practice in over 100 countries, representing the world's largest collection of expertise and insight into the treatment of cancer. More than one-half of ASCO's Annual Meeting attendees come from outside the United States. The Journal of Clinical Oncology is read by more than 24,000 subscribers worldwide and is available in a number of different languages. To fulfill its mission, ASCO has a number of international programs for sharing knowledge and providing the tools to assist clinicians worldwide in treating their patients. These programs include mentoring and knowledge exchange, education initiatives, and scientific and educational meetings. This provides ample opportunity for involvement to enhance cancer care worldwide.",0,0,
847,Global minimum essential requirements: a road towards competence-oriented medical education,"With the growing globalization of medicine and the emerging concept of a 'global profession of physicians', the issue of the essential competences that all physicians must possess becomes sharply focused. If defined, these competences would help indicate what teachers are supposed to teach, what students are expected to learn and what educational experiences all physicians must have. The 'minimum essential competences' that all graduates must have if they wish to be called physicians were identified by the Institute for International Medical Education (IIME), sponsored by the China Medical Board of New York, through working groups of educational and health policy experts and representatives of major international medical education organizations. In the first phase of the project, seven domains have been identified that define the knowledge, skills, professional behavior and ethics that all physicians must have, regardless of where they received their general medical training. Appropriate tools to assess each of the domains have been identified. In the second phase of the project the 'global minimum essential requirements' (GMER) will be implemented experimentally in a number of Chinese medical schools. The aim of the third phase will be to share the outcomes of this educational experiment, aimed at improving the quality of medical education, with the global education community.",0,0,
848,"Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015","BackgroundImproving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures."";"" BackgroundImproving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.",0,0,
849,Go,,0,0,
850,GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines,"Summary points Clinicians regularly face situations with two or more alternative actions. Each alternative often has different advantages and disadvantages, including differences in effectiveness, adverse effects, costs and other factors …",0,0,
851,Gradual Versus Abrupt Smoking Cessation,,0,0,
852,"Group cognitive behavioural therapy for first episode psychosis: who's referred, who attends and who completes it?","AIM: Most national guidelines recommend psychological therapy for people with first-episode psychosis (FEP) but interventions proven effective in randomized control trials (RCTs) conducted in research settings do not always translate effectively to real-world clinical environments. In a limited health system, it is important to understand the system and patient barriers to participation in effective treatment. We sought to determine what patient characteristics influenced clinicians' decision to refer or not to refer to group cognitive behavioural therapy for FEP and what characteristics were associated with those referred attending/not attending and adhering/not adhering to the programme. METHODS: Between 2006 and 2008, all cases of confirmed FEP from a defined geographical region were examined using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses, the Scale for Assessment of Positive Symptoms, Scale for Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia and Birchwood Insight Scale. Duration of untreated psychosis was established using the Beiser Scale. RESULTS: Of the 124 (77 males, 47 females) people in the final sample, 88 (72%) were referred for cognitive behavioural therapy (CBT), 52 (59%) attended and 12 (23%) did not complete CBT. Those with higher levels of insight into the need for treatment (U = 740.00, z = -2.63, P = 0.008) and higher levels of positive symptoms (t (120) = -3.064, P = 0.003) were more likely to be referred to CBT. Those with higher educational attainment (chi(2) = 9.48, P = 0.03) and fewer negative symptoms, particularly in relation to global attention (t (85) = 2.32, P = 0.03), were more likely to attend and complete CBT. CONCLUSION: Within an early intervention service for FEP, it appears that individuals with less education, more negative symptoms and less insight experienced significant barriers to successfully completing group CBT. More information for referring clinicians about the benefits of CBT for FEP could help increase referral rates. Assertive outreach for people at risk of disengaging or non-adherence should also be considered.",0,0,
853,Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation,"OBJECTIVE To examine the effectiveness and cost-effectiveness of group therapy for self harm in young people. DESIGN Two arm, single (assessor) blinded parallel randomised allocation trial of a group therapy intervention in addition to routine care, compared with routine care alone. Randomisation was by minimisation controlling for baseline frequency of self harm, presence of conduct disorder, depressive disorder, and severity of psychosocial stress. PARTICIPANTS Adolescents aged 12-17 years with at least two past episodes of self harm within the previous 12 months. Exclusion criteria were: not speaking English, low weight anorexia nervosa, acute psychosis, substantial learning difficulties (defined by need for specialist school), current containment in secure care. Setting Eight child and adolescent mental health services in the northwest UK. INTERVENTIONS Manual based developmental group therapy programme specifically designed for adolescents who harm themselves, with an acute phase over six weekly sessions followed by a booster phase of weekly groups as long as needed. Details of routine care were gathered from participating centres. MAIN OUTCOME MEASURES Primary outcome was frequency of subsequent repeated episodes of self harm. Secondary outcomes were severity of subsequent self harm, mood disorder, suicidal ideation, and global functioning. Total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses, were recorded. RESULTS 183 adolescents were allocated to each arm (total n = 366). Loss to follow-up was low (<4%). On all outcomes the trial cohort as a whole showed significant improvement from baseline to follow-up. On the primary outcome of frequency of self harm, proportional odds ratio of group therapy versus routine care adjusting for relevant baseline variables was 0.99 (95% confidence interval 0.68 to 1.44, P = 0.95) at 6 months and 0.88 (0.59 to 1.33, P = 0.52) at 1 year. For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to 1.20, P = 0.29) at 6 months and 0.94 (0.63 to 1.40, P = 0.75) at 1 year. Total 1 year costs were higher in the group therapy arm (£21,781) than for routine care (£15,372) but the difference was not significant (95% CI -1416 to 10782, P = 0.132). CONCLUSIONS The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations. Trial registration ISRCTN 20496110.",0,0,
854,Growth and nutritional risk in children with developmental delay,"INTRODUCTION: Nutritional risk impacts outcome in developmental delay. The main objectives were to identify the incidence and factors contributing to growth faltering. METHODS: Clinical data review was completed for 500 patients with developmental delay accepted to an Early Intervention service. Data was collected using the standardised parent nutrition screening checklist prior to and at time of initial dietary assessment. Data was compared to nutritional assessment data, GOSH and FSAI dietary guidelines. Weight category was determined using RCPCH growth and BMI charts. Statistical analysis was conducted using Statistical Package for the Social Sciences version 20 (IBM Statistics 20.0). RESULTS: Nutritional risk was identified in 48.6 %. Weight categories were growth faltering (13.5 %), underweight (7.7 %), overweight (8.4 %) and obesity (4.3 %) at initial assessment. Growth faltering was correlated with age <1 year (p = 0.000) and with gestational age (p = 0.017) with highest rates identified in those born 32-36 weeks (3.6 %). Weight category was associated with introduction of solids pre 17 weeks recommendation (10.1 %), ANOVA demonstrating significance (P = 0.013). There was poor parental recognition of nutritional risk in 22.7 % of those assessed. Nutritional difficulties were common: 4.2 % were enterally fed, 7.7 % were on prescribed nutritional supplements, 29.1 % (n = 121) had feeding difficulties and 13.9 % (n = 58) had behavioural feeding difficulties. Iron intake did not meet the recommended intake in 20.9 % (n = 87), calcium in 4.5 % (n = 19). The prevalence of constipation was 21.6, 11.8 % of whom required medical management. CONCLUSIONS: Developmental delay predisposes to nutritional deficits which influence outcome. Screening, assessment and timely interventions are warranted to prevent poorer developmental outcomes.",0,0,
855,Guideline adherence in management of stable chronic obstructive pulmonary disease,"BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the only leading cause of death with rising morbidity and mortality. Clinical practice guidelines (CPGs) to optimize pharmacotherapy for patients with COPD have been updated based on promising results of randomized clinical trials. We examined the frequency of and factors associated with guideline adherence by physicians in clinical practice at an academic medical center. METHODS: Patients with a clinical diagnosis of COPD, confirmed by spirometry, who presented to the ambulatory clinics, were enrolled. The primary outcome was provider's adherence to the 2007 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Subjects were categorized as guideline-concordant who received a rescue inhaler (all patients), or at least one long-acting bronchodilator (stage II), or at least one long-acting bronchodilator plus an inhaled corticosteroid (stage III-IV). Demographics, clinical information and type of provider were recorded. Provider type was classified as primary care physician (PCP), pulmonologist, or co-management by both. RESULTS: Among 450 subjects who met study criteria, 246 (54.7%) received guideline-concordant treatment. Age, sex, race, disease severity, and co-morbidities were not associated with guideline adherence. Multivariate analysis showed that patients co-managed by a PCP and pulmonologist had a higher likelihood of receiving guideline-concordant treatment than those managed by one or the other (Odds Ratio: 4.59"";"" 95% Confidence Interval: 2.92, 7.22, p < 0.001). CONCLUSIONS: Just over half of stable COPD patients receive guideline-concordant care. Co-management by a PCP and pulmonologist increases the likelihood of receiving guideline-concordant inhaler therapy.",0,0,
856,Guideline implementation in allied health professions: a systematic review of the literature,"BACKGROUND: Clinical guidelines aim to improve the safety and quality of patient care by providing clinicians with graded recommendations based on evidence of best practice. OBJECTIVE: To evaluate the effects of the introduction of clinical guidelines for allied health professionals, and to estimate the effectiveness of the guideline dissemination and implementation strategies used. METHODS: A comprehensive search of six electronic databases to June 2006 and the Cochrane Effective Practice and Organisation of Care database was conducted. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies were included if the intervention was aimed at implementing guidelines in the allied health professions. Articles were screened for eligibility and their methodological quality was assessed"";"" data were extracted independently by two reviewers. RESULTS: Fourteen studies met the inclusion criteria. The methodological quality varied greatly, with the proportion of quality criteria met ranging from 0 to 6 out of seven. In most studies, the effects reported for patient and process outcomes were small and in favour of the intervention group. Of the 14 included studies, 10 focused on educational interventions. Six of the 14 studies used a single intervention strategy and seven used a multi-faceted implementation strategy. One study compared both single and multi-faceted strategies. Multi-faceted interventions were no more effective than single intervention strategies and effects of the same strategy varied across trials. CONCLUSIONS: There is no evidence to support a set guideline implementation strategy for allied health professionals. When implementing clinical guidelines it is important to first identify specific barriers to change using theoretical frameworks of behaviour change and then develop strategies that deal with these barriers. When measuring the effectiveness of these strategies, professionals should consider the use of both patient and process outcomes and choose outcomes that reflect their aims.",0,1,
857,Guideline implementation: what the literature doesn't tell us,"BACKGROUND: Despite large numbers of studies and literature reviews about guideline implementation, it remains unclear whether and how clinical guidelines can be used to improve the quality of medical care. This study sought to learn whether these studies and reviews have recognized the importance of systems thinking and organizational change for implementation. METHODS: A literature search was conducted for systematic reviews of guideline implementation or practice improvement studies. Each review was studied for the extent to which it identified or discussed the value of systems changes, organizational support, practice environmental factors, and use of a change process. RESULTS: Forty-seven good-quality systematic reviews were found. They largely concurred that using reminders and perhaps using feedback in the course of clinical encounters were the most effective ways of implementing guidelines. However, these same reviews rarely identified these strategies as systems changes, and there was little discussion about any need for organizational support or attention to various environmental variables that might affect implementation. The change process required to introduce a new or changed practice system received even less attention. CONCLUSION: Reviews of guideline implementation trials have focused on how to change the behavior of individual clinicians. There has been little attention to the impact of practice systems or organizational support of clinician behavior, the process by which change is produced, or the role of the practice environmental context within which change is being attempted. New attention to these issues may help us to better understand and undertake the process of improving medical care delivery.",0,1,
858,Guideline 'Overweight' for child health care,"The '5th National Growth Study' indicates that the percentage of overweight children in the Netherlands has risen from 9-12% in 1997 to 13-15% in 2009. Child Health Care is a unique setting for promotion of development, growth and behaviour of children, in which tailored prevention can be offered. Detection of overweight in children and intervention by Child Health Care takes place in a multidisciplinary setting linking general practitioners, paediatricians, dieticians, teachers, physiotherapists, pedagogues and psychologists. For overweight children, a change plan is created based on exercise, playing outside, having breakfast every day, as little as possible sweetened beverages and fast-food, and less time spent in front of the television or computer, with fewer energy-rich snacks. As recommended in the Dutch CBO guideline 'Obesity', obese children are referred to a general practitioner or paediatrician.",0,0,
859,Guideline-based early rehabilitation after myocardial infarction. A pragmatic randomised controlled trial,"OBJECTIVES: To determine the effectiveness of individualised educational behavioural treatment delivered by cardiac nurses in hospital compared to usual care for patients following acute myocardial infarction. METHODS: One hundred and fourteen consecutive patients were randomised to receive the intervention or usual care. Outcome assessment was by self-report questionnaire (the Hospital Anxiety and Depression Scale and Dartmouth COOP Health Status), interview at 1 month, and self-report at 3 and 12 months. The primary outcome was improvement in the Dartmouth COOP total score from baseline to 3 months. RESULTS: Four patients needed to be treated to give an additional patient with improvement in health status at 3 months (number needed to treat [NNT] 4, 95% confidence intervals [CIs] 3 to 12). The intervention group were more confident about returning to activities 1 month after discharge from hospital. Treated patients had fewer further treatment needs. CONCLUSIONS: An individualised educational behavioural treatment delivered by cardiac nurses in hospital may have substantial benefits. A large-scale pragmatic RCT is needed.",0,0,
860,Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial,"OBJECTIVES: To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control""; mailed guidelines;"" mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed. RESULTS: No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions. CONCLUSIONS: Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour.",0,0,
861,Guidelines and the psychology of medical decision making in the treatment of depressive disorders,Guidelines aim at improving medical decision making. Guidelines try to influence medical behaviour in contrast to textbooks and reviews which want to improve medical knowledge. Scientific models of medical decision making such as the action theory and empirical data on the effects of guidelines suggest that guidelines will not always reach their goal but instead can even deteriorate medical quality. The problem of guidelines in medicine is discussed in reference to depressive disorders. The problems at stake are nevertheless valid for medicine as a whole. Therefore it must be tested in controlled clinical trials whether guideline exposed physicians have better results with their patients than guideline naive physicians. Only such guidelines should be called evidence based for which positive effects have been empirically demonstrated.,0,0,
862,Guidelines as rationing tools: a qualitative analysis of psychosocial patient selection criteria for cardiac procedures,"BACKGROUND: Cardiac procedure guidelines often include psychosocial criteria for selecting patients that potentially introduce social value judgements into clinical decisions and decisions about the rationing of care. The aim of this study was to investigate the terms and justifications for and the meanings of psychosocial patient characteristics used in cardiac procedure guidelines. METHODS: We selected English-language guidelines published since 1990 and chapters in textbooks published since 1989. These guidelines amalgamated multiple sources of evidence and expertise and made recommendations regarding patient selection for specific procedures. A multidisciplinary team of physicians and social scientists extracted passages regarding psychosocial criteria and developed categories and conceptual relationships to describe and interpret their content. RESULTS: Sixty-five papers met the criteria for inclusion in the study. Forty-five (69%) mentioned psychosocial criteria as procedure indications or contraindications. The latter fell into several categories, including behavioural and psychological issues, relationships with significant others, financial resources, social roles and environmental circumstances. INTERPRETATION: Psychosocial characteristics are portrayed as having 2 roles in patient selection: as risk factors intrinsic to the candidate or as indicators of need for special intervention. Guidelines typically simply list psychosocial contraindications without clarifying their specific nature or providing any justification for their use. Psychosocial considerations can help in the evaluation of patients for cardiac procedures, but they become ethically controversial when used to restrict access. The use of psychosocial indications and contraindications could be improved by more precise descriptions of the psychosocial problem at issue, explanations regarding why the criterion matters and justification of the characteristic using a biological rationale or research evidence.",0,0,
863,Guidelines for Adolescent Preventive Services: the GAPS in practice,"DESIGN: Pre- and post-Guidelines for Adolescent Preventive Services (GAPS) comparison of outcomes gathered via chart audit. SETTING: A rural hospital-based general pediatric clinic. PARTICIPANTS: Adolescents who underwent annual examinations between April 1, 1998, and March 31, 2001. A random sample of 441 medical records was reviewed. INTERVENTION: Training in the GAPS model and use of the questionnaire began in April 1998. MAIN OUTCOME MEASURES: Detection of, discussion of, and referrals for GAPS-related risk behavior. RESULTS: The medical records of 162 younger adolescents (aged 11-15 years) and 279 older adolescents (aged 16-19 years) were audited. Detection of risk behaviors increased from 19% at baseline to 95% with the initial GAPS and 87% with the periodic GAPS. The most prevalent risk factor was having a rifle or gun in the home (younger adolescents, 47% and older adolescents, 39%). The mean number of risk behaviors and health concerns documented was higher in the initial GAPS (4.8 and 1.3, respectively) than in the periodic GAPS (3.8 and 0.7) (P =.01 and.006). The GAPS questionnaires detected lower levels of risk behavior compared with a local Youth Risk Behavior Survey. Controlling for sex, age, and clinician, discussion of psychosocial topics increased during the study period"";"" however, there was considerable variation among clinicians regarding the topics addressed. The GAPS-related referral rate did not change significantly. CONCLUSION: The GAPS model increases clinicians' detection and discussion of risk behaviors.",0,0,
864,Guidelines for assessing postnatal problems: introducing evidence-based guidelines in Australian general practice,"BACKGROUND: Postnatal morbidity is high, and many GPs lack the confidence and knowledge to deal with common postnatal problems. There is a high consultation rate, but few women disclose common health problems. OBJECTIVE: The aim of the present study was to increase the knowledge and skills of GPs to enable them to identify and manage common health problems experienced by women in the year following childbirth. METHODS: An educational programme [Guidelines for Assessing Postnatal Problems (GAPP)] embedded within a large randomized community intervention trial [Program of Resources, Information and Support for Mothers (PRISM)] with a before/after evaluation was undergone by Australian GPs working in four metropolitan and four rural communities. The programme comprised audit, interactive workshops, role-play and evidence-based guidelines, and was evaluated at baseline and 6 months through written questionnaires and a surgery consultation with a trained simulated patient evaluator. RESULTS: A total of 68 (86%) GPs took part in the full GAPP programme. The odds of a GP improving on the knowledge items ranged from 1.0 to 16, with the greatest change occurring in knowledge about the effectiveness of cognitive behavioural therapy for maternal depression. Of the GPs with an incorrect response at baseline, the percentage demonstrating improved knowledge at follow-up ranged from 22 to 100%. Around half of the GPs demonstrated excellent communication skills at baseline. Of the remaining GPs, more than half demonstrated greatly improved skills to detect common postnatal problems at follow-up. At baseline simulated patient visit, 70% of GPs inquired about sexual problems yet none inquired about the possibility of abuse, whereas at follow-up 94% inquired about sexual problems and 51.5% facilitated the disclosure of physical and emotional abuse. Anonymous feedback on the programme by participating GPs showed that 89% believed the programme positively influenced their actual practice. Interestingly, GPs demonstrated greater knowledge and skills in the simulated setting than on the written questionnaire. CONCLUSIONS: This relatively brief multifaceted educational programme assisted many participants in improving their knowledge and the skills required to improve both physical and emotional health after birth. Despite being experienced clinicians and participating actively in a programme on interviewing skills, half of the GPs did not facilitate disclosure of the underlying sensitive issue (abuse) during the follow-up consultation and could benefit from further in-depth training in effective communication skills.",0,0,
865,"Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU","OBJECTIVE: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. METHODS: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. RESULTS: The scoping review yielded 683 qualitative studies""; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches;"" 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. CONCLUSIONS: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.",0,0,
866,Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel,"DESCRIPTION: After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. METHODS: A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. RECOMMENDATIONS: Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.",0,0,
867,Guidelines for interaction by the therapeutic team in inpatient treatment of patients with chronic neurotic disorders,"In treatment of in-patients with chronic neurotic disorders we tried both to reduce distress in the therapeutic team (doctors, nurses, other therapists) as usually caused by those patients, and to improve outcome of treatment. Therefore, three to five guidelines on how to deal with the patient were given to the therapeutic team, and illustrated by possible literal statements to the patient. The guidelines aimed at a general interactional approach to the patient and did not determine specific therapeutic interventions. They were set up following principles of Brief Therapy as developed at the Mental Research Institute in Palo Alto. Results of our intervention in treatment of ten patients are reported. The therapeutic team rated the guidelines generally as positive. The therapeutic outcome varied greatly. A comparison with a matched pair control group showed a favourable tendency. Initial ratings by the team of the prescriptions predicted eventual improvement of the patients.",0,0,
868,Guidelines for medical treatment for stroke prevention,,0,0,
869,Guidelines for Quality Management of Apallic Syndrome / Vegetative State,"INTRODUCTION: Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade. METHODS: A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations. FINDINGS: The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of ""AS full, remission, defect and end stages"" require further professional training and expertise for doctors and rehabilitation personnel. INTERPRETATION: Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment"";"" however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.",0,0,
870,Guidelines for reporting of health interventions using mobile phones: mobile health (mHealth) evidence reporting and assessment (mERA) checklist,"To improve the completeness of reporting of mobile health (mHealth) interventions, the WHO mHealth Technical Evidence Review Group developed the mHealth evidence reporting and assessment (mERA) checklist. The development process for mERA consisted of convening an expert group to recommend an appropriate approach, convening a global expert review panel for checklist development, and pilot testing the checklist. The guiding principle for the development of these criteria was to identify a minimum set of information needed to define what the mHealth intervention is (content), where it is being implemented (context), and how it was implemented (technical features), to support replication of the intervention. This paper presents the resulting 16 item checklist and a detailed explanation and elaboration for each item, with illustrative reporting examples. Through widespread adoption, we expect that the use of these guidelines will standardise the quality of mHealth evidence reporting, and indirectly improve the quality of mHealth evidence. #### Summary points Mobile technologies have the potential to bridge systemic gaps needed to improve access to and use of health services, particularly among underserved populations. mHealth—defined as the use of mobile and wireless technologies for health—aims to capitalise on the rapid uptake of information and communication technologies (ICT) to improve health system efficiency and health outcomes. Over the past decade, global enthusiasm and the interest of development …",0,0,
871,Guidelines for the use and interpretation of assays for monitoring autophagy (3rd edition),,0,0,
872,Guidelines in professions allied to medicine,"BACKGROUND: Clinical practice guidelines aim to reduce inappropriate variations in practice and to promote the delivery of evidence-based health care. OBJECTIVES: To identify and assess the effects of studies of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (1975 to 1996), EMBASE, Cinahl and Sigle to 1996, the NHS Economic Evaluations Database (1994 to 1996), DHSS-Data (1983 to 1996), the Database of Abstracts of Reviews of Effectiveness (1994 to 1996) and reference lists of articles. We also hand searched the journal Quality in Health Care, made personal contact with content experts and contacted libraries identified by an expert panel. SELECTION CRITERIA: Randomised trials, controlled before-and-after studies and interrupted time series analyses of the introduction of interventions comparing 1. Clinical guidelines plus dissemination and/or implementation strategies versus no guidelines""; 2. Guidelines plus dissemination and/or implementation strategies versus guidelines plus alternative dissemination and/or implementation strategies; and 3. (post hoc) Guidelines used by professions allied to medicine versus standard physician care. The participants were nurses, midwives and other professions allied to medicine. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Eighteen studies were included involving more than 467 health care professionals. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group;"" one study was aimed solely at dieticians. The various behaviours targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies were identified for comparison 1. Three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies were identified for comparison 2 but it was difficult to draw firm conclusions because of poor methods. Six studies were identified for comparison 3 (post hoc). These studies generally supported the hypothesis that there was no difference between care given by nurses using clinical guidelines and standard physician care. REVIEWER'S CONCLUSIONS: There is some evidence that guideline-driven care is effective in changing the process and outcome of care provided by professions allied to medicine. However, caution is needed in generalising findings to other professions and settings.",0,1,
873,Guidelines on smoking management during the perioperative period,"Smoking is a public health problem of particular importance during the perioperative period, since it exposes patients scheduled for surgery to risk increases of 20% in hospital mortality and 40% in major postoperative complications. In addition, current smoking increases almost all specific surgical complications. The perioperative period offers a genuine opportunity for smoking cessation. The rate of preoperative smoking cessation can be increased significantly by offering behavior management and the prescription of a nicotine substitute before any scheduled surgical intervention. Preoperative smoking cessation should be routinely recommended independently of the timing of the intervention, even though the benefits increase in proportion with the length of cessation. All professionals of the care pathway (general practitioners, surgeons, anesthetists-intensivists, caregivers) must inform smokers of the positive effects of smoking cessation and offer them dedicated management and personalized follow-up. In children, cessation of parental smoking or removal of the child from environmental tobacco smoke as long before surgery as possible is indispensable.",0,0,
874,"Guidelines, editors, pharma and the biological paradigm shift","Private investment in biomedical research has increased over the last few decades. At most places it has been welcomed as the next best thing to technology itself. Much of the intellectual talent from academic institutions is getting absorbed in lucrative positions in industry. Applied research finds willing collaborators in venture capital funded industry, so a symbiotic growth is ensured for both.There are significant costs involved too. As academia interacts with industry, major areas of conflict of interest especially applicable to biomedical research have arisen. They are related to disputes over patents and royalty, hostile encounters between academia and industry, as also between public and private enterprise, legal tangles, research misconduct of various types, antagonistic press and patient-advocate lobbies and a general atmosphere in which commercial interest get precedence over patient welfare.Pharma image stinks because of a number of errors of omission and commission. A recent example is suppression of negative findings about Bayer's Trasylol (Aprotinin) and the marketing maneuvers of Eli Lilly's Xigris (rhAPC). Whenever there is a conflict between patient vulnerability and profit motives, pharma often tends to tilt towards the latter. Moreover there are documents that bring to light how companies frequently cross the line between patient welfare and profit seeking behaviour.A voluntary moratorium over pharma spending to pamper drug prescribers is necessary. A code of conduct adopted recently by OPPI in India to limit pharma company expenses over junkets and trinkets is a welcome step.Clinical practice guidelines (CPG) are considered important as they guide the diagnostic/therapeutic regimen of a large number of medical professionals and hospitals and provide recommendations on drugs, their dosages and criteria for selection. Along with clinical trials, they are another area of growing influence by the pharmaceutical industry. For example, in a relatively recent survey of 2002, it was found that about 60% of 192 authors of clinical practice guidelines reported they had financial connections with the companies whose drugs were under consideration. There is a strong case for making CPGs based not just on effectivity but cost effectivity. The various ramifications of this need to be spelt out. Work of bodies like the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration and Guidelines Advisory Committee (GAC) are also worth a close look.Even the actions of Foundations that work for disease amelioration have come under scrutiny. The process of setting up 'Best Practices' Guidelines for interactions between the pharmaceutical industry and clinicians has already begun and can have important consequences for patient care. Similarly, Good Publication Practice (GPP) for pharmaceutical companies have also been set up aimed at improving the behaviour of drug companies while reporting drug trialsThe rapidly increasing trend toward influence and control by industry has become a concern for many. It is of such importance that the Association of American Medical Colleges has issued two relatively new documents - one, in 2001, on how to deal with individual conflicts of interest""; and the other, in 2002, on how to deal with institutional conflicts of interest in the conduct of clinical research. Academic Medical Centers (AMCs), as also medical education and research institutions at other places, have to adopt means that minimize their conflicts of interest.Both medical associations and research journal editors are getting concerned with individual and institutional conflicts of interest in the conduct of clinical research and documents are now available which address these issues. The 2001 ICMJE revision calls for full disclosure of the sponsor's role in research, as well as assurance that the investigators are independent of the sponsor, are fully accountable for the design and conduct of the trial, have independent access to all trial data and control all editorial and publication decisions. However the findings of a 2002 study suggest that academic institutions routinely participate in clinical research that does not adhere to ICMJE standards of accountability, access to data and control of publication.There is an inevitable slant to produce not necessarily useful but marketable products which ensure the profitability of industry and research grants outflow to academia. Industry supports new, not traditional, therapies, irrespective of what is effective. Whatever traditional therapy is supported is most probably because the company concerned has a product with a big stake there, which has remained a 'gold standard' or which that player thinks has still some 'juice' left.Industry sponsorship is mainly for potential medications, not for trying to determine whether there may be non-pharmacological interventions that may be equally good, if not better. In the paradigm shift towards biological psychiatry, the role of industry sponsorship is not overt but probably more pervasive than many have realised, or the right thinking may consider good, for the health of the branch in the long run.An issue of major concern is protection of the interests of research subjects. Patients agree to become research subjects not only for personal medical benefit but, as an extension, to benefit the rest of the patient population and also advance medical research.We all accept that industry profits have to be made, and investment in research and development by the pharma industry is massive. However, we must also accept there is a fundamental difference between marketing strategies for other entities and those for drugs.The ultimate barometer is patient welfare and no drug that compromises it can stand the test of time. So, how does it make even commercial sense in the long term to market substandard products? The greatest mistake long-term players in industry may make is try to adopt the shady techniques of the upstart new entrant. Secrecy of marketing/sales tactics, of the process of manufacture, of other strategies and plans of business expansion, of strategies to tackle competition are fine business tactics. But it is critical that secrecy as a tactic not extend to reporting of research findings, especially those contrary to one's product.Pharma has no option but to make a quality product, do comprehensive adverse reaction profiles, and market it only if it passes both tests.Why does pharma adopt questionable tactics? The reasons are essentially two:What with all the constraints, a drug comes to the pharmacy after huge investments. There are crippling overheads and infrastructure costs to be recovered. And there are massive profit margins to be maintained. If these were to be dependent only on genuine drug discoveries, that would be taking too great a risk.Industry players have to strike the right balance between profit making and credibility. In profit making, the marketing champions play their role. In credibility ratings, researchers and paid spokes-persons play their role. All is hunky dory till marketing is based on credibility. When there is nothing available to make for credibility, something is projected as one and marketing carried out, in the calculated hope that profits can accrue, since profit making must continue endlessly. That is what makes pharma adopt even questionable means to make profits.Essentially, there are four types of drugs. First, drugs that work and have minimal side-effects; second, drugs which work but have serious side-effects; third, drugs that do not work and have minimal side-effects;"" and fourth, drugs which work minimally but have serious side-effects. It is the second and fourth types that create major hassles for industry. Often, industry may try to project the fourth type as the second to escape censure.The major cat and mouse game being played by conscientious researchers is in exposing the third and fourth for what they are and not allowing industry to palm them off as the first and second type respectively. The other major game is in preventing the second type from being projected as the first. The third type are essentially harmless, so they attract censure all right and some merriment at the antics to market them. But they escape anything more than a light rap on the knuckles, except when they are projected as the first type.What is necessary for industry captains and long-term players is to realise:Their major propelling force can only be producing the first type. 2. They accept the second type only till they can lay their hands on the first. 3. The third type can be occasionally played around with to shore up profits, but never by projecting them as the first type. 4. The fourth type are the laggards, real threat to credibility and therefore do not deserve any market hype or promotion.In finding out why most pharma indulges in questionable tactics, we are lead to some interesting solutions to prevent such tactics with the least amount of hassles for all concerned, even as both profits and credibility are kept intact.",0,0,
875,Guidelines-based indicators to measure quality of antenatal care,"RATIONALE, AIMS AND OBJECTIVES: No comprehensive measurement of quality of antenatal care is available. Late booking or low number of checks are often used as surrogate for poor quality, leaving uncertainty on the actual content of the care received. In order to fill this gap, we have reviewed two sets of clinical guidelines and developed corresponding indicators of quality. METHOD: A group of clinicians and methodologists reviewed the National Institute for Clinical Excellency Clinical Guidelines on antenatal care, and the list of prenatal care interventions recommended by the Research and Development Group, both based on evidence of effectiveness of specific interventions. We identified single aspects in three domains: (1) services utilization""; (2) screening; and (3) interventions. For each indicator, we defined: (1) eligibility, that is the characteristics of the women to whom the indicator applies; (2) standard, that is the situation when the target is met;"" and (3) moderators, that is all conditions which legitimately hamper the fulfilment of the standard. RESULTS: We developed four indicators of service utilization, 25 of screening and 17 of intervention. The respective eligibility, standard and moderators criteria were described for each indicator. While many indicators could be retrospectively evaluated from medical charts, quality of communication with provider, screening for sensible issues and counselling on behaviours to be avoided could only be obtained with a prospective data collection. CONCLUSIONS: The indicators of quality of antenatal care, complemented by measures of social position, social support and immigrant/ethnic status, allow for a careful description of the gaps in quality of care for specific groups of women.",0,0,
876,Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia,"BACKGROUND: Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. METHODS: LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing"";"" and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. CONCLUSION: While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.",0,0,
877,Harnessing the power of default options to improve health care,Decision makers sometimes face a default choice — the option that will be implemented if an alternative is not actively chosen. Health care quality can be improved by default options such as administering vaccinations to eligible hospitalized patients who do not decline them. The authors argue that these options should be set strategically and used to improve public health.,0,1,
878,Hazards at work,,0,0,
879,"Head Start children's lifestyle behaviors, parental perceptions of weight, and body mass index","This study examined lifestyle behaviors (food intake, active play, and screen time), parental perception of children's weight, and body mass index (BMI) of children enrolled in Head Start. Ninety-six parent-child dyads participated. Obesity prevalence (15.6%) was higher than the national average (10.4%)"";"" however, most parents (86.5%) of obese children did not perceive their children as obese. Regardless of BMI, food intake and active play levels generally did not meet recommended guidelines. Further, children who were less active were more likely to eat snacks (chi(2) = 6.24, p < or = .04). The role of pediatric nurses in counseling and referring Head Start families is explored.",0,0,
880,Heal thyself or heal thy system: can doctors help to improve medical care?,,0,0,
881,Health and nutrition education unit in a children's hospital,,0,0,
882,"Health information, behavior change, and decision support for patients with type 2 diabetes: development of a tailored, preference-sensitive health communication application","PURPOSE: Patient involvement in diabetes treatment such as shared decision-making and patient self-management has significant effects on clinical parameters. As a prerequisite for active involvement, patients need to be informed in an adequate and preference-sensitive way. Interactive Health Communication Applications (IHCAs) that combine web-based health information for patients with additional support offer the opportunity to reach great numbers of patients at low cost and provide them with high-quality information and support at the time, place, and learning speed they prefer. Still, web-based interventions often suffer from high attrition. Tailoring the intervention to patients' needs and preferences might reduce attrition and should thereby increase effectiveness. The purpose of this study was to develop a tailored IHCA offering evidence-based, preference-sensitive content and treatment decision support to patients with type 2 diabetes. The content was developed based on a needs assessment and two evidence-based treatment guidelines. The delivery format is a dialogue-based, tunneled design tailoring the content and tone of the dialogue to relevant patient characteristics (health literacy, attitudes toward self-care, and psychological barriers to insulin treatment). Both content and tailoring were revised by an interdisciplinary advisory committee. CONCLUSION: The World Wide Web holds great potential for patient information and self-management interventions. With the development and evaluation of a tailored IHCA, we complement face-to-face consultations of patients with their health care practitioners and make them more efficient and satisfying for both sides. Effects of the application are currently being tested within a randomized controlled trial.",0,0,
883,"Health literacy training for public health nurses in fukushima: a case-study of program adaptation, implementation and evaluation","Health literacy comprises not only an individual's ability to gain access to, understand and use health information, but also health care providers' ability to make health information accessible and usable. The Fukushima nuclear accident has posed challenges related to the communication of radiation-related health information. Public health nurses are gatekeepers of community health in Japan, and have primary responsibility for communicating this complex information about science and risk to lay members of the community. A health literacy training program was designed to augment communication skills of participating nurses with two primary goals: changing communication practices and norms among public health nurses, and improving access to information for community residents. Training content incorporated an overview of health literacy skills (including numeracy), processes for assessing written materials and visual displays, as well as guidelines for text improvement. The workshop was spread across two days with two-hour sessions each day. A proximal post-training evaluation survey was conducted, followed by a more distal one-month follow-up evaluation to assess the application of learned skills in practice. Twenty-six nurses in Fukushima City attended the first trial. Post-training evaluations were highly positive, with agreement from 85-100% of participants on the appropriateness and usefulness of the workshop. During a one-month follow-up, the nurses reported applying new knowledge and skills to develop written materials. However, they faced difficulties sharing their new skills with colleagues and challenges changing work norms. Participants also encountered difficulties using graphics and explaining risks in practice. This paper highlights the importance of providing health literacy training opportunities for professionals to strengthen health system's ability to accessible information and services. This program also serves as important reference for future disaster management efforts.",0,0,
884,Health professionals' attitudes toward acute diarrhea management,"BACKGROUND: Travelers' diarrhea is the most frequent health problem in those participating in international journeys, and is responsible for many consultations abroad and on return home. METHODS: A questionnaire assessing attitudes toward treatment and management of travel-related and nontravel-related diarrhea was administered to 542 GPs, nurses and pharmacists. RESULTS: Health professionals' attitudes to management of acute diarrhea are variable, with marked divergence regarding adherence to published ""good practice"" guidelines and recommendations. Inconsistencies exist in stated attitudes toward prescribing antispasmodics and antimotility agents and actual prescribing behavior. CONCLUSIONS: Current treatment guidelines may be outdated. Inappropriate or delayed treatment disadvantages the patient. Limiting the use of antidiarrheal agents can deny access, for those inflicted with diarrhea, to a medication which may shorten symptomatology and morbidity, and speed the return to normality. Review of guidelines for diarrhea management in adults is overdue, as is standardization of treatment response. Educational initiatives are required to encourage active intervention and improved provision of care.",0,0,
885,Health promotion in adolescent and young adult cancer survivors: mobilizing compliance in a multifaceted risk profile,"With rising cure rates of childhood cancer, nurse practitioners have an increased chance of encountering a large survivor cohort in practice. A variety of late effects programs exist"";"" however, funding is limited for these programs and is not accessible for all patients. Primary providers may increasingly act as a medical home for childhood cancer survivors (CCS). Understanding the inherent risks of cytotoxic treatment and the progressive consequences of late effects is vital to limit morbidity and mortality. Adolescent and young adult survivors (AYA) are particularly apt to make health behavior decisions that create risks for comorbidities. Developmentally appropriate experimentation with drug, alcohol, or tobacco use and increased ultraviolet ray exposure intensifies the risk for secondary malignancies and novel diseases. The paucity of evidence-based surveillance guidelines and survivor-specific health promotion programs cumulatively widen the gap in noncompliance and misinformation. This article overviews the risk profile of CCS. It explores health practices, as well as emerging health promotion techniques, within the AYA survivor population and the role nurse practitioners have in enhancing health maintenance.",0,0,
886,Health systems guidance appraisal—a critical interpretive synthesis,"Background Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process.  Methods We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed.  Results We identified 43 papers that met eligibility criteria. No existing review was found on this topic, and no HSG appraisal tool was identified. Over one third of the authors implicitly or explicitly identified the need for a high-quality tool aimed to systematically evaluate HSG and contribute to its development/reporting. We identified 30 concepts that may be relevant to the appraisal of HSG and were able to cluster them into three meaningful domains: process principles, content, and context principles.  Conclusions Our study showed the role that the quality criteria play in the development, appraisal, and reporting of HSG and demonstrated the link and resonance within and between the various concepts in the three domains.",0,0,
887,Health technologies for monitoring and managing diabetes: a systematic review,"BACKGROUND: The primary objective of this review was to determine the strength of evidence for the effectiveness of self-monitoring devices and technologies for individuals with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) based on specific health-related outcome measures. Self-monitoring devices included those that assist patients with managing diabetes and preventing cardiovascular complications (CVCs). A secondary objective was to explore issues of feasibility, usability, and compliance among patients and providers. METHODS: Study criteria included individuals >or=14 years and youth (7-14 years) with T1DM or T2DM, intervention with a self-monitoring device, assessment of clinical outcomes with the device, literature in English, and >or=10 participants. Relevant published literature was searched from 1985 to 2008. Randomized controlled trials and observational studies were included. Data were extracted for clinical outcomes, feasibility and compliance methods, and results. Selected studies were independently evaluated with a validated instrument for assessing methodological quality. RESULTS: Eighteen trials were selected. Predominant types of device interventions included self-monitoring of blood glucose, pedometers, and cell phone or wireless technologies. Feasibility and compliance were measured in the majority of studies. CONCLUSIONS: Self-monitoring of blood glucose continues to be an effective tool for the management of diabetes. Wireless technologies can improve diabetes self-care, and pedometers are effective lifestyle modification tools. The results of this review indicate a need for additional controlled trial research on existing and novel technologies for diabetes self-monitoring, on health outcomes associated with diabetes and CVCs, and device feasibility and compliance.",0,0,
888,Healthcare system use by risky alcohol drinkers: A secondary data analysis,"PURPOSE: To examine the effects of at-risk alcohol use on patterns of healthcare use and health outcomes. DATA SOURCES: Using the National Health Interview Survey and the Medical Expenditures Panel Survey, a total sample of 4449 adults, mean age 45 (SD 15), were grouped according to responses to the question: ""In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage?"" CONCLUSIONS: Three categories of respondents were grouped as follows: not at-risk group = 0 days of 5+ drinks/day (n = 2991, 67%)""; the low at-risk group = 1-11 days of 5+ drinks/day (n = 796, 18%); and the high at-risk group = 12-365 days of 5+ drinks/day (n = 662, 15%). The level of risky alcohol use did not predict healthcare use or healthcare outcomes; high at-risk alcohol drinkers were less likely to use the healthcare system than other drinkers. When divided by rural versus urban living, rural high at-risk alcohol drinkers reported more emergency department visits and all rural living groups reported poorer physical and mental health than their urban counterparts. IMPLICATIONS FOR PRACTICE: Risky alcohol use, defined as drinking above low-risk guidelines, affects 3 out of 10 adults, and risky drinking plays a role in over 60 chronic health conditions. Nurse practitioners encounter risky alcohol users in multiple practice settings. It may be difficult to identify the underlying alcohol issues, particularly in those living in rural settings;"" however, identification of at-risk drinkers is essential for prompt intervention in the potential progression from risky alcohol use to an alcohol use disorder.",0,0,
889,Healthcare workers' hand decontamination practices: compliance with recommended guidelines,"AIM: This paper reports a study of healthcare workers' handwashing/hand hygiene practices from a behavioural perspective. BACKGROUND: Hospital acquired infection poses a very real and serious threat to all who are admitted to hospital. Pathogens are readily transmitted on healthcare workers' hands, and hand hygiene substantially reduces this transmission. Evidence-based guidelines for healthcare workers' hand hygiene practices exist, but compliance with these is internationally low. METHODS: A quasi-experimental design with a convenient sample was used. The Predisposing, Reinforcing, Enabling Constructs in Educational Diagnosis and Evaluation Health Education Theory was used as the theoretical framework, and the data were collected in 2001. Healthcare workers' handwashing practices (observation of behaviour, n = 314) and their predisposition (attitudes, beliefs and knowledge) towards compliance with hand hygiene guidelines (questionnaire, n = 62) were studied. Nurses, doctors, physiotherapists and care assistants involved in direct patient care in the study unit participated in the study. The interventional hand hygiene programme aimed to predispose healthcare workers to adopt hand hygiene behaviour (poster campaign and educational handout), reinforce (feedback on pretest results) and enable the behaviour (provision of an alcohol hand rub beside each patients bedside). RESULTS: Implementation of the multifaceted interventional behavioural hand hygiene programme resulted in an overall improvement in compliance with hand hygiene guidelines (51-83%, P < 0.001). Furthermore, healthcare workers believed that their skin condition improved (P < 0.001). An increase in knowledge about handwashing guidelines was also found. CONCLUSIONS: In order to be effective, efforts to improve compliance with handwashing guidelines must be multifaceted. Alcohol hand rubs (with emollients) need to be provided at each patient's bedside. Issues surrounding healthcare workers' skin irritation need to be addressed urgently.",1,1,
890,Healthcare workers' self-reported effect of an interventional programme on knowledge and behaviour related to infection control,"INTRODUCTION: Adherence to infection control guidelines is low, and several efforts have been made to improve healthcare workers' performance of infection control measures. In this study, the performance and evaluation of a hospital-wide infection control programme is described. The most important measure was distribution of an infection control newsletter. METHODS: In evaluation of the programme, a randomised selection of healthcare workers received a questionnaire to investigate in what degree the healthcare workers was aware of the programme and whether they reported behavioural change and refreshed knowledge as result of the programme. RESULTS: The intervention made it possible to reach >80% of the personnel in a Norwegian university hospital. Among those who actually read Infection Control Newsletter, 92.9% reported that their knowledge was refreshed and 60.6% reported behavioural change. DISCUSSION: The intervention had a significant impact on nurses and nurse assistants' reports on knowledge and behaviour related to infection control. Our study supports the importance of a long-term and multimodal approach to healthcare workers in infection control work. The time and resources spent to produce and distribute the Infection Control Newsletter was an effective way to reach out to a large number of healthcare workers.",0,0,
891,Healthy active living: Physical activity guidelines for children and adolescents,"The epidemic of childhood obesity is rising globally. Although the risk factors for obesity are multifactorial, many are related to lifestyle and may be amenable to intervention. These factors include sedentary time and non-exercise activity thermogenesis, as well as the frequency, intensity, amounts and types of physical activity. Front-line health care practitioners are ideally suited to monitor children, adolescents and their families' physical activity levels, to evaluate lifestyle choices and to offer appropriate counselling. This statement presents guidelines for reducing sedentary time and for increasing the level of physical activity in the paediatric population. Developmentally appropriate physical activity recommendations for infants, toddlers, preschoolers, children and adolescents are provided. Advocacy strategies for promoting healthy active living at the local, municipal, provincial/territorial and federal levels are included.",0,0,
892,Healthy Living after Cancer: a dissemination and implementation study evaluating a telephone-delivered healthy lifestyle program for cancer survivors,"BACKGROUND: Given evidence shows physical activity, a healthful diet and weight management can improve cancer outcomes and reduce chronic disease risk, the major cancer organisations and health authorities have endorsed related guidelines for cancer survivors. Despite these, and a growing evidence base on effective lifestyle interventions, there is limited uptake into survivorship care. METHODS/DESIGN: Healthy Living after Cancer (HLaC) is a national dissemination and implementation study that will evaluate the integration of an evidence-based lifestyle intervention for cancer survivors into an existing telephone cancer information and support service delivered by Australian state-based Cancer Councils. Eligible participants (adults having completed cancer treatment with curative intent) will receive 12 health coaching calls over 6 months from Cancer Council nurses/allied health professionals targeting national guidelines for physical activity, healthy eating and weight control. Using the RE-AIM evaluation framework, primary outcomes are service-level indicators of program reach, adoption, implementation/costs and maintenance, with secondary (effectiveness) outcomes of patient-reported anthropometric, behavioural and psychosocial variables collected at pre- and post-program completion. The total participant accrual target across four participating Cancer Councils is 900 over 3 years. DISCUSSION: The national scope of the project and broad inclusion of cancer survivors, alongside evaluation of service-level indicators, associated costs and patient-reported outcomes, will provide the necessary practice-based evidence needed to inform future allocation of resources to support healthy living among cancer survivors. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR)--ACTRN12615000882527 (registered on 24/08/2015).",0,0,
893,"Height, body mass index, and socioeconomic status: mendelian randomisation study in UK Biobank","OBJECTIVE To determine whether height and body mass index (BMI) have a causal role in five measures of socioeconomic status. DESIGN Mendelian randomisation study to test for causal effects of differences in stature and BMI on five measures of socioeconomic status. Mendelian randomisation exploits the fact that genotypes are randomly assigned at conception and thus not confounded by non-genetic factors. SETTING UK Biobank. PARTICIPANTS 119,669 men and women of British ancestry, aged between 37 and 73 years. MAIN OUTCOME MEASURES Age completed full time education, degree level education, job class, annual household income, and Townsend deprivation index. RESULTS In the UK Biobank study, shorter stature and higher BMI were observationally associated with several measures of lower socioeconomic status. The associations between shorter stature and lower socioeconomic status tended to be stronger in men, and the associations between higher BMI and lower socioeconomic status tended to be stronger in women. For example, a 1 standard deviation (SD) higher BMI was associated with a £210 (€276""; $300; 95% confidence interval £84 to £420; P=6 × 10(-3)) lower annual household income in men and a £1890 (£1680 to £2100; P=6 × 10(-15)) lower annual household income in women. Genetic analysis provided evidence that these associations were partly causal. A genetically determined 1 SD (6.3 cm) taller stature caused a 0.06 (0.02 to 0.09) year older age of completing full time education (P=0.01), a 1.12 (1.07 to 1.18) times higher odds of working in a skilled profession (P=6 × 10(-7)), and a £1130 (£680 to £1580) higher annual household income (P=4 × 10(-8)). Associations were stronger in men. A genetically determined 1 SD higher BMI (4.6 kg/m(2)) caused a £2940 (£1680 to £4200;"" P=1 × 10(-5)) lower annual household income and a 0.10 (0.04 to 0.16) SD (P=0.001) higher level of deprivation in women only. CONCLUSIONS These data support evidence that height and BMI play an important partial role in determining several aspects of a person's socioeconomic status, especially women's BMI for income and deprivation and men's height for education, income, and job class. These findings have important social and health implications, supporting evidence that overweight people, especially women, are at a disadvantage and that taller people, especially men, are at an advantage.",0,0,
894,Helicobacter pylori management: how to improve the therapeutic confusion in practice,"There appears to be a disconnect between current guidelines for Helicobacter pylori testing and treatment, and clinical practice, including physician beliefs and actual prescribing patterns. In particular, there are markedly different approaches in primary and secondary care, and country-specific differences in eradication therapy for H pylori infection. Although most physicians do not believe that H pylori causes non-ulcer dyspepsia, the majority appear to prescribe eradication. Less information is available on the management of H pylori infection and gastro-esophageal reflux disease, and more marked differences in attitudes and practice occur in this condition. Even in peptic ulcer disease, where most clinicians both in primary and in secondary care believe H pylori should be eradicated, there is often a breakdown in the translation of this belief into practice. There is also confusion in terms of treatment regimens applied for H pylori eradication. Eradication regimens are less successful in practice than in clinical trials. Furthermore, a sizable proportion of patients with peptic ulcer remain symptomatic despite cure of the ulcer diathesis, which may undermine confidence. Therapeutic confusion about what to prescribe, side effects limiting compliance, bacterial resistance, and socioeconomic factors may all impair therapeutic success with eradication therapy in practice. Unfortunately, it has been well documented that guidelines alone are likely to have little or no impact in practice. Publication in a journal is unlikely to lead to effective implementation in primary care. On the basis of available evidence, clinical behaviour is most likely changed when guidelines are developed by the peer group of clinicians for whom they were intended, are disseminated through a specific educational program, and are implemented by applying, preferably during the consultation, specific reminders.",0,0,
895,Helping doctors and patients make sense of health statistics,"Many doctors, patients, journalists, and politicians alike do not understand what health statistics mean or draw wrong conclusions without noticing. Collective statistical illiteracy refers to the widespread inability to understand the meaning of numbers. For instance, many citizens are unaware that higher survival rates with cancer screening do not imply longer life, or that the statement that mammography screening reduces the risk of dying from breast cancer by 25% in fact means that 1 less woman out of 1,000 will die of the disease. We provide evidence that statistical illiteracy (a) is common to patients, journalists, and physicians""; (b) is created by nontransparent framing of information that is sometimes an unintentional result of lack of understanding but can also be a result of intentional efforts to manipulate or persuade people; and (c) can have serious consequences for health.  The causes of statistical illiteracy should not be attributed to cognitive biases alone, but to the emotional nature of the doctor–patient relationship and conflicts of interest in the healthcare system. The classic doctor–patient relation is based on (the physician's) paternalism and (the patient's) trust in authority, which make statistical literacy seem unnecessary;"" so does the traditional combination of determinism (physicians who seek causes, not chances) and the illusion of certainty (patients who seek certainty when there is none). We show that information pamphlets, Web sites, leaflets distributed to doctors by the pharmaceutical industry, and even medical journals often report evidence in nontransparent forms that suggest big benefits of featured interventions and small harms. Without understanding the numbers involved, the public is susceptible to political and commercial manipulation of their anxieties and hopes, which undermines the goals of informed consent and shared decision making.  What can be done? We discuss the importance of teaching statistical thinking and transparent representations in primary and secondary education as well as in medical school. Yet this requires familiarizing children early on with the concept of probability and teaching statistical literacy as the art of solving real-world problems rather than applying formulas to toy problems about coins and dice. A major precondition for statistical literacy is transparent risk communication. We recommend using frequency statements instead of single-event probabilities, absolute risks instead of relative risks, mortality rates instead of survival rates, and natural frequencies instead of conditional probabilities. Psychological research on transparent visual and numerical forms of risk communication, as well as training of physicians in their use, is called for.  Statistical literacy is a necessary precondition for an educated citizenship in a technological democracy. Understanding risks and asking critical questions can also shape the emotional climate in a society so that hopes and anxieties are no longer as easily manipulated from outside and citizens can develop a better-informed and more relaxed attitude toward their health.",0,1,
896,Helping hands: a cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses,"BACKGROUND: Hand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses. METHODS/DESIGN: This study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point. DISCUSSION: Performing and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing. TRIAL REGISTRATION: The study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT00548015.",0,0,
897,"Helping someone with problem drug use: a Delphi consensus study of consumers, carers, and clinicians","BACKGROUND: Problem use of illicit drugs (i.e. drug abuse or dependence) is associated with considerable health and social harms, highlighting the need for early intervention and engagement with health services. Family members, friends and colleagues play an important role in supporting and assisting individuals with problem drug use to seek professional help, however there are conflicting views about how and when such support should be offered. This paper reports on the development of mental health first aid guidelines for problem drug use in adults, to help inform community members on how to assist someone developing problem drug use or experiencing a drug-related crisis. METHODS: A systematic review of the scientific and lay literature was conducted to develop a 228-item survey containing potential first-aid strategies to help someone developing a drug problem or experiencing a drug-related crisis. Three panels of experts (29 consumers, 31 carers and 27 clinicians) were recruited from Australia, Canada, New Zealand, the United Kingdom, and the United States. Panel members independently rated the items over three rounds, with strategies reaching consensus on importance written into the guidelines. RESULTS: The overall response rate across three rounds was 80% (86% consumers, 81% carers, 74% clinicians). 140 first aid strategies were endorsed as essential or important by 80% or more of panel members. The endorsed strategies provide information and advice on what is problem drug use and its consequences, how to approach a person about their problem drug use, tips for effective communication, what to do if the person is unwilling to change their drug use, what to do if the person does (or does not) want professional help, what are drug-affected states and how to deal with them, how to deal with adverse reactions leading to a medical emergency, and what to do if the person is aggressive. CONCLUSIONS: The guidelines provide a consensus-based resource for community members who want to help someone with a drug problem. It is hoped that the guidelines will lead to better support and understanding for those with problem drug use and facilitate engagement with professional help.",0,0,
898,Helsinki Declaration revising continues,,0,0,
899,Hepatic reactions associated with ketoconazole in the United Kingdom,"Ketoconazole was introduced in the United Kingdom in 1981. By November 1984 the Committee on Safety of Medicines had received 82 reports of possible hepatotoxicity associated with the drug, including five deaths. An analysis of the 75 cases that had been adequately followed up suggested that 16, including three deaths, were probably related to treatment with the drug. Of the remainder, 48 were possibly related to treatment, five were unlikely to be so, and six were unclassifiable. The mean age of patients in the 16 probable cases was 57.9, with hepatotoxicity being more common in women. The average duration of treatment before the onset of jaundice was 61 days. None of these well validated cases occurred within the first 10 days after treatment. The results of serum liver function tests suggested hepatocellular injury in 10 (63%)"";"" the rest showed a mixed pattern. In contrast, the results of histological examination of the liver often showed evidence of cholestasis. The characteristics of the 48 patients in the possible cases were similar. Allergic manifestations such as rash and eosinophilia were rare. Hepatitis was usually reversible when treatment was stopped, with the results of liver function tests returning to normal after an average of 3.1 months. In two of the three deaths probably associated with ketoconazole treatment the drug had been continued after the onset of jaundice and other symptoms of hepatitis. Clinical and biochemical monitoring at regular intervals for evidence of hepatitis is advised during long term treatment with ketoconazole to prevent possible serious hepatic injury.",0,0,
900,Hepatitis (Hep-Net) competence network,"In Germany almost 1 million people are affected by chronic viral hepatitis. Despite of the improved therapy options for the treatment of hepatitis B and C, several questions regarding epidemiology, pathophysiology and therapy are still unclear. Vaccines against hepatitis C and D viruses are still not available. Additionally, many patients and their relatives need information about infectiosity, course of the disease and therapy options. By the integration of doctors' practices and patient advocacy groups, Hep-Net aims at the educational information on the infection and tries to give access to qualified therapy strategies for all patients with an indication for therapy. After 18 months the Hep-Net Homepage already shows more than 9000 hits per day. Consultation hours via telephone, email-services and numerous activities in cooperation with the Deutsche Leberhilfe e.V. are highly frequented. In the Hep-Net study-house high-standard clinical studies with first successful results are centrally organized. Further, basic questions in the fields of epidemiology, virology and immunology are processed in cooperative research projects within the network.",0,0,
901,Hepatitis A,,0,0,
902,Herding: a new phenomenon affecting medical decision-making in multiple sclerosis care? Lessons learned from DIScUTIR MS,"PURPOSE: Herding is a phenomenon by which individuals follow the behavior of others rather than deciding independently on the basis of their own private information. A herding-like phenomenon can occur in multiple sclerosis (MS) when a neurologist follows a therapeutic recommendation by a colleague even though it is not supported by best practice clinical guidelines. Limited information is currently available on the role of herding in medical care. The objective of this study was to determine the prevalence (and its associated factors) of herding in the management of MS. METHODS: We conducted a study among neurologists with expertise in MS care throughout Spain. Participants answered questions regarding the management of 20 case scenarios commonly encountered in clinical practice and completed 3 surveys and 4 experimental paradigms based on behavioral economics. The herding experiment consisted of a case scenario of a 40-year-old woman who has been stable for 3 years on subcutaneous interferon and developed a self-limited neurological event. There were no new magnetic resonance imaging (MRI) lesions. Her neurological examination and disability scores were unchanged. She was advised by an MS neurologist to switch from interferon to fingolimod against best practice guidelines. Multivariable logistic regression analysis was conducted to evaluate factors associated with herding. RESULTS: Out of 161 neurologists who were invited to participate, 96 completed the study (response rate: 60%). Herding was present in 75 (78.1%), having a similar prevalence in MS experts and general neurologists (68.8% vs 82.8%"";"" P=0.12). In multivariate analyses, the number of MS patients seen per week was positively associated with herding (odds ratio [OR] 1.08, 95% CI 1.01-1.14). Conversely, physician's age, gender, years of practice, setting of practice, or risk preferences were not associated with herding. CONCLUSION: Herding was a common phenomenon affecting nearly 8 out of 10 neurologists caring for MS patients. Herding may affect medical decisions and lead to poorer outcomes in the management of MS.",0,0,
903,"Heterogeneity: we can't live with it, and we can't live without it",,0,0,
904,Heterogeneous demographic and cultural profiles of Chinese American patients nonadherent to colorectal cancer screening: a latent class analysis,"BACKGROUND: Colorectal cancer (CRC) is one of the leading causes of cancer death in Chinese Americans, but their CRC screening rates remain low. OBJECTIVE: We examined subgroups of Chinese American patients nonadherent to CRC screening guidelines to better inform clinical practices to effectively promote screening. METHODS: Using latent class analysis of data from 327 participants recruited from 18 primary care clinics, we classified nonadherent patients based on sociodemographics, screening barriers, and attitudinal and clinical factors for CRC screening. RESULTS: The best-fitting latent class analysis model described 3 distinctive classes: Western healthcare class (36%), Eastern healthcare class (18%), and mixed healthcare class (46%). Western healthcare class patients were highly educated, with average US residency of 20 years, a high level of English proficiency, the least Eastern cultural views of care, and the greatest exposure to physician recommendations, but reported having no time for screenings. Eastern healthcare class patients were highly educated seniors and recent immigrants with the least CRC knowledge and the most Eastern cultural views. Mixed healthcare class patients had low level of education, resided in the United States for 20 years, and half had sought services of their physicians for at least 3 years, but their knowledge and cultural views were similar to those of Eastern healthcare class patients. CONCLUSIONS: Nonadherent Chinese American patients are heterogeneous. It is essential to have future intervention programs tailored to address specific screening beliefs and barriers for subtypes of nonadherent patients. IMPLICATIONS FOR PRACTICE: Training primary care physicians to recognize patients' different demographic characteristics and healthcare beliefs may facilitate physicians' communication with patients to overcome their barriers and improve screening behaviors.",0,0,
905,Heterogeneous effect of an Emergency Department Expert Charting System,"STUDY OBJECTIVE: We compare results from different modules (occupational exposure to blood and body fluids, low back pain, and fever in children) of the Emergency Department Expert Charting System. Each module of this electronic medical record provides real-time advice based on clinical guidelines embedded in the software. METHODS: We used a staggered off-on-off interrupted time-series design with an intent-to-treat analysis to implement the Emergency Department Expert Charting System in a university hospital emergency department for the treatment of fever in children, low back pain, and occupational exposure to blood and body fluids. We measured the quality of documentation as the percentage of essential items contained in the medical record and discharge instructions, the percentage of appropriate testing and treatment decisions, median charges per patient visit, physician satisfaction by pre-experiment and postexperiment questionnaires, and patient satisfaction by telephone questionnaire. RESULTS: The Emergency Department Expert Charting System improved documentation rates for all modules. The Emergency Department Expert Charting System consistently improved the appropriateness of diagnostic testing and treatment decisions for patients with occupational exposure to blood and body fluids while decreasing median charges. For the low back pain and fever in children modules, improvements in appropriateness of testing and treatment were less consistent and did not result in a decrease in charges. Although physicians were generally supportive of the intervention, the physicians' use of the Emergency Department Expert Charting System and satisfaction with the modules were greatest with occupational exposure to blood and body fluids and least with fever in children. For each presenting complaint, mean patient satisfaction was highest during the Emergency Department Expert Charting System phase. CONCLUSION: The delivery of guidelines through an electronic medical record with background decision support improved documentation, patient care, and patient satisfaction, although effects were heterogeneous across presenting complaints. The optimal guideline implementation strategy likely varies with the nature of the clinical problem and the type of health care delivery setting. For selected problems, delivering guidelines in this format through the Internet holds great promise for modifying physician behavior and improving care (see http://www.needlestick.mednet.ucla.edu ).",0,1,
906,High-risk management guidelines for elderly suicidal patients in primary care settings,"Older adults, especially older white men, are more likely to commit suicide than other age-groups. The assessment and management of suicide ideation and behavior for the elderly is especially relevant for primary care physicians because many patients visit their physician shortly before committing suicide. In 1993, the Agency for Health Care Policy and Research (AHCPR) released clinical practice guidelines for the treatment of depression in primary care settings. The AHCPR guidelines offered some assistance with respect to detecting and treating patients who are suicidal. However, these guidelines lacked detailed and specific instructions for managing high-risk patients within the context of intervention research. The current set of guidelines builds upon this previous work by describing (1) a general approach for interacting with suicidal patients""; (2) structured assessments for determining the degree of risk for suicide; (3) crisis intervention strategies;"" and (4) ongoing management procedures for working with suicidal patients in primary care settings.",0,0,
907,Historical background of changes in FDA policy on the study and evaluation of drugs in women,"The Food and Drug Administration (FDA) has recently made two important changes in its policy for the study and evaluation of drugs in women: (1) sex-specific analyses of the safety and efficacy of drugs will be required as part of all new drug applications, and (2) it will no longer be recommended that women of childbearing potential be restricted from participating in the earliest phases of drug trials. These changes have come about as a result of continuous efforts to individualize therapy, to improve upon the safety and efficacy of drugs, and to respond to important questions about whether the drug development process produces adequate information about the effects of drugs in women. In turn, these efforts are the outgrowth of a long history in the United States of changes in the clinical care for women, changes in the use of women as research subjects, changing attitudes about the balance between protection and risks for women in clinical trials, and national movements by women to focus on issues of their health care and to transform the male-oriented model of clinical research. The new FDA guidelines, published in July 1993, will provide guidance to researchers on accumulating valuable information on how drugs work in women and will help make it possible for physicians and other caregivers to consider the effects of gender on health and treatment.",0,0,
908,"History of evidence-based medicine. Oranges, chloride of lime and leeches: barriers to teaching old dogs new tricks","Knowledge translation is the process of taking evidence from research and applying it in clinical practice. In this article I will cite some pivotal moments in the history of medicine to highlight the difficulties and delays associated with getting evidence into practice. These historical examples have much in common with modern medical trials and quality improvement processes. I will also review the reasons why evidence is not used and consider what factors facilitate the uptake of evidence. Understanding these concepts will make it easier for individual clinicians and institutions to change clinical behaviour and provide a starting point for those looking at implementing 'new' practices, new therapies and clinical guidelines. Finally, I will offer a list of criteria that clinicians might choose to consider when deciding on whether or not to adopt a new practice, treatment or concept.",0,0,
909,HIV prevention in Mexican schools: prospective randomised evaluation of intervention,"OBJECTIVE To assess effects on condom use and other sexual behaviour of an HIV prevention programme at school that promotes the use of condoms with and without emergency contraception. DESIGN Cluster randomised controlled trial. SETTING 40 public high schools in the state of Morelos, Mexico. PARTICIPANTS 10 954 first year high school students. INTERVENTION Schools were randomised to one of three arms: an HIV prevention course that promoted condom use, the same course with emergency contraception as back-up, or the existing sex education course. Self administered anonymous questionnaires were completed at baseline, four months, and 16 months. Students at intervention schools received a 30 hour course (over 15 weeks) on HIV prevention and life skills, designed in accordance with guidelines of the joint United Nations programme on HIV/AIDS. Two extra hours of education on emergency contraception were given to students in the condom promotion with contraception arm. MAIN OUTCOME MEASURES Primary outcome measure was reported condom use. Other outcomes were reported sexual activity""; knowledge and attitudes about HIV and emergency contraception;"" and attitudes and confidence about condom use. RESULTS Intervention did not affect reported condom use. Knowledge of HIV improved in both intervention arms and knowledge of emergency contraception improved in the condom promotion with contraception arm. Reported sexual behaviour was similar in the intervention arms and the control group. CONCLUSION A rigorously designed, implemented, and evaluated HIV education course based in public high schools did not reduce risk behaviour, so such courses need to be redesigned and evaluated. Addition of emergency contraception did not decrease reported condom use or increase risky sexual behaviour but did increase reported use of emergency contraception.",0,0,
910,HIV/AIDS competence network research group presents first results,"Germany's clinical HIV research efforts are underrepresented on an international level. This deficit is primarily due to a lack of clinical studies involving patients from across the country and the fact that no national patient cohort system exists in Germany which could provide a basis for such clinical studies. The competence network HIV/AIDS is filling this shortcoming by serving as a comprehensive, nationwide research alliance. The establishment of a patient cohort is linked to 20 projects. The success of this new structure is becoming visible.",0,0,
911,Home blood pressure management and improved blood pressure control: results from a randomized controlled trial,"BACKGROUND: To determine which of 3 interventions was most effective in improving blood pressure (BP) control, we performed a 4-arm randomized trial with 18-month follow-up at the primary care clinics at a Veterans Affairs Medical Center. METHODS: Eligible patients were randomized to either usual care or 1 of 3 telephone-based intervention groups: (1) nurse-administered behavioral management, (2) nurse- and physician-administered medication management, or (3) a combination of both. Of the 1551 eligible patients, 593 individuals were randomized"";"" 48% were African American. The intervention telephone calls were triggered based on home BP values transmitted via telemonitoring devices. Behavioral management involved promotion of health behaviors. Medication management involved adjustment of medications by a study physician and nurse based on hypertension treatment guidelines. RESULTS: The primary outcome was change in BP control measured at 6-month intervals over 18 months. Both the behavioral management and medication management alone showed significant improvements at 12 months-12.8% (95% confidence interval [CI], 1.6%-24.1%) and 12.5% (95% CI, 1.3%-23.6%), respectively-but not at 18 months. In subgroup analyses, among those with poor baseline BP control, systolic BP decreased in the combined intervention group by 14.8 mm Hg (95% CI, -21.8 to -7.8 mm Hg) at 12 months and 8.0 mm Hg (95% CI, -15.5 to -0.5 mm Hg) at 18 months, relative to usual care. CONCLUSIONS: Overall intervention effects were moderate, but among individuals with poor BP control at baseline, the effects were larger. This study indicates the importance of identifying individuals most likely to benefit from potentially resource intensive programs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00237692.",0,0,
912,Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking),"BACKGROUND: Clinical guidelines for smoking cessation may not be sufficient for helping some subgroups of smokers quit. Incorporating smoking cessation into home-based medical care can proactively reach high-risk smokers who may not have access to (or spontaneously seek) smoking cessation. METHOD: Home health care nurses (N = 98) were randomly assigned to deliver either Motivational Enhancement (ME""; Motivational Interviewing + Carbon Monoxide Feedback) or Standard Care (AHCPR Guidelines for smoking cessation) to their patients. Seventy percent of patients were eligible and willing to participate (N = 273;"" 54% female, mean age = 57 years, 83% Caucasian, 41% 0.05). ME reported more quit attempts and significantly greater reductions in the number of cigarettes smoked per day at all follow-ups through 12 months of post-treatment (all P values < 0.05). CONCLUSIONS: Use of an existing public health channel such as home health care to reach smokers who vary in their motivation to quit could have the potential for large public health impact.",0,0,
913,Hormonal breast cancer agents: implications for the primary care provider,"PURPOSE: Over 2 million breast cancer survivors are in the United States, making women with breast cancer the largest group of cancer survivors. The purpose of this article is to review the current knowledge regarding survivorship issues in women with early-stage, estrogen receptor-positive breast cancer, focusing on advances in hormonal therapies for reducing risk of recurrence. DATA SOURCES: Published research studies, clinical treatment guidelines, and ongoing clinical trials. CONCLUSIONS: Innovations in antiestrogenic and estrogen modulator therapies are an important aspect of ongoing care after primary breast cancer treatment. Primary care providers may play an important role in monitoring potential complications of antiestrogenic treatment. IMPLICATIONS FOR PRACTICE: This article reviews the current state of the science in hormonal breast cancer agents for breast cancer survivors. With the high incidence and prevalence of breast cancer, primary care providers need to be aware of the potential short- and long-term health risks and benefits of hormonal therapies for breast cancer survivors.",0,0,
914,Hormone therapy discontinuation: physician practices after the Women's Health Initiative,"OBJECTIVE: No guidelines or randomized trials address best practices for hormone therapy (HT) discontinuation. METHODS: We conducted a survey study to explore HT discontinuation practices at Group Health and Harvard Vanguard, large integrated health systems in the Northwest and Northeast United States, focusing on differences between specialties and study site. RESULTS: The response rate to the written questionnaire (mailed between December 2005 and May 2006) was 78.5% (736/928)""; this article reports the results for 483 eligible physicians. To discontinue oral HT, most physicians (91%) advised tapering, not immediate cessation (8%), and most (60%) suggested decreasing both dose and days per week. Almost 60% of physicians reported no experience with tapering patches. Harvard Vanguard physicians were more likely than Group Health physicians to encourage discontinuing HT and less likely to recommend resuming HT when a woman's symptoms returned after discontinuing HT. Physicians were most strongly influenced by their own experience (48%), advice from colleagues (25%), and the woman's preference (19%) when choosing a discontinuation strategy;"" only 2% relied on research evidence. Physicians endorsed various approaches to manage symptoms after HT discontinuation, most often behavioral changes (44%) and increased exercise (37%), and these approaches were more often endorsed by Harvard Vanguard physicians and obstetrician/gynecologists than Group Health physicians or family practitioners or internists. CONCLUSIONS: Two health plans in the Northwestern and Northeastern United States have no standard protocol for HT discontinuation. Physicians customized approaches, influenced by their location, colleagues, and specialty. Research is needed to guide approaches to HT discontinuation.",0,0,
915,Hospital building in the NHS. Ideas and designs II: harness and nucleus,,0,0,
916,Hospital clinicians’ responsiveness to assay cost feedback: a prospective blinded controlled intervention study.,,1,1,
917,Hospital doctors' smoking behavior and attitude towards smoking cessation interventions for patients: a survey in an Italian Comprehensive Cancer Centre,"PURPOSE: Tobacco control guidelines recommend all healthcare professionals to ask patients about their smoking status and to offer them at least minimal cessation advice. However, few data are available about the daily practice of hospital clinicians who work with smoking cancer patients. This study assesses, in a comprehensive cancer center, the physicians' smoking habit, their clinical practice in offering a smoking cessation intervention to patients who smoke, and the training they received in this field. METHODS: A Web-based survey was sent to 285 physicians. RESULTS: The survey response rate was 75%. Sixty-two percent, 24%, and 14% of responders were never, former, and current smokers, respectively. Six percent of all responding physicians have already participated in smoking cessation training and 43% of them declared their willingness to be trained. Eighty-six percent of all responding physicians asked about the patients' smoking status, 50% routinely advised patients to quit smoking, and 32% assessed their motivation to do so. Smoking cessation guidelines were not followed mostly for lack of time, fear to increase patients' stress, and lack of smoking cessation training. Ninety-four percent of responding physicians knew the smoking cessation service for outpatients and 65% referred at least one patient, 66% of responding physicians knew the service for inpatients, and 36% of them asked for at least one intervention in the ward. CONCLUSIONS: This study pointed out partial adherence of the physicians working in a leading cancer center to the smoking cessation guidelines. The clinicians' smoking habits did not influence the training and the clinical practice in offering patients smoking cessation interventions.",0,0,
918,"Household income directly affects children's development, research shows","Children in low income households have worse cognitive, sociobehavioural, and health outcomes, concludes a new report by the social policy research charity the Joseph Rowntree Foundation.1 The report says that money makes a direct difference to children’s outcomes and not just because low income is correlated with parents’ level of education, attitudes towards bringing up children, and other parental factors. Kerris Cooper and Kitty Stewart from the Centre for …",0,0,
919,How did formative research inform the development of a women's group intervention in rural Nepal?,"Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.",0,0,
920,How Do Clinicians Prefer Cultural Competence Training? Findings from the DSM-5 Cultural Formulation Interview Field Trial,"OBJECTIVE: This study's objective is to analyze training methods clinicians reported as most and least helpful during the DSM-5 Cultural Formulation Interview field trial, reasons why, and associations between demographic characteristics and method preferences. METHOD: The authors used mixed methods to analyze interviews from 75 clinicians in five continents on their training preferences after a standardized training session and clinicians' first administration of the Cultural Formulation Interview. Content analysis identified most and least helpful educational methods by reason. Bivariate and logistic regression analysis compared clinician characteristics to method preferences. RESULTS: Most frequently, clinicians named case-based behavioral simulations as ""most helpful"" and video as ""least helpful"" training methods. Bivariate and logistic regression models, first unadjusted and then clustered by country, found that each additional year of a clinician's age was associated with a preference for behavioral simulations: OR = 1.05 (95 % CI: 1.01-1.10"";"" p = 0.025). CONCLUSIONS: Most clinicians preferred active behavioral simulations in cultural competence training, and this effect was most pronounced among older clinicians. Effective training may be best accomplished through a combination of reviewing written guidelines, video demonstration, and behavioral simulations. Future work can examine the impact of clinician training satisfaction on patient symptoms and quality of life.",0,0,
921,How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists,"Guidelines for the management of low back pain (LBP) have existed for many years, but adherence to these by health care practitioners (HCPs) remains suboptimal. The aim of this study was to measure the attitudes, beliefs and reported clinical behaviour of UK physiotherapists (PTs) and general practitioners (GPs) about LBP and to explore the associations between these. A cross-sectional postal survey of GPs (n=2000) and PTs (n=2000) was conducted that included the Pain Attitudes and Beliefs Scale (PABT.PT), and a vignette of a patient with non-specific LBP (NSLBP) with questions asking about recommendations for work, activity and bedrest. Data from 1022 respondents (442 GPs and 580 PTs) who had recently treated patients with LBP were analysed. Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations, 28% reported they would advise this patient to remain off work. Work advice was significantly related to the PABS.PT scores with higher biomedical (F(1,986)=77.5, p<0.0001) and lower behavioural (F(1,981)=31.9, p<0.001) scores associated with advice to remain off work. We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse. Many HCPs held the belief that LBP necessitates some avoidance of activities and work. The attitudes and beliefs of these HCPs were associated with their self-reported clinical behaviour regarding advice about work. Future studies need to investigate whether approaches aimed at modifying these HCP factors can lead to improved patient outcomes.",0,0,
922,How many steps/day are enough? for children and adolescents,"Worldwide, public health physical activity guidelines include special emphasis on populations of children (typically 6-11 years) and adolescents (typically 12-19 years). Existing guidelines are commonly expressed in terms of frequency, time, and intensity of behaviour. However, the simple step output from both accelerometers and pedometers is gaining increased credibility in research and practice as a reasonable approximation of daily ambulatory physical activity volume. Therefore, the purpose of this article is to review existing child and adolescent objectively monitored step-defined physical activity literature to provide researchers, practitioners, and lay people who use accelerometers and pedometers with evidence-based translations of these public health guidelines in terms of steps/day. In terms of normative data (i.e., expected values), the updated international literature indicates that we can expect 1) among children, boys to average 12,000 to 16,000 steps/day and girls to average 10,000 to 13,000 steps/day""; and, 2) adolescents to steadily decrease steps/day until approximately 8,000-9,000 steps/day are observed in 18-year olds. Controlled studies of cadence show that continuous MVPA walking produces 3,300-3,500 steps in 30 minutes or 6,600-7,000 steps in 60 minutes in 10-15 year olds. Limited evidence suggests that a total daily physical activity volume of 10,000-14,000 steps/day is associated with 60-100 minutes of MVPA in preschool children (approximately 4-6 years of age). Across studies, 60 minutes of MVPA in primary/elementary school children appears to be achieved, on average, within a total volume of 13,000 to 15,000 steps/day in boys and 11,000 to 12,000 steps/day in girls. For adolescents (both boys and girls), 10,000 to 11,700 may be associated with 60 minutes of MVPA. Translations of time- and intensity-based guidelines may be higher than existing normative data (e.g., in adolescents) and therefore will be more difficult to achieve (but not impossible nor contraindicated). Recommendations are preliminary and further research is needed to confirm and extend values for measured cadences, associated speeds, and MET values in young people; continue to accumulate normative data (expected values) for both steps/day and MVPA across ages and populations;"" and, conduct longitudinal and intervention studies in children and adolescents required to inform the shape of step-defined physical activity dose-response curves associated with various health parameters.",0,0,
923,How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study,"BackgroundCountries with high rates of child mortality tend to have shortages of qualified health workers. Little rigorous evidence has been done to assess how much the quality of care varies between types of health workers. We compared the performance of different categories of health workers who are trained in Integrated Management of Childhood Illness (IMCI)."";"" BackgroundCountries with high rates of child mortality tend to have shortages of qualified health workers. Little rigorous evidence has been done to assess how much the quality of care varies between types of health workers. We compared the performance of different categories of health workers who are trained in Integrated Management of Childhood Illness (IMCI).",0,0,
924,How organizational escalation prevention potential affects success of implementation of innovations: electronic medical records in hospitals,"Background Escalation of commitment is the tendency that (innovation) projects continue, even if it is clear that they will not be successful and/or become extremely costly. Escalation prevention potential (EPP), the capability of an organization to stop or steer implementation processes that do not meet their expectations, may prevent an organization of losing time and money on unsuccessful projects. EPP consists of a set of checks and balances incorporated in managerial practices that safeguard management against irrational (but very human) decisions and may limit the escalation of implementation projects. We study whether successful implementation of electronic medical records (EMRs) relates to EPP and investigate the organizational factors accounting for this relationship.  Methods Structural equation modelling (SEM), using questionnaire data of 427 doctors and 631 nurses who had experience with implementation and use of EMRs in hospitals, was applied to study whether formal governance and organizational culture mediate the relationship between EPP and the perceived added value of EMRs.  Results Doctors and nurses in hospitals with more EPP report more successful implementation of EMR (in terms of perceived added value of the EMR). Formal governance mediates the relation between EPP and implementation success. We found no evidence that open or innovative culture explains the relationship between EPP and implementation success.  Conclusions There is a positive relationship between the level of EPP and perceived added value of EMRs. This relationship is explained by formal governance mechanisms of organizations. This means that management has a set of tangible tools to positively affect the success of innovation processes. However, it also means that management needs to be able to critically reflect on its (previous) actions and decisions and is willing to change plans if elements of EPP signal that the implementation process is hampered.",0,0,
925,How payment systems affect physicians’ provision behaviour—an experimental investigation. ,"Understanding how physicians respond to incentives from payment schemes is a central concern in health economics research. We introduce a controlled laboratory experiment to analyse the influence of incentives from fee-for-service and capitation payments on physicians’ supply of medical services. In our experiment, physicians choose quantities of medical services for patients with different states of health. We find that physicians provide significantly more services under fee-for-service than under capitation. Patients are overserved under fee-for-service and underserved under capitation. However, payment incentives are not the only motivation for physicians’ quantity choices, as patients’ health benefits are of considerable importance as well. We find that patients in need of a high (low) level of medical services receive larger health benefits under fee-for-service (capitation).",0,1,
926,How science thinks and practice acts: bridging the gap in weight management interventions for adolescents,"BACKGROUND: Adolescent obesity calls for evidence-based treatment approaches given its long-term physical and psychosocial consequences. However, research shows there are many problems in the translation of scientific evidence into practice. OBJECTIVE: The aim of this study was to develop science- and practice-based recommendations for the planning of future adolescent weight management interventions. METHODS: We performed (i) literature reviews on intervention studies targeting treatment of obesity in adolescents and Dutch clinical guidelines for obesity as well as practice-based documents and grey literature on treating obesity and delivering health programs for adolescents and (ii) semi-structured interviews with eight clinicians and four non-clinicians working in obesity treatment, management and prevention to explore perspectives on treating adolescent obesity and using evidence in practice. RESULTS: After merging the results from the literature reviews and interviews, four issues emerged: (i) little reporting on theoretical models used in intervention studies, Dutch clinical guidelines and semi-structured interviews""; (ii) inconsistency on age-specific considerations for treating obesity in adolescents in intervention studies and Dutch clinical guidelines;"" (iii) inconsistency on addressing the social nature of obesity in intervention studies and Dutch clinical guidelines and (iv) how professional responsibility should be divided is unclear from intervention studies, Dutch clinical guidelines and semi-structured interviews. CONCLUSIONS: Joined action of science and practice is required for future interventions. Future interventions should include topics relevant to the stage of adolescence and give greater focus to the complex social nature of obesity. Lastly, practitioners can generate more practice-based evidence by starting their own practice-based research.",0,0,
927,How to attribute causality in quality improvement: lessons from epidemiology,,0,0,
928,How to enhance physician and public acceptance and utilisation of colon cancer screening recommendations,"Colorectal Cancer (CRC) screening delivery is a multidisciplinary undertaking, aiming at reducing mortality from and incidence of CRC without adversely affecting the health status of participants. The adoption of a public health perspective involves commitment to ensure equity of access and sustainability of the program over time. We reviewed available evidence concerning predictors of CRC screening uptake and the impact of interventions to improve adoption of screening using conceptual frameworks defining the role of determinants of preventive behaviours and the reach and target of interventions. The results of this review indicate that policy measures aimed at supporting screening delivery, as well as organisational changes, influencing the operational features of preventive services, need to be implemented, in order to allow individual's motivation to be eventually realised. To ensure coverage and equity of access and to maximise the impact of the intervention, policies aimed at implementing organised programs should be adopted, ensuring that participation in screening and any follow-up assessment should not be limited by financial barriers. Participants and providers beliefs may determine the response to different screening modalities. To achieve the desired health impact, an active follow-up of people with screening abnormalities should be implemented, supported by the introduction of infrastructural changes and multidisciplinary team work, which can ensure sustainability over time of effective interventions. Continuous monitoring as well as the adoption of plans to evaluate for program effectiveness represent crucial steps in the implementation of a successful program.",0,1,
929,How to implement clinical practice guidelines in iran,"BACKGROUND: Evidence-based medicine would come to the result by evidence-based implementation. Clinical Practice Guidelines (CPG) as one of the evidence-based knowledge products requires appropriate interventions after being produced to be applied. OBJECTIVES: The aim of this qualitative study was to identify the strategies for application of CPGs produced in Iran. MATERIALS AND METHODS: The purposive snowball sampling was performed and it continued until reaching the theoretical saturation. In-depth semistructured individual interviews and Focus Group Discussion (FGD) were performed aiming at triangulation. The thematic framework approach was used for the analysis. RESULTS: Twelve interviews were conducted with three health system policy makers and decision makers, four experienced in the production or adaptation of clinical practices, and five experts in evidence-based medicine development and education. In addition, 11 policy makers, managers, and decision makers of the health system took part in FGD. The proposed interventions were classified in the following themes: Health professionals-oriented, Financial, Organizational, Regulatory, and Multifaceted interventions. CONCLUSIONS: Along with adaptation and development process of CPGs, their utilization should also be planned"";"" otherwise spent time and money would be in vain. Certainly, imposing above-mentioned interventions with the ultimate goal of sustainable behavior change in health system service providers is beyond the capacity of specific groups or few academic centers. It requires the participation of all practitioners under the monitoring and support of the Ministry of Health and Medical Education. Deployment of the family physician plan and referral system is an opportunity which must be considered a trophy.",0,0,
930,How to translate therapeutic recommendations in clinical practice guidelines into rules for critiquing physician prescriptions? Methods and application to five guidelines,"BACKGROUND: Clinical practice guidelines give recommendations about what to do in various medical situations, including therapeutical recommendations for drug prescription. An effective way to computerize these recommendations is to design critiquing decision support systems, i.e. systems that criticize the physician's prescription when it does not conform to the guidelines. These systems are commonly based on a list of ""if conditions then criticism"" rules. However, writing these rules from the guidelines is not a trivial task. The objective of this article is to propose methods that (1) simplify the implementation of guidelines' therapeutical recommendations in critiquing systems by automatically translating structured therapeutical recommendations into a list of ""if conditions then criticize"" rules, and (2) can generate an appropriate textual label to explain to the physician why his/her prescription is not recommended. METHODS: We worked on the therapeutic recommendations in five clinical practice guidelines concerning chronic diseases related to the management of cardiovascular risk. We evaluated the system using a test base of more than 2000 cases. RESULTS: Algorithms for automatically translating therapeutical recommendations into ""if conditions then criticize"" rules are presented. Eight generic recommendations are also proposed"";"" they are guideline-independent, and can be used as default behaviour for handling various situations that are usually implicit in the guidelines, such as decreasing the dose of a poorly tolerated drug. Finally, we provide models and methods for generating a human-readable textual critique. The system was successfully evaluated on the test base. CONCLUSION: We show that it is possible to criticize physicians' prescriptions starting from a structured clinical guideline, and to provide clear explanations. We are now planning a randomized clinical trial to evaluate the impact of the system on practices.",0,0,
931,How well are clinicians following dementia practice guidelines?,"Although there are numerous clinical guidelines regarding the management of dementia, there have been few studies on their implementation in practice. Clinicians in six United States Department of Veterans Affairs medical centers (n = 200, 85% response rate) were surveyed regarding their use of practices recommended in the California Workgroup Guidelines for Alzheimer's Disease Management. The majority of providers (89% to 73%) reported that they routinely conducted neurological examinations, obtained histories from caregivers, discussed the diagnosis with the patient's family, discussed durable power of attorney, and made legally-required reports of drivers with dementia. Roughly two-thirds of providers said they routinely conducted cognitive screening examinations, screened for depression, reported elder abuse, and discussed care needs and decision-making issues with patients' families. Only half of all outpatient providers implemented caregiver support practices for at least half of their patients. Clinicians' choices of medications for cognition, mood, and behavior problems were broadly consistent with current practice guidelines. These results suggest possible priorities for quality improvement efforts. Further research is needed to clarify reasons for particular gaps between guidelines and practice and to identify specific targets for intervention.",0,0,
932,Human experimentation and medical ethics,,0,0,
933,Human experimentation in historical and ethical perspectives,"KIE: Prepared as background material for a World Health Organization/Council for International Organizations of Medical Sciences document, Proposed International Guidelines for Biomedical Research Involving Human Subjects (1982), this article reviews historical aspects of human experimentation and considers several current issues. It refers to early experiments, including auto-experiments by physicians""; traces the history of drug trials through the pharmacotherapeutic revolution and the thalidomide tragedy;"" and describes the formulation of ethical requirements during the Weimar Republic in Germany. Contemporary problems discussed are the use of controls and placebos, investigators as subjects, special categories of subjects, and informed and vicarious consent. The text of the proposed WHO/CIOMS Guidelines is appended.",0,0,
934,Human fetal tissue for medical research,,0,0,
935,Human tissue research: EORTC recommendations on its practical consequences,"Improvement in cancer care is possible by applying new treatment modalities, which are emerging from knowledge and discoveries coming from laboratory research. This is possible through international collaboration and the collection of tumour tissues. Creation of a European Organisation for Research and Treatment of Cancer (EORTC) Tumor Bank is a natural step in this direction, by offering tumour sample collection from patients entered in EORTC trials. The aim of such a bank is not only to improve the diagnostic review process, but also to facilitate translational research by allowing clinicians and basic scientists to enter into close collaborations. The EORTC Tissue Research Policy is developed to assure, under the EORTC legal framework, an ethical and scientific review of research projects, guarantee adequate information is given to patients, establish procedures on the use of materials, including legal aspects, and publication policies. Being part of the EU TubaFrost project, the EORTC will provide a common international platform for the use of tissues for research purposes, finding a balance between different laws and assuring scientific progress.",0,0,
936,Hypertension Improvement Project (HIP): study protocol and implementation challenges,"BACKGROUND: Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care. METHODS AND DESIGN: This paper describes the protocol of a nested 2 x 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months. DISCUSSION: Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice"";"" 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00201136.",0,0,
937,Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients,"Despite widely publicized hypertension treatment guidelines for physicians and lifestyle recommendations for patients, blood pressure control rates remain low. In community-based primary care clinics, we performed a nested, 2 x 2 randomized, controlled trial of physician intervention versus control and/or patient intervention versus control. Physician intervention included internet-based training, self-monitoring, and quarterly feedback reports. Patient intervention included 20 weekly group sessions followed by 12 monthly telephone counseling contacts and focused on weight loss, Dietary Approaches to Stop Hypertension dietary pattern, exercise, and reduced sodium intake. The primary outcome was change in systolic blood pressure at 6 months. Eight primary care practices (32 physicians) were randomized to physician intervention or control groups. Within those practices, 574 patients were randomized to patient intervention or control groups. Patient mean age was 60 years, 61% were women, and 37% were black. Blood pressure data were available for 91% of patients at 6 months. The main effect of physician intervention on systolic blood pressure at 6 months, adjusted for baseline pressure, was 0.3 mm Hg (95% CI: 1.5 to 2.2""; P=0.72). The main effect of the patient intervention was 2.6 mm Hg (95% CI: 4.4 to 0.7; P=0.01). The interaction of the 2 interventions was significant (P=0.03); the largest impact was observed with the combination of physician and patient intervention (9.7 +/- 12.7 mm Hg). Differences between treatment groups did not persist at 18 months. Combined physician and patient interventions lowers blood pressure;"" future research should focus on enhancing effectiveness and sustainability of these interventions.",0,0,
938,Hypertension in black patients: an update,"Black individuals are at high risk for hypertension and increased morbidity from cardiovascular and renal disease, in particular. Increased understanding of racial disparities in hypertension, in terms of risk factors, patient/physician behaviors, and treatment outcomes, is key to improving racially oriented care in black patients. Recent data suggest that black patients progress more rapidly from prehypertension to hypertension, highlighting the need for early and prompt intervention. Unfortunately, adherence to and persistence with antihypertensive therapy are generally poor in black patients and are compounded by the increased need for multidrug therapy in this patient population. Treatment strategies currently under investigation are focusing on methods to improve self-care behaviors and medication adherence. Because this is a constantly and rapidly evolving field of study, this article provides an update of recent findings that should be of relevance and interest to practicing clinicians.",0,0,
939,Identification and evaluation of the salient physical activity beliefs of colorectal cancer survivors,"BACKGROUND: Physical activity (PA) has been associated with lower risk of disease recurrence and longer survival in colorectal cancer (CRC) survivors"";"" however, less than one-third of CRC survivors are meeting PA guidelines. Interventions to promote PA in CRC survivors need to understand the most critical beliefs that influence PA behavior. OBJECTIVE: The objective of this study was to examine the strength of associations between the most common PA beliefs of CRC survivors and motivational constructs from the Theory of Planned Behavior (TPB) as well as PA behavior. INTERVENTION/METHODS: Colorectal cancer survivors (n = 600) residing in Alberta, Canada, completed self-report questionnaires assessing medical and demographic variables, PA beliefs, constructs from the TPB, and PA behavior. RESULTS: Colorectal cancer survivors identified improved fitness (69.5%), family members (67.3%), and medical/health problems (8.8%) as the most prevalent behavioral, normative, and control beliefs, respectively. All PA beliefs were significantly correlated with all TPB constructs and PA. CONCLUSIONS: Physical activity interventions for CRC survivors should target many salient beliefs including behavioral, normative, and control beliefs. IMPLICATIONS FOR PRACTICE: Insights into the salient beliefs for PA in CRC survivors can guide nurses in developing successful strategies to promote PA in this population and likely improve quality of life and possibly disease outcomes.",0,0,
940,Identification of perceived barriers of pain management in Iranian children: a qualitative study,"Hospitalized children are often inadequately treated for their pain. Paediatric nurses experience these inadequacies more than other health-care team members. This research was an attempt in the form of a phenomenological study to reveal some major barriers in children pain management as the nurses had perceived. Sixteen nurses were interviewed in the medical, surgical and infectious paediatric wards of a hospital in Iran. Data analysis were based on Colaizzi method that surfaced three main themes in different areas namely: organizational barriers, limitations relating to child's characteristics and barriers relating to the nature of disease and its treatments. The study results have shown organizational limitations added to the lack of authority for administering some medical intervention, inadequate equipment and utilities and unavailability of opioids as the main pain controlling and restricting factors. Additional factors that relate to the child specifications like age, temperament, behaviour, expression and gender affect the assessment and treatment of pain. The results revealed identified barriers in real context. It seems that some guidelines are needed to achieve optimal pain management.",0,0,
941,"Identification, evaluation, and management of obesity in an academic primary care center","BACKGROUND: The rapidly increasing prevalence of obesity among children is one of the most challenging dilemmas facing pediatricians today. While the medical community struggles to develop effective strategies for the treatment of this epidemic, timely identification of obesity by pediatric health care providers remains the crucial initial step in the management of obesity. OBJECTIVE: Direct assessment of pediatric clinicians' performance in identifying and managing obesity in clinical practice has not been conducted to date. The objective of this study was to determine rates of identification of obesity by pediatric residents, nurse practitioners, and faculty members in an academic primary care setting and to describe the actions taken by these providers in their evaluation and management of obesity. DESIGN: A retrospective medical record review of all health supervision visits for children 3 months to 16 years of age, examined between December 1, 2001, and February 28, 2002, was performed. For children 120% of the 50th percentile of weight-for-height was defined as obese. For children > or =5 years of age, a body mass index of >95th percentile for age and gender was defined as obese. SETTING: A large, primary care practice located in a tertiary-care, academic, pediatric hospital, which serves a predominantly urban, minority (70% African American), Medical Assistance-insured (90%) population. PARTICIPANTS: Primary care providers, including pediatric residents, nurse practitioners, and faculty physicians. RESULTS: Of the 2515 visits reviewed, a total of 244 patients met the study definition of obesity, yielding an estimated prevalence of obesity visits of 9.7% among health supervision visits for children 3 months to 16 years of age. This prevalence of obesity visits cannot be used to estimate the population prevalence of obesity, given the skewed distribution of visits toward very young children. For all children who met the study definition of obesity, providers documented obesity in their assessments in only 53% of the reviewed visits (129 visits). Although the majority of charts (69%) contained an adequate dietary history, only 15% included a description of the child's activity level or television viewing. Obesity was noted in the physical examination in 39% of cases. For children for whom obesity was identified as a problem by their clinicians (129 patients), 81% of charts contained an adequate dietary history, whereas 27% contained a description of the child's activity level or television viewing. Obesity was noted in the physical examination in 64% of cases. Most children identified as obese by their providers received some management specific to their obesity, including education, screening, and specialist referral. Dietary changes were recommended for 71%, increased activity for 33%, and limitation of television viewing for only 5%. Eighty-three percent of providers recommended close follow-up monitoring. Other recommendations included referral to a dietitian (22%), screening laboratory studies (13%), a food diary (9%), endocrine referral (5%), or preventive cardiology referral (3%). Provider identification of obesity was affected by the age of the patient and by the degree of obesity. Obesity identification was lowest among preschool children (31%) and highest among adolescent patients (76%). Providers evaluating older and heavier children were also more likely to obtain activity histories, note obesity in the physical examination, recommend changes in activity, refer the patient to a nutritionist, obtain screening laboratory studies, and recommend close follow-up monitoring. Identification of obesity and other outcome variables were not significantly influenced by the level of provider training or patient gender. CONCLUSIONS: Although the prevalence of childhood obesity has now reached epidemic proportions, it was under-recognized and under-treated by pediatric primary care providers in our study. Providers identified obesity as a problem for only one-half of the obese children examined for health supervision. The lowest rates of obesity identification occurred among children <5 years of age and those with milder degrees of obesity. Identification did not improve with additional years of pediatric training. Even for the subset of children identified as obese by their providers, evaluation and treatment often were not consistent with current recommendations. For example, more attention was given to the role of diet, compared with activity, in the evaluation of obesity. In particular, only a small number of providers (5%) recommended a decrease in television viewing to their obese patients, despite evidence linking television viewing and pediatric obesity. This finding is of concern, because obesity is known to be a multifactorial disease that responds only to significant changes in both dietary and activity behaviors. Only 13% of providers requested laboratory studies as part of their recommendations. The American Academy of Pediatrics currently recommends obtaining a lipid profile, total cholesterol level, and screening test for type 2 diabetes mellitus as part of the evaluation of obesity. The majority of clinicians who requested laboratory studies included thyroid function tests, which are not recommended by the American Academy of Pediatrics because of the very low likelihood of hypothyroidism as a cause of obesity. Although the extent of evaluation and management for children who were recognized as obese did not meet current guidelines, it was far better than that for patients who were not identified as obese by their providers. This demonstrates the importance of timely identification as the crucial initial step in the management of obesity. The results of this study are disheartening, especially as evidence mounts regarding the importance of early intervention in preventing the medical and psychosocial sequelae of obesity, as well as the persistence of obesity into adulthood. This study highlights the need for increased awareness and identification of obesity in the primary care setting, especially among younger children and those with mild obesity.",0,0,
942,Identifying and reducing errors with surgical simulation,"The major determinant of a patient’s safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills—which are at the core of the profession—are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and “near misses”. Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.",0,1,
943,"Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF)","BACKGROUND: Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED. METHODS: Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy. RESULTS: Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of ""environmental, context and resources"" (such as stressful working conditions or lack of resources) and ""knowledge"" (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of ""knowledge"" (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and ""skills"" (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were ""focus on past success"" and ""information about health consequences."" CONCLUSIONS: Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.",0,0,
944,Idiopathic Pulmonary Fibrosis: Prevailing and Evolving Hypotheses about Its Pathogenesis and Implications for Therapy,"Idiopathic pulmonary fibrosis is a progressive and usually fatal lung disease characterized by fibroblast proliferation and extracellular matrix remodeling, which result in irreversible distortion of the lung's architecture. Although the pathogenetic mechanisms remain to be determined, the prevailing hypothesis holds that fibrosis is preceded and provoked by a chronic inflammatory process that injures the lung and modulates lung fibrogenesis, leading to the end-stage fibrotic scar. However, there is little evidence that inflammation is prominent in early disease, and it is unclear whether inflammation is relevant to the development of the fibrotic process. Evidence suggests that inflammation does not play a pivotal role. Inflammation is not a prominent histopathologic finding, and epithelial injury in the absence of ongoing inflammation is sufficient to stimulate the development of fibrosis. In addition, the inflammatory response to a lung fibrogenic insult is not necessarily related to the fibrotic response. Clinical measurements of inflammation fail to correlate with stage or outcome, and potent anti-inflammatory therapy does not improve outcome. This review presents a growing body of evidence suggesting that idiopathic pulmonary fibrosis involves abnormal wound healing in response to multiple, microscopic sites of ongoing alveolar epithelial injury and activation associated with the formation of patchy fibroblast–myofibroblast foci, which evolve to fibrosis. Progress in understanding the fibrogenic mechanisms in the lung is likely to yield more effective therapies.",0,0,
945,"If only it were so: medical physics, U.S. human radiation experiments, and the Final Report of the President's Advisory Committee (ACHRE)",,0,0,
946,Impact of a clinical decision support system on antibiotic prescribing for acute respiratory infections in primary care: quasi-experimental trial,"Objective To assess the effect of a clinical decision support system (CDSS) integrated into an electronic health record (EHR) on antibiotic prescribing for acute respiratory infections (ARIs) in primary care.  Materials and methods Quasi-experimental design with nine intervention practices and 61 control practices in the Practice Partner Research Network, a network of practices which all use the same EHR (Practice Partner). The nine intervention practices were located in nine US states. The design included a 3-month baseline data collection period (October through December 2009) before the introduction of the intervention and 15 months of follow-up (January 2010 through March 2011). The main outcome measures were the prescribing of antibiotics in ARI episodes for which antibiotics are inappropriate and prescribing of broad-spectrum antibiotics in all ARI episodes.  Results In adult patients, prescribing of antibiotics in ARI episodes where antibiotics are inappropriate declined more (-0.6%) among intervention practices than in control practices (+4.2%) (p=0.03). However, among adults, the CDSS intervention improved prescribing of broad-spectrum antibiotics, with a decline of 16.6% among intervention practices versus an increase of 1.1% in control practices (p<0.0001). A similar effect on broad-spectrum antibiotic prescribing was found in pediatric patients with a decline of 19.7% among intervention practices versus an increase of 0.9% in control practices (p<0.0001).  Conclusions A CDSS embedded in an EHR had a modest effect in changing prescribing for adults where antibiotics were inappropriate but had a substantial impact on changing the overall prescribing of broad-spectrum antibiotics among pediatric and adult patients.",0,1,
947,Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial.,"Objective: Many hospitals utilize antimicrobial management teams (AMTs) to improve patient care. However, most function with minimal computer support. We evaluated the effectiveness and cost-effectiveness of a computerized clinical decision support system for the management of antimicrobial utilization.  Design: A randomized controlled trial in adult inpatients between May 10 and August 3, 2004. Antimicrobial utilization was managed by an existing AMT using the system in the intervention arm and without the system in the control arm. The system was developed to alert the AMT of potentially inadequate antimicrobial therapy.  Measurements: Outcomes assessed were hospital antimicrobial expenditures, mortality, length of hospitalization, and time spent managing antimicrobial utilization.  Results: The AMT intervened on 359 (16%) of 2,237 patients in the intervention arm and 180 (8%) of 2,270 in the control arm, while spending approximately one hour less each day on the intervention arm. Hospital antimicrobial expenditures were $285,812 in the intervention arm and $370,006 in the control arm, for a savings of $84,194 (23%), or $37.64 per patient. No significant difference was observed in mortality (3.26% vs. 2.95%, p = 0.55) or length of hospitalization (3.84 vs. 3.99 days, p = 0.38).  Conclusion: Use of the system facilitated the management of antimicrobial utilization by allowing the AMT to intervene on more patients receiving inadequate antimicrobial therapy and to achieve substantial time and cost savings for the hospital. This is the first study that demonstrates in a patient-randomized controlled trial that computerized clinical decision support systems can improve existing antimicrobial management programs.",0,1,
948,Impact of a computerized decision support system on compliance with guidelines on antibiotics prescribed for urinary tract infections in emergency departments: a multicentre prospective before-and-after controlled interventional study,"Objectives Urinary tract infections (UTIs) are one of the leading reasons for antibiotic prescriptions in emergency departments (EDs), with half of these antibiotics being inappropriately prescribed. Our objective was to assess the impact of a computerized decision support system (CDSS) on compliance with guidelines on empirical antibiotic prescriptions (antibiotic and duration) for UTIs in EDs.  Methods A multicentre prospective before-and-after controlled interventional study was conducted from 19 March to 28 October 2012. All adults diagnosed with community-acquired UTIs (cystitis, pyelonephritis or prostatitis) at three French EDs were included. The antibiotic therapy was considered compliant with guidelines if the antibiotic and the duration prescribed were in accordance with the national guidelines. Data were collected using electronic medical records. Paired tests were used when comparing periods within each ED and global analyses used multivariate logistic mixed models.  Results Nine hundred and twelve patients were included during the 30 week study period. The CDSS was used in 59% of cases (182/307). The CDSS intervention improved the compliance of antibiotic prescriptions in only one ED in a bivariate analysis (absolute increase +20%, P?=?0.007). The choice of the antibiotic was improved in multivariate analyses but only when the CDSS was used [OR?=?1.94 (95% CI 1.13–3.32)]. The CDSS also changed the initial diagnosis in 23% of cases, in all three EDs.  Conclusions The CDSS only partially improved compliance with guidelines on antibiotic prescriptions in UTIs.",0,1,
949,Impact of a computerized template on antibiotic prescribing for acute respiratory infections in children and adolescents,"Background. Computerized decision support (CDS) can potentially improve patient safety and guideline adherence. The authors developed an acute respiratory illness interactive template (ARI-IT) within an electronic health record (EHR) to manage pediatric ARIs and assessed the impact on antibiotic prescribing. Methods. They randomized 12 practices either to receive the ARI-IT or to the control group. Antibiotic rates among all eligible ARI diagnoses were compared among control and intervention ARI visits, controlling for clustering by clinician. Results. There was no difference in total antibiotic prescriptions between control and intervention clinics. Use of the ARI-IT significantly reduced antibiotic prescriptions (31.7% vs 39.9%""; P = .02) and use of macrolides (6.2% vs 9.5%;"" P = .02) among visits compared with those eligible visits where it was not used. Conclusion. Use of the CDS reduced antibiotic prescribing and macrolide prescriptions among children with an ARI. Nonetheless, the low overall use resulted in an ineffective intervention.",0,1,
950,Impact of a multifaceted intervention on cholesterol management in primary care practices: guideline adherence for heart health randomized trial,"Background  Physician adherence to National Cholesterol Education Program clinical practice guidelines has been poor.  Methods  We recruited 68 primary care family and internal medicine practices""; 66 were randomly allocated to a study arm; 5 practices withdrew, resulting in 29 receiving the Third Adult Treatment Panel (ATP III) intervention and 32 receiving an alternative intervention focused on the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7). The ATP III providers received a personal digital assistant providing the Framingham risk scores and ATP III–recommended treatment. All practices received copies of each clinical practice guideline, an introductory lecture, 1 performance feedback report, and 4 visits for intervention-specific academic detailing. Data were abstracted at 61 practices from random samples of medical records of patients treated from June 1, 2001, through May 31, 2003 (baseline), and from May 1, 2004, through April 30, 2006 (follow-up). The proportion screened with subsequent appropriate decision making (primary outcome) was calculated. Generalized estimating equations were used to compare results by arm, accounting for clustering of patients within practices.  Results  We examined 5057 baseline and 3821 follow-up medical records. The screening rate for lipid levels increased from 43.6% to 49.0% (ATP III practices) and from 40.1% to 50.8% (control practices) (net difference, -5.3% [P = .22]). Appropriate management of lipid levels decreased slightly (73.4% to 72.3%) in ATP III practices and more markedly (79.7% to 68.9%) in control practices. The net change in appropriate management favored the intervention (+9.7%; 95% confidence interval [CI], 2.8%-16.6% [P < .01]). Appropriate drug prescription within 4 months decreased in both arms (38.8% to 24.8% in ATP III practices and 45.3% to 24.1% in control practices;"" net change, +7.2% [P = .37]) Overtreatment declined from 6.6% to 3.9% in ATP III and rose from 4.2% to 6.4% in control practices (net change, -4.9% [P = .01]).  Conclusions  A multifactor intervention including personal digital assistant–based decision support may improve primary care physician adherence to the ATP III guidelines.",0,1,
951,Impact of a multifaceted intervention on nurses' and physicians' attitudes and behaviors toward family presence during resuscitation,"Recent studies on the attitudes of healthcare providers toward the presence of patients’ family members during cardiopulmonary resuscitations and invasive procedures (family presence) have focused on retrospective or cross-sectional surveys of staff. The research reveals that clinicians’ opinions about the value of this practice are mixed. Although guidelines have been suggested for the implementation of family presence, few reports have been published that describe actual programs or effective strategies for changing practice. As staff members who advocated initiation of a family presence program in our own emergency department, we were interested in evaluating the attitudes of staff members before the family presence program was started and after it had been established. We also wanted to see if attitudes differed between nurses and physicians. In this article, we report our experience with the implementation of a family presence program in the emergency department at a major academic teaching hospital.",0,1,
952,Impact of a quality improvement program on care and outcomes for children with asthma.,"Objective  To test a quality improvement intervention, a learning collaborative based on the Institute for Healthcare Improvement’s Breakthrough Series methodology, specifically intended to improve care and outcomes for patients with childhood asthma.  Design  Randomized trial in primary care practices.  Setting  Practices in greater Boston, Mass, and greater Detroit, Mich.  Participants  Forty-three practices, with 13 878 pediatric patients with asthma, randomized to intervention and control groups.  Intervention  Participation in a learning collaborative project based on the Breakthrough Series methodology of continuous quality improvement.  Main Outcome Measures  Change from baseline in the proportion of children with persistent asthma who received appropriate medication therapy for asthma, and in the proportion of children whose parent received a written management plan for their child’s asthma, as determined by telephone interviews with parents of 631 children.  Results  After adjusting for state, practice size, child age, sex, and within-practice clustering, no overall effect of the intervention was found.  Conclusions  This methodologically rigorous assessment of a widely used quality improvement technique did not demonstrate a significant effect on processes or outcomes of care for children with asthma. Potential deficiencies in program implementation, project duration, sample selection, and data sources preclude making the general inference that this type of improvement program is ineffective. Additional rigorous studies should be undertaken under more optimal settings to assess the efficacy of this method for improving care.",0,1,
953,Impact of a web-based antimicrobial approval system on broad-spectrum cephalosporin use at a teaching hospital.,"Objective: To achieve sustained improvement in use of cefotaxime and ceftriaxone (CEFX) in a major teaching hospital, as measured against national antibiotic guidelines.  Design and setting: Pre- and post-intervention survey of CEFX use in the Royal Melbourne Hospital, a tertiary hospital in Melbourne, Victoria.  Intervention: Web-based antimicrobial approval system linked to national antibiotic guidelines was developed by a multidisciplinary team and implemented in March 2001.  Main outcome measures: Change in rate of CEFX use (defined daily doses [DDDs] per 1000 acute occupied bed days) over 8 months pre- and 15 months post-intervention"";"" concordance of indication for CEFX with national antibiotic guidelines pre- and post-intervention.  Results: CEFX use decreased from a mean of 38.3 DDDs/1000 bed days pre-intervention to 15.9, 18.7 and 21.2 DDDs/1000 bed days at 1, 4 and 15 months post-intervention. Concordance with national antibiotic guidelines rose from 25% of courses pre-intervention to 51% within 5 months post-intervention (P < 0.002). Gentamicin use also increased, from a mean of 30.0 to 48.3 DDDs/1000 bed days (P = 0.0001).  Conclusion: The web-based antimicrobial approval system achieved a sustained reduction in CEFX use over 15 months as well as increased prescribing concordance with antibiotic guidelines. It has potential for linking to electronic prescribing and for wider use for other drugs, as well as for research into the epidemiology of antibiotic use.",0,1,
954,Impact of an educational intervention to improve prescribing by private physicians in Uganda,"INTRODUCTION: Private physicians in urban Uganda treat a large percentage of common adult illnesses. Improving their prescribing would not only encourage more rational drug use, but also reduce costs to patients. Interventions to improve drug use are generally more successful when face-to-face educational methods are included. OBJECTIVES: To determine the effectiveness of a face-to-face educational intervention on the treatment of acute respiratory infections (ARI), malaria, and non-dysenteric diarrhoea by private physicians in three urban areas of Uganda. METHODS: The study used an intervention with comparison group design to evaluate the impact of the educational intervention. A total of 108 private physicians was divided into intervention (n = 30) and control (n = 78) groups. Surrogate patients, trained to simulate presenting symptoms and signs of the target conditions, were used to collect data on the medical practices and prescribing behaviours of the physicians. Intervention physicians were invited to a one-day interactive educational seminar facilitated by local opinion leaders that covered principles of rational drug use and the National Standard Treatment Guidelines for treating the target conditions. Physicians were also provided with data about baseline practices. RESULTS: Baseline data indicated high rates of inappropriate treatment practices by both intervention and control groups. There was nearly universal antibiotic use for ARI (over 90%), high rates of injections recommended for malaria (over 30%), and high rates of polypharmacy (over thee drugs per patient). After the intervention, some significant improvements in key practices were observed in the intervention group. Compared to control physicians, antibiotic prescribing for ARI decreased by 23% in the intervention group, use of combination products for malaria declined by 28%, there were trends towards better adherence to guidelines for ARI and malaria, and marginal decreases in drug costs. However, the overall impacts of the intervention were limited, especially on quality indicators concerning history taking, adequate examination, and advice to patients. CONCLUSION: The face-to-face educational intervention resulted in some small improvements in key prescribing practices of private physicians. However, an intervention that involved repeated contacts with prescribers and which addressed economic considerations would be needed to obtain larger improvements. Private physicians need to be sensitized to and encouraged to use the National Standard Treatment Guidelines, and attempts to improve their prescribing should be supported by community education.",0,0,
955,Impact of clinical practice guidelines on clinicians' behaviour: tonsillectomy in children,"OBJECTIVE: This study was conducted to assess the extent to which developing and implementing clinical practice guidelines for listing children for tonsillectomy (with or without adenoidectomy) influenced the behaviour of participating ENT surgeons. METHOD: A before and after study in which the intervention (the development and dissemination of local practice guidelines) was introduced sequentially into different hospitals and surgical practice. The study was conducted in four ear, nose, and throat surgical services in the North of England, with 16 consultant ENT surgeons and their junior staff on 1190 children aged 0 to 14 years who were judged, prior to consultation with an ENT surgeon, to have been referred for throat-related problems for which tonsillectomy was one possible treatment option were included in the study. Decision reached by surgeons and proportion of decisions that complied with new guidelines. RESULTS: Of the clinical decisions to list children for tonsillectomy taken before introduction of locally agreed guidelines, 73% (486/660) conformed to the criteria in the subsequent guidelines, 15% (97/660) did not, and in 12% (77/660), it was impossible to judge. After the intervention, the corresponding figures were 73% (386/530), 14% (73/53), and 13% (71/530), respectively. When decisions were taken to break the guidelines, this was more often to list for tonsillectomy when it was not indicated--83% (141/170)--than to withhold tonsillectomy when it was indicated--17% (29/170). The aspects of guidelines that were breached in decisions to carry out tonsillectomy were: the age of the child was younger than the guidelines recommended--54% (75/141)""; there had been fever attacks of tonsillitis than the guidelines recommended--22% (32/141);"" and there were ""significant"" symptoms not included in the guidelines--20% (29/141). CONCLUSIONS: In spite of strong evidence to the contrary, local guidelines were formulated at a level that the majority of surgeons already attained. Guideline development and implementation, therefore, had very little impact on clinical practice. The process of local formulation of guidelines was not sufficient to achieve change toward evidence-based practice"";"" clinical preference proved to be quite intractable. There is a need to enhance the ability of clinicians in the assessment and interpretation of research evidence. Previous work has emphasized the need to explore factors that influence clinical behaviour toward evidence-based practice. Our study suggests the need for more research into why clinicians continue to follow clinical preference even when invited to base agreed local clinical policies on evidence.",0,0,
956,"Impact of Clinical Trial Results on National Trends in α-Blocker Prescribing, 1996-2002","Context Research on factors that influence prescribing patterns and the extent of change produced by clinical trial findings is limited.  Objective To examine the changes in prescribing of a-blockers for hypertension treatment before and after the April 2000 publication of the unfavorable Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) early termination involving the study's doxazosin mesylate arm. Changes in prescribing were considered in the context of other potential concurrent influences on medication use between 1996 and 2002, including changes in a-blocker drug prices, generic conversion, drug promotion, and competition.  Design, Setting, and Patients Using 2 national pharmaceutical market research reports published by IMS HEALTH, a-blocker prescription orders reported in the National Prescription Audit—a random computerized sample of about 20 000 of 29 000 retail, independent, and mail order pharmacies and mass merchandise and discount houses—and office-based physician a-blocker prescribing patterns reported in the National Disease and Therapeutic Index—a random stratified sample of about 3500 physician offices—were tracked.  Outcome Measures Trends in physician-reported use of a-blockers and a-blocker prescribing and dispensing by US pharmacies.  Results There were steady increases in a-blocker new prescriptions, dispensed prescriptions, and physician drug use from 1996 through 1999. There was a moderate reversal in these trends following ALLHAT early termination and subsequent publications in early 2000. Between 1999 and 2002, new annual a-blocker prescription orders declined by 26% (from 5.15 million to 3.79 million), dispensed prescriptions by 22% (from 17.2 million to 13.4 million), and physician-reported drug use by 54% (from 2.26 million to 1.03 million). Other potential influences did not appear to have contributed significantly to this decline although cessation of a-blocker marketing may have hastened the decline.  Conclusions Modest yet statistically significant declines in the use of doxazosin and other a-blockers coincided with the early termination of the ALLHAT doxazosin arm. Although physicians responded to this new evidence, strategies to augment the impact of clinical trials on clinical practice are warranted.",0,0,
957,Impact of computerized decision support on blood pressure management and control: a randomized controlled trial.,"BACKGROUND We conducted a cluster randomized controlled trial to examine the effectiveness of computerized decision support (CDS) designed to improve hypertension care and outcomes in a racially diverse sample of primary care patients.  METHODS We randomized 2,027 adult patients receiving hypertension care in 14 primary care practices to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group. We assessed prescribing of guideline-recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients’ race/ethnicity using interaction terms.  MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42% at baseline and 46% at the outcome visit with no significant differences between groups. After adjustment for patients’ demographic and clinical characteristics, number of prior visits, and levels of baseline blood pressure control, there were no differences between intervention groups in the odds of outcome blood pressure control. The use of CDS to providers significantly improved Joint National Committee (JNC) guideline adherent medication prescribing compared to usual care (7% versus 5%, P?<?0.001);"" the effects of the intervention remained after multivariable adjustment (odds ratio [OR] 1.39 [CI, 1.13–1.72]) and the effects of the intervention did not differ by patients’ race and ethnicity.  CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control. Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed.",1,1,
958,Impact of decision support in electronic medical records on lipid management in primary care.,"Electronic decision-support tools may help to improve management of hyperlipidemia and other chronic diseases. This study examined the impact of lipid management tools integrated into an electronic medical record (EMR) in primary care practices. This randomized controlled trial was conducted in a national network of physicians who use an outpatient EMR. Adult primary care physicians were randomized by office to receive an electronic form that was embedded in the EMR. The form contained prompts regarding suboptimal care based on Adult Treatment Panel-III (ATP-III) guidelines, as well as reporting tools to identify patients outside of office visits whose lipid management was suboptimal. All active patients, ages 20–79 years, whose physicians participated in the study, were categorized as high, moderate, or low cardiovascular risk, and the proportion who were tested for hyperlipidemia, at lipid goal, and on lipid-lowering medications if not at goal were measured according to ATP-III guidelines. A total of 105 physicians from 25 offices and 64,150 patients were included in the study.  Outcomes improved for most measures from before to 1 year after the intervention (November 1, 2005 to October 31, 2006). However, after controlling for confounding variables and for clustering in multilevel modeling, only up-to-date lipid testing for high-risk patients was statistically better in the intervention group as compared to the control group (adjusted odds ratio 15.0, P?<?0.05).  This study showed few differences in quality of lipid management after implementing an EMR-based disease management intervention in primary care settings. Future studies may need to examine more comprehensive interventions that include office staff in a team approach to care. (Population Health Management 2009"";""12:221–226)",1,1,
959,Impact of EHR-based clinical decision support on adherence to guidelines for patients on NSAIDs: a randomized controlled trial,"PURPOSE: Electronic health records (EHRs) with clinical decision support hold promise for improving quality of care, but their impact on management of chronic conditions has been mixed. This study examined the impact of EHR-based clinical decision support on adherence to guidelines for reducing gastrointestinal complications in primary care patients on nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: This randomized controlled trial was conducted in a national network of primary care offices using an EHR and focused on patients taking traditional NSAIDs who had factors associated with a high risk for gastrointestinal complications (a history of peptic ulcer disease""; concomitant use of anticoagulants, anti-platelet medications [including aspirin], or corticosteroids; or an age of 75 years or older). The offices were randomized to receive EHR-based guidelines and alerts for high-risk patients on NSAIDs, or usual care. The primary outcome was the proportion of patients who received guideline-concordant care during the 1-year study period (June 2007-June 2008), defined as having their traditional NSAID discontinued (including a switch to a lower-risk medication), having a gastroprotective medication coprescribed, or both. RESULTS: Participants included 27 offices with 119 clinicians and 5,234 high-risk patients. Intervention patients were more likely than usual care patients to receive guideline-concordant care (25.4% vs 22.4%, adjusted odds ratio = 1.19; 95% confidence interval, 1.01-1.42). For individual high-risk groups, patients on low-dose aspirin were more likely to receive guideline-concordant care with the intervention vs usual care (25.0% vs 20.8%, adjusted odds ratio = 1.30;"" 95% confidence interval, 1.04-1.62), but there was no significant difference for patients in other high-risk groups. CONCLUSIONS: This study showed only a small impact of EHR-based clinical decision support for high-risk patients on NSAIDs in primary care offices. These results add to the growing literature about the complexity of EHR-based clinical decision support for improving quality of care.",0,0,
960,Impact of environmental olfactory cues on hand hygiene behaviour in a simulated hospital environment: a randomized study,"This study investigated the impact of a fresh scent on the rate of hand hygiene compliance (HHC) among novice healthcare providers. In all, 165 participants examined a standardized patient with one sample exposed to fresh scent (N = 79) and the other exposed to the standard environment (N = 86). Hand hygiene behaviours were tracked before patient contact using video surveillance. The standard environment group had an HHC rate of 51% whereas participants in the fresh scent group had a higher HHC rate of 80% (P < 0.001). These data demonstrate that hand hygiene behaviour may be subconsciously influenced by cues in the environment.",1,1,
961,Impact of environmental patient education on preventive medicine practices,"BACKGROUND: Studies show that provider-oriented reminders alone are less effective at increasing physician compliance with prevention guidelines than are combinations of patient- and provider-oriented physician reminders. The effectiveness of environmental patient education (ie, office-based videos, pamphlets, and posters) without individual staff or educator involvement has not been well established. The objective of this study was to evaluate the effectiveness of environmental patient education in increasing the amount of preventive services patients receive. METHODS: A nonrandomized controlled trial using historical controls was conducted in a model family practice clinic at the University of New Mexico School of Medicine in Albuquerque. The study group (n = 389) included adult women who had been seen at the clinic at a time when educational materials were present in the waiting area. The control group (n = 381) were similarly selected patients seen during the same period of the previous year, when no such materials were available. During the intervention, patients in the waiting area were exposed to educational materials that encouraged them to ask their physicians about cholesterol testing, Papanicolaou (Pap) smears, tetanus boosters, and mammograms. For both the control and study groups, physician orders for preventive services were monitored over a 4-month follow-up period by reviewing medical records. RESULTS: There were no statistically significant changes in the number of cholesterol tests, Pap smears, tetanus boosters, or mammograms ordered after the environmental patient education intervention, despite adequate statistical power. CONCLUSIONS: Environmental patient education materials were not effective in increasing the amount of preventive services performed by physicians in this study. Although such interventions are inexpensive, easily comprehended, and well intended, they may be ineffective in increasing the performance of patient preventive services.",0,0,
962,Impact of feedback and didactic sessions on the reporting behavior of upper endoscopic findings by physicians and nurses,"BACKGROUND & AIMS: Guidelines for reporting Barrett's esophagus and hiatal hernia measurements and reflux esophagitis grades have been developed to improve consistency, communication, and, ultimately, patient care. Our aims were to assess the percentage of cases in which findings were reported in accordance with guidelines and to assess the impact of education and feedback on reporting behavior. METHODS: Prospective cross-sectional study design was used. Chart reviews were performed for all adult patients who underwent esophagogastroduodenoscopy at a tertiary care center during three 2-month time periods during a 12-month interval: Time 1 (March 1, 2004-April 30, 2004), Time 2 (July 1, 2004-August 31, 2004), and Time 3 (March 1, 2005-April 30, 2005). Standardized educational sessions began 2 years before Time 1. No intervention took place between Time 1 and Time 2"";"" data were collected to examine secular change. Between Time 2 and Time 3, individual and group feedback and refresher sessions were given. RESULTS: Five thousand six hundred nine eligible esophagogastroduodenoscopies were performed, of which 2675 demonstrated Barrett's esophagus, hiatal hernia, and/or reflux esophagitis. At baseline, Barrett's esophagus and hiatal hernia measurements were dictated correctly in a median of 67% and 86% of cases, respectively, improving to 100% (P < .05) and 98% (P < .01) of cases, respectively. The Los Angeles Classification system was used in a median of 100% of cases at baseline and at follow-up. CONCLUSIONS: Anonymous individual and group feedback, in combination with brief, structured didactic educational sessions, significantly improves compliance with established guidelines for the reporting of Barrett's esophagus and hiatal hernia. Once successfully incorporated into clinical practice, adherence to the esophagitis Los Angeles Classification System is easy to maintain.",0,1,
963,Impact of information leaflets on behavior of patients with gastroenteritis or tonsillitis: a cluster randomized trial in French primary care,"OBJECTIVE: To assess the impact of four patient information leaflets on patients' behavior in primary care. DESIGN: Cluster randomized multicenter controlled trial between November 2009 and January 2011. PARTICIPANTS: French adults and children consulting a participating primary care physician and diagnosed with gastroenteritis or tonsillitis. Patients were randomized to receive patient information leaflets or not, according to the cluster randomization of their primary care physician. INTERVENTION: Adult patients or adults accompanying a child diagnosed with gastroenteritis or tonsillitis were informed of the study. Physicians in the intervention group gave patients an information leaflet about their condition. Two weeks after the consultation patients (or their accompanying adult) answered a telephone questionnaire on their behavior and knowledge about the condition. MAIN MEASURES: The main and secondary outcomes, mean behavior and knowledge scores respectively, were calculated from the replies to this questionnaire. RESULTS: Twenty-four physicians included 400 patients. Twelve patients were lost to follow-up (3 %). In the group that received the patient information leaflet, patient behavior was closer to that recommended by the guidelines than in the control group (mean behavior score 4.9 versus 4.2, p < 0.01). Knowledge was better for adults receiving the leaflet than in the control group (mean knowledge score 4.2 versus 3.6, p < 0.01). There were fewer visits for the same symptoms by household members of patients given leaflets (23.4 % vs. 56.2 %, p < 0.01). CONCLUSION: Patient information leaflets given by the physician during the consultation significantly modify the patient's behavior and knowledge of the disease, compared with patients not receiving the leaflets, for the conditions studied.",0,0,
964,Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings,"Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.",0,1,
965,Impact of Mediterranean diet education versus posted leaflet on dietary habits and serum cholesterol in a high risk population for cardiovascular disease,"OBJECTIVE: To investigate the impact of intensive group education on the Mediterranean diet on dietary intake and serum total cholesterol after 16 and 52 weeks, compared to a posted leaflet with the Dutch nutritional guidelines, in the context of primary prevention of cardiovascular disease (CVD). DESIGN: Controlled comparison study of an intervention group given intensive group education about the Mediterranean diet and a control group of hypercholesterolaemic persons given usual care by general practitioners (GPs). SETTING: A socioeconomically deprived area in the Netherlands with an elevated coronary heart disease (CHD) mortality ratio. SUBJECTS: Two hundred and sixty-six hypercholesterolaemic persons with at least two other CVD risk factors. RESULTS: After 52 weeks, the intervention group decreased total and saturated fat intake more than the control group (net differences were 1.8 en% (95%CI 0.2-3.4) and 1.1 en% (95%CI 0. 4-1.9), respectively). According to the Mediterranean diet guidelines the intake of fish, fruit, poultry and bread increased in the intervention group, more than in the control group. Within the intervention group, intake of fish (+100%), poultry (+28%) and bread (+6%) was significantly increased after 1 year (P < 0.05). The intensive programme on dietary education did not significantly lower serum cholesterol level more (-3%) than the posted leaflet (-2%) (net difference 0.06 mmol l-1, 95%CI -0.10 to 0.22). Initially, the body mass index (BMI) decreased more in the intervention group, but after 1 year the intervention and control group gained weight equally (+1%). CONCLUSIONS: Despite beneficial changes in dietary habits in the intervention group compared with the control group, after 1 year BMI increased and total fat and saturated fat intake were still too high.",0,0,
966,Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.,"Objective: Interruptive alerts within electronic applications can cause “alert fatigue” if they fire too frequently or are clinically reasonable only some of the time. We assessed the impact of non-interruptive, real-time medication laboratory alerts on provider lab test ordering.  Design: We enrolled 22 outpatient practices into a prospective, randomized, controlled trial. Clinics either used the existing system or received on-screen recommendations for baseline laboratory tests when prescribing new medications. Since the warnings were non-interruptive, providers did not have to act upon or acknowledge the notification to complete a medication request.  Measurements: Data were collected each time providers performed suggested laboratory testing within 14 days of a new prescription order. Findings were adjusted for patient and provider characteristics as well as patient clustering within clinics.  Results: Among 12 clinics with 191 providers in the control group and 10 clinics with 175 providers in the intervention group, there were 3673 total events where baseline lab tests would have been advised: 1988 events in the control group and 1685 in the intervention group. In the control group, baseline labs were requested for 771 (39%) of the medications. In the intervention group, baseline labs were ordered by clinicians in 689 (41%) of the cases. Overall, no significant association existed between the intervention and the rate of ordering appropriate baseline laboratory tests.  Conclusion: We found that non-interruptive medication laboratory monitoring alerts were not effective in improving receipt of recommended baseline laboratory test monitoring for medications. Further work is necessary to optimize compliance with non-critical recommendations.",1,1,
967,Impact of pharmacist and clinician dual intervention on prescribed benzodiazepines in prisoner patients: a retrospective study,"High-dose benzodiazepine (BDZs) represents an important risk factor for dependence, particularly in a prison environment. In Lyon's prison, BDZs and/or opioid maintenance treatment are often prescribed to patients with mental disorders. The aim of this retrospective study was to assess the impact of psychiatrist and pharmacist collaboration on reducing the BDZs dose prescribed to prisoner patients. Since 2001, clinicians and pharmacists have been holding monthly meetings to develop prescribing guidelines and discuss those patients receiving high-dose BDZs. All prescribed psychotropic drugs were noted for each included patient in the control (before guidelines) and intervention groups. Criteria used to define each patient profile included age, diagnosis (mental disorder), and concomitant treatment (opioids, antidepressants). To compare each group, the daily dose of prescribed BDZs was used as a quantitative variable and expressed in diazepam equivalent. Four hundred and seventy-three patients were included, 222 in the control group and 251 in the intervention group. The two groups showed no difference in terms of diagnosis. The daily dose of BDZ was higher in the control group when all patients were considered (mean(CONTROL GROUP) = 46 mg in diazepam equivalent vs. mean(INTERVENTIION GROUP) = 34 mg) and for each of the following patient categories: 'mental disorder' (48 mg vs. 30 mg), 'no opioid treatment' (44 mg vs. 31 mg), 'buprenorphin treatment' (58 mg vs. 63 mg), 'no antidepressant treatment' (41 mg vs. 29 mg), and 'antidepressant treatment' (53 mg vs. 38 mg). The results of this retrospective study show the positive impact of multidisciplinary intervention on reducing the prescribed daily dose of BDZs. This experience confirms the positive impact that pharmacist feedback on prescriptions and the development of treatment guidelines by clinician and pharmacist collaboration have on improving the prescribing practice in a prison environment.",0,0,
968,Impact of Physician Asthma Care Education on patient outcomes,"OBJECTIVE: We evaluated the effectiveness of a continuing medical education program, Physician Asthma Care Education, in improving pediatricians' asthma therapeutic and communication skills and patients' health care utilization for asthma. METHODS: We conducted a randomized trial in 10 regions in the United States. Primary care providers were recruited and randomly assigned by site to receive the program provided by local faculty. The program included 2 interactive seminar sessions (2.5 hours each) that reviewed national asthma guidelines, communication skills, and key educational messages. Format included short lectures, case discussions, and a video modeling communication techniques. We collected information on parent perceptions of physicians' communication, the child's asthma symptoms, and patients' asthma health care utilization. We used multivariate regression models to determine differences between control and intervention groups. RESULTS: A total of 101 primary care providers and a random sample of 870 of their asthma patients participated. After 1 year, we completed follow-up telephone interviews with the parents of 731 of the 870 patients. Compared to control subjects, parents reported that physicians in the intervention group were more likely to inquire about patients' concerns about asthma, encourage patients to be physically active, and set goals for successful treatment. Patients of physicians that attended the program had a greater decrease in days limited by asthma symptoms (8.5 vs 15.6 days), as well as decreased emergency department asthma visits (0.30 vs 0.55 visits per year). CONCLUSIONS: The Physician Asthma Care Education program was used in a range of locations and was effective in improving parent-reported provider communication skills, the number of days affected by asthma symptoms, and asthma health care use. Patients with more frequent asthma symptoms and higher health care utilization at baseline were more likely to benefit from their physician's participation in the program.",0,0,
969,Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome,"OBJECTIVE: Antimicrobial stewardship programs have been shown to help reduce the use of unnecessary antimicrobial agents in the hospital setting. To date, there has been very little data focusing on high-use areas, such as the medical ICU. A prospective intervention was done to assess guideline compliance, antimicrobial expenditure, and healthcare cost when an infectious disease fellow interacts regularly with the medical ICU team. DESIGN: A 3-month retrospective chart review was followed by a 3-month prospective intervention the following year. Two hundred forty-six total charts were reviewed to assess generally accepted guideline compliance, demographics, and microbiologic results. SETTING: Twenty-four-bed medical ICU at an 861-bed tertiary care, university teaching hospital in North Carolina. SUBJECTS: Patients receiving antibiotics in the medical ICU. INTERVENTION: During the intervention period, the infectious disease fellow reviewed the charts, including physician notes and microbiology data, and discussed antimicrobial use with the medical ICU team. MEASUREMENTS AND MAIN RESULTS: Antimicrobial use, treatment duration, Acute Physiology and Chronic Health Evaluation II scores, length of stay, mechanical ventilation days, and mortality rates were compared during the two periods. RESULTS: No baseline statistically significant differences in the two groups were noted (i.e., age, gender, race, or Acute Physiology and Chronic Healthcare Evaluation II scores). Indications for antibiotics included healthcare-associated (53%) and community-acquired pneumonias (17%). Significant reductions were seen in extended-spectrum penicillins (p=0.0080), carbapenems (p=0.0013), vancomycin (p=0.0040), and metronidazole (p=0.0004) following the intervention. Antimicrobial modification led to an increase in narrow-spectrum penicillins (p=0.0322). The intervention group had a significantly lower rate of treatments that did not correspond to guidelines (p<0.0001). There was a reduction in mechanical ventilation days (p=0.0053), length of stay (p=0.0188), and hospital mortality (p=0.0367). The annual calculated healthcare savings was $89,944 in early antibiotic cessation alone. CONCLUSION: Active communication with an infectious disease practitioner can significantly reduce medical ICU antibiotic overuse by earlier modification or cessation of antibiotics without increasing mortality. This in turn can reduce healthcare costs, foster prodigious education, and strengthen relations between the subspecialties.",0,0,
970,Impact of the WHO depression guideline on patient care by psychiatrists: a randomized controlled trial,"BACKGROUND: Scientific literature reviews aim to summarize the state of knowledge and published empirical evidence. In contrast, medical guidelines are intervention tools that aim to improve physician behaviour and patient outcome. They can have positive effects, but they can also have negative effects. Their effects must be tested by research. METHODS: In a randomized controlled trial, 103 psychiatrists in private practice were either provided with the WHO depression guideline only (information group), or provided with the WHO depression guideline and trained for one day in this guideline (intervention group), or left uninformed (control group). They then treated a total of 497 patients according to individual clinical considerations and the needs of the patients. Observation of routine treatment lasted 12weeks. Physicians and patients documented the course of illness and treatment, including the patient-physician interaction. RESULTS: Psychiatrists in the intervention group saw more psychosocial stressors in their patients, prescribed higher dosages of medication, had fewer drop-outs, and rated treatment outcome as better. The ratings of patient-physician interactions indicated more strain in their relationships. CONCLUSIONS: The results show both positive and negative effects of guideline exposure, but only in the training group and not in the information group. Guidelines should be empirically tested before being called ""evidence based"". Every guideline should also explain how it can or must be implemented in order to become effective.",0,0,
971,Impaired self-awareness after moderately severe to severe traumatic brain injury,"Patients with moderately severe to severe traumatic brain injury (TBI) can demonstrate disturbances in self-awareness several months or years after injury. Patients may underreport cognitive and behavioral difficulties, which are the true residuals of their brain injury. Increasingly, research indicates that the residuals of these disturbances in consciousness greatly affect the process and outcome of rehabilitation. A recent model for conceptualizing disturbances of self-awareness after various forms of brain injury is reviewed.",0,0,
972,"Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in ""early adopter"" hospitals","OBJECTIVES To evaluate the implementation and adoption of the NHS detailed care records service in ""early adopter"" hospitals in England. DESIGN Theoretically informed, longitudinal qualitative evaluation based on case studies. SETTING 12 ""early adopter"" NHS acute hospitals and specialist care settings studied over two and a half years. DATA SOURCES Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders""; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. RESULTS Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems;"" and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. CONCLUSIONS Implementation of the NHS Care Records Service in ""early adopter"" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.",0,0,
973,Implementation and success of nurse telephone counseling in linguistically isolated Korean American patients with high blood pressure,"OBJECTIVE: Nurse telephone counseling can improve the management of chronic conditions, but the effectiveness of this approach in underserved populations is unclear. This study evaluated the use of bilingual nurse-delivered telephone counseling in Korean Americans (KAs) participating in a community-based intervention trial to improve management of hypertension. METHODS: KAs were randomized to receive 12 months of hypertension-related telephone counseling that was more intensive (bi-weekly) or less intensive (monthly). Counseling logs were kept for 360 KAs who completed the pre- and post-intervention evaluations. RESULTS: The overall success rate for the intervention was 80.3%. The level of success was significantly influenced by the dose of counseling, employment status, and years of US residence. Over the 12-month counseling period, both groups showed improvement with regard to medication-taking, alcohol consumption, and exercise but not smoking, with no significant group differences. CONCLUSION: Bilingual telephone counseling could reach monolingual KAs and improve their hypertension management behavior. PRACTICE IMPLICATIONS: Bilingual nurse telephone counseling may have wide applicability, serving as an effective means of disseminating evidence-based chronic disease management guidelines to a linguistically isolated community with limited health resources and information.",0,0,
974,Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care,"Background Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary settings and the relationship with changes in patients¡¯ health behavior.  Methods This study used longitudinal data from the nationwide implementation of an evidence-informed physical activity promotion program in Dutch rehabilitation care. Fidelity scores were calculated based on annual surveys filled in by involved professionals (n?=?¡À?70). Higher fidelity scores indicate a more complete implementation of the program¡¯s core components. A hierarchical cluster analysis was conducted on the implementation fidelity scores of 17 organizations at three different time points. Quantitative and qualitative data were used to explore organizational and professional differences between identified trajectories. Regression analyses were conducted to determine differences in patient outcomes.  Results Three trajectories were identified as the following: ¡®stable high fidelity¡¯ (n?=?9), ¡®moderate and improving fidelity¡¯ (n?=?6), and ¡®unstable fidelity¡¯ (n?=?2). The stable high fidelity organizations were generally smaller, started earlier, and implemented the program in a more structured way compared to moderate and improving fidelity organizations. At the implementation period¡¯s start and end, support from physicians and physiotherapists, professionals¡¯ appreciation, and program compatibility were rated more positively by professionals working in stable high fidelity organizations as compared to the moderate and improving fidelity organizations (p?<?.05). Qualitative data showed that the stable high fidelity organizations had often an explicit vision and strategy about the implementation of the program. Intriguingly, the trajectories were not associated with patients¡¯ self-reported physical activity outcomes (adjusted model ¦Â?=???651.6, t(613)?=???1032, p?=?.303).  Conclusions Differences in organizational-level implementation fidelity trajectories did not result in outcome differences at patient-level. This suggests that an effective implementation fidelity trajectory is contingent on the local organization¡¯s conditions. More specifically, achieving stable high implementation fidelity required the management of tensions: realizing a localized change vision, while safeguarding the program¡¯s standardized core components and engaging the scarce physicians throughout the process. When scaling up evidence-informed health promotion programs, we propose to tailor the management of implementation tensions to local organizations¡¯ starting position, size, and circumstances.",0,1,
975,Implementation of a new policy results in a decrease of pressure ulcer frequency,"OBJECTIVE: To determine the effects of a new policy on the efficiency of pressure ulcer care. DESIGN: Series of 1-day pressure ulcer surveys before and after the implementation. SETTING: A 900-bed University Medical Centre in The Netherlands. PARTICIPANTS: On the days of the surveys, 657 patients were included before the implementation, 735 patients at 4 months after the implementation, and 755 patients at 11 months after the implementation. INTERVENTION: Implementation of a hospital guideline for pressure ulcer care combined with the introduction of viscoelastic foam mattresses on the efficiency of the prevention and treatment of pressure ulcers. MAIN OUTCOME MEASURES: Comparisons before versus after the implementation were made regarding the care behaviour of nurses and the frequency of patients with pressure ulcer. RESULTS: Inadequate prevention decreased from 19 to 4% after 4 months and to 6% after 11 months (P < 0.001), and inadequate treatment decreased from 60 to 31% (P = 0.005). Excluding the use of mattresses as a positive indicator for care behaviour, we found no significant increase in adequate care to prevent pressure ulcers. Also, in adequate treatment activities, we found no significant difference. Overall, we found a significant decrease in hospital-acquired pressure ulcer frequency from 18 to 13% (P = 0.003) after 4 months and 11% (P < 0.001) after 11 months. CONCLUSION: The number of pressure ulcer patients in hospital can successfully be reduced. General measures such as the introduction of adequate mattresses and guidelines for prevention and treatment are promising tools in this respect.",0,1,
976,Implementation of an efficacious intervention for high risk women in Mexico: protocol for a multi-site randomized trial with a parallel study of organizational factors,"Background Studies of implementation of efficacious human immunodeficiency virus (HIV) prevention interventions are rare, especially in resource-poor settings, but important, because they have the potential to increase the impact of interventions by improving uptake and sustainability. Few studies have focused on provider and organizational factors that may influence uptake and fidelity to core intervention components. Using a hybrid design, we will study the implementation of an efficacious intervention to reduce sexually transmitted infections (STIs) among female sex workers (FSWs) in 12 cities across Mexico. Our protocol will test a ¡®train-the-trainer¡¯ implementation model for transporting the Mujer Segura (Healthy Woman) intervention into community-based organizations (CBOs).  Methods We have partnered with Mexican Foundation for Family Planning (Mexfam), a non-governmental organization that has CBOs throughout Mexico. At each CBO, trained ethnographers will survey CBO staff on characteristics of their organization and on their attitudes toward their CBO and toward the implementation of evidence-based interventions (EBIs). Then, after CBO staff recruit a sample of 80 eligible FSWs and deliver a standard-care, didactic intervention to 40 women randomly selected from that pool, a Mexfam staff person will be trained in the Mujer Segura intervention and will then train other counselors to deliver Mujer Segura to the 40 remaining participating FSWs. FSW participants will receive a baseline behavioral assessment and be tested for HIV and STIs (syphilis, gonorrhea, and chlamydia)"";"" they will be reassessed at six months post-intervention to measure for possible intervention effects. At the same time, both qualitative and quantitative data will be collected on the implementation process, including measures of counselors¡¯ fidelity to the intervention model. After data collection at each CBO is complete, the relative efficacy of the Mujer Segura intervention will be analyzed, and across CBOs, correlations will be examined between individual and organizational provider characteristics and intervention efficacy.  Discussion This cooperative, bi-national research study will provide critical insights into barriers and facilitating factors associated with implementing interventions in CBOs using the ¡®train the trainer¡¯ model. Our work builds on similar scale-up strategies that have been effective in the United States. This study has the potential to increase our knowledge of the generalizability of such strategies across health issues, national contexts, and organizational contexts.",0,0,
977,"Implementation of clinical guidelines through an electronic medical record: physician usage, satisfaction and assessment","CONTEXT: We developed and evaluated the Emergency Department Expert Charting System (EDECS) to provide real-time guidance regarding the care of low back pain in adults, fever in children, and occupational exposure to blood and body fluids in health care workers, by embedding clinical guidelines within an electronic medical record. OBJECTIVE: To describe the behaviors and attitudes of physicians who used EDECS. DESIGN: Pre-post questionnaires were used to assess physician attitudes. Time studies of the intervention phase were observational, using clocks embedded in the software. PARTICIPANTS: One hundred and forty two residents and interns in emergency, pediatric, internal, and family medicine and patients with the above-mentioned complaints. MAIN OUTCOME MEASURES: Physician utilization of EDECS, time spent using EDECS, physician satisfaction and beliefs. RESULTS: Eighty four percent of the 142 eligible physicians used EDECS at least once. Five hundred and ninety one of 789 (75%) eligible cases were completed using EDECS. Median session time decreased from 12 min for session 1, to 5.5 min for sessions 16 and above. Physicians generally agreed that care with EDECS was better than standard care, particularly with respect to documentation. There was, however, considerable heterogeneity in belief among complaints. CONCLUSIONS: These data illuminate both the potentials of computer-assisted decision making and the need for context-specific approaches when attempting to implement guidelines.",0,1,
978,Implementation of clinical practice guidelines for prevention of thromboembolism in spinal cord injury.,"Background/Objectives: The purpose of this study was to determine whether publication of the “Prevention of Thromboembolism in Spinal Cord Injury” clinical practice guideline (CPG) changed patient management and whether adherence to CPG recommendations improved after a targeted implementation strategy.  Methods: Data were abstracted from medical records of 1 34 and 520 patients with acute and chronic spinal cord injury (SCI), respectively, from 6 Veterans Affairs medical centers over 3 time periods: prepublication (T1 ), pre implementation (T2), and postimplementation (T3) of the CPG. Targeted interventions were developed to address provider-perceived barriers to guideline adherence, based on findings from focus groups conducted at each site. The interventions incorporated two implementation strategies: standardized documentation templates/standing orders and social marketing /outreach visits.  Results: Use of the specified duration for pharmacologic prophylaxis increased from 60% to 65% to 75% of patients with acute SCI in T1, T2, and T3, respectively (P = 0.060 and 0.041 for T1 vs T2 and T2 vs T3, respectively). Rates of use for individual pharmacologic prophylaxis agents changed significantly over the course of the study, with use of low-molecular-weight heparin increasing from 7% in T1 to 42% in T3. Physical assessments for thrombosis on hospitalization days 1 and 30 improved between T2 and T3. Use of prophylaxis in chronically injured patients with new risk factors for thromboembolism increased from 16% to 31% to 34% during T1, T2, and T3 (P = 0.001 and 0.87, respectively).  Conclusions: The CPG publication had only a modest effect on practice. Use of structured implementation further increased the adherence to some CPG recommendations for thromboembolism prophylaxis. Similar implementation strategies should be considered for CPG recommendations with low adherence and high potential for morbidity and mortality.",0,1,
979,Implementation of diagnosis in asymptomatic patients with aortic stenosis: the Implementation of Diagnosis in asymptomatic patiEnts with Aortic Stenosis registry,"Frequently in clinical practice, some physicians refer patients with aortic stenosis for an invasive approach in the asymptomatic phase of the disease. This empirical behaviour, which is in contrast with the recommendations of the current international clinical guidelines, is due to the perception that the prognosis of these patients is truly worse than retained. Actually, the management of asymptomatic patients with aortic stenosis remains controversial, and there is no clear agreement on how to reduce excess clinical events associated with the presence of aortic stenosis mortality and morbidity demonstrated in these patients by recent randomized clinical trials. The prevailing attention of the attending physicians is often limited to the assessment of the aortic stenosis severity and appearance of symptoms, but it has been clearly shown, instead, that the prognosis of these patients is associated with excessive left-ventricular mass growth and increased atherosclerosis leading to coronary artery disease, heart failure, stroke and death. Thus, apart from the markers of faster aortic stenosis progression, many other clinical and echocardiographic variables should be considered, collected and used together with the clinical/echocardiographic prognostic scores recently validated by several authors in clinical practice, where the vast majority of these variables are guiltily not taken into any consideration. The registry on the Implementation of Diagnosis in asymptomatic patiEnts with Aortic Stenosis is a prospective study designed with the aim to improve the diagnostic evaluation and improve the prognostic stratification of patients with asymptomatic aortic stenosis.",0,0,
980,Implementation of evidence-based rehabilitation for non-specific back pain and common mental health problems: a process evaluation of a nationwide initiative,"BACKGROUND: Nationwide implementation of guaranteed access to evidence-based rehabilitation was established in Sweden in 2009, through an Act of the Swedish Government. The rehabilitation guarantee's primary goal was to increase the rate of return-to-work, reduce and prevent long-term absenteeism after diagnoses related to back pain and common mental health problems. This study aims to develop knowledge about factors influencing large-scale implementation of complex and extensive interventions in healthcare settings. METHODS: Three different data sources questionnaires, interviews and documents were used in data collection and analysis. The data were analysed using iterative thematic analysis. RESULTS: The following main facilitators contributed to realization of the rehabilitation guarantee: financial incentives, establishment of project organization, recruitment, in-service training and previous experiences of working in similar projects. Barriers were: the rehabilitation guarantee's short-term project-form, clinicians' attitudes to and competence in working towards return-to-work, lack of guidelines describing treatment modalities in multimodal rehabilitation, and lack of well-defined criteria for inclusion of patients. Documents revealed that the return-to-work goal became less pronounced during the implementation process. Instead, care and health were more often described in documents used to disseminate information about the rehabilitation guarantee. Intermediate outcomes found were: patients with rehabilitation needs were given more adequate priority, increased readiness for future implementation efforts, and increased general competence in psychotherapy, and team-work, which thus became available to patient groups other than those covered by the rehabilitation guarantee. CONCLUSIONS: To facilitate implementation of established national policy goals in clinical practice, tools are needed that specifically aim at changing clinicians' attitudes and behaviours in relation to such goals. Our results underline the importance of investing both time and sufficient resources in the activities and in supporting the implementation process.",0,0,
981,"Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial","BackgroundWe assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs)."";"" BackgroundWe assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs).",0,1,
982,Implementation of Spanish adaptation of the European guidelines on cardiovascular disease prevention in primary care,"BACKGROUND: The successful implementation of cardiovascular disease (CVD) prevention guidelines relies heavily on primary care physicians (PCPs) providing risk factor evaluation, intervention and patient education. The aim of this study was to ascertain the degree of awareness and implementation of the Spanish adaptation of the European guidelines on CVD prevention in clinical practice (CEIPC guidelines) among PCPs. METHODS: A cross-sectional survey of PCPs was conducted in Spain between January and June 2011. A random sample of 1,390 PCPs was obtained and stratified by region. Data were collected by means of a self-administered questionnaire. RESULTS: More than half (58%) the physicians were aware of and knew the recommendations, and 62% of those claimed to use them in clinical practice, with general physicians (without any specialist accreditation) being less likely to so than family doctors. Most PCPs (60%) did not assess cardiovascular risk, with the limited time available in the surgery being cited as the greatest barrier by 81%. The main reason to be sceptical about recommendations, reported by 71% of physicians, was that there are too many guidelines. Almost half the doctors cited the lack of training and skills as the greatest barrier to the implementation of lifestyle and behavioural change recommendations. CONCLUSIONS: Most PCPs were aware of the Spanish adaptation of the European guidelines on CVD prevention (CEIPC guidelines) and knew their content. However, only one third of PCPs used the guidelines in clinical practice and less than half CVD risk assessment tools.",0,0,
983,"Implementation of the NHLBI integrated guidelines for cardiovascular health and risk reduction in children and adolescents: rationale and study design for young hearts, strong starts, a cluster-randomized trial targeting body mass index, blood pressure, and tobacco","BACKGROUND: Cardiovascular disease (CVD) and the underlying atherosclerosis begin in childhood, and their presence and intensity are related to known cardiovascular disease risk factors. Attention to risk factor control in childhood has the potential to reduce subsequent risk of CVD. OBJECTIVE: The Young Hearts Strong Starts Study was designed to test strategies facilitating adoption of the National, Heart, Lung and Blood Institute supported Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. This study compares guideline-based quality measures for body mass index, blood pressure, and tobacco using two strategies: a multifaceted, practice-directed intervention versus standard dissemination. STUDY DESIGN: Two primary care research networks recruited practices and provided support for the intervention and outcome evaluations. Individual practices were randomly assigned to the intervention or control groups using a cluster randomized design based on network affiliation, number of clinicians per practice, urban versus nonurban location, and practice type. The units of observation are individual children because measure adherence is abstracted from individual patient's medical records. The units of randomization are physician practices. This results in a multilevel design in which patients are nested within practices. The intervention practices received toolkits and supported guideline implementation including academic detailing, an ongoing e-learning group. This project is aligned with the American Board of Pediatrics Maintenance of Certification requirements including monthly physician self-abstraction, webinars, and other elements of the trial. SIGNIFICANCE: This trial will provide an opportunity to demonstrate tools and strategies to enhance CV prevention in children by guideline-based interventions.",0,0,
984,Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals,"BACKGROUND: Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework. METHODS: This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention. Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended). RESULTS: Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated"";"" 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. IMPLEMENTATION: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (""user friendly,"" ""streamlined,"" or ""saves time""), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended. CONCLUSIONS: Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01309217.",0,1,
985,IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): cluster randomised controlled trial study protocol,"BACKGROUND: Evidence generated from reliable research is not frequently implemented into clinical practice. Evidence-based clinical practice guidelines are a potential vehicle to achieve this. A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines. Recommendations from this review, and other studies, have suggested the use of interventions that are theoretically based because these may be more effective than those that are not. An evidence-based clinical practice guideline for the management of acute low back pain was recently developed in Australia. This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common, has a high burden, and for which there is an evidence-practice gap in the primary care setting. AIM: This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria, Australia. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray, and improving mean level of disability for patients three months post-consultation. METHODS/DESIGN: This study protocol describes the details of a cluster randomised controlled trial. Ninety-two general practices (clusters), which include at least one consenting general practitioner, will be randomised to an intervention or control arm using restricted randomisation. Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion. An average of twenty-five patients per general practice will be recruited, providing a total of 2,300 patient participants. General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy. Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory. Investigators (not involved in the delivery of the intervention), patients, outcome assessors and the study statistician will be blinded to group allocation.",0,0,
986,Implementing a guideline for the treatment of type 2 diabetics: results of a cluster-randomized controlled trial (C-RCT),"BACKGROUND: In Italy many diabetics still lack adequate care in general practice. We assessed the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes among General Practitioners (GPs) of Lazio region. METHODS: Three-arm cluster-randomised controlled trial with GPs as units of randomisation (clusters). 252 GPs were randomised either to an active strategy (training module with administration of the guideline), or to a passive dissemination (administration of the guideline only), or to usual care (control). Data on prescriptions of tests and drugs were collected by existing information systems, whereas patients' data came from GPs' databases. Process outcomes were measured at the cluster level one year after the intervention. Primary outcomes concerned the measurement of glycosilated haemoglobin and the commissioning of micro- and macrovascular complications assessment tests. In order to assess the physicians' drug prescribing behaviour secondary outcomes were also calculated. RESULTS: GPs identified 6395 uncomplicated type 2 patients with a high prevalence of cardiovascular risk factors. Data on GPs baseline performance show low proportions of glycosilated haemoglobin assessments. Results of the C-RCT analysis indicate that the active implementation strategy was ineffective relating to all primary outcomes (respectively, OR 1.06 [95% IC: 0.76-1.46]""; OR 1.07 [95% IC: 0.80-1.43];"" OR 1.4 [95% IC:0.91-2.16]. Similarly, passive dissemination of the guideline showed no effect. CONCLUSION: In our region compliance of GPs with guidelines was not enhanced by a structured learning programme. Implementation through organizational measures appears to be essential to induce behavioural changes. TRIAL REGISTRATION: ISRCTN80116232.",0,0,
987,Implementing a public-private mix model for tuberculosis treatment in urban Pakistan: lessons and experiences,"SETTING: Six towns of Karachi, Pakistan. OBJECTIVES: 1) To strengthen the capacity of general practitioners (GPs) in providing tuberculosis (TB) treatment through DOTS""; and 2) to enhance collaboration between the public and private sectors in TB management and case reporting. DESIGN: A quasi-experimental study design was adopted to ensure enrolment of TB patients through trained GPs with the support of laboratory networks and to improve the case detection rate. RESULTS: The following challenges were faced during implementation of the model in urban settings: no systematic list of GPs was available; the majority of the GPs were untrained health practitioners working in squatter settlements, where formally trained GPs are most needed; the motivation of GPs with high patient loads is very low;"" and access to a laboratory is difficult. Of 35 patients enrolled in the first quarter (third quarter 2009), 87% completed their treatment successfully. CONCLUSION: Public-private mix (PPM) DOTS is feasible in the cities of Pakistan. However, the cost, time and effort required to establish the programme is higher than in many other developing countries.",0,0,
988,Implementing academic detailing for breast cancer screening in underserved communities,"BACKGROUND: African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians. METHODS: Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE). RESULTS: Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over"";"" mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening. CONCLUSION: We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.",0,0,
989,Implementing Best Evidence in Smoking Cessation Treatment for Hospitalized Veterans: Results from the VA-BEST Trial,"BACKGROUND: Although the US Department of Veterans Affairs (VA) has promoted adherence to smoking cessation guidelines since 1997, hospitalized smokers do not consistently receive assistance in quitting. METHODS: In a pre-post guideline implementation trial on the inpatient medicine units of four VA hospitals, the effectiveness of a multimodal intervention (enhanced academic detailing, modification of the nursing admission template, patient education materials and quitline referral, practice facilitation and staff feedback) changing practice behavior was evaluated. Peridischarge interviews were conducted with 824 patients to assess receipt of nurses' and physicians' delivery of the 5A's (Ask, Advise, Assess, Assist, Arrange) in hospitalized smokers. RESULTS: Subjects were significantly more likely to have received each of the 5A's from a nurse during the postimplementation period (except for ""advise to quit""). More patients were assisted in quitting (75% versus 56%, adjusted odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.6, 3.1) and had follow-up arranged (23% versus 18%, adjusted OR = 1.5, 95% CI = 1.0, 2.2) by a nurse during the postimplementation period. However, unadjusted results showed no improvement in seven-day point prevalence abstinence at six-month follow-up (13.5% versus 13.9%). Nurses' self-efficacy in cessation counseling, as measured in a survey of 166 unit nurses, improved following guideline implementation. DISCUSSION: A multifaceted intervention including enhanced academic detailing is an effective strategy for improving the delivery of smoking cessation services in medical inpatients. To promote long-term cessation, more intensive interventions are needed to ensure that motivated smokers receive guideline-recommended treatment (including pharmacotherapy and referral to outpatient cessation counseling).",0,0,
990,"Implementing clinical guidelines in the treatment of diabetes mellitus in general practice. Evaluation of effort, process, and patient outcome related to implementation of a computer-based decision support system","OBJECTIVES: To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. METHODS: Randomized study with health center as unit. General practice in Sor- and Nord-Trondelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation). RESULTS: Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%""; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%);"" all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was -2.3 mm Hg (95% CI, -3.8, -0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, -0.1% (95% CI, -0.4, 0.1), systolic blood pressure, -1.2 mm Hg (95% CI, -4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, -4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, -0.8, 1.4), risk score in female +0.1 (95% CI, -5.1, 5.2), and risk score in male +2.6 (95% CI, -14.2, 19.5). CONCLUSIONS: Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.",0,1,
991,Implementing clinical guidelines in the treatment of hypertension in general practice.,"Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs 87.1%), cardiovascular inheritance (79.5% vs 73.4%) and body mass index (81.5% vs 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures.",0,1,
992,Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community,"OBJECTIVE: To evaluate the ability of a systematic educational intervention strategy to change the plain radiography ordering behavior of chiropractors toward evidence-based practice for patients with acute low back pain (LBP). DESIGN: A quasi-experimental method was used comparing outcomes before and after the intervention with those of a control community. SETTING: Two communities in southern Ontario. DATA SOURCE: Mailed survey data on the management of acute LBP. Outcome Measures Plain radiography use rates for acute LBP based on responses to mailed surveys. RESULTS: Following the intervention, there was a 42% reduction in the self-report need for plain radiography for uncomplicated acute LBP (P .05). CONCLUSIONS: The educational intervention strategy used in this study appeared to have an effect in reducing the perceived need for plain radiography in acute LBP.",0,0,
993,Implementing evidence-based practice: effectiveness of a structured multifaceted mentorship programme,"AIM: This paper is a report of the effectiveness of a structured multifaceted mentorship programme designed to implement evidence-based practice in a clinical research intensive environment. BACKGROUND: Barriers to implementing evidence-based practice are well-documented in the literature. Evidence-based practice is associated with higher quality care and better patient outcomes than care that is steeped in tradition. However, the integration of evidence-based practice implementation into daily clinical practice remains inconsistent, and the chasm between research and bedside practice remains substantial. METHODS: This quasi-experimental mixed methods study included three focused discussions with nursing leadership and shared governance staff as well as pre- (N = 159) and post-intervention (N = 99) questionnaires administered between June 2006 and February 2007. Online questionnaires included measures of organizational readiness, evidence-based practice beliefs, evidence-based practice implementation, job satisfaction, group cohesion and intent to leave nursing and the current job. Results. Participants in the evidence-based practice mentorship programme had a larger increase in perceived organizational culture and readiness for evidence-based practice and in evidence-based practice belief scores than those who did not participate. Qualitative findings suggested that leadership support of a culture for evidence-based practice and the dedication of resources for sustainability of the initiative needed to be a priority for engaging staff at all levels. CONCLUSION: These findings corroborate other studies showing that nurses' beliefs about evidence-based practice are significantly correlated with evidence-based practice implementation and that having a mentor leads to stronger beliefs and greater implementation by nurses as well as greater group cohesion, which is a potent predictor of nursing turnover rates.",0,0,
994,Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation,"BACKGROUND: Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing. METHODS: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network. RESULTS: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92). CONCLUSIONS: An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.",0,1,
995,Implementing guidelines on the prevention of opportunistic infections in inflammatory bowel disease,"INTRODUCTION: Opportunistic infections are a key safety concern in the management of patients with inflammatory bowel disease (IBD). Despite the existence of international guidelines, many gastroenterologists have not adopted routine screening and vaccination. The aim of this study was to modify clinical behaviour by use of a simple screening tool. METHODS: A screening and vaccination proforma for hepatitis B, varicella, Influenza, Pneumococcus, human papillomavirus, tuberculosis, hepatitis C and HIV was provided to each participating gastroenterologist. Gastroenterologists were surveyed for awareness of vaccine recommendations and current practice prior to and following the introduction of the proforma. Rates of immunity and the proportion of patients receiving the recommended screening and vaccinations were documented. RESULTS: 30 gastroenterologists at 8 different IBD centres took part in the assessment. A total of 919 patients were included (55% female, 65% Crohn's, 33% ulcerative colitis, 2% indeterminate IBD). Introduction of the proforma increased self-reported gastroenterologist screening from 47% to 97% pre- and post-intervention respectively, p<0.001. After the proforma was applied, vaccination against hepatitis B, varicella, Influenza, and Pneumococcus was recommended in 67%, 2.5%, 75% and 69% of the patients respectively. Of these, 42%, 39%, 66% and 49% patients followed the recommendations and were vaccinated. Cervical smears were recommended in 31%, with 62% of these obtaining the recommended cervical smear. CONCLUSIONS: Implementation of a screening and vaccination proforma significantly changed gastroenterologist self-reported behaviour. Patient compliance with these recommendations was not optimal and suggests the need for further patient education, in addition to other forms of support.",0,1,
996,Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial,"Background Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8–12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model.  Methods/design A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants’ treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER).  Discussion The results from the present study will add to the current knowledge on tailored strategies, which aims to improve the uptake of evidence-based OA care recommendations and improve the quality of OA care in primary health care. The new knowledge can be used in national and international initiatives designed to improve the quality of OA care. Trial registration ClinicalTrials.gov NCT02333656",0,1,
997,Implementing nutritional guidelines -- the effect of systematic training for nurse nutrition practitioners,"INTRODUCTION: Approximately 40% of patients admitted to hospitals are undernourished. Implementing nutritional guidelines might reduce the incidence of malnutrition, and it requires education and training for the hospital staff. AIM: It was hypothesised that a training programme focusing on the staff behaviour would increase the identification of eating difficulties, improve patients' knowledge about appropriate food choices and increase the number of snacks eaten between meals and thereby to reduce the risk of undernutrition. METHODS: A pre- and post-test design was used to evaluate the effect of the training programme for nurses. The training was conducted in five modules over 1 year and combined nutritional issues with issues on implementation and theories of planned change. The programme was based on experimental learning theories and the steps of look, think and act. The effect on the patients was measured by a patient questionnaire. RESULTS: After implementing the guidelines, more patients discussed their eating difficulties with the staff, received relevant assistance during the meal and were served the type of food they had ordered and could chew. The patients' knowledge of appropriate food choices from the menu increased, suggesting that the nutritional intake of the patients had improved. CONCLUSION: Our findings suggest that a strategy based on the principles of experimental learning theory and the phases in the look, think and act model facilitated the implementation of nutritional guidelines in a hospital setting.",0,0,
998,Implementing of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids.,"Context.  —While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care.  Objective.  —To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines.  Design.  —Prospective off-on-off, interrupted time series with intent-to-treat analysis.  Setting.  —University hospital emergency department.  Subjects.  —Patients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study.  Interventions.  —Implementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines.  Main Outcome Measures.  —Quality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities.  Results.  —Mean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase""; 95% confidence interval [CI], 34%-49%) and 11 items in aftercare instruction increased from 31% at baseline to 93% during the intervention phase (62% increase; 95% CI, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% CI, 9%-31%) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% Ci, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase;"" 95% CI, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively.  Conclusions.  —Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.",0,1,
999,Implementing research findings into practice using clinical opinion leaders: barriers and lessons learned,"BACKGROUND: An opinion leader-driven intervention to improve practice guideline-based medication management for patients with schizophrenia was tested at four Department of Veterans Affairs health care facilities. The concept of using opinion leaders as disseminators of research evidence and internal agents of change has been widely reported. PROJECT OVERVIEW: Each intervention site received an intensive, multicomponent intervention during the course of one year. The project's process evaluation included ongoing brief surveys of physicians' attitudes and behaviors, logs of reports from opinion leader conference calls, and interviews with the opinion leaders toward the end of the implementation period. BARRIERS OR ISSUES AND POTENTIAL SOLUTIONS: Several barriers or problematic issues surfaced: (1) physicians do not always agree on who is an opinion leader""; some sites may have no opinion leader; (2) some sites had poorly developed formal and informal social networks among physicians; (3) a focus on physicians only as agents of change;"" and (4) how much directive should be given to the opinion leaders concerning how to influence attitudes and behaviors? DISCUSSION: Four major problematic issues encountered during the project offer potential solutions for addressing them.",0,1,
1000,Implementing the NHS information technology programme: qualitative study of progress in acute trusts,"OBJECTIVES To describe progress and perceived challenges in implementing the NHS information and technology (IT) programme in England. DESIGN Case studies and in-depth interviews, with themes identified using a framework developed from grounded theory. We interviewed personnel who had been interviewed 18 months earlier, or new personnel in the same posts. SETTING Four NHS acute hospital trusts in England. PARTICIPANTS Senior trust managers and clinicians, including chief executives, directors of IT, medical directors, and directors of nursing. RESULTS Interviewees unreservedly supported the goals of the programme but had several serious concerns. As before, implementation is hampered by local financial deficits, delays in implementing patient administration systems that are compliant with the programme, and poor communication between Connecting for Health (the agency responsible for the programme) and local managers. New issues were raised. Local managers cannot prioritise implementing the programme because of competing financial priorities and uncertainties about the programme. They perceive a growing risk to patients' safety associated with delays and a loss of integration of components of the programme, and are discontented with Choose and Book (electronic booking for referrals from primary care). CONCLUSIONS We recommend that the programme sets realistic timetables for individual trusts and advises managers about interim IT systems they have to purchase because of delays outside their control. Advice needs to be mindful of the need for trusts to ensure longer term compatibility with the programme and value for money. Trusts need assistance in prioritising modernisation of IT by, for example, including implementation of the programme in the performance management framework. Even with Connecting for Health adopting a different approach of setting central standards with local implementation, these issues will still need to be addressed. Lessons learnt in the NHS have wider relevance as healthcare systems, such as in France and Australia, look to realise the potential of large scale IT modernisation.",0,0,
1001,Implications of stroke prevention trials: treatment of global risk,"Clinical trials have demonstrated that risk of cardiovascular events may be reduced in patients with stroke, using blood pressure (BP) reduction and statin therapy, independently of the presence of specific risk factors. These results suggest an alternative approach to secondary stroke prevention, focused more on global risk than on detection and modification of individual categorical risk factors such as hypertension, dyslipidemia, and diabetes mellitus. A risk-based approach is warranted because stroke patients are at high risk of several cardiovascular events, not just stroke, and because physiologic risk factors such as BP demonstrate a continuous, or log-linear, relationship with cardiovascular risk. Essential to the implementation of such an approach is the development of adequate risk stratification models for stroke patients. Based on limited available evidence, however, it appears that most patients who experience an ischemic stroke or TIA are at high long-term absolute risk of a subsequent cardiovascular event and should be treated with all available risk-reduction strategies.",0,0,
1002,Importance of characteristics and modalities of physical activity and exercise in defining the benefits to cardiovascular health within the general population: recommendations from the EACPR (Part I),"Over the last decades, more and more evidence is accumulated that physical activity (PA) and exercise interventions are essential components in primary and secondary prevention for cardiovascular disease. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit in achieving cardiovascular health. The present paper, as the first of a series of three, will make specific recommendations on the importance of these characteristics for cardiovascular health in the population at large. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and the individual member of the public. Based on previous and the current literature, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and exercise.",0,0,
1003,Improved asthma outcomes using a coordinated care approach in a large medical group.,"The objective of this study was to review the development of a multidisciplinary asthma disease management program in a large medical group practice in an urban area, and evaluate the impact of the program on processes of care and health care utilization for adults and children with asthma. The disease management intervention included the development of a patient registry, a systematic approach to assessment of asthma control using the Asthma Therapy Assessment Questionnaire (ATAQ), case management, and physician education. An administrative database was used to examine hospital admissions and emergency department (ED) visits. A medical record audit was conducted to examine recorded compliance with asthma guidelines and documentation practices. The baseline study population included 3,486 adults and children with asthma. The ATAQ suggested that, at baseline, control problems were frequent, with 34% of adult respondents missing work because of asthma. ATAQ also revealed several areas for care improvement. For example, only 20% of adult respondents reported having a written treatment plan. The chart review and administrative claims analyses showed that the program had beneficial results in several areas. Medical record documentation improved for asthma diagnosis (83.3% vs. 98.6%""; p < 0.001) and patient education (15.7% vs. 26.1%;"" p < 0.001). No improvements were seen in documentation of peak flow ownership/use, smoking cessation advice, or influenza vaccination. ED visits related to asthma decreased from 148 per 1000 to 88 per 1000 (p < 0.001), and hospitalizations related to asthma decreased from 81 per 1000 to 37 per 1000 (p < 0.001). The outcomes suggest that this program was associated with a marked reduction in rates of hospitalization and ED usage for asthma, as well as significant improvement in several essential processes of care.",0,1,
1004,Improved Clinical Performance and Teamwork of Pediatric Interprofessional Resuscitation Teams With a Simulation-Based Educational Intervention,"OBJECTIVES: To measure the effect of a 1-day team training course for pediatric interprofessional resuscitation team members on adherence to Pediatric Advanced Life Support guidelines, team efficiency, and teamwork in a simulated clinical environment. DESIGN: Multicenter prospective interventional study. SETTING: Four tertiary-care children's hospitals in Canada from June 2011 to January 2015. SUBJECTS: Interprofessional pediatric resuscitation teams including resident physicians, ICU nurse practitioners, registered nurses, and registered respiratory therapists (n = 300""; 51 teams). INTERVENTIONS: A 1-day simulation-based team training course was delivered, involving an interactive lecture, group discussions, and four simulated resuscitation scenarios, each followed by a debriefing. The first scenario of the day (PRE) was conducted prior to any team training. The final scenario of the day (POST) was the same scenario, with a slightly modified patient history. All scenarios included standardized distractors designed to elicit and challenge specific teamwork behaviors. MEASUREMENTS AND MAIN RESULTS: Primary outcome measure was change (before and after training) in adherence to Pediatric Advanced Life Support guidelines, as measured by the Clinical Performance Tool. Secondary outcome measures were as follows: 1) change in times to initiation of chest compressions and defibrillation and 2) teamwork performance, as measured by the Clinical Teamwork Scale. Correlation between Clinical Performance Tool and Clinical Teamwork Scale scores was also analyzed. Teams significantly improved Clinical Performance Tool scores (67.3-79.6%; p < 0.0001), time to initiation of chest compressions (60.8-27.1 s; p < 0.0001), time to defibrillation (164.8-122.0 s; p < 0.0001), and Clinical Teamwork Scale scores (56.0-71.8%; p < 0.0001). A positive correlation was found between Clinical Performance Tool and Clinical Teamwork Scale (R = 0.281;"" p < 0.0001). CONCLUSIONS: Participation in a simulation-based team training educational intervention significantly improved surrogate measures of clinical performance, time to initiation of key clinical tasks, and teamwork during simulated pediatric resuscitation. A positive correlation between clinical and teamwork performance suggests that effective teamwork improves clinical performance of resuscitation teams.",0,0,
1005,Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care,"BACKGROUND: There is a need to find innovative approaches for translating best practices for chronic disease care into daily primary care practice routines. Primary care plays a crucial role in the prevention and management of cardiovascular disease. There is, however, a substantive care gap, and many challenges exist in implementing evidence-based care. The Improved Delivery of Cardiovascular Care (IDOCC) project is a pragmatic trial designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices using practice outreach facilitation. METHODS: The IDOCC project is a stepped-wedge cluster randomized control trial in which Practice Outreach Facilitators work with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk. Primary care practices in a large health region in Eastern Ontario, Canada, were eligible to participate. The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices are supported in changing practice behavior by incorporating chronic care model elements. These elements include (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients. The primary outcome is a composite score measured at the level of the patient to represent each practice's adherence to evidence-based guidelines for cardiovascular care. Qualitative analysis of the Practice Outreach Facilitators' written narratives of their ongoing practice interactions will be done. These textual analyses will add further insight into understanding critical factors impacting project implementation. DISCUSSION: This pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00574808.",0,0,
1006,Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis.,"A prospective study was performed over a two-year period to determine whether computer-generated reminders of perioperative antibiotic use could improve prescribing habits and reduce postoperative wound infections. During the first year, baseline patterns of antibiotic use and postoperative infection rates were established. During the second year, computer-generated reminders regarding perioperative antibiotic use were placed in the patient's medical record prior to surgery and patterns of antibiotic use and postoperative wound infections monitored.  Hospitalized patients undergoing non-emergency surgery from June to November 1985 (3,263 patients), and from June to November 1986 (3,568) were monitored with respect to indications for perioperative antibiotic use, timing of antibiotic use and postoperative infectious complications. Perioperative antibiotic use was considered advisable for 1,621 (50%) patients in the 1985 sample and for 1,830 (51%) patients in the 1986 sample. Among these patients, antibiotics were given within two hours before the surgical incision in 638 (40%) of the 1985 sample and 1,070 (58%) of the 1986 sample (p<0.001). Overall, postoperative wound infections were detected in 28 (1.8%) of 1,621 patients in 1985 compared with 16 (0.9%) of 1,830 such patients in 1986 (p<0.03).  We conclude that computer-generated reminders of perioperative antibiotic use improved prescribing habits with a concurrent decline in postoperative wound infections.",1,1,
1007,Improved therapeutic monitoring with several interventions: a randomized trial.,"Background  Medication errors are frequently related to failure to appropriately select medications or adjust for laboratory parameters. Differences between guideline recommendations and actual frequency of therapeutic laboratory monitoring are substantial. This study evaluated interventions to improve laboratory monitoring at initiation of medication therapy.  Methods  This cluster-randomized trial compared 3 interventions to usual care for 10 medications in 15 primary care clinics in a health maintenance organization with an electronic medical record system. Eligible patients, identified from electronic databases, had not received recommended laboratory monitoring within 5 days after new dispensing of a study medication. Interventions were an electronic medical record reminder to the prescribing health care professional, an automated voice message to the patient, and a pharmacy team outreach to the patient. Primary outcome was completion of all recommended baseline laboratory monitoring.  Results  A total of 961 patients participated in the study. At 25 days, 95 (48.5%) of 196 patients in the electronic medical record reminder group, 177 (66.3%) of 267 in the automated voice message group, 214 (82.0%) of 261 in the pharmacy team outreach group, and 53 (22.4%) of 237 in the usual care group had completed all recommended baseline laboratory monitoring (P<.001). After adjustments, the hazard ratios for completing laboratory monitoring compared with usual care were 2.5 (95% confidence interval, 1.8-3.5) for electronic medical record reminder, 4.1 (95% confidence interval, 3.0-5.6) for automated voice message, and 6.7 (95% confidence interval, 4.9-9.0) for pharmacy team outreach.  Conclusions  All 3 interventions were effective in increasing laboratory monitoring when initiating new medications in primary care. Further work is necessary to determine if these interventions improve patient outcomes.",1,1,
1008,Improvement of antibiotic prescription in outpatient care: a cluster-randomized intervention study using a sentinel surveillance network of physicians,"OBJECTIVES: To assess the effectiveness of implementing guidelines, coupled with individual feedback, on antibiotic prescribing behaviour of primary care physicians in Switzerland. METHODS: One hundred and forty general practices from a representative Swiss sentinel network of primary care physicians participated in this cluster-randomized prospective intervention study. The intervention consisted of providing guidelines on treatment of respiratory tract infections (RTIs) and uncomplicated lower urinary tract infections (UTIs), coupled with sustained, regular feedback on individual antibiotic prescription behaviour during 2 years. The main aims were: (i) to increase the percentage of prescriptions of penicillins for all RTIs treated with antibiotics""; (ii) to increase the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics; (iii) to decrease the percentage of quinolone prescriptions for all cases of exacerbated COPD (eCOPD) treated with antibiotics;"" and (iv) to decrease the proportion of sinusitis and other upper RTIs treated with antibiotics. The study was registered at ClinicalTrials.gov (NCT01358916). RESULTS: While the percentage of antibiotics prescribed for sinusitis or other upper RTIs and the percentage of quinolones prescribed for eCOPD did not differ between the intervention group and the control group, there was a significant increase in the percentage of prescriptions of penicillins for all RTIs treated with antibiotics [57% versus 49%, OR=1.42 (95% CI 1.08-1.89), P=0.01] and in the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics [35% versus 19%, OR=2.16 (95% CI 1.19-3.91), P=0.01] in the intervention group. CONCLUSIONS: In our setting, implementing guidelines, coupled with sustained individual feedback, was not able to reduce the proportion of sinusitis and other upper RTIs treated with antibiotics, but increased the use of recommended antibiotics for RTIs and UTIs, as defined by the guidelines.",0,0,
1009,Improvement of hypertension management by structured physician education and feedback system: cluster randomized trial,"INTRODUCTION: We aimed to assess whether hypertension management with a structured physician information program and a feedback system leads to improved blood pressure (BP) control and cardiovascular outcomes. METHODS: Cluster randomized (3 : 1), open, monitored, multicenter trial in Germany. Primary care-based physicians in the information group (IG) received detailed training on hypertension guidelines, feedback on target-level attainment, and a reminder to intensify treatment after each patient visit, whereas the observation/control group (CG) did not receive any such measures. A three-level mixed model was developed. Time-independent level differences between groups, group-independent changes, and nonparallel group-specific changes over time were tested. RESULTS: A total of 15 041 (78.1%) hypertensive patients were in the IG and 4213 (21.9%) in the CG. By 1-year follow-up, 82.9% of patients in the IG and 81.5% in the CG remained in the study. The guideline-oriented BP target was attained by 56.8% in the IG and 52.5% in the CG (+4.3%, P = 0.03), whereas the individual BP target was attained by 57.0% in the IG and 51% in the CG (P = NS). BP control in the IG was achieved 2 months earlier on average. Clinical inertia, defined as the absence of medication changes, despite noncontrol of BP, occurred significantly less often in the IG group. One-year cardiovascular outcomes did not differ between groups. CONCLUSION: The delivery of systematic information in connection with a feedback system reduces clinical inertia and improves guideline adherence. Although compared with earlier studies, the hypertension control rates obtained are higher, there is still considerable room for improvement.",0,0,
1010,Improvement of intraoperative antibiotic prophylaxis in prolonged cardiac surgery by automated alerts in the operating room,"Objective: To assess the impact of an automated intraoperative alert to redose prophylactic antibiotics in prolonged cardiac operations.  Design: Randomized, controlled, evaluator-blinded trial.  Setting: University-affiliated hospital.  Patients: Patients undergoing cardiac surgery that lasted more than 4 hours after the preoperative administration of cefazolin, unless they were receiving therapeutic antibiotics at the time of surgery.  Intervention: Randomization to an audible and visual reminder on the operating room computer console at 225 minutes after the administration of preoperative antibiotics (reminder group, n = 137) or control (n = 136). After another 30 minutes, the circulating nurse was required to indicate whether a follow-up dose of antibiotics had been administered.  Results: Intraoperative redosing was significantly more frequent in the reminder group (93 of 137""; 68%) than in the control group (55 of 136; 40%) (adjusted odds ratio, 3.31; 95% confidence interval, 1.97 to 5.56; P < .0001). The impact of the reminder was even greater when compared with the 6 months preceding the study period (129 of 480;27%; P < .001), suggesting some spillover effect on the control group. Redosing was formally declined for 19 of the 44 patients in the reminder group without redosing. The rate of surgical-site infection in the reminder group (5 of 137; 4%) was similar to that in the control group (8 of 136;6%; P = .42), but significantly lower than that in the pre-study period (48 of 480;10%;"" P = .02).  Conclusion: The use of an automatic reminder system in the operating room improved compliance with guidelines on perioperative antibiotic prophylaxis.",1,1,
1011,Improving adherence to guidelines for hypertension drug prescribing: cluster-randomized controlled trial of general versus patient-specific recommendations,"OBJECTIVE: To determine whether an intervention focusing clinician attention on drug choice for hypertension treatment improves concordance between drug regimens and guidelines. STUDY DESIGN: Cluster-randomized controlled trial comparing an individualized intervention with a general guideline implementation in geographically diverse primary care clinics of a university-affiliated Department of Veterans Affairs healthcare system. METHODS: Participants were 36 attending physicians and nurse practitioners (16 in the general group and 20 in the individualized group), with findings based on 4500 hypertensive patients. A general guideline implementation for all clinicians, including education about guideline-based drug recommendations and goals for adequacy of blood pressure control, was compared with addition of a printed individualized advisory sent to clinicians at each patient visit, indicating whether or not the patient's antihypertensive drug regimen was guideline concordant. We measured change from baseline to end point in the proportion of clinicians' patients whose drug therapy was guideline concordant. RESULTS: The individualized intervention resulted in an improvement in guideline concordance more than twice that observed for the general intervention (10.9% vs 3.8%, t = 2.796, P = .008). Bootstrap analysis showed that being in the individualized group increased the odds of concordance 1.5-fold (P = .025). The proportion of patients with adequate blood pressure control increased within each study group"";"" however, the difference between groups was not significant. CONCLUSION: An individualized advisory regarding drug therapy for hypertension given to the clinician at each patient visit was more effective in changing clinician prescribing behavior than implementation of a general guideline.",0,1,
1012,Improving Adherence to Therapy and Clinical Outcomes While Containing Costs: Opportunities From the Greater Use of Generic Medications: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians,"Description:The discrepancy between health care spending and achieved outcomes in the United States has fueled efforts to identify and address situations where unnecessarily expensive therapies are used when less costly, equally effective options are available. The underuse of generic medications is an important example.Methods:A literature review was conducted to answer 5 questions about generic medications: 1) How commonly are brand-name medications used when a generic version is available? 2) How does the use of generic medications influence adherence? 3) What is the evidence that brand-name and generic medications have similar clinical effects? 4) What are the barriers to increasing the use of generic medications? 5) What strategies can be used to promote cost savings through greater generic medication use? This article was reviewed and approved by the American College of Physicians Clinical Guidelines Committee.Best Practice Advice:Clinicians should prescribe generic medications, if possible, rather than more expensive brand-name medications.",0,0,
1013,Improving antibiotic prescribing for adults with community acquired pneumonia: Does a computerised decision support system achieve more than academic detailing alone?--A time series analysis,"BACKGROUND: The ideal method to encourage uptake of clinical guidelines in hospitals is not known. Several strategies have been suggested. This study evaluates the impact of academic detailing and a computerised decision support system (CDSS) on clinicians' prescribing behaviour for patients with community acquired pneumonia (CAP). METHODS: The management of all patients presenting to the emergency department over three successive time periods was evaluated"";"" the baseline, academic detailing and CDSS periods. The rate of empiric antibiotic prescribing that was concordant with recommendations was studied over time comparing pre and post periods and using an interrupted time series analysis. RESULTS: The odds ratio for concordant therapy in the academic detailing period, after adjustment for age, illness severity and suspicion of aspiration, compared with the baseline period was OR = 2.79 [1.88, 4.14], p < 0.01, and for the computerised decision support period compared to the academic detailing period was OR = 1.99 [1.07, 3.69], p = 0.02. During the first months of the computerised decision support period an improvement in the appropriateness of antibiotic prescribing was demonstrated, which was greater than that expected to have occurred with time and academic detailing alone, based on predictions from a binary logistic model. CONCLUSION: Deployment of a computerised decision support system was associated with an early improvement in antibiotic prescribing practices which was greater than the changes seen with academic detailing. The sustainability of this intervention requires further evaluation.",1,1,
1014,Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach,"BACKGROUND: Inappropriate use of antibiotics is a major clinical problem and public health concern. We developed and implemented a pilot hospitalist-delivered academic detailing intervention to improve the patterns of antibiotic prescribing for inpatients. OBJECTIVE: To improve antibiotic prescribing patterns on the hospitalist service of an academic medical center. DESIGN, SETTING, AND PARTICIPANTS: Hospitalist practitioners were recruited to participate in this pre- and postintervention pilot study at Johns Hopkins Bayview Medical Center (JHBMC). Public health principles for creating a conceptual framework based on behavioral change theory were used in developing the intervention. METHODS: Antibiotic prescribing patterns of 17 hospitalist practitioners were retrospectively reviewed. Antimicrobial prescriptions were classified as appropriate, effective but inappropriate, or inappropriate. A profile was assembled for each hospitalist, and an academic detailing intervention session was arranged. The session reviewed inappropriate prescribing practices as well as current practice guidelines. After the detailing meeting, the prescribing patterns of the hospitalists were followed prospectively. MAIN OUTCOME MEASURES: The main outcome measures were the proportions of antibiotics prescribed inappropriately before the intervention, during the detailing period, and after the intervention. RESULTS: Seventeen hospitalist practitioners who participated in the study. A total of 247 prescriptions were reviewed in the preintervention and 129 prescriptions in the postintervention period. Prior to academic detailing, 43% (95% CI 37%-49%) of the prescriptions were appropriate and 57% (95% CI 51%-63%) were inappropriate. After the intervention, 74% (95% CI 65%-81%) of the prescriptions were appropriate and 26% (95% CI 19%-35%) were inappropriate"";"" P < .0001. CONCLUSIONS: A carefully planned and methodically executed intervention can result in behavior change, even among busy hospitalists. The academic detailing intervention, which included a practice-based learning component, improved antibiotic prescribing practices of hospitalists at JHBMC.",0,0,
1015,Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina,"BACKGROUND: In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. The Emergency Department Asthma Program was a quality-improvement initiative designed to better understand the population of patients who use the ED for asthma care in rural western North Carolina and to demonstrate whether EDs at small hospitals could, by implementing National Asthma Education and Prevention Program treatment guidelines, improve asthma care and reduce subsequent asthma-related ED visits. METHODS: Eight hospitals in western North Carolina participated in the project, which lasted from November 2003 through December 2007. The intervention consisted of a series of individual and structured continuing medical education events directed at ED physicians and staff. Additionally, patients presenting to EDs for asthma-related problems were selected to receive a short patient questionnaire, to determine their basic understanding of asthma and barriers to asthma care""; to undergo asthma staging by the treating physician; to receive focused bedside asthma education by a respiratory therapist; and, finally, at the treating physician's discretion, to receive a free packet of asthma medications, including rescue therapy with a beta-agonist and corticosteroid therapy delivered via a metered-dose inhaler, before discharge. RESULTS: During the 37-month project, a total of 1,739 patients presented to the participating EDs for 2,481 asthma-related episodes of care;"" at 11% of these visits, patients received the intervention, with nearly 100 ED physicians referring patients to the program. Most of the patients using the ED for asthma treatment were judged to have the mildest stages, and nearly half were uninsured or were covered by Medicaid. For only 20% of the visits was a primary care physician or practice identified. The patient intervention did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. LIMITATIONS: Selection bias is likely, as patients enrolled in the study were more likely than patients in the target sample to be adults and insured. Because we did not measure ED staff attendance at educational sessions or their knowledge of and attitudes about asthma care before and after the educational program, we cannot draw conclusions about the effectiveness of the program to change their knowledge, attitudes, or behavior. CONCLUSIONS: Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach.",0,0,
1016,"Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies","OBJECTIVE. The purpose of this work was to improve asthma-related health outcomes in an ethnically and geographically disparate population of economically disadvantaged school-aged children by using a team-based approach using continuous quality improvement and community health workers. PATIENTS AND METHODS. A demonstration project was conducted with 7 community clinics treating 
3000 children with asthma 5 to 18 years of age. The overall clinic population with asthma was assessed for care-process changes through random cross-sectional chart reviews at baseline and 24 months (N  560). A subset of patients with either moderate or severe persistent asthma or poorly controlled asthma (N  405) was followed longitudinally for specific asthma-related clinical outcomes, satisfaction with care, and confidence managing asthma by family interview at baseline and at 12 or 24 months. Patient-centered and care-process outcomes included patient/parent assessment of quality of care and confidence in self-management, asthma action plan review, and documentation of guidelinebased indicators of quality of care. Direct clinical outcomes included daytime and nighttime symptoms, use of rescue medications, acute care and emergency department visits, hospitalizations, and missed school days. Each clinic site’s degree of adherence to the intervention model was evaluated and ranked to examine the correlation between model adherence and outcomes.",0,1,
1017,"Improving Blood Pressure Control through Provider Education, Provider Alerts, and Patient Education","Background: Inadequate blood pressure control is a persistent gap in quality care. Objective: To evaluate provider and patient interventions to improve blood pressure control. Design: Cluster randomized, controlled trial. Setting: 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System. Patients: 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent. Intervention: Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education)""; provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education). Measurements: Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication. Results: Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62];"" P = 0.012). Limitations: Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control. Conclusions: A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.",0,1,
1018,"Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial.","Background: Inadequate blood pressure control is a persistent gap in quality care.  Objective: To evaluate provider and patient interventions to improve blood pressure control.  Design: Cluster randomized, controlled trial.  Setting: 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System.  Patients: 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent.  Intervention: Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education)""; provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education).  Measurements: Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication.  Results: Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62];"" P = 0.012).  Limitations: Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control.  Conclusions: A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.",0,1,
1019,"Improving cardiovascular risk management: a randomized, controlled trial on the effect of a decision support tool for patients and physicians","BACKGROUND: There is nonoptimal adherence of general practitioners (GPs) and patients to cardiovascular risk reducing interventions. GPs find it difficult to assimilate multiple risk factors into an accurate assessment of cardiovascular risk. In addition, communicating cardiovascular risk to patients has proved to be difficult. AIMS: Improving primary prevention of cardiovascular disease (CVD) in primary care by enhancing patient involvement in the use of a decision support tool. DESIGN: Cluster randomized trial. METHODS: Thirty-four GPs included patients (40-75 years old) without CVD. In an interactive, small group training session lasting 4 h, the GPs in the intervention group were trained to use the guidelines on cardiovascular risk and a decision support tool. The control group received educational materials about the guidelines on paper. GPs' clinical performance and patients' risk perception and self-reported lifestyles were measured at baseline and after 6 months. RESULTS: Thirty-four GPs recorded 490 consultations, 276 in the intervention and 214 in the control group. After 6 months, no significant effect of the intervention on the GPs' performance or the patients' risk perception was found. There was only an effect on self-reported lifestyle, in that more men in the intervention group than in the control group increased their physical activity (odds ratio 3.8, 95% confidence interval 1.7-8.7). CONCLUSION: The 4-h interactive, small group training did not guarantee correct application of the decision support tool and as such failed to improve GPs' performance or correct patients' risk perception. The positive effect on physical activity justifies further research on patient involvement.",0,1,
1020,Improving care for minority children with asthma: professional education in public health clinics,"OBJECTIVE: Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma. METHODS: We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods. RESULTS: In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000""; P < .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P < .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P < .001); and for quality, greater percentage of patients receiving inhaled beta agonists (52% vs 15%; P < .001) and inhaled antiinflammatory drugs (25% vs 2%; P < .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P < .01) and nurses (61% vs 44%;"" P < .05). CONCLUSION: We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.",0,0,
1021,Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial,"BACKGROUND: Primary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care. METHODS: Pragmatic two-way factorial cluster RCT with Primary Care Physicians' practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control"";"" 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians' rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored 'prevention prescription'. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted. RESULTS: 789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95% CI: $16 to $44) per additional action met. CONCLUSIONS: A Prevention Practitioner can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner.",0,0,
1022,Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge.,"Purpose To systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge.  Methods PubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies.  Results From the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points.  Conclusions This review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies.",0,1,
1023,Improving compliance with immunization in the older adult: Results of a randomized cohort study.,"OBJECTIVE: To compare three approaches for improving compliance with influenza and pneumococcal vaccination of elderly patients.  DESIGN: Randomized controlled trial using three parallel group practices at a public urban teaching hospital.  SETTING: Public teaching hospital.  SUBJECTS: All patients 65 years of age and older (n = 1202) seen by resident physicians (n = 66) attending three ambulatory medical practices from October 1, 1989 to March 31, 1990.  INTERVENTIONS: All three provider groups received intensive education in immunization standards. The control group received no further intervention. Staff in the second group offered education to patients at their visits. In the third group, the prevention team, a flowsheet was used, patient education offered, and staff had their tasks redefined to facilitate compliance"";"" for vaccinations, eg, nurses could vaccinate independent of MD initiative.  MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for the 1202 patients seen, including 756 patients seen during both the 1988-89 and 1989-90 influenza seasons, to determine documented offering and receipt of vaccinations. During the intervention period (1989-90), influenza vaccinations were offered significantly more frequently to prevention team patients (68.3%) than to patients in either the patient education (50.4%) or control (47.6%) groups (P = 0.006), even after adjusting for the patients' prior vaccination status, age, gender, race, and high-risk co-morbidity and for physicians' level of training. Likewise, pneumococcal vaccinations were offered more frequently to previously unvaccinated prevention team patients (28.3%) than to patient education (6.5%) or control (5.4%) group patients (P = 0.001), even after adjusting for the factors using multivariate analysis. Compliance rates did not differ between patient education and control subjects for either vaccine. Pre-intervention physician surveys documented higher perceived than actual compliance for both vaccines, with 89.0% and 52.8% of physicians believing that they complied with influenza and pneumococcal vaccination guidelines, respectively.  CONCLUSIONS: The results of this trial provide strong support for organizational changes that involve non-physician personnel to enhance vaccination rates among older adults.",0,1,
1024,Improving delivery of preventive health care with the comprehensive annotated reminder tool (CART),"OBJECTIVES: We assessed the effect of the Comprehensive Annotated Reminder Tool (CART) on physician adherence to preventive services recommendations. STUDY DESIGN: Using a randomized pretest/posttest control group design, we assigned physicians to the CART group or the control group, followed up prospectively, and evaluated for appropriate adherence to guidelines. The 3 age-specific versions of the CART annotated history and physical examination form contained up to 49 preventive services recommendations. POPULATION: All resident physicians in a large family practice residency program were studied over the course of 1 academic year. OUTCOMES MEASURED: We performed blinded chart reviews to assess the appropriateness of preventive services ordered by the physicians before the introduction of the CART, during its use, and after its removal. A multiple-choice test completed before and after the use of the CART forms assessed knowledge. RESULTS: When the CART was used, the appropriateness of physician preventive behavior increased by 21% overall. The appropriateness of history, physical examination, and laboratory interventions increased by 33%. When the CART was removed, physician behavior returned to baseline (P < or = .0025 for 16 of 20 interventions). No significant differences were observed in the control group over time. Knowledge increased over the study period for all physicians (P < or = .005) but did not differ significantly between the treatment and control groups (P = .608). CONCLUSIONS: Use of the CART significantly improved physician performance in the appropriate delivery of preventive care.",0,1,
1025,Improving Depression Care Through an Online Learning Collaborative,"Depression is a leading cause of disability worldwide, and many internists diagnose and treat depression. This study aimed to examine the impact of a practice improvement intervention on screening and managing patients with depression in primary care. This pre-post study design included a physician practice survey designed to capture what the physicians believed they were doing in practice, a chart audit tool to capture what physicians were actually doing in practice, and an intervention that included an evidence-based educational program, online toolkit, and practice improvement coaching conference calls that promoted group learning. Following completion of the intervention, participants increasingly used the Patient Health Questionnaire-9 to detect, diagnose, and gauge treatment success for depression and reported increased use of guidelines and team-based care. Although barriers to improving depression care exist, this study suggests that evidence-based quality improvement programs can positively affect practice.",0,0,
1026,Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial,"AIMS: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in people with diabetes in South Asia. The CARRS Translation Trial tests the effectiveness, cost-effectiveness, and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan. METHODS: We randomly assigned 1146 adults with diabetes recruited from 10 urban clinic sites, to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention. The intervention involves electronic health record management, decision-support prompts to the healthcare team, and the support of a care coordinator to actively facilitate patient and provider adherence to evidence-based guidelines. The primary outcome is a composite of multiple CVD risk factor control (blood glucose and either blood pressure or cholesterol, or all three). Other outcomes include control of the individual CVD risk factors, process and patient-centered measures, cost-effectiveness, and acceptability/feasibility. CONCLUSION: The CARRS Translation Trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients (clinicaltrials.gov number: NCT01212328).",0,0,
1027,Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study,"BACKGROUND: It is difficult to put research findings into clinical practice by either guidelines or prescription feedback. AIM: To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups. METHODS: 199 general practitioners in 32 groups were randomised to participate in peer review meetings related to either asthma or urinary tract infections. The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback. The intervention feedback was designed to describe the treatment given in relation to recommendations in the national guidelines. In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations. Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments. MAIN OUTCOME MEASURE: Difference in the prescribing behaviour between the year before and the year after the intervention. RESULTS: Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection (control) group were 28% and 27%, respectively. The mean proportion of acceptably treated patients in the asthma group was increased by 6% relative to the control group"";"" this difference was statistically significant. The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma (control) group were 12% for both groups which increased by 13% in the urinary tract infection group relative to the control group. Relative to the mean pre-intervention values this represented an improvement in treatment of 21% in the asthma group and 108% in the urinary tract infection group. CONCLUSIONS: Deriving quality criteria of prescribing by discussing guideline recommendations gave the doctors a basis for judging their treatment of individual patients as acceptable or unacceptable. Presented with feedback on their own prescribing, they learned what they did right and wrong. This provided a foundation for improvement and the process thus instigated resulted in the doctors providing better quality patient care.",0,1,
1028,Improving empiric antibiotic selection using computer decision support.,"Background:  Physicians frequently need to start antibiotic therapy before the results of bacterial cultures and antibiotic susceptibility tests are available. We developed and evaluated a computerized antibiotic consultant to assist physicians in the selection of appropriate empiric antibiotics.  Methods:  We used a two-stage random-selection study to compare antibiotics suggested by the antibiotic consultant with 482 associated antibiotic susceptibility results and the concurrent antibiotics ordered by physicians. The antibiotics ordered by randomized physicians were then compared between crossover periods of antibiotic consultant use.  Results:  The antibiotic consultant suggested an antibiotic regimen to which all isolated pathogens were shown to be susceptible for 453 (94%) of 482 culture results, while physicians ordered an antibiotic regimen to which all isolated pathogens were susceptible for 369 culture results (77%) (P<.001). The physicians who prescribed antibiotics to which all pathogens were susceptible did so a mean of 21 hours after the culture specimens were collected. Physicians ordered appropriate antibiotics within 12 hours of the culture collection significantly more often when they had use of the antibiotic consultant than during the period before use (P<.035). Moreover, 88% of the physicians stated they would recommend the program to other physicians, 85% said the program improved their antibiotic selection, and 81% said they felt use of the program improved patient care.  Conclusions:  Information from computer-based medical records can be used to help improve physicians' selection of empiric antibiotics for infections.(Arch Intern Med. 1994"";""154:878-884)",0,1,
1029,"Improving empirical antibiotic treatment using TREAT, a computerized decision support system: cluster randomized trial.","Background: Appropriate antibiotic treatment decreases mortality, while superfluous treatment is associated with antibiotic resistance. We built a computerized decision support system for antibiotic treatment (TREAT) targeting these outcomes.  Methods: Prospective cohort study comparing TREAT's advice to physician's treatment followed by a cluster randomized trial comparing wards using TREAT (intervention) versus antibiotic monitoring without TREAT (control). We included patients suspected of harbouring bacterial infections in three hospitals (Israel, Germany and Italy). The primary outcome, appropriate antibiotic treatment, was assessed among patients with microbiologically documented infections (MDI). Length of hospital stay, adverse events, mortality (interventional trial) and antibiotic costs (both studies), including costs related to future antibiotic resistance, were compared among all included patients.  Results: Among 1203 patients included in the cohort study (350 with MDI), TREAT prescribed appropriate empirical antibiotic treatment significantly more frequently than physicians (70% versus 57%, P < 0.001) using less broad-spectrum antibiotics at half physicians' antibiotic costs. The randomized trial included 2326 patients, 570 with MDI. The rate of appropriate empirical antibiotic treatment was higher in intervention versus control wards [73% versus 64%, odds ratio (OR): 1.48, 95% confidence interval (CI): 0.95–2.29, intention to treat, adjusted for location and clustering]. For patients treated according to TREAT's advice in intervention wards, the difference with controls was highly significant (OR: 3.40, 95% CI: 2.25–5.14). Length of hospital stay, costs related to future resistance and total antibiotic costs were lower in intervention versus control wards.  Conclusions: TREAT improved the rate of appropriate empirical antibiotic treatment while reducing antibiotic costs and the use of broad-spectrum antibiotic treatment.",0,1,
1030,"Improving empirical antibiotic treatment using TREAT, a computerized decision support system: cluster randomized trial.","Background: Appropriate antibiotic treatment decreases mortality, while superfluous treatment is associated with antibiotic resistance. We built a computerized decision support system for antibiotic treatment (TREAT) targeting these outcomes.  Methods: Prospective cohort study comparing TREAT's advice to physician's treatment followed by a cluster randomized trial comparing wards using TREAT (intervention) versus antibiotic monitoring without TREAT (control). We included patients suspected of harbouring bacterial infections in three hospitals (Israel, Germany and Italy). The primary outcome, appropriate antibiotic treatment, was assessed among patients with microbiologically documented infections (MDI). Length of hospital stay, adverse events, mortality (interventional trial) and antibiotic costs (both studies), including costs related to future antibiotic resistance, were compared among all included patients.  Results: Among 1203 patients included in the cohort study (350 with MDI), TREAT prescribed appropriate empirical antibiotic treatment significantly more frequently than physicians (70% versus 57%, P < 0.001) using less broad-spectrum antibiotics at half physicians' antibiotic costs. The randomized trial included 2326 patients, 570 with MDI. The rate of appropriate empirical antibiotic treatment was higher in intervention versus control wards [73% versus 64%, odds ratio (OR): 1.48, 95% confidence interval (CI): 0.95–2.29, intention to treat, adjusted for location and clustering]. For patients treated according to TREAT's advice in intervention wards, the difference with controls was highly significant (OR: 3.40, 95% CI: 2.25–5.14). Length of hospital stay, costs related to future resistance and total antibiotic costs were lower in intervention versus control wards.  Conclusions: TREAT improved the rate of appropriate empirical antibiotic treatment while reducing antibiotic costs and the use of broad-spectrum antibiotic treatment.",0,1,1029
1031,Improving feedback on junior doctors’ prescribing errors: mixed-methods evaluation of a quality improvement project,"Background Prescribing errors occur in up to 15% of UK inpatient medication orders. However, junior doctors report insufficient feedback on errors. A barrier preventing feedback is that individual prescribers often cannot be clearly identified on prescribing documentation.  Aim To reduce prescribing errors in a UK hospital by improving feedback on prescribing errors.  Interventions We developed three linked interventions using plan–do–study–act cycles: (1) name stamps for junior doctors who were encouraged to stamp or write their name clearly when prescribing"";"" (2) principles of effective feedback to support pharmacists to provide feedback to doctors on individual prescribing errors and (3) fortnightly prescribing advice emails that addressed a common and/or serious error.  Implementation and evaluation Interventions were introduced at one hospital site in August 2013 with a second acting as control. Process measures included the percentage of inpatient medication orders for which junior doctors stated their name. Outcome measures were junior doctors' and pharmacists' perceptions of current feedback provision (evaluated using quantitative pre-questionnaires and post-questionnaires and qualitative focus groups) and the prevalence of erroneous medication orders written by junior doctors between August and December 2013.  Results The percentage of medication orders for which junior doctors stated their name increased from about 10% to 50%. Questionnaire responses revealed a significant improvement in pharmacists' perceptions but no significant change for doctors. Focus group findings suggested increased doctor engagement with safe prescribing. Interrupted time series analysis showed no difference in weekly prescribing error rates between baseline and intervention periods, compared with the control site.  Conclusion Findings suggest improved experiences around feedback. However, attempts to produce a measurable reduction in prescribing errors are likely to need a multifaceted approach of which feedback should form part.",0,1,
1032,Improving guideline adherence: a randomized trial evaluating strategies to increase beta-blocker use in heart failure,"Background— The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of ß-blockers for heart failure patients.  Methods and Results— This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction =45% and no contraindications to ß-blockers. Patients’ primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education""; (2) provider and patient notification: computerized provider reminders and patient letters advocating ß-blockers;"" and (3) nurse facilitator: supervised nurse to initiate and titrate ß-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on ß-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target ß-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups.  Conclusions— The use of a nurse facilitator was a successful approach for implementing a ß-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.",0,1,
1033,Improving hand hygiene behaviour of nurses using action planning: a pilot study in the intensive care unit and surgical ward,"Compliance with hand hygiene guidelines by hospital physicians and nurses is universally low and there is a need to apply powerful intervention methods from social sciences in order to improve compliance. One method is the formation of implementation intentions (or action planning) in which concrete 'if then' plans are formulated to link an environmental cue with performance of an intended behavioural action. This pilot study explored the practicality and effects of action planning on the hand hygiene behaviour (HHB) of nurses in an ICU and surgical ward of a university teaching hospital. A pre-post test design was used, and 17 nurses were invited to participate. A trained researcher observed HHB of nurses before and three weeks after the intervention in which action plans were formulated. Frequencies were calculated and logistic regression analysis was performed to assess changes in HHB. Of the 17 participants, 10 (seven in surgical ward, three in ICU) had complete data and were included in the analyses. In total, 283 potential moments for hand hygiene were identified, 142 in the surgical ward and 141 in the ICU. HHB increased from 9.3% at baseline to 25.4% post intervention (odds ratio: 3.3""; confidence interval: 1.7-6.5;"" P<0.001). Although this was a small scale study, the results show promise for the use of action planning to improve the HHB of nurses in the short term. Action planning has shown success in closing the intention-behaviour gap in other fields, and its use for improving HHB in healthcare should be further investigated.",1,1,
1034,Improving handover from intensive care to ward medical teams with simple changes to paperwork,"Medical handover has been highlighted by the General Medical Council[1] as a critical step in patient care, ensuring continuity of care, patient safety, and enabling efficient multidisciplinary functioning. Handover between doctors on the intensive care team and the ward teams in the Great Western Hospital on step down was evaluated by assessing discharge summaries and patient notes, and by following up discharged patients. Handover was found to be present only in the minority of patients and documented in none.  Simple changes were made to discharge paperwork in the form of a prompt and documentation of to whom handover was made, as well as the creation of space in the daily review sheets for patients with outstanding handover to be completed. The initial audit findings were presented at a local meeting to remind staff of the importance of handover. These simple modifications brought the handover rates up to 100% (n=12). The rates of documentation of handover also rose from 0% to 100%. This quality improvement project serves to demonstrate that carefully targeted, simple changes to practice in identified critical areas can produce dramatic as well as legally and ethically required results in a very short space of time.",1,1,
1035,Improving knowledge and changing behavior towards guideline based decisions in diabetes care: a controlled intervention study of a team-based learning approach for continuous professional development of physicians,"BACKGROUND: Continuing Professional Development (CPD) courses should ideally improve a physician's knowledge and change their professional behavior in daily practice towards a best clinical practice reference model and guideline adherence. Interactive methods such as team-based learning and case-based learning, as compared to lectures, can impart sustainable knowledge and lead to high satisfaction among participants. We designed an interactive case-based CPD-seminar on diabetes care using a team-based learning approach to evaluate whether it leads to an improvement of short-term knowledge and changing of behavior towards guideline based decisions and how this learning approach is perceived by participants. METHODS: Questionnaires and an electronic voting system were used to evaluate motivation, acceptance and knowledge of voluntary participants. Furthermore, we analyzed data on index diagnostic tests and referrals of patients with diabetes of participating physicians over a period of six months before and after the course in comparison with a matched control group in a quasi-experimental design. RESULTS: Participants (n=103) rated the interactivity and team-based discussions as the main reasons for enhanced learning. They also expected that the course would change their professional behavior. Participants scored a mean of 43.9% right answers before and 62.6% after the course (p<0.001). The referral to diabetes specialists increased by 30.8% (p<0.001). Referral for fundoscopy also increased (8.5%, n.s.) while it dropped in the control group. Furthermore, the participating physicians tested their patients more often for microalbuminuria (7.1%, n.s.). CONCLUSIONS: Our team-based learning CPD-approach was highly accepted and resulted in an increase of short-term knowledge. It significantly increased the referral to diabetes specialists in daily practice whereas all other key professional behavior indicators did change but not significantly.",0,0,
1036,Improving laboratory monitoring at initiation of drug therapy in ambulatory care: a randomized trial.,"Background  The importance of laboratory monitoring for drugs is reflected in product labeling and published guidelines, but monitoring recommendations are followed inconsistently. Opportunity exists to improve monitoring, with the potential to decrease therapy complications.  Methods  The objective of this randomized trial was to determine whether computerized alerts were effective at increasing the percentage of ambulatory patients with laboratory monitoring at initiation of drug therapy. Physicians and pharmacists teamed up to develop organization-specific guidelines for monitoring selected drugs. In collaboration with physicians, pharmacists were alerted to missing laboratory test results, ordered missing tests, reminded patients to obtain tests, assessed test completion, reviewed test results, and managed abnormal results. Eligible individuals included patients with therapy initiated for any of 15 drugs among 400 000 health plan members.  Results  In the intervention group, 79.1% (n = 4076""; 95% confidence interval [CI], 78.0%-80.2%) of dispensings were monitored compared with 70.2% (n = 3522;"" 95% CI, 68.9%-71.5%) in the usual-care group (P<.001). For example, 78.6% of amiodarone (95% CI, 73.1%-83.5%) dispensing was monitored in the intervention group vs 51.4% (95% CI, 44.4%-58.4%) in the group receiving usual care (P<.001).  Conclusions  This study demonstrates the effectiveness of a computerized tool plus collaboration among health care professionals at increasing the percentage of patients receiving laboratory monitoring at initiation of therapy. Coupling data available from information systems with the knowledge and skills of physicians and pharmacists can result in improved patient monitoring.",0,1,
1037,Improving mammography recommendation: a nurse-initiated intervention,"We attempted to improve our compliance with recommendations for screening mammography, according to the American Cancer Society (ACS) guidelines, for eligible women patients seen by family practice residents by using a multipart intervention designed to eliminate identified barriers of knowledge and behavior on the part of the residents. Copies of the ACS cancer screening guidelines were posted in all examination and conference rooms and were provided to all residents. The intervention addressing the behavioral barriers had three components: (1) identification by the nursing staff of eligible women who were overdue for a mammogram as they presented for care, (2) completion of a checklist by residents indicating whether a mammogram was or was not recommended and why, and (3) a nurse-initiated backup reminder system for patients who escaped the primary checklist system. An audit of 200 preintervention and 270 postintervention charts showed statistically and clinically significant increases in mammograms recommended or done. Similar statistically significant increases were found in a cohort of 111 charts of patients in both the pre- and the postintervention audits. Results indicate that an intervention designed to eliminate identified resident-dependent barriers to compliance with screening mammography guidelines can be effective in increasing recommended mammography rates.",0,0,
1038,Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel,"BACKGROUND: Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. METHODS: Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. RESULTS: We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs' capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. CONCLUSIONS: This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.",0,1,
1039,Improving mental health care transitions for children and youth: a protocol to implement and evaluate an emergency department clinical pathway,"Background While the emergency department (ED) is often a first point of entry for children and youth with mental health (MH) concerns, there is a limited capacity to respond to MH needs in this setting. Child MH systems are typically fragmented among multiple ministries, organizations, and providers. Communication among these groups is often poor, resulting in gaps, particularly in transitions of care, for this vulnerable population. The evidence-based Emergency Department Mental Health Clinical Pathway (EDMHCP) was created with two main goals: (1) to guide risk assessment and disposition decision-making for children and youth presenting to the ED with MH concerns and (2) to provide a streamlined transition to follow-up services with community MH agencies (CMHAs) and other providers. The purpose of this paper is to describe our study protocol to implement and evaluate the EDMHCP.  Methods/design This mixed methods health services research project will involve implementation and evaluation of the EDMHCP in four exemplar ED-CMHA dyads. The Theoretical Domains Framework will be used to develop a tailored intervention strategy to implement the EDMHCP. A multiple baseline study design and interrupted time-series analysis will be used to determine if the EDMHCP has improved health care utilization, medical management of the MH problems, and health sector coordination. The primary process outcome will be the proportion of patients with MH-specific recommendations documented in the health record. The primary service outcome will be the proportion of patients receiving the EDMHCP-recommended follow-up at 24-h or at 7 days. Data sources will include qualitative interviews, health record audits, administrative databases, and patient surveys. A concurrent process evaluation will be conducted to assess the degree of variability and fidelity in implementation across the sites.  Discussion This paper presents a novel model for measuring the effects of the EDMHCP. Our development process will identify how the EDMHCP is best implemented among partner organizations to deliver evidence-based risk management of children and youth presenting with MH concerns. More broadly, it will contribute to the body of evidence supporting clinical pathway implementation within novel partnerships.",0,0,
1040,"Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers","INTRODUCTION: In North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor patient outcomes and societal harm. Factors at the provider and system level may hinder or facilitate the application of evidence-based guidelines"";"" interventions designed to address such factors are needed. METHODS AND ANALYSIS: Using implementation science and behaviour change theory, we have planned the development and evaluation of a comprehensive Opioid Self-Assessment Package, designed to increase adherence to the Canadian Opioid Guideline among family physicians. The intervention uses practical educational and self-assessment tools to provide prescribers with feedback on their current knowledge and practices, and resources to improve their practice. The evaluation approach uses a pretest and post-test design and includes both quantitative and qualitative methods at baseline and 6 months. We will recruit a purposive sample of approximately 10 family physicians in Ontario from diverse practice settings, who currently treat patients with long-term opioid therapy for chronic pain. Quantitative data will be analysed using basic descriptive statistics, and qualitative data will be analysed using the Framework Method. ETHICS AND DISSEMINATION: The University Health Network Research Ethics Board approved this study. Dissemination plan includes publications, conference presentations and brief stakeholder reports. This evidence-informed, theory-driven intervention has implications for national application of opioid quality improvement tools in primary care settings. We are engaging experts and end users in advisory and stakeholder roles throughout our project to increase its national relevance, application and sustainability. The performance measures could be used as the basis for health system quality improvement indicators to monitor opioid prescribing. Additionally, the methods and approach used in this study could be adapted for other opioid guidelines, or applied to other areas of preventive healthcare and clinical guideline implementation processes.",0,0,
1041,Improving paediatric asthma outcomes in primary health care: a randomised controlled trial,"OBJECTIVE: To evaluate the effectiveness of the Practitioner Asthma Communication and Education (PACE) Australia program, an innovative communication and paediatric asthma management program for general practitioners. DESIGN: Randomised controlled trial. SETTING: General practices from two regions in metropolitan Sydney. PARTICIPANTS: 150 GPs, who were recruited between 2006 and 2008, and 221 children with asthma in their care. INTERVENTION: GPs in the intervention group participated in two 3-hour workshops, focusing on communication and education strategies to facilitate quality asthma care. MAIN OUTCOME MEASURES: Patient outcomes included receipt of a written asthma action plan (WAAP), appropriate medication use, parent days away from work, and child days away from school or child care. GP outcomes included frequency of providing a WAAP and patient education, communication and teaching behaviour, and adherence to national asthma guidelines regarding medication use. RESULTS: More patients of GPs in the intervention group reported receipt of a WAAP (difference, 15%""; 95% CI, 2% to 28%; adjusted P=0.046). In the intervention group, children with infrequent intermittent asthma symptoms had lower use of inhaled corticosteroids (difference, 24%; 95% CI, -43% to -5%; P=0.03) and long-acting bronchodilators (difference, 19%; 95% CI, -34% to -5%; P=0.02). GPs in the intervention group were more confident when communicating with patients (difference 22%; 95% CI, 3% to 40%; P=0.03). A higher proportion of GPs in the intervention group reported providing a WAAP more than 70% of the time (difference, 23%; 95% CI, 11% to 36%; adjusted P=0.002) and prescribing spacer devices more than 90% of the time (difference, 29%; 95% CI, 16% to 42%;"" adjusted P=0.02). CONCLUSIONS: The PACE Australia program improved GPs' asthma management practices and led to improvements in some important patient outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000067471.",0,0,
1042,Improving Patient Care Through Medical Image Perception Research,"The interpretation of medical images across medical specialties is critical to patient care. As technology changes, so does health care, and clinicians today are increasingly viewing medical images in a variety of environments. Although access to such data is useful, even clinicians with expertise in image interpretation make errors. These errors may become more frequent as clinician workdays become longer and the number of images to be interpreted becomes larger. To prevent errors in medical image interpretation, we need to understand the underlying perceptual and cognitive mechanisms that guide image interpretation. We can then use what is learned to develop better training methods, automated image analysis, and processing tools. We can devise methods to reduce clinician fatigue and stress, and develop practice guidelines thereby improving patient care and outcomes.",0,1,
1043,Improving patient discharge and reducing hospital readmissions by using Intervention Mapping,"Background There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.  Methods The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance.  Results Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.  Conclusions This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.",0,1,
1044,Improving physician compliance with preventive medicine guidelines,"Similar general medical outpatient clinics with randomly assigned patients were used to evaluate the effectiveness of a program that was to increase house staff compliance with preventive medicine guidelines. Two clinics were designated experimental and two served as controls. In the experimental clinics, age-specific checklists of all recommended preventive procedures (drawn from the Canadian Task Force report on The Periodic Health Examination and American Cancer Society guidelines) were appended to each patient's chart. In addition, house officers were presented with a series of weekly seminars dealing with issues in screening, as well as the specific recommendations included in the checklist. House officers in all four clinics were tested for their knowledge and attitudes toward the preventive program before and after the intervention. Counts of immunizations and mammograms performed and the total populations eligible for these procedures were determined for all four clinics. As predicted, test scores as well as mammography and immunization rates increased significantly (from 2-40 per cent) in the intervention clinics as compared with controls. We conclude that this intervention was clearly effective in the short run. However, follow-up studies will be necessary to determine whether the desired long-term effect has been achieved.",0,1,
1045,Improving population-based cervical cancer screening in general practice: effects of a national strategy,"OBJECTIVE: To assess the effects of a Dutch national prevention programme, aimed at general practitioners (GPs), on the adherence to organizational guidelines for effective cervical cancer screening in general practice. To identify the characteristics of general practices determining success. DESIGN: A prospective questionnaire study with pre- and post-measurement (before and 15 months after the introduction of the national programme). SETTING AND STUDY PARTICIPANTS: A random sample of one-third of all 4758 Dutch general practices. One GP was asked to participate per practice. INTERVENTION: A national GP prevention programme to improve population-based prevention of cervical cancer combining various methods for quality improvement in general practice, performed on a national, district and practice level. Outreach visitors were a key strategy in bringing about behavioural changes. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 recommendations (in four guidelines) to organize effective cervical cancer screening. RESULTS: After 15 months, all Dutch practices showed significant improvement in adherence to nine out of 10 recommendations. Two recommendations, in particular 'identifying women who should be medically excluded from screening' and 'sending a reminder to non-compliers' showed the largest absolute increases of 26% and 33%, respectively. Besides more intensive support of outreach visitors, practice characteristics such as 'computerization' and 'delegation of many clinical tasks to the practice assistant' were important in improving the adherence to guidelines. CONCLUSION: The national programme, with a combination of various methods for quality improvement, appeared to be effective in improving the organization of cervical screening in general practice. Computerization and, to a lesser extent, delegation of many clinical tasks to the practice assistant and more intensive support to practices, positively influenced the effectiveness of the national programme.",0,0,
1046,Improving Prescribing Patterns for the Elderly Through an Online Drug Utilization Review Intervention,"Context.— Pharmacotherapy is among the most powerful interventions to improve health outcomes in the elderly. However, since some medications are less appropriate for older patients, systems approaches to improving pharmacy care may be an effective way to reduce inappropriate medication use.  Objective.— To determine whether a computerized drug utilization review (DUR) database linked to a telepharmacy intervention can improve suboptimal medication use in the elderly.  Design.— Population-based cohort design, April 1, 1996, through March 31, 1997.  Setting.— Ambulatory care.  Patients.— A total of 23269 patients aged 65 years and older throughout the United States receiving prescription drug benefits from a large pharmaceutical benefits manager during a 12-month period.  Intervention.— Evaluation of provider prescribing through a computerized online DUR database using explicit criteria to identify potentially inappropriate drug use in the elderly. Computer alerts triggered telephone calls to physicians by pharmacists with training in geriatrics, whereby principles of geriatric pharmacology were discussed along with therapeutic substitution options.  Main Outcome Measures.— Contact rate with physicians and change rate to suggested drug regimen.  Results.— A total of 43007 alerts were triggered. From a total of 43007 telepharmacy calls generated by the alerts, we were able to reach 19368 physicians regarding 24266 alerts (56%). Rate of change to a more appropriate therapeutic agent was 24% (5860), but ranged from 40% for long half-life benzodiazepines to 2% to 7% for drugs that theoretically were contraindicated by patients' self-reported history. Except for rate of change of ß-blockers in patients with chronic obstructive pulmonary disease, all rates of change were significantly greater than the expected baseline 2% rate of change.  Conclusions.— Using a system integrating computers, pharmacists, and physicians, our large-scale intervention improved prescribing patterns and quality of care and thus provides a population-based approach to advance geriatric clinical pharmacology. Future research should focus on the demonstration of improved health outcomes resulting from improved prescribing choices for the elderly.",0,1,
1047,Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial.,"Context Performance feedback and benchmarking, common tools for health care improvement, are rarely studied in randomized trials. Achievable Benchmarks of Care (ABCs) are standards of excellence attained by top performers in a peer group and are easily and reproducibly calculated from existing performance data.  Objective To evaluate the effectiveness of using achievable benchmarks to enhance typical physician performance feedback and improve care.  Design Group-randomized controlled trial conducted in December 1996, with follow-up through 1998.  Setting and Participants Seventy community physicians and 2978 fee-for-service Medicare patients with diabetes mellitus who were part of the Ambulatory Care Quality Improvement Project in Alabama.  Intervention Physicians were randomly assigned to receive a multimodal improvement intervention, including chart review and physician-specific feedback (comparison group""; n = 35) or an identical intervention plus achievable benchmark feedback (experimental group; n = 35).  Main Outcome Measure Preintervention (1994-1995) to postintervention (1997-1998) changes in the proportion of patients receiving influenza vaccination; foot examination;"" and each of 3 blood tests measuring glucose control, cholesterol level, and triglyceride level, compared between the 2 groups.  Results The proportion of patients who received influenza vaccine improved from 40% to 58% in the experimental group (P<.001) vs from 40% to 46% in the comparison group (P = .02). Odds ratios (ORs) for patients of achievable benchmark physicians vs comparison physicians who received appropriate care after the intervention, adjusted for preintervention care and nesting of patients within physicians, were 1.57 (95% confidence interval [CI], 1.26-1.96) for influenza vaccination, 1.33 (95% CI, 1.05-1.69) for foot examination, and 1.33 (95% CI, 1.04-1.69) for long-term glucose control measurement. For serum cholesterol and triglycerides, the achievable benchmark effect was statistically significant only after additional adjustment for physician characteristics (OR, 1.40 [95% CI, 1.08-1.82] and OR, 1.40 [95% CI, 1.09-1.79], respectively).  Conclusion Use of achievable benchmarks significantly enhances the effectiveness of physician performance feedback in the setting of a multimodal quality improvement intervention.",1,1,
1048,Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial,"BACKGROUND: Clinical practice guidelines have been developed to improve screening, prevention and management of delirium. AIMS: To implement delirium guidelines in general medical patients to reduce incidence and duration of delirium and improve outcomes in delirious patients. METHODS: Implementation was led by a multidisciplinary team of clinicians and project staff on one medical ward. Evaluation was undertaken as a controlled trial in patients aged 65 years or older with/at risk of delirium, compared with a control medical ward. Interventions included risk screening, delirium detection, multidisciplinary education, ward modifications including a four-bed delirium bay, behaviour and medication protocols, and use of nursing assistant and volunteers. Primary outcome measures were incidence and duration of delirium"";"" secondary outcomes were length of stay, mortality, falls and discharge destination in delirious subgroup. Process measures included ward moves, use of neuroleptics, allied health review and delirium bay use. RESULTS: Of 206 consenting older medical patients, 22% were delirious at admission and 44% were at risk. No incident cases of delirium were identified. In the delirious subgroup, significantly fewer intervention participants were discharged with persistent delirium (32% vs 71%, P = 0.016), with trends to reduced inpatient mortality (0% vs 18.5%, P = 0.07) and falls (11% vs 22%, P = 0.16), at the expense of a longer medical ward stay (16 days vs 8 days, P = 0.01). CONCLUSIONS: Low incidence of new delirium may reflect the established interdisciplinary care environment. Improved outcomes in the delirious group are encouraging although implementation was costly, including increased length of acute ward stay.",0,0,
1049,Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders.,"Context Computerized systems to remind physicians to provide appropriate care have not been widely evaluated in large numbers of patients in multiple clinical settings.  Objective To examine whether a computerized reminder system operating in multiple Veterans Affairs (VA) ambulatory care clinics improves resident physician compliance with standards of ambulatory care.  Design, Setting, and Participants A total of 275 resident physicians at 12 VA medical centers were randomly assigned in firms or half-day clinic blocks to either a reminder group (n = 132) or a control group (n = 143). During a 17-month study period (January 31, 1995–June 30, 1996), the residents cared for 12,989 unique patients for whom at least 1 of the studied standards of care (SOC) was applicable.  Main Outcome Measures Compliance with 13 SOC, tracked using hospital databases and encounter forms completed by residents, compared between residents in the reminder group vs those in the control group.  Results Measuring compliance as the proportion of patients in compliance with all applicable SOC by their last visit during the study period, the reminder group had statistically significantly higher rates of compliance than the control group for all standards combined (58.8% vs 53.5%""; odds ratio [OR], 1.24; 95% confidence interval [CI], 1.08-1.42; P = .002) and for 5 of the 13 standards examined individually. Measuring compliance as the proportion of all visits for which care was indicated in which residents provided proper care, the reminder group also had statistically significantly higher rates of compliance than the control group for all standards combined (17.9% vs 12.2%; OR, 1.57; 95% CI, 1.45-1.71;"" P<.001) and for 9 of the 13 standards examined individually. The benefit of reminders, however, declined throughout the course of the study, even though the reminders remained active.  Conclusions Our data indicate that reminder systems installed at multiple sites can improve residents' compliance to multiple SOC. The benefits of such systems, however, appear to deteriorate over time. Future research needs to explore methods to better sustain the benefits of reminders.",0,1,
1050,Improving smoking cessation counseling using a point-of-care health intervention tool (IT): from the Virginia Practice Support and Research Network (VaPSRN),"PURPOSE: Primary care practices are an ideal setting for reducing national smoking rates because >70% of smokers visit their physician annually, yet smoking cessation counseling is inconsistently delivered to patients. We designed and created a novel software program for handheld computers and hypothesized that it would improve clinicians' ability to provide patient-tailored smoking cessation counseling at the point of care. METHODS: A handheld computer software program was created based on smoking cessation guidelines and an adaptation of widely accepted behavioral change theories. The tool was evaluated using a validated before/after survey to measure physician smoking cessation counseling behaviors, knowledge, and comfort/self-efficacy. RESULTS: Participants included 17 physicians (mean age, 41 years""; 71% male;"" 5 resident physicians) from a practice-based research network. After 4 months of use in direct patient care, physicians were more likely to advise patients to stop smoking (P = .049) and reported an increase in use of the ""5 As"" (P = .03). Improved self-efficacy in counseling patients regarding smoking cessation (P = .006) was seen, as was increased comfort in providing follow-up to patients (P = .04). CONCLUSIONS: Use of a handheld computer software tool improved smoking cessation counseling among physicians and shows promise for translating evidence about smoking cessation counseling into practice and educational settings.",0,1,
1051,Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only,"PURPOSE: We wanted to evaluate the added value of small peer-group quality improvement meetings compared with simple feedback as a strategy to improve test-ordering behavior. Numbers of tests ordered by primary care physicians are increasing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines. METHODS: We enrolled 194 primary care physicians from 27 local primary care practice groups in 5 health care regions (5 diagnostic centers). The study was a cluster randomized trial with randomization at the local physician group level. We evaluated an innovative, multifaceted strategy, combining written comparative feedback, group education on national guidelines, and social influence by peers in quality improvement sessions in small groups. The strategy was aimed at 3 specific clinical topics: cardiovascular issues, upper abdominal complaints, and lower abdominal complaints. The mean number of tests per physician per 6 months at baseline and the physicians' region were used as independent variables, and the mean number of tests per physician per 6 months was the dependent variable. RESULTS: The new strategy was executed in 13 primary care groups, whereas 14 groups received feedback only. For all 3 clinical topics, the decrease in mean total number of tests ordered by physicians in the intervention arm was far more substantial (on average 51 fewer tests per physician per half-year) than the decrease in mean number of tests ordered by physicians in the feedback arm (P = .005). Five tests considered to be inappropriate for the clinical problem of upper abdominal complaints decreased in the intervention arm, with physicians in the feedback arm ordering 13 more tests per 6 months (P = .002). Interdoctor variation in test ordering decreased more in the intervention arm. CONCLUSION: Compared with only disseminating comparative feedback reports to primary care physicians, the new strategy of involving peer interaction and social influence improved the physicians' test-ordering behavior. To be effective, feedback needs to be integrated in an interactive, educational environment.",0,1,
1052,Improving the application of a practice guideline for the assessment and treatment of suicidal behavior by training the full staff of psychiatric departments via an e-learning supported Train-the-Trainer program: study protocol for a randomized controlled trial,"BACKGROUND: In 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program. METHOD: In a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments. DISCUSSION: We aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study. TRIAL REGISTRATION: Dutch trial register: NTR3092.",0,0,
1053,Improving the appropriateness of antimicrobial use in primary care after implementation of a local antimicrobial guide in both levels of care,"Objective This study aims to assess the effectiveness of multiple interventions carried out during the implementation of a guide, on the improvement of the appropriateness of antimicrobial prescribing in primary care.  Design This is a cross-sectional before/after study carried out in Aljarafe Health Care Area (Andalusia, Spain), with a population of 368,728 inhabitants assisted in 37 health centers.  Subjects Subjects include patients with antibiotic prescriptions during 2009 (pre-intervention phase) or 2012 (postintervention phase) selected by simple random sampling (confidence level, 95 %"";"" accuracy, 5 %), with infections registered in the electronic clinical history.  Interventions This study involve training sessions in primary care centers and hospital services, incorporation of the electronic guide to the Health Care Service Websites, and incorporation of the guide to the Digital Health History as a tool to support decision making.  Main outcome Difference on appropriate antibiotic prescribing before and after interventions resulted from the study. Other variables also include age, gender, type of pharmacy, antibiotic prescribed, number of treatments per year, infection site, and main comorbidities  Sources In addition, this study uses computerized pharmacy records of reimbursed and dispensed drugs and electronic medical histories.  Results The percentage of appropriate antibiotic prescribing increased from 36 % in 2009 to 57 % in 2012 (p?<?0.001) is shown. The improvement was observed in all age patients of any sex and was higher among working-age patients and patients with comorbidities. The best results were observed in the group of beta-lactams and in the treatment of respiratory and skin infections.  Conclusion The realization of multifactorial interventions involving professionals from both levels of care could be an effective strategy to improve the use of antimicrobials in primary care.",0,1,
1054,Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol,"Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care. A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines. Further, the review recommended the use of theory in the development of implementation interventions. A clinical practice guideline for the management of acute low-back pain has been developed in Australia (2003). Acute low-back pain is a common condition, has a high burden, and there is some indication of an evidence-practice gap in the allied health setting. This provides an opportunity to develop and test a theory-based implementation intervention which, if effective, may provide benefits for patients with this condition.  Aims This study aims to estimate the effectiveness of a theory-based intervention to increase allied health practitioners' (physiotherapists and chiropractors in Victoria, Australia) compliance with a clinical practice guideline for acute non-specific low back pain (LBP), compared with providing practitioners with a printed copy of the guideline. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray, and improving mean level of disability for patients three months post-onset of acute LBP.  Methods The design of the study is a cluster randomised trial. Restricted randomisation was used to randomise 210 practices (clusters) to an intervention or control group. Practitioners in the control group received a printed copy of the guideline. Practitioners in the intervention group received a theory-based intervention developed to address prospectively identified barriers to practitioner compliance with the guideline. The intervention primarily consisted of an educational symposium. Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period, three months post the intervention symposia, are eligible for inclusion. Sample size calculations are based on recruiting between 15 to 40 patients per practice. Outcome assessors will be blinded to group allocation.",0,1,
1055,"Improving the management of hypertension in Kazakhstan: implications for improving clinical practice, patient behaviours and health outcomes","This paper presents findings from the assessment of a strategy aimed at improving case-finding and management of hypertension patients. Study findings suggest that providers' orientation to clinical guidelines, public information on hypertension risks, promotion of yearly blood pressure screening, and universal access to an outpatient drug benefit package, improve case-finding and management. In addition, training of providers at pilot sites resulted in a substantial and significant difference in patient care and health outcomes. Provider training and tools, especially focused on effective patient counselling, made a significant contribution to increased case-finding, patient adherence to prescribed drugs, reducing salt, and increasing regular exercise. However, further refinements are required to achieve the expected adherence of patients to medication and lifestyle advice. In the pilot area, we compared two samples of patients before and after the initiation of the intervention. We found an increase in the proportion of patients with blood pressure or =160/100 mmHg. The strategy involved the joint efforts of the Research Institute of Cardiology and Internal Diseases, Karaganda Drug Information Centre, Karaganda Oblast Health Department, Kazakhstan Association of Family Physicians, Almaty Postgraduate Institute for Physicians, and USAID ZdravPlus Project in Central Asia.",0,0,
1056,Improving the outcome of bipolar disorder through non-pharmacological strategies: the role of psychoeducation,"The present paper addresses the efficacy of psychoeducation and related strategies in bipolar disorders. Recently, several randomised clinical trials have shown the efficacy of psychological interventions--namely identification of prodromal signs, cognitive-behavioral therapy, psychoeducation and family-focused interventions--as a prophylactic add-on to medication. All these studies are presented hereby, together with the pioneer studies in the field. There are several topics that every psychoeducational program should include to ensure its usefulness, and they will be summarized in twelve points. Roughly, psychoeducation should contain general information about bipolar illness, compliance enhancement elements, teaching on early recognition of relapses and lifestyle regularity issues. Nowadays, several treatment guidelines include psychoeducation as a crucial prophylactic tool. Clinicians should be aware of this and start performing psychoeducation in their everyday clinical practice.",0,0,
1057,Improving the success of mailed letter intervention programs to influence prescribing behaviors: a review,"BACKGROUND: Educational interventions have long been used as a means of influencing prescribing behavior. Various techniques including educational mailings, academic detailing, prescriber feedback with or without disclosing patient-identifying data, and supplemental patient information have been used to promote appropriate prescribing habits, reduce costs, and optimize patient care. While the effects of educational intervention programs are widely reported, little information is available regarding the effectiveness of various mailed intervention techniques. OBJECTIVE: To review the effectiveness of mailed intervention programs and identify factors that may promote successful outcomes. METHODS: A literature search was conducted via PubMed for reports of mailed intervention programs published through May 2012. Specific search terms included ""drug utilization review,"" ""drug utilization,"" ""Medicaid,"" ""prescribing feedback,"" ""mailed physician intervention,"" and ""mailed physician communications."" Identified publications that met the following criteria were selected for inclusion: (a) evaluated printed educational materials disseminated via postal mail, (b) occurred in an outpatient setting, and (c) measured intervention impact on prescribing patterns, health care utilization, or economic outcomes. Publications that met all 3 criteria were abstracted for intervention strategy, follow-up period, data source, intervention target, prescriber acceptance of intervention, and effect on prescribing patterns, health care utilization, and economic outcomes. RESULTS: A total of 40 published reports regarding 39 unique interventions met inclusion criteria. The majority (34/39 [87.2%]) of studies were conducted in state or federally funded programs""; only 5 programs involved private insurers. All programs used follow-up periods of </=12 months after final intervention mailing. A total of 26 of the 39 unique interventions reported a positive impact on at least 1 target outcome. Programs that included a second recipient such as pharmacists (n = 4) reported a greater impact as compared with interventions mailed to prescribers alone. Programs that provided patient-identifying data had a higher success rate than those that supplied prescriber feedback and/or educational materials (21/25 [84.0%] vs. 5/14 [35.7%]); it should be noted that 2 of the 5 successful programs that provided nonpatient-identifying materials also used academic detailing. Programs that sent education material and/or prescriber feedback pertaining to multiple medication classes or disease states had minimal impact on prescribing patterns (n = 4). However, targeting 1 specific disease or medication supported by appropriate evidence resulted in favorable change in a short period of time. Additionally, providing recommendations that were supported by widely accepted clinical guidelines or literature were also associated with a high rate of success. A subset of programs that sought to evaluate health care utilization (n=5) and economic impact (n = 9) observed little change in measured outcomes. Evaluation of prescriber response forms conducted by 7 programs revealed that changes in therapy occurred in approximately 50% of patients with prescribers who intended to accept intervention recommendations. CONCLUSIONS: Though the degree of heterogeneity between articles prevents provision of definite results, it appears that a well-constructed mailed intervention program has the potential to evoke significant changes in prescribing patterns. Prescribers appear to be receptive to mailed interventions;"" however, there are limited data to determine the association between acceptance and actual prescribing change. Future research should focus on identifying barriers that may prohibit acceptance of recommendations from translating into changes in therapy. Additionally, future projects should include longer assessment periods to determine the duration of impact following final intervention mailing and potential effect on health care and economic outcomes.",0,1,
1058,Improving the use of early follow-up care after emergency department visits. A randomized trial,"OBJECTIVE: To test the hypothesis that the appropriateness of parents' use of early follow-up care after emergency department (ED) visits can be improved by postvisit support from a nurse practitioner. DESIGN: Randomized controlled trial, single blinded. SETTING: Urban university hospital ED linked to hospital's primary care center. PARTICIPANTS: Parents of 190 children younger than 8 years who sought care in the ED for acute illnesses and who were treated as outpatients with primary care center follow-up at the discretion of ED clinicians. INTERVENTION: Parents in the experimental group were called by a nurse practitioner who offered both individualized guidance regarding follow-up and access to a nurse practitioner for further help as needed. The control group received ""usual"" follow-up advice during ED visits. MEASUREMENTS/MAIN RESULTS: In the week after the ED visits, parents in the experimental group, compared with parents in the control group, were more compliant with instructions regarding follow-up (79% vs 61%), less apt to miss appointments (15% vs 31%), and less apt to ""shop"" elsewhere for care (2% vs 9%). Appropriateness of follow-up was assessed in ""blinded"" fashion using preestablished guidelines. Inappropriate use of follow-up care was significantly reduced among experimental group subjects (10% vs 20%). CONCLUSION: The nurse practitioner's intervention improved parents' use of follow-up care in our sample. Overall care for episodic ED users might be improved by similar interventions.",0,0,
1059,In tepid defense of population health: physicians and antibiotic resistance,"Antibiotic resistance menaces the population as a dire public health threat and costly social problem. Recent proposals to combat antibiotic resistance focus to a large degree on supply side approaches. Suggestions include tinkering with patent rights so that pharmaceutical companies have greater incentives to discover novel antibiotics as well as to resist overselling their newer drugs already on market. This Article argues that a primarily supply side emphasis unfortunately detracts attention from physicians' important demand side influences. Physicians have a vital and unavoidably necessary role to play in ensuring socially optimal access to antibiotics. Dismayingly, physicians' management of the antibiotic supply has been poor and their defense of population health tepid at best. Acting as a prudent steward of the antibiotic supply often seems to be at odds with a physician's commonly understood fiduciary duties, ethical obligations, and professional norms, all of which traditionally emphasize the individual health paradigm as opposed to population health responsibilities. Meanwhile, physicians face limited incentives for antibiotic conservation from other sources, such as malpractice liability, regulatory standards, and reimbursement systems. While multifaceted efforts are needed to combat antibiotic resistance effectively, physician gatekeeping behavior should become a priority area of focus. This Article considers how health law and policy tools could favorably change the incentives physicians face for antibiotic conservation. A clear lesson from the managed care reform battles of the recent past is that interventions, to have the best chance of success, need to respect physician interest in clinical autonomy and individualized medicine even if, somewhat paradoxically, vigorously promoting population health perspectives. Also, physicians' legal and ethical obligations need to be reconceptualized in the antibiotic context in order to better support gatekeeping in defense of population health. The principal recommendation is for increased use of financial incentives to reward physicians for compliance with recommended guidelines on antibiotic prescribing. Although not a panacea, greater experimentation with financial incentives can provide a much needed jump-start to physician interest in antibiotic conservation and likely best address physicians' legitimate clinical autonomy concerns.",0,0,
1060,"In treatment-resistant depression, adding cognitive–behavioral therapy to usual care was cost-effective at 1 y","Question  In primary care patients with treatment-resistant depression, is adding individual cognitive¨Cbehavioral therapy (CBT) to usual care cost-effective? Methods  Design  Cost-utility analysis from a UK National Health Service (NHS) and Personal Social Services (PSS) perspective based on 1-year follow-up of a randomized controlled trial (CoBalT trial). Setting  Primary care practices in Bristol, Exeter, and Glasgow, UK. Patients  469 patients 18 to 75 years of age (mean age 50 y, 72% women) who were adherent to antidepressant medication for ¡Ý 6 weeks but continued to have depressive symptoms, had depression diagnosed using the Revised Clinical Interview Schedule, and had a Beck Depression Inventory (BDI)-II score ¡Ý 14. Intervention  Individual CBT, 12 to 18 one-hour sessions done in primary care practices or similar settings, plus usual care (n = 234), or usual care alone (n = 235). Usual care could include antidepressant drugs. Outcomes  Treatment response (¡Ý 50% reduction in BDI-II score)""; quality-adjusted life-years (QALYs), based on EQ-5D-3L scores and quality-of-life valuations from the UK general population; costs in 2010 UK pounds sterling {UK ¡ê1 = US $1.56}*;"" and incremental cost-effectiveness ratio (ICER). Costs included NHS and PSS costs obtained from primary care records, CBT therapist records, and patient questionnaires. Follow-up was 83% to 84% for clinical outcomes and 78% for health and social care costs at 1 year. Main results  Adding CBT to usual care reduced depression symptoms and increased QALYs (Table). CBT plus usual care cost more than usual care alone (Table), with an ICER of ¡ê14 911 (US $23 261) per QALY gained over 12 months. In sensitivity analyses using the Short Form-6 dimensions algorithm to estimate QALYs, the ICER was ¡ê29 626 (US $46 217). Conclusion  In primary care patients with treatment-resistant depression in the UK, adding cognitive¨Cbehavioral therapy to usual care was cost-effective at 1 year.",0,0,
1061,Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD,"OBJECTIVE: Posttraumatic stress disorder (PTSD) is a prevalent and often disabling condition. Fortunately, effective psychological treatments for PTSD are available. However, research indicates that these treatments may be underutilized in clinical practice. One reason for this underutilization may be clinicians' unwarranted exclusion of patients from these treatments based on their understanding of exclusion criteria used in clinical trials of psychological treatments for PTSD. There is no comprehensive and up-to-date review of inclusion and exclusion criteria used in randomized clinical trials (RCTs) of psychological treatments for PTSD. Therefore, our objective was to better understand how patients were excluded from such RCTs in order to provide guidance to clinicians regarding clinical populations likely to benefit from these treatments. METHODS: We conducted a comprehensive literature review of RCTs of psychological treatments for PTSD from January 1, 1980 through April 1, 2012. We categorized these clinical trials according to the types of psychotherapy discussed in the major guidelines for treatment of PTSD and reviewed all treatments that were studied in at least two RCTs (N=64 published studies with 75 intervention arms since some studies compared two or more interventions). We abstracted and tabulated information concerning exclusion criteria for each type of psychotherapy for PTSD. RESULTS: We identified multiple RCTs of cognitive behavioral therapy (n=56), eye movement desensitization and reprocessing (n=11), and group psychotherapy (n=8) for PTSD. The most common exclusions were psychosis, substance abuse and dependence, bipolar disorder, and suicidal ideation. Clinical trials varied in how stringently these criteria were applied. It is important to note that no exclusion criterion was used in all studies and there was at least one study of each type of therapy that included patients from each of the commonly excluded groups. A paucity of evidence exists concerning the treatment of patients with PTSD and four comorbidities: alcohol and substance abuse or dependence with current use, current psychosis, current mania, and suicidal ideation with current intent. CONCLUSIONS: Psychological treatments for PTSD have been studied in broad and representative clinical populations. It appears that more liberal use of these treatments regardless of comorbidities is warranted.",0,0,
1062,"INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness","INTRODUCTION: Traumatic brain injury (TBI) results in complex cognitive (and other) sequelae. Impairments in executive function and self-awareness are among the most characteristic neuropsychological sequelae and can exert a profound effect on resuming previous life roles. An international group of researchers and clinicians (known as INCOG) convened to develop recommendations for interventions to improve impairments in executive functioning and self-awareness after TBI. METHODS: The team reviewed the available literature and ensured the recommendations were current. To promote implementation, the team developed decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials. The team then prioritized the recommendations for implementation and developed audit criteria to evaluate the adherence to the best practice recommendations. RESULTS: Intervention programs incorporating metacognitive strategy instruction for planning, problem-solving, and other cognitive-executive impairments have a solid evidence base. New evidence supports the use of strategies to specifically improve reasoning skills. Substantial support exists for use of direct corrective feedback to improve self-awareness. CONCLUSIONS: An increasing number of scientifically well-designed studies are available that demonstrate the effectiveness of a variety of interventions for the remediation of impairments in executive function and self-awareness after TBI.",0,0,
1063,Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study,"OBJECTIVES: To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. BACKGROUND: Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. METHODS: A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated""; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using chi(2) tests. RESULTS: AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%;"" P < 0.002). CONCLUSIONS: A multifaceted intervention improved compliance with a pediatric AP guideline.",0,0,
1064,Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses,"OBJECTIVES:Low tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. 'Nudges' influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU). SETTING: University Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year. PARTICIPANTS: Data were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis. INTERVENTIONS: (1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive. PRIMARY OUTCOME MEASURE: TVe in mL/kg IBW. FINDINGS: TVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years. CONCLUSIONS: This study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice.",1,1,
1065,Increasing the quantity and quality of searching for current best evidence to answer clinical questions: protocol and intervention design of the MacPLUS FS Factorial Randomized Controlled Trials,"Background & aims Finding current best evidence for clinical decisions remains challenging. With 3,000 new studies published every day, no single evidence-based resource provides all answers or is sufficiently updated. McMaster Premium LiteratUre Service - Federated Search (MacPLUS FS) addresses this issue by looking in multiple high quality resources simultaneously and displaying results in a one-page pyramid with the most clinically useful at the top. Yet, additional logistical and educational barriers need to be addressed to enhance point-of-care evidence retrieval. This trial seeks to test three innovative interventions, among clinicians registered to MacPLUS FS, to increase the quantity and quality of searching for current best evidence to answer clinical questions. Methods & design In a user-centered approach, we designed three interventions embedded in MacPLUS FS: (A) a web-based Clinical Question Recorder""; (B) an Evidence Retrieval Coach composed of eight short educational videos;"" (C) an Audit, Feedback and Gamification approach to evidence retrieval, based on the allocation of `badges’ and `reputation scores.’ We will conduct a randomized factorial controlled trial among all the 904 eligible medical doctors currently registered to MacPLUS FS at the hospitals affiliated with McMaster University, Canada. Postgraduate trainees (n = 429) and clinical faculty/staff (n = 475) will be randomized to each of the three following interventions in a factorial design (A x B x C). Utilization will be continuously recorded through clinicians’ accounts that track logins and usage, down to the level of individual keystrokes. The primary outcome is the rate of searches per month per user during the six months of follow-up. Secondary outcomes, measured through the validated Impact Assessment Method questionnaire, include: utility of answers found (meeting clinicians’ information needs), use (application in practice), and perceived usefulness on patient outcomes. Discussion Built on effective models for the point-of-care teaching, these interventions approach evidence retrieval as a clinical skill. If effective, they may offer the opportunity to enhance it for a large audience, at low cost, providing better access to relevant evidence across many top EBM resources in parallel.",0,0,
1066,Indications for cholesterol-lowering medication: comparison of risk-assessment methods,"BackgroundRecommendations for the prescription of lipidlowering drugs emphasise the importance of an assessment of absolute coronary heart disease (CHD) risk based on all risk factors, rather than simply the serum cholesterol concentration. If, however, the methods recommended for risk assessment are inaccurate, recommended prescribing will not occur. We compared several sets of guidelines for such treatment in a series of patients referred to a lipid clinic, to assess the difference in degree of risk of CHD at which lipid-lowering medication is recommended by each set of guidelines."";"" BackgroundRecommendations for the prescription of lipidlowering drugs emphasise the importance of an assessment of absolute coronary heart disease (CHD) risk based on all risk factors, rather than simply the serum cholesterol concentration. If, however, the methods recommended for risk assessment are inaccurate, recommended prescribing will not occur. We compared several sets of guidelines for such treatment in a series of patients referred to a lipid clinic, to assess the difference in degree of risk of CHD at which lipid-lowering medication is recommended by each set of guidelines.",0,0,
1067,"Individualised treatment targets for elderly patients with type 2 diabetes using vildagliptin add-on or lone therapy (INTERVAL): a 24 week, randomised, double-blind, placebo-controlled study","BackgroundGuidelines suggest setting individualised targets for glycaemic control in elderly patients with type 2 diabetes, despite no evidence. We aimed to assess the feasibility of setting and achieving individualised targets over 24 weeks along with conventional HbA1c reduction using vildagliptin versus placebo."";"" BackgroundGuidelines suggest setting individualised targets for glycaemic control in elderly patients with type 2 diabetes, despite no evidence. We aimed to assess the feasibility of setting and achieving individualised targets over 24 weeks along with conventional HbA1c reduction using vildagliptin versus placebo.",0,0,
1068,Individuals with low back pain: how do they view physical activity?,"BACKGROUND: Recent guidelines for those with acute low back pain have advocated early resumption of normal activity and increased physical activity. Little is known about the relationship between low back pain and physical activity, and on the impact of that relationship on the promotion of increased levels of physical activity within a general practice population. OBJECTIVES: We aimed to explore associations between factors that influence changes in physical activity and the way individuals perceive and behave with their low back pain, and the impact of those perceptions and behaviour on physical activity. METHODS: Twenty-seven informants were chosen using a purposive sample from a larger group of individuals who, because of their low back trouble, had been referred by their GPs to a community-based, single-blind, randomized controlled trial (RCT) at the University of York, which is evaluating the effectiveness and cost-effectiveness of a progressive exercise programme. Fifty-four interviews were conducted with this subgroup of the RCT"";"" four informants were interviewed once, 19 twice and four of them three times. Interviews were transcribed and analysed using manual and computer-aided approaches. RESULTS: Physical activity was perceived as (i) activities of daily living, (ii) activities causing breathlessness that they went out of the way to do and (iii) more competitive-type activity. The avoidance of physical activity and fear of pain returning were the two main factors directly associated with informants' backs and changes in physical activity. These two factors hindered increases in physical activity, even though the majority of informants believed strongly that being physically active helped ease their low back pain. CONCLUSIONS: When advocating that individuals with acute low back pain return to or increase physical activity, it is important that clinicians identify avoidance of physical activity and/or fear of pain at the earliest stage in order to tailor advice and reassurance appropriately. If avoidance of activity and fear of pain is identified and clinicians want to encourage patients to take up and sustain increased physical activity, they should explore issues of fear of pain, and avoidance of and confidence to do physical activities, in addition to other factors influencing physical activity.",0,0,
1069,Inequities among the very poor: health care for children in rural southern Tanzania,"BackgroundFew studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania."";"" BackgroundFew studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania.",0,0,
1070,Infectious diseases in general practice and antibiotic prescription. Observational study in Sicily,"Drug utilisation studies have shown wide differences, among different countries, in the prescribing behaviour in general practice. In Italy, for instance, the choice of antibiotic prescription seems to show a wider use of parental antibiotic. Aim of this study was to describe antibiotic prescribing pattern and therapeutic doses used by Sicilian general practitioners (GPs) and evaluate their prescribing attitudes regarding the use of parental ones. Each practitioner had to fill a questionnaire for each therapeutic intervention ended with an antibiotic prescription during a period of 6 months. Diagnosis and drugs were classified according to the International Classification of Diseases (ICD-10) and to Anatomical Therapeutic Chemical Classification (ATC), respectively. On 9395 prescriptions performed by 76 doctors of 25 Sicilian towns, the analysis indicated that acute respiratory symptoms represent the commonest indication (31.7%) for a medical consultation, and that Macrolides [such as azithromycin (8.8%) and clarithromycin (8.3%)], Penicillin [such as amoxycillin (7.1%%) and co-amoxiclav (8.4%)], III generation of Cephalosporins [such as cefixime (5.5%) and ceftriaxone (5.1%)] represent the most common used therapeutic groups. The choice of the route of administration was influenced by age of the patients and, more significantly, by symptoms and signs of the disease, rather than by bacteria suspected to cause the disease. In conclusion, our data clearly indicate lack of knowledge of antibacterial therapy guidelines among GPs in Sicily, as well as the need of an independent educational training in order to improve knowledge of antibiotics and to decrease the cost of the health care.",0,0,
1071,Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial,"Context Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized.  Objective To ascertain the effects of patients¡¯ DTC-related requests on physicians¡¯ initial treatment decisions in patients with depressive symptoms.  Design Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none).  Setting Offices of primary care physicians in Sacramento, Calif""; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004.  Participants One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations;"" cooperation rates ranged from 53% to 61%.  Interventions The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits.  Main Outcome Measures Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics.  Results Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001).  Conclusions Patients¡¯ requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.",0,0,
1072,Influence on lifestyle measures and five-year coronary risk by a comprehensive lifestyle intervention programme in patients with coronary heart disease,"BACKGROUND: Lifestyle measures of coronary heart disease (CHD) prevention have been overshadowed by the efficacy of drug treatments. This is particularly the case in the setting of secondary prevention where the benefits of lipid lowering, anti-platelet and anti-hypertensive drugs have been emphasised in numerous trials. Lifestyle measures address several CHD risk factors at once and are generally free of serious side effects. OBJECTIVES: The objective of the present study was to determine whether a comprehensive programme of lifestyle modification could favourably influence dietary and exercise habits in addition to smoking cessation over two years. In addition, an attempt was made to evaluate if this programme could favourably influence the five-year CHD-risk in the male population included in the study. DESIGN: A total of 197 patients with proven coronary heart disease were included and randomised to a lifestyle intervention programme or to usual care. Follow-up was after a period of two years. METHODS: Intervention comprised a low fat diet, regular exercise, smoking cessation, psychosocial support and education, delivered by nurses on the rationale for pharmacological and lifestyle measures. Usual care comprised follow-up in the routine outpatient clinic. Both groups were given the same comprehensive medication according to recent guidelines. RESULTS: Patients in the lifestyle intervention group reduced the intake of saturated fat, sugar and cholesterol (P<0.001), increased their exercise level (P<0.01) and stopped smoking (P<0.05) when compared with the usual care group. A sub-analysis of the influence of five-year CHD calculated risk in males resulted in a relative risk reduction of 22% (95% confidence intervals 9-35). Although significant, this result must be interpreted with caution due to poor statistical power and reproducibility of the method. CONCLUSIONS: In the presence of modern drug treatments for secondary cardiovascular disease prevention it remains possible through a favourable diet, exercise and smoking cessation to show an additional reduction in the five-year risk for CHD in males.",0,0,
1073,Influences of educational interventions and adverse news about calcium-channel blockers on first-line prescribing of antihypertensive drugs to elderly people in British Columbia,"BackgroundThe way in which dissemination of evidence changes medical practice needs to be better understood. Controversy about calcium-channel blockers (CCB) in the past 3 years has provided a natural experiment, enabling assessment of the impact of media stories, a national warning letter, a teleconference, small group workshops, and newsletters on first-line prescribing of antihypertensive drugs."";"" BackgroundThe way in which dissemination of evidence changes medical practice needs to be better understood. Controversy about calcium-channel blockers (CCB) in the past 3 years has provided a natural experiment, enabling assessment of the impact of media stories, a national warning letter, a teleconference, small group workshops, and newsletters on first-line prescribing of antihypertensive drugs.",0,0,
1074,Influencing antibiotic prescribing by prescriber feedback and management guidelines: a 5-year follow-up,"BACKGROUND: The extent of use of antibiotics for upper respiratory tract infection (URTI) prompted a previous study of an educational intervention based on prescriber feedback and management guidelines. This study demonstrated a reduction in antibiotic prescribing for URTI and a more appropriate choice of antibiotic for tonsillitis/streptococcal pharyngitis. There are few long-term follow-up studies of educational programmes of this kind. OBJECTIVES: This follow-up study aimed to examine if the reduction in antibiotic prescribing observed in the intervention group of the original study remained present after 5 years, and how the prescribing behaviour of the GPs involved in the follow-up differed from a large national survey of GP prescribing. METHODS: Attempts were made to contact the 157 GPs involved in the original study. Of these, 121 were both located and currently working in general practice. Ninety-six consented to take part and, of these, 79 completed a morbidity and treatment survey of 100 patient encounters (response rate 65.3%). RESULTS: The intervention group (n = 37) maintained their pattern of prescribing of antibiotics for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis, with no significant change between the completion of the original study and the 5-year follow-up. The control group (n = 42) showed a downward trend in antibiotic prescribing for URTI, with the effect that no significant differences remained between groups at the 5-year follow-up. At the 5-year follow-up, both groups prescribed significantly fewer antibiotics for URTI and showed greater adherence to prescribing guidelines for tonsillitis/streptococcal pharyngitis than participants in a large national GP survey (n = 984). CONCLUSION: This study demonstrated maintenance of prescribing behaviour in the intervention group in the long term. However, the changes in prescribing observed in the control group and the power limitations of the study make it uncertain whether this was the result of a sustained effect of the educational intervention. The differences in both groups from the large national GP survey suggest that other influences on prescribing (such as participation in vocational training for general practice) were also having an important effect.",0,0,
1075,Influencing antibiotic prescribing in general practice: a trial of prescriber feedback and management guidelines,"BACKGROUND: The extent of use of antibiotics to treat upper respiratory infections in general practice is an area for concern due to the increasing problem of bacterial resistance. Effective educational strategies to promote rational prescribing are needed. OBJECTIVES: We aimed to examine the effectiveness of prescriber feedback and management guidelines in reducing antibiotics prescribing by GP trainees for undifferentiated upper respiratory tract infection, and in improving the choice of antibiotic for tonsillitis/streptococcal pharyngitis. The research tested a stepwise approach to targeting educational input to high prescribers. METHOD: General Practice trainees in New South Wales (n = 157) were randomly allocated to a treatment group (n = 78) which received an education intervention on antibiotic use, or to a control group (n = 79) which received an intervention on an unrelated topic. Trainees completed three practice activity surveys, each of 110 consecutive patient encounters, with 6-month intervals between surveys. Prescriber feedback and management guidelines on use of antibiotics for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis were delivered in a written form between surveys 1 and 2. An educational outreach visit to high prescribers occurred between surveys 2 and 3. Outcome measures were the rate of antibiotic prescribing for all indications, for URTI and prescribing of select antibiotics for tonsillitis/streptococcal pharyngitis. RESULTS: Antibiotic prescribing by the intervention group declined over three occasions from 25.0 to 23.3 to 19.7 per 100 URTI problems, while the control group increased from 22.0 to 25.0 to 31.7 per 100 URTI problems (P = 0.002). Prescribing in agreement with accepted guidelines for tonsillitis/streptococcal pharyngitis increased over time in the intervention group from 55.6 to 69.8 to 73.0 per 100 problems, but decreased in the control group from 59.6 to 57.5 to 58.5 (P = 0.05). CONCLUSION: Prescriber feedback and management guidelines were shown to influence antibiotic prescribing for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis. This study provides a model for targeting educational input to those prescribers who most need to change their behaviour.",0,0,
1076,Information technology for patient safety,"Background Research on patient care has identified substantial variations in the quality and safety of healthcare and the considerable risks of iatrogenic harm as significant issues. These failings contribute to the high rates of potentially avoidable morbidity and mortality and to the rising levels of healthcare expenditure seen in many health systems. There have been substantial developments in information technology in recent decades and there is now real potential to apply these technological developments to improve the provision of healthcare universally. Of particular international interest is the use of eHealth applications. There is, however, a large gap between the theoretical and empirically demonstrated benefits of eHealth applications. While these applications typically have the technical capability to help professionals in the delivery of healthcare, inadequate attention to the socio-technical dimensions of their use can result in new avoidable risks to patients.  Results and discussion Given the current lack of evidence on quality and safety improvements and on the cost–benefits associated with the introduction of eHealth applications, there should be a focus on implementing more mature technologies"";"" it is also important that eHealth applications should be evaluated against a comprehensive and rigorous set of measures, ideally at all stages of their application life cycle.",0,1,
1077,Informed consent in clinical research at a general hospital in Mexico: opinions of the investigators,"In Mexico informed consent is a legal requirement that ensures that patients who are invited to participate in clinical trials are provided with all the information needed to decide whether to participate, or not, in a research protocol. To improve our understanding of the problems physicians in developing countries encounter, when obtaining informed consent (IC), we examined their opinion on the importance of IC in clinical research, the quantity and quality of the information provided to the participant, and the conditions in which the IC is obtained. Investigators considered that IC was useful to the patients, providing information that helped the patient to make a decision about his/her participation. Nevertheless, they felt that for some aspects of the research, like drug development in general, the use of placebos, and the randomization process, many of the patients were not capable of fully understanding the information provided, referring to the complexity of the information and illiteracy as the main reasons. Many investigators were not acquainted with some of the guidelines established in the Mexican General Law of Health,(1) 36% of them admitting to not having completed their IC letters. Most investigators gave only minutes to the patient to make a decision and 20% of ICs were obtained while the patient was hospitalized. Except for one investigator, all of them considered that specific training in medical ethics would be useful for the daily clinical work.",0,0,
1078,Informed consent in human experimentation before the Nuremberg code,"The issue of ethics with respect to medical experimentation in Germany during the 1930s and 1940s was crucial at the Nuremberg trials and related trials of doctors and public health officials. Those involved in horrible crimes attempted to excuse themselves by arguing that there were no explicit rules governing medical research on human beings in Germany during the period and that research practices in Germany were not different from those in allied countries. In this context the Nuremberg code of 1947 is generally regarded as the first document to set out ethical regulations in human experimentation based on informed consent. New research, however, indicates that ethical issues of informed consent in guidelines for human experimentation were recognised as early as the nineteenth century. These guidelines shed light on the still contentious issue of when the concepts of autonomy, informed consent, and therapeutic and non-therapeutic research first emerged. This issue assumes renewed importance in the context of current attempts to assess liability and responsibility for the abuse of people in various experiments conducted since the second world war in the United States, Canada, Russia, and other nations.",0,0,
1079,Informed consent: coronary artery bypass grafting,"Coronary artery bypass graft surgery (CABG) is well-documented procedure. Despite the increased prevalence of percutaneous coronary intervention (PCI), surgical revascularization will continue to have a major role in patients with coronary artery disease. As shown in previous clinical studies, physicians can provide important information about risk-adjusted outcomes to patients. A number of databases have been used to develop risk models for predicting morbidity and mortality in patients undergoing CABG. Patients must make a choice between CABG and PCI based on physicians' explanations. Major trials demonstrated a marked survival benefit from CABG among those patients at high risk of death from the disease itself as defined by the severity of angina, number of diseased vessels, and left ventricular function. However, it is not clear that patients always receive the correct information on whether CABG or PCI is the more appropriate procedure. The initial informed consent should be obtained using the relevant guidelines by an independent adviser.",0,0,
1080,Informed shared decision-making supported by decision coaches for women with ductal carcinoma in situ: study protocol for a cluster randomized controlled trial,"BACKGROUND: Women with breast cancer want to participate in treatment decision-making. Guidelines have confirmed the right of informed shared decision-making. However, previous research has shown that the implementation of informed shared decision-making is suboptimal for reasons of limited resources of physicians, power imbalances between patients and physicians and missing evidence-based patient information. We developed an informed shared decision-making program for women with primary ductal carcinoma in situ (DCIS). The program provides decision coaching for women by specialized nurses and aims at supporting involvement in decision-making and informed choices. In this trial, the informed shared decision-making program will be evaluated in breast care centers. METHODS/DESIGN: A cluster randomized controlled trial will be conducted to compare the informed shared decision-making program with standard care. The program comprises an evidence-based patient decision aid and training of physicians (2 hours) and specialized breast care and oncology nurses (4 days) in informed shared decision-making. Sixteen certified breast care centers will be included, with 192 women with primary DCIS being recruited. Primary outcome is the extent of patients' involvement in shared decision-making as assessed by the MAPPIN-Odyad (Multifocal approach to the 'sharing' in shared decision-making: observer instrument dyad). Secondary endpoints include the sub-measures of the MAPPIN-inventory (MAPPIN-Onurse, MAPPIN-Ophysician, MAPPIN-Opatient, MAPPIN-Qnurse, MAPPIN-Qpatient and MAPPIN-Qphysician), informed choice, decisional conflict and the duration of encounters. It is expected that decision coaching and the provision of evidence-based patient decision aids will increase patients' involvement in decision-making with informed choices and reduce decisional conflicts and duration of physician encounters. Furthermore, an accompanying process evaluation will be conducted. DISCUSSION: To our knowledge, this is the first study investigating the implementation of decision coaches in German breast care centers. TRIAL REGISTRATION: Current Controlled Trials ISRCTN46305518 , date of registration: 5 June 2015.",0,0,
1081,Infrastructure for quality transformation: measurement and reporting in veterans administration intensive care units,"Background Veterans Health Administration (VA) intensive care units (ICUs) develop an infrastructure for quality improvement using information technology and recruiting leadership.  Methods Setting Participation by the 183 ICUs in the quality improvement program is required. Infrastructure includes measurement (electronic data extraction, analysis), quarterly web-based reporting and implementation support of evidence-based practices. Leaders prioritise measures based on quality improvement objectives. The electronic extraction is validated manually against the medical record, selecting hospitals whose data elements and measures fall at the extremes (10th, 90th percentile). Results are depicted in graphic, narrative and tabular reports benchmarked by type and complexity of ICU.  Results The VA admits 103?689±1156 ICU patients/year. Variation in electronic business practices, data location and normal range of some laboratory tests affects data quality. A data management website captures data elements important to ICU performance and not available electronically. A dashboard manages the data overload (quarterly reports ranged 106—299 pages). More than 85% of ICU directors and nurse managers review their reports. Leadership interest is sustained by including ICU targets in executive performance contracts, identification of local improvement opportunities with analytic software, and focused reviews.  Conclusion Lessons relevant to non-VA institutions include the: (1) need for ongoing data validation, (2) essential involvement of leadership at multiple levels, (3) supplementation of electronic data when key elements are absent, (4) utility of a good but not perfect electronic indicator to move practice while improving data elements and (5) value of a dashboard.",0,0,
1082,Initiation of quality improvement activities in mental health services,"In the public sector mental health service setting, accountability for quality has often been considered the responsibility of the individual clinician. This presents a particular challenge for introducing an organization-wide quality improvement culture in this setting. The introduction of a systemic view of quality may encounter resistance from individual clinicians reluctant to accept that some clinical autonomy must be subsumed within more standardized patterns of intervention and evaluation. Services must firstly tackle the issue of clinicians' readiness to embrace such a culture, which requires strong direction from the executive level. The area of recently diagnosed psychosis was selected in one public sector mental health service as a starting point for initiating the quality improvement culture. The eventual outcome for the organization has been a positive commitment to improvement, but the journey was long and hard. This paper describes the beginning of this ultimately rewarding journey.",0,0,
1083,Innovative strategy for implementing chronic heart failure guidelines among family physicians in different healthcare settings in Berlin,"AIMS: The aim of this study was to improve drug therapy for chronic heart failure (CHF) patients. METHODS AND RESULTS: This prospective interventional pilot study was performed with cross-sectional comparative analysis before and after the intervention. Usual pharmacotherapy was observed for 8 months in two different outpatient healthcare settings in Berlin [11 family physicians from individual GP (IGP) practices and 12 working in a medical care centre (MCC)]. Medical care centres provide a novel structure for outpatient care and have recently been introduced in Germany. The subsequent intervention entailed implementation of heart failure guidelines via a computer-based reminder system, followed by renewed cross-sectional observation of prescription behaviour for 1 year. Family physicians recruited patients, assessed CHF severity according to the NYHA class, and referred patients for echocardiography. The study included 190 patients in the baseline phase and 209 in the intervention phase. Longitudinal follow-up was performed in 172 cases. Echocardiography was ordered by 94.6% of MCC-physicians and 79.9% of IGP's. Undermedication was observed in both settings. Guideline-based beta-blocker therapy was prescribed for 46.3% of patients (44.8% of IGPs and 48.5% of MCC-GPs). Prescription improved by 12.3% after the intervention. There were marked deficiencies in the prescription of aldosterone antagonists (35%) for severe heart failure, which improved to 44.2% after the intervention. CONCLUSION: The problem of inadequate implementation of evidence-based therapy for CHF was partially overcome by using the reminder system, which provided participating physicians with short guideline recommendations during the intervention phase.",0,0,
1084,Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial.,"Context Computerized reminder systems increase influenza and pneumococcal vaccination rates, but computerized standing order systems have not been previously described or evaluated.  Objective To determine the effects of computerized physician standing orders compared with physician reminders on inpatient vaccination rates.  Design, Setting, and Patients Randomized trial of 3777 general medicine patients discharged from 1 of 6 study wards during a 14-month period (November 1, 1998, through December 31, 1999) composed of 2 overlapping influenza seasons at an urban public teaching hospital.  Interventions The hospital’s computerized physician order entry system identified inpatients eligible for influenza and pneumococcal vaccination. For patients with standing orders, the system automatically produced vaccine orders directed to nurses at the time of patient discharge. For patients with reminders, the computer system provided reminders to physicians that included vaccine orders during routine order entry sessions.  Main Outcome Measure Vaccine administration.  Results During the approximately 6 months of the influenza season, 50% of all hospitalized patients were identified as eligible for influenza vaccination. Twenty-two percent of patients hospitalized during the entire 14 months of the study were found eligible for pneumococcal vaccination. Patients with standing orders received an influenza vaccine significantly more often (42%) than those patients with reminders (30%) (P <.001). Patients with standing orders received a pneumococcal vaccine significantly more often (51%) than those with reminders (31%) (P <.001).  Conclusions Computerized standing orders were more effective than computerized reminders for increasing both influenza and pneumococcal vaccine administration. Our findings suggest that computerized standing orders should be used more widely for this purpose.",1,1,
1085,Insomnia,,0,0,
1086,Integrated guidance on the care of familial hypercholesterolaemia from the International FH Foundation,"Familial hypercholesterolaemia (FH) is a dominantly inherited disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL) cholesterol and causes premature coronary heart disease. There are at least 20 million people with FH worldwide, but the majority remains undetected and current treatment is often suboptimal.To address this major gap in coronary prevention we present, from an international perspective, consensus-based guidance on the care of FH. The guidance was generated from seminars and workshops held at an international symposium. The recommendations focus on the detection, diagnosis, assessment and management of FH in adults and children, and set guidelines for clinical purposes. They also refer to best practice for cascade screening and risk notifying and testing families for FH, including use of genetic testing. Guidance on treatment is based on risk stratification, management of non-cholesterol risk factors and safe and effective use of LDL lowering therapies. Recommendations are given on lipoprotein apheresis. The use of emerging therapies for FH is also foreshadowed.This international guidance acknowledges evidence gaps, but aims to make the best use of contemporary practice and technology to achieve the best outcomes for the care of FH. It should accordingly be employed to inform clinical judgment and be adjusted for country-specific and local healthcare needs and resources.",0,0,
1087,Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial,"OBJECTIVES To evaluate the effectiveness of integrated motivational interviewing and cognitive behavioural therapy in addition to standard care for patients with psychosis and a comorbid substance use problem. DESIGN Two centre, open, rater blind randomised controlled trial. SETTING Secondary care in the United Kingdom. PARTICIPANTS 327 patients with a clinical diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder and a diagnosis of dependence on or misuse of drugs, alcohol, or both according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. INTERVENTION The intervention was integrated motivational interviewing and cognitive behavioural therapy plus standard care, which was compared with standard care alone. Phase one of therapy-""motivation building""-concerns engaging the patient, then exploring and resolving ambivalence for change in substance use. Phase two-""action""-supports and facilitates change using cognitive behavioural approaches. Up to 26 therapy sessions were delivered over one year. MAIN OUTCOME MEASURES The primary outcome was death from any cause or admission to hospital in the 12 months after completion of therapy. Secondary outcomes were frequency and amount of substance use (assessed using the timeline followback method), readiness to change, perceived negative consequences of use, psychotic symptom ratings, number and duration of relapses, and global assessment of functioning and deliberate self harm at 12 and 24 months, with additional timeline followback assessments at 6 and 18 months. Analysis was by intention to treat and robust treatment effect estimates were produced. RESULTS 327 participants were randomly allocated to either the intervention (n=164) or treatment as usual (n=163). At 24 months, 326 (99.7%) were assessed on the primary outcome and 246 (75.2%) on the main secondary outcomes. Treatment had no beneficial effect on hospital admissions or death during follow-up, with 23.3% (38/163) of the therapy group and 20.2% (33/163) of controls deceased or admitted (adjusted odds ratio 1.16, 95% confidence interval 0.68 to 1.99""; P=0.579). Therapy had no effect on the frequency of substance use or the perceived negative consequences of misuse, but did have a statistically significant effect on amount used per substance using day (adjusted ORs for main substance 1.50, 95% CI 1.08 to 2.09; P=0.016; and all substances 1.48, 95% CI 1.07 to 2.05; P=0.017). Treatment had a statistically significant effect on readiness to change use at 12 months (adjusted OR 2.05, 95% CI 1.26 to 3.31; P=0.004) that was not maintained at 24 months (0.78, 95% CI 0.48 to 1.28;"" P=0.320). There were no effects of treatment on clinical outcomes such as relapses, psychotic symptoms, functioning, and self harm. CONCLUSIONS Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and substance misuse do not improve outcome in terms of hospitalisation, symptom outcomes, or functioning. This approach does reduce the amount of substance used for at least one year after completion of therapy. TRIAL REGISTRATION Current Controlled Trials: ISRCTN14404480.",0,0,
1088,"Integrating ""Back to Sleep"" recommendations into neonatal ICU practice","BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics stresses that NICUs should endorse and model the sudden infant deaths syndrome risk-reduction recommendations significantly before anticipated discharge of the infant. Medical personnel are critical role models for parents, and the way they position infants in the hospital strongly influences parental practices at home. The aims of this project were to increase the percentage of infants following safe sleep practices in the NICU before discharge and to determine if improving compliance with these practices would influence parent behavior at home. METHODS: An algorithm detailing when to start safe sleep practices, a ""Back to Sleep"" crib card, educational programs for nurses and parents, a crib audit tool, and postdischarge telephone reminders were developed as quality improvement intervention strategies. RESULTS: NICU compliance with supine positioning increased from 39% to 83% (P < .001), provision of a firm sleeping surface increased from 5% to 96% (P < .001), and the removal of soft objects from the bed improved from 45% to 75% (P = .001). Through the use of a postdischarge telephone survey, parental compliance with safe sleep practices was noted to improve from 23% to 82% (P < .001). CONCLUSIONS: Multifactorial interventions improved compliance with safe sleep practices in the NICU and at home.",0,1,
1089,Integrating addiction treatment into primary care using mobile health technology: protocol for an implementation research study,"Background Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians.  Methods/Design Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers¡¯s diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods ¡ª pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance ¡ª with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixed-methods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs.  Discussion If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems.",0,0,
1090,Integrating evidence on patient preferences in healthcare policy decisions: protocol of the patient-VIP study,"Background Despite a strong movement towards active patient involvement in healthcare policy decisions, systematic and explicit consideration of evidence of this research on patient preferences seems limited. Furthermore, little is known about the opinions of several stakeholders towards consideration of research evidence on patient preferences in healthcare policy decisions. This paper describes the protocol for an explorative study on the integration of research on patient preferences in healthcare policy decisions. The study questions: to what extent research evidence on patient preferences is considered in current procedures for healthcare policy decisions""; opinions of stakeholders regarding the integration of this type of evidence in healthcare policy decisions; and what could be a decision framework for the integration of such research evidence in healthcare policy decisions.  Methods/design The study is divided in three sub-studies, predominantly using qualitative methods. The first sub-study is a scoping review in five European countries to investigate whether and how results of research on patient preferences are considered in current procedures for coverage decisions and clinical practice guideline development. The second sub-study is a qualitative study to explore the opinions of stakeholders with regard to the possibilities for integrating evidence on patient preferences in the process of healthcare decision-making in the Netherlands. The third sub-study is the development of a decision framework for research on patient preferences. The framework will consist of: a process description regarding the place of evidence on patient preferences in the decision-making process;"" and a taxonomy describing different terminologies and conceptualisations of ¡®preferences¡¯ and an overview of existing methodologies for investigating preferences. The concept framework will be presented to and discussed with experts.  Discussion This study will create awareness regarding the existence and potential value of research evidence on patient preferences for healthcare policy decision-making and provides insight in the methods for investigating patient preferences and the barriers and facilitators for integration of such research in healthcare policy decisions. Results of the study will be useful for researchers, clinical practice guideline developers, healthcare policy makers, and patient representatives.",0,0,
1091,Integrative medicine in residency education: developing competency through online curriculum training,"INTRODUCTION: The Integrative Medicine in Residency (IMR) program, a 200-hour Internet-based, collaborative educational initiative was implemented in 8 family medicine residency programs and has shown a potential to serve as a national model for incorporating training in integrative/complementary/alternative medicine in graduate medical education. INTERVENTION: The curriculum content was designed based on a needs assessment and a set of competencies for graduate medical education developed following the Accreditation Council for Graduate Medical Education outcome project guidelines. The content was delivered through distributed online learning and included onsite activities. A modular format allowed for a flexible implementation in different residency settings. EVALUATION: TO ASSESS THE FEASIBILITY OF IMPLEMENTING THE CURRICULUM, A MULTIMODAL EVALUATION WAS UTILIZED, INCLUDING: (1) residents' evaluation of the curriculum""; (2) residents' competencies evaluation through medical knowledge testing, self-assessment, direct observations, and reflections;"" and (3) residents' wellness and well-being through behavioral assessments. RESULTS: The class of 2011 (n = 61) had a high rate of curriculum completion in the first and second year (98.7% and 84.2%) and course evaluations on meeting objectives, clinical utility, and functioning of the technology were highly rated. There was a statistically significant improvement in medical knowledge test scores for questions aligned with content for both the PGY-1 and PGY-2 courses. CONCLUSIONS: The IMR program is an advance in the national effort to make training in integrative medicine available to physicians on a broad scale and is a success in terms of online education. Evaluation suggests that this program is feasible for implementation and acceptable to residents despite the many pressures of residency.",0,0,
1092,Intensive investigation in management of Hodgkin's disease,"Ninety-eight patients with clinically localised Hodgkin's disease underwent laparotomy and splenectomy to determine the extent of microscopic spread. In 68 patients the procedure was carried out for untreated disease apparently confined above the diaphragm. Abdominal disease cannot be confidently excluded on the basis of non-invasive investigation at presentation. Clinical assessment of splenic disease was unreliable unless gross splenomegaly was present. Pedal lymphography was accurate in assessing para-aortic and iliac disease but of no value in assessing other intra-abdominal lymph node involvement, including that of the mesenteric lymph node. Trephine bone marrow biopsy findings were normal in all patients before surgery, and only one patient was found to have diseased bone marrow by Stryker-saw biopsy at operation. Liver disease was identified at operation in nine patients, some of whom were asymptomatic with clinically undetectable splenic and nodal disease. Detailed clinical staging failed to detect disease in one-third of patients who underwent laparotomy. These studies show that if radiotherapy is to remain the treatment of choice for disease truly localised to lymph nodes a detailed staging procedure, including laparotomy and splenectomy, remains essential. The value of this potentially curative treatment is considerably diminished in the patient who has been inadequately staged.",0,0,
1093,"Intensive speech and language therapy in patients with chronic aphasia after stroke: a randomised, open-label, blinded-endpoint, controlled trial in a health-care setting","BackgroundTreatment guidelines for aphasia recommend intensive speech and language therapy for chronic (≥6 months) aphasia after stroke, but large-scale, class 1 randomised controlled trials on treatment effectiveness are scarce. We aimed to examine whether 3 weeks of intensive speech and language therapy under routine clinical conditions improved verbal communication in daily-life situations in people with chronic aphasia after stroke."";"" BackgroundTreatment guidelines for aphasia recommend intensive speech and language therapy for chronic (≥6 months) aphasia after stroke, but large-scale, class 1 randomised controlled trials on treatment effectiveness are scarce. We aimed to examine whether 3 weeks of intensive speech and language therapy under routine clinical conditions improved verbal communication in daily-life situations in people with chronic aphasia after stroke.",0,0,
1094,Intentions and statins prescribing: can the theory of planned behaviour explain physician behaviour in following guideline recommendations?,"OBJECTIVES: Few studies have assessed the utility of the Theory of Planned Behaviour (TPB) in explaining physicians' behaviour. This study uses the TPB for explaining physicians' implementation of guidelines' prescribing recommendations. METHODS: We developed the questionnaire via conducting qualitative interviews and pilot study. A random sample of 155 general practitioners (GPs) in England participated in the study. Prescribing and practice data were collected from routine sources. We analysed the data using regression methods. RESULTS: TPB explained 48% of variation in reported intentions to follow guidelines' prescribing recommendations. Attitude and perceived controls, but not subjective norms, were predictors of variation in intentions. TPB belief variables significantly explained variation in effective and efficient prescribing indicators (14% and 12% respectively). Normative, control and behavioural beliefs contributed to the models. Only for efficient prescribing, the TPB items retained their significance in presence of demographic variables. We found no significant relationship between intention and prescribing. CONCLUSIONS: TPB helped understanding of GPs prescribing behaviour and their intentions to implement a clinical guideline. Beliefs (e.g. normative beliefs) were better predictors of behaviour than the composite scores for their corresponding higher-level construct (e.g. indirect subjective norm). TPB models should be tested alongside randomized trials to test the assumption of causality that change in beliefs ultimately results in change in behaviour.",0,0,
1095,Interactions between pharmaceutical representatives and doctors in training. A thematic review,"OBJECTIVE: Medical school and residency are formative years in establishing patterns of prescribing. We aimed to review the literature regarding the extent of pharmaceutical industry contact with trainees, attitudes about these interactions, and effects on trainee prescribing behavior, with an emphasis on points of potential intervention and policy formation. DESIGN: We searched MEDLINE from 1966 until May 2004 for English language articles. All original articles were included if the abstract reported content relevant to medical training and the pharmaceutical industry. Editorials, guidelines, and policy recommendations were excluded. MEASUREMENTS AND MAIN RESULTS: Contact with pharmaceutical representatives was common among residents. The majority of trainees felt that the interactions were appropriate. A minority felt that their own prescribing could be influenced by contact or gifts, but were more likely to believe that others' prescribing could be influenced. Resident prescribing was associated with pharmaceutical representative visits and the availability of samples. A variety of policy and educational interventions appear to influence resident attitudes toward interactions with industry, although data on the long-term effects of these interventions are limited. Overall, residents reported insufficient training in this area. CONCLUSIONS: The pharmaceutical industry has a significant presence during residency training, has gained the overall acceptance of trainees, and appears to influence prescribing behavior. Training programs can benefit from policies and curricula that teach residents about industry influence and ways in which to critically evaluate information that they are given. Recommendations for local and national approaches are discussed.",0,0,
1096,Interactions between physicians and the pharmaceutical industry: what does the literature say?,"OBJECTIVE: To determine the effect of three types of interaction between physicians and the pharmaceutical industry--company-funded clinical trials, company-sponsored continuing medical education (CME) and information for physicians supplied by pharmaceutical detailers--on orientation and quality of clinical trials, content of CME courses and physicians' prescribing behaviour. DATA SOURCES: MEDLINE and HEALTH searches for English-language articles published from 1978 to 1993, supplemented by material from the author's personal collection. STUDY SELECTION: A total of 227 papers from the MEDLINE and HEALTH searches and about 2000 items from the author's library were initially reviewed. The following selection criteria were used: studies conducted in Australia, Canada, New Zealand, Britain and the United States""; studies conducted after 1977; quantitative surveys containing details of the survey methods; studies on the orientation and quality of company-funded clinical trials and on the content of CME courses giving explicit criteria used in the evaluation;"" and reports on the outcome of interactions stating how the outcomes were assessed. Thirty-six studies met these criteria. DATA EXTRACTION: Information was extracted on five topics: physicians' attitudes toward drug industry interactions, frequency with which physicians participate in the interactions, orientation and quality of company-funded clinical trials, content of company-sponsored CME courses and changes in physicians' prescribing behaviour as a result of an interaction. DATA SYNTHESIS: Although most physicians participate only occasionally in company-sponsored clinical trials, most see detailers and attend company-sponsored CME courses. However, physicians do not have a very high opinion of the information from detailers or of company-sponsored CME events. Many doctors regard pharmaceutical companies as an important source of funding for clinical trials, but they also have concerns about accepting money from this source. Company funding of clinical trials may affect the quality of the trials and the types of research that physicians undertake. Company-sponsored CME courses may have a commercial bias even if conducted under guidelines designed to ensure the independence of the event. All three types of interactions affect physicians' prescribing behaviour and, in the case of obtaining information from detailers, physicians' prescribing practices are less appropriate as a result of the interaction. CONCLUSIONS: Physicians are affected by their interactions with the pharmaceutical industry. Further research needs to be done in most cases to determine whether such interactions lead to more or less appropriate prescribing practices. The CMA's guidelines on this topic should be evaluated to see whether they are effective in controlling physician-industry interactions. Further measures may be necessary if the guidelines fail to prevent negative effects on prescribing practices.",0,0,
1097,Interdisciplinary perspectives on the management of the unsettled baby: key strategies for improved outcomes,"The objectives of this study were to analyse the perspectives of key informants with clinical expertise in the care of unsettled babies in the first few months of life and their families, concerning changes required to improve outcomes. The research used a purposive selection strategy and thematic analysis of key informant interviews of24 health professionals from 11 disciplines. Informants were selected for extensive experience in the management of unsettled babies and their families. Participants corroborated existing evidence that post-birth care in Australia is fragmented. All held the view that, first, early primary care intervention for unsettled infants and their families, and second, improved cross-professional communication, are vital if the burden of this problem to the infant, family and health system are to be minimised. There was consensus, third, that significant gaps exist in health professionals' knowledge base and management behaviours. The development of education resources, best practice guidelines, shared assessment frameworks for primary care practitioners and strategies for improved cross-professional communication are necessary to improve the health outcomes and decrease the burden of this common yet complex post-birth problem.",0,0,
1098,Internal and external validity of cluster randomised trials: systematic review of recent trials,"OBJECTIVES To assess aspects of the internal validity of recently published cluster randomised trials and explore the reporting of information useful in assessing the external validity of these trials. DESIGN Review of 34 cluster randomised trials in primary care published in 2004 and 2005 in seven journals (British Medical Journal, British Journal of General Practice, Family Practice, Preventive Medicine, Annals of Internal Medicine, Journal of General Internal Medicine, Pediatrics). DATA SOURCES National Library of Medicine (Medline) via PubMed. DATA EXTRACTION To assess aspects of internal validity we extracted data on appropriateness of sample size calculations and analyses, methods of identifying and recruiting individual participants, and blinding. To explore reporting of information useful in assessing external validity we extracted data on cluster eligibility, cluster inclusion and retention, cluster generalisability, and the feasibility and acceptability of the intervention to health providers in clusters. RESULTS 21 (62%) trials accounted for clustering in sample size calculations and 30 (88%) in the analysis""; about a quarter were potentially biased because of procedures surrounding recruitment and identification of patients;"" individual participants were blind to allocation status in 19 (56%) and outcome assessors were blind in 15 (44%). In almost half the reports, information relating to generalisability of clusters was poorly reported, and in two fifths there was no information about the feasibility and acceptability of the intervention. CONCLUSIONS Cluster randomised trials are essential for evaluating certain types of interventions. Issues affecting their internal validity, such as appropriate sample size calculations and analysis, have been widely disseminated and are now better addressed by researchers. Blinding of those identifying and recruiting patients to allocation status is recommended but is not always carried out. There may be fewer barriers to internal validity in trials in which individual participants are not recruited. External validity seems poorly addressed in many trials, yet is arguably as important as internal validity in judging quality as a basis for healthcare intervention.",0,0,
1099,International Collegium of Rehabilitative Audiology (ICRA) recommendations for the construction of multilingual speech tests. ICRA Working Group on Multilingual Speech Tests,"OBJECTIVE: To provide guidelines for the development of two types of closed-set speech-perception tests that can be applied and interpreted in the same way across languages. The guidelines cover the digit triplet and the matrix sentence tests that are most commonly used to test speech recognition in noise. They were developed by a working group on Multilingual Speech Tests of the International Collegium of Rehabilitative Audiology (ICRA). DESIGN: The recommendations are based on reviews of existing evaluations of the digit triplet and matrix tests as well as on the research experience of members of the ICRA Working Group. They represent the results of a consensus process. RESULTS: The resulting recommendations deal with: Test design and word selection""; Talker characteristics; Audio recording and stimulus preparation; Masking noise; Test administration;"" and Test validation. CONCLUSIONS: By following these guidelines for the development of any new test of this kind, clinicians and researchers working in any language will be able to perform tests whose results can be compared and combined in cross-language studies.",0,0,
1100,Intervening in infancy: implications for autism spectrum disorders,"There is a scarcity of empirically validated treatments for infants and toddlers under age 3 years with autism spectrum disorders (ASD), as well as a scarcity of empirical investigation into successful intervention characteristics for this population. Yet early screening efforts are focused on identifying autism risk in children under age 3 years. In order to build ASD interventions for infants and toddlers upon a foundation of evidence-based characteristics, the current paper presents the results of a systematic literature search and effect size analysis of efficacious interventions for infants and toddlers with other developmental disorders: those who were born prematurely, have developmental impairments, or are at high risk for developmental impairments due to the presence of a biological or familial condition associated with developmental impairments. A review of 32 controlled, high-quality experimental studies revealed that the most efficacious interventions routinely used a combination of four specific intervention procedures, including (1) parent involvement in intervention, including ongoing parent coaching that focused both on parental responsivity and sensitivity to child cues and on teaching families to provide the infant interventions, (2) individualization to each infant's developmental profile, (3) focusing on a broad rather than a narrow range of learning targets, and (4) temporal characteristics involving beginning as early as the risk is detected and providing greater intensity and duration of the intervention. These four characteristics of efficacious interventions for infants and toddlers with other developmental challenges likely represent a solid foundation from which researchers and clinicians can build efficacious interventions for infants and toddlers at risk for or affected by ASD.",0,0,
1101,Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice,"BACKGROUND: Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners - that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal. METHODS: Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews""; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation. RESULTS: CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention. CONCLUSIONS: The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner's role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners' work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence;"" and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners' clinical behavior is underway.",0,0,
1102,Intervention for autistic spectrum disorders,"A comprehensive approach to the assessment of any child with autism must be matched specifically to each individual child and family. This premise holds for medical therapies and special education services as well as psychopharmacologic interventions. Behavioral, as opposed to pharmacologic, treatment is the hallmark of effective intervention for autism. Physicians involved in the care of children with autism need to become familiar with educational law and intervention recommendations. Goals should include improved functional verbal and nonverbal communication and social skills, increased engagement in developmentally appropriate activities, improved fine and gross motor skills, and the development of independent academic and organizations skills, as well as replacement of problem behaviors with developmentally appropriate behaviors.. Medicating children with autism is difficult, but is often necessary for chronic behavioral difficulties. In the absence of clear and present guidelines, we have attempted to use evidence and clinical experience to suggest an algorithm based on symptom clusters. Although children with autism may be responsive to medications at lower doses and more susceptible to side effects than other children, medical intervention can produce a significant improvement in the quality of life for the child and family. Careful thought leading to correct identification of target behaviors can appropriately direct better alternatives for medication. Although these approaches are costly and time-consuming endeavors, the expenditure of such efforts is the only available pathway to improve the potential outcomes for individuals with autism as well as decrease the lifetime societal costs for each individual.",0,0,
1103,Intervention mapping for the development of a strategy to implement the insurance medicine guidelines for depression,"BACKGROUND: This article describes the development of a strategy to implement the insurance medicine guidelines for depression. Use of the guidelines is intended to result in more transparent and uniform assessment of claimants with depressive symptoms. METHODS: The implementation strategy was developed using the Intervention Mapping (IM) method for alignment with insurance-medical practice. The ASE behavioural explanation model (Attitude, Social Influence and Self-Efficacy) was used as theoretical basis for the development work. A literature study of implementation strategies and interviews with insurance physicians were performed to develop instruments for use with the guideline. These instruments were designed to match the needs and the working circumstances of insurance physicians. Performance indicators to measure the quality of the assessment and the adherence to the guidelines were defined with input from insurance physicians. RESULTS: This study resulted in the development of a training course to teach insurance physicians how to apply the guidelines for depression, using the aforementioned instruments. The efficacy of this training course will be evaluated in a Randomized Controlled Trial. CONCLUSIONS: The use of IM made it possible to develop guideline support instruments tailored to insurance medical practice.",0,0,
1104,Interventions by Health Care Professionals Who Provide Routine Child Health Care to Reduce Tobacco Smoke Exposure in Children: A Review and Meta-analysis,"IMPORTANCE: Reducing child exposure to tobacco smoke is a public health priority. Guidelines recommend that health care professionals in child health settings should address tobacco smoke exposure (TSE) in children. OBJECTIVE: To determine the effectiveness of interventions delivered by health care professionals who provide routine child health care in reducing TSE in children. DATA SOURCES: A secondary analysis of 57 trials included in a 2014 Cochrane review and a subsequent extended search was performed. Controlled trials (published through June 2015) of interventions that focused on reducing child TSE, with no restrictions placed on who delivered the interventions, were identified. Secondary data extraction was performed in August 2015. STUDY SELECTION: Controlled trials of routine child health care delivered by health care professionals (physicians, nurses, medical assistants, health educators, and dieticians) that addressed the outcomes of interest (TSE reduction in children and parental smoking behaviors) were eligible for inclusion in this review and meta-analysis. DATA EXTRACTION AND SYNTHESIS: Study details and quality characteristics were independently extracted by 2 authors. If outcome measures were sufficiently similar, meta-analysis was performed using the random-effects model by DerSimonian and Laird. Otherwise, the results were described narratively. MAIN OUTCOMES AND MEASURES: The primary outcome measure was reduction in child TSE. Secondary outcomes of interest were parental smoking cessation, parental smoking reduction, and maternal postpartum smoking relapse prevention. RESULTS: Sixteen studies met the selection criteria. Narrative analysis of the 6 trials that measured child TSE indicated no intervention effects relative to comparison groups. Similarly, meta-analysis of 9 trials that measured parental smoking cessation demonstrated no overall intervention effect (n = 6399) (risk ratio 1.05""; 95% CI, 0.74-1.50; P = .78). Meta-analysis of the 3 trials that measured maternal postpartum smoking relapse prevention demonstrated a significant overall intervention effect (n = 1293) (risk ratio 1.53; 95% CI, 1.10-2.14;"" P = .01). High levels of study heterogeneity likely resulted from variability in outcome measures, length of follow up, intervention strategies, and unknown intervention fidelity. CONCLUSIONS AND RELEVANCE: Interventions delivered by health care professionals who provide routine child health care may be effective in preventing maternal smoking relapse. Further research is required to improve the effectiveness of such interventions in reducing child TSE and increasing parental smoking cessation. The findings of this meta-analysis have policy and practice implications relating to interventions by routine pediatric health care professionals that aim to reduce child exposure to tobacco smoke.",0,0,
1105,Interventions for adolescent depression in primary care,"BACKGROUND: Depression in adolescents is underrecognized and undertreated despite its poor long-term outcomes, including risk for suicide. Primary care settings may be critical venues for the identification of depression, but there is little information about the usefulness of primary care interventions. OBJECTIVE: We sought to examine the evidence for the treatment of depression in primary care settings, focusing on evidence concerning psychosocial, educational, and/or supportive intervention strategies. METHODS: Available data on brief psychosocial treatments for adolescent depression in primary settings were reviewed. Given the paucity of direct studies, we also drew on related literature to summarize available evidence whether brief, psychosocial support from a member of the primary care team, with or without medication, might improve depression outcomes. RESULTS: We identified 37 studies relevant to treating adolescent depression in primary care settings. Only 4 studies directly examined the impact of primary care-delivered psychosocial interventions for adolescent depression, but they suggest that such interventions can be effective. Indirect evidence from other psychosocial/behavioral interventions, including anticipatory guidance and efforts to enhance treatment adherence, and adult depression studies also show benefits of primary care-delivered interventions as well as the impact of provider training to enhance psychosocial skills. CONCLUSIONS: There is potential for successful treatment of adolescent depression in primary care, in view of evidence that brief, psychosocial support, with or without medication, has been shown to improve a range of outcomes, including adolescent depression itself. Given the great public health problem posed by adolescent depression, the likelihood that most depressed adolescents will not receive specialty services, and new guidelines for managing adolescent depression in primary care, clinicians may usefully consider initiation of supportive interventions in their primary care practices.",0,0,
1106,Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism,"BACKGROUND: Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous randomized controlled trials (RCTs) show that using thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective and cost-effective. Despite this, prophylactic therapies for VTE are underutilized. System-wide interventions may be more effective to improve the use of VTE prophylaxis than relying on individual providers' prescribing behaviors. OBJECTIVES: To assess the effects of interventions designed to increase the implementation of thromboprophylaxis in hospitalized adult medical and surgical patients at risk for venous thromboembolism (VTE), assessed in terms of: 1. Increase in the proportion of patients who receive prophylaxis and appropriate prophylaxis 2. Reduction in risk of symptomatic VTE3. Reduction in risk of asymptomatic VTE4. Safety of the intervention. SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Group's Specialised Register (last searched July 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) 2010, Issue 3. We searched the PubMed, EMBASE, and SCOPUS databases (19 April 2010) as well as the reference lists of relevant review articles. SELECTION CRITERIA: We included all studies whose interventions aimed to increase the use of prophylaxis and/or appropriate prophylaxis, decrease the proportion of symptomatic VTE, or decrease the proportion of asymptomatic VTE in hospitalized adult patients. We excluded studies that simply distributed published guidelines and studies whose interventions were not clearly described. DATA COLLECTION AND ANALYSIS: We collected the following outcomes: the proportion of patients who received prophylaxis (RP), the proportion of patients who received appropriate prophylaxis (RAP) (primary outcomes), and the occurrence of symptomatic VTE, asymptomatic VTE, and safety outcomes such as bleeding. We categorized interventions into education, alerts, and multifaceted interventions. We meta-analyzed RCTs and non-randomized studies (NRS) separately by random effects meta-analysis, and assessed heterogeneity using the I(2)statistic and subgroup analyses. Before analysis, we decided that results would be pooled if three or more studies were available for a particular intervention. We assessed publication bias using funnel plots and cumulative meta-analysis. MAIN RESULTS: We included a total of 55 studies. One of these reported data in patient-days and could not be quantitatively analyzed with the others. The 54 remaining studies (8 RCTs and 46 NRS) eligible for inclusion in our quantitative synthesis enrolled a total of 78,343 participants. Among RCTs, there were sufficient data to pool results for one primary outcome (received prophylaxis) for the 'alert' intervention. Alerts, such as computerized reminders or stickers on patients' charts, were associated with a risk difference (RD) of 13%, signifying an increase in the proportion of patients who received prophylaxis (95% confidence interval (CI) 1% to 25%). Among NRS, there were sufficient data to pool both primary outcomes for each intervention type. Pooled risk differences for received prophylaxis ranged from 8% to 17%, and for received appropriate prophylaxis ranged from 11% to 19%. Education and alerts were associated with statistically significant increases in prescription of appropriate prophylaxis, and multifaceted interventions were associated with statistically significant increases in prescription of any prophylaxis and appropriate prophylaxis. Multifaceted interventions had the largest pooled effects. I(2) results showed substantial statistical heterogeneity which was in part explained by patient types and type of hospital. A subgroup analysis showed that multifaceted interventions which included an alert may be more effective at improving rates of prophylaxis and appropriate prophylaxis than those without an alert. Results for VTE and safety outcomes did not show substantial benefits or harms, although most studies were underpowered to assess these outcomes. AUTHORS' CONCLUSIONS: We reviewed a large number of studies which implemented a variety of system-wide strategies aimed to improve thromboprophylaxis rates in many settings and patient populations. We found statistically significant improvements in prescription of prophylaxis associated with alerts (RCTs) and multifaceted interventions (RCTs and NRS), and improvements in prescription of appropriate prophylaxis in NRS with the use of education, alerts and multifaceted interventions. Multifaceted interventions with an alert component may be the most effective. Demonstrated sources of heterogeneity included patient types and type of hospital. The results of our review will help physicians, nurses, pharmacists, hospital administrators and policy makers make practical decisions about local adoption of specific system-wide measures to improve prevention of VTE, an important public health issue. We did not find a significant benefit for VTE outcomes"";"" however, earlier RCTs assessing the efficacy of thromboprophylaxis which were powered to address these outcomes have demonstrated the benefit of prophylactic therapies and a favourable balance of benefits versus the increased risk of bleeding events.",0,1,
1107,Interventions for improving patients' trust in doctors and groups of doctors,"BACKGROUND: Trust is a fundamental component of the patient-doctor relationship and is associated with increased satisfaction, adherence to treatment, and continuity of care. It is not clear if there are interventions known to be effective in enhancing patient trust in doctors. OBJECTIVES: To assess the effects of interventions intended to improve a patient's trust in the doctor or a group of doctors. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1 2003), MEDLINE(1966 to week 4 2003), EMBASE (1985 to July 2003), Health Star (1975 to July 2004), PsycINFO (1967 to July 2004), CINAHL (1982 to June 2003), LILACS (1982 to April 2003), African Trials Register (1948 to April 2003), African Health Anthology (1924 to April 2003), Dissertation Abstracts International (1861 to April 2003) and the bibliographies of studies assessed for inclusion. We also searched the bibliographies of studies assessed for inclusion, and contacted researchers active in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions (informative, educational, behavioural, organisational) directed at doctors or patients (or carers) where trust was assessed as a primary or secondary outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: Three RCTs, all published in English and set in North American primary care, and involving 1916 participants, were included. There was considerable heterogeneity in terms of aims, format and content of the interventions. One trial of a training intervention for family doctors to improve communication behaviours (20 doctors assessed by 414 patients) showed no effect on trust. The other two interventions were patient focussed. One explored the impact on trust of disclosing physician incentives to patients (n= 918) in a Health Maintenance Organisation (HMO) and showed no diminution in trust. Another investigated the effect of induction visits on new HMO members' (n=564) trust in their HMO doctors. Trust in doctors rose compared with control following the visit for one type of induction visit, the group visit (Trust out of 10 (standard deviation (SD)) was 8.8 (1.5) and 7.1 (2.2), difference 1.7, (95% confidence interval 1.22 to 2.18)). However there were many drop-outs and analysis was not on intention to treat. AUTHORS' CONCLUSIONS: Overall there remains insufficient evidence to conclude that any intervention may increase or decrease trust in doctors. Further trials are required to explore the impact of policy changes, guidelines and specific doctors' training on patients' trust.",0,0,
1108,Interventions for migraine prophylaxis: protocol of an umbrella systematic review and network meta-analysis,"INTRODUCTION: Multiple interventions are effective for migraine prophylaxis. However, the comparative effectiveness of these interventions is still not clear. Therefore, the aim of this study is to summarise the direct and indirect evidence for pharmacological and non-pharmacological interventions to prevent migraine attack. METHODS AND ANALYSIS: We will perform an umbrella systematic review to identify eligible randomised controlled trials (RCTs) for the recommended interventions for migraine prophylaxis according to the guidelines. A comprehensive literature search will be conducted in MEDLINE, EMBASE and the Cochrane library for systematic reviews, which will be screened for RCTs. We will describe the general information of the RCTs for participants, interventions, outcome measurements, comparisons and the primary findings. Additionally, a network meta-analysis will be conducted to determine the comparative effectiveness of the treatments with a random-effects model. The absolute and relative effectiveness of the treatments will be provided. The heterogeneity and inconsistency between trials will be assessed by the I(2) statistical test and Cochrane's Q test. Risk of bias will be assessed and the overall strength of the evidence will be summarised. DISCUSSION: The result of this network meta-analysis will provide direct and indirect evidence of treatments for migraine prophylaxis, and it may provide a ranking of the treatments for patients and clinicians to help them select the best option. TRIAL REGISTRATION NUMBER: PROSPERO CRD42015015297.",0,0,
1109,Interventions that change clinician behaviour: mapping the literature,,0,1,
1110,Interventions to change maternity healthcare professionals' behaviours to promote weight-related support for obese pregnant women: a systematic review,"BACKGROUND: There has been a rapid increase in the publication of guidelines for managing obesity and weight gain during pregnancy over the past five years. Healthcare professionals have identified multiple barriers to this area of practice, including the need to improve their communication skills, beliefs that pregnant women will have negative reactions to weight-related discussions, and a lack of weight management knowledge. This systematic review aimed to identify: the effectiveness of interventions in changing healthcare professionals' practice relating to maternal obesity or weight management during pregnancy"";"" and which behaviour change techniques and modes of intervention delivery have been used in interventions to date. FINDINGS: The search strategy included searching electronic databases, trial registers, and citation searching. Inclusion criteria were intervention studies targeted towards changing healthcare professionals' practice in relation to maternal obesity or weight management. The searches identified 3,608 studies. However, no eligible completed studies were identified. One registered Canadian randomised controlled trial was identified. The trial includes a training intervention for family physicians with the aim of supporting adherence to gestational weight gain guidelines. The trial had not yet commenced therefore no effectiveness data were available. CONCLUSIONS: The current focus of maternal obesity and weight management research is targeted towards changing pregnant women's behaviours. These interventions do not address the multiple healthcare professionals' barriers to maternal obesity and weight management practice. Further research is required to identify the most effective approaches to support healthcare professionals to implement maternal obesity and weight management guidelines into practice.",0,0,
1111,Interventions to improve follow-up of abnormal findings in cancer screening,"The potential reduction in morbidity and mortality through cancer screening cannot be realized without receipt of appropriate follow‐up care for abnormalities identified via screening. In this paper, the authors critically examine the existing literature on correlates of receipt of appropriate follow‐up care for screen‐detected abnormalities, as well as the literature on interventions designed to increase rates of receipt of follow‐up care. Lessons learned describe what is known and not known about factors that are related to or predict receipt of follow‐up care. Similarly, effective interventions to increase follow‐up are described and gaps identified. A conceptual model is developed that categorizes the health care system in the United States as comprising four levels: policy, practice, provider, and patient. Some patient‐level factors that influence follow‐up receipt are identified, but the lack of data severely limit the understanding of provider, practice, and policy‐level correlates. The majority of intervention studies to increase follow‐up receipt have focused on patient‐level factors and have targeted follow‐up of abnormal Papanicolaou smears. Insufficient information is available regarding the effectiveness of provider, practice, or policy‐level interventions. Standard definitions of what constitutes appropriate follow‐up are lacking, which severely limit comparability of findings across studies. The validity of various methods of obtaining outcome data has not been clearly established. More research is needed on interventions targeting provider, system, and policy‐level factors, particularly interventions focusing on follow‐up of colorectal and breast abnormalities. Standardization of definitions and measures is needed to facilitate comparisons across studies. Cancer 2004. Published 2004 by the American Cancer Society.",0,1,
1112,Interventions to improve hospital patient satisfaction with healthcare providers and systems: a systematic review,"Background Many hospital systems seek to improve patient satisfaction as assessed by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. A systematic review of the current experimental evidence could inform these efforts and does not yet exist.  Methods We conducted a systematic review of the literature by searching electronic databases, including MEDLINE and EMBASE, the six databases of the Cochrane Library and grey literature databases. We included studies involving hospital patients with interventions targeting at least 1 of the 11 HCAHPS domains, and that met our quality filter score on the 27-item Downs and Black coding scale. We calculated post hoc power when appropriate.  Results A total of 59 studies met inclusion criteria, out of these 44 did not meet the quality filter of 50% (average quality rating 27.8%±10.9%). Of the 15 studies that met the quality filter (average quality rating 67.3%±10.7%), 8 targeted the Communication with Doctors HCAHPS domain, 6 targeted Overall Hospital Rating, 5 targeted Communication with Nurses, 5 targeted Pain Management, 5 targeted Communication about Medicines, 5 targeted Recommend the Hospital, 3 targeted Quietness of the Hospital Environment, 3 targeted Cleanliness of the Hospital Environment and 3 targeted Discharge Information. Significant HCAHPS improvements were reported by eight interventions, but their generalisability may be limited by narrowly focused patient populations, heterogeneity of approach and other methodological concerns.  Conclusions Although there are a few studies that show some improvement in HCAHPS score through various interventions, we conclude that more rigorous research is needed to identify effective and generalisable interventions to improve patient satisfaction.",0,0,
1113,Interventions to increase the use of electronic health information by healthcare practitioners to improve clinical practice and patient outcomes,"BACKGROUND: There is a large volume of health information available, and, if applied in clinical practice, may contribute to effective patient care. Despite an abundance of information, sub-optimal care is common. Many factors influence practitioners' use of health information, and format (electronic or other) may be one such factor. OBJECTIVES: To assess the effects of interventions aimed at improving or increasing healthcare practitioners' use of electronic health information (EHI) on professional practice and patient outcomes. SEARCH METHODS: We searched The Cochrane Library (Wiley), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and LISA (EBSCO) up to November 2013. We contacted researchers in the field and scanned reference lists of relevant articles. SELECTION CRITERIA: We included studies that evaluated the effects of interventions to improve or increase the use of EHI by healthcare practitioners on professional practice and patient outcomes. We defined EHI as information accessed on a computer. We defined 'use' as logging into EHI. We considered any healthcare practitioner involved in patient care. We included randomized, non-randomized, and cluster randomized controlled trials (RCTs, NRCTs, CRCTs), controlled clinical trials (CCTs), interrupted time series (ITS), and controlled before-and-after studies (CBAs).The comparisons were: electronic versus printed health information""; EHI on different electronic devices (e.g. desktop, laptop or tablet computers, etc.; cell / mobile phones); EHI via different user interfaces; EHI provided with or without an educational or training component;"" and EHI compared to no other type or source of information. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias for each study. We used GRADE to assess the quality of the included studies. We reassessed previously excluded studies following our decision to define logins to EHI as a measure of professional behavior. We reported results in natural units. When possible, we calculated and reported median effect size (odds ratio (OR), interquartile ranges (IQR)). Due to high heterogeneity across studies, meta-analysis was not feasible. MAIN RESULTS: We included two RCTs and four CRCTs involving 352 physicians, 48 residents, and 135 allied health practitioners. Overall risk of bias was low as was quality of the evidence. One comparison was supported by three studies and three comparisons were supported by single studies, but outcomes across the three studies were highly heterogeneous. We found no studies to support EHI versus no alternative. Given these factors, it was not possible to determine the relative effectiveness of interventions. All studies reported practitioner use of EHI, two reported on compliance with electronic practice guidelines, and none reported on patient outcomes.One trial (139 participants) measured guideline adherence for an electronic versus printed guideline, but reported no difference between groups (median OR 0.85, IQR 0.74 to 1.08). One small cross-over trial (10 participants) reported increased use of clinical guidelines when provided with a mobile versus stationary, desktop computer (mean use per shift: intervention group (IG) 3.6, standard deviation (SD) 1.7 vs. control group (CG) 2.0 (SD 1.9), P value = 0.033). One cross-over trial (203 participants) reported that using a customized versus a generic interface had little impact on practitioners' use of EHI (mean difference in adjusted end-of-study rate: 0.77 logins/month/user, 95% confidence interval (CI) CI 0.43 to 1.11). Three trials included education or training and reported increased use of EHI by practitioners following training. AUTHORS' CONCLUSIONS: This review provided no evidence that the use of EHI translates into improved clinical practice or patient outcomes, though it does suggest that when practitioners are provided with EHI and education or training, the use of EHI increases. We have defined use as the activity of logging into an EHI resource, but based on our findings use does not automatically translate to the application of EHI in practice. While using EHI may be an important component of evidence-based medicine, alone it is insufficient to improve patient care or clinical practices. For EHI to be applied in patient care, it will be necessary to understand why practitioners' are reluctant to apply EHI when treating people, and to determine the most effective way(s) to reduce this reluctance.",0,1,
1114,Interventions to modify health care provider adherence to asthma guidelines: a systematic review,"BACKGROUND AND OBJECTIVE: Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers' adherence to asthma guidelines on health care process and clinical outcomes. METHODS: Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence. RESULTS: Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance. CONCLUSIONS: Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes.",0,1,
1115,Interventions to promote the evidence-based care of children with ADHD in primary-care settings,"Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been published by the American Academy of Pediatrics that provides best-practice diagnostic procedures for primary-care physicians. These recommendations emphasize the importance of using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as the basis for making an ADHD diagnosis and conducting systematic follow-up, including the collection of parent and teacher ratings scales to quantitatively assess response to treatment. Although these recommendations have been widely disseminated and their adoption actively promoted, guideline adherence, in general, is known to be poor. Two types of intervention models, ancillary service and office systems modification, have been proposed to promote adoption of evidence-based ADHD practice in primary-care settings. The present article reviews the efficacy of these intervention models, and discusses the cost and sustainability of each model as related to feasibility of intervention dissemination.",0,1,
1116,Intrinsic conflicts of interest in clinical research: a need for disclosure,"Protection of human subjects from investigators' conflicts of interest is critical to the integrity of clinical investigation. Personal financial conflicts of interest are addressed by university policies, professional society guidelines, public standards, and government regulation, but ""intrinsic conflict of interest""--conflicts of interest inherent in all clinical research--have received relatively less attention. Such conflicts arise in all clinical research endeavors as a result of the tension among professionals' responsibilities to their research and to their patients and both academic and financial incentives. These conflicts should be disclosed to research subjects and managed as assiduously as are financial conflicts of interest.",0,0,
1117,Introduction: Understanding and influencing multilevel factors across the cancer care continuum,"Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.",0,0,
1118,Investigating breast symptoms in primary care: enhancing concordance with current best advice,"The purpose of this study was to determine whether a targeted intervention could improve primary care practitioners' concordance with guidelines regarding management of women with breast symptoms. One hundred and twelve practitioners from randomly selected areas around Australia prospectively audited their investigations for each woman with a new breast symptom over two 12-week periods, before and five months after the release of national guidelines. Between the two audits, doctors received feedback on practice in relation to peers and attended one seminar in their local areas led by specialists from the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons. For five recommendations, there were statistically significant improvements at the second audit in line with standard Investigation of a New Breast Symptom (INBS) guidelines. All these were for investigations of breast lumps. At first audit, there were seven recommendations where practitioners were already managing more than 80% of women in accordance with the INBS, and where there were no statistically significant increases in concordance at second audit. Another six recommendations had lower concordance with the recommendations prior to the release of the guidelines and did not significantly improve at second audit. These tended to be for less-common presentations and where clinical findings were not consistent with other test results. We concluded that a targeted intervention improved physician concordance with current best advice for investigating women who present with new breast symptoms in a primary care setting. Further educational programs are needed to improve investigations for rarer symptoms, and to enhance physicians' confidence in the results of their clinical examinations.",0,0,
1119,Is it possible to predict improved diabetes outcomes following diabetes self-management education: a mixed-methods longitudinal design,"OBJECTIVE: To predict the diabetes-related outcomes of people undertaking a type 2 Diabetes Self-Management Education (DSME) programme from their baseline data. DESIGN: A mixed-methods longitudinal experimental study. 6 practice nurses and 2 clinical academics undertook blind assessments of all baseline and process data to predict clinical, behavioural and psychological outcomes at 6 months post-DSME programme. SETTING: Primary care. PARTICIPANTS: -31 people with type 2 diabetes who had not previously undertaken DSME. INTERVENTION: All participants undertook the Diabetes Manual 1:1 self-directed learning 12-week DSME programme supported by practice nurses trained as Diabetes Manual facilitators. OUTCOME VARIABLES: Glycated haemoglobin (HbA1c), diabetes knowledge, physical activity, waist circumference, self-efficacy, diabetes distress, anxiety, depression, demographics, change talk and treatment satisfaction. These variables were chosen because they are known to influence self-management behaviour or to have been influenced by a DSME programme in empirical evidence. RESULTS: Baseline and 6-month follow-up data were available for 27 participants of which 13 (48%) were male, 22 (82%) white British, mean age 59 years and mean duration of type 2 diabetes 9.1 years. Significant reductions were found in HbA1c t(26)=2.35, p=0.03, and diabetes distress t(26)=2.30, p=0.03, and a significant increase in knowledge t(26)=-2.06, p=0.05 between baseline and 6 months. No significant changes were found in waist circumference, physical activity, anxiety, depression or self-efficacy. Accuracy of predictions varied little between clinical academics and practice nurses but greatly between outcome (0-100%). The median and mode accuracy of predicted outcome was 66.67%. Accuracy of prediction for the key outcome of HbA1c was 44.44%. Diabetes distress had the highest prediction accuracy (81.48%). CONCLUSIONS: Clinicians in this small study were unable to identify individuals likely to achieve improvement in outcomes from DSME. DSME should be promoted to all patients with diabetes according to guidelines.",0,0,
1120,"Is provider type associated with cancer screening and prevention: advanced practice registered nurses, physician assistants, and physicians","BACKGROUND: Physician recommendations for cancer screening and prevention are associated with patient compliance. However, time constraints may limit physicians' ability to provide all recommended preventive services, especially with increasing demand from the Affordable Care Act in the United States. Team-based practice that includes advanced practice registered nurses and physician assistants (APRN/PA) may help meet this demand. This study investigates the relationship between an APRN/PA visit and receipt of guideline-consistent cancer screening and prevention recommendations. METHODS: Data from the 2010 National Health Interview Survey were analyzed with multivariate logistic regression to assess provider type seen and receipt of guideline-consistent cancer screening and prevention recommendations (n = 26,716). RESULTS: In adjusted analyses, women who saw a primary care physician (PCP) and an APRN/PA or a PCP without an APRN/PA in the past 12 months were more likely to be compliant with cervical and breast cancer screening guidelines than women who did not see a PCP or APRN/PA (all p < 0.0001 for provider type). Women and men who saw a PCP and an APRN/PA or a PCP without an APRN/PA were also more likely to receive guideline consistent colorectal cancer screening and advice to quit smoking and participate in physical activity than women and men who did not see a PCP or APRN/PA (all p < 0.01 for provider type). CONCLUSIONS: Seeing a PCP alone, or in conjunction with an APRN/PA is associated with patient receipt of guideline-consistent cancer prevention and screening recommendations. Integrating APRN/PA into primary care may assist with the delivery of cancer prevention and screening services. More intervention research efforts are needed to explore how APRN/PA will be best able to increase cancer screening, HPV vaccination, and receipt of behavioral counseling, especially during this era of healthcare reform.",0,0,
1121,Is there a gap between recommended and 'real world' practice in the management of depression in young people? A medical file audit of practice,"BACKGROUND: Literature has shown that dissemination of guidelines alone is insufficient to ensure that guideline recommendations are incorporated into every day clinical practice. METHODS: We aimed to investigate the gaps between guideline recommendations and clinical practice in the management of young people with depression by undertaking an audit of medical files in a catchment area public mental health service for 15 to 25 year olds in Melbourne, Australia. RESULTS: The results showed that the assessment and recording of depression severity to ensure appropriate treatment planning was not systematic nor consistent"";"" that the majority of young people (74.5%) were prescribed an antidepressant before an adequate trial of psychotherapy was undertaken and that less than 50% were monitored for depression symptom improvement and antidepressant treatment emergent suicide related behaviours (35% and 30% respectively). Encouragingly 92% of first line prescriptions for those aged 18 years or under who were previously antidepressant-naive was for fluoxetine as recommended. CONCLUSIONS: This research has highlighted the need for targeted strategies to ensure effective implementation. These strategies might include practice system tools that allow for systematic monitoring of depression symptoms and adverse side effects, particularly suicide related behaviours. Additionally, youth specific psychotherapy that incorporates the most effective components for this age group, delivered in a youth friendly way would likely aid effective implementation of guideline recommendations for engagement in an adequate trial of psychotherapy before medication is initiated.",0,0,
1122,Is untargeted outreach visiting in primary care effective? A pragmatic randomized controlled trial,"BACKGROUND: There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. Outreach visits may improve prescribing behaviour. METHODS: Within a before-and-after pragmatic randomized controlled trial, involving all general practices in one health district, routine methods were used to distribute guidelines for management of Helicobacter pylori eradication. Intervention practices were offered a visit and the conduct of an audit by a pharmacist trained in the techniques of outreach visiting. The intervention was evaluated using level three Prescribing Analysis and Cost (PACT) data for metronidazole and omeprazole for the two 12 month periods around the introduction of the guidelines. RESULTS: Of the 38 intervention practices 19 accepted an outreach visit and three accepted the offer of an audit. There was a significant increase in omeprazole use during the study of 0.24 [95 per cent confidence interval (CI) +0.19 to +0.29] dose units per year but no effect from the offer [-0.02 (95 per cent CI -0.12 to +0.08) dose units] or acceptance of a visit [-0.03 (95 per cent CI -0.15 to +0.08) dose units]. The results for metronidazole were similar, with an increase in use of 0.028 (95 per cent CI +0.018 to +0.038) dose units per year. The effect of the intervention was a non-significant change in prescribing of -0.005 (95 per cent CI -0.025 to +0.015) dose units. Accepting a visit had little effect on prescribing: a change of 0.003 (95 per cent CI -0.021 to +0.027) dose units. CONCLUSIONS: The routine use of untargeted outreach visiting is probably not a worthwhile strategy.",0,0,
1123,Issues related to the protection of human research participants,"Making ethical decisions related to the protection of human research participants is often complex and fraught with uncertainty and conflict. Awareness of the basic principles outlined in the Belmont Report as well as in federal regulations and guidelines can provide a useful framework for such decisions, although the ultimate responsibility for ensuring ethical research practices rests with the individual investigator. Ongoing dialogue and discussion about these ethical issues will provide a basis for strengthening nursing research and practice while ensuring the maximum protection for research participants who make possible the advancement of nursing science.",0,0,
1124,It’s not all about me motivating hand hygiene among health care professionals by focusing on patients.,"Diseases often spread in hospitals because health care professionals fail to wash their hands. Research suggests that to increase health and safety behaviors, it is important to highlight the personal consequences for the actor. However, because people (and health care professionals in particular) tend to be overconfident about personal immunity, the most effective messages about hand hygiene may be those that highlight its consequences for other people. In two field experiments in a hospital, we compared the effectiveness of signs about hand hygiene that emphasized personal safety (“Hand hygiene prevents you from catching diseases”) or patient safety (“Hand hygiene prevents patients from catching diseases”). We assessed hand hygiene by measuring the amount of soap and hand-sanitizing gel used from dispensers (Experiment 1) and conducting covert, independent observations of health care professionals’ hand-hygiene behaviors (Experiment 2). Results showed that changing a single word in messages motivated meaningful changes in behavior: The hand hygiene of health care professionals increased significantly when they were reminded of the implications for patients but not when they were reminded of the implications for themselves.",1,1,
1125,Jarvis v. Levine,"KIE: Minnesota's Court of Appeals ruled that an involuntarily committed mentally ill patient has the qualified constitutional right to refuse neuroleptic treatment in a nonemergency situation, subject to the exercise of professional judgment by state hospital physicians according to mandatory guidelines. It affirmed the trial court's ruling that patient Jarvis was not entitled to postmedication review on the grounds that the due process requirements for the administration of neuroleptic medication were satisfied by compliance with the involuntary medication policy set forth by Minnesota's Department of Public Welfare.",0,0,
1126,JNC-7 guidelines: are they still relevant?,"The recommendations of the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), published in 2003, are largely relevant today. Lowering blood pressure (BP) to goal in hypertensive patients is of primary importance in reducing cardiovascular risk. Antihypertensive drugs vary in their efficacy to lower BP and can have BP-independent effects on cardiovascular events, as seen especially with regard to preventing heart failure and stroke. Thiazide-type diuretics were recommended as the preferred initial drugs for treatment of hypertension in most patients, and this is still an appropriate recommendation. Several other classes were recommended as next in priority, but beta-blockers should now have a lesser role in the management of uncomplicated hypertension. Although a new JNC report would be reassuring to practitioners and should include some changes since JNC 7, I consider most of the recommendations to still be relevant today.",0,0,
1127,JOURNAL CLUB: Predictors of Provider Response to Clinical Decision Support: Lessons Learned From the Medicare Imaging Demonstration,"OBJECTIVE: The efficacy of imaging clinical decision support (CDS) varies. Our objective was to identify CDS factors contributing to imaging order cancellation or modification. SUBJECTS AND METHODS: This pre-post study was performed across four institutions participating in the Medicare Imaging Demonstration. The intervention was CDS at order entry for selected outpatient imaging procedures. On the basis of the information entered, computerized alerts indicated to providers whether orders were not covered by guidelines, appropriate, of uncertain appropriateness, or inappropriate according to professional society guidelines. Ordering providers could override or accept CDS. We considered actionable alerts to be those that could generate an immediate order behavior change in the ordering physician (i.e., cancellation of inappropriate orders or modification of orders of uncertain appropriateness that had a recommended alternative). Chi-square and logistic regression identified predictors of order cancellation or modification after an alert. RESULTS: A total of 98,894 radiology orders were entered (83,114 after the intervention). Providers ignored 98.9%, modified 1.1%, and cancelled 0.03% of orders in response to alerts. Actionable alerts had a 10 fold higher rate of modification (8.1% vs 0.7%""; p < 0.0001) or cancellation (0.2% vs 0.02%; p < 0.0001) orders compared with nonactionable alerts. Orders from institutions with preexisting imaging CDS had a sevenfold lower rate of cancellation or modification than was seen at sites with newly implemented CDS (1.4% vs 0.2%; p < 0.0001). In multivariate analysis, actionable alerts were 12 times more likely to result in order cancellation or modification. Orders at sites with preexisting CDS were 7.7 times less likely to be cancelled or modified (p < 0.0001). CONCLUSION: Using results from the Medicare Imaging Demonstration project, we identified potential factors that were associated with CDS effect on provider imaging ordering;"" these findings may have implications for future design of such computerized systems.",1,1,
1128,Judgments of the rule-related behaviour of health care professionals: An experimental study,"OBJECTIVES: To explore the judgments of rule-related behaviour by health care professionals and the general public in the UK, against a background in which clinical guidelines and protocols are proliferating. DESIGN: A questionnaire survey was used in which short scenarios describing medical practice were presented to a sample of health care professionals and members of the general public. METHODS: The health care sample consisted of 315 nurses, doctors and midwives from three English National Health Service (NHS) Trusts who volunteered to take part in the study. A stratified sample of members of the general public (N = 350) was recruited via a market research organization. Three types of behaviour (compliance with a protocol, violation of a protocol, and improvization, where no protocol exists) and three types of outcome for the patient (good, bad, poor) were manipulated within nine scenarios. Respondents were asked to make judgments about (1) the inappropriateness of behaviour (2) likelihood that they would take further action and (3) responsibility for the outcome. RESULTS: Findings suggest that the process of care has a greater effect on judgments of the behaviour of health care professionals than does the outcome of that behaviour. This was equally true of the professional and public samples. CONCLUSIONS: The study has both theoretical and practical implications. First, information about a behaviour's relationship to existing rules has a stronger influence than the consequence of the behaviour on attributions of responsibility. Secondly, using clinical protocols as a way of managing risk in the NHS may be counterproductive unless full compliance is achieved.",0,0,
1129,Judicial Council offers new research guidelines,,0,0,
1130,Judicious use of antibiotics for common pediatric respiratory infections,"BACKGROUND: Antibiotic resistance among common respiratory infection-producing bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis has become a major global public health problem. The use of antibiotics, whether or not medically justified for a particular illness, contributes to the development of resistant bacteria. To help to contain the proliferation of drug-resistant bacteria, members of the CDC and the American Academy of Pediatrics (AAP) recently published principles for the judicious use of antibiotics in common pediatric respiratory infections including the common cold, otitis media, sinusitis and tonsillopharyngitis. This article reviews the CDC/AAP principles for management of these illnesses and describes results of clinical practice studies in which efforts to improve the judicious use of antibiotics were undertaken. CONCLUSIONS: The success of the CDC/AAP principles in containing the increase in antimicrobial resistance depends upon their being practiced. Results of clinical practice studies indicate that judicious use of antimicrobial therapy in pediatric respiratory infections can be realized through education and persistence. More widespread educational and behavior modification efforts are necessary to reduce unnecessary prescription of antibiotics and to curtail the still burgeoning problem of bacterial resistance.",0,0,
1131,Juniors' hours of work,,0,0,
1132,"Just-in-time evidence-based e-mail ""reminders"" in home health care: impact on patient outcomes","OBJECTIVE: To assess the impact and cost-effectiveness of two information-based provider reminder interventions designed to improve self-care management and outcomes of heart failure (HF) patients. DATA SOURCES/STUDY SETTING: Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF. STUDY DESIGN: Patients were treated by nurses randomly assigned to usual care or one of two intervention groups. The basic intervention was an e-mail to the patient's nurse highlighting six HF-specific clinical recommendations. The augmented intervention supplemented the initial nurse reminder with additional clinician and patient resources. DATA COLLECTION: Patient interviews were conducted 45 days post admission to measure self-management behaviors, HF-specific outcomes (Kansas City Cardiomyopathy Questionnaire-KCCQ), health-related quality of life (EuroQoL), and service use. PRINCIPAL FINDINGS: Both interventions improved the mean KCCQ summary score (15.3 and 12.9 percent, respectively) relative to usual care (p< or =.05). The basic intervention also yielded a higher EuroQoL score relative to usual care (p< or =.05). In addition, the interventions had a positive impact on medication knowledge, diet, and weight monitoring. The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes. CONCLUSIONS: This study demonstrates the positive impact of targeting evidence-based computer reminders to home health nurses to improve patient self-care behaviors, knowledge, and clinical outcomes. It also advances the field's limited understanding of the cost-effectiveness of selected strategies for translating research into practice.",0,0,1133
1133,Just-in-time evidence-based e-mail “reminders” in home health care: impact on patient outcomes.,"Objective. To assess the impact and cost-effectiveness of two information-based provider reminder interventions designed to improve self-care management and outcomes of heart failure (HF) patients.  Data Sources/Study Setting. Interview and agency administrative data on 628 home care patients with a primary diagnosis of HF.  Study Design. Patients were treated by nurses randomly assigned to usual care or one of two intervention groups. The basic intervention was an e-mail to the patient's nurse highlighting six HF-specific clinical recommendations. The augmented intervention supplemented the initial nurse reminder with additional clinician and patient resources.  Data Collection. Patient interviews were conducted 45 days post admission to measure self-management behaviors, HF-specific outcomes (Kansas City Cardiomyopathy Questionnaire-KCCQ), health-related quality of life (EuroQoL), and service use.  Principal Findings. Both interventions improved the mean KCCQ summary score (15.3 and 12.9 percent, respectively) relative to usual care (p=.05). The basic intervention also yielded a higher EuroQoL score relative to usual care (p=.05). In addition, the interventions had a positive impact on medication knowledge, diet, and weight monitoring. The basic intervention was more cost-effective than the augmented intervention in improving clinical outcomes.  Conclusions. This study demonstrates the positive impact of targeting evidence-based computer reminders to home health nurses to improve patient self-care behaviors, knowledge, and clinical outcomes. It also advances the field's limited understanding of the cost-effectiveness of selected strategies for translating research into practice.",0,1,
1134,"Just-in-time evidence-based e-mail “reminders” in home health care: impact on""nurse practices.","Objective. To test the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses caring for heart failure (HF) patients.  Data Sources/Study Setting. Information on nurse practices was abstracted from the clinical records of patients admitted between June 2000 and November 2001 to the care of 354 study nurses at a large, urban, nonprofit home care agency.  Study Design. The study employed a randomized design with nurses assigned to usual care or one of two intervention groups upon identification of an eligible patient. The basic intervention was a one-time e-mail reminder highlighting six HF-specific clinical recommendations. The augmented intervention consisted of the initial e-mail reminder supplemented by provider prompts, patient education material, and clinical nurse specialist outreach.  Data Collection. At each home health visit provided by a study nurse to an eligible HF patient during the 45-day follow-up period, a structured chart abstraction tool was used to collect information on whether the nurse provided the care practices highlighted in the e-mail reminder.  Principal Findings. Both the basic and the augmented interventions greatly increased the practice of evidence-based care, according to patient records, in the areas of patient assessment and instructions about HF disease management. While not all results were statistically significant at conventional levels, intervention effects were positive in virtually all cases and effect magnitudes frequently were large.  Conclusions. The results of this randomized trial strongly support the efficacy of just-in-time evidence-based reminders as a means of changing clinical practice among home health nurses who are geographically dispersed and spend much of their time in the field.",1,1,
1135,Kids Safe and Smokefree (KiSS): a randomized controlled trial of a multilevel intervention to reduce secondhand tobacco smoke exposure in children,"BACKGROUND: Secondhand smoke exposure (SHSe) harms children's health, yet effective interventions to reduce child SHSe in the home and car have proven difficult to operationalize in pediatric practice. A multilevel intervention combining pediatric healthcare providers' advice with behavioral counseling and navigation to pharmacological cessation aids may improve SHSe control in pediatric populations. METHODS/DESIGN: This trial uses a randomized, two-group design with three measurement periods: pre-intervention, end of treatment and 12-month follow-up. Smoking parents of children < 11-years-old are recruited from pediatric clinics. The clinic-level intervention includes integrating tobacco intervention guideline prompts into electronic health record screens. The prompts guide providers to ask all parents about child SHSe, advise about SHSe harms, and refer smokers to cessation resources. After receiving clinic intervention, eligible parents are randomized to receive: (a) a 3-month telephone-based behavioral counseling intervention designed to promote reduction in child SHSe, parent smoking cessation, and navigation to access nicotine replacement therapy or cessation medication or (b) an attention control nutrition education intervention. Healthcare providers and assessors are blind to group assignment. Cotinine is used to bioverify child SHSe (primary outcome) and parent quit status. DISCUSSION: This study tests an innovative multilevel approach to reducing child SHSe. The approach is sustainable, because clinics can easily integrate the tobacco intervention prompts related to ""ask, advise, and refer"" guidelines into electronic health records and refer smokers to free evidence-based behavioral counseling interventions, such as state quitlines. TRIAL REGISTRATION: NCT01745393 (clinicaltrials.gov).",0,0,
1136,"Kindergarten readiness after prematurity: Integrating health, development, and behavioral functioning to optimize educational outcomes of vulnerable children","In the past 20 years, many advances (e.g., maternal steroids and surfactant) have changed the course of neonatal medicine. As a result, extremely preterm infants survive medical complications that were previously fatal. Once they are discharged from the neonatal intensive care unit, preterm infants may continue to experience a spectrum of medical and developmental challenges, and their families are faced with the potentially daunting task of nurturing a vulnerable child. Families may be referred to multiple systems of care, including primary care physicians, pediatric subspecialists, and early intervention services. The ultimate goal for preterm infants is to optimize their motor, communicative, social-emotional, and adaptive development as well as to promote their learning at home, at school, and in the community. As children transition to school, key indicators of their functional status include the amount of developmental, educational, habilitative, and behavioral supports they require to participate in learning activities with their peers. Success may be measured by whether preterm infants are ready for large-group learning with peers and the extent of supports required to make this important transition. The purpose of this review is to describe what is known about certain indicators of school readiness in preterm infants, including neurodevelopmental impairments, social-emotional skills, and social factors. We conclude with guidelines for using this transition as an important indicator of developmental trajectories that may help us to better understand risk and resilience in this vulnerable population of children.",0,0,
1137,"Knowledge of, attitudes toward, and use of low-dose computed tomography for lung cancer screening among family physicians","BACKGROUND: The results of the National Lung Screening Trial showed a 20% reduction in lung cancer mortality and a 6.7% reduction in all-cause mortality when high-risk patients were screened with low-dose computed tomography (LDCT) versus chest x-ray (CXR). The US Preventive Services Task Force has issued a grade B recommendation for LDCT screening, and the Centers for Medicare and Medicaid Services and private insurers now cover the screening cost under certain conditions. The purpose of this study was to assess the knowledge of, attitudes toward, and use of LDCT screening for lung cancer among family physicians. METHODS: A 32-item questionnaire was distributed to members of the South Carolina Academy of Family Physicians in 2015. Descriptive statistics were calculated. RESULTS: There were 101 respondents, and most had incorrect knowledge about which organizations recommended screening. Many physicians continued to recommend CXR for lung cancer screening. Most felt that LDCT screening increased the odds of detecting disease at earlier stages (98%) and that the benefits outweighed the harms (75%). Concerns included unnecessary procedures (88%), stress/anxiety (52%), and radiation exposure (50%). Most physicians discussed the risks/benefits of screening with their patients in some capacity (76%)""; however, more than 50% reported making 1 or no screening recommendations in the past year. CONCLUSIONS: Most family physicians report discussing LDCT with patients at high risk for lung cancer; however, referrals remain low. There are gaps in physician knowledge about screening guidelines and reimbursement, and this indicates a need for further educational outreach. The development of decision aids may facilitate shared decision-making discussions about screening, and targeted interventions may improve knowledge gaps. Cancer 2016;""122:2324-2331. (c) 2016 American Cancer Society.",0,0,
1138,Knowledge translation of research findings,"Background One of the most consistent findings from clinical and health services research is the failure to translate research into practice and policy. As a result of these evidence-practice and policy gaps, patients fail to benefit optimally from advances in healthcare and are exposed to unnecessary risks of iatrogenic harms, and healthcare systems are exposed to unnecessary expenditure resulting in significant opportunity costs. Over the last decade, there has been increasing international policy and research attention on how to reduce the evidence-practice and policy gap. In this paper, we summarise the current concepts and evidence to guide knowledge translation activities, defined as T2 research (the translation of new clinical knowledge into improved health). We structure the article around five key questions: what should be transferred""; to whom should research knowledge be transferred; by whom should research knowledge be transferred; how should research knowledge be transferred;"" and, with what effect should research knowledge be transferred?  Discussion We suggest that the basic unit of knowledge translation should usually be up-to-date systematic reviews or other syntheses of research findings. Knowledge translators need to identify the key messages for different target audiences and to fashion these in language and knowledge translation products that are easily assimilated by different audiences. The relative importance of knowledge translation to different target audiences will vary by the type of research and appropriate endpoints of knowledge translation may vary across different stakeholder groups. There are a large number of planned knowledge translation models, derived from different disciplinary, contextual (i.e., setting), and target audience viewpoints. Most of these suggest that planned knowledge translation for healthcare professionals and consumers is more likely to be successful if the choice of knowledge translation strategy is informed by an assessment of the likely barriers and facilitators. Although our evidence on the likely effectiveness of different strategies to overcome specific barriers remains incomplete, there is a range of informative systematic reviews of interventions aimed at healthcare professionals and consumers (i.e., patients, family members, and informal carers) and of factors important to research use by policy makers.  Summary There is a substantial (if incomplete) evidence base to guide choice of knowledge translation activities targeting healthcare professionals and consumers. The evidence base on the effects of different knowledge translation approaches targeting healthcare policy makers and senior managers is much weaker but there are a profusion of innovative approaches that warrant further evaluation.",0,0,
1139,Knowledge translation of the American College of Emergency Physicians' clinical policy on syncope using computerized clinical decision support,"AIMS: To influence physician practice behavior after implementation of a computerized clinical decision support system (CDSS) based upon the recommendations from the 2007 ACEP Clinical Policy on Syncope. METHODS: This was a pre-post intervention with a prospective cohort and retrospective controls. We conducted a medical chart review of consecutive adult patients with syncope. A computerized CDSS prompting physicians to explain their decision-making regarding imaging and admission in syncope patients based upon ACEP Clinical Policy recommendations was embedded into the emergency department information system (EDIS). The medical records of 410 consecutive adult patients presenting with syncope were reviewed prior to implementation, and 301 records were reviewed after implementation. Primary outcomes were physician practice behavior demonstrated by admission rate and rate of head computed tomography (CT) imaging before and after implementation. RESULTS: There was a significant difference in admission rate pre- and post-intervention (68.1% vs. 60.5% respectively, p = 0.036). There was no significant difference in the head CT imaging rate pre- and post-intervention (39.8% vs. 43.2%, p = 0.358). There were seven physicians who saw ten or more patients during the pre- and post-intervention. Subset analysis of these seven physicians' practice behavior revealed a slight significant difference in the admission rate pre- and post-intervention (74.3% vs. 63.9%, p = 0.0495) and no significant difference in the head CT scan rate pre- and post-intervention (42.9% vs. 45.4%, p = 0.660). CONCLUSIONS: The introduction of an evidence-based CDSS based upon ACEP Clinical Policy recommendations on syncope correlated with a change in physician practice behavior in an urban academic emergency department. This change suggests emergency medicine clinical practice guideline recommendations can be incorporated into the physician workflow of an EDIS to enhance the quality of practice.",1,1,
1140,Knowledge versus practice: the necessity of education for successful guideline implementation,"This study assessed physicians' familiarity with a practice guideline for bronchiolitis, evaluated attitudes regarding guidelines, determined preference of educational materials for guideline accessibility and examined the relationship between guideline familiarity and attitudes with clinical practice behaviors. Six months following guideline implementation, surveys were distributed to eligible physicians. The response rate was 68%. Retrospective analyses of inhalation therapies across three study cohorts were also performed. Most physicians surveyed in this study were aware of and utilized a recently introduced guideline, though use of unproven inhalation therapies continued. Despite demonstrated efficiencies of care, continued educational intervention is necessary to sustain these gains.",0,0,
1141,"Knowledge, attitudes, and practices surrounding breast cancer screening in educated Appalachian women","PURPOSE/OBJECTIVES: To determine how and what women learn about breast cancer and screening practices and which factors influence women's breast cancer screening practices. DESIGN: Descriptive analysis of questionnaire data collected at the time of enrollment in a clinical trial. SETTING: Breast care center of a mid-Atlantic academic health sciences center. SAMPLE: 185 women in a predominantly Appalachian, entirely rural state. METHODS: Participants completed the Modified Toronto Breast Self-Examination Inventory and questions related to personal mammography practices at the time of enrollment before randomization in a longitudinal clinical intervention study. MAIN RESEARCH VARIABLES: Women's demographics, knowledge of breast cancer screening practices, adherence to breast cancer screening guidelines, and motivation, knowledge, and practice proficiency surrounding breast cancer screening. FINDINGS: These educated women had knowledge deficits about breast cancer, breast cancer risk factors, and screening guidelines, particularly the timing and practice behaviors of breast self-examination. Women who had received healthcare and cancer-screening instruction by healthcare providers, including advanced practice nurses, had greater knowledge of breast cancer and detection practices. CONCLUSIONS: Women still have knowledge deficits about breast cancer, breast cancer detection, and personal risk factors. In addition, some educated women in this study failed to practice breast cancer screening according to current guidelines. IMPLICATIONS FOR NURSING: Practitioners must continue to remind and update women about breast disease, and women's cancer-screening practices must be reinforced. All levels of providers should improve their rates of performing clinical breast examinations with physical examinations. Nurses, who greatly influence women's health care, must remain current in their knowledge of breast disease, screening, and treatment.",0,0,
1142,KRAS and colorectal cancer: ethical and pragmatic issues in effecting real-time change in oncology clinical trials and practice,"Systemic therapy has led to a median survival time for patients with advanced colorectal cancer (CRC) almost fourfold longer than that expected with best supportive care, an outcome achieved through combining chemotherapeutic and targeted biologic agents. Although the latter can include anti-epidermal growth factor receptor antibodies, such as cetuximab and panitumumab, we now have strong evidence that patients whose tumors harbor mutated KRAS will not benefit from this class of agent. Acceptance of the reliability and importance of the KRAS data took several years to evolve, however, for a variety of reasons. The timeline from the presentation and publication of small, retrospective phase II studies to widespread acceptance of the KRAS predictive value and changes in behavior-specifically, modifications of ongoing national trials in advanced/metastatic CRC, changes in national guidelines and practice patterns, and adjustments to the labeled indications for the monoclonal antibodies-was lengthy. In this commentary, we discuss whether or not the process of data disclosure regarding KRAS status and treatment of advanced CRC patients was effective in permitting timely decisions regarding ongoing publicly funded clinical trials and whether or not such decisions were rational and ethical. The overall goals are to highlight lessons learned regarding early disclosure of clinical trial results, as well as vetting and adoption of new scientific data, and to propose modifications for handling similar situations in the future.",0,0,
1143,Laboratory test form design influences test ordering by general practitioners in The Netherlands,"The effect of listing fewer laboratory tests on the test request form on test-ordering behavior of a group of 47 Dutch general practitioners was studied. The number of laboratory tests ordered by this experimental group during a 12-month period was recorded. The usual, old standard form was used by a control group of 28 general practitioners in a different region. After having used the old, standard form with 178 tests for 5 months, the experimental group received forms listing only 15 hematological and chemical tests plus several urine and feces tests, and space was allowed for ""others."" A comparison of the experimental and control periods showed that the number of tests ordered monthly in the experimental group was reduced by 18. When the usual standard form was re-introduced, the general practitioners quickly returned to their old pattern. Results revealed that fixed and often unsound routine influences the use of additional diagnostic procedures. In addition, limiting and restructuring the test-ordering forms may break the routine but does not essentially modify the rationale of test-ordering behavior.",1,1,
1144,Lack of chart reminder effectiveness on family medicine resident JNC-VI and NCEP III guideline knowledge and attitudes,"BACKGROUND: The literature demonstrates that medical residents and practicing physicians have an attitudinal-behavioral discordance concerning their positive attitudes towards clinical practice guidelines (CPG), and the implementation of these guidelines into clinical practice patterns. METHODS: A pilot study was performed to determine if change in a previously identified CPG compliance factor (accessibility) would produce a significant increase in family medicine resident knowledge and attitude toward the guidelines. The primary study intervention involved placing a summary of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP III) CPGs in all patient (>18 yr.) charts for a period of three months. The JNC VI and NCEP III CPGs were also distributed to each Wayne State family medicine resident, and a copy of each CPG was placed in the preceptor's area of the involved clinics. Identical pre- and post- intervention questionnaires were administered to all residents concerning CPG knowledge and attitude. RESULTS: Post-intervention analysis failed to demonstrate a significant difference in CPG knowledge. A statistically significant post-intervention difference was found in only on attitude question. The barriers to CPG compliance were identified as 1) lack of CPG instruction""; 2) lack of critical appraisal ability; 3) insufficient time; 4) lack of CPG accessibility;"" and 5) lack of faculty modeling. CONCLUSION: This study demonstrated no significant post intervention changes in CPG knowledge, and only one question that reflected attitude change. Wider resident access to dedicated clinic time, increased faculty modeling, and the implementation of an electronic record/reminder system that uses a team-based approach are compliance factors that should be considered for further investigation. The interpretation of CPG non-compliance will benefit from a causal matrix focused on physician knowledge, attitudes, and behavior. Recent findings in resident knowledge-behavior discordance may direct the future investigation of physician CPG non-compliance away from generalized barrier research, and toward the development of information that maximizes the sense of individual practitioner urgency and certainty.",0,1,
1145,Late-life depression in primary care. How well are we doing?,"OBJECTIVE: To discover primary care physicians' attitudes toward their abilities to detect and treat depression in the elderly. DESIGN: A self-administered questionnaire sent to 1,000 primary care physicians in the state of Michigan. SETTING: The survey was sent to physicians who practice general internal medicine or family medicine. PARTICIPANTS: The questionnaire was sent to 500 MD and 500 DO physicians""; equal representation was given to general internal medicine and family medicine. Of all 1,000 physicians, 60% (n = 604) responded, 51% (n = 309) were MD's, 48% (n = 295) were DO's, 41% (n = 245) were general internists, and 59% (n = 359) were family medicine physicians. MEASUREMENTS AND MAIN RESULTS: Despite positive attitudes about their skills for detecting and treating depression in the elderly, only one quarter of the respondents routinely used a screening tool in practice. Forty-one percent of all physicians were not aware of depression practice guidelines. Family physicians were more confident about their treatment skills than were general internists (85% vs 50%;"" chi 2 = 11.42, p < or = .003). Male physicians more often endorsed pharmacologic treatment, while female physicians more frequently used counseling and exercise techniques to treat depressed older patients. Half of all physicians felt knowledgeable about community resources to treat older depressed patients. CONCLUSIONS: This survey identified several perceived needs for future targeted interventions: (1) additional Agency for Health Care Policy and Research guideline exposure for all primary care physicians, (2) targeted counseling skill intervention for male physicians and medication management for female physicians, and (3) additional continuing medical education intervention for practicing general internists. Further research is needed to correlate physician attitudes with ensuing behaviors to fully appreciate the nature of late-life depression treatment within the primary care arena.",0,0,
1146,"Learning and behavior., 5th ed.","This book examines how people and animals learn and how their behaviors are later changed. This text is designed for introductory or intermediate level courses in learning, conditioning, or the experimental analyses of behavior. Chapter 1 discusses the nature of scientific theories and experiments, and contrasts the behavioral and cognitive learning approaches. Chapter 2 describes theories about the learning process. Chapters 3 and 4 discuss innate behaviors and habituation and examine basic principles of classical conditioning. Chapter 5 describes more recent theoretical developments and experimental findings in this area. Chapters 6,7, and 8 involve operant conditioning and examine positive reinforcement""; schedules of reinforcement;"" and negative reinforcement and punishment, respectively. Chapter 9 presents differing views on such questions as what constitutes a reinforcer and what conditions are necessary for learning to occur. Chapter 10 takes a more thorough look at generalization and discrimination and examines research on concept formation. Chapter 11 surveys a wide range of findings in the area of comparative cognition. Chapters 12 and 13 discuss observational and motor-skills learning. Finally, Chapter 14 presents an overview of behavioral research on choice. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
1147,Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations,"Background In healthcare change interventions, on-the-ground learning about the implementation process is often lost because of a primary focus on outcome improvements. This paper describes the Learning Evaluation, a methodological approach that blends quality improvement and implementation research methods to study healthcare innovations.  Methods Learning Evaluation is an approach to multi-organization assessment. Qualitative and quantitative data are collected to conduct real-time assessment of implementation processes while also assessing changes in context, facilitating quality improvement using run charts and audit and feedback, and generating transportable lessons. Five principles are the foundation of this approach: (1) gather data to describe changes made by healthcare organizations and how changes are implemented""; (2) collect process and outcome data relevant to healthcare organizations and to the research team; (3) assess multi-level contextual factors that affect implementation, process, outcome, and transportability; (4) assist healthcare organizations in using data for continuous quality improvement; and (5) operationalize common measurement strategies to generate transportable results.  Results Learning Evaluation principles are applied across organizations by the following: (1) establishing a detailed understanding of the baseline implementation plan; (2) identifying target populations and tracking relevant process measures; (3) collecting and analyzing real-time quantitative and qualitative data on important contextual factors; (4) synthesizing data and emerging findings and sharing with stakeholders on an ongoing basis;"" and (5) harmonizing and fostering learning from process and outcome data. Application to a multi-site program focused on primary care and behavioral health integration shows the feasibility and utility of Learning Evaluation for generating real-time insights into evolving implementation processes.  Conclusions Learning Evaluation generates systematic and rigorous cross-organizational findings about implementing healthcare innovations while also enhancing organizational capacity and accelerating translation of findings by facilitating continuous learning within individual sites. Researchers evaluating change initiatives and healthcare organizations implementing improvement initiatives may benefit from a Learning Evaluation approach.",0,0,
1148,Learning with computerized guidelines in general practice? A randomized controlled trial.,"Background. Evidence-based guidelines are seen as an important instrument to transfer scientifically generated knowledge into daily clinical practice and to ensure high standards of clinical care. Despite wide promulgation, clinical guidelines so far have a limited impact on individual professional learning and on changing daily medical practice.  Objectives. Our aims were (i) to study a potential knowledge increase among German GPs after implementation of web- and evidence-based guidelines and (ii) to identify and analyse potential barriers to individual professional learning with computerized guidelines.  Methods. A prospective, randomized controlled trial was conducted including 72 GPs (21% female, 79% male). The intervention group (n = 38) had access to clinical guidelines via the Internet or CD-ROM, the control group had not (n = 34). Both groups received a standardized two-part questionnaire. An increase of knowledge was measured with 25 multiple choice questions related to four different medical topics. In addition, reasons for using or not using computerized guidelines were analysed after access to guidelines was open to all participating physicians.  Results. There was no significant knowledge increase in the intervention group (P = 0.69). Twenty-two (58%) GPs of the intervention group had used the guidelines. Unspecified curiosity (76%) and a specific medical question (38%) were predominant motives for usage among physicians who had used the guidelines. Among ‘non-users’, 78% stated ‘lack of time’ as the main reason for not using guidelines.  Conclusion. An efficient knowledge transfer through computerized guidelines was not achieved. Usage, individual learning and potential implementation depend on adequate incentives and pragmatic aspects of clinical practice: easy and quick access.",0,1,
1149,Left handedness,,0,0,
1150,Legal liability of physicians in medical research,"The intent of this paper is to provide an overview, in layperson's language, of the concepts in law which may be applicable to a physician who undertakes research. The paper is divided into 2 parts. Part I deals with liability issues and standards of care. It is meant to enable the physician/researcher to recognize a potential liability situation. Part II examines insurance and related issues such as the role of the Canadian Medical Protective Association (CMPA). The paper begins with a review of 2 potential categories of liability: criminal and civil tort. Next, legal issues surrounding the consent process, which form the majority of negligence claims, are dealt with. The research process is then discussed with emphasis on the Medical Research Council of Canada Guidelines on Human Experimentation. Part II covers how research projects are funded and identifies the parties from whom insurance coverage may be sought. Information is provided from the various sources offering insurance and quasi-insurance protection with special attention on the CMPA. Each source details the circumstances necessary for its particular coverage to be triggered. Other issues addressed include those arising when research is conducted outside Canada and multiple coverage.",0,0,
1151,"Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians","In this position paper, the American College of Physicians examines the health disparities experienced by the lesbian, gay, bisexual, and transgender (LGBT) community and makes a series of recommendations to achieve equity for LGBT individuals in the health care system. These recommendations include enhancing physician understanding of how to provide culturally and clinically competent care for LGBT individuals, addressing environmental and social factors that can affect their mental and physical well-being, and supporting further research into understanding their unique health needs.",0,0,
1152,Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma,"Primary objective : To investigate whether computer decision support software used in the management of patients with asthma improves clinical outcomes. Research design : Randomized controlled trial with practices each reporting on 30 patients with asthma over a 6 month period. Methods and procedures : 447 patients were randomly selected from practice asthma registers managed by 17 general practices from throughout the UK. Intervention practices used the software during consultations with these patients throughout the study while control practices did not. Main outcomes and results : Practice consultations, acute exacerbations of asthma, hospital contacts, symptoms on assessment and medication use. A smaller proportion of patients within the intervention group initiated practice consultations for their asthma: 34 (22%) vs 111 (34%), odds ratio (OR)= 0.59, 95% confidence interval (CI) (0.37-0.95)"";"" and suffered acute asthma exacerbations: 12 (8%) vs 57 (17%) , OR = 0.43, 95% CI = 0.21- 0.85 six months after the introduction of the computer decision support software. There were no discernable differences in reported symptoms, maintenance prescribing or use of hospital services between the two groups. Conclusion : The use of computer decision support software that implements guidelines during patient consultations may improve clinical outcomes for patients with asthma.",0,1,
1153,Lessons from the evaluation of the UK's NHS R&D Implementation Methods Programme,"Background Concern about the effective use of research was a major factor behind the creation of the NHS R&D Programme in 1991. In 1994, an advisory group was established to identify research priorities in research implementation. The Implementation Methods Programme (IMP) flowed from this, and its commissioning group funded 36 projects. In 2000 responsibility for the programme passed to the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, which asked the Health Economics Research Group (HERG), Brunel University, to conduct an evaluation in 2002. By then most projects had been completed. This evaluation was intended to cover: the quality of outputs, lessons to be learnt about the communication strategy and the commissioning process, and the benefits from the projects.  Methods We adopted a wide range of quantitative and qualitative methods. They included: documentary analysis, interviews with key actors, questionnaires to the funded lead researchers, questionnaires to potential users, and desk analysis.  Results Quantitative assessment of outputs and dissemination revealed that the IMP funded useful research projects, some of which had considerable impact against the various categories in the HERG payback model, such as publications, further research, research training, impact on health policy, and clinical practice.  Qualitative findings from interviews with advisory and commissioning group members indicated that when the IMP was established, implementation research was a relatively unexplored field. This was reflected in the understanding brought to their roles by members of the advisory and commissioning groups, in the way priorities for research were chosen and developed, and in how the research projects were commissioned. The ideological and methodological debates associated with these decisions have continued among those working in this field. The need for an effective communication strategy for the programme as a whole was particularly important. However, such a strategy was never developed, making it difficult to establish the general influence of the IMP as a programme.  Conclusion Our findings about the impact of the work funded, and the difficulties faced by those developing the IMP, have implications for the development of strategic programmes of research in general, as well as for the development of more effective research in this field.",0,0,
1154,Letter: Mucosal ulceration in coeliac disease,,0,0,
1155,Leveraging insights from behavioral economics to increase the value of health-care service provision,"United States health expenditures continue to escalate at unsustainable rates. A recent movement around increasing price transparency has been suggested as a way of reducing the rate of increase in expenditures, with legislative efforts taking place at both the state and federal level. While this seems on the surface like a good idea, simply providing information on prices to physicians, particularly trainees, may not achieve the type of large changes in practice patterns that proponents expect. The manner in which price transparency is implemented will likely play a significant role in its effectiveness as an intervention. In this article, the authors review efforts of transparency and default options from other contexts and leverage insights from behavioral economics to provide recommendations for increasing the likelihood that price transparency will lead to physicians weighing the relative value of interventions.",0,1,
1156,LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach,"OBJECTIVES: We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. METHOD: Young gay and bisexual men (n = 63"";"" M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. RESULTS: Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. CONCLUSION: This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual men's co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record",0,0,
1157,Life style advice provided by primary health care to prevent cardiovascular diseases,"BACKGROUND: The Working Group on Hypertension of the Norwegian College of General Practitioners reports in this paper on the documentation on behavioural advice in the prevention of cardiovascular disease. Emphasis is given to hypertension. MATERIAL AND METHODS: The recommendations are mainly based on updated metaanalyses and randomised controlled trials. Hypertension is treated to prevent cardiovascular disease"";"" that is why we put emphasis on documentation with significant end points. The validity of the documentation for general practice is assessed. We have also assessed whether certain methods or theories for behavioural change could be helpful to the general practitioner. RESULTS: The value of advice against smoking, dietary advice (increased intake of grain products, vegetables, fruit, poultry and fish), and advice about exercise are well documented and applicable in general practice. Respect for the patient's autonomy and interest in the patients and their health-related habits seem to be important factors for improving doctor's chances of influencing patient behaviour. INTERPRETATION: The value of life-style advice is well documented and should play an important role in clinical strategies to prevent cardiovascular disease in high-risk patients.",0,0,
1158,Life sustaining technologies and the elderly,,0,0,
1159,Lifestyle counselling in primary care: long-term effects on cholesterol level,"OBJECTIVE: To evaluate the long-term effectiveness of lifestyle counselling for low-moderate cardiovascular (CV) risk subjects in primary care. METHODS: DESIGN: Prospective comparison of baseline vs post-intervention, and comparison of enrolled patients vs control subjects extracted from a large primary care database. SETTING: 94 general practices in Italy. PARTICIPANTS: All the 20-70-year-old hypercholesterolaemic subjects who did not qualify for statin treatment according to the guidelines and who were seen on 12 predetermined working days""; 713 patients; 94 general practitioners. INTERVENTION: Short (5-10 min) educational intervention (qualitative dietary advice, encouraging walking or other aerobic physical activities);"" handing out simple dietetic advice at physician discretion. MAIN OUTCOME MEASURES: Total cholesterol level and global CV risk calculated according to the Framingham equation. RESULTS: Total cholesterol and global CV risk (10 years) decreased by 0.31 mmol/l (p < 0.0001, 95% CI 0.23-0.40) and 1.35% (p < 0.01, 95% CI -1.73 to -0.97), respectively, after a 54-month follow-up. Enrolled patients showed a greater total cholesterol decrease than control patients: 2.24% (p < 0.05, 95% CI 0.58-3.91%). CONCLUSIONS: A simple, office-based, long-term, lifestyle counselling programme produces a small, but clinically significant reduction of total cholesterol and of global CV risk. This result should encourage GPs to systematically offer simple, unstructured lifestyle counselling to all their patients.",0,0,
1160,Lifestyle interventions in primary health care: professional and organizational challenges,"BACKGROUND: Interventions that support patient efforts at lifestyle changes that reduce tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity represent important areas of development for health care. Current research shows that it is challenging to reorient health care toward health promotion. The aim of this study was to explore the extent of health care professional work with lifestyle interventions in Swedish primary health care, and to describe professional knowledge, attitudes and perceived organizational support for lifestyle interventions. METHODS: The study is based on a cross-sectional Web-based survey directed at general practitioners, other physicians, residents, public health nurses and registered nurses (n = 315) in primary health care. RESULTS: Fifty-nine percent of the participants indicated that lifestyle interventions were a substantial part of their duties. A majority (77%) would like to work more with patient lifestyles. Health professionals generally reported a thorough knowledge of lifestyle intervention methods for disease prevention. Significant differences between professional groups were found with regard to specific knowledge and extent of work with lifestyle interventions. Alcohol was the least addressed lifestyle habit. Management was supportive, but structures to sustain work with lifestyle interventions were scarce, and a need for national guidelines was identified. CONCLUSIONS: Health professionals reported thorough knowledge and positive attitudes toward lifestyle interventions. When planning for further implementation of lifestyle interventions in primary health care, differences between professional groups in knowledge, extent of work with promotion of healthy lifestyles and lifestyle issues and provision of organizational support such as national guidelines should be considered.",0,0,
1161,Lifestyle or life-saving medicines? A primary healthcare professional and consumer opinion survey on over-the-counter statins,"BACKGROUND: Over-the-counter (OTC) simvastatin 10 mg became available in the UK in July 2004 with the aim of improving primary prevention of ischemic heart disease. OBJECTIVE: To document the views of the main stakeholders (general practitioners [GPs], community pharmacists, and consumers) on issues pertaining to the reclassification of simvastatin to OTC availability, highlight differences between stakeholder groups, and identify factors likely to influence consumer behavior. METHODS: A self-administered questionnaire survey of GPs, community pharmacists, and potentially eligible consumers was carried out 8 months after the UK launch of OTC simvastatin. Participants were asked about their awareness of the drug, their willingness to use such medicines, and their views on relevant management practices. RESULTS: Awareness of OTC simvastatin was high among GPs but limited among consumers. Although OTC availability was favored by pharmacists, consumers and GPs generally thought it was not a good idea. GPs and pharmacists cited increased consumer choice as the most important likely benefit"";"" consumers thought potential savings to the National Health Service were equally important. Medication misuse and neglect of lifestyle risk factors were unanimously considered to be the most important likely risks. Unlike the majority of pharmacists, most GPs thought that current dosing guidelines were inappropriate, but there was consensus that long-term nonadherence would probably curtail any treatment benefit. Most respondents agreed that GPs should be informed if their patients were using OTC statins but disagreed as to the best way to communicate this information. CONCLUSIONS: OTC availability of statins did not appear to be considered a popular public health intervention by consumers and GPs, as the drugs were widely perceived as being prone to misuse. However, OTC availability was favored by pharmacists, who saw this as empowering both for consumers and themselves. Key issues in dispensing, managing, and evaluating the public health impact of this intervention remain outstanding.",0,0,
1162,Lifetime Prevalence of Gender-Based Violence in Women and the Relationship With Mental Disorders and Psychosocial Function,"Context Intimate partner physical violence, rape, sexual assault, and stalking are pervasive and co-occurring forms of gender-based violence (GBV). An association between these forms of abuse and lifetime mental disorder and psychosocial disability among women needs to be examined.  Objectives To assess the association of GBV and mental disorder, its severity and comorbidity, and psychosocial functioning among women.  Design, Setting, and Participants A cross-sectional study based on the Australian National Mental Health and Well-being Survey in 2007, of 4451 women (65% response rate) aged 16 to 85 years.  Main Outcome Measures The Composite International Diagnostic Interview version 3.0 of the World Health Organization's World Mental Health Survey Initiative was used to assess lifetime prevalence of any mental disorder, anxiety, mood disorder, substance use disorder, and posttraumatic stress disorder (PTSD). Also included were indices of lifetime trauma exposure, including GBV, sociodemographic characteristics, economic status, family history of mental disorder, social supports, general mental and physical functioning, quality of life, and overall disability.  Results A total of 1218 women (27.4%) reported experiencing at least 1 type of GBV. For women exposed to 3 or 4 types of GBV (n = 139), the rates of mental disorders were 77.3% (odds ratio [OR], 10.06""; 95% confidence interval [CI], 5.85-17.30) for anxiety disorders, 52.5% (OR, 3.59; 95% CI, 2.31-5.60) for mood disorder, 47.1% (OR, 5.61; 95% CI, 3.46-9.10) for substance use disorder, 56.2% (OR, 15.90; 95% CI, 8.32-30.20) for PTSD, 89.4% (OR, 11.00; 95% CI, 5.46-22.17) for any mental disorder, and 34.7% (OR, 14.80; 95% CI, 6.89-31.60) for suicide attempts. Gender-based violence was associated with more severe current mental disorder (OR, 4.60; 95% CI, 2.93-7.22), higher rates of 3 or more lifetime disorders (OR, 7.79; 95% CI, 6.10-9.95), physical disability (OR, 4.00; 95% CI, 1.82-8.82), mental disability (OR, 7.14; 95% CI, 2.87-17.75), impaired quality of life (OR, 2.96; 95% CI, 1.60-5.47), an increase in disability days (OR, 3.14; 95% CI, 2.43-4.05), and overall disability (OR, 2.73;"" 95% CI, 1.99-3.75).  Conclusion Among a nationally representative sample of Australian women, GBV was significantly associated with mental health disorder, dysfunction, and disability.",0,0,
1163,'Like sugar and honey': the embedded ethics of a larval control project in The Gambia,"This paper describes a malaria research project in The Gambia to provoke thinking on the social value of transnational research. The Larval Control Project (LCP) investigated the efficacy of a microbial insecticide to reduce vector density and, ultimately, clinical malaria in Gambian children. The LCP's protocol delineated a clinical surveillance scheme that involved Village Health Workers (VHWs) supported by project nurses. Combining insights from ethnographic fieldwork conducted at the Medical Research Council (MRC) Laboratories in Farafenni from 2005 to 2009, open-ended interviews with project nurses, and eight focus group discussions held with participant mothers in October 2007, we consider the social impact of the LCP's investigative method against the backdrop of several years of research activity. We found that while participants associated the LCP with the clinical care it provided, they also regarded the collaboration between the nurses and VHWs added additional benefits. Organised around the operational functions of the trial, small-scale collaborations provided the platform from which to build local capacity. While ethical guidelines emphasise the considerations that must be added to experimental endeavour in southern countries (e.g. elaborating processes of informed consent, developing strategies of community engagement or providing therapeutic access to participants after the trial concludes), these findings suggest that shifting attention from supplementing ethical protocols to the everyday work of research -embedding ethics through scientific activity - may provide a sounder basis to reinforce the relationship between scientific rigour and social value.",0,0,
1164,Limited impact of a multicenter intervention to improve the quality and efficiency of pneumonia care,"STUDY OBJECTIVES: To evaluate the impact of a multifactorial intervention to improve the quality, efficiency, and patient understanding of care for community-acquired pneumonia. DESIGN: Times series cohort study. SETTING: Four academic health centers in the New York City metropolitan area. PATIENTS OR PARTICIPANTS: All consecutive adults hospitalized for pneumonia during a 5-month period before (n = 1,013) and after (n = 1,081) implementation of an inpatient quality improvement (QI) initiative. INTERVENTIONS: A multidisciplinary team of opinion leaders developed evidence-based treatment guidelines and critical pathways, conducted educational sessions with physicians, distributed pocket reminder cards, promoted standardized orders, and developed bilingual patient education materials. MEASUREMENTS AND RESULTS: The average age was 71.4 years, and 44.1% of cases were low risk, 36.8% were moderate risk, and 19.2% were high risk. The preintervention and postintervention groups were well matched on age, sex, race, nursing home residence, pneumonia severity, initial presentation, and most major comorbidities. The intervention increased the use of guideline-recommended antimicrobial therapy from 78.1 to 83.4% (p = 0.003). There was also a borderline decrease in the proportion of patients being discharged prior to becoming clinically stable, from 27.0 to 23.5% (p = 0.06). However, there were no improvements in the other targeted indicators, including time to first dose of antibiotics, proportion receiving antibiotics within 8 h, timely switch to oral antibiotics, timely discharge, length of stay, or patient education outcomes. CONCLUSIONS: This real-world QI program was able to improve modestly on some quality indicators, but not effect resource use or patient knowledge of their disease. Changing physician and organizational behavior in academic health centers will require the development and implementation of more intensive, system-oriented strategies.",0,0,
1165,Local clinical guidelines: description and evaluation of a participative method for their development and implementation,"BACKGROUND: National guidelines are rarely followed by immediate change in clinical behaviour. We present our experience of an active educational method for local development and implementation of a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method for developing local clinical guidelines. METHODS: A trial in a district of the effect of guideline development incorporating active participation of intended recipients on subsequent relevant prescribing. It was carried out in Wirral Family Health Services Authority district (the Wirral peninsula) comprising 69 general practices covering a population of 345,763. An exemplar guideline on 'hypertension in the elderly' was developed by the method described. The principal recommended drug was bendrofluazide 2.5 mg once daily. The differences in prescribed daily doses (PDD) of bendrofluazide 2.5 mg tablets per quarter per 1000 prescribing units (age-weighted population) between the intervention district and England as a whole was measured. RESULTS: Comparison of the intervention district with England data demonstrates a median difference of 122.49 PDD before and 206.34 PDD after guideline production, this change is statistically highly significant (Mann-Whitney two-tailed P < 0.0001""; 95% CI = 36.51-104.77). Grouped regression analysis shows no significant difference (0.89) in slope gradients before guideline production (P = 0.35, 95% CI = -3.97-5.76), but the difference in slope gradients after (12.95) is statistically highly significant (P < 0.0001;"" 95% CI = 8.17-17.73). The data suggests that the change in clinical behaviour persisted for at least two years. CONCLUSION: Participation of intended recipient general practitioners and local specialists in the development of a guideline by an active educational method as described was followed by a favourable change in clinical behaviour which persisted for at least two years.",0,0,
1166,Local Learning Collaboratives to Improve Quality for Chronic Kidney Disease (CKD): From Four Regional Practice-based Research Networks (PBRNs),"BACKGROUND: Four practice-based research networks (PBRNs) participated in a project to increase the diffusion of evidence-based treatment guidelines for chronic kidney disease (CKD). A multicomponent organizational intervention engaged regionally proximal primary care practices in a series of facilitated meetings, referred to as local learning collaboratives (LLCs). METHODS: The 2-wave strategy began with 8 practices in each PBRN receiving practice facilitation and subsequently joining an LLC. A sequential mixed-methods design addressed the conduct, content, and fidelity of the intervention"";"" clinicians in 2 PBRNs participated in interviews, and PBRN coordinators reflected on implementation challenges. RESULTS: LLCs were formed in 3 PBRNs, with 121 monthly meetings held across 20 LLCs. Slightly more than half of the participants were clinicians. Qualitative data suggest that clinicians increased the priority for CKD care, improved knowledge and skills, were satisfied with the project, and attempted to improve care. Implementation challenges were encountered and concerns about sustainability expressed. CONCLUSION: While PBRNs can successfully leverage resources to diffuse treatment guidelines, and LLCs are well-accepted by clinical staff, the formation of LLCs was not feasible for 1 PBRN, and others struggled to meet regularly and have performance data available despite logistic support.",0,0,
1167,Long term effectiveness on prescribing of two multifaceted educational interventions: results of two large scale randomized cluster trials,"INTRODUCTION: Information on benefits and risks of drugs is a key element affecting doctors' prescribing decisions. Outreach visits promoting independent information have proved moderately effective in changing prescribing behaviours. OBJECTIVES: Testing the short and long-term effectiveness on general practitioners' prescribing of small groups meetings led by pharmacists. METHODS: Two cluster open randomised controlled trials (RCTs) were carried out in a large scale NHS setting. Ad hoc prepared evidence based material were used considering a therapeutic area approach--TEA, with information materials on osteoporosis or prostatic hyperplasia--and a single drug oriented approach--SIDRO, with information materials on me-too drugs of 2 different classes: barnidipine or prulifloxacin. In each study, all 115 Primary Care Groups in a Northern Italy area (2.2 million inhabitants, 1737 general practitioners) were randomised to educational small groups meetings, in which available evidence was provided together with drug utilization data and clinical scenarios. Main outcomes were changes in the six-months prescription of targeted drugs. Longer term results (24 and 48 months) were also evaluated. RESULTS: In the TEA trial, one of the four primary outcomes showed a reduction (prescription of alfuzosin compared to tamsulosin and terazosin in benign prostatic hyperplasia: prescribing ratio -8.5%, p = 0.03). Another primary outcome (prescription of risedronate) showed a reduction at 24 and 48 months (-7.6%, p = 0.02""; and -9,8%, p = 0.03), but not at six months (-5.1%, p = 0.36). In the SIDRO trial both primary outcomes showed a statistically significant reduction (prescription of barnidipine -9.8%, p = 0.02;"" prescription of prulifloxacin -11.1%, p = 0.04), which persisted or increased over time. INTERPRETATION: These two cluster RCTs showed the large scale feasibility of a complex educational program in a NHS setting, and its potentially relevant long-term impact on prescribing habits, in particular when focusing on a single drug. National Health systems should invest in independent drug information programs. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN05866587.",0,0,
1168,"Long-term effects of an occupational health guideline on employees' body weight-related outcomes, cardiovascular disease risk factors, and quality of life: results from a randomized controlled trial","OBJECTIVE: This study aims to evaluate the effectiveness of a draft occupational health guideline, aimed at preventing weight gain, on employees' body weight-related outcomes, cardiovascular disease (CVD) risk factors, and quality of life. METHODS: In a cluster randomized controlled trial including 16 occupational physicians (OP) and 523 employees, guideline-based care was compared to usual care by OP between 2009-2011 in the Netherlands. Guideline-based care consisted of (i) providing advice to employers on how to assess and intervene on the obesogenic work environment, (ii) conducting five face-to-face behavioral change counseling sessions with employees to improve their lifestyles, and (iii) evaluating the outcome and maintaining sections i and ii. Data were collected at baseline and 6, 12, and 18-months follow-up. To evaluate the effects of the intervention, multilevel analyses were performed. RESULTS: No significant differences were found between the intervention and control group on waist circumference [beta 1.2 cm, 95% confidence interval (95% CI) -0.6-2.9], body weight (beta 0.3 kg, 95% CI -1.0-1.6), body mass index (beta 0.1 kg/m (2), 95% CI -0.3-0.5), systolic blood pressure (beta 1.7 mmHG, 95% CI -2.4-5.8), diastolic blood pressure (beta 0.3 mmHG, 95% CI -1.0-0.6), cholesterol (beta 0 mmol/l, 95% CI -0.2-0.2), or quality of life indicators after 18-months follow-up. Stratified analyses showed an increase in waist circumference among men (beta 2.5 cm, 95% CI 0.5-4.5) and obese intervention participants (beta 2.7 cm, 95% CI 0.6-4.7) compared to control participants. CONCLUSION: The draft occupational health guideline was not more effective than usual care. Therefore, the guideline in its current form cannot be recommended for implementation.",0,0,
1169,Long-term effects of asthma education for physicians on patient satisfaction and use of health services,"This randomized clinical trial evaluated the long-term impact of an interactive seminar for physicians based on principles of self-regulation on clinician behaviour, children's use of health services for asthma, and parent's views of physician performance. Seventy-four general practice paediatricians, and 637 of their asthma patients aged 1-12 yrs, were randomized to treatment or control. Children and parents were blind to physicians' participation. Data were collected at baseline and follow-up through self-administered surveys (paediatricians), telephone interviews (parents) and medical records. The seminar focused on development of communication and teaching skills and use of therapeutic medical regimens for asthma as outlined in the National Asthma Education and Prevention Program guidelines. Approximately 2 yrs postintervention, treatment group physicians were more likely than control physicians to: use protocols for delivering asthma education (odds ratio (OR) 4.9, p=0.2), write down for patients how to adjust medicines when symptoms change (OR 5.7, p=0.05), and provide more guidelines for modifying therapy (OR 3.8, p=0.06). Parents scored treatment group physicians higher than control physicians on five specific positive communication behaviours. Children seen by treatment group physicians had fewer hospitalizations (p=0.03) and those with higher levels of emergency department (ED) use at baseline had fewer subsequent ED visits (p=0.03). No differences regarding the number of office visits were noted. There were no significant differences found between treatment and control group physicians in the amount of time spent with patients during office visits (26 versus 29 min) or in the number of patients treated with anti-inflammatory medicine. It is concluded that interactive asthma seminars for paediatricians had significant long-term benefits for their asthma care.",0,0,
1170,Long-term reduction in adverse drug events: an evidence-based improvement model,"OBJECTIVES: To develop and test an evidence-based model for reducing medication errors and harm in hospitalized children. METHODS: Prospective interrupted time series study evaluating the effectiveness of a multifaceted, staged intervention over 4 years in a major urban pediatric referral hospital. Guidelines for safe pediatric prescribing were implemented by using an evidence-based model. Key components included early clinician engagement and improved multidisciplinary communication, consensus development, interactive education, and timely data feedback by using iterative Plan-Do-Study-Act cycles. Impact on medication error and harm (adverse drug events, [ADEs]) was measured by using standard definitions and a multimethod approach. Prospective data from voluntary reports by nursing, medical, and pharmacy staff and intensive chart review were combined. All data were reviewed by a multidisciplinary panel, including causality assessments for ADEs. RESULTS: Reviewed over 3 time periods were 1011 patients with 6651 medication orders. Total ADEs decreased by > 50% in the first year and this was maintained at 4 years. Greatest improvements were in potential ADEs, which decreased from 12.26 per 100 patients at baseline to 4.60 per 100 patients at 4 years (P < .05). Total medication errors decreased from 4.51 per 100 orders at baseline to 2.78 per 100 orders at 4 years (P < .05). Prescribing errors decreased by 65%, from 4.07 per 100 orders at baseline to 2.05 orders at 4 years (P < .05). CONCLUSIONS: A multifaceted, evidence-based model for safe prescribing guideline implementation, engaging multidisciplinary clinicians, was effective in reducing medication error and harm in hospitalized children, resulting in sustained long-term improvement.",0,0,
1171,Looking for gall bladder disease in the patient's iris,In alternative health care iridology is used as a diagnostic aid. The diagnosis of gall bladder disease was used to study its validity and interperformer consistency. The presence of an inflamed gall bladder containing gall stones is said to be easily recognised by certain signs in the lower lateral part of the iris of the right eye. Stereo colour slides were made of the right eye. Stereo colour slides were made of the right eye of 39 patients with this disease and 39 control subjects of the same sex and age. The slides were presented in a random order to five leading iridologists without supplementary information. The prevalence of the disease was estimated at 56%. The median validity was 51% with 54% sensitivity and 52% specificity. These results were close to chance validity (iota = 0.03). None of the iridologists reached a high validity. The median interperformer consistency was 60%. This was only slightly higher than chance consistency (kappa = 0.18). This study showed that iridology is not a useful diagnostic aid.,0,0,
1172,Low-value care: an intractable global problem with no quick fix,,0,0,
1173,Magnetic resonance imaging of the head and spine: effective for the clinician or the patient?,"OBJECTIVES To test how the results of magnetic resonance imaging influence clinicians' diagnoses and management plans for patients with cranial and spinal problems and to assess changes in the quality of life of these patients. DESIGN Survey of patients undergoing cranial and spinal magnetic resonance imaging with questionnaires about diagnoses and intended management plans before and after imaging and quality of life questionnaires at the time of imaging and again four months later. SETTING Regional magnetic resonance imaging and spectroscopy unit. SUBJECTS 100 consecutive patients referred for cranial imaging in early 1989""; 100 similar patients referred for spinal imaging. MAIN OUTCOME MEASURES Changes in clinicians' leading diagnoses after magnetic resonance imaging and their confidence in these diagnoses; changes in intended management plans; assessment of the contribution to the future management of the patient;"" changes in patients' quality of life. RESULTS Magnetic resonance imaging altered the clinicians' leading diagnoses in 35 of 169 (21%) cases. The clinicians became more confident about their leading diagnoses in 90 of 167 (54%). There was a change in management plan in 113 of 182 (62%). The clinicians considered that magnetic resonance imaging made an important contribution to management in 119 of 162 (73%) patients. Overall, the patients' quality of life was unchanged at the four month assessment. CONCLUSIONS Magnetic resonance imaging of patients with cranial and spinal problems influences clinicians' diagnoses and management plans, but the quality of life of these patients remains unchanged.",0,0,
1174,Maintenance Phase Efficacy of Sertraline for Chronic Depression A Randomized Controlled Trial,"Context.¡ª The chronic form of major depression is associated with a high rate of prevalence and disability, but no controlled research has examined the impact of long-term treatment on the course and burden of illness.  Objective.¡ª To determine if maintenance therapy with sertraline hydrochloride can effectively prevent recurrence of depression in the high-risk group of patients experiencing chronic major depression or major depression with antecedent dysthymic disorder (""double depression"").  Design.¡ª A 76-week randomized, double-blind, parallel-group study, conducted from September 1993 to November 1996.  Setting.¡ª Outpatient psychiatric clinics at 10 academic medical centers and 2 clinical research centers.  Intervention.¡ª Maintenance treatment with either sertraline hydrochloride (n=77) in flexible doses up to 200 mg or placebo (n=84).  Patients.¡ª A total of 161 outpatients with chronic major or double depression who responded to sertraline in a 12-week, double-blind, acute-phase treatment trial and continued to have a satisfactory therapeutic response during a subsequent 4-month continuation phase.  Main Outcome Measure.¡ª Time to recurrence of major depression.  Results.¡ª Sertraline afforded significantly greater prophylaxis against recurrence than did placebo (5 [6%] of 77 in the sertraline group vs 19 [23%] of 84 in the placebo group""; P=.002 for the log-rank test of time-to-recurrence distributions). Clinically significant depressive symptoms reemerged in 20 (26%) of 77 patients treated with sertraline vs 42 (50%) of 84 patients who received placebo (P=.001). With use of a Cox proportional hazards model, patients receiving placebo were 4.07 times more likely (95% CI, 1.51-10.95;"" P=.005) to experience a depression recurrence, after adjustment for study site, type of depression, and randomization strata.  Conclusions.¡ª Maintenance therapy with sertraline is well tolerated and has significant efficacy in preventing recurrence or reemergence of depression in chronically depressed patients.",0,0,
1175,Making comparative performance information more comprehensible: an experimental evaluation of the impact of formats on consumer understanding,"Study objectives We aimed to investigate how different presentation formats influence comprehension and use of comparative performance information (CPI) among consumers.  Methods An experimental between-subjects and within-subjects design with manipulations of CPI presentation formats. We enrolled both consumers with lower socioeconomic status (SES)/cognitive skills and consumers with higher SES/cognitive skills, recruited through an online access panel. Respondents received fictitious CPI and completed questions about interpretation and information use. Between subjects, we tested (1) displaying an overall performance score (yes/no)""; (2) displaying a small number of quality indicators (5 vs 9);"" and (3) displaying different types of evaluative symbols (star ratings, coloured dots and word icons vs numbers and bar graphs). Within subjects, we tested the effect of a reduced number of healthcare providers (5 vs 20). Data were analysed using descriptive analysis, analyses of variance and paired-sampled t tests.  Results A total of 902 (43%) respondents participated. Displaying an overall performance score and the use of coloured dots and word icons particularly enhanced consumer understanding. Importantly, respondents provided with coloured dots most often correctly selected the top three healthcare providers (84.3%), compared with word icons (76.6% correct), star ratings (70.6% correct), numbers (62.0%) and bars (54.2%) when viewing performance scores of 20 providers. Furthermore, a reduced number of healthcare providers appeared to support consumers, for example, when provided with 20 providers, 69.5% correctly selected the top three, compared with 80.2% with five providers.  Discussion Particular presentation formats enhanced consumer understanding of CPI, most importantly the use of overall performance scores, word icons and coloured dots, and a reduced number of providers displayed. Public report efforts should use these formats to maximise impact on consumers.",0,0,
1176,Making Electronic Health Records Meaningful,,0,0,
1177,Making research a requirement of treatment: why we should sometimes let doctors pressure patients to participate in research,"When a patient could be offered one of multiple established treatments, doctors should be able to offer treatment only if the patient agrees to participate in research aimed at determining which of the treatments is most effective. Making treatment conditional on research participation will help researchers complete badly needed studies.",0,0,
1178,"Making the invisible visible: a qualitative study of the values, attitudes and norms of radiologists relating to radiation safety","Some shortcomings regarding safety have emerged in inspections by the Swedish Radiation Safety Authority of Swedish radiology departments which perform 5.4 million radiological examinations and 100 000 nuclear scans annually. To ensure safety in the healthcare system and to build a strong environment of radiation protection for patients (and for employees) there must be a strong culture of safety. To understand an organization's behaviour, decisions and actions it is important to study its cultural values. The aims of this study were to discuss how values, attitudes and norms affect radiologists' decisions as well as how they influence the implementation of various radiation protection measures. To investigate this, focus group interviews and in-depth individual interviews were performed in a sample from a number of radiology departments at hospitals in Sweden. The results show that the core value was derived from the patients' perspective with the focus on the knowledge that he or she has come to the healthcare system for a particular reason: to discover disease or, in the best case, to be declared healthy. The majority attitudes were based on experiences associated with aspects that the radiologist could not influence. This often concerns increased pressure on radiology investigations from clinics in the various operational units. Under the concept of norms, the radiologists in the study requested that the development of regulations and guidelines should be connected to issues of justification for various radiological queries.",0,0,
1179,"Malaria policies versus practices, a reality check from Kinshasa, the capital of the Democratic Republic of Congo","BACKGROUND: Artemisinin-based combination therapy (ACT) following a confirmed parasitological diagnosis is recommended by the World Health Organization (WHO) and the Congolese National Malaria Control Program (NMCP). However, commitment and competence of all stakeholders (patients, medical professionals, governments and funders) is required to achieve effective case management and secure the ""useful therapeutic life"" of the recommended drugs. The health seeking behaviour of patients and health care professionals' practices for malaria management were assessed. METHODS: This was an observational study embedded in a two-stage cluster randomized survey conducted in one health centre (HC) in each of the 12 selected health zones in Kinshasa city. All patients with clinical malaria diagnosis were eligible. Their health seeking behaviour was recorded on a specific questionnaire, as well as the health care practitioners' practices. The last were not aware that their practices would be assessed. RESULTS: Six hundred and twenty four patients were assessed, of whom 136 (21.8%) were under five years. Three hundred and thirty five (55%) had taken medication prior to the current consultation (self -medication with any product or visiting another HC) of whom 47(14%) took an antimalarial drug, and 56 (9%) were treated presumptively. Among those, 53.6% received monotherapy either with quinine, artesunate, phytomedicines, sulfadoxine-pyrimethamine or amodiaquine. On the other side, when clinicians were informed about laboratory results, monotherapy was prescribed in 39.9% of the confirmed malaria cases. Only 285 patients (45.7%) were managed in line with WHO and NMCP guidelines, of whom 120 (19.2%) were prescribed an ACT after positive blood smear and 165 (26.4%) received no antimalarial after a negative result. CONCLUSION: This study shows the discrepancy between malaria policies and the reality on the field in Kinshasa, regarding patients' health seeking behaviour and health professionals' practices. Consequently, the poor compliance to the policies may contribute to the genesis and spread of antimalarial drug resistance and also have a negative impact on the burden of the disease.",0,0,
1180,Malignant lymphoma competence network,"The competence network Malignant Lymphomas is one out of 3 oncological networks which have been funded by the German Federal Ministry of Education and Research since 1999. The network's activities are based on the work of the German lymphoma research groups, which have led to significant progress in the diagnosis and therapy of malignant lymphoma over the last few years. Based on this infrastructure, the network aims to establish a professional quality management for the diagnostics and treatment of malignant lymphomas. Key aspects of activity include: 1st the establishment of an IT-based information and communication platform, 2nd IT-based networking of study groups and collaborating centres of pathology and radiotherapy, 3rd epidemiological and health care-economical research, 4th research on improved and new therapeutical approaches, 5th evidence-based medicine. Further information is presented in http://www.lymphome.de.",0,0,
1181,Management for Physicians: An Annotated Bibliography of Recent Literature,"As THE HEALTH CARE delivery system in the United States has become increasingly organized and bureaucratized, physicians frequently find themselves required to assume managerial roles. The exact nature of the physician's responsibilities may range from the line management tasks of running an emergency room, subspecialty section, or clinical department to the more advisory activities of serving on hospital committees for quality assurance, facilities design, long-range planning, personnel, or finance. Regardless of their assigned tasks and responsibilities, physicians rarely have adequate backgrounds or skills in the various management disciplines to be as effective as they want to be. As concerns over health care costs and quality force difficult decisions on hospitals and other health care institutions, however, it will be increasingly important for physicians to become better managers and to understand the opportunities and limitations of improved management.",0,1,
1182,Management of acute coronary syndromes at hospital discharge: do targeted educational interventions improve practice quality?,"Evidence-based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline-recommended medications""; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients, and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention, and reaudit. Interventions involved educational meetings, academic detailing and point-of-care reminders, and feedback of baseline audit results. Outcome measures included prescription of guideline-recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1,545 patients, and postintervention, 45 hospitals remained active in the project and recruited 1,589 patients. Three thousand and thirty-four hospital staff attended group education or academic detailing sessions. Postintervention, there was a significant increase in the prescription of all four guideline-recommended medications (69% vs. 57%; p<.0001); short-acting nitrates (68% vs. 56%; p<.0001); and documented referral to CR (68% vs. 57%;"" p<.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling, and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence-based guidelines for the management of patients with ACS.",0,0,
1183,Management of Alzheimer disease,"Management of Alzheimer disease is based on drug and nondrug treatments. Specific drug treatment includes acetylcholinesterase inhibitors and memantine. They show moderate efficacy superior to that of placebo for global condition, cognitive disorders, need for care, and behavioral problems, but do not prevent further decline. These treatments remain underused. The efficacy of psychotropic drugs (antidepressants, neuroleptics, and antipsychotic agents) in treating behavioral problems is not well documented. Nondrug activities and interventions have not been sufficiently evaluated scientifically. These involve interventions against the consequences of the disease (loss of autonomy, malnutrition) and helping patients' family caregivers. Among these activities, the best evaluated and most interesting are: educational programs for caregivers, occupational therapy at home, and interventions at home by nurses specially trained as case managers.",0,0,
1184,Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial,"BackgroundPreliminary evidence is equivocal about the role of exhaled nitric oxide (NO) in clinical asthma management. We aimed to assess whether measurement of exhaled NO, as a biomarker of airway inflammation, could increase the effectiveness of asthma treatment, when used as an adjunct to clinical care based on asthma guidelines for inner-city adolescents and young adults."";"" BackgroundPreliminary evidence is equivocal about the role of exhaled nitric oxide (NO) in clinical asthma management. We aimed to assess whether measurement of exhaled NO, as a biomarker of airway inflammation, could increase the effectiveness of asthma treatment, when used as an adjunct to clinical care based on asthma guidelines for inner-city adolescents and young adults.",0,0,
1185,Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey,"BackgroundHeart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries."";"" BackgroundHeart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries.",0,0,
1186,Management of high blood pressure in clinical practice: perceptible qualitative differences in approaches utilized by clinicians,"The authors recruited a group of physicians from among the investigators participating in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) with a greater (more successful) or lesser (less successful) proportion of trial patients meeting blood pressure (BP) control goals. The authors utilized qualitative focus group methods to identify similarities and differences in practice behaviors. Successful and less successful physicians had similarities in knowledge and practice behaviors regarding awareness of treatment guidelines, approaches to diagnosis, use of pharmacologic management, and the opinion that systolic BP guidelines should consider a patient's age. However, there were discernible differences between the two physician groups in their views on doctor-patient relationships: physicians from the less successful group were more paternalistic with their patients, while physicians from the more successful group were more likely to use a patient-centered clinical approach to BP awareness and management.",0,0,
1187,Management of obesity in patients with type 2 diabetes mellitus in primary care,"AIMS: Obesity and being overweight is the most powerful risk factor accounting for 80-90% of patients with type 2 diabetes mellitus (T2DM). The epidemic of obesity is driving the diabetes epidemic to alarming levels and primary care is becoming an important setting for obesity management in T2DM in India. Yet many primary care providers feel ill-equipped or inadequately supported to address obesity in patients with diabetes. This article reviews the most recent and strongest evidence-based strategies that may aid physicians in management of obesity in patients with T2DM in primary care. MATERIAL AND METHODS: A systematic literature search of MEDLINE using the search terms Obesity, Obesity in T2DM, weight loss and Primary Care was conducted. The American Diabetes Association, National Institute for Health, National Institute of Health and Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and World Health Organization websites were also searched. Most studies in this area are observational in design with few randomized controlled trials (RCTs). Articles and studies involving meta-analysis or RCTs were preferred over other types. RESULTS AND CONCLUSION: Effective weight management treatment in T2DM patient can be implemented in the primary care setting. Evidence based individualized lifestyle and pharmacologic measures supported by behavioral intervention and counseling with appropriate and informed surgical referrals has the potential to improve the success of weight management within primary care.",0,0,
1188,Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians,"Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the management of obstructive sleep apnea (OSA) in adults. Methods: This guideline is based on published literature from 1966 to September 2010 that was identified by using MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. A supplemental MEDLINE search identified additional articles through October 2012. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included cardiovascular disease (such as heart failure, hypertension, stroke, and myocardial infarction), type 2 diabetes, death, sleep study measures (such as the Apnea¨CHypopnea Index), measures of cardiovascular status (such as blood pressure), measures of diabetes status (such as hemoglobin A1c levels), and quality of life. This guideline grades the evidence and recommendations using ACP's clinical practice guidelines grading system. Recommendation 1: ACP recommends that all overweight and obese patients diagnosed with OSA should be encouraged to lose weight. (Grade: strong recommendation""; low-quality evidence) Recommendation 2: ACP recommends continuous positive airway pressure treatment as initial therapy for patients diagnosed with OSA. (Grade: strong recommendation; moderate-quality evidence) Recommendation 3: ACP recommends mandibular advancement devices as an alternative therapy to continuous positive airway pressure treatment for patients diagnosed with OSA who prefer mandibular advancement devices or for those with adverse effects associated with continuous positive airway pressure treatment. (Grade: weak recommendation;"" low-quality evidence)",0,0,
1189,"Management of occupational therapy services for persons with cognitive impairments (statement). The American Occupational Therapy Association, Inc","In summary, occupational therapy practitioners play a critical role in helping persons with cognitive impairments establish or maintain meaningful and productive lives within their social and cultural environment. Occupational therapy practitioners effectively address a wide range of cognitive difficulties in clients with a variety of ages and diagnoses. Intervention may be directed toward the individual with cognitive impairments or toward persons who care for or interact with them (e.g., family members, significant others, employers, school personnel, other health care workers). Treatment includes changing the person's skills or behaviors or adapting the task and/or environment to maintain function, ease care-giving, reduce safety hazards, and maximize independence.",0,0,
1190,Management of persistent pain in the older patient: a clinical review,"IMPORTANCE: Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE: To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities""; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION: Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS: Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities;"" the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE: Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.",0,0,
1191,Management of severe hypertension in France in 1999 and 2000: intermediate results of a health insurance intervention program,"AIM: Within the framework of its long-term public health program aimed at improving the clinical management of hypertension (HBP), the French health care funds performed two nationwide surveys concerning affiliates who were recently waived from making co-payments for severe hypertension. The aim was to measure the difference between observed clinical management and benchmark care, defined by the 1997 ANAES guidelines (National Agency for Accreditation and Health Evaluation), at the onset (May 1999) and during the program (November 1999) in order to detect any changes in clinical management between the two study periods, the timeframe corresponding to the intervention period. METHODS: The patient samples used in the two studies involved affiliates aged between 20 and 80 years old living in France or one of its overseas territories who were recently waived from making co-payments (ETM) for severe hypertension (these patients are reimbursed 100% for all care related to the disorder). The evaluation was based on retrospective data furnished by attending physicians. The indicators isolated in order to compare the two study periods were blood pressure control, suggested life-style changes and prescribed drugs. RESULTS: The first survey took place between May and November 1999 and enrolled 10,665 patients (corresponding to a weighted patient population of 50,383) while the second studied 2,649 patients in November 2000. The study population in 1999 was, on the average, younger than the study population in November 2000: 63.1 years +/- 0.2 vs 65.4 years +/- 0.4. Nearly two patients out of three presented at least one other major cardiovascular risk factor in addition to HBP (cigarette smoking, diabetes mellitus or dyslipidemia): 63.9% in 1999 and 64.4% in 2000. Nearly one patient out of seven had associated coronary artery disease: 14.1% in 1999 and 15.3% in 2000 and more than one out of ten had associated cerebro-vascular disease: 12.7% in 1999 and 12.2% in 2000. There were more diabetic patients in the 1999 group than in the 2000 group: 27.5% +/- 1.0 vs 23.9% +/- 1.6. The proportion of patients who had poorly controlled blood pressure (systolic > 140 mmHg or > 160 mmHg in subjects aged between 60 and 80 years with isolated systolic hypertension, or a diastolic > 90 mmHg) did not change: 46.8% +/- 1.1 in 1999 and 45.7% +/- 1.9 in 2000. If the guideline recommendations for diabetics (blood pressure < 130/85) are applied. 85.4% of the diabetic patients were poorly controlled in 1999 and 86.6% in 2000. Similarly, in hypertensive patients with kidney failure (guideline recommendations: < 125/75 mmHg), 94.5% were poorly controlled in 1999 and 96.3% in 2000. Recommended life-style changes (reduction in salt intake, weight loss, lower alcohol consumption, increased physical activity) were not well followed in both studies: in 1999, fewer than one patient out of four completely implemented the desired changes (23.7%) while only 24.5% did so in 2000. Physicians prescribed specifically indicated therapeutic agents considering associated diseases in 68.0% of the patients in 1999 and in 67.6% in 2000. Prescriptions contained a potentially contraindicated drug in 27.3% of the cases in 1999 and in 28.0% in 2000. CONCLUSION: A comparison of the results of the two surveys performed in 1999 and 2000 concerning the management of patients with severe hypertension failed to demonstrate any significant differences in blood pressure control or treatment modalities. While not questioning the value of the interventions of the health funds, these findings illustrate how difficult it is to change clinical practice over a short time period, especially in a disorder involving a number of different elements which include, among others, individual patient behavior. In order to significantly improve clinical management, it will probably be necessary to continue the dialogue between medical advisors of the health care funds (medecins conseils) and clinicians and to renew campaigns aimed at helping patients become more responsible.",0,0,
1192,Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study,"OBJECTIVES To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign's resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance. DESIGN Prospective cohort study. SETTING 150 intensive care units in 16 Asian countries. PARTICIPANTS 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients' baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded. MAIN OUTCOME MEASURE Compliance with the Surviving Sepsis Campaign's resuscitation (six hours) and management (24 hours) bundles. RESULTS Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285""; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870;"" 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle. CONCLUSIONS While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.",0,1,
1193,Management of Stable Ischemic Heart Disease: Summary of a Clinical Practice Guideline From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons,"Description: The American College of Physicians (ACP) developed this guideline with the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons to present the available evidence on the management of stable known or suspected ischemic heart disease. Methods: Literature on this topic published before November 2011 was identified by using MEDLINE, Embase, Cochrane CENTRAL, PsychINFO, AMED, and SCOPUS. Searches were limited to human studies published in English. This guideline grades the evidence and recommendations according to a translation of the ACCF/AHA grading system into ACP's clinical practice guidelines grading system. Recommendations: The guideline includes 48 specific recommendations that address the following issues: patient education, management of proven risk factors (dyslipidemia, hypertension, diabetes, physical activity body weight, and smoking), risk factor reduction strategies of unproven benefit, medical therapy to prevent myocardial infarction and death and to relieve symptoms, alternative therapy, revascularization to improve survival and symptoms, and patient follow-up.",0,0,
1194,Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting,"INTRODUCTION: Patient agitation represents a significant challenge in the emergency department (ED), a setting in which medical staff are working under pressure dealing with a diverse range of medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff, and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time constraints and limited access to specialist psychiatric support have in the past led to the strategy of ""restrain and sedate,"" which was believed to represent the optimal approach"";"" however, it is increasingly recognized that more patient-centered approaches result in improved outcomes. The objective of this review is to raise awareness of best practices for the management of agitation in the ED and to consider the role of new pharmacologic interventions in this setting. DISCUSSION: The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines address the complete management of agitation, including triage, diagnosis, interpersonal calming skills, and medicine choices. Since their publication in 2012, there have been further developments in pharmacologic approaches for dealing with agitation, including both new agents and new modes of delivery, which increase the options available for both patients and physicians. Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/sublingual and intranasal formulations. To date, the only formulation administered via a non-intramuscular route with a specific indication for agitation associated with bipolar or schizophrenia is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have the potential to improve overall patient experience, thereby improving future cooperation between patients and healthcare providers. CONCLUSION: Management of agitation in the ED should encompass a patient-centered approach, incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is necessary, a cooperative approach using non-invasive medications should be employed where possible.",0,0,
1195,Managing pain in high-risk patients within a patient-centered medical home,"Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the ""true"" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid.",0,0,
1196,Managing panic attacks in emergency patients,"Patients experiencing panic attacks often seek help at emergency departments. However, the symptoms of panic can be difficult to distinguish from some common medical emergencies. Furthermore, many emergency medicine clinicians may not be equipped to deal effectively with panic attacks and related psychiatric conditions such as panic disorder and agoraphobia. Early misdiagnosis and inadequate management of panic attacks can have devastating long-term clinical and financial consequences. The purpose of this paper is to provide information designed to increase the comfort and efficacy of emergency physicians and allied professionals in dealing with panic attacks. The authors offer guidelines regarding differential diagnosis, present strategies for management of acute symptoms of panic and anxiety, and make recommendations for brief postpanic clinical intervention.",0,0,
1197,Managing perceived conflicts of interest while ensuring the continued innovation of medical technology,"If it were not for the ongoing collaboration between vascular surgeons and the medical technology industry, many of these advanced treatments used every day in vascular interventional surgery would not exist. The flip side of this coin is that these vital relationships create multiple roles for surgeons and must be appropriately managed. The dynamic process of innovation, along with factors such as product delivery technique refinement, education, testing and clinical trials, and product support, all make it necessary for ongoing and close collaboration between surgeons and the device industry. This unique relationship sometimes leads to the perception of conflicts of interest for physicians, in part because the competing pressures from the multiple, overlapping roles as clinician/caregiver/investigator/innovator/customer are significant. To address this issue, the Advanced Medical Technology Association (AdvaMed), the nation's largest medical technology association representing medical device and diagnostics companies, developed a Code of Ethics to guide medical technology companies in their interactions with health care professionals. First introduced in 1993, the AdvaMed Code strongly encourages both industry and physicians to commit to openness and high ethical standards in the conduct of their business interactions. The AdvaMed Code addresses many of the types of interactions that can occur between companies and health care professionals, including training, consulting agreements, the provision of demonstration and evaluation units, and charitable donations. By following the Code, companies send a strong message that treatment decisions must always be based on the best interest of the patient.",0,0,
1198,Managing urinary incontinence in stroke rehabilitation--a review,"BACKGROUND: Urinary incontinence following stroke is an extensive problem for the patients and their relatives that influences the well-being and care in the future. There are a lot of therapeutic interventions available, their effectiveness, however, is not known in detail. For rehabilitation practice the ongoing question is how Urinary Incontinence (UI) can best be treated in a way that the patients daily life is not compromised. METHOD: The search for clinical trials was carried out in PubMed, CINAHL, and Cochrane Library, restricted to German and English papers published between 1989 and April 2005. Medical, nursing and physiotherapeutic interventions for treating UI after stroke were described and analysed. RESULTS: The clinical trials were divided into process-oriented trials and those looking at individual interventions. The process trials could be divided into three different groups with an overall success of 82-95 %, 50-56 % and 23-36 % respectively. Behavioral methods (caregiver-induced, patient-active and other interventions) and medical interventions are available. The studies of the most successful group include staff education and application of interventions based on an assessment procedure and a guideline. No clinical trial on individual interventions reached a result like the process-oriented studies. CONCLUSION: For treating urinary incontinence a multimodal approach is necessary: special education of the nurses, applying and acting in a problem-solving process, for example in the Rehabilitation Cycle and delivering care based on an assessment procedure and guidelines. Development of a guideline for treating urinary incontinence after stroke can be recommended. Further research in the efficacy of individual interventions is needed.",0,0,
1199,Marketing an investigational drug service,"The customer survey was a useful tool for marketing the IDS. It provided guidelines for making decisions about the best use of limited human and material resources. Analyzing the results of the survey provided new priorities and directions for the IDS. These results were then used in conjunction with pharmacy financial and operational data to focus on areas of greatest importance to the customers and the pharmacy. Physicians should not be reluctant to pursue compassionate use treatments because of the administrative programs responsibilities that accompany such programs. Every patient should have the opportunity to benefit from alternative therapies that are investigational. For the quality of patient care to be maintained or even enhanced when studies are conducted, nurses must be well trained. The marketing survey fulfilled its purpose of identifying service gaps and allowing us to improve our services.",0,0,
1200,Massachusetts General Physicians Organization’s quality incentive program produces encouraging results,"Physicians are increasingly becoming salaried employees of hospitals or large physician groups. Yet few published reports have evaluated provider-driven quality incentive programs for salaried physicians. In 2006 the Massachusetts General Physicians Organization began a quality incentive program for its salaried physicians. Eligible physicians were given performance targets for three quality measures every six months. The incentive payments could be as much as 2 percent of a physician’s annual income. Over thirteen six-month terms, the program used 130 different quality measures. Although quality-of-care improvements and cost reductions were difficult to calculate, anecdotal evidence points to multiple successes. For example, the program helped physicians meet many federal health information technology meaningful-use criteria and produced $15.5 million in incentive payments. The program also facilitated the adoption of an electronic health record, improved hand hygiene compliance, increased efficiency in radiology and the cancer center, and decreased emergency department use. The program demonstrated that even small incentives tied to carefully structured metrics, priority setting, and clear communication can help change salaried physicians’ behavior in ways that improve the quality and safety of health care and ease the physicians’ sense of administrative burden.",0,1,
1201,MASTERPLAN: study of the role of nurse practitioners in a multifactorial intervention to reduce cardiovascular risk in chronic kidney disease patients,"Moderate to severe chronic kidney disease (CKD) is associated with increased cardiovascular risk. Usually nephrologists are primarily responsible for the care of CKD patients. However, in many cases treatment goals, as formulated in guidelines, are not met. The addition of a nurse practitioner might improve the quality of care. The Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN) study is a randomized controlled multicenter trial, aimed at investigating whether a multifactorial approach in patients with moderate to severe CKD (stage 3 and 4) to achieving treatment goals using both a polydrug strategy and lifestyle treatment either with or without the addition of a nurse practitioner will reduce cardiovascular risk and slow the decline of kidney function. Patients (n=793) have been randomized to nurse care or physician care. In the nurse-care arm of the study, nurse practitioners use flowcharts to address risk factors requiring drug and/or lifestyle modification. They have been trained to coach patients by motivational interviewing with the aim of improving patient self-management. At baseline, both treatment groups show equal distributions with regard to key variables in the study. Moreover, in only 1 patient were all risk factors within the limits as defined in various guidelines, which underscores the relevance of our initiative.",0,0,
1202,Maternal dietary intake and physical activity habits during the postpartum period: associations with clinician advice in a sample of Australian first time mothers,"BACKGROUND: Numerous health benefits are associated with achieving optimal diet and physical activity behaviours during and after pregnancy. Understanding predictors of these behaviours is an important public health consideration, yet little is known regarding associations between clinician advice and diet and physical activity behaviours in postpartum women. The aims of this study were to compare the frequency of dietary and physical activity advice provided by clinicians during and after pregnancy and assess if this advice is associated with postpartum diet and physical activity behaviours. METHODS: First time mothers (n = 448) enrolled in the Melbourne InFANT Extend trial completed the Cancer Council of Australia's Food Frequency Questionnaire when they were three to four months postpartum, which assessed usual fruit and vegetable intake (serves/day). Total physical activity time, time spent walking and time in both moderate and vigorous activity for the previous week (min/week) were assessed using the Active Australia Survey. Advice received during and following pregnancy were assessed by separate survey items, which asked whether a healthcare practitioner had discussed eating a healthy diet and being physically active. Linear and logistic regression assessed associations of advice with dietary intake and physical activity. RESULTS: In total, 8.6% of women met guidelines for combined fruit and vegetable intake. Overall, mean total physical activity time was 350.9 +/- 281.1 min/week. Time spent walking (251.97 +/- 196.78 min/week), was greater than time spent in moderate (36.68 +/- 88.58 min/week) or vigorous activity (61.74 +/- 109.96 min/week) and 63.2% of women were meeting physical activity recommendations. The majority of women reported they received advice regarding healthy eating (87.1%) and physical activity (82.8%) during pregnancy. Fewer women reported receiving healthy eating (47.5%) and physical activity (51.9%) advice by three months postpartum. There was no significant association found between provision of dietary and/or physical activity advice, and mother's dietary intakes or physical activity levels. CONCLUSIONS: Healthy diet and physical activity advice was received less after pregnancy than during pregnancy yet no association between receipt of advice and behaviour was observed. More intensive approaches than provision of advice may be required to promote healthy diet and physical activity behaviours in new mothers. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12611000386932 13/04/2011).",0,0,
1203,McMaster PLUS: a cluster randomized clinical trial of an intervention to accelerate clinical use of evidence-based information from digital libaries,"Background: Physicians have difficulty keeping up with new evidence from medical research.  Methods: We developed the McMaster Premium LiteratUre Service (PLUS), an internet-based addition to an existing digital library, which delivered quality- and relevance-rated medical literature to physicians, matched to their clinical disciplines. We evaluated PLUS in a cluster-randomized trial of 203 participating physicians in Northern Ontario, comparing a Full-Serve version (that included alerts to new articles and a cumulative database of alerts) with a Self-Serve version (that included a passive guide to evidence-based literature). Utilization of the service was the primary trial end-point.  Results: Mean logins to the library rose by 0.77 logins/month/user (95% CI 0.43, 1.11) in the Full-Serve group compared with the Self-Serve group. The proportion of Full-Serve participants who utilized the service during each month of the study period showed a sustained increase during the intervention period, with a relative increase of 57% (95% CI 12, 123) compared with the Self-Serve group. There were no differences in these proportions during the baseline period, and following the crossover of the Self-Serve group to Full-Serve, the Self-Serve group's usage became indistinguishable from that of the Full-Serve group (relative difference 4.4 (95% CI -23.7, 43.0). Also during the intervention and crossover periods, measures of self-reported usefulness did not show a difference between the 2 groups.  Conclusion: A quality- and relevance-rated online literature service increased the utilization of evidence-based information from a digital library by practicing physicians.",0,1,
1204,Measures for assessing practice change in medical practitioners,"BACKGROUND: There are increasing numbers of randomised trials and systematic reviews examining the efficacy of interventions designed to bring about a change in clinical practice. The findings of this research are being used to guide strategies to increase the uptake of evidence into clinical practice. Knowledge of the outcomes measured by these trials is vital not only for the interpretation and application of the work done to date, but also to inform future research in this expanding area of endeavour and to assist in collation of results in systematic reviews and meta-analyses. METHODS: The objective of this review was to identify methods used to measure change in the clinical practices of health professionals following an intervention aimed at increasing the uptake of evidence into practice. All published trials included in a recent, comprehensive Health Technology Assessment of interventions to implement clinical practice guidelines and change clinical practice (n = 228) formed the sample for this study. Using a standardised data extraction form, one reviewer (SH), extracted the relevant information from the methods and/or results sections of the trials. RESULTS: Measures of a change of health practitioner behaviour were the most common, with 88.8% of trials using these as outcome measures. Measures that assessed change at a patient level, either actual measures of change or surrogate measures of change, were used in 28.8% and 36.7% of studies (respectively). Health practitioners' knowledge and attitudes were assessed in 22.8% of the studies and changes at an organisational level were assessed in 17.6%. CONCLUSION: Most trials of interventions aimed at changing clinical practice measured the effect of the intervention at the level of the practitioner, i.e. did the practitioner change what they do, or has their knowledge of and/or attitude toward that practice changed? Less than one-third of the trials measured, whether or not any change in practice, resulted in a change in the ultimate end-point of patient health status.",0,0,
1205,Measuring and Monitoring Success in Compressing Morbidity,,0,0,
1206,Measuring persistence of implementation: QUERI Series,"As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the ""need for further research"" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses.  This article is one in a Series of articles documenting implementation science frameworks and approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).",0,1,
1207,Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care?,"Objective.—To examine whether a collaborative to improve pediatric asthma care positively influenced processes and outcomes of that care.  Methods.—Medical record abstractions and patient/parent interviews were used to make pre- and postintervention comparisons of patients at 9 sites that participated in the evaluation of a Breakthrough Series (BTS) collaborative for asthma care with patients at 4 matched control sites.  Setting.—Thirteen primary care clinics.  Patients.—Three hundred eighty-five asthmatic children who received care at an intervention clinic and 126 who received care at a control clinic (response rate = 76%).  Intervention.—Three 2-day educational sessions for quality improvement teams from participating sites followed by 3 “action” periods over the course of a year.  Results.—The overall process of asthma care improved significantly in the intervention group but remained unchanged in the control group (change in process score +13% vs 0%""; P < .0001). Patients in the intervention group were more likely than patients in the control group to monitor their peak flows (70% vs 43%; P < .0001) and to have a written action plan (41% vs 22%; P = .001). Patients in the intervention group had better general health-related quality of life (scale score 80 vs 77; P = .05) and asthma-specific quality of life related to treatment problems (scale score 89 vs 85;"" P < .05).  Conclusions.—The intervention improved some important aspects of processes of care that have previously been linked to better outcomes. Patients who received care at intervention clinics also reported higher general and asthma-specific quality of life.",0,1,
1208,Measuring the effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: a systematic review,"BACKGROUND: Mentoring as a knowledge translation (KT) intervention uses social influence among healthcare professionals to increase use of evidence in clinical practice. AIM: To determine the effectiveness of mentoring as a KT intervention designed to increase healthcare professionals' use of evidence in clinical practice. METHODS: A systematic review was conducted using electronic databases (i.e., MEDLINE, CINAHL), grey literature, and hand searching. Eligible studies evaluated mentoring of healthcare professionals responsible for patient care to enhance the uptake of evidence into practice. Mentoring is defined as (a) a mentor more experienced than mentee""; (b) individualized support based on mentee's needs;"" and (c) involved in an interpersonal relationship as indicated by mutual benefit, engagement, and commitment. Two reviewers independently screened citations for eligibility, extracted data, and appraised quality of studies. Data were analyzed descriptively. RESULTS: Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Mentoring as a KT intervention was evaluated in Canada, USA, and Australia. Exposure to mentoring compared to no mentoring improved some behavioral outcomes (one study). Compared to controls or other multifaceted interventions, multifaceted interventions with mentoring improved practitioners' knowledge (four of five studies), beliefs (four of six studies), and impact on organizational outcomes (three of four studies). There were mixed findings for changes in professionals' behaviors and impact on practitioners' and patients' outcomes: some outcomes improved, while others showed no difference. LINKING EVIDENCE TO ACTION: Only one study evaluated the effectiveness of mentoring alone as a KT intervention and showed improvement in some behavioral outcomes. The other nine studies that evaluated the effectiveness of mentoring as part of a multifaceted intervention showed mixed findings, making it difficult to determine the added effect of mentoring. Further research is needed to identify effective mentoring as a KT intervention.",0,0,
1209,Measuring the effects of reminders for outpatient influenza immunizations at the point of clinical opportunity,"OBJECTIVE: To evaluate the influence of computer-based reminders about influenza vaccination on the behavior of individual clinicians at each clinical opportunity. DESIGN: The authors conducted a prospective study of clinicians' influenza vaccination behavior over four years. Approximately one half of the clinicians in an internal medicine clinic used a computer-based patient record system (CPR users) that generated computer-based reminders. The other clinicians used traditional paper records (PR users). MEASUREMENTS: Each nonacute visit by a patient eligible for an influenza vaccination was considered an opportunity for intervention. Patients who had contraindications for vaccination were excluded. Compliance with the guideline was defined as documentation that a clinician ordered the vaccine, counseled the patient about the vaccine, offered the vaccine to a patient who declined it, or verified that the patient had received the vaccine elsewhere. The authors calculated the proportion of opportunities on which each clinician documented action in the CPR and PR user groups. RESULTS: The CPR and PR user groups had different baseline compliance rates (40.1 and 27.9 per cent, respectively"";"" P<0.05). Both rates remained stable during a two-year baseline period (P = 0.34 and P = 0.47, respectively). The compliance rates in the CPR user group increased 78 per cent from baseline (P<0.001), whereas the rates for the PR user group did not change significantly (P = 0.18). CONCLUSIONS: Clinicians who used a CPR with reminders had higher rates of documentation of compliance with influenza-vaccination guidelines than did those who used a paper record. Measurements of individual clinician behavior at the point of each clinical opportunity can provide precise evaluation of interventions that are designed to improve compliance with guidelines.",0,1,
1210,Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes,"Preliminary results were presented as a poster at the American Medical Informatics Association Annual Meeting, Washington, DC, October 2005. After the study was completed, C.O. and K.D. became officers of Open Source Order Sets (OSOS), a company that has created an order set collaborative for Canadian hospitals. OSOS had no involvement in the current study. This study received no specific funding. J.F. is supported by a Canadian Institutes of Health Research (CIHR) Clinician‐Scientist Award. We thank Barbara Stanek for her invaluable assistance with collection of health records data.",1,1,
1211,Medical care of type 2 diabetes mellitus in light of international and national recommendations: a retrospective analysis,"QUESTION UNDER STUDY: Type 2 diabetes mellitus (T2Dm) is a chronic disease with great economic impact. In 2009, the Swiss Society for Endocrinology and Diabetes (SSED) published recommendations for treatment of T2Dm. In Switzerland, few data are currently available on metabolic control and physician compliance with treatment guidelines. We aimed to investigate clinical care in T2Dm in the year after the publication of SSED recommendations. METHODS: We retrospectively studied the charts of all patients with T2Dm admitted to our general internal medicine clinic during 2009. Metabolic control was judged from glycated haemoglobin A1c (HbA1c) levels. Antidiabetic therapy was analysed, and frequencies of screening for end-organ damage were investigated. A group with newly diagnosed T2Dm was analysed separately from patients with known T2Dm upon admission. RESULTS: In patients with known T2Dm, the mean (+/- standard deviation) HbA1c level was 7.66% +/- 1.73%. Only 44% of patients showed HbA1c levels at the target of 8.5%, the proportion of those treated with insulin increased from 49% upon admission to 76% at discharge. Only half the patients received a lifestyle intervention in the year prior to admission or during hospital stay. Screening for diabetic retinopathy and nephropathy was performed in approximately one-third and two-thirds of patients, respectively. CONCLUSIONS: In the majority of unselected T2Dm patients admitted to our hospital, metabolic control was suboptimal. Implementation of treatment recommendations by both general practitioners and hospitals should be improved.",0,0,
1212,Medical communication and technology: a video-based process study of the use of decision aids in primary care consultations,"BACKGROUND: Much of the research on decision-making in health care has focused on consultation outcomes. Less is known about the process by which clinicians and patients come to a treatment decision. This study aimed to quantitatively describe the behaviour shown by doctors and patients during primary care consultations when three types of decision aids were used to promote treatment decision-making in a randomised controlled trial. METHODS: A video-based study set in an efficacy trial which compared the use of paper-based guidelines (control) with two forms of computer-based decision aids (implicit and explicit versions of DARTS II). Treatment decision concerned warfarin anti-coagulation to reduce the risk of stroke in older patients with atrial fibrillation. Twenty nine consultations were video-recorded. A ten-minute 'slice' of the consultation was sampled for detailed content analysis using existing interaction analysis protocols for verbal behaviour and ethological techniques for non-verbal behaviour. RESULTS: Median consultation times (quartiles) differed significantly depending on the technology used. Paper-based guidelines took 21 (19-26) minutes to work through compared to 31 (16-41) minutes for the implicit tool""; and 44 (39-55) minutes for the explicit tool. In the ten minutes immediately preceding the decision point, GPs dominated the conversation, accounting for 64% (58-66%) of all utterances and this trend was similar across all three arms of the trial. Information-giving was the most frequent activity for both GPs and patients, although GPs did this at twice the rate compared to patients and at higher rates in consultations involving computerised decision aids. GPs' language was highly technically focused and just 7% of their conversation was socio-emotional in content;"" this was half the socio-emotional content shown by patients (15%). However, frequent head nodding and a close mirroring in the direction of eye-gaze suggested that both parties were active participants in the conversation CONCLUSION: Irrespective of the arm of the trial, both patients' and GPs' behaviour showed that they were reciprocally engaged in these consultations. However, even in consultations aimed at promoting shared decision-making, GPs' were verbally dominant, and they worked primarily as information providers for patients. In addition, computer-based decision aids significantly prolonged the consultations, particularly the later phases. These data suggest that decision aids may not lead to more 'sharing' in treatment decision-making and that, in their current form, they may take too long to negotiate for use in routine primary care.",0,0,
1213,Medical Diagnosis through Semiotics: Giving Meaning to the Sign,"Physicians are engaged in incorporating quantitative methods for making clinical decisions into their practices. An acquaintance with semiotics, the doctrine of signs, may complement this project. A sign stands for something. We communicate indirectly through signs, and by interpreting what signs mean we make sense of our world and diagnose and understand our patients. Thus, through association and inference, we transform flowers into love, Othello into jealousy, and staring eyes into thyrotoxicosis.Characteristically in diagnosis, beginning with an unstable inference, we test and otherwise ask questions likely to produce signs that support (or discredit) our hypothesis. In a literary sense, we join with the author to clarify and rewrite the text""; creative interpretation is the key. Diagnosis is concluded through narration, by the meaning that is revealed by telling the story of the patient.Diagnosis will succeed only to the extent that we respect the principles and caveats of sign interpretation. The sign is both the key to the unknown and the master impersonator. The sign and its meaning are usually not the same;"" meaning has to be inferred. Because interpretations are made subjectively, they are circumscribed by the experience and bias of the clinician. Moreover, the contexts in which the sign appears shape the meaning of the sign and may change it altogether.",0,0,
1214,Medical ethics in a revolutionary age,,0,0,
1215,Medical research and Alzheimer's disease: a study of the hazards of conducting research on the incompetent patient,"Following a review of legal issues concerning the significance of capacity and consent in the context of clinical research involving groups of patients where some may be incompetent, the question is addressed how those involved in this area resolve the problems. Responses from 101 Local Research Ethics Committees, 13 pharmaceutical companies and 10 researchers engaged in work involving patients with Alzheimer's Disease indicate a considerable variation in approaches to the legal and ethical issues, as well as a degree of conflict concerning the assessment of patients' capacity to consent. The conclusion is that recent proposals from the Law Commission in this area need further consideration and elaboration in several respects.",0,0,
1216,Medical research: the role and responsibilities of doctors,"The General Medical Council in the UK has decided to join the already very large number of organisations, nationally and internationally, that issue guidelines on the conduct of research. This might be related to the fact that the UK, via the GMC, takes research misconduct more seriously than most countries, except that the GMC is developing separate guidelines in that area, in association with the Royal College of Physicians. So the purpose of yet another set of guidelines, albeit ones that will be professionally binding on doctors, is unclear. The draft guidelines are available for comment until 21 June and are reprinted below.",0,0,
1217,Medical treatment of benign prostatic hyperplasia: physician and patient preferences and satisfaction,"Practice guidelines acknowledge the importance of patient preferences in determining the appropriate treatment of benign prostatic hyperplasia (BPH). Recent literature suggests that patient and physician perspectives and satisfaction with BPH treatment management may differ"";"" this may have an impact on clinical outcomes and patient compliance. This review evaluates patients' and physicians' preferred treatment options for managing BPH and patient satisfaction with therapy. A Medline-based systematic review using the terms 'Benign prostatic hyperplasia' + 'Patient preference/perception/satisfaction' or 'Physician/urologist preference/perception' was performed. Patients prefer therapies affecting long-term disease progression over those that provide short-term symptom improvement, which contrasts with the beliefs of their physicians. The prescribing behaviour of urologists and primary care physicians can be very varied. Studies of patient satisfaction with specific treatments generally show a high level of overall satisfaction, but cross-study comparisons are limited because of heterogeneity in study design. The evidence to date suggests that patients' views and beliefs and those of their physician may not always be in agreement. Improved physician-patient communication will help determine the best treatment option for patients with BPH and may ensure greater compliance and treatment success.",0,0,
1218,Medication Reconciliation During Transitions of Care as a Patient Safety Strategy,"Medication reconciliation identifies and resolves unintentional discrepancies between patients' medication lists across transitions in care. The purpose of this review is to summarize evidence about the effectiveness of hospital-based medication reconciliation interventions. Searches encompassed MEDLINE through November 2012 and EMBASE and the Cochrane Central Register of Controlled Trials through July 2012. Eligible studies evaluated the effects of hospital-based medication reconciliation on unintentional discrepancies with nontrivial risks for harm to patients or 30-day postdischarge emergency department visits and readmission. Two reviewers evaluated study eligibility, abstracted data, and assessed study quality.Eighteen studies evaluating 20 interventions met the selection criteria. Pharmacists performed medication reconciliation in 17 of the 20 interventions. Most unintentional discrepancies identified had no clinical significance. Medication reconciliation alone probably does not reduce postdischarge hospital utilization but may do so when bundled with interventions aimed at improving care transitions.",0,0,
1219,Medication review and reconciliation with cooperation between pharmacist and general practitioner and the benefit for the patient: a systematic review,"This article systematically reviews the literature on the impact of collaboration between pharmacists and general practitioners and describes its effect on patients' health. A systematic literature search provided 1041 articles. After first review of title and abstract, 152 articles remained. After review of the full text, 83 articles were included. All included articles are presented according to the following variables: (i) reference""; (ii) design and setting of the study; (iii) inclusion criteria for patients; (iv) description of the intervention; (v) whether a patient interview was performed to involve patients' experiences with their medicine-taking behaviour; (vi) outcome; (vii) whether healthcare professionals received additional training; and (viii) whether healthcare professionals received financial reimbursement. Many different interventions are described where pharmacists and general practitioners work together to improve patients' health. Only nine studies reported hard outcomes, such as hospital (re)admissions;"" however, these studies had different results, not all of which were statistically significant. Randomized controlled trials should be able to describe hard outcomes, but large patient groups will be needed to perform such studies. Patient involvement is important for long-term success.",0,0,
1220,Medicine and human rights: reflections on the fiftieth anniversary of the doctors' trial,"1996 marks the fiftieth anniversary of the commencement of the trial of Nazi physicians at Nuremberg, a trial that has been variously designated as the ""Doctors' Trial"" and the ""Medical Case."" In addition to documenting atrocities committed by physicians and scientists during WWII, the most significant contribution of the trial has come to be known as the ""Nuremberg Code,"" a judicial codification of 10 prerequisites for the moral and legal use of human beings in experiments. Anniversaries provide us with an opportunity to reflect upon the past, but they also ena ble us to renew our efforts to plan for the future. This article describes briefly the historical evolution of the Nuremberg Code, discusses its current relevance and applicability by using a case study example, and proposes future steps to be taken by the international community.",0,0,
1221,Meeting expectations: the pilot evaluation of the Solihull Approach Parenting Group,"We have developed a new parenting group based on National Institute for Health and Clinical Excellence guidelines for parenting groups for conduct disorder and the Solihull Approach, a multi-agency approach to improve the parent-child relationship and behaviour management. Our aims were to create a parenting group that was theoretically coherent, of proven effectiveness, time efficient, for universal through to more complex problems, for parents of children from birth to 18 years, accessible to parents with literacy difficulties, able to be run by community practitioners such as health visitors and school nurses, and supported by a cost-effective and uncomplicated staff training model. This article describes the development of the Solihull Approach Parenting Group and the results of its first large-scale pilot evaluation. The results show an improvement in child behaviour and reductions in parental anxiety.",0,0,
1222,"Melding regulatory, pharmaceutical industry, and U.S. payer perspectives on improving approaches to heterogeneity of treatment effect in research and practice","Effective pursuit of the science and management of heterogeneity of treatment effect (HTE) relies on the mutual understanding of the perspectives of, and collaboration among, the various stakeholders in health care. In this article, we compare, contrast, and endeavor to find areas of alignment across the perspectives of three such stakeholders -regulators, the biopharmaceutical and device industry, and U.S. payers. First, we discuss how evidence of HTE is generated and could be improved upon. For pharmaceuticals, much of the initial research is conducted by the pharmaceutical industry, guided by basic science but also delimited by potential markets, regulatory approval requirements, trial size considerations, and payer expectations for evidence of value. Once a drug is marketed, further evidence can be generated via combining trial data, conducting meta-analysis, and analyzing real-world results through observational research designs"";"" we explore how these efforts can benefit from cooperation across these stakeholders. Second, we discuss the equally important utilization of HTE evidence so that physicians and patients have access to and can benefit from the learnings from this research. Research findings must be translated into actionable information and guidelines that can be incorporated into everyday practice. Doing so requires interaction and collaboration among all involved, based on facilitated communication as well as further evaluation research. We provide examples of several cross-sectorial initiatives that are under way in this area. Finally, we explore some economic aspects of HTE research as part of the drug development, marketing, and treatment process. Understanding the economic incentives present is fundamental to aligning those incentives to improve the availability and utilization of HTE evidence. Clear understandings among regulators, pharma, and payers about high-value targets, methods to efficiently generate and communicate information, and value propositions can lead to ""win-win"" scenarios for patients, individual payers, the health care system overall, and the future of drug development in producing new medicines.",0,0,
1223,Menopause and exercise,"OBJECTIVE: Accumulating data suggest that regular physical exercise reduces mortality and extends the functional life span of men and women. This review seeks to describe the current state of the medical literature on this topic. METHODS: A narrative review of the current medical literature including randomized clinical trials and clinical guidelines that address the benefits of physical fitness and regular exercise on the health of midlife and postmenopausal women. RESULTS: Reduction and avoidance of obesity and its related comorbidities (hypertension, glucose intolerance, dyslipidemia, and heart disease) are one major benefit of exercise. However, long-term physical exercise is also associated with reduced rates of cancer, dementia and cognitive decline, adverse mood and anxiety symptoms, and reduction of osteoporosis, osteopenia, falls, and fractures. Beneficial physical activity includes exercise that will promote cardiovascular fitness (aerobic), muscle strength (resistance), flexibility (stretching), and balance (many of the preceding, and additional activities such as yoga). CONCLUSIONS: Given that it is unambiguously beneficial, inexpensive, and minimal risk, maintaining a healthy exercise regimen should be a goal for every participant to enhance lifelong wellness. Clinicians should use a number of behavioral strategies to support the physical fitness goals of their participants.",0,0,
1224,Mental Health Link: the development and formative evaluation of a complex intervention to improve shared care for patients with long-term mental illness,"AIMS AND OBJECTIVES: This study aims to develop an intervention and related conceptual framework for developing shared care for patients with long-term mental illness, and to provide a case study of the development of a complex intervention in primary care. METHODS: A pragmatic iterative design involved a literature review and focus groups followed by a formative evaluation including reflection, questionnaires and interviews. General practices and associated community mental health teams in Southeast London were involved. Participants included community mental health workers, psychiatrists, practice nurses, general practitioners, managers and local experts with an interest in primary mental health care. RESULTS: The model for shared care includes the core components of improved communication together with the development of a register and database with systems for review and recall. Local needs assessment, audit, training and guidelines are complimentary components. The intervention, Mental Health Link, is a facilitated quality improvement programme which aims to expedite the development of services by bringing the teams together to agree on a model of shared care suited to local needs, skills and interests, and by supporting the development of practice systems. CONCLUSIONS: A model for shared care needs to take into account interdependencies of the components as well as the relationship with the context. The heterogeneity of primary and community care need to be reflected in the development of complex interventions designed to enhance shared care. It is possible to develop a generalizable complex intervention which is sensitive to local circumstances.",0,0,
1225,Mentally ill families. When are the children unsafe?,"This article examines the impact of parental mental illness on the behaviour and development of children. Early identification and intervention is crucial"";"" too often the child is not considered, particularly if the parent is not frankly abusive. Supports and aid to parenting may be crucial for mentally ill parents to prevent relapse and promote the child's mental health. General practitioners have a crucial role in this process.",0,0,
1226,Meta-analysis: The Effect of Dietary Counseling for Weight Loss,"Background: Dietary and lifestyle modification efforts are the primary treatments for people who are obese or overweight. The effect of dietary counseling on long-term weight change is unclear. Purpose: To perform a meta-analysis of the effect of dietary counseling compared with usual care on body mass index (BMI) over time in adults. Data Sources: Early studies (1980 through 1997) from a previously published systematic review""; MEDLINE and the Cochrane Central Register of Controlled Trials from 1997 through July 2006. Study Selection: English-language randomized, controlled trials (≥16 weeks in duration) in overweight adults that reported the effect of dietary counseling on weight. The authors included only weight loss studies with a dietary component. Data Extraction: Single reviewers performed full data extraction;"" at least 1 additional reviewer reviewed the data. Data Synthesis: Random-effects model meta-analyses of 46 trials of dietary counseling revealed a maximum net treatment effect of −1.9 (95% CI, −2.3 to −1.5) BMI units (approximately −6%) at 12 months. Meta-analysis of changes in weight over time (slopes) and meta-regression suggest a change of approximately −0.1 BMI unit per month from 3 to 12 months of active programs and a regain of approximately 0.02 to 0.03 BMI unit per month during subsequent maintenance phases. Different analyses suggested that calorie recommendations, frequency of support meetings, inclusion of exercise, and diabetes may be independent predictors of weight change. Limitations: The interventions, study samples, and weight changes were heterogeneous. Studies were generally of moderate to poor methodological quality. They had high rates of missing data and failed to explain these losses. The meta-analytic techniques could not fully account for these limitations. Conclusions: Compared with usual care, dietary counseling interventions produce modest weight losses that diminish over time. In future studies, minimizing loss to follow-up and determining which factors result in more effective weight loss should be emphasized.",0,0,
1227,Methadone substitution--a scientific review in the context of out-patient therapy in Germany,"The German Betaubungsmittelverschreibungsverordnung BtmVV (prescription regulation of narcotics), 5 part 2, 01 July 2001 commissioned the German Medical Association to establish guidelines on methadone maintenance therapy according to the medical-scientific state of the art. A joint commission of the German Medical Association and the National Association of Statutory Health Insurance Physicians developed guidelines for substitution therapy of opiate dependence which were adopted by the board of the German Medical Association in March 2002 and were published in the Deutsche Arzteblatt in May 24, 2002. The present study is a systematic review of the scientific literature on successful treatment in general, as well as on particular aspects of methadone substitution therapy considered by the German Medical Association's guidelines. The literature was updated until January 2004. Older randomised controlled trials and more recent quasi-experimental studies provide evidence that methadone maintenance therapy is an effective strategy to reduce illicit drug use, to improve the health situation of drug users, to diminish criminal behaviour, and to promote rehabilitation of opiate-dependent individuals. The evaluation of international studies clearly shows that access criteria to substitution therapy beyond the diagnosis of opiate dependence, e.g. the presence of a life-threatening co-morbidity, is not a prerequisite for substitution in other countries, and therefore is not discussed in the international literature. Study evidence shows that the German Medical Association's guidelines for substitution therapy of opiate dependence reflect the best evidence available from scientific studies and apply it to the conditions of the German healthcare system.",0,0,
1228,Methodology and Reporting of Mobile Heath and Smartphone Application Studies for Schizophrenia,"The increasing prevalence of mobile devices among patients of all demographic groups has the potential to transform the ways we diagnose, monitor, treat, and study mental illness. As new tools and technologies emerge, clinicians and researchers are confronted with an increasing array of options both for clinical assessment, through digital capture of the essential behavioral elements of a condition, and for intervention, through formalized treatments, coaching, and other technology-assisted means of patient communication. And yet, as with any new set of tools for the assessment or treatment of a medical condition, establishing and adhering to reporting guidelines-that is, what works and under what conditions-is an essential component of the translational research process. Here, using the recently published World Health Organization mHealth Evaluation, Reporting and Assessment guidelines for evaluating mobile health applications, we review the methodological strengths and weaknesses of existing studies on smartphones and wearables for schizophrenia. While growing evidence supports the feasibility of using mobile tools in severe mental illness, most studies to date failed to adequately report accessibility, interoperability, costs, scalability, replicability, data security, usability testing, or compliance with national guidelines or regulatory statutes. Future research efforts addressing these specific gaps in the literature will help to advance our understanding and to realize the clinical potential of these new tools of psychiatry.",0,0,
1229,Methods for treating cognitive deficits in schizophrenia,"Studies from the molecular to clinical level suggest that cognitive dysfunction is central in characterizing schizophrenia. Accordingly, there have been increased efforts to search for effective treatments of these broad and debilitating cognitive deficits. Three general strategies for treating cognitive dysfunction in schizophrenia have emerged in the literature. The second-generation (atypical) antipsychotic medications have received much attention but their procognitive effects tend to be modest. Augmentation strategies, driven from basic science or translational research, have often been promising in small uncontrolled trials"";"" however, few agents have fared well in rigorously designed trials. Behavioral interventions have demonstrated positive effects that generalize to other symptom domains and persist after the intervention, but tend to be costly and labor intensive. Thus, although there have been some exciting advances in treating cognitive dysfunction, the gains to date are modest and the search for treatment methods continues.",0,0,
1230,Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines,"Recent studies have documented that physician compliance with recommended periodic health screening improves with reminders to physicians. These reminders, however, are often costly to maintain and modify. This study investigates the influence of a microcomputer tickler system on the ordering of mammograms. All women (N = 1262) aged 40 years and older who made visits to an outpatient office during a 6-month period were randomly assigned to one of two groups. For the experimental group, the date of the last mammogram ordered and recorded in the clinical database was printed on the encounter form generated for each patient visit. No information regarding previous mammograms was printed for patients in the control group. Women in the experimental group were more likely to have a mammogram ordered during the study period (19% compared with 12%, P = .001) and, as a result, were more likely to be in compliance with mammography guidelines at the study's completion (27% compared with 21%, P = .011). Microcomputerized data storage and retrieval systems may help increase physicians' attention to preventive health screening recommendations.",0,1,
1231,Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines.,"A study was undertaken to investigate the influence of microcomputer-generated ""reminders"" prompting physicians to schedule periodic mammographic screenings for patients. The major reasons cited by clinicians for not performing health screening tests like mammography included forgetfulness, lack of time, inconvenience and patient discomfort or refusal. Physician failure to recommend mammography is often due to oversight on the part of the physician at the time of a patient visit. This study demonstrates that a microcomputerized reminder system can be used to increase physicians' compliance with preventive health screening recommendations. An experimental system resulted in a 50 percent increase in mammogram ordering for a group of women over 40 involved in the study.",0,1,1230
1232,"Minimal risk, administrative firm trials, and informed consent",,0,0,
1233,Minimizing errors of omission: behavioural reenforcement of heparin to avert venous emboli: the BEHAVE study,"OBJECTIVE: To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation. DESIGN: Prospective longitudinal observational study. SETTING: Medical-surgical intensive care unit. PARTICIPANTS: Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit. INTERVENTIONS: Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services""; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence;"" and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period. MEASUREMENTS AND MAIN RESULTS: Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001). CONCLUSIONS: After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.",0,1,
1234,Misprescribing controlled substances: An evaluation of a professional development program,"BACKGROUND: Controlled prescription drug (CPD) abuse has reached epidemic proportions in the United States. Most physicians attending a 3-day continuing medical education (CME) professional development program (PDP) lack training in identifying risk and in managing patients who misuse CPDs. To address this issue, the authors conducted an evaluation of a PDP that trains physicians on proper prescribing, identifying substance abuse, utilizing screening, brief intervention, and referral to treatment (SBIRT), and implementing motivational interviewing (MI). METHODS: The authors conducted a program evaluation to assess the efficacy and impact of the PDP on physicians' knowledge and prescribing behaviors. RESULTS: Participants (N = 174) were typically middle-aged (average age of 53 years), male (89%), and physicians (82%) and other health care professionals (18%). Many physicians practice in solo primary care settings (46%). Course evaluations were completed by n = 155 (89%) participants who rated the course and presenters highly (mean 4.8/5 respectively). Physicians' knowledge scores on pre/post assessments increased significantly: pretest (M = 58.7, SD = 13.12) and posttest (M = 78.28, SD = 9.83) (t(173) = 20.06, P </= .0001, 95% confidence interval, CI: [-21.51, -17.65]). Almost half of the participants, n = 83/174 (48%), completed the follow-up survey, and 93% agreed/strongly agreed (A/SA) they made professional practice changes. Of participants practicing with an active DEA (Drug Enforcement Administration) registration (n = 57), most agreed/strongly agreed they implemented changes to align their practices with current guidelines (89%), used CPD more appropriately (87%), implemented office policies on prescribing (81%), identified and referred more substance abuse patients to treatment (80%), shared new information/experience from course with other 25 health professionals (93%), and felt the course positively impacted their behaviors personally and professionally (90% and 96%, respectively). CONCLUSIONS: This is the first known study evaluating a PDP in this population. Results demonstrated participant satisfaction and improvement in prescribers' knowledge and self-reported prescribing behaviors. However, further study is needed to assess actual clinical practice changes, direct impact on patient outcomes, and rates of recidivism.",0,0,
1235,Mitigating Prenatal Zika Virus Infection in the Americas,"Background: Because of the risk for Zika virus infection in the Americas and the links between infection and microcephaly, other serious neurologic conditions, and fetal death, health ministries across the region have advised women to delay pregnancy. However, the effectiveness of this policy in reducing prenatal Zika virus infection has yet to be quantified. Objective: To evaluate the effectiveness of pregnancy-delay policies on the incidence and prevalence of prenatal Zika virus infection. Design: Vector-borne Zika virus transmission model fitted to epidemiologic data from 2015 to 2016 on Zika virus infection in Colombia. Setting: Colombia, August 2015 to July 2017. Patients: Population of Colombia, stratified by sex, age, and pregnancy status. Intervention: Recommendations to delay pregnancy by 3, 6, 9, 12, or 24 months, at different levels of adherence. Measurements: Weekly and cumulative incidence of prenatal infections and microcephaly cases. Results: With 50% adherence to recommendations to delay pregnancy by 9 to 24 months, the cumulative incidence of prenatal Zika virus infections is likely to decrease by 17% to 44%, whereas recommendations to delay pregnancy by 6 or fewer months are likely to increase prenatal infections by 2% to 7%. This paradoxical exacerbation of prenatal Zika virus exposure is due to an elevated risk for pregnancies to shift toward the peak of the outbreak. Limitation: Sexual transmission was not explicitly accounted for in the model because of limited data but was implicitly subsumed within the overall transmission rate, which was calibrated to observed incidence. Conclusion: Pregnancy delays can have a substantial effect on reducing cases of microcephaly but risks exacerbating the Zika virus outbreak if the duration is not sufficient. Duration of the delay, population adherence, and the timing of initiation of the intervention must be carefully considered. Primary Funding Source: National Institutes of Health.",0,0,
1236,Mobile diabetes intervention study: testing a personalized treatment/behavioral communication intervention for blood glucose control,"BACKGROUND: National data find glycemic control is within target (A1c or =7.5%) at baseline (n=260) are enrolled in study groups based on PCP randomization. All study patients receive blood glucose (BG) meters and a year's supply of testing materials. Patients in three treatment groups select one of two mobile phone models, receive one-year unlimited mobile phone data and service plan, register on the web-based individual patient portal and receive study treatment phone software based on study assignment. Control group patients receive usual care from their PCP. The primary outcome is mean change in A1c over a 12-month intervention period. CONCLUSION: Traditional methods of disease management have not achieved adequate control for BG and other conditions important to persons with diabetes. Tools to improve communication between patients and PCPs may improve patient outcomes and be satisfactory to patients and physicians. This RCT is ongoing.",0,0,
1237,Mobile-Web app to self-manage low back pain: randomized controlled trial,"BACKGROUND: Nonspecific low back pain (NLBP) is the diagnosis for individuals with back pain that has no underlying medical cause (eg, tumor, infection, fracture, herniated disc, spinal stenosis). The American College of Physicians (ACP) and American Pain Society (APS) recommend multidisciplinary treatments for NLBP that lasts more than 4 weeks. This approach, however, is impractical for many physicians to implement, and relatively few providers offer NLBP treatment that meets the joint ACP-APS guidelines. OBJECTIVE: This study evaluated the efficacy of a mobile-Web intervention called ""FitBack"" to help users implement self-tailored strategies to manage and prevent NLBP occurrences. METHODS: A total of 597 adults were recruited, screened, consented, and assessed online at baseline, at 2 months (T2), and at 4 months (T3). After baseline assessments, participants were randomized into three groups: FitBack intervention, alternative care group that received 8 emails urging participants to link to six Internet resources for NLBP, and control group. The FitBack group also received weekly email reminder prompts for 8 weeks plus emails to do assessments. The control group was only contacted to do assessments. RESULTS: Users of the FitBack program showed greater improvement compared to the control group in every comparison of the critical physical, behavioral, and worksite outcome measures at 4-month follow-up. In addition, users of the FitBack program performed better than the alternative care group on current back pain, behavioral, and worksite outcomes at 4-month follow-up. For example, subjects in the control group were 1.7 times more likely to report current back pain than subjects in the FitBack group""; subjects in the alternative care group were 1.6 times more likely to report current back pain at 4-month follow-up. Further, the users of the FitBack program showed greater improvement compared to both the control and alternative care groups at 4-month follow-up on patient activation, constructs of the Theory of Planned Behavior, and attitudes toward pain. CONCLUSIONS: This research demonstrated that a theoretically based stand-alone mobile-Web intervention that tailors content to users' preferences and interests can be an effective tool in self-management of low back pain. When viewed from the RE-AIM perspective (ie, reach, efficacy/effectiveness, adoption, implementation fidelity, and maintenance), this study supports the notion that there is considerable value in this type of intervention as a potentially cost-effective tool that can reach large numbers of people. The results are promising considering that the FitBack intervention was neither supported by professional caregivers nor integrated within a health promotion campaign, which might have provided additional support for participants. Still, more research is needed on how self-guided mobile-Web interventions will be used over time and to understand factors associated with continuing user engagement. TRIAL REGISTRATION: Clinicaltrials.gov NCT01950091;"" http://clinicaltrials.gov/ct2/show/NCT01950091 (Archived by WebCite at http://www.webcitation.org/6TwZucX77).",0,0,
1238,Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis,"OBJECTIVE: The aim of this study was to examine whether lag sequential analysis could be used to describe eye gaze orientation between clinicians and patients in the medical encounter. This topic is particularly important as new technologies are implemented into multiuser health care settings in which trust is critical and nonverbal cues are integral to achieving trust. This analysis method could lead to design guidelines for technologies and more effective assessments of interventions. BACKGROUND: Nonverbal communication patterns are important aspects of clinician-patient interactions and may affect patient outcomes. METHOD: The eye gaze behaviors of clinicians and patients in 110 videotaped medical encounters were analyzed using the lag sequential method to identify significant behavior sequences. Lag sequential analysis included both event-based lag and time-based lag. RESULTS: Results from event-based lag analysis showed that the patient's gaze followed that of the clinician, whereas the clinician's gaze did not follow the patient's. Time-based sequential analysis showed that responses from the patient usually occurred within 2 s after the initial behavior of the clinician. CONCLUSION: Our data suggest that the clinician's gaze significantly affects the medical encounter but that the converse is not true. APPLICATION: Findings from this research have implications for the design of clinical work systems and modeling interactions. Similar research methods could be used to identify different behavior patterns in clinical settings (physical layout, technology, etc.) to facilitate and evaluate clinical work system designs.",0,0,
1239,Moderators of remission with interpersonal counselling or drug treatment in primary care patients with depression: randomised controlled trial,"BACKGROUND: Despite depressive disorders being very common there has been little research to guide primary care physicians on the choice of treatment for patients with mild to moderate depression. AIMS: To evaluate the efficacy of interpersonal counselling compared with selective serotonin reuptake inhibitors (SSRIs), in primary care attenders with major depression and to identify moderators of treatment outcome. METHOD: A randomised controlled trial in nine centres (DEPICS, Australian New Zealand Clinical Trials Registry number: ACTRN12608000479303). The primary outcome was remission of the depressive episode (defined as a Hamilton Rating Scale for Depression score </=7 at 2 months). Daily functioning was assessed using the Work and Social Adjustment Scale. Logistic regression models were used to identify moderators of treatment outcome. RESULTS: The percentage of patients who achieved remission at 2 months was significantly higher in the interpersonal counselling group compared with the SSRI group (58.7% v. 45.1%, P = 0.021). Five moderators of treatment outcome were found: depression severity, functional impairment, anxiety comorbidity, previous depressive episodes and smoking habit. CONCLUSIONS: We identified some patient characteristics predicting a differential outcome with pharmacological and psychological interventions. Should our results be confirmed in future studies, these characteristics will help clinicians to define criteria for first-line treatment of depression targeted to patients' characteristics.",0,0,
1240,Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination,"BACKGROUND: Quality improvement initiatives in health services rely upon the effective introduction of clinical practice guidelines. However, even well constructed guidelines have little effect unless supported by dissemination and implementation strategies. AIM: To test the effectiveness of 'educational outreach' as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care. DESIGN OF STUDY: A pragmatic, cluster-randomised controlled trial of guideline introduction, comparing educational outreach with postal guideline dissemination alone. SETTING: One-hundred and fourteen general practices (233 general practitioners) in the Salford and Trafford Health authority catchment area in the northwest of England. METHOD: All practices received guidelines by post in July 1997. The intervention group practices began to receive educational outreach three months later. This consisted of practice-based seminars with hospital specialists at which guideline recommendations were appraised, and implementation plans formulated. Seminars were followed up with 'reinforcement' visits after a further 12 weeks. Outcome measures were: (a) the appropriateness of referral for""; and (b) findings at, open access upper gastrointestinal endoscopy; (c) costs of GP prescriptions for acid-suppressing drugs, and (d) the use of laboratory-based serological tests for Helicobacter pylori. Data were collected for seven months before and/or after the intervention and analysed by intention-to-treat. RESULTS: (a) The proportion of appropriate referrals was higher in the intervention group in the six-month post-intervention period (practice medians: control = 50.0%, intervention = 63.9%, P < 0.05); (b) the proportion of major findings at endoscopy did not alter significantly; (c) there was a greater rise in overall expenditure on acid-suppressing drugs in the intervention as compared with the control group (+8% versus +2%, P = 0.005);"" and (d) the median testing rate per practice for H pylori in the post-intervention period was significantly greater in the intervention group (four versus O, P < 0.001). CONCLUSION: This study suggests that educational outreach may be more effective than passive guideline dissemination in changing clinical behaviour. It also demonstrates that unpredictable and unanticipated outcomes may emerge.",0,0,
1241,Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan.,"AIMS To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre-approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs). METHODS HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensinconverting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated. RESULTS The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1–28.4) of patients receiving losartan met the criteria for receiving ARBs. CONCLUSIONS Rescinding the PA requirement for this drug alone was an effective limitedduration strategy for reduction of prescription of relatively expensive drugs",0,1,
1242,Modular ICT-based patient empowerment framework for self-management of diabetes: Design perspectives and validation results,"INTRODUCTION: It is estimated that more than 382 million people suffer from diabetes across the globe, most of which are between the age of 40 and 59 years. ICT can play a key role in better management of diabetes and in patient empowerment. Patient empowerment involves patients to a greater extent in their own healthcare process and disease management becomes an integrated part of their daily life. Self-management opens the possibility for patients to contribute to their own healthcare as well as to be more in control of their disease. OBJECTIVES: The objective of our study was to explore the impact of an ICT-based patient empowerment framework in diabetes self-management. METHODS: A modular patient empowerment framework that fosters diabetes self-management was designed and implemented. The framework incorporates expert knowledge in the form of clinical guidelines, and it supports patients in the specification of personalized activities that are based on medical recommendations and personal goals, and in the collection of observations of daily living. The usability and usefulness of the proposed framework were assessed in a pilot study with the participation of 60 patients and 12 health professionals. RESULTS: The study revealed that a patient empowerment approach based on self-management ICT tools is useful and accepted by both the patients and the physicians. For those patients who were already disciplined in their disease management the piloted solution served as a facilitator for data logging. For the rest, it served as an incentive for better adherence to disease management principles. The ICT tools prompted many patients into becoming more physically active and into making dietary habits' adjustments. However, this impact proved to be tightly correlated with the sociocultural background of the subjects. The study also demonstrated that even in patient-centric self-management interventions the physicians still have a key role to play. However, the acceptance of such interventions by the healthcare professionals depends not only on the level of impact in their patients' disease management but also on the level of impact in their workflow. CONCLUSIONS: It is evident that a patient empowerment approach based on self-management ICT tools is useful and accepted by patients and physicians. Further, there are clear indications that ICT frameworks such as the one presented in this paper support patients in behavioral changes and in better disease management. Finally, it was realized that self-management solutions should be built around the objective not only to educate and guide patients in disease self-management, but also to assist them in exploring the decision space and to provide insight and explanations about the impact of their own values on the decision.",0,0,
1243,"Molecular sources of residual cardiovascular risk, clinical signals, and innovative solutions: relationship with subclinical disease, undertreatment, and poor adherence: implications of new evidence upon optimizing cardiovascular patient outcomes","Residual risk, the ongoing appreciable risk of major cardiovascular events (MCVE) in statin-treated patients who have achieved evidence-based lipid goals, remains a concern among cardiologists. Factors that contribute to this continuing risk are atherogenic non-low-density lipoprotein (LDL) particles and atherogenic processes unrelated to LDL cholesterol, including other risk factors, the inherent properties of statin drugs, and patient characteristics, ie, genetics and behaviors. In addition, providers, health care systems, the community, public policies, and the environment play a role. Major statin studies suggest an average 28% reduction in LDL cholesterol and a 31% reduction in relative risk, leaving a residual risk of about 69%. Incomplete reductions in risk, and failure to improve conditions that create risk, may result in ongoing progression of atherosclerosis, with new and recurring lesions in original and distant culprit sites, remodeling, arrhythmias, rehospitalizations, invasive procedures, and terminal disability. As a result, identification of additional agents to reduce residual risk, particularly administered together with statin drugs, has been an ongoing quest. The current model of atherosclerosis involves many steps during which disease may progress independently of guideline-defined elevations in LDL cholesterol. Differences in genetic responsiveness to statin therapy, differences in ability of the endothelium to regenerate and repair, and differences in susceptibility to nonlipid risk factors, such as tobacco smoking, hypertension, and molecular changes associated with obesity and diabetes, may all create residual risk. A large number of inflammatory and metabolic processes may also provide eventual therapeutic targets to lower residual risk. Classically, epidemiologic and other evidence suggested that raising high-density lipoprotein (HDL) cholesterol would be cardioprotective. When LDL cholesterol is aggressively lowered to targets, low HDL cholesterol levels are still inversely related to MCVE. The efflux capacity, or ability to relocate cholesterol out of macrophages, is believed to be a major antiatherogenic mechanism responsible for reduction in MCVE mediated in part by healthy HDL. HDL cholesterol is a complex molecule with antioxidative, anti-inflammatory, anti-thrombotic, antiplatelet, and vasodilatory properties, among which is protection of LDL from oxidation. HDL-associated paraoxonase-1 has a major effect on endothelial function. Further, HDL promotes endothelial repair and progenitor cell health, and supports production of nitric oxide. HDL from patients with cardiovascular disease, diabetes, and autoimmune disease may fail to protect or even become proinflammatory or pro-oxidant. Mendelian randomization and other clinical studies in which raising HDL cholesterol has not been beneficial suggest that high plasma levels do not necessarily reduce cardiovascular risk. These data, coupled with extensive preclinical information about the functional heterogeneity of HDL, challenge the ""HDL hypothesis"", ie, raising HDL cholesterol per se will reduce MCVE. After the equivocal AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides: Impact on Global Health Outcomes) study and withdrawal of two major cholesteryl ester transfer protein compounds, one for off-target adverse effects and the other for lack of efficacy, development continues for two other agents, ie, anacetrapib and evacetrapib, both of which lower LDL cholesterol substantially. The negative but controversial HPS2-THRIVE (the Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events) trial casts further doubt on the HDL cholesterol hypothesis. The growing impression that HDL functionality, rather than abundance, is clinically important is supported by experimental evidence highlighting the conditional pleiotropic actions of HDL. Non-HDL cholesterol reflects the cholesterol in all atherogenic particles containing apolipoprotein B, and has outperformed LDL cholesterol as a lipid marker of cardiovascular risk and future mortality. In addition to including a measure of residual risk, the advantages of using non-HDL cholesterol as a primary lipid target are now compelling. Reinterpretation of data from the Treating to New Targets study suggests that better control of smoking, body weight, hypertension, and diabetes will help lower residual risk. Although much improved, control of risk factors other than LDL cholesterol currently remains inadequate due to shortfalls in compliance with guidelines and poor patient adherence. More efficient and greater use of proven simple therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, combined with statin therapy, may be more fruitful in improving outcomes than using other complex therapies. Comprehensive, intensive, multimechanistic, global, and national programs using primordial, primary, and secondary prevention to lower the total level of cardiovascular risk are necessary.",0,0,
1244,Monitoring and managing metabolic effects of antipsychotics: a cluster randomized trial of an intervention combining evidence-based quality improvement and external facilitation,"Background Treatment of psychotic disorders consists primarily of second generation antipsychotics, which are associated with metabolic side effects such as overweight/obesity, diabetes, and dyslipidemia. Evidence-based clinical practice guidelines recommend timely assessment and management of these conditions""; however, research studies show deficits and delays in metabolic monitoring and management for these patients. This protocol article describes the project ¡®Monitoring and Management for Metabolic Side Effects of Antipsychotics,¡¯ which is testing an approach to implement recommendations for these practices.  Methods/Design This project employs a cluster randomized clinical trial design to test effectiveness of an evidence-based quality improvement plus facilitation intervention. Eligible study sites were VA Medical Centers with ¡Ý300 patients started on a new antipsychotic prescription in a six-month period. A total of 12 sites, matched in pairs based on scores on an organizational practice survey, were then randomized within pairs to intervention or control conditions.  Study participants include VA employees involved in metabolic monitoring and management of patients treated with antipsychotics at participating sites. The intervention involves researchers partnering with clinical stakeholders to facilitate tailoring of local implementation strategies to address barriers to metabolic side-effect monitoring and management. The intervention includes a Design Phase (initial site visit and subsequent development of a local implementation plan); Implementation Phase (guided by an experienced external facilitator);"" and a Sustainability Phase. Evaluation includes developmental, implementation-focused, progress-focused and interpretative formative evaluation components, as well as summative evaluation. Evaluation methods include surveys, qualitative data collection from provider participants, and quantitative data analysis of data for all patients prescribed a new antipsychotic medication at a study site who are due for monitoring or management of metabolic side effects during the study phases. Changes in rates of recommended monitoring and management actions at intervention and control sites will be compared using time series analyses.  Discussion Improving monitoring for metabolic side effects of antipsychotics, as well as promoting timely evidence-based management when these effects emerge, will lead to improved patient safety and long-term outcomes. This article discusses key strengths and challenges of the study.",0,0,
1245,More Informative Abstracts of Articles Describing Clinical Practice Guidelines,"Recommendations are proposed for preparing more informative abstracts of articles describing clinical practice guidelines. Information about the development and content of guidelines should be summarized with the following structure.Objective:a succinct statement of the objective of the guideline, including the targeted health problem, the targeted patients and providers, and the main reason for developing recommendations concerning this problem for this population.Options:principal practice options that were considered in formulating the guideline.Outcomes:significant health and economic outcomes identified as potential consequences of the practice options.Evidence:methods used to gather, select, and synthesize evidence, and the date of the most recent evidence obtained.Values:persons and methods used to assign values (relative importance) to potential outcomes of alternative practice options.Benefits, Harms, and Costs:the type and magnitude of the main benefits, harms, and costs that are expected to result from guideline implementation.Recommendations:a brief and specific list of key recommendations.Validation:the results of any external review, comparison with guidelines developed by other groups, or clinical testing of guideline use.Sponsors:key persons or groups that developed, funded, or endorsed the guideline.Abstracts adhering to these recommendations could enhance readers' ability to appraise the applicability, importance, and validity of guidelines for specific providers, patients, and settings. More informative abstracts could also promote the use of more explicit methods of guideline development, more consistent reporting of guideline documents, and the more appropriate use of guidelines by clinicians.",0,0,
1246,Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study,"BackgroundExclusive breastfeeding, though better than other forms of infant feeding and associated with improved child survival, is uncommon. We assessed the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding."";"" BackgroundExclusive breastfeeding, though better than other forms of infant feeding and associated with improved child survival, is uncommon. We assessed the HIV-1 transmission risks and survival associated with exclusive breastfeeding and other types of infant feeding.",0,0,
1247,Motivation is a crucial factor for adherence to a healthy lifestyle among people with coronary heart disease after percutaneous coronary intervention,"AIM: To test the Theory of Adherence of People with Chronic Disease with regard to adherence to treatment among patients with coronary heart disease after a percutaneous coronary intervention. BACKGROUND: Increased knowledge of the concept of adherence is needed for the development of nursing interventions and nursing guidelines for patients with coronary heart disease. DESIGN: A cross-sectional, multi-centre study. METHODS: This study was conducted from February-December 2013 with 416 patients with coronary heart disease 4 months after undergoing a percutaneous coronary intervention. A self-reported questionnaire was used to assess their adherence to treatment. Data were analysed using structural equation modelling. RESULTS: The theory explained 45% of the adherence to a healthy lifestyle and 7% of the adherence to medication. Structural equation modelling confirmed that motivation and results of care had the highest association with adherence to a healthy lifestyle. Responsibility was associated with adherence to medication. Support from next of kin, support from nurses and physicians, and motivation, co-operation, fear of complications and a sense of normality were associated with adherence. CONCLUSION: Patients who are motivated to perform self-care and consider the results of care to be important were more likely to adhere to a healthy lifestyle. Responsible patients were more likely to adhere to their medication. It is important to account for these elements as a part of secondary prevention strategies among patients with coronary heart disease after a percutaneous coronary intervention.",0,0,
1248,Motivational Enhancement Therapy with and without Cognitive Behavior Therapy to Treat Type 1 Diabetes,"Background:Although psychological issues can interfere with diabetes care, the effectiveness of psychological treatments in improving diabetes outcomes is uncertain.Objective:To determine whether motivational enhancement therapy with or without cognitive behavior therapy improves glycemic control in type 1 diabetes compared with usual care.Design:Randomized, controlled trial.Setting:8 diabetes centers in London and Manchester, United Kingdom.Patients:344 adults with type 1 diabetes for longer than 2 years, with hemoglobin A1c levels of 8.2% to 15%, and without complications or severe comorbid disease.Intervention:Nurse-delivered motivational enhancement therapy (4 sessions over 2 months), motivational enhancement therapy plus cognitive behavior therapy (12 sessions over 6 months), or usual care.Measurements:12-month change in hemoglobin A1c levels (primary outcome), hypoglycemic events, depression, quality of life, fear of hypoglycemia, diabetes self-care activities, and body mass index (secondary outcomes).Results:In an analysis including all randomly assigned patients, the 12-month change in hemoglobin A1c levels compared with usual care was 0.46% (95% CI, 0.81% to 0.11%) in the motivational enhancement therapy plus cognitive behavior therapy group and 0.19% (CI, 0.53% to 0.16%) in the motivational enhancement therapy group alone. There was no evidence of treatment effects on secondary outcomes.Limitations:Of 1659 screened patients, only 507 were eligible and 344 participated. Data on the primary outcome were unavailable for 11.3% of the participants. Study design did not permit distinction of the additive effect of cognitive behavior therapy plus motivational enhancement therapy from the effect of greater intensity and duration of the combined intervention compared with the motivational enhancement therapy alone.Conclusion:Nurse-delivered motivational enhancement therapy and cognitive behavior therapy is feasible for adults with poorly controlled type 1 diabetes. Combined therapy results in modest 12-month improvement in hemoglobin A1c levels compared with usual care, but motivational enhancement therapy alone does not.",0,0,
1249,"Motivational interviewing: Helping people change., 3rd edition","This bestselling work for professionals and students is the authoritative presentation of motivational interviewing (MI), the powerful approach to facilitating change. More than an update, the third edition has been fully restructured around the new four-process model of MI (engaging, focusing, evoking, and planning). MI originators William R. Miller and Stephen Rollnick demonstrate what the processes look like in practice, describe a rich range of applications, and review the growing evidence base. Infused with respect and compassion for clients, the book begins with a thorough overview of the spirit and method of MI. Sections on each of the four processes offer step-by-step guidance for establishing a strong working relationship, developing a clear focus and direction, evoking and strengthening the client's motivation for change, and formulating a concrete plan of action. The core communication skills used in MI are explained"";"" vignettes and interview examples vividly illustrate the ""dos and don'ts"" of successful implementation in diverse contexts. Ways to build proficiency in MI, integrate it with other practices, and assess intervention fidelity are discussed. Key points at the end of each chapter enhance the book's utility for teaching and professional development. The companion Web page (www.guilford.com/p/miller2) provides other helpful resources, including reflection questions, annotated case material, an extended bibliography, and a glossary of terms. Reflecting major advances in understanding and teaching MI, this book is essential reading for practitioners across the mental health and health care disciplines, including addictions specialists, clinical psychologists, psychiatrists, social workers, family therapists, counselors, nurses, physicians, and health educators. Graduate students in these fields will find it an accessible, uniquely informative course text. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
1250,Motivational interviewing: Is it all our clients need?,"Motivational Interviewing (MI) and its offshoots such as the Drinker's Check-up and Motivational Enhancement Therapy have become enormously popular in scientific and addiction treatment circles over the past decade. This article first addresses the reasons for this popularity and suggests that it is due to presumed cost-effectiveness, relevance to interventions in non-treatment-seeking populations, and the essential nature of addictions as motivational disorders. The article then goes on to examine evidence for the effectiveness of MI in both non-treatment-seeking and treatment-seeking samples, taking account of published systematic reviews and, particularly, the findings of Project MATCH. The relevance of possible findings from the UK Alcohol Treatment Trial is also considered. The article also looks at mechanisms of change that may account for the way MI works. It ends with a list of conclusions bearing on the effectiveness of MI, the possible roles in treatment that it can serve, the client groups for whom it may be especially appropriate, and what further research is needed. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
1251,Mouthrinse in oral mucositis in the context of allogeneic stem cell transplantation: a qualitative study,"BACKGROUND: Oral mucositis is a common side effect of allogeneic stem cell transplantation and can lead to increased morbidity, mortality and higher costs. It also has an impact on the quality of patients' lives. In the stem cell transplantation ward of a Swiss university hospital, patients are instructed according to current guidelines for mouthwash and their mouth status is evaluated daily. RESEARCH QUESTION: How do patients experience oral mucositis and what factors influence their behaviour to perform the mouth rinsing regularly? METHOD: In this qualitative part of a concurrent nested mixed methods research, 14 patients were interviewed using an interview guide. Data was analysed using content analysis methods. RESULTS: The results showed that, oral mucositis cannot be viewed separately from illness, isolation and care. The mucositis was only a heavy burden for patients with a severe occurrence. For patients with lower grade occurrences, other symptoms were more important. The research identified motivating and debilitating factors for a regular mouth rinsing, which is one of the most important preventive procedures. CONCLUSIONS: This study highlights how important it is to view oral mucositis in the context of the transplantation and that knowledge about motivating and hindering factors can support the nurses in caring for the patients. Improvement of patient self-management is a key aspect.",0,0,
1252,"Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation","Under conditions of constrained resources, cost-saving innovations may improve overall outcomes, even when they are slightly less effective than available options, by permitting more efficient reallocation of resources. The authors systematically reviewed all MEDLINE-cited cost–utility analyses written in English from 2002 to 2007 to identify and describe cost- and quality-decreasing medical innovations that might offer favorable “decrementally” cost-effective tradeoffs—defined as saving at least $100 000 per quality-adjusted life-year lost. Of 2128 cost-effectiveness ratios from 887 publications, only 9 comparisons (0.4% of total) described 8 innovations that were deemed to be decrementally cost-effective. Examples included percutaneous coronary intervention (instead of coronary artery bypass graft) for multivessel coronary disease, repetitive transcranial magnetic stimulation (instead of electroconvulsive therapy) for drug-resistant major depression, watchful waiting for inguinal hernias, and hemodialyzer sterilization and reuse. On a per-patient basis, these innovations yielded savings from $122 to almost $12 000 but losses of 0.001 to 0.021 quality-adjusted life-years (approximately 8 hours to 1 week). These findings demonstrate the rarity of decrementally cost-effective innovations in the medical literature.",0,0,
1253,Multidimensional analyses to assess the relations between treatment choices by physicians and patients' characteristics: the example of COPD,"BACKGROUND: In some situations, practice guidelines do not provide firm evidence-based guidance regarding COPD treatment choices, especially when large trials have failed to identify subgroups of particularly good or poor responders to available medications. METHODS: This observational cross-sectional study explored the yield of four types of multidimensional analyses to assess the associations between the clinical characteristics of COPD patients and pharmacological and non-pharmacological treatments prescribed by lung specialists in a real-life context. RESULTS: Altogether, 2494 patients were recruited by 515 respiratory physicians. Multiple correspondence analysis and hierarchical clustering identified 6 clinical subtypes and 6 treatment subgroups. Strong bi-directional associations were found between clinical subtypes and treatment subgroups in multivariate logistic regression. However, although the overall frequency of prescriptions varied from one clinical subtype to the other for all types of pharmacological treatments, clinical subtypes were not associated with specific prescription profiles. When canonical analysis of redundancy was used, the proportion of variation in pharmacological treatments that was explained by clinical characteristics remained modest: 6.23%. This proportion was greater (14.29%) for non-pharmacological components of care. CONCLUSION: This study shows that, although pharmacological treatments of COPD are quantitatively very well related to patients' clinical characteristics, there is no particular patient profile that could be qualitatively associated to prescriptions. This underlines uncertainties perceived by physicians for differentiating the respective effects of available pharmacological treatments. The methodology applied here is useful to identify areas of uncertainty requiring further research and/or guideline clarification.",0,0,
1254,Multidisciplinary treatment of pediatric obesity: nutrition evaluation and management,"Assessment and treatment methods for pediatric obesity are rapidly evolving. Thought to be caused by an imbalance of caloric intake and expenditure, obesity requires a comprehensive evaluation of patient, familial, environmental, genetic, and cultural characteristics so clinicians can design successful interventions. Quantitative nutrition assessment of caloric intake is difficult and time consuming and should be used only in isolated settings, such as in the research setting, or if initial approaches to management have been unsuccessful. As an alternative, providers should identify dietary patterns or behaviors that have been linked to obesity and are promising targets for change. Clinicians should tailor interventions by considering patient and family motivation and readiness to change. Current guidelines recommend stepwise increases in treatment plans, and multidisciplinary treatment teams are recommended for patients who require intense intervention. Providers involved at the multidisciplinary level must incorporate their area of expertise into that of the team to develop a comprehensive management plan. This article reviews current recommendations for the evaluation and treatment of pediatric obesity with a focus on nutrition evaluation as part of a multidisciplinary team.",0,0,
1255,Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context,"BACKGROUND AND AIMS: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care. APPROACH: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n=30). Observations focused on nurses' interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses. FINDINGS: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration. IMPLICATIONS: Nurses' abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error. CONCLUSIONS: Nurses displayed behaviours that increased medication administration quality and safety"";"" however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.",0,0,
1256,Multifactorial intervention with nurse practitioners does not change cardiovascular outcomes in patients with chronic kidney disease,"Strict implementation of guidelines directed at multiple targets reduces vascular risk in diabetic patients. Whether this also applies to patients with chronic kidney disease (CKD) is uncertain. To evaluate this, the MASTERPLAN Study randomized 788 patients with CKD (estimated GFR 20-70 ml/min) to receive additional intensive nurse practitioner support (the intervention group) or nephrologist care (the control group). The primary end point was a composite of myocardial infarction, stroke, or cardiovascular death. During a mean follow-up of 4.62 years, modest but significant decreases were found for blood pressure, LDL cholesterol, anemia, proteinuria along with the increased use of active vitamin D or analogs, aspirin and statins in the intervention group compared to the controls. No differences were found in the rate of smoking cessation, weight reduction, sodium excretion, physical activity, or glycemic control. Intensive control did not reduce the rate of the composite end point (21.3/1000 person-years in the intervention group compared to 23.8/1000 person-years in the controls (hazard ratio 0.90)). No differences were found in the secondary outcomes of vascular interventions, all-cause mortality or end-stage renal disease. Thus, the addition of intensive support by nurse practitioner care in patients with CKD improved some risk factor levels, but did not significantly reduce the rate of the primary or secondary end points.",0,0,
1257,Multi-level support for physical activity and healthy eating,"AIM: This paper reports a study evaluating the relationship between social and community level supports and physical activity and dietary behaviours among a low-income Latino population with multiple chronic conditions. BACKGROUND: With consistently lower physical activity than whites and documented nutritional deficiencies, Latinos in the United States of America represent a disproportionate share of the population with chronic illness. This pattern of health disparities is seen across countries, where there is a struggle to raise the health status of low-income, immigrant and aboriginal communities. Social-ecological theories of health behaviour stress the importance of considering social and community support for health behaviour, and represent a useful framework for considering ways to improve physical activity and nutrition for immigrant and aboriginal groups. METHOD: We report here on data from a baseline assessment of 200 patients from a health clinic in the United States of America serving a low-income, primarily Latino population. Participants were enrolled in Resources for Health, a randomized controlled trial to promote multi-level support for chronic illness self-management. Measures included self-reported physical activity, dietary behaviour and multi-level support for chronic illness management as well as demographic data. Baseline data reported on here were collected between February 2002 and September 2003. FINDINGS: Use of multi-level supports (e.g. family, individual and healthcare provider) was statistically significantly associated with meeting physical activity guidelines and better dietary behaviours. Being female and having multiple chronic conditions were also associated with better dietary behaviour. These variables explained 20% of the variance in dietary behaviour. CONCLUSION: Results support a social-ecological approach for promoting healthy behaviour in this low-income, primarily Latino sample with multiple chronic conditions. Addressing multiple levels of support for healthy behaviour is important in interventions to improve physical activity and diet, and nurses may be particularly well placed to address such issues for low-income, aboriginal and immigrant patients with chronic conditions.",0,0,
1258,Multiple antipsychotic medication prescribing patterns,"OBJECTIVE: To assess current prescribing practices regarding concomitant use of antipsychotic medications and summarize the reasons clinicians may prescribe >1 scheduled agent. METHODS: The pharmacy identified patients at William R Sharpe Jr Hospital currently receiving antipsychotic therapy. All patients receiving >/=2 scheduled antipsychotic agents concomitantly were included in the study. Data regarding the demographics, current medication combinations used, history of therapeutic regimens tried, and prescriber rationale were prospectively evaluated for a 60-day period beginning December 13, 2000, and ending February 10, 2001. Prescriber rationale for using >1 antipsychotic simultaneously and other drug therapy regimens that had been tried were compared with chart documentation and published therapeutic guidelines for schizophrenia. RESULTS: Over a 60-day surveillance period, 206 patients were placed on scheduled antipsychotic medications, with 85 (41%) receiving at least 2 agents. Responders to a prescriber questionnaire (59%) indicated the most common rationale for combination therapy was augmentation"";"" the least likely rationale was cross-titration. Survey responses also indicated a belief that there was questionable therapeutic benefit in more than half of the patients being treated with multiple antipsychotic combinations. Additionally, chart documentation showed that the majority of these patients did not receive an adequate trial of monotherapy with other atypical or typical agents, or clozapine prior to the combination antipsychotic regimen. Fifty-one percent of medical records did not document the rationale for concomitant therapy. CONCLUSIONS: Due to the lack of published data, the practice of using multiple antipsychotic agents is considered to be a gray area that requires the prescriber to be at a heightened level of awareness in assessing effectiveness and safety. Documentation of rationale, adverse effects, and response to the treatment regimen is essential in providing optimal care for the patient.",0,0,
1259,Multi-screen electronic alerts to augment venous thromboembolism prophylaxis,"Venous thromboembolism (VTE) prophylaxis in high-risk patients is frequently underutilised. We previously devised a one-screen computer alert program that identified hospitalised patients at high risk for VTE who were not receiving prophylaxis and advised their physicians to prescribe prophylaxis. While this strategy reduced the 90-day incidence of symptomatic VTE by 41%, the majority of electronic alerts were ignored. We have now developed a serial three-screen alert computer program designed to educate physicians who initially declined to order prophylaxis after a single screen alert. Of a total cohort of 880, the responsible physicians for 425 patients received a single electronic alert, whereas 455 who declined prophylaxis after the first screen received the second and third screens of the novel three-screen alert. Our enhanced serial three-screen alert program generated VTE prophylaxis orders for 58.4% of the 455 patients whose physicians initially declined to order prophylaxis following the one-screen alert. There was no significant difference in symptomatic 90-day VTE rates between the two cohorts (2.8% for the one-screen vs. 2.2% for the three-screen, p=0.55). We conclude that our three-screen computer alert program can markedly increase prophylaxis among physicians who decline an initial single screen alert.",0,1,
1260,Must diabetes be a fatal disease in Africa? Study of costs of treatment,"OBJECTIVE To estimate the costs of diagnosis and treatment of diabetes in Tanzania. DESIGN Costs estimated from the reported and recorded experience of patients with newly presenting diabetes in 1989-90 and of diabetic patients first seen in 1981-2. SETTING Muhimbili Medical Centre, Dar es Salaam. SUBJECTS 464 patients (315 men and 149 women). 262 patients diagnosed during 1 September 1989-31 August 1990 (group 1) and 202 during 1 June 1981-31 August 1982 (group 2). RESULTS The average annual direct cost of diabetes care in 1989-90 was $287 for a patient requiring insulin and $103 for a patient not requiring insulin. Purchase of insulin accounted for 68.2% ($156) of the average annual outpatient costs for patients requiring insulin. For patients not requiring insulin the cost of oral hypoglycaemic drugs and treatment of chronic complications and infections accounted for 42.5% ($29.3) and 48.8% ($33.7) of costs respectively. Cost of outpatient care of diabetic patients for the whole of Tanzania was estimated at $2.7m, *75,128 (32.2%) of which was for insulin. Doctors' and nurses' costs accounted for 0.2% of total costs of outpatient care. The annual direct inpatient care costs were estimated at $1.25m. Around 0.2% of the Tanzanian population aged 15 years and over used the equivalent of 8% of the total government health expenditure, which was $47,4088,382. CONCLUSION Diabetes places a severe strain on the limited resources of developing countries. If African patients with diabetes have to pay for their treatment most will be unable to do so and will die.",0,0,
1261,Nationwide survey of alcohol screening and brief intervention practices at US Level I trauma centers,"BACKGROUND: In 2007, the American College of Surgeons (ACS) Committee on Trauma implemented a requirement that Level I trauma centers must have a mechanism to identify patients who are problem drinkers and the capacity to provide an intervention for patients who screen positive. Although the landmark alcohol screening and brief intervention (SBI) mandate is anticipated to impact trauma practice nationwide, a literature review revealed no studies that have systematically documented SBI practice pre-ACS requirement. STUDY DESIGN: Trauma programs at all US Level I trauma centers were contacted and asked to complete a survey about pre-ACS requirement trauma center SBI practice. RESULTS: One hundred forty-eight of 204 (73%) Level I trauma centers responded to the survey. More than 70% of responding centers routinely used laboratory tests (eg, blood alcohol concentration) to screen patients for alcohol and 39% routinely used a screening question or standardized screening instrument. Screen-positive patients received a formal alcohol consult or had an informal alcohol discussion with staff members approximately 25% of the time. CONCLUSIONS: The investigation observed marked variability across Level I centers in the percentage of patients screened and in the nature and extent of intervention delivery in screen-positive patients. In the wake of the ACS Committee on Trauma requirement, future research could systematically implement and evaluate training in the delivery of evidence-based alcohol interventions and training in development of trauma center organizational capacity for sustained delivery of SBI.",0,0,
1262,Naturopathic treatment for ear pain in children,"OBJECTIVE: Otitis media is 1 of the most frequent diseases of early infancy and childhood and 1 of the most common reasons for children to visit a physician. In the past 2 decades, there has been a substantial increase in the diagnosis of otitis media worldwide. In the United States, 93% of all children have had at least 1 episode of acute otitis media (AOM) by 7 years of age. Otalgia is the hallmark of AOM. Most affected children either complain of earache or manifest behavior that the parents interpret as indicating ear pain. Treatment of the ear pain early in the course of AOM decreases both parental anxiety and the child's discomfort and accelerates the healing process. The objective of this study was to determine the efficacy and tolerability of naturopathic versus traditional treatment for the management of otalgia commonly associated with AOM in children. METHODS: The study was designed as a double-blind trial in an outpatient community clinic. A total of 171 children who were aged 5 to 18 years and had otalgia and clinical findings associated with middle-ear infection were studied. The children were randomly assigned to receive treatment with Naturopathic Herbal Extract Ear Drops (NHED) or anesthetic ear drops, with or without amoxicillin. On enrollment, the children were assigned by computer-numbered randomization to receive NHED (contents: allium sativum, verbascum thapsus, calendula flores, hypericum perfoliatum, lavender, and vitamin E in olive oil) 5 drops 3 times daily, alone (group A) or together with a topical anesthetic (amethocaine and phenazone in glycerin) 5 drops 3 times daily (group B), or oral amoxicillin 80 mg/kg/d (maximum 500 mg/dose) divided into 3 doses with either NHED 5 drops 3 times daily (group C) or topical anesthetic 5 drops 3 times daily (group D). A double-blind design was used, and all ear drops were placed in identical bottles. Treatment was initiated by the nurse in all cases. A single physician (M.S.) evaluated and treated all of the patients included in the study and recorded all of the data. The presence or absence of ear pain was assessed over 3 days with a visual analog scale. Ear pain was assessed by a specially devised observational instrument based on previous reports. One side of the instrument consisted of a linear numbered scale, from 1 (no pain) to 10 (worst possible pain), and a corresponding color scale, ranging from blue to dark red. The reverse side contained a scale of 5 facial expressions, ranging from broad smile (no pain) to a sad and crying face (worst possible pain), and a corresponding color scale, ranging from blue to dark red. RESULTS: There were no significant between-group differences in patient age or gender, degree of fever, main symptoms, associated symptoms, and severity or laterality of acute otitis media. Each group had a statistically significant improvement in ear pain over the course of the 3 days. Patients who were given ear drops alone had a better response than patients who were given ear drops together with amoxicillin. Results were better in the NHED group than in the controls. Nevertheless, the findings indicated that the pain was mostly (80%) self-limited and could be explained simply by the time elapsed. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend topical medications as the first line of treatment for ear pain in the absence of systemic infection or serious underlying disease. Because no evidence was found that systemic antibiotics alone improved treatment outcome, if antibiotics do not change the natural course of otitis media, then the main goal of treatment, as in the present study, should be to alleviate the ear pain. The alternative, naturopathic herbal extract medications, may offer many new possibilities in the management of ear pain associated with AOM. Primary care physicians should be aware that at least 10% of their patients may have tried 1 or more forms of alternative/complementary medicine before presenting for consultation. As it was widely reported in the medical literature, these herb, these herbal extracts have the potential to meet all of the requirements of appropriate medication that could be routinely used in the pediatric patient, namely in vitro bacteriostatic and bacteriocidal activity against common pathogens, immunostimulation ability, antioxidant activity, and anti-inflammatory effects. They are also well-absorbed with good penetration into the tissue surrounding the tympanic membrane. They have been found to enhance local immunologic activity. Finally, herbal extracts are well-tolerated (owing to their long elimination time), easy to administer, and less expensive than the new antibiotics. There are no documented side effects. On the basis of our findings that the group with the most significant treatment effects (NHED with topical anesthetic) explained only 7.3% of the total pain reduction, we propose that sometimes the general practitioner or pediatrician needs to give the human body a chance to repair itself. Nevertheless, if the physician believes that there is an indication for some treatment, especially if the parents are anxious, then a local treatment such as one used in our study might be adequate. CONCLUSIONS: This study suggests that in cases of ear pain caused by AOM in children in which active treatment, besides a simple 2- to 3-day waiting period, is needed, an herbal extract solution may be beneficial. Concomitant antibiotic treatment is apparently not contributory.",0,0,
1263,Needs and opportunities in rehabilitation. Aids and the environment,,0,0,
1264,"Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial","BackgroundDiabetic foot wounds, particularly those secondary to amputation, are very complex and difficult to treat. We investigated whether negative pressure wound therapy (NPWT) improves the proportion and rate of wound healing after partial foot amputation in patients with diabetes."";"" BackgroundDiabetic foot wounds, particularly those secondary to amputation, are very complex and difficult to treat. We investigated whether negative pressure wound therapy (NPWT) improves the proportion and rate of wound healing after partial foot amputation in patients with diabetes.",0,0,
1265,Neonatal end-of-life decision making: Physicians' attitudes and relationship with self-reported practices in 10 European countries,"Context The ethical issues surrounding end-of-life decision making for infants with adverse prognoses are controversial. Little empirical evidence is available on the attitudes and values that underlie such decisions in different countries and cultures.  Objective To explore the variability of neonatal physicians' attitudes among 10 European countries and the relationship between such attitudes and self-reported practice of end-of-life decisions.  Design and Setting Survey conducted during 1996-1997 in 10 European countries (France, Germany, Italy, the Netherlands, Spain, Sweden, the United Kingdom, Estonia, Hungary, and Lithuania).  Participants A total of 1391 physicians (response rate, 89%) regularly employed in 142 neonatal intensive care units (NICUs).  Main Outcome Measures Scores on an attitude scale, which measured views regarding absolute value of life (score of 0) vs value of quality of life (score of 10)"";"" self-report of having ever set limits to intensive neonatal interventions in cases of poor neurological prognosis.  Results Physicians more likely to agree with statements consistent with preserving life at any cost were from Hungary (mean attitude scores, 5.2 [95% confidence interval {CI}, 4.9-5.5]), Estonia (4.9 [95% CI, 4.3-5.5]), Lithuania (5.5 [95% CI, 4.8-6.1]), and Italy (5.7 [95% CI, 5.3-6.0]), while physicians more likely to agree with the idea that quality of life must be taken into account were from the United Kingdom (attitude scores, 7.4 [95% CI, 7.1-7.7]), the Netherlands (7.3 [95% CI, 7.1-7.5]), and Sweden (6.8 [95% CI, 6.4-7.3]). Other factors associated with having a pro–quality-of-life view were being female, having had no children, being Protestant or having no religious background, considering religion as not important, and working in an NICU with a high number of very low-birth-weight newborns. Physicians with scores reflecting a more quality-of-life view were more likely to report that in their practice, they had set limits to intensive interventions in cases of poor neurological prognosis, with an adjusted odds ratio of 1.5 (95% CI, 1.3-1.7) per unit change in attitude score.  Conclusions In our study, physicians' likelihood of reporting setting limits to intensive neonatal interventions in cases of poor neurological prognosis is related to their attitudes. After adjusting for potential confounders, country remained the most important predictor of physicians' attitudes and practices.",0,0,
1266,Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review,"STUDY OBJECTIVES: To comprehensively review research on the association between childhood sleep-disordered breathing (SDB) and neurobehavioral functioning. DESIGN: Qualitative and quantitative literature review. SETTING: N/A. PATIENTS OR PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: The findings of 61 studies of the relationship between childhood SDB and neurobehavioral functioning were critically evaluated and synthesized. There is strong evidence that childhood SDB is associated with deficits in behavior and emotion regulation, scholastic performance, sustained attention, selective attention, and alertness. There is also evidence that SDB has minimal association with a child's typical mood, expressive language skills, visual perception, and working memory. Findings have been insufficient to draw conclusions about intelligence, memory, and some aspects of executive functioning. Mechanisms by which SDB might result in neurobehavioral morbidity are being explored, but clinical symptoms such as chronic snoring remain the best predictors of morbidity. Short-term SDB treatment outcome studies are encouraging, but the long-term outcomes are not known. Failing to treat SDB appears to leave children at risk for long-term neurobehavioral deficits. CONCLUSIONS: Childhood SDB is associated with neurobehavioral morbidity. Applying commonly used guidelines for causal inference, even in the absence of a much-needed randomized clinical trial, there is strong evidence of association, consistent findings, and specificity of effect. There is suggestive evidence that this association fits the expected temporal pattern and that SDB is a biologically plausible cause of neurobehavioral deficits. Clinicians should be alert to the coexistence of SDB symptoms and concerns about a child's academic progress, attention, arousal, or behavior or emotion regulation.",0,0,
1267,Neurotropic viruses and cerebral palsy: population based case-control study,"OBJECTIVE To investigate the association between cerebral palsy and direct evidence for perinatal exposure to neurotropic viruses. DESIGN Population based case-control study. SETTING Adelaide Women's and Children's Hospital Research Laboratory. PARTICIPANTS AND MAIN OUTCOME MEASURES Newborn screening cards of 443 white case patients with cerebral palsy and 883 white controls were tested for viral nucleic acids from enteroviruses and herpes viruses by using polymerase chain reaction. Herpes group A viruses included herpes simplex viruses 1 and 2 (HSV-1 and HSV-2), Epstein-Barr virus (EBV), cytomegalovirus (CMV), and human herpes virus 8 (HHV-8), and herpes group B viruses included varicella zoster virus (VZV) and human herpes viruses 6 and 7 (HHV-6 and HHV-7). RESULTS The prevalence of viral nucleic acids in the control population was high: 39.8% of controls tested positive, and the prevalence was highest in preterm babies. The detection of herpes group B viral nucleic acids increased the risk of developing cerebral palsy (odds ratio 1.68, 95% confidence interval 1.09 to 2.59). CONCLUSIONS Perinatal exposure to neurotropic viruses is associated with preterm delivery and cerebral palsy.",0,0,
1268,Never too old? Age should not be a barrier to enrollment in cancer clinical trials,"Throughout Europe and the U.S., over 60% of the total incidence of cancer occurs in the elderly (> or =65 years) population, a patient group that requires particular consideration when making treatment decisions due to a number of factors. Despite this, elderly patients are generally under-represented in clinical trials such that study data should be interpreted with caution because results in younger cancer patients may not always extrapolate to the typical elderly cancer patient. Reports suggest that elderly cancer patients represent around 22% of patients enrolled in phase II clinical studies. Barriers to the accrual of elderly patients to clinical trials include lack of appropriate trials, high burden of comorbidity, study-imposed restrictions, and attitudes of physicians. There is a belief that elderly patients may be unable to tolerate various cancer therapies, which may result in this patient population being excluded from prospective trials. However, clinical data demonstrate that age alone is not a sufficient reason to withhold treatment. Lack of clinical trial data and the associated lack of evidence-based guidelines for elderly patients mean physicians have little to guide them, with the result that patients may not receive the optimal therapy. As clinical trials are the primary method of evaluating the efficacy and safety of adjuvant and palliative cancer therapies, trials that specifically target the elderly cancer patient are required to adequately assess the risks and benefits of treatment in this vulnerable population. This review aims to assess the clinical reality and clinical trial age mismatch to evaluate implications for elderly cancer patients and to identify how this situation may be addressed. Possible reasons for the disparity, and the resulting clinical consequences, are also considered.",0,0,
1269,New challenges in family interventions for schizophrenia,"This review first outlines the rationale and research base supporting the development of family interventions for schizophrenia. The over-riding principles guiding effective family interventions for schizophrenia are then presented, along with the key components (engagement, assessment, education, communication skills training and problem-solving) shared by most family programs in schizophrenia. Meta-analyses demonstrating the efficacy of family interventions in reducing relapse and rehospitalization in schizophrenia are then discussed, along with issues regarding minimal duration of effective treatment, differential benefits of single and multiple family modalities and mixed evidence for the maintenance of treatment effects after termination. The benefits of participation in family-organized, nonprofessional support and education programs are then described. Finally, three issues meriting further study are outlined.",0,0,
1270,New developments in psychotherapy for schizophrenic psychoses,"There already exists sufficient evidence of the efficacy of psychotherapeutic interventions, in particular cognitive behavioral therapy, for symptom reduction and relapse prevention. Evidence-based treatment guidelines recommend this approach for routine care. An increasing number of randomized clinical trials and research on active elements of treatment characterize this field. This paper presents research and clinical implications. Treatment strategies for reducing positive and negative symptoms, which represent an innovative field of research, are presented and discussed in terms of efficacy, treatment principles, and possible future developments.",0,0,
1271,New drugs in anaesthesia: can we afford them?,"The most important challenge facing physicians today is the dilemma of providing high quality care in a fiscally responsible fashion. Cost can no longer be ignored. Pharmacoeconomics is a fundamental component of medical education. Economic issues should be an integral part of the drug development and clinical trials. While anaesthetists are concerned that the use of less expensive drugs may compromise patient outcome and satisfaction there is little evidence to support such concerns. This is a fertile area for intense future research. Pharmacoeconomics is a dynamic. The cost of drugs is not static, patterns of drug use shift rapidly and clinical practice is in a state of constant change. The answer to cost containment is not simply to cut, cap, delist or merely hope for the best, but rather to manage and modify practice while accommodating changing needs. Educational programmes, guidelines, department policies, system changes and financial incentives can be implemented to ensure consistent and enduring adherence to the principles of pharmacoeconomics and value based care. Some suggest that national societies should create guidelines for cost-beneficial practice. Others favour physician autonomy in drug selection. Changing physician behaviour is difficult. This change will occur gradually and will be the topic of many emotionally charged philosophical debates. There will be great reluctance to deny patients pharmacologically superior drugs based on cost alone, especially since drugs are such a small portion of the total costs. We must exercise caution to ensure that we don't become penny wise and pound foolish. Drug acquisition costs are only one element in a large and complex equation. Concentrating on acquisition drug cost may be dangerous, even naive if we fall prey to knowing the cost of everything but the value of nothing.",0,0,
1272,New format for BMJ research articles in print,"It's nearly 10 years since we began abridging original research articles for readers of the print BMJ . Now we’re going a step further, using the advantages of both web and print. The full, open access version of this original article by Hollingshurst and colleagues is published online (doi:10.1136/bmj.a2656), along with our first ever BMJ research video and a podcast. Here are two abridged versions: a BMJ Pico—a new evidence abstract prepared by the authors—and a Short Cuts article written by the BMJ . Which version would you read and use? Which would you prefer if you were the author? Please tell us your views, as readers and researchers, by posting rapid responses to this article. Sandra Hollinghurst,1 Debbie Sharp,1 Kathleen Ballard,3 Jane Barnett,2 Angela Beattie,1 Maggie Evans,1 George Lewith,2 Karen Middleton,2 Frances Oxford,3 Fran Webley,2 Paul Little2 Study question What is the difference in cost effectiveness between long and short courses in the Alexander technique, massage, and a general practitioner’s prescription for exercise for patients with persistent back pain? Answer An exercise prescription and six lessons in Alexander technique alone were each more than 85% likely to be cost effective at values above £20 000 per quality adjusted life year (QALY), but the Alexander …",0,0,
1273,New Insights into Common Variable Immunodeficiency,"Common variable immunodeficiency (CVI) is a heterogenous immunodeficiency syndrome characterized by hypogammaglobulinemia, recurrent bacterial infections, and various immunologic abnormalities. In addition to recurrent infections, patients with this syndrome also have an increased incidence of autoimmune disease and malignancy. Because the spectrum of associated diseases is broad, patients with CVI are seen by various medical specialists. This review discusses the pathogenesis, clinical manifestations, diagnosis, and treatment of CVI.",0,0,
1274,Newly diagnosed idiopathic thrombocytopenic purpura in childhood: an observational study,"BackgroundDiagnosis and management of idiopathic thrombocytopenic purpura (ITP) have been based primarily on expert opinion and practice guidelines rather than on evidence. We have used a registry to prospectively survey the presenting features and the diagnostic evaluation and management practices used for children with ITP worldwide."";"" BackgroundDiagnosis and management of idiopathic thrombocytopenic purpura (ITP) have been based primarily on expert opinion and practice guidelines rather than on evidence. We have used a registry to prospectively survey the presenting features and the diagnostic evaluation and management practices used for children with ITP worldwide.",0,0,
1275,NHMRC guidelines for clinical practice for ASD and PTSD,"Dear Editor, Recently I described the case of a scuba instructor suffering from acute stress disorder (ASD), a type of post-traumatic stress disorder (PTSD), following the death of one of her students. The treatment described was a combination of eye movement desensitization and reprocessing (EMDR) and cognitive-behavioural therapy (CBT) exposure based exercises. As it happens, in August the Australian Centre for Post Traumatic Mental Health published Australian clinical practice guidelines for ASD and PTSD. These have been endorsed by the National Health and Medical Research Council (NHMRC). The treatment described in the diver injury case is consistent with these guidelines. The NHMRC guidelines suggest that immediately following a traumatic episode (e.g., diver death or serious injury) the most helpful response is to offer psychological first aid. This includes providing information on traumatic stress reactions, encouraging self care and using available social support. It is recommended that the medical practitioner monitor the patient, watching for improvement, plateau or deterioration, and be ready to offer assistance or appropriate referral if needed. The guidelines recommend the use of trauma-focused psychological therapy as the first-line intervention for ASD and PTSD. EMDR, with in vivo exposure included, and CBT are considered the most effective treatments. If medication is required, selective serotonin re-uptake inhibitor antidepressants are considered the best choice. For the benefit and convenience of patients and practitioners, the NHMRC guidelines and a comprehensive set of information guides on ASD and PTSD are available online as pdf file downloads at http://www.acpmh.unimelb.edu.au. An update in Medical Journal of Australia provides traumatic stress information for medical practitioners including screening questions that can be used to identify patients suffering with ASD and PTSD. This article is available online at: http://www.mja.com.au/public/issues/187_02_160707/for10467_fm.html. Brief articles and summary sheets specifically for divers on the subjects of traumatic stress reactions, death and panic are available at http://psychodiver.com.",0,0,
1276,"NHS 1948-88: less ideology, more humanity",,0,0,
1277,NHS profile. Enter the men from the Audit Commission. Interview by Richard Smith,,0,0,
1278,NICE guidance on prevention of STIs and teenage pregnancies,"NICE has published new public health intervention guidance to halt the rising numbers of sexually transmitted infections, including HIV, and to prevent conceptions in under-18s. This article outlines nurses' roles in implementation.",0,0,
1279,No impact from active dissemination of the Ottawa Ankle Rules: further evidence of the need for local implementation of practice guidelines,"BACKGROUND: Local implementation strategies are often required to promote consistent adherence to clinical guidelines, but they are time consuming and expensive. The authors tested an educational intervention designed to increase use of the Ottawa Ankle Rules, a widely publicized set of clinical guidelines previously shown to reduce the use of radiography for diagnosis of acute ankle injuries. METHODS: The study consisted of a quasi-experimental, before-and-after comparative analysis. Trained experts provided 1-hour educational sessions and supplied resource materials on the Ottawa Ankle Rules to health care professionals from 63 Ontario hospitals. Participants were asked to evaluate the intervention. The authors then compared, for periods before and after the educational sessions, the use of ankle radiography for adults with acute ankle injury in 10 hospitals that received the educational intervention and reported no (n = 5) or some (n = 5) prior use of the rules and in 5 control hospitals, which declined the educational intervention because they were already implementing the rules. RESULTS: Although participants gave highly positive appraisals of the Ottawa Ankle Rules and the educational sessions, there was no reduction in the use of ankle radiography for the 10 hospitals that received the educational sessions (73% before and 78% after the intervention, p = 0.11). In contrast, use of radiography decreased significantly, from 75% to 65%, in the 5 control hospitals (p = 0.022). INTERPRETATION: Even when a dissemination strategy is well received and involves a widely accepted clinical guideline, the impact on behaviour in clinical practice may be small. In addition to broad dissemination, an active local implementation strategy is necessary to encourage physicians to adopt clinical guidelines.",0,0,
1280,"Nonalcoholic Fatty Liver Disease and Fibrosis in Youth Taking Psychotropic Medications: Literature Review, Case Reports, and Management","OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) has become a worldwide epidemic because of the greater prevalence of obesity. Despite implications for youth with severe mental disorders, little has been published in the psychiatric literature about this increasingly common medical comorbidity. The goals of this article are to: 1) provide an overview of the epidemiology and pathophysiology of NAFLD, including progression to nonalcoholic steatohepatitis (NASH)""; 2) describe two clinical cases illustrating difficulties faced in management;"" and 3) review screening recommendations, differential diagnosis, and monitoring and intervention approaches. METHODS: A literature review was conducted, including guidelines and recommendations, with case presentations including case and control liver histology biopsy photographs. RESULTS: NAFLD in childhood and adolescence, as a precursor to NASH, progresses to fibrosis in a small percentage of youth, leading to risk for early onset cirrhosis and the need for transplantation. The cases presented raise concern that youth with severe mental health disorders, already at greater risk for obesity and its sequelae, may be at higher risk for progression to NASH, potentially because of greater rates of weight gain on top of overweight or obese status, and to liver metabolism changes from psychotropic medications favoring fat deposition. CONCLUSIONS: Patients with rapid weight gain into the overweight or obese categories, or who develop elevated liver transaminases that persist across 3-6 months, should be screened or referred for screening by their psychotropic-providing clinicians for early detection, diagnosis, and co-management by a pediatric gastroenterologist, to decrease risk of progression to NASH, which is reversible if early and sufficient lifestyle change results in significant weight loss. There is urgent need for controlled research on the relationships among weight gain, psychotropic medications, ultrasound and biopsy findings, and rates of progression to NAFLD and NASH in youth taking weight-gain-inducing psychotropic medications.",0,0,
1281,Noninvasive imaging predicts failure load of the spine with simulated osteolytic defects,"BACKGROUND: The clinical management of lytic tumors of the spine is currently based on geometric measurements of the defect. However, the mechanical behavior of a structure depends on both its material and its geometric properties. Quantitative computed tomography and dual-energy x-ray absorptiometry were investigated as noninvasive tools for measuring the material and geometric properties of vertebrae with a simulated lytic defect. From these measures, yield loads were predicted with use of composite beam theory. METHODS: Thirty-four fresh-frozen cadaveric spines were segmented into functional spinal units of three vertebral bodies with two intervertebral discs at the thoracic and lumbar levels. Lytic defects of equal size were created in one of three locations: the anterior, lateral, or posterior region of the vertebra. Each spinal unit was scanned with use of computed tomography and dual-energy x-ray absorptiometry, and axial and bending rigidities were calculated from the image data. Each specimen was brought to failure under combined compression and forward flexion, and the axial load and bending moment at yield were recorded. RESULTS: Although the relative defect size was nearly constant, measured yield loads had a large dispersion, suggesting that defect size alone was a poor predictor of failure. However, image-derived measures of structural rigidity correlated moderately well with measured yield loads. Furthermore, with use of composite beam theory with quantitative computed tomography-derived rigidities, vertebral yield loads were predicted on a one-to-one basis (concordance, r(c) = 0.74). CONCLUSIONS: Although current clinical guidelines for predicting fracture risk are based on geometric measurements of the defect, we have shown that the relative size of the defect alone does not account for the variation in vertebral yield loads. However, composite beam theory analysis with quantitative computed tomography-derived measures of rigidity can be used to prospectively predict the yield loads of vertebrae with lytic defects. CLINICAL RELEVANCE: Image-predicted vertebral yield loads and analytical models that approximate loads applied to the spine during activities of daily living can be used to calculate a factor of fracture risk that can be employed by physicians to plan appropriate treatment or intervention.",0,0,
1282,Non-operative management of blunt splenic injury,,0,0,
1283,Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline,"BACKGROUND: Many nonpharmacologic therapies are available for treatment of low back pain.PURPOSE: To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).DATA SOURCES: English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.STUDY SELECTION: Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.DATA EXTRACTION: We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.DATA SYNTHESIS: We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland-Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.LIMITATIONS: Our primary source of data was systematic reviews. We included non-English-language trials only if they were included in English-language systematic reviews.CONCLUSIONS: Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.",0,0,
1284,Non-pharmacological management of hypertension: results from interviews with 100 general practitioners,"OBJECTIVE: To describe the type and level of non-pharmacological management offered by general practitioners for essential hypertension. DESIGN: An open-ended interviewer-administered survey using a standard case of a 60-year-old man with essential hypertension. Seventy interviews were conducted face-to-face and 30 by telephone. SETTING: Auckland general practices. SUBJECTS: A random sample of 100 Auckland general practitioners. MAIN OUTCOME MEASURES: Aspects of the medical histories of patients, physical examination, laboratory testing and treatment relevant to non-pharmacological management. RESULTS: There was an 84% response rate. Most general practitioners reported offering non-pharmacological management at the first consultation before prescribing medication. However, few offered detailed programmes. Dietary therapy, restriction of alcohol consumption and exercise were suggested by most general practitioners. Restriction of sodium intake and behavioural therapy were less popular non-pharmacological interventions. The median number of visits of patients to a general practitioner before drugs were prescribed was five, which is in keeping with guidelines. The median number of days from the first visit to prescription of drug therapy was 42 (range 2-341). The clinical advice given by the majority of participants was consistent with current guidelines on the treatment of hypertension but the range of advice given was wide. CONCLUSIONS: The results suggest that general practitioners are aware of non-pharmacological interventions for the management of hypertension. They report making routine use of non-pharmacological therapies for blood pressure reduction and other health benefits early in the clinical process before considering pharmacological therapy. These non-pharmacological therapies are not delivered with well-defined and detailed programmes.",0,0,
1285,Non-responsive coeliac disease,,0,0,
1286,"Nordic Myeloma Study Group, the first 15 years: scientific collaboration and improvement of patient care","The accomplishments of the Nordic Myeloma Study Group (NMSG) during its first 15 yr are briefly surveyed, together with a discussion of principles guiding the group's clinical trials and of problems that need to be addressed in coming years. The group has so far carried out 12 clinical trials, comprising more than 2500 patients, spanning from minor phase II to large randomised phase III trials. At the time of writing, two randomised trials are running (comparing two doses of i.v. pamidronate, and melphalan-prednisone (MP) vs. MP-thalidomide to elderly patients). The group has strived for a simple organisation with much responsibility delegated to regional coordinators (Denmark 3, Norway 5, Sweden 5). With regard to trial design, the group has considered it important that studies are based on sound scientific questions, are simple to handle for the participants, population based, investigator initiated, include quality of life and health resources assessment as end-points, and can be used as basis for diverse scientific spin-off projects. Like other clinical trial groups, NMSG faces a number of challenges in coming years. The financial situation for independent investigator-initiated trials is far from satisfactory, especially with regard to the resource-consuming implementation of more stringent good clinical practice rules and ethical committee demands. NMSG has also encountered increasing difficulties in recruiting patients to recent trials, partly because of problems related to participating physicians (lack of support, laborious paper work, insufficient credit for participation). Solutions to these problems have to be found if industry-independent clinical trial groups are to survive.",0,0,
1287,Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial,"BackgroundInternational guidelines for management of septic shock recommend that dopamine or norepinephrine are preferable to epinephrine. However, no large comparative trial has yet been done. We aimed to compare the efficacy and safety of norepinephrine plus dobutamine (whenever needed) with those of epinephrine alone in septic shock."";"" BackgroundInternational guidelines for management of septic shock recommend that dopamine or norepinephrine are preferable to epinephrine. However, no large comparative trial has yet been done. We aimed to compare the efficacy and safety of norepinephrine plus dobutamine (whenever needed) with those of epinephrine alone in septic shock.",0,0,
1288,Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies,"BackgroundAlthough heart rate and respiratory rate in children are measured routinely in acute settings, current reference ranges are not based on evidence. We aimed to derive new centile charts for these vital signs and to compare these centiles with existing international ranges."";"" BackgroundAlthough heart rate and respiratory rate in children are measured routinely in acute settings, current reference ranges are not based on evidence. We aimed to derive new centile charts for these vital signs and to compare these centiles with existing international ranges.",0,0,
1289,Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial,"IMPORTANCE: ""Nudges"" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice. OBJECTIVE: To investigate the use of a behavioral ""nudge"" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs). DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period)"";"" 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention). INTERVENTIONS: The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs. MAIN OUTCOMES AND MEASURES: Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status. RESULTS: Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time. CONCLUSIONS AND RELEVANCE: Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01767064.",1,1,
1290,Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. ,"Background Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse.  Objective The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers.  Participants We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51 % response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting.  Design The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition.  Main Measures The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics.  Key Results Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95 % CI: 2.9 to 20.1 %"";"" p?=?.008).  Conclusions Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians’ ability to prescribe what they believe is best for their patients.",1,1,
1291,Nudging to prudence? The effect of reminders on antibiotics prescriptions.,"Antibiotic resistance is a large and growing global health threat with important consequences. Prudent use of antibiotics is vital to delay the spread of resistance. In this study I use a randomized controlled trial to test the effect on antibiotics use of reminders to primary care patients. The intervention was implemented across 31 clinics during the flu season in Stockholm. A two-level randomization was used, with randomization at clinic level as well as at individual patient level. With reminders antibiotics use fell by 12.6 per cent relative to the control clinics. The effect is at clinic level, suggesting that doctors or doctor – patient interactions, not individual patients, are affected. Results from a follow-up experiment further suggest that an effect on the interactions between doctor and patient is the primary driver of the main results. Behavioural interventions targeting these interactions have the potential to reduce antibiotics use. More research is needed, though, as monitoring and adherence may also play a role.",0,1,
1292,"Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial","OBJECTIVE To evaluate the effectiveness of home delivered pragmatic rehabilitation-a programme of gradually increasing activity designed collaboratively by the patient and the therapist-and supportive listening-an approach based on non-directive counselling-for patients in primary care with chronic fatigue syndrome/myalgic encephalomyelitis or encephalitis (CFS/ME). DESIGN Single blind, randomised, controlled trial. SETTING 186 general practices across the north west of England between February 2005 and May 2007. PARTICIPANTS 296 patients aged 18 or over with CFS/ME (median illness duration seven years) diagnosed using the Oxford criteria. INTERVENTIONS Participants were randomly allocated to pragmatic rehabilitation, supportive listening, or general practitioner treatment as usual. Both therapies were delivered at home in 10 sessions over 18 weeks by one of three adult specialty general nurses who had received four months' training, including supervised practice, in each of the interventions. GP treatment as usual was unconstrained except that patients were not to be referred for systematic psychological therapies during the treatment period. Main outcome measures The primary clinical outcomes were fatigue and physical functioning at the end of treatment (20 weeks) and 70 weeks from recruitment compared with GP treatment as usual. Lower fatigue scores and higher physical functioning scores denote better outcomes. RESULTS A total of 257 (87%) of the 296 patients who entered the trial were assessed at 70 weeks, the primary outcome point. Analysis was on an intention to treat basis, with robust treatment effects estimated after adjustment for missing data using probability weights. Immediately after treatment (at 20 weeks), patients allocated to pragmatic rehabilitation (n=95) had significantly improved fatigue (effect estimate -1.18, 95% confidence interval -2.18 to -0.18""; P=0.021) but not physical functioning (-0.18, 95% CI -5.88 to +5.52; P=0.950) compared with patients allocated to treatment as usual (n=100). At one year after finishing treatment (70 weeks), there were no statistically significant differences in fatigue or physical functioning between patients allocated to pragmatic rehabilitation and those on treatment as usual (-1.00, 95% CI -2.10 to +0.11; P=0.076 and +2.57, 95% CI 3.90 to +9.03; P=0.435). At 20 weeks, patients allocated to supportive listening (n=101) had poorer physical functioning than those allocated to treatment as usual (-7.54, 95% CI -12.76 to -2.33;"" P=0.005) and no difference in fatigue. At 70 weeks, patients allocated to supportive listening did not differ significantly from those allocated to treatment as usual on either primary outcome. CONCLUSIONS For patients with CFS/ME in primary care, pragmatic rehabilitation delivered by trained nurse therapists improves fatigue in the short term compared with unconstrained GP treatment as usual, but the effect is small and not statistically significant at one year follow-up. Supportive listening delivered by trained nurse therapists is not an effective treatment for CFS/ME. Trial registration International Standard Randomised Controlled Trial Number IRCTN74156610.",0,0,
1293,Nurse practitioners improve quality of care in chronic kidney disease: two-year results of a randomised study,"BACKGROUND: Chronic kidney disease (CKD) is associated with increased cardiovascular risk. Here we evaluate whether strict implementation of guidelines aimed at multiple targets with the aid of nurse practitioners (NP) improves management in patients with CKD. METHODS: MASTER PLAN is a randomised controlled clinical trial, performed in nine Dutch hospitals. Patients with CKD (estimated glomerular filtration rate (eGFR) 20-70 ml/min) were randomised to receive NP support (intervention group (IG)) or physician care (control group (CG)). Patients were followed for a median of five years. Presented data are an interim analysis on risk factor control at two-year follow-up. RESULTS: We included 788 patients (532 M, 256 F), (393 CG, 395 IG), mean (+/-SD ) age 59 (+/-13) years, eGFR 38 (+/-15) ml/min/1.73m(2), blood pressure (BP) 138 (+/-21)/80 (+/-11) mmHg. At two years 698 patients (352 IG, 346 CG) could be analysed. IG as compared with CG had lower systolic (133 vs 135 mmHg&semi""; p= 0.04) and diastolic BP (77 vs 80 mmHg&semi; p=0.007), LDL cholesterol (2.30 vs 2.45 mmol(-l);"" p= 0.03), and increased use of ACE inhibitors, statins, aspirin and vitamin D. The intervention had no effect on smoking cessation, body weight, physical activity or sodium excretion. CONCLUSION: In both groups, risk factor management improved. However, changes in BP control, lipid management and medication use were more pronounced in IG than in CG. Lifestyle interventions were not effective. Coaching by NPs thus benefits everyday care of CKD patients. Whether these changes translate into improvement in clinical endpoints remains to be established.",0,0,
1294,"Nurse-led motivational interviewing to change the lifestyle of patients with type 2 diabetes (MILD-project): protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations","BACKGROUND: The diabetes of many patients is managed in general practice"";"" healthcare providers aim to promote healthful behaviors, such as healthful diet, adequate physical activity, and smoking cessation. These measures may decrease insulin resistance, improve glycemic control, lipid abnormalities, and hypertension. They may also prevent cardiovascular disease and complications of diabetes. However, professionals do not adhere optimally to guidelines for lifestyle counseling. Motivational interviewing to change the lifestyle of patients with type 2 diabetes is intended to improve diabetes care in accordance with the national guidelines for lifestyle counseling. Primary care nurses will be trained in motivational interviewing embedded in structured care in general practice. The aim of this paper is to describe the design and methods of a study evaluating the effects of the nurses' training on patient outcomes. METHODS/DESIGN: A cluster, randomized, controlled trial involving 70 general practices (35 practices in the intervention arm and 35 in the control arm) starting in March 2007. A total of 700 patients with type 2 diabetes will be recruited. The patients in the intervention arm will receive care from the primary care nurse, who will receive training in an implementation strategy with motivational interviewing as the core component. Other components of this strategy will be adaptation of the diabetes protocol to local circumstances, introduction of a social map for lifestyle support, and educational and supportive tools for sustaining motivational interviewing. The control arm will be encouraged to maintain usual care. The effect measures will be the care process, metabolic parameters (glycosylated hemoglobin, blood pressure and lipids), lifestyle (diet, physical activity, smoking, and alcohol), health-related quality of life, and patients' willingness to change behaviors. The measurements will take place at baseline and after 14 months. DISCUSSION: Applying motivational interviewing for patients with diabetes in primary care has been studied, but to our knowledge, no other study has yet evaluated the implementation and sustainability of motivating and involving patients in day-to-day diabetes care in general practice. If this intervention proves to be effective and cost-effective, large-scale implementation of this nurse-oriented intervention will be considered and anticipated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68707773.",0,0,
1295,"Nurse-run, telephone-based outreach to improve lipids in people with diabetes","BACKGROUND: There is a need for randomized, prospective trials of case management interventions with resource utilization analyses. OBJECTIVES: To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes. DESIGN: Prospective, randomized, controlled trial. PARTICIPANTS: Adults with diabetes at a federally funded community health center were randomly assigned to intervention (n = 381) or usual-care (n = 381) groups. INTERVENTIONS: Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques. Other parameters of diabetes care were addressed based on time constraints. MAIN MEASURES: The primary outcome was the proportion of patients with a low-density lipoprotein (LDL) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions, total hospital charges per patient, and the proportion of patients meeting other lipid, glycemic, and blood pressure guidelines. KEY RESULTS: The percent of patients with an LDL < 100 mg/dL increased from 52.0% to 58.5% in the intervention group and decreased from 55.6% to 46.7% in the control group (P < .01). Average cost per patient to the healthcare system was less for the intervention group ($6600 vs $9033, P = .03). Intervention patients trended toward fewer hospital admissions (P = .06). The intervention did not affect glycemic and blood pressure outcomes. CONCLUSIONS: Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms, but a more targeted approach is warranted. Telephone-based outreach may decrease resource utilization, but more study is needed.",0,0,
1296,Nurses' evaluations of the CPOT use at 12-month post-implementation in the intensive care unit,"BACKGROUND: Performing routine pain assessments with all intensive care unit (ICU) patients is strongly recommended in clinical practice guidelines. As many ICU patients are unable to self-report, the Critical-Care Pain Observation Tool (CPOT) is one of the two behavioural pain scales suggested for clinical use. Still, no study has described the evaluations of its use in ICU daily practice. OBJECTIVE: To describe the nurses' evaluation of the feasibility, clinical relevance and satisfaction with the CPOT use 12 months after its implementation in the ICU. METHOD: A descriptive design was used. It was conducted in the medical-surgical ICU of a university affiliated setting at Greenfield Park (Quebec, Canada). A self-administered evaluation questionnaire including four sections (i.e. feasibility, clinical relevance, satisfaction and socio-demographic information) was completed by ICU nurses who were all trained to use the CPOT. The questionnaires were completed anonymously. RESULTS: A total of 38 ICU nurses returned their completed questionnaire (63% participation rate). Regarding its feasibility, the majority rated the CPOT as quick to use, simple to understand and easy to complete (92-100%). According to clinical relevance, close to 70% of ICU nurses acknowledged that the CPOT had influenced their practice, but lower results (<50%) were found for effective communication of pain assessment findings with the physicians and other health professionals. More than 80% of ICU nurses were satisfied with its daily use. CONCLUSION: The CPOT use was deemed feasible and relevant in daily practice as per the nurses' evaluations but did not allow an effective communication with other ICU care team members. RELEVANCE TO CLINICAL PRACTICE: Training should be offered to all members of the ICU care team, and other implementation strategies should be explored as well to ensure optimal uptake of a pain assessment approach which impacts on their decision-making process for pain management.",0,0,
1297,Nurses' pay,,0,0,
1298,Nurses' representations of caring for intellectually disabled patients and perceived needs to ensure quality care,"AIMS AND OBJECTIVES: To explore nurses' representations of caring for people with an intellectual disability, intervention strategies they currently use, and to identify needs to ensure quality care. BACKGROUND: Nurses work in many environments and with diverse clienteles. Certain clienteles have needs that require specific approaches, such as persons who have an intellectual disability. The care offered to these patients can be influenced by the representations held by the nurses caring for them. DESIGN: Qualitative descriptive study. METHODS: Semi-structured interviews using thematic analysis were conducted with 18 nurses working in hospital and community settings. RESULTS: Nurses are concerned with their ability to recognise the specific nature and complex needs associated with patients' intellectual disabilities, promoting quality care by managing the behavioural and communication challenges, as well as coping with the perceived lack of time and organisation within the work environment. Current strategies involve trying to promote the continuity of care. Participants also identified their learning needs, which are relational and informational in nature. CONCLUSIONS: Nurses appear typically mindful of wanting to provide quality care to patients who have an intellectual disability, while recognising that there are many contextual and practical elements that require improvement to ensure the security of these patients. RELEVANCE TO CLINICAL PRACTICE: Nurses must be educated to adapt to findings emerging from current research showing that people with an intellectual disability want to be part of their local communities and encourage these persons to do so. This can be facilitated through the adoption of specific guidelines, protocols and care programmes. Further research is needed to develop a better understanding of the expectations of these patients and their caregivers, focusing on self-advocacy as well as health promotion techniques, with the goal of enhancing personalised practice standards and reducing health education inequalities for these patients.",0,0,
1299,Nurses' strategies to address self-care aspects related to medication adherence and symptom recognition in heart failure patients: an in-depth look,"OBJECTIVE: Despite an increasing body of knowledge on self-care in heart failure patients, the need for effective interventions remains. We sought to deepen the understanding of interventions that heart failure nurses use in clinical practice to improve patient adherence to medication and symptom monitoring. METHODS: A qualitative study with a directed content analysis was performed, using data from a selected sample of Dutch-speaking heart failure nurses who completed booklets with two vignettes involving medication adherence and symptom recognition. RESULTS: Nurses regularly assess and reassess patients before they decide on an intervention. They evaluate basic/factual information and barriers in a patient's behavior, and try to find room for improvement in a patient's behavior. Interventions that heart failure nurses use to improve adherence to medication and symptom monitoring were grouped into the themes of increasing knowledge, increasing motivation, and providing patients with practical tools. Nurses also described using technology-based tools, increased social support, alternative communication, partnership approaches, and coordination of care to improve adherence to medications and symptom monitoring. CONCLUSION: Despite a strong focus on educational strategies, nurses also reported other strategies to increase patient adherence. Nurses use several strategies to improve patient adherence that are not incorporated into guidelines. These interventions need to be evaluated for further applications in improving heart failure management.",0,0,
1300,Nursing research in the United States: the protection of human subjects,"In the United States the protection of the rights of human subjects in experimentation has evolved at three levels: professional, public, and private. At the professional level, codes, guidelines and the Patient's Bill of Rights address the issues of protecting the dignity, privacy and autonomy of individuals who serve as research subjects. At the public level, regulations promulgated by the Food and Drug Administration and the Department of Health and Human Services have become the standard for protecting human subjects. At the private level, United States common law regulates the conduct of individual researchers by requiring them to act in a manner consistent with generally accepted standards of care. As professionals, nurses must be actively involved in the formation of public policy regarding the conduct of research and strive to formulate a research agenda that will ensure that the ethics of research in nursing is above question.",0,0,
1301,Nursing standard of practice protocol: depression in elderly patients. NICHE faculty,"Depression is a highly prevalent but underrecognized and undertreated mental health problem in community-dwelling, medically ill, and institutionalized older adults. Untreated depression is associated with serious negative consequences for the elderly patient. Nurses in various practice settings can reduce the negative effects of depression through early recognition, intervention, and referral of patients with depression. This article presents an overview of depression in late life with emphasis on age-related assessment considerations, clinical decision-making, and nursing intervention strategies for elders with depression. A standard of practice protocol for use by nurses in a variety of practice settings is also presented.",0,0,
1302,"Nursing students' beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention","As the largest group of health care professionals, nurses are in a unique position to influence their patients who smoke. They also have more contact with patients than any other provider. The purpose of this survey study was to describe nursing students' beliefs about cigarette smoking, their smoking behaviors, and use of evidence-based tobacco treatment intervention. Of 200 surveyed, undergraduate nursing students, only 6% were smokers. The most inaccurate perception about tobacco treatment was that counseling of less than 3 minutes did not have an effect on improving smoking quit rate. Eight percent of surveyed smokers reported providing tobacco use treatment to all patients who smoke compared with 26% of non-smokers. Smoking-related morbidity and mortality warrant consistent use of clinical practice guidelines by nursing students and professional nurses.",0,0,
1303,"Nurture is more important than nature in childhood obesity, study finds","A study comparing the weight of biological and adopted children to that of their parents has found that lifestyles, rather than genes, are primarily responsible for the children being overweight.1 The researchers, from the Centre for Economic Performance at the London School of Economics and Political Science, concluded that policies to influence parents’ lifestyles could help to tackle overweight in children. For the study the researchers compiled data from 13 years …",0,0,
1304,Nutrition and Policy,,0,0,
1305,"Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services","OBJECTIVES: The development of recommendations for physicians, nurse practitioners, and nutritionists to guide the evaluation and treatment of overweight children and adolescents. METHODS: The Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services convened a committee of pediatric obesity experts to develop the recommendations. RESULTS: The Committee recommended that children with a body mass index (BMI) greater than or equal to the 85th percentile with complications of obesity or with a BMI greater than or equal to the 95th percentile, with or without complications, undergo evaluation and possible treatment. Clinicians should be aware of signs of the rare exogenous causes of obesity, including genetic syndromes, endocrinologic diseases, and psychologic disorders. They should screen for complications of obesity, including hypertension, dyslipidemias, orthopedic disorders, sleep disorders, gall bladder disease, and insulin resistance. Conditions that indicate consultation with a pediatric obesity specialist include pseudotumor cerebri, obesity-related sleep disorders, orthopedic problems, massive obesity, and obesity in children younger than 2 years of age. Recommendations for treatment evaluation included an assessment of patient and family readiness to engage in a weight-management program and a focused assessment of diet and physical activity habits. The primary goal of obesity therapy should be healthy eating and activity. The use of weight maintenance versus weight loss to achieve weight goals depends on each patient's age, baseline BMI percentile, and presence of medical complications. The Committee recommended treatment that begins early, involves the family, and institutes permanent changes in a stepwise manner. Parenting skills are the foundation for successful intervention that puts in place gradual, targeted increases in activity and targeted reductions in high-fat, high-calorie foods. Ongoing support for families after the initial weight-management program will help families maintain their new behaviors. CONCLUSIONS: These recommendations provide practical guidance to pediatric clinicians who evaluate and treat overweight children.",0,0,
1306,Observational study of telephone consults by stroke experts supporting community tissue plasminogen activator delivery,"OBJECTIVES: Barriers to intravenous (IV) tissue plasminogen activator (tPA) use in ischemic stroke include limited treatment experience of community physicians. Models of acute stroke care have been designed to address these limitations by providing community support. These include support by telephone or televideo, with or without subsequent transport to tertiary care centers. The authors describe the frequency, characteristics, and effect of community phone consultations to a 24/7 stroke ""hotline"" staffed by stroke physicians at an academic stroke center using such a model. METHODS: Twelve intervention hospitals participating in the INcreasing Stroke Treatment through Interventional behavior Change Tactics (INSTINCT) trial were provided a single-access number (""hotline"") for expert consultation on tPA use. Experts consisted of stroke-trained physicians at an academic medical center. Hotline use was not mandated by the study protocol, nor was patient transfer required. Consultants were required to record all treatment questions in a Web-based log. All patients discussed over the hotline and/or treated with tPA in an INSTINCT hospital underwent multilevel chart review by trained nurse coordinators. Cases were linked to logged hotline calls, based on the time of treatment and the initial treating hospital. Physician adjudicators assessed appropriateness of tPA treatment, presence of deviation from standard guidelines, and treatment complications (intracranial hemorrhage [ICH], systemic hemorrhage, or death). RESULTS: Over 27 months, there were a total of 204 hotline calls regarding 116 patients. Ninety-one percent of calls were between 8 a.m. and midnight, and 77% of questions explored issues of eligibility for IV tPA, particularly for minor stroke or improving stroke (26%). A total of 243 patients were treated with IV tPA at the 12 intervention hospitals, 54 of which were following hotline consult. Seventy-six percent of hotline patients in whom tPA was recommended actually received tPA, while 2% of those in whom tPA was not recommended received the medication. There were no differences in protocol deviations (27.8% hotline group vs. 23.8% nonhotline group), incidence of symptomatic ICH (5.6% vs. 7.3%), or in-hospital mortality (5.6% vs. 13.2%). No medico-legal issues have been reported for any case in the study. CONCLUSIONS: Providing tPA decision-making support via telephone consult to community physicians is feasible and safe. Consultants may play a more prominent role in determining tPA ineligibility than acceptance. Future work should include a real-time survey of physician providers to ascertain such potential qualitative benefits of a stroke hotline.",0,0,
1307,Oncologist Perspectives on Rare Cancer Care: A Nationwide Survey,"PURPOSE: In response to the challenges and difficulties imposed by rare cancers, multi-stakeholder initiatives dedicated to improving rare cancer care was launched, and several recommendations were made by professional societies. However, these primarily reflect the view of the advocates and supporters, and may not represent the views of the ""average"" clinician or researcher. In this study, we sought to investigate perceived difficulties with regard to rare cancer care and potential solutions endorsed by oncologists. MATERIALS AND METHODS: A representative sample of 420 oncologists recruited in 13 cancer centers participated in a nationwide survey. RESULTS: Oncologists faced various difficulties in treatment of patients with rare cancers, including the lack of clinical practice guidelines (65.7%) and personal experience (65.2%), lack of approved treatment options (39.8%), and reimbursement issues (44.5%). They were generally supportive of recent recommendations by multi-stakeholder initiatives as well as professional societies for development of clear clinical practice guidelines (66.0%), flexible reimbursement guidelines (52.9%), and a national rare cancer registry (47.4%). However, there was only moderate endorsement for referrals to high-volume centers (35.5%) and encouragement of off-label treatments (21.0%). CONCLUSION: Insights into the general attitudes of oncologists gained through our nationwide survey of representative samples would be helpful in development of clinical practices and public health policies in rare cancer treatment and research.",0,0,
1308,Oncology healthcare providers' implementation of the 5A's model of brief intervention for smoking cessation: patients' perceptions,"OBJECTIVE: Health care providers (HCPs) can play an important role in promoting smoking cessation and preventing relapse. Public Health Service guidelines recommend the ""5A's"" model of brief intervention. The goal of the current study was to examine cancer patients' perceptions of 5A's model implementation by their oncology HCPs. METHODS: This study included 81 thoracic and 87 head and neck cancer patients at a large NCI-designated comprehensive cancer center. Patients completed questionnaires assessing perceptions of their oncology HCPs' implementation of the 5A's model of brief intervention. RESULTS: Results indicate partial implementation of the 5A's model. The majority of patients reported that their providers had asked about smoking and advised them to quit, however"";"" only half reported that their interest in quitting had been assessed, and few reported assistance in quitting or follow-up. Delivery of the 5A's was greater among patients who requested cessation advice from their HCPs. CONCLUSION: The current findings suggest a need to increase adherence to the 5A's in the oncology setting. PRACTICAL IMPLICATIONS: Efforts to increase smoking cessation treatment provision by HCPs may improve the rate of cessation among cancer patients, and ultimately translate into better long-term cancer treatment outcomes.",0,0,
1309,"One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs","Background and objectives There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience""; safety outcomes; and costs.  Methods Mixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals;"" analysis of capital and operational costs associated with single rooms.  Results Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time.  Conclusions Staff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.",0,0,
1310,One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study,"BACKGROUND CONTEXT: The clinical entity ""discogenic back pain"" remains controversial at fundamental levels, including its pathophysiology, diagnostic criteria, and optimal treatment. This is true despite availability of four randomized trials comparing the efficacy of surgical and nonsurgical treatments. One trial showed benefit for lumbar fusion compared with unstructured nonoperative care, and three others showed roughly similar results for lumbar surgery and structured rehabilitation. PURPOSE: To compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels. DESIGN: Prospective observational cohort study. PATIENT SAMPLE: Patients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area. OUTCOME MEASURES: Roland-Morris back disability score (primary outcome), current rating of overall pain severity on a numerical scale, back and leg pain bothersomeness measures, the physical function scale of the short-form 36 version 2 questionnaire, use of medications for pain, work status, emergency department visits, hospitalizations, and further surgery. METHODS: Patients receiving spine surgery within 6 months of enrollment were designated as the ""surgical treatment"" group and the remainder as ""nonsurgical treatment."" Outcomes were assessed at 3, 6, 9, and 12 months after enrollment. RESULTS: We enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons. Eighty-six patients (17%) had surgery within 6 months of enrollment. Surgery consisted of instrumented fusion (79%), disc replacement (12%), laminectomy, or discectomy (9%). Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery. Adjusting for baseline differences among groups, surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified (23-point) Roland disability questionnaire (primary outcome) 1 year after enrollment. Using a composite definition of success incorporating 30% improvement in the Roland score, 30% improvement in pain, no opioid pain medication use, and working (if relevant), the 1-year success rate was 33% for surgery and 15% for nonsurgical treatment. The rate of reoperation was 11% in the surgical group"";"" the rate of surgery after treatment designation in the nonsurgical group was 6% at 12 months after enrollment. CONCLUSIONS: The surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines.",0,0,
1311,Ongoing provision of individual clinician performance data improves practice behavior,"BACKGROUND: Clinical practice guidelines summarize evidence from science and attempt to translate those findings into clinical practice. Pervasive and consistent adoption of these guidelines into daily provider practice has proven slow. METHODS: Using postoperative nausea and vomiting (PONV) prophylaxis guideline compliance as our metric, we compared the effects of continuing medical education (CME) alone (I), CME with a single snapshot of provider compliance (II), and ongoing reporting of provider compliance data without further CME (III). We retrospectively analyzed guideline compliance of 23,279 anesthetics at the University of Texas M.D. Anderson Cancer Center. Compliance was defined as a patient with 1 risk factor for PONV receiving at least 1 antiemetic, 2 risk factors receiving at least 2 antiemetics, and 3 risk factors receiving at least 3 antiemetics. Drugs of the same class were counted as single antiemetic administration. Propofol-based anesthetic techniques were counted as receiving 1 antiemetic. Patients with 0 risk factors for PONV were not included. We estimated the compliance rates for each of the 4 time periods of the study adjusting for multiple observations on the same clinician. Individual performance feedback was given once at 6 months after intervention I coincident with a refresher presentation on PONV (start of intervention II) and on an ongoing quarterly basis during intervention III. RESULTS: Compliance rates were not significantly influenced with CME (intervention I) compared with baseline behavior (54.5% vs 54.4%, P = 0.9140). Significant improvement occurred during the time period when CME was paired with performance data (intervention II) compared with intervention I (59.2% vs 54.4%, P = 0.0002). Further significant improvement occurred when data alone were presented (intervention III) compared with intervention II (65.1% vs 59.2%, P < 0.0001). For patients with 3 risk factors, we saw significant improvement in compliance rates during intervention III (P = 0.0002). In post hoc analysis of overtreatment, the percentage differences between the baseline and time period III decreased as the number of risk factors increased. CONCLUSIONS: We observed the greatest improvement in guideline compliance with ongoing personal performance feedback. Provider feedback can be an effective tool to modify clinical practice but can have unanticipated consequences.",0,1,
1312,Online interventions for social marketing health behavior change campaigns: a meta-analysis of psychological architectures and adherence factors,"BACKGROUND: Researchers and practitioners have developed numerous online interventions that encourage people to reduce their drinking, increase their exercise, and better manage their weight. Motivations to develop eHealth interventions may be driven by the Internet's reach, interactivity, cost-effectiveness, and studies that show online interventions work. However, when designing online interventions suitable for public campaigns, there are few evidence-based guidelines, taxonomies are difficult to apply, many studies lack impact data, and prior meta-analyses are not applicable to large-scale public campaigns targeting voluntary behavioral change. OBJECTIVES: This meta-analysis assessed online intervention design features in order to inform the development of online campaigns, such as those employed by social marketers, that seek to encourage voluntary health behavior change. A further objective was to increase understanding of the relationships between intervention adherence, study adherence, and behavioral outcomes. METHODS: Drawing on systematic review methods, a combination of 84 query terms were used in 5 bibliographic databases with additional gray literature searches. This resulted in 1271 abstracts and papers""; 31 met the inclusion criteria. In total, 29 papers describing 30 interventions were included in the primary meta-analysis, with the 2 additional studies qualifying for the adherence analysis. Using a random effects model, the first analysis estimated the overall effect size, including groupings by control conditions and time factors. The second analysis assessed the impacts of psychological design features that were coded with taxonomies from evidence-based behavioral medicine, persuasive technology, and other behavioral influence fields. These separate systems were integrated into a coding framework model called the communication-based influence components model. Finally, the third analysis assessed the relationships between intervention adherence and behavioral outcomes. RESULTS: The overall impact of online interventions across all studies was small but statistically significant (standardized mean difference effect size d=0.19, 95% confidence interval [CI]=0.11-0.28, P<.001, number of interventions k=30). The largest impact with a moderate level of efficacy was exerted from online interventions when compared with waitlists and placebos (d=0.28, 95% CI=0.17-0.39, P<.001, k=18), followed by comparison with lower-tech online interventions (d=0.16, 95% CI=0.00-0.32, P=.04, k=8);"" no significant difference was found when compared with sophisticated print interventions (d=-0.11, 95% CI=-0.34 to 0.12, P=.35, k=4), though online interventions offer a small effect with the advantage of lower costs and larger reach. Time proved to be a critical factor, with shorter interventions generally achieving larger impacts and greater adherence. For psychological design, most interventions drew from the transtheoretical approach and were goal orientated, deploying numerous influence components aimed at showing users the consequences of their behavior, assisting them in reaching goals, and providing normative pressure. Inconclusive results suggest a relationship between the number of influence components and intervention efficacy. Despite one contradictory correlation, the evidence suggests that study adherence, intervention adherence, and behavioral outcomes are correlated. CONCLUSIONS: These findings demonstrate that online interventions have the capacity to influence voluntary behaviors, such as those routinely targeted by social marketing campaigns. Given the high reach and low cost of online technologies, the stage may be set for increased public health campaigns that blend interpersonal online systems with mass-media outreach. Such a combination of approaches could help individuals achieve personal goals that, at an individual level, help citizens improve the quality of their lives and at a state level, contribute to healthier societies.",0,0,
1313,"Operational research as implementation science: definitions, challenges and research priorities","Background Operational research (OR) is the discipline of using models, either quantitative or qualitative, to aid decision-making in complex implementation problems. The methods of OR have been used in healthcare since the 1950s in diverse areas such as emergency medicine and the interface between acute and community care""; hospital performance; scheduling and management of patient home visits; scheduling of patient appointments;"" and many other complex implementation problems of an operational or logistical nature.  Discussion To date, there has been limited debate about the role that operational research should take within implementation science. I detail three such roles for OR all grounded in upfront system thinking: structuring implementation problems, prospective evaluation of improvement interventions, and strategic reconfiguration. Case studies from mental health, emergency medicine, and stroke care are used to illustrate each role. I then describe the challenges for applied OR within implementation science at the organisational, interventional, and disciplinary levels. Two key challenges include the difficulty faced in achieving a position of mutual understanding between implementation scientists and research users and a stark lack of evaluation of OR interventions. To address these challenges, I propose a research agenda to evaluate applied OR through the lens of implementation science, the liberation of OR from the specialist research and consultancy environment, and co-design of models with service users.  Summary Operational research is a mature discipline that has developed a significant volume of methodology to improve health services. OR offers implementation scientists the opportunity to do more upfront system thinking before committing resources or taking risks. OR has three roles within implementation science: structuring an implementation problem, prospective evaluation of implementation problems, and a tool for strategic reconfiguration of health services. Challenges facing OR as implementation science include limited evidence and evaluation of impact, limited service user involvement, a lack of managerial awareness, effective communication between research users and OR modellers, and availability of healthcare data. To progress the science, a focus is needed in three key areas: evaluation of OR interventions, embedding the knowledge of OR in health services, and educating OR modellers about the aims and benefits of service user involvement.",0,0,
1314,Opinion survey of physicians on ethical issues in medical research,"A total of 3622 physicians registered in the Association of Physicians of India were contacted through mail and requested to respond to a semistructured questionnaire pertaining to different aspects of medical ethics, with particular focus on informed consent. Six hundred twenty-nine physicians (17.4%) responded to the questionnaire""; 86% of the respondents reported having had no formal training in medical ethics;"" 49% of the subjects who undertook research obtained oral consent only. Majority of the respondents noted the relevance of ethics in different medical situations, though in certain areas like community health and research using animals ethical issues were felt to be less important. Patients' inability to come for regular follow-up and illiteracy were opined to be the main constraints in obtaining consent. Opinion on the amount of information to be imported to research participants as part of informed consent was at variance with standard guidelines. Physicians who reported having had an orientation course in medical ethics and those with prior research experience were more aware of ethical issues. Majority of the professionals desired for inclusion of ethics in medical curriculum.",0,0,
1315,Opportunistic electronic reminders. Improving performance of preventive care in general practice,"BACKGROUND: Preventive care is an important role for general practitioners, yet opportunities for prevention are often missed. METHOD: We provided an automatic electronic record preventive care reminder system for 12 preventive care activities for one 10 doctor practice. All patients who attended were randomised by the terminal digit of their record number. RESULTS: The control uptake of opportunistic prevention was low"";"" ranging from 1.5% (tetanus immunisation) to 27% (influenza immunisation). The reminders increased this by significant but small amounts for four out of 12 activities (immunisation for tetanus and pneumococcus and recording of allergies and weight), insignificant increases for four (mumps, measles and rubella immunisation, recording of smoking, and taking of cervical smears and of blood pressure), and insignificantly decreased influenza immunisation, and screening for diabetes and hyperlipidaemia. DISCUSSION: Opportunistic electronic reminders have the potential to increase preventive care in general practice.",1,1,
1316,"Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions","OBJECTIVE: A comprehensive review was conducted of the theoretical and empirical work that addresses the preference-match strategy in physician-patient communication. METHODS: Searches were conducted on Medline, PsychINFO, InFoTrac One File Plus, Sociological Abstracts, and Dissertation Abstracts through 2004. The following keywords were used: patient preferred and received information""; patient preferred and actualized treatment decision-making; patient-physician beliefs in shared decision-making; patient-physician match, fit, or concordance; reciprocal relationship or mutuality; doctor-patient affiliation, control, relationship;"" match/fit between patient and physician in affiliation, control, or relationship. RESULTS: Findings revealed varying degrees of support for the positive effects of matching patients' preferred levels of information, decisional control, and consultative interpersonal behavior. CONCLUSIONS: Findings justify not only continued but expanded research efforts in this area that would incorporate recommended changes in research design and implementation. PRACTICE AND RESEARCH IMPLICATIONS: Assessment strategies and match interventions are discussed that, if evidence continues to be supportive, might routinely optimize patient-physician encounters toward more positive outcomes. Methodological guidelines are suggested that can improve future preference-match studies of the patient-physician interaction. Practitioners need to consider adoption of patient-match assessment and intervention strategies in addition to recent exclusive concentrations on patient-centered and shared decision-making approaches.",0,0,
1317,Optimal patterns of care in patients with chronic obstructive pulmonary disease,"An intimate relationship exists between the physiological processes of respiration and swallowing at all levels of neuromotor control and peripheral function in healthy adults. Little is known regarding the potential alterations in these patterns in patients with chronic obstructive pulmonary disease (COPD), yet the impact of swallowing impairment and aspiration on the health outcomes of patients with COPD may be significant. COPD is a common comorbidity in patients with head and neck cancer and neurological disorders seen by swallowing clinicians, and warrants consideration during swallowing treatment. This article summarizes reports of alterations in the nutritional status, airway protective mechanisms, and swallowing efficiency that potentially contribute to or exacerbate the chronic and debilitating pulmonary condition. Care guidelines are given for modification of eating and swallowing behavior to optimize the health status of the patient with COPD. The need for controlled clinical trials for validation of the impact of these care guidelines on clinical outcomes is explained.",0,0,
1318,Optimizing Antiretroviral Therapy (ART) for Maternal and Child Health (MCH): Rationale and Design of the MCH-ART Study,"BACKGROUND: Prevention of mother-to-child transmission of HIV implementation faces significant challenges globally, particularly in the context of universal lifelong antiretroviral therapy (ART) for all HIV-infected pregnant women. METHODS: We describe the rationale and methods of the Maternal and Child Health-Antiretroviral Therapy (MCH-ART) study, an implementation science project examining strategies for providing HIV care and treatment to HIV-infected women who initiate ART during pregnancy and their HIV-exposed infants. RESULTS: MCH-ART is composed of 3 interrelated study designs across the antenatal and postnatal periods. Phase 1 is a cross-sectional evaluation of consecutive HIV-infected pregnant women seeking antenatal care""; phase 2 is an observational cohort of all women from phase 1 who are eligible for initiation of ART following local guidelines; and phase 3 is a randomized trial of strategies for delivering ART to breastfeeding women from phase 2 during the postpartum period. During each phase, a set of study measurement visits is carried out separately from antenatal care and ART services;"" a maximum of 9 visits takes place from the beginning of antenatal care through 12 months postpartum. In parallel, in-depth interviews are used to examine issues of ART adherence and retention qualitatively, and costs and cost-effectiveness of models of care are examined. Separate substudies examine health outcomes in HIV-uninfected women and their HIV-unexposed infants, and the role of the adherence club model for long-term adherence and retention. DISCUSSION: Combining observational and experimental components, the MCH-ART study presents a novel approach to understand and optimize ART delivery for MCH.",0,0,
1319,Optimizing hypertension management in clinical practice,"A clear relationship exists between elevated blood pressure (BP) and various manifestations of cardiovascular disease. Despite the availability of numerous treatment guidelines, hypertension remains inadequately controlled, with only a small proportion of patients achieving target BP levels. Many factors, both patient and physician related, contribute to this poor level of hypertension control. Major determinants include the implementation of inappropriate treatment regimens that do not enable patients to achieve goal and poor patient compliance. For example, it is widely acknowledged that most patients require two or more antihypertensive drugs to achieve BP goal"";"" however, physicians may be reluctant to employ such treatment strategies. The aim of this review is to explore factors that contribute to poor hypertension control rates and how to overcome these, including the rationale for selecting combination therapy, with particular reference to angiotensin II receptor blocker combinations.",0,0,
1320,Optimizing management of hypertension with combination therapy: considerations for the nurse practitioner,"Hypertension is an important contributor to the risk of cardiovascular disease and death, yet success in achieving blood pressure (BP) control has been limited. Most patients will require 2 or more medications to control their BP. Nurse practitioners play a vital role in treating patients with hypertension and can help overcome barriers to reaching BP goals. Measures to improve therapeutic adherence include educating the patient and simplifying the medication regimen. Use of single-pill combination therapy, which reduces the pill burden, can contribute to improved medication persistence and compliance. Rational combination therapy combines medications with complementary mechanisms of action, such as a calcium channel blocker (CCB) and a renin-angiotensin-aldosterone system (RAAS) inhibitor"";"" it is often more efficacious than monotherapy and allows the use of lower doses of the individual components, which usually results in improved tolerability. Current guidelines support the first-line use of combination therapy in many patients. Initiating therapy with a RAAS inhibitor-based combination can reduce BP and cardiovascular risk and may be more effective for some patients than traditional combinations such as a beta-blocker with a diuretic. Adverse events associated with any medication can compromise its therapeutic usefulness. Peripheral edema is a common and dose-dependent adverse event seen with dihydropyridine CCBs, which can cause marked patient distress, reduce adherence to therapy, and result in dose reduction or even discontinuation of therapy. In most cases, CCB-induced peripheral edema can be managed successfully, and CCB therapy need not be abandoned. Management strategies include nonpharmacologic and pharmacologic measures. Several clinical trials have shown a lower incidence of peripheral edema in patients receiving combination therapy with a CCB and a RAAS blocker compared with CCB monotherapy.",0,0,
1321,"Oral contraceptives and smoking, current considerations: recommendations of a consensus panel","In a closed meeting, members of the consensus panel evaluated the presentations of the scientific panel and developed a series of recommendations. They outlined clinical imperatives related to the identification and education of patients who smoke, the physician's role in smoking cessation, and the prescription of oral contraceptives for patients who smoke. They also outlined research objectives for the future. The most important suggestions include the following: All patients should be asked about their smoking status at every visit, and all smokers should be encouraged and helped to quit. The decision to prescribe an oral contraceptive requires a detailed personal and family history of thrombotic disease. Measurement of lipid profile should be considered, along with exercise and dietary intervention, for smokers >35 years old who use or request oral contraceptives. Patients >35 years old who smoke heavily (>15 cigarettes/d) should be denied the use of oral contraceptives. Preliminary data suggest that an oral contraceptive with the very low dose of 20 micrograms ethinyl estradiol may be safer for oral contraceptive users who smoke, even for those >35 years old who have an occasional cigarette, but these laboratory findings require clinical corroboration."";"" PIP: This article summarizes the activities of a conference in Montreal, Canada, entitled ""Oral Contraceptives and Smoking: Current Considerations."" Members of the consensus panel evaluated the presentations of the scientific panel and developed a series of recommendations. The clinical imperatives related to the identification and education of patients who smoke, physicians inverted question mark role in smoking cessation, and prescription of OCs for patients who smoke were elaborated. The following recommendations were made: 1) encourage patients who smoke to quit smoking""; 2) counsel patients regarding OC benefits; furthermore, counsel patients concerning the risks of concomitant smoking and OC use;"" and 3) prescribe 20 mcg ethinyl estradiol for women who smoke. In view of the remaining unanswered questions, the panel outlined several research objectives for the future.",0,0,
1322,Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention.,"Objective. To determine whether a computerized decision support system could increase the proportion of oral quinolone antibiotic orders placed for hospitalized patients.  Design. Prospective, interrupted time-series analysis.  Setting. University hospital in the south-eastern United States.  Subjects. Inpatient quinolone orders placed from 1 February 2001 to 31 January 2003.  Intervention. A web-based intervention was deployed as part of an existing order entry system at a university hospital on 5 February 2002. Based on an automated query of active medication and diet orders, some users ordering intravenous quinolones were presented with a suggestion to consider choosing an oral formulation.  Main outcome measure. The proportion of inpatient quinolone orders placed for oral formulations before and after deployment of the intervention.  Results. There were a total of 15 194 quinolone orders during the study period, of which 8962 (59%) were for oral forms. Orders for oral quinolones increased from 4202 (56%) before the intervention to 4760 (62%) after, without a change in total orders. In the time-series analysis, there was an overall 5.6% increase (95% CI 2.8–8.4%"";"" P < 0.001) in weekly oral quinolone orders due to the intervention, with the greatest effect on nonintensive care medical units.  Conclusions. A web-based intervention was able to increase oral quinolone orders in hospitalized patients. This is one of the first studies to demonstrate a significant effect of a computerized intervention on dosing route within an antibiotic class. This model could be applied to other antibiotics or other drug classes with good oral bioavailability.",1,1,
1323,Oral triptans (serotonin 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials,"BackgroundThe triptans, selective serotonin 5-HT1B/1D agonists, are very effective acute migraine drugs with a well-developed scientific rationale. Seven different triptans will soon be clinically available, making evidence-based selection guidelines necessary. Triptan trials have similar designs, facilitating meta-analysis""; this will provide a foundation for using triptans in clinical practice.; BackgroundThe triptans, selective serotonin 5-HT1B/1D agonists, are very effective acute migraine drugs with a well-developed scientific rationale. Seven different triptans will soon be clinically available, making evidence-based selection guidelines necessary. Triptan trials have similar designs, facilitating meta-analysis;"" this will provide a foundation for using triptans in clinical practice.",0,0,
1324,Orbital/Periorbital Plexiform Neurofibromas in Children with Neurofibromatosis Type 1: Multidisciplinary Recommendations for Care,"TOPIC: Children and adults with neurofibromatosis type 1 (NF1), a common autosomal dominant condition, manifest a variety of ophthalmologic conditions. Plexiform neurofibromas (PNs) involving the eyelid, orbit, periorbital, and facial structures (orbital-periorbital plexiform neurofibroma [OPPN]) can result in significant visual loss in children. Equally important, OPPNs can cause significant alteration in physical appearance secondary to proptosis, ptosis, and facial disfigurement, leading to social embarrassment and decreased self-esteem. CLINICAL RELEVANCE: Although NF1 is a relatively common disease in which routine ophthalmologic examinations are required, no formal recommendations for clinical care of children with OPPNs exist. Although medical and surgical interventions have been reported, there are no agreed-on criteria for when OPPNs require therapy and which treatment produces the best outcome. METHODS: Because a multidisciplinary team of specialists (oculofacial plastics, pediatric ophthalmology, neuro-ophthalmology, medical genetics, and neuro-oncology) direct management decisions, the absence of a uniform outcome measure that represents visual or aesthetic sequelae complicates the design of evidence-based studies and feasible clinical trials. RESULTS: In September 2013, a multidisciplinary task force, composed of pediatric practitioners from tertiary care centers experienced in caring for children with OPPN, was convened to address the lack of clinical care guidelines for children with OPPN. CONCLUSIONS: This consensus statement provides recommendations for ophthalmologic monitoring, outlines treatment indications and forthcoming biologic therapy, and discusses challenges to performing clinical trials in this complicated condition.",0,0,
1325,Organization of surveillance in GI practice,"BACKGROUND: Several reports documented an inefficient utilisation of available resources, as well as a suboptimal compliance with surveillance recommendations. Although, evidence suggests that organisational issues can influence the quality of care delivered, surveillance protocols are usually based on non-organized approaches. METHODS: We conducted a literature search (publication date: 01/2000-06/2016) on PubMed and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Cochrane Central Register of Controlled Trials for guidelines, or consensus statements, for surveys of practice, reporting information about patients, or providers attitudes and behaviours, for intervention studies to enhance compliance with guidelines. Related articles were also scrutinised. Based on the clinical relevance and burden on endoscopy services this review was focused on surveillance for Barrett's oesophagus, IBD and post-polypectomy surveillance of colonic adenomas. RESULTS: Existing guidelines are generally recognising structure and process requirements influencing delivery of surveillance interventions, while less attention had been devoted to transitions and interfaces in the care process. Available evidence from practice surveys is suggesting the need to design organizational strategies aimed to enable patients to attend and providers to deliver timely and appropriate care. Well designed studies assessing the effectiveness of specific interventions in this setting are however lacking. Indirect evidence from screening settings would suggest that the implementation of automated standardized recall systems, utilisation of clinical registries, removing financial barriers, could improve appropriateness of use and compliance with recommendations. CONCLUSIONS: Lack of sound evidence regarding utility and methodology of surveillance can contribute to explain the observed variability in providers and patients attitudes and in compliance with the recommended surveillance.",0,0,
1326,Organizational theory for dissemination and implementation research,"Background Even under optimal internal organizational conditions, implementation can be undermined by changes in organizations’ external environments, such as fluctuations in funding, adjustments in contracting practices, new technology, new legislation, changes in clinical practice guidelines and recommendations, or other environmental shifts. Internal organizational conditions are increasingly reflected in implementation frameworks, but nuanced explanations of how organizations’ external environments influence implementation success are lacking in implementation research. Organizational theories offer implementation researchers a host of existing, highly relevant, and heretofore largely untapped explanations of the complex interaction between organizations and their environment. In this paper, we demonstrate the utility of organizational theories for implementation research.  Discussion We applied four well-known organizational theories (institutional theory, transaction cost economics, contingency theories, and resource dependency theory) to published descriptions of efforts to implement SafeCare, an evidence-based practice for preventing child abuse and neglect. Transaction cost economics theory explained how frequent, uncertain processes for contracting for SafeCare may have generated inefficiencies and thus compromised implementation among private child welfare organizations. Institutional theory explained how child welfare systems may have been motivated to implement SafeCare because doing so aligned with expectations of key stakeholders within child welfare systems’ professional communities. Contingency theories explained how efforts such as interagency collaborative teams promoted SafeCare implementation by facilitating adaptation to child welfare agencies’ internal and external contexts. Resource dependency theory (RDT) explained how interagency relationships, supported by contracts, memoranda of understanding, and negotiations, facilitated SafeCare implementation by balancing autonomy and dependence on funding agencies and SafeCare developers.  Summary In addition to the retrospective application of organizational theories demonstrated above, we advocate for the proactive use of organizational theories to design implementation research. For example, implementation strategies should be selected to minimize transaction costs, promote and maintain congruence between organizations’ dynamic internal and external contexts over time, and simultaneously attend to organizations’ financial needs while preserving their autonomy. We describe implications of applying organizational theory in implementation research for implementation strategies, the evaluation of implementation efforts, measurement, research design, theory, and practice. We also offer guidance to implementation researchers for applying organizational theory.",0,0,
1327,Osteoporosis prevention education: behavior theories and calcium intake,"Osteoporosis is a worldwide health concern. Preventing osteoporosis, and subsequent fractures, has become a goal of many health care practitioners, especially dietetics professionals. However, few prevention models have proven effective. The goal of this project was to determine whether an educational, theory-based osteoporosis prevention program would significantly impact calcium intake. This project used a convenience sample of 42 women who participated in an 8-week educational intervention, similarly to a community class. The program included hands-on activities to increase self-efficacy and was based on the Health Belief Model and Theory of Reasoned Action (TRA). The main outcome measures were calcium intake and constructs from the Health Belief Model and TRA. Significant changes in the Health Belief Model and TRA constructs at postintervention included increased perceived susceptibility to osteoporosis ( P <.001), perceived benefits to increasing calcium intake ( P <.001), and increased self-efficacy related to calcium intake ( P </=.003). Statistically significant regression equations were found for all preintervention intentions related to calcium. Postintervention calcium intake significantly increased to 821+/-372 mg/day ( P <.0001). Results of this project can be used as guidelines for dietetics professionals to develop osteoporosis prevention programs for their clientele.",0,0,
1328,Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomised controlled trial,"OBJECTIVE To determine whether ascertainment of childhood obesity by surveillance followed by structured secondary prevention in primary care improved outcomes in overweight or mildly obese children. DESIGN Randomised controlled trial nested within a baseline cross sectional survey of body mass index (BMI). Randomisation and outcomes measurement, but not participants, were blinded to group assignment. SETTING 45 family practices (66 general practitioners) in Melbourne, Australia. PARTICIPANTS 3958 children visiting their general practitioner in May 2005-July 2006 were surveyed for BMI. Of these, 258 children aged 5 years 0 months up to their 10th birthday who were overweight or obese by International Obesity Taskforce criteria were randomised to intervention (n=139) or control (n=119) groups. Children who were very obese (UK BMI z score >or=3.0) were excluded. INTERVENTION Four standard consultations over 12 weeks targeting change in nutrition, physical activity, and sedentary behaviour, supported by purpose designed family materials. Main outcomes measures Primary measure was BMI at 6 and 12 months after randomisation. Secondary measures were mean activity count/min by 7-day accelerometry, nutrition score from 4-day abbreviated food frequency diary, and child health related quality of life. Differences were adjusted for socioeconomic status, age, sex, and baseline BMI. RESULTS Of 781 eligible children, 258 (33%) entered the trial""; attrition was 3.1% at 6 months and 6.2% at 12 months. Adjusted mean differences (intervention - control) at 6 and 12 months were, for BMI, -0.12 (95% CI -0.40 to 0.15, P=0.4) and -0.11 (-0.45 to 0.22, P=0.5); for physical activity in counts/min, 24 (-4 to 52, P=0.09) and 11 (-26 to 49, P=0.6);"" and, for nutrition score, 0.2 (-0.03 to 0.4, P=0.1) and 0.1 (-0.1 to 0.4, P=0.2). There was no evidence of harm to the child. Costs to the healthcare system were significantly higher in the intervention arm. CONCLUSIONS Primary care screening followed by brief counselling did not improve BMI, physical activity, or nutrition in overweight or mildly obese 5-10 year olds, and it would be very costly if universally implemented. These findings are at odds with national policies in countries including the US, UK, and Australia. TRIAL REGISTRATION ISRCTN 52511065 (www.isrctn.org).",0,0,
1329,Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: Let's Learn Language cluster randomised controlled trial,"OBJECTIVE To determine the benefits of a low intensity parent-toddler language promotion programme delivered to toddlers identified as slow to talk on screening in universal services. DESIGN Cluster randomised trial nested in a population based survey. SETTING Three local government areas in Melbourne, Australia. PARTICIPANTS Parents attending 12 month well child checks over a six month period completed a baseline questionnaire. At 18 months, children at or below the 20th centile on an expressive vocabulary checklist entered the trial. INTERVENTION Maternal and child health centres (clusters) were randomly allocated to intervention (modified ""You Make the Difference"" programme over six weekly sessions) or control (""usual care"") arms. MAIN OUTCOME MEASURES The primary outcome was expressive language (Preschool Language Scale-4) at 2 and 3 years""; secondary outcomes were receptive language at 2 and 3 years, vocabulary checklist raw score at 2 and 3 years, Expressive Vocabulary Test at 3 years, and Child Behavior Checklist/1.5-5 raw score at 2 and 3 years. RESULTS 1217 parents completed the baseline survey; 1138 (93.5%) completed the 18 month checklist, when 301 (26.4%) children had vocabulary scores at or below the 20th centile and were randomised (158 intervention, 143 control). 115 (73%) intervention parents attended at least one session (mean 4.5 sessions), and most reported high satisfaction with the programme. Interim outcomes at age 2 years were similar in the two groups. Similarly, at age 3 years, adjusted mean differences (intervention-control) were -2.4 (95% confidence interval -6.2 to 1.4; P=0.21) for expressive language; -0.3 (-4.2 to 3.7; P=0.90) for receptive language; 4.1 (-2.3 to 10.6; P=0.21) for vocabulary checklist; -0.5 (-4.4 to 3.4; P=0.80) for Expressive Vocabulary Test; -0.1 (-1.6 to 1.4; P=0.86) for externalising behaviour problems; and -0.1 (-1.3 to 1.2;"" P=0. 92) for internalising behaviour problems. CONCLUSION This community based programme targeting slow to talk toddlers was feasible and acceptable, but little evidence was found that it improved language or behaviour either immediately or at age 3 years. TRIAL REGISTRATION Current Controlled Trials ISRCTN20953675.",0,0,
1330,Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research,,0,1,
1331,"Overweight and obesity in pregnancy: the evidence-practice gap in staff knowledge, attitudes and practices","BACKGROUND: Statewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. However, dissemination of guidelines alone do not change practice. AIM: To systematically assess evidence-practice gap in the multidisciplinary management of overweight and obesity (ow/ob) in pregnancy to inform an intervention to facilitate translating obesity guidelines into practice in a tertiary maternity service. MATERIALS AND METHODS: An online survey, available over a three-week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff. Outcomes of interest included a 15-point guideline adherence score, knowledge of guideline content, advice given, knowledge of obesity-pregnancy-related complications, previous training and referral patterns. RESULTS: Eighty-four staff completed surveys (57% response rate). Widespread discordance with the guideline was noted. The majority (88.1%) reported overweight/obesity (ow/ob) as an important/very important general obstetric issue, most correctly identified associated complications. However, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. Compliance with referral recommendations varied"";"" 20% of staff considered referral 'was not their job'. CONCLUSIONS: Staff are aware of negative outcomes associated with maternal ow/ob, although few are fully compliant with referral guidelines or provide advice in line with recommendations. These findings will be categorised using implementation of science methodological frameworks, and effective behaviour change interventions will be constructed to facilitate translation of this important guideline into practice.",0,0,
1332,Oxygen therapy in hospitalized patients: the impact of local guidelines,"OBJECTIVE: To study the influence of local guidelines on the behaviour of nursing and medical staff to optimize the oxygen use in patients admitted to hospital. METHODS: Study was performed in a district teaching hospital. Guidelines produced suggested indications, monitoring, use of arterial blood gases (ABGs) and advice on when to stop oxygen therapy. The guidelines were implemented both verbally and in writing to all the nursing and medical staff before and after an audit studying the oxygen use by patients on medical and surgical wards. RESULTS: Ninety patients were included in pre-intervention audit and 59 in post-intervention study. Oxygen prescription did not change with guidelines 30% (27/90) vs. 32% (19/59). Nurses administered oxygen better 95% (18/19) vs. 70% (19/27) (P = 0.043) and monitored more frequently using oximetry 91% (54/59) vs. 69% (62/90) (P = 0.001) after the guidelines. Patients with airway disease had their ABGs checked more frequently 87% (14/16) vs. 65% (15/23) on admission and after they started oxygen inhalation 68% (11/16) vs. 34% (8/23). CONCLUSION: The guidelines disseminated verbally and in writing had no influence on oxygen prescription but improved the practice of close monitoring of patients with airway disease. Nurses improved their performance of both administration of oxygen according to the prescribed dose and monitoring with oximetry.",0,0,
1333,Paediatric nurses' postoperative pain management practices in hospital based non-critical care settings: a narrative review,"OBJECTIVES: To investigate paediatric nurses' postoperative pain management practices with the aim of identifying the factors associated with undermanaged paediatric postoperative pain. DESIGN: Systematic search and review. DATA SOURCES: PsychInfo, CINAHL, PubMed, EMBASE and hand searching. REVIEW METHODS: English peer-reviewed quantitative, qualitative, or mixed methods research articles published between 1990 and 2012 exploring registered nurses' paediatric postoperative pain management practices were included. Articles with a primary focus on nurses' pain management practices in the neonatal or paediatric intensive care units, recovery room, and/or focused on children with cognitive impairment were excluded. The search terms used were: postoperative pain""; nurs*; paediatrics; pediatrics; children; pain assessment; non-pharm*; analges*. Titles and abstracts were used for initial screening. Two researchers conducted data extraction and assessment of rigour for each paper. RESULTS: From the initial 248 citations, 27 studies were included. Most studies were descriptive and examined relationships between personal factors and nurses' pain management practices. Observational data from four papers added insights beyond that provided in self-report studies. Two articles used experimental designs with vignettes. Data were categorised into four topics: pain assessment; pharmacological practices; non-pharmacological practices;"" and factors affecting practices. Despite improvements in analgesic administration over the past 20 years, practices remain suboptimal. Children's behaviour appears to influence nurses' pain assessment more than validated measures. A significant proportion of children did not have pain scores recorded in the first 24-h postoperatively. Children receive more analgesia when ordered around the clock compared to as required. However, around the clock analgesia prescription did not guarantee administration. Nurses reported using several non-pharmacological strategies routinely but some are not evidence based. CONCLUSIONS: The results of this review indicate nurses' assessment and management of children's pain is not consistent with published guidelines. Results of studies exploring nurse and child related factors are inconclusive. Research needs to examine the impact of organisational factors on nurses' pain care practices. Intervention studies are needed to determine the most effective strategies to support and improve nurses' pain care for children.",0,1,
1334,Pain descriptors for critically ill patients unable to self-report,"AIM: To examine descriptors used by nurses in two Canadian intensive care units to document pain presence for critically ill patients unable to self-report. BACKGROUND: Systematic documentation of pain assessment is essential for communication and continuity of pain management, thereby enabling better pain control, maximizing recovery and reducing physical and psychological sequelae. METHOD: A retrospective, mixed method, having observational design in two Level-III intensive care units of a quaternary academic centre in Toronto, Canada. During 2008-2009, data were abstracted via chart review guided by a reference compendium of potential behavioural descriptors compiled from existing behavioural pain assessment tools. RESULTS: A total of 679 narrative descriptions were extracted. Behavioural descriptors (232, 34%), physiological descriptors (93, 14%), and descriptors indicating the patient was pain free (117, 17%) were used to describe pain presence or absence. Narratives also described analgesia administered without descriptors of pain assessment (117, 17%) and assessment and analgesic administration prior to a known painful procedure (30, 4%). Emerging themes included life-threatening treatment interference, decisional uncertainty and a wakefulness continuum. CONCLUSION: Inconsistent or ambiguous documentation was problematic in this sample. This may reflect confounding behaviours and concomitant safety priorities. Developing a lexicon of pain assessment descriptors of critically ill patients unable to self-report for use in combination with valid and reliable measures may improve documentation facilitating appropriate analgesic management. Protocols or unit guidelines that prioritize a trial of analgesia before administration of sedatives may decrease decisional uncertainty when patients exhibit ambiguous behaviours such as agitation or restlessness.",0,0,
1335,Pain in the ankle,,0,0,
1336,Parallel paths to improve heart failure outcomes: evidence matters,"Gaps and disparities in delivery of heart failure education by nurses and performance in accomplishing self-care behaviors by patients with advanced heart failure may be factors in clinical decompensation and unplanned consumption of health care. Is nurse-led education effectively delivered before hospital discharge? Nurse leaders must understand the strength of nurses' knowledge base related to self-care principles and important barriers to best practice. Nurses may not be comfortable teaching patients about dry weight, meal planning, heart failure medications, or progressive steps of activity and exercise. Further, clinical nurses may not have time to provide in-depth education to patients before discharge. Equally important, research is needed to learn about factors that enhance patients' adherence to heart failure self-care behaviors, because adherence to recommendations of national, evidence-based, heart failure guidelines improves clinical outcomes. Thus, nurses and patients are on parallel paths related to setting the foundation for improved self-care adherence in advanced heart failure. Through research, we found that nurses were not adequately prepared as heart failure educators and that patients did not believe they were able to control heart failure. In 2 educational intervention studies that aimed to help patients understand that they could control fluid management and follow a strict daily fluid limit, patients had improved clinical outcomes. Thus, misperceptions about heart failure can be overcome with interventions that move beyond communicating ""what"" self-care behaviors are recommended. Research results reflect that evidence matters! Systems and processes are needed to support nurses' knowledge, comfort, and frequency in delivering self-care education before discharge, increase the accuracy of patients' beliefs about controlling heart failure, and enhance patients' desire to adhere to guideline-recommended heart failure self-care behaviors. This article describes the development of the parallel paths of nurse and patient programs of research and explores translation of findings into practice and development of clinical translational research.",0,0,
1337,Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change,"RATIONALE: Parent presence during invasive procedures and/or resuscitation is a relatively underdeveloped and controversial practice. Much of the concern stems from the apprehension of the medical community. OBJECTIVES: To evaluate whether implementation of formal practice guidelines and corresponding interprofessional education would improve clinicians' sense of preparation and comfort in providing parents with options during their children's procedures. METHODS: Multiphase pre-post survey of (1) clinician perceptions and (2) practice from the perspective of clinicians and parents experiencing the same procedure. Data were collected over 4 years from a cardiovascular and critical care program in one U.S. children's hospital. MEASUREMENTS AND MAIN RESULTS: More than 70% of clinicians participated in the perception surveys (n = 782) and 538 clinicians and 274 parents participated in the practice surveys. After the intervention, clinicians reported that parents were present during more invasive procedures and reported higher levels of comfort with the practice of providing options to parents during resuscitative events. Levels of comfort were higher in clinicians who had practiced skills in a simulated learning environment. During both phases, few clinicians reported that parent presence affected their technical performance (4%), therapeutic decision-making (5%), or ability to teach (9%). During the post phase, clinicians reported more active parent behaviors during procedures. Parents who reported receiving information to help them prepare for their children's procedures reported higher levels of procedural understanding and emotional support. CONCLUSIONS: Implementation of practice guidelines and interprofessional education had a positive impact on clinicians' perceptions and practice when providing parents with options and support during their children's invasive procedures and/or resuscitation.",0,0,
1338,Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial,"OBJECTIVE To evaluate the effectiveness of a parenting programme as a preventive intervention with parents of preschool children considered to be at risk of developing conduct disorder. DESIGN Pragmatic randomised controlled trial using a block design with allocation by area. SETTING Eleven Sure Start areas in north and mid-Wales. PARTICIPANTS 153 parents from socially disadvantaged areas, with children aged 36-59 months at risk of conduct disorder defined by scoring over the clinical cut off on the Eyberg child behaviour inventory. Participants were randomised on a 2:1 basis, 104 to intervention and 49 to remaining on the wait listing (control). Twenty (13%) were lost to follow-up six months later, 18 from the intervention group. INTERVENTION The Webster-Stratton Incredible Years basic parenting programme, a 12 week group based intervention. MAIN OUTCOME MEASURES Problem behaviour in children and parenting skills assessed by self reports from parents and by direct observation in the home. Parents' self reported parenting competence, stress, and depression. Standardised and well validated instruments were used throughout. RESULTS At follow-up, most of the measures of parenting and problem behaviour in children showed significant improvement in the intervention group. The intention to treat analysis for the primary outcome measure, the Eyberg child behaviour inventory, showed a mean difference between groups of 4.4 points (95% confidence interval 2.0 to 6.9, P<0.001) on the problem scale with an effect size of 0.63, and a mean difference of 25.1 (14.9 to 35.2, P<0.001) on the intensity scale with an effect size of 0.89. CONCLUSION This community based study showed the effectiveness of an evidence based parenting intervention delivered with fidelity by regular Sure Start staff. It has influenced policy within Wales and provides lessons for England where, to date, Sure Start programmes have not been effective. TRIAL REGISTRATION ISRCTN46984318.",0,0,
1339,Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis,"OBJECTIVE To investigate the cost effectiveness of a parenting programme. DESIGN An incremental cost effectiveness analysis alongside a pragmatic randomised controlled trial of the effectiveness of a group parenting programme delivered through Sure Start in the community. SETTING Sure Start areas in north and mid Wales. PARTICIPANTS Parents of 116 children aged 36-59 months (87% of the clinical sample) at risk of developing conduct disorders defined by scoring over the clinical cut off on the Eyberg child behaviour inventory). Children were identified by health visitors and recruited by the research team. INTERVENTION The Webster-Stratton Incredible Years basic parenting programme or a six month waiting list control. MAIN OUTCOME MEASURE Incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory. RESULTS The bootstrapped incremental cost effectiveness ratio point estimate was 73 pounds sterling (109 euros, $142) per one point improvement on the intensity score (95% confidence interval 42 pounds sterling to 140 pounds sterling ). It would cost 5486 (8190 euros, $10,666) to bring the child with the highest intensity score to below the clinical cut-off point and 1344 (2006 euros, $2618) to bring the average child in the intervention group within the non-clinical limits on the intensity score (below 127). For a ceiling ratio of 100 pounds sterling (149 euros, $194) per point increase in intensity score, there is an 83.9% chance of the intervention being cost effective. The mean cost per child attending the parenting group was 1934 pounds sterling (2887 euros, $3760) for eight children and 1289 pounds sterling (1924 euros, $2506) for 12 children, including initial costs and materials for training group leaders. When we categorised the sample into relatively mild, moderate, and severe behaviour groups based on intensity scores at baseline the intervention seemed more cost effective in those with the highest risk of developing conduct disorder. CONCLUSION This parenting programme improves child behaviour as measured by the intensity score of the Eyberg child behaviour inventory at a relatively low cost and was cost effective compared with the waiting list control. This parenting programme involves modest costs and demonstrates strong clinical effect, suggesting it would represent good value for money for public spending.",0,0,
1340,Parkinson Disease,,0,0,
1341,Participant- and study-related characteristics predicting treatment completion and study retention in an adolescent smoking cessation trial.,"Purpose: To determine which factors predict smoking cessation treatment completion and retention among adolescents. Methods: In a multisite, randomized, controlled trial, the efficacy of motivational interviewing was compared with structured brief advice for smoking cessation and reduction in adolescents (n = 355) aged 14-18 years (55% female, 45% black, 12% Hispanic). Treatment spanned 12 weeks, with follow-up assessments at 24 weeks. Treatment completion was defined as completion of all five counseling sessions. Study retention was defined as completing the 24-week assessment. Participant and study variables served as predictors of treatment completion and retention. Results: In all, 79% of participants completed all five counseling sessions and the same percent completed the 24-week assessment. Black race, precontemplation stage to cut back, and shorter length of time between the baseline assessment and the first counseling session were significantly associated with treatment completion. For every 7.5-day delay in starting treatment after the baseline visit, there was a 50% decrease in the odds of completing all five treatment sessions. Retention at 24 weeks was predicted by black race, younger age, greater maternal education, expectations of graduating college, and structured brief advice intervention. Conclusions: High rates of treatment completion and study retention can be achieved in a multisession, behavioral intervention for adolescent smoking cessation. Findings suggest that treatment should begin soon after the intake session to maximize treatment completion. Enhanced efforts to retain older adolescents and youth with lower academic goals and lower family income will be important in future studies. (PsycINFO Database Record (c) 2017 APA, all rights reserved)",0,0,
1342,"Participation in biomedical research: the consent process as viewed by children, adolescents, young adults, and physicians","We examined the capacity of children, adolescents, and young adults to assent and consent to participation in biomedical research, and what physician-investigators believe is important for patients in these age groups to know about such participation. The sample included 44 male and female subjects, ranging in age from 7 to 20 years, who were hospitalized to treat either pediatric cancer or obesity. The participants completed a structured interview that assessed knowledge of research participation using the elements outlined in the federal guidelines for informed consent. The study subjects were most knowledgeable about those elements of consent that assessed concrete information (e.g., freedom to ask questions, time elements involved, and the benefits of participation). They were less knowledgeable about those elements of informed consent that assessed abstract information (e.g., scientific vs therapeutic purpose of the study, and alternative treatments). Chronologic age was not related to knowledge of the elements of informed consent. The strategies that the study subjects used to reason about participation in research appeared to parallel their reasoning about other physical phenomena.",0,0,
1343,"Participation of children in clinical trials: UK, European and international legal perspectives on consent","The Declaration of Helsinki was, until recently, the leading international code on the conduct of clinical trials on human subjects. The Council of Europe's Convention on Human Rights and Biomedicine (1997) and the ICH guidelines for Good Clinical Practice (1996) represent a significant step towards increased harmonization of standards in the conduct of medical experiments on human subjects. But in spite of emerging areas of consensus, there remain important areas of unclarity and divergence. Medical practitioners involved in paediatric research in the UK are concerned about the lack of certainty in the law, particularly on the application of consent rules to emergency research. This paper examines UK, European and International norms on the participation of children in medical research and compares the circumstances under which consent rules may be waived under each normative regime.",0,0,
1344,Participatory action research in antimicrobial stewardship: a novel approach to improving antimicrobial prescribing in hospitals and long-term care facilities,"It is challenging to change physicians' antimicrobial prescribing behaviour. Although antimicrobial prescribing is determined by contextual (e.g. a lack of guidelines), cultural (e.g. peer practice) and behavioural (e.g. perceived decision making autonomy) factors, most antimicrobial stewardship programmes fail to consider these factors in their approach. This may lead to suboptimal intervention effectiveness. We present a new approach in antimicrobial stewardship programme development that addresses relevant determinants of antimicrobial prescribing: participatory action research (PAR). PAR is a collaborative process that aims to bring about change in social situations by producing practical knowledge that is useful in local practice. It requires substantial involvement of relevant stakeholders to address determinants of the studied behaviour and to facilitate empowerment. PAR is well suited for complex problems in multidisciplinary settings as it adapts to local needs, delivering a tailored approach to improving local practice. We describe how PAR can be applied to antimicrobial stewardship, and describe the PAR design of two ongoing multicentre antimicrobial stewardship projects, in the acute care setting and the long-term care setting, respectively.",0,0,
1345,Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study,"BackgroundChronic obstructive pulmonary disease (COPD) is a leading cause of mortality in China, where the population is also exposed to high levels of passive smoking, yet little information exists on the effects of such exposure on COPD. We examined the relation between passive smoking and COPD and respiratory symptoms in an adult Chinese population."";"" BackgroundChronic obstructive pulmonary disease (COPD) is a leading cause of mortality in China, where the population is also exposed to high levels of passive smoking, yet little information exists on the effects of such exposure on COPD. We examined the relation between passive smoking and COPD and respiratory symptoms in an adult Chinese population.",0,0,
1346,Pathology of poverty: the need for quality improvement efforts to address social determinants of health,,0,0,
1347,Patient adherence to family practitioners' recommendations for breast cancer screening: a historical cohort study,"BACKGROUND: Breast cancer is the most prevalent malignancy among women in Israel, and routine screening is recommended for early detection. In 1997, a health management organization primary care centre in rural Israel established a 1-year programme wherein family physicians were encouraged to remind their patients to undergo breast cancer examinations. This study evaluates the impact of the physicians' intervention on patient compliance. METHODS: Family practitioners from two practices were requested to discuss the importance of early breast cancer detection with all eligible patients who visited the clinic for any reason and to assist them in scheduling an appointment for screening. The files of the patients who received the recommendation were stamped accordingly. On completion of the programme, the physicians' files were audited, and the potential candidates for breast cancer screening were divided into two groups: those who had received the intervention (n = 251) and those who had not (n = 187)"";"" results were also compared with those of a third group of patients who had gone for an examination on their own initiative (n = 100) prior to the study (i.e. did not require intervention). A random sample of half the patients also completed an ad hoc questionnaire covering sociodemographic variables and the impact of the doctors' intervention on their behaviour. RESULTS: Patients in the intervention group showed a significantly greater change in behaviour regarding breast cancer screening than the controls (32% versus 13%, P = 0.001). This change was manifested particularly in the group of women aged 50-74 years who received the recommendation for mammography to be performed (according to the guidelines). CONCLUSION: Although this is a study in only two practices, the results suggest that primary care physicians can significantly alter the behaviour of their patients regarding regular breast examinations. The use of a special reminder can also help the individual doctor to ensure that each patient has been properly instructed.",0,0,
1348,Patient advocacy and advance care planning in the acute hospital setting,"OBJECTIVE: The aim of this study was to explain the role of patient advocacy in the Advance Care Planning (ACP-ing) process. Nurses rate prolonging the dying process with inappropriate measures as their most disturbing ethical issue and protecting patients' rights to be of great concern (Johnston et al 2002). Paradoxically ethical codes assume nurses have the autonomy to uphold patients' health-care choices. Advance Directives (AD) designed to improve end-of-life care are poorly taken up and acute hospitals are generally not geared for the few they receive. The Respecting Patient Choices Program (RPCP) improves AD utilisation through providing a supportive framework for ACP-ing and primarily equipping nurses as RPC consultants. Assisting patients with this process requires attributes consistent with patient advocacy arising out of nursing's most basic tenet, the care of others. DESIGN: Likert Scales survey administered pre and six months post-intervention to pilot and control groups, with coinciding focus groups. SETTING: Selected wards in an acute care public hospital in South Australia. SUBJECTS: Nurses on the palliative care, respiratory, renal and colo-rectal pilot wards and the haem-oncology, coronary care, cardiology and neurology/geriatric control wards. INTERVENTION: The RPCP during the 2004-2005 South Australian pilot of the (RPCP). MAIN OUTCOMES: The organisational endorsement of ACP-ing gave nurses the autonomy to be patient advocates with respect to end-of-life care, reconciling clinical practice to their code of ethics and easing distress about prolonging the dying process inappropriately. RESULTS: Statistically significant survey results in the post-intervention group showed nurses experienced: encouragement to ensure patients could make informed choices about their end-of-life treatment (84%)""; the ability to uphold these wishes in practice (73%); and job satisfaction from delivering appropriate end-of-life care (67%);"" compared to approximately half (42-55%) of respondents in the pre-intervention and control groups. Focus group participants shared that it used to be hard to advocate for patients, but now they could act legitimately and felt ethically comfortable about ensuing end-of-life-care. CONCLUSION: Findings suggested patient advocacy, fostered by the supportive RPC environment, effectuates the ACP-ing process. It is recommended that the RPCP should be recognised and developed as integral to promoting quality end-of-life assurance and associated job satisfaction.",0,0,
1349,Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial.,"Background  Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates  Methods  We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas.  Results  Screening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%""; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%;"" P = .09).  Conclusions  Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.",1,1,
1350,Patient education about cough: effect on the consulting behaviour of general practice patients,"The aim of this general practice study was to examine how the consulting behaviour of patients with a cough was affected when the tasks and responsibilities of patients, practice nurses and general practitioners were reorganized. In four 'average' single-handed general practices the effects on the consulting behaviour of patients of a rational practice policy on cough and the provision of systematic patient education on cough were compared with patient behaviour in four matched control practices. Changes of behaviour were measured in 548 patients who consulted for cough at least twice, in two successive autumn-winter periods. Significantly more patients in the experimental practice changed their behaviour to follow the practice guidelines than did patients in the control practices (56% versus 30%, P less than 0.001). The proportion of patients who continued to consult in the approved manner was greater among patients receiving intervention (66% versus 29%, P less than 0.001). This was equally true for patients who had suffered less than four episodes of cough or more than four episodes. The more often the patients received the education, the more effective it was. All patients who consulted the general practitioner for cough during the first autumn-winter period filled in a cough diary during the second period. From this it appeared that the intervention did not result in patients delaying consultation when they had a cough lasting longer than three weeks or one with 'serious' symptoms. It would appear that a rational practice policy and the provision of patient education can stimulate patients to modify their consulting behaviour. This could result in a reduction in the costs of health care.",0,0,
1351,Patient education for colon cancer screening: a randomized trial of a video mailed before a physical examination,"BACKGROUND: Colorectal cancer screening is underused, and primary care clinicians are challenged to provide patient education within the constraints of busy practices. OBJECTIVE: To test the effect of an educational video, mailed to patients' homes before a physical examination, on performance of colorectal cancer screening, particularly sigmoidoscopy. DESIGN: Randomized, controlled trial. SETTING: 5 primary care practices in central Massachusetts. PARTICIPANTS: 938 patients age 50 to 74 years who were scheduled for an upcoming physical examination, had no personal history of colorectal cancer, and were eligible for lower-endoscopy screening according to current guidelines. INTERVENTION: Participants were randomly assigned to receive usual care (n = 488) or a video about colorectal cancer, the importance of early detection, and screening options (n = 450). MEASUREMENTS: Baseline and 6-month follow-up telephone assessments were conducted. A dependent variable classified screening since baseline as 1) sigmoidoscopy with or without other tests, 2) another test or test combination, or 3) no tests. RESULTS: Overall screening rates were the same in the intervention and control groups (55%). In regression modeling, intervention participants were nonsignificantly more likely to complete sigmoidoscopy alone or in combination with another test (odds ratio, 1.22 [95% CI, 0.88 to 1.70]). Intervention dose (viewing at least half of the video) was significantly related to receiving sigmoidoscopy with or without another test (odds ratio, 2.81 [CI, 1.85 to 4.26]). Recruitment records showed that at least 23% of people coming for periodic health assessments were currently screened by a lower-endoscopy procedure and therefore were not eligible. LIMITATIONS: The primary care sample studied consisted primarily of middle-class white persons who had high screening rates at baseline. The results may not be generalizable to other populations. The trial was conducted during a period of increased health insurance coverage for lower-endoscopy procedures and public media attention to colon cancer screening. CONCLUSIONS: A mailed video had no effect on the overall rate of colorectal cancer screening and only modestly improved sigmoidoscopy screening rates among patients in primary care practices.",0,0,
1352,Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care,"Importance  Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.  Objective  To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.  Design, Setting, and Participants  Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire¨C9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.  Interventions  DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).  Main Outcomes and Measures  Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome)""; depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.  Results  Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, ?6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control,??0.2 (95% CI, ?1.2 to 0.8); IMCP vs control,?0.9 (95% CI, ?0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control,??2.2 [90% CI, ?8.0 to 3.49], P?=?.0499 for noninferiority; IMCP vs control,??3.3 [90% CI, ?9.1 to 2.4], P?=?.02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,?0.9 [90% CI, ?4.9 to 6.7], P?=?.23 for noninferiority;"" IMCP vs control,?0.3 [90% CI, ?5.1 to 5.7], P?=?.16 for noninferiority).  Conclusions and Relevance  A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.",0,0,
1353,Patient perceptions of risky drinking: knowledge of daily and weekly low-risk guidelines and standard drink sizes,"BACKGROUND: Effective intervention for risky drinking requires that clinicians and patients know low-risk daily and weekly guidelines and what constitutes a ""standard drink."" The authors hypothesized that most patients lack this knowledge, and that education is required. METHODS: Following primary care visits, patients completed anonymous exit questionnaires that included the 3 Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questions, ""How many drinks (containing alcohol) can you safely have in one day?"" and questions about size, in ounces, of a standard drink of wine, beer, and liquor. Descriptive analyses were done in Stata. RESULTS: Of 1,331 respondents (60% female, mean age: 49.6, SD = 17.5), 21% screened positive on the AUDIT-C for risky drinking. Only 10% of those accurately estimated daily low-risk limits, with 9% accurate on weekly limits, and half estimated low-risk limits at or below guidelines. Fewer than half who checked ""Yes"" to ""Do you know what a 'standard drink' is?"" provided accurate answers for beer, wine, or liquor. Patients with a positive screen were twice as likely to say they knew what a standard drink is, but only a third gave accurate estimates. When asked about plans in the next month regarding change in drinking behavior, 23% with a positive AUDIT-C indicated they were at least considering a change. CONCLUSIONS: Most patients in primary care don't know specifics of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for low-risk drinking. Exploring patient perceptions of low-risk guidelines and current drinking behavior may reveal discrepancies worth discussing. For risky drinkers, most of whom don't know daily and weekly low-risk guidelines or standard drink sizes, education can be vital in intervening. Findings suggest the need for detailed and explicit social marketing and communication on exactly what low-risk drinking entails.",0,0,
1354,Patient safety research: an overview of the global evidence,"Background Unsafe medical care may cause substantial morbidity and mortality globally, despite imprecise estimates of the magnitude of the problem. To better understand the extent and nature of the problem of unsafe care, the WHO World Alliance for Patient Safety commissioned an overview of the world's literature on patient safety research.  Methods Major patient safety topics were identified through a consultative and investigative process and were categorised into the framework of structure, process and outcomes of unsafe care. Lead experts examined current evidence and identified major knowledge gaps relating to topics in developing, transitional and developed nations. The report was reviewed by internal and external experts and underwent improvements based on the feedback.  Findings Twenty-three major patient safety topics were examined. Much of the evidence of the outcomes of unsafe care is from developed nations, where prevalence studies demonstrate that between 3% and 16% of hospitalised patients suffer harm from medical care. Data from transitional and developing countries also suggest substantial harm from medical care. However, considerable gaps in knowledge about the structural and process factors that underlie unsafe care globally make solutions difficult to identify, especially in resource-poor settings.  Interpretation Harm from medical care appears to pose a substantial burden to the world's population. However, much of the evidence base comes from developed nations. Understanding the scope of and solutions for unsafe care for the rest of the world is a critical component of delivering safe, effective care to all of the world's citizens.",0,1,
1355,Patient safety: the doctor's perspective,"Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Beyond their economic cost and their cost in human lives, errors cause loss of trust in the healthcare system by patients and diminished satisfaction by both patients and health professionals. There are many evidence-based safety-oriented behaviours and interventions that are easily implemented, such as ultrasound-guided central venous catheter insertion, prevention of catheter-related bloodstream infection and more. In vascular access, the development of research in patient safety has raised a variety of issues requiring study in order to provide the optimal patient safety approach. Patients are major contributors to their own safety, and as such, physicians should develop a new approach to involve them in the cycle of decision making through every step of their treatment. There are many opportunities along this path for the patient to be engaged in safety behaviours and for the access team to ensure such behaviours by employing simple strategies. The advent of the access centre, based on multidisciplinary teamwork, has enhanced the potential to improve patient safety by prevention of errors in planning and performing access surgery, avoiding delay in treatment of access malfunction and improving communication between the team members. However, a significant effort in research is still needed in order to implement intervention by evidence-based data focused on patient safety.",0,0,
1356,Patient-carried card prompts vs computer-generated prompts to remind private practice physicians to perform health maintenance measures.,"Background:  We compared the efficacy of a computer-generated prompt sheet placed on the front of patients' charts with a patient-carried prompt card to remind physicians to perform selected health maintenance items.  Methods:  A randomized prospective single-blind study was performed in private practice offices in rural eastern North Carolina, with 28 family practitioners and nine general internists participating. Twenty-two physicians were randomized to the computer prompt group and 22 to the card prompt group. Four physicians in the computer group did not complete the study because of computer software problems, and three physicians did not complete the study because their limited staff was unable to enter patient data into the computer. Before the intervention, 20 patient charts (10 males and 10 females) from each physician were audited for the performance of influenza vaccinations, stool for occult blood, pap smears, breast examinations performed by the physicians, and mammograms. One year after the intervention was instituted, chart audits for the above five items were done again on 20 different patient charts for each physician.  Results:  There was a 7% increase in the performance of influenza vaccinations in the card group (17% vs 24%) compared with a 6% increase in the computer group (20% vs 26%). There was a 5% decrease in the performance of stool for occult blood in the card group (28% vs 23%) compared with a 1% increase in the computer group (30% vs 31%). There was an 11% decrease in the performance of pap smears in the card group (26% vs 15%) compared with a 3% increase in the computer group (23% vs 26%). There was a 2% decrease in the performance of breast examinations by the physician in the card group (35% vs 33%) compared with a 3% increase in the computer group (30% vs 33%). Finally, there was a 3% increase in the performance of mammograms in the card group (22% vs 25%) compared with an 11% increase in the computer group (15% vs 26%).  Conclusions:  Our data show a greater increase in performance of health maintenance items in the computer-prompted group. The performance of stool for occult blood, pap smears, breast examinations performed by the physician, and mammograms were increased more in the computer-prompted group than in the card group. However, there was not a statistically significant difference after intervention for any of the audited health maintenance items for either the computer group or the card group. Overall, health maintenance measures were performed in only a minority of appropriate patients.(Arch Intern Med. 1994"";""154:1957-1960)",0,1,
1357,Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study,"INTRODUCTION: Many doctors believe that patients with gout are unwilling to receive urate-lowering therapy (ULT) and blame them for poor adherence to management. OBJECTIVE: To test the effectiveness of a complex intervention for gout that incorporates key elements of current guidelines, including full patient information, delivered in an optimal setting (specialist hospital clinic). METHOD: Observational study of patients reporting ongoing attacks of gout recruited from primary care lists. 106 participants (94 men, 12 women""; mean age 61 years) were enrolled in the study. Patients received a predominantly nurse-delivered intervention that included education, individualised lifestyle advice and appropriate ULT. The predefined goal was to achieve serum uric acid (SUA) levels</=360 mumol/l after 1 year in at least 70% of participants. RESULTS: Of the 106 participants at baseline, 16% had tophi; mean (SD) baseline SUA was 456 (98) micromol/l. All participants agreed to joint aspiration to confirm gout and all wished to receive ULT. At 12 months, 92% of the 106 participants had achieved the therapeutic target (SUA</=360 micromol);"" 85% had SUA<300 micromol/l. Allopurinol was the most commonly used ULT, requiring a median dose of 400 mg daily to achieve the target. Improvements in Short Form-36 were observed (significant for pain) after 1 year. CONCLUSION: A predominantly nurse-led intervention including education, lifestyle advice and ULT can successfully achieve the recommended treatment target in more than 9 out of 10 patients. Full explanation and discussion about the nature of gout and its treatment options and individualisation of management probably account for this success.",0,0,
1358,"Pearls, perils, and pitfalls in the assessment and treatment of attention-deficit/hyperactivity disorder in adolescents","PURPOSE OF REVIEW: To provide clinicians with an updated overview of key considerations related to the clinical assessment and management of attention-deficit/hyperactivity disorder (ADHD) in adolescents. RECENT FINDINGS: The American Psychiatric Association's recently revised Diagnostic and Statistical Manual of Mental Disorders-5 included significant changes regarding diagnostic criteria for ADHD in adolescents. The American Academy of Pediatrics (AAP) also recently revised their Clinical Practice Guidelines for ADHD"";"" whereas prior guidelines were focused on children aged 6-12, the new guidelines extend up to age 17. An understanding of these revised diagnostic criteria and clinical guidelines is essential for pediatricians and others who care for adolescents. In addition to providing an updated review of the clinical approach to assessment and treatment of ADHD in adolescents, recent findings are briefly described relating to common comorbidities, psychosocial risks, and long-term outcome. SUMMARY: Diagnosis and treatment of adolescents with ADHD present unique challenges and obstacles. Clinicians need to be careful and deliberate in their evaluation of a teenager with recent-onset symptoms suggestive of ADHD, giving consideration to other conditions that could mimic ADHD and screening for common comorbid conditions. In terms of treatment of adolescents, the AAP recommends medication as the first-line intervention, noting that stimulants have a much broader evidence base and larger effect size than nonstimulants. Although clinicians now have a multitude of medication formulations to choose among, they must also be vigilant to the potential for stimulant misuse and diversion.",0,0,
1359,Pediatric Nurse Practitioner Management of Child Anxiety in a Rural Primary Care Clinic With the Evidence-Based COPE Program,"INTRODUCTION: Anxiety is the most common mental health disorder in children. Many communities have shortages of mental health providers, and the majority of children with anxiety are not receiving the evidence-based treatment they need. The purpose of this pilot study was to assess the feasibility and effects of a brief seven-session cognitive behavioral skills-building intervention, Creating Opportunities for Personal Empowerment (COPE), which was delivered to anxious children by a pediatric nurse practitioner in a primary care setting. METHODS: A pre-experimental, one-group, pretest and post-test design was used. RESULTS: Children who participated had a significant decrease in anxiety symptoms (13.88 points, SD = 17.96, 95% confidence interval [CI] = -1.13-28.89), as well as an increase in knowledge of cognitive-behavioral coping skills (M = 11.38, CI = 5.99-8.26, p = .00) and improved functioning (at school and at home). Evaluations by parents and children were positive. DISCUSSION: COPE is a promising evidence-based intervention for children with anxiety with feasible delivery by pediatric nurse practitioners in primary care.",0,0,
1360,Peer support for patients with type 2 diabetes: cluster randomised controlled trial,"OBJECTIVE To test the effectiveness of peer support for patients with type 2 diabetes. DESIGN Cluster randomised controlled. SETTING 20 general practices in the east of the Republic of Ireland. PARTICIPANTS 395 patients (192 in intervention group, 203 in control group) and 29 peer supporters with type 2 diabetes. INTERVENTION All practices introduced a standardised diabetes care system. The peer support intervention ran over a two year period and contained four elements: the recruitment and training of peer supporters, nine group meetings led by peer supporters in participant's own general practice, and a retention plan for the peer supporters. MAIN OUTCOME MEASURES HbA(1c)""; cholesterol concentration; systolic blood pressure;"" and wellbeing score. RESULTS There was no difference between intervention and control patients at baseline. All practices and 85% (337) of patients were followed up. At two year follow-up, there were no significant differences in HbA(1c) (mean difference -0.08%, 95% confidence interval -0.35% to 0.18%), systolic blood pressure (-3.9 mm Hg, -8.9 to 1.1 mm Hg), total cholesterol concentration (-0.03 mmol/L, -0.28 to 0.22 mmol/L), or wellbeing scores (-0.7, -2.3 to 0.8). While there was a trend towards decreases in the proportion of patients with poorly controlled risk factors at follow-up, particularly for systolic blood pressure (52% (87/166) >130 mm Hg in intervention v 61% (103/169) >130 mm Hg in control), these changes were not significant. The process evaluation indicated that the intervention was generally delivered as intended, though 18% (35) of patients in the intervention group never attended any group meetings. CONCLUSIONS A group based peer support intervention is feasible in general practice settings, but the intervention was not effective when targeted at all patients with type 2 diabetes. While there was a trend towards improvements of clinical outcomes, the results do not support the widespread adoption of peer support. Trial registration Current Controlled Trials ISRCTN42541690.",0,0,
1361,Perceptions and performance of function and physical activity in assisted living communities,"OBJECTIVE: The purpose of this study was to describe residents' self-efficacy and outcome expectations with regard to function and physical activity (PA)""; to measure functional performance and time in PA; to evaluate the fit between the resident and the environment; and to evaluate knowledge, beliefs, and care behaviors of nursing assistants (NAs) in 4 different assisted living (AL) communities. DESIGN: This was a descriptive study using baseline data from an ongoing intervention study, Testing the Impact of a Function Focused Care Intervention, Res-Care-AL. SETTING: Four assisted living communities in Maryland. PARTICIPANTS: A total of 171 residents and 96 NAs consented, passed eligibility, and were included in this study. MEASUREMENTS: Descriptive data were obtained from NAs and residents. Resident data also included self-efficacy and outcome expectations associated with functional tasks and exercise, social support for exercise, and subjective and objective information about function and physical activity. NA data included self-efficacy and outcome expectations, knowledge, and performance of function-focused care. RESULTS: Residents were mostly female, white, and widowed; needed some assistance with activities of daily living; and engaged in very little PA based on subjective and objective reports. NAs were mostly female and black, had more than a decade of nursing experience, strong confidence but limited knowledge of function-focused care, and performed this care in 76% of observed care interactions. There were no site-specific differences among NAs with regard to beliefs, knowledge, or performance of function-focused care. There were site-specific differences in residents with regard to self-efficacy for functional ability; functional performance; social supports for exercise from experts;"" and from family, person-environment fit, and PA based on subjective surveys. There were no differences noted based on actigraphy. CONCLUSION: Residents in AL communities engage in very limited amounts of PA and staff in these sites could benefit from ongoing education about how to increase PA among residents and help them adhere to current guidelines for PA so as to optimize overall health status.",0,0,
1362,Performance of the TREAT decision support system in an environment with a low prevalence of resistant pathogens.,"Objectives To evaluate a decision support system (TREAT) for guidance of empirical antimicrobial therapy in an environment with a low prevalence of resistant pathogens.  Methods A retrospective trial of TREAT has been performed at Copenhagen University, Hvidovre Hospital. The cohort of patients included adults with systemic inflammation and suspicion of community-acquired bacterial infection. The empirical antimicrobial treatment recommended by TREAT was compared with the empirical antimicrobial treatment prescribed by the first attending clinical physician.  Results Out of 171 patients recruited, 161 (65 with microbiologically documented infections) fulfilled the inclusion criteria of TREAT. Coverage achieved by TREAT was significantly higher than that by clinical practice (86% versus 66%, P = 0.007). There was no significant difference in the cost of future resistance between treatments chosen by TREAT and those by physicians. The direct expenses for antimicrobials were higher in TREAT when including patients without antimicrobial treatment, while there was no significant difference otherwise. The cost of side effects was significantly lower using TREAT.  Conclusions The results of the study suggest that TREAT can improve the appropriateness of antimicrobial therapy and reduce the cost of side effects in regions with a low prevalence of resistant pathogens, however, at the expense of increased use of antibiotics.",0,1,
1363,Perioperative care map improves compliance with best practices for the morbidly obese,"BACKGROUND: Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. METHODS: A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. RESULTS: In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. CONCLUSION: After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes.",0,0,
1364,Perioperative β blockers in patients having non-cardiac surgery: a meta-analysis,"BackgroundAmerican College of Cardiology and American Heart Association (ACC/AHA) guidelines on perioperative assessment recommend perioperative ? blockers for non-cardiac surgery, although results of some clinical trials seem not to support this recommendation. We aimed to critically review the evidence to assess the use of perioperative ? blockers in patients having non-cardiac surgery."";"" BackgroundAmerican College of Cardiology and American Heart Association (ACC/AHA) guidelines on perioperative assessment recommend perioperative ? blockers for non-cardiac surgery, although results of some clinical trials seem not to support this recommendation. We aimed to critically review the evidence to assess the use of perioperative ? blockers in patients having non-cardiac surgery.",0,0,
1365,Person-Centered Primary Care Strategies for Assessment of and Intervention for Aggressive Behaviors in Dementia,"With an increase in the number of individuals affected by dementia, it is imperative for health care providers to be well versed in the most effective ways to manage neuropsychiatric symptoms, such as aggression. Aggression can be particularly hard to manage because it creates risk of harm for formal and informal caregivers, and options for medical intervention are complex and situation dependent. Although multiple guidelines for management of aggression in dementia are available in the literature, their scope is widespread and suggested treatments often vary, making decision making difficult to navigate for busy clinicians. Using a composite case as a model, the current article provides guidelines that take outpatient providers through the steps needed to provide effective treatment for aggression in individuals with dementia. Shifting the current focal point of health care for aggressive dementia patients toward a more person-centered approach will have a positive impact on patient care. [Journal of Gerontological Nursing, 43(2), 9-17.].",0,0,
1366,Pharmaceutical care in chronic kidney disease: experience at Grenoble University Hospital from 2006 to 2010,"BACKGROUND: Clinical pharmacists (CPs) specifically manage lab-test follow-up, adapt drug dosage according to guidelines and evaluate cardiovascular risk factors and decline in renal function. The aim of this study was to assess the impact of clinical pharmacy services in outpatient nephrology clinics. METHOD: For each patient, medical history and current treatment were obtained. Each intervention was classified according to the Act-IP document of the French Society of Clinical Pharmacy. This tool contains identifications and guidelines for prevention and resolution of drug-related problems (DRPs). RESULTS: From January 2008 until April 2009, 42 patients seen by the CP on at least 2 visits were included in the study. We observed 350 pharmaceutical consultations and 263 interventions. The pharmaceutical interventions concerned: untreated indication (30%), underdosage (25.9%) and overdosage (18.3%). The CP interventions consisted of: adapting doses (42.2%) and adding treatments (31.9%). The main drugs involved concerned the cardiovascular (33.1%), digestive-metabolic (28.6%) and hematopoietic (21.6%) systems. CONCLUSION: The inclusion of a CP in the management of chronic kidney disease (CKD) patients is necessary for identification and prevention of DRPs. Besides the medical improvement of CKD patients, the CP participates in the development of prescription recommendations and therapeutic education programs for patients. Moreover, redefining roles and practices of members of a clinical team proved its efficiency in optimizing the medical care of CKD patients. Furthermore, patient entry into dialysis is postponed, which leads to a reduction in costs for health care insurance.",0,0,
1367,Pharmacoeconomic consequences of measurement and modification of hospital drug use,"Patterns of drug usage affect hospital-based delivery of healthcare in a variety of ways. Adverse reactions to drugs (ADR) precipitate some 5% of admissions and prejudice the care of some 20% of patients who are in hospital, while inadequate drug therapy prejudices outcomes and prolongs hospital stay. Conversely, appropriate application of drugs can promote recovery and increase the quality of care. Well documented examples include prevention of deep vein thrombosis and postoperative wound infections. Accordingly, optimisation of drug use represents a major quality assurance issue in addition to determining cost-efficiency of healthcare delivery. Drug utilisation review (DUR) requires all elements of the quality assurance process. In practice, therapeutically meaningful and cost-efficient exercises can only be mounted if there is knowledge of the linkage between patterns of drug use and clinical outcomes. These processes of measurement are currently rate-limiting in quality assurance. There are various ways that hospital drug usage can be measured. These range from readily available and relatively cheap quantitative methods to methods requiring the availability of expert staff. There is a sequence of methods involving increasing costs and increasing resource demands yielding increasing detail of information obtained. This sequence commences with pharmacy purchases, followed by pharmacy issues to particular clinical areas, prescription or treatment sheet survey, clinical record review, and finally the reports of trained investigators working in the clinical area. The simpler methods can provide useful information and an efficient basis for choosing and planning definitive studies. Once a category of drug use is appropriately targeted for intervention, drug use can be modified by planned intervention with improvement in clinical outcomes and reduced economic costs in many instances. The intervention strategies to modify drug usage may be classed as re-educative, persuasive, facilitative and power strategies. Other models for implementing behavioural change have been considered, including the impact of trained investigators and the use of online computer prescribing with interactive software with appropriate guidelines. The challenge is to achieve sustained change when interventions are implemented. Cost-efficient quality assurance of drug use is possible with modest resources if outcome-orientated activities are prioritised.",0,0,
1368,Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians,"Background: Pharmacologic interventions are often prescribed for insomnia disorder. Purpose: To assess the benefits, harms, and comparative effectiveness of pharmacologic treatments for adults with insomnia disorder. Data Sources: Several electronic databases (2004¨CSeptember 2015), reference lists, and U.S. Food and Drug Administration (FDA) documents. Study Selection: 35 randomized, controlled trials of at least 4 weeks' duration that evaluated pharmacotherapies available in the United States and that reported global or sleep outcomes""; 11 long-term observational studies that reported harm information; FDA review data for nonbenzodiazepine hypnotics and orexin receptor antagonists; and product labels for all agents. Data Extraction: Data extraction by single investigator confirmed by a second reviewer; dual-investigator assessment of risk of bias; consensus determination of strength of evidence. Data Synthesis: Eszopiclone, zolpidem, and suvorexant improved short-term global and sleep outcomes compared with placebo, although absolute effect sizes were small (low- to moderate-strength evidence). Evidence for benzodiazepine hypnotics, melatonin agonists, and antidepressants, and for most pharmacologic interventions in older adults, was insufficient or low strength. Evidence was also insufficient to compare efficacy within or across pharmacotherapy classes or versus behavioral therapy. Harms evidence reported in trials was judged insufficient or low strength;"" observational studies suggested that use of hypnotics for insomnia was associated with increased risk for dementia, fractures, and major injury. The FDA documents reported that most pharmacotherapies had risks for cognitive and behavioral changes, including driving impairment, and other adverse effects, and they advised dose reduction in women and in older adults. Limitations: Most trials were small and short term and enrolled individuals meeting stringent criteria. Minimum important differences in outcomes were often not established or reported. Data were scant for many treatments. Conclusion: Eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Pharmacotherapies for insomnia may cause cognitive and behavioral changes and may be associated with infrequent but serious harms. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42014009908)",0,0,
1369,Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians,"Description: The American College of Physicians (ACP) developed this guideline to present the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis. Methods: Published literature on this topic was identified by using MEDLINE (1966 to December 2006), the ACP Journal Club database, the Cochrane Central Register of Controlled Trials (no date limits), the Cochrane Database of Systematic Reviews (no date limits), Web sites of the United Kingdom National Institute of Health and Clinical Excellence (no date limits), and the United Kingdom Health Technology Assessment Program (January 1998 to December 2006). Searches were limited to English-language publications and human studies. Keywords for search included terms for osteoporosis, osteopenia, low bone density, and the drugs listed in the key questions. This guideline grades the evidence and recommendations according to the ACP's clinical practice guidelines grading system. Recommendation 1: ACP recommends that clinicians offer pharmacologic treatment to men and women who have known osteoporosis and to those who have experienced fragility fractures (Grade: strong recommendation""; high-quality evidence). Recommendation 2: ACP recommends that clinicians consider pharmacologic treatment for men and women who are at risk for developing osteoporosis (Grade: weak recommendation; moderate-quality evidence). Recommendation 3: ACP recommends that clinicians choose among pharmacologic treatment options for osteoporosis in men and women on the basis of an assessment of risk and benefits in individual patients (Grade: strong recommendation;"" moderate-quality evidence). Recommendation 4: ACP recommends further research to evaluate treatment of osteoporosis in men and women.",0,0,
1370,Pharmacologic treatment of neuropsychiatric disorders,"Emotional and cognitive symptomatologies, such as depression, mania, lability of mood and affect, psychosis, impaired arousal, anxiety, and irritability and aggression often occur in neurologic disorders. These neuropsychiatric syndromes significantly impair functioning and efforts at rehabilitation. Patients with brain damage are especially sensitive to the side effects of medication. When appropriate guidelines are followed, psychopharmacologic intervention alleviates these symptoms, enhances rehabilitation, and avoids impairment of arousal and cognition.",0,0,
1371,Pharmacological treatment of bipolar disorder among children and adolescents,"There is growing recognition that bipolar disorder frequently first presents in adolescence. Preadolescents with volatile behavior and severe mood swings also comprise a large group of patients whose difficulties may lie within the bipolar spectrum. However, the preponderance of scientific effort and clinical trials for this condition has focused on adults. This review summarizes the complexity of bipolar disorder and diagnosis of the disease among young people. It proceeds to review the principles of pharmacotherapy, assess current treatment options and to highlight areas where evidence-based guidance is lacking. Recent developments have enlarged the range of potential treatments for bipolar disorder. Nonetheless, differences in the phenomenology, course and sequelae of bipolar disorder among young people compel greater attention to the benefits and liabilities of therapy for those affected by this illness' early onset. By summarizing current research and opinion on diagnostic issues and treatment approaches, this review aims to provide an update on a clinically important yet controversial topic.",0,0,
1372,Pharmacotherapy of social anxiety disorder at the turn of the millennium,"Over the past 21 years since the birth of SP into the diagnostic nomenclature, there have been significant gains in knowledge about effective pharmacologic and psychotherapeutic treatments. The SSRIs have emerged as the first-line pharmacologic treatment, although good evidence shows efficacy of benzodiazepines""; MAOIs;"" and anticonvulsant agents, such as gabapentin and pregabalin. There is also emerging evidence about the efficacy of the novel antidepressant venlafaxine and also optimism for the potential utility of nefazodone and possibly bupropion. However, there are many areas requiring further investigation. There has been a great deal of excitement about the publication of the RUPP Anxiety Study, demonstrating efficacy for fluvoxamine in socially phobic youth. Given that SP starts in childhood and adolescence, more data are needed to support the use of pharmacotherapy in this age group because early intervention may prevent the sequelae of chronic SP. There needs to be more investigation into what is required for social phobic individuals who obtain a good response to pharmacotherapy to move into full-remission status. Additional research is needed regarding the evaluation of the comparative efficacy of different drug classes and to develop an improved capability of predicting treatment response to a particular type of treatment. In addition, more research is needed regarding treatment resistance. In most of the anxiety disorders that have been studied, combining CBT with psychopharmacologic treatment has shown little advantage over either treatment alone. These findings may be due to methodologic problems. Research is needed on how to sequence treatments to maximize the benefits of combining the two types of effective treatments together. Finally, many clinicians are seeing an emerging trend of individuals who have had untreated SP all of their lives and are now presenting for treatment in their ""golden years."" The current established treatments need to be evaluated further in this geriatric population.",0,0,
1373,Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community.,"Background: Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design.  Methods: Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.  Results: 186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from “severe” to “not severe” than control patients (OR 2.68, 95% CI 1.64 to 4.37""; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p?=?0.03), decreased mean daily dose of reliever medication (difference -149.11 µg, 95% CI -283.87 to -14.36; p?=?0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting ß agonist (OR 3.80, 95% CI 1.40 to 10.32; p?=?0.01) and improved scores on risk of non-adherence (difference -0.44, 95% CI -0.69 to -0.18; p?=?0.04), quality of life (difference -0.23, 95% CI -0.46 to 0.00; p?=?0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference -1.39, 95% CI -2.44 to -0.35;"" p<0.01). No significant change in spirometric measures occurred in either group.  Conclusions: A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.",0,1,
1374,Physical activity on prescription (PAP) from the general practitioner's perspective - a qualitative study,"BACKGROUND: Physical activity on prescription (PAP) is a successful intervention for increasing physical activity among patients with a sedentary lifestyle. The method seems to be sparsely used by general practitioners (GPs) and there is limited information about GPs' attitudes to counselling using PAP as a tool. The aim of the study was to explore and understand the meaning of prescribing physical activity from the general practitioner's perspective. METHODS: Three focus group interviews were conducted with a purposive sample of 15 Swedish GPs in the south of Sweden. Participants were invited to talk about their experience of using PAP. The interviews were transcribed verbatim, analysed using qualitative content analysis. RESULTS: The analysis resulted in four categories: The tradition makes it hard to change attitude, Shared responsibility is necessary, PAP has low status and is regarded with distrust and Lack of procedures and clear guidelines. Traditionally GPs talk with patients about the importance of an increased level of physical activity but they do not prescribe physical activity as a treatment. Physician's education focuses on the use of pharmaceuticals. The responsibility for patients' physical activity level is shared with other health professionals, the patient and society. The GPs express reservations about prescribing physical activity. A heavy workload is a source of frustration. PAP is regarded with distrust and considered to be a task of less value and status. Using a prescription to emphasize an increased level is considered to be redundant and the GPs think it should be administered by someone else in the health care system. Scepticism about the result of the method was also expressed. CONCLUSIONS: There is uncertainty about using PAP as a treatment since physicians lack education in non-pharmaceutical methods. The GPs do not regard the written referral as a prioritized task and rather refer to other professionals in the health care system to prescribe PAP. GPs pointed out a need to create routines and arrangements for the method to gain credibility and become everyday practice among GPs.",0,0,
1375,Physician Advice to Adolescents About Smoking: Who Gets Advised and Who Benefits Most?,"PURPOSE: The Clinical Practice Guidelines instruct physicians to ask their patients about smoking and to advise against tobacco use. Physicians are urged especially to attend to racial minorities and teens because of these groups' increased susceptibility to smoking. Research on race and physician advice against smoking has produced contradictory findings. The purpose of this study is to clarify the relationships between physician communication about tobacco, race, and smoking among adolescents. METHODS: This cross-sectional retrospective study explored (1) racial differences in rates of receiving physician communication and (2) whether the relationship between physician communication and smoking among adolescents was moderated by race. Multiple measures of smoking status were used (e.g., intentions to quit, quit attempts, quits, relapse status). We used a large (N = 5,154), predominately African-American (82.9%) sample of 11th graders. RESULTS: Regular smokers were more likely to be screened about smoking. African Americans were more frequently advised against tobacco than Caucasians. Among African Americans, nonsmokers were most likely to be both screened and advised"";"" among Caucasians, regular were most likely to be screened and advised. Overall, physician intervention was associated with greater benefits for young African Americans, including fewer intentions to smoke, greater likelihood of quitting, and less relapse. CONCLUSIONS: Physician communication about smoking may hold particular promise for African-American teens, reducing health disparities because of racial differences in smoking-related mortality and morbidity. Physicians should be encouraged to screen and advise all young people about tobacco, regardless of race or smoking status.",0,0,
1376,Physician and patient predictors of evidence-based prescribing in heart failure: a multilevel study,"BACKGROUND: The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence. METHODS: To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of >/=50% of recommended RAAS-I dosage being investigated by two-level logistic regression models. RESULTS: Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR/=50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92-0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02-1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38-1.05, p = 0.08). CONCLUSIONS: A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.",0,0,
1377,Physician and patient willingness to pay for electronic cardiovascular disease management,"OBJECTIVES: Cardiovascular disease (CVD) is an important target for electronic decision support. We examined the potential sustainability of an electronic CVD management program using a discrete choice experiment (DCE). Our objective was to estimate physician and patient willingness-to-pay (WTP) for the current and enhanced programs. METHODS: Focus groups, expert input and literature searches decided the attributes to be evaluated for the physician and patient DCEs, which were carried out using a Web-based program. Hierarchical Bayes analysis estimated preference coefficients for each respondent and latent class analysis segmented each sample. Simulations were used to estimate WTP for each of the attributes individually and for an enhanced vascular management system. RESULTS: 144 participants (70 physicians, 74 patients) completed the DCE. Overall, access speed to updated records and monthly payments for a nurse coordinator were the main determinants of physician choices. Two distinctly different segments of physicians were identified - one very sensitive to monthly subscription fee and speed of updating the tracker with new patient data and the other very sensitive to the monthly cost of the nurse coordinator and government billing incentives. Patient choices were most significantly influenced by the yearly subscription cost. The estimated physician WTP was slightly above the estimated threshold for sustainability while the patient WTP was below. CONCLUSION: Current willingness to pay for electronic cardiovascular disease management should encourage innovation to provide economies of scale in program development, delivery and maintenance to meet sustainability thresholds.",0,0,
1378,Physician attitudes toward dissemination of optical spectroscopy devices for cervical cancer control: an industrial-academic collaborative study,"BACKGROUND: Optical spectroscopy has been studied for biologic plausibility, technical efficacy, clinical effectiveness, patient satisfaction, and cost-effectiveness. OBJECTIVE: We sought to identify health care provider attitudes or practices that might act as barriers or to the dissemination of this new technology. METHODS: Through an academic-industrial partnership, we conducted a series of focus groups to examine physician barriers to optical diagnosis. The study was conducted in 2 stages. First, a pilot group of 10 physicians (8 obstetrician gynecologists and 2 family practitioners) was randomly selected from 8 regions of the United States and each physician was interviewed individually. Physicians were presented with the results of a large trial (N = 980) testing the accuracy of a spectroscopy-based device in the detection of cervical neoplasia. They were also shown a prototype of the device and were given a period of time to ask questions and receive answers regarding the device. They were also asked to provide feedback on a questionnaire that was then revised and presented to 3 larger focus groups (n = 13, 15, and 17 for a total N = 45). The larger focus groups were conducted during national scientific meetings with 20 obstetrician gynecologists and 25 primary care physicians (family practitioners and internists). RESULTS: When asked about the dissemination potential of the new cervical screening technology, all study groups tended to rely on established clinical guidelines from their respective professional societies with regard to the screening and diagnosis of cervical cancer. In addition, study participants consistently agreed that real-time spectroscopy would be viewed positively by their patients. Participants were positive about the new technology's potential as an adjunct to colposcopy and agreed that the improved accuracy would result in reduced health care costs (due to decreased biopsies and decreased visits). Although all participants saw the potential of real-time diagnosis, there were many perceived barriers. These barriers included changes in scheduling and work-flow, liability, documentation, ease of use, length of training, device cost, and reimbursement by third-party payers. CONCLUSIONS: Barriers exist to the dissemination of optical technologies into physician practice. These will need to be addressed before cervical screening and diagnosis programs can take advantage of spectroscopy-based instruments for cancer control.",0,0,
1379,Physician behavior in the care of pediatric chronic illness: association with health outcomes and treatment adherence,"OBJECTIVE: Physician behavior is an important but understudied influence on child and parental adherence to medical treatment. METHOD: To address this need, research was reviewed in the following topic areas: child and adolescent perceptions of physicians' behavior in pediatric chronic illness management, parental perceptions of physicians' behavior in pediatric chronic illness management""; physicians' adherence to guidelines for pediatric chronic illness management; physicians' communication of information concerning pediatric chronic illness treatment; the relationship of physician behavior to treatment adherence;"" and interventions to enhance physicians' management of pediatric chronic illness. RESULTS: Findings underscore discrepancies between the needs of parents and adolescents and physician behavior as well as inconsistencies in physician behavior, including adherence to practice guidelines, which may limit children's adherence to medical treatment. However, results of interventions designed to enhance physicians' management of pediatric asthma have been promising. CONCLUSIONS: Future research should be guided by a comprehensive model of physician behavior in chronic illness management that considers contextual determinants (e.g., culture and socioeconomic status), identifies clinically relevant targets for intervention, and documents the impact on health outcomes. Approaches to chronic illness management that involve physicians in active communication, support, and decision making with children with chronic illness and their parents should be developed and evaluated.",0,0,
1380,Physician intervention and patient risk perception among smokers with acute respiratory illness in the emergency department,"BACKGROUND: Acute Respiratory Illness accounts for over 12 million visits to emergency departments in the United States each year. Between one-fourth and one-half of these patients are smokers. We examined the frequency of physician intervention for smoking cessation among acute respiratory illness patients in the emergency department, and examined the influence of physician intervention on patients' perceived risk from smoking and motivation to quit. METHODS: This study was conducted in the emergency department of a large inner-city hospital. Adult smokers (n = 63) presenting with symptoms of acute respiratory illness were surveyed by exit interview while in the emergency department. The frequency and extent of physician interventions for smoking were examined using the Agency for Health Care Policy and Research guidelines as a model. We also assessed patients' perceptions of risk from smoking, the presence of other household smokers, and the patients' motivation to quit. RESULTS: Emergency department physicians provided incomplete and inconsistent intervention for smoking. While most patients reported being asked if they smoked, only half of smokers were advised to quit. Only 9% were offered any assistance with quitting. Risk perception was generally low, however, the majority of smokers were willing to receive on-site smoking cessation counseling while in the emergency department. CONCLUSIONS: The small sample size in this study requires that results be interpreted with caution. However, the findings of this study suggest that the emergency department setting may provide a unique ""teachable moment"" in which to initiate smoking cessation counseling for this high-risk population.",0,0,
1381,Physician involvement in the management of obesity as a primary medical condition,"As the obesity epidemic escalates, increasing numbers of patients present with serious comorbidities related to excess body weight. Obesity should be recognized and treated as a primary medical condition that is progressive, chronic, and relapsing. Effective treatment of obesity has been shown to reduce cardiovascular risk factors and comorbid conditions. Physician involvement is necessary for medical assessment, management, counseling, and coordination of multidisciplinary obesity treatment. Obese patients who receive counseling and weight management from physicians are significantly more likely to undertake weight management programs than those who do not. Obesity treatment guidelines and materials are available from various health organizations. A comprehensive weight management program must include dietary adjustments, increased physical activity, and behavioral modification. Nutritional modifications should take into account the diet's energy content, composition, and suitability for the individual patient. The physical activity component should be safe and practical, including aerobic activity, strength training, and increased daily lifestyle activities. Various behavioral strategies enable the patient to make lifestyle changes that will promote weight loss and management. Adjunct therapies may serve to support lifestyle modifications in severe or resistant cases of obesity. Models for multidisciplinary care vary depending on whether they are designed for an individual medical practice or as part of the health care services of a larger facility. Lifestyle changes for healthy weight management must be permanently incorporated into a patient's daily lifestyle to reduce obesity and its associated health risks. Such intervention is necessary if the growing epidemic of obesity is to be slowed and reversed.",0,0,
1382,Physician management of hypercholesterolemia. A randomized trial of continuing medical education,"To determine the effect of continuing medical education (CME) on compliance with the recommendations of the National Cholesterol Education Program Expert Panel on high serum cholesterol levels in adults, we randomly assigned primary physicians in 174 practices to 3 groups, 2 that underwent either standard or intensive CME and a control group. The standard CME group was offered a free 3-hour seminar on high serum cholesterol levels""; the intensive CME group was offered in addition follow-up seminars and free office materials. After 18 months, we audited 13,099 medical records from the 140 practices that remained in the study. There were no significant differences (P > .15) in screening for high serum cholesterol or compliance with guidelines between the groups receiving continuing medical education (51% screening; 33% compliance) and the control group (57% screening;"" 37% compliance). In the prespecified subgroup of patients with hypercholesterolemia, there was a trend toward a modest benefit from the continuing medical education interventions: compliance was 21% in the control group, 23% in the standard CME group, and 27% in the intensive CME group (P = .07 overall). These results emphasize the need for better ways to change behavior in practicing physicians and the importance of studying the implementation of preventive health recommendations.",0,0,
1383,Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study,"We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)",0,0,
1384,Physician response to computer reminders.,"A computerized medical record system was designed to detect and remind the responsible clinician about clinical events that might need corrective action. These reminders significantly increased the clinician response rate (in terms of test orders and treatment changes) to the events in question. The addition of relevant medical literature citations to the reminders did not significantly change the clinician response rate as compared with that with reminders alone, nor did it stimulate the physicians to read any of the cited articles kept in an immediately available ""library"" of reprints.",0,1,
1385,Physician responses to a community-level trial promoting judicious antibiotic use,"PURPOSE: In an environment of multiple campaigns promoting judicious antibiotic use in children, identification of effective strategies is important. We assessed physician responses to a community-level intervention with respect to antibiotic prescribing, related practices, and perceived effectiveness. METHODS: This study was a mixed qualitative and quantitative evaluation of a randomized controlled community-wide educational intervention in 16 Massachusetts communities. Physicians in intervention communities received locally endorsed guidelines, group educational sessions, and biweekly newsletters. Parents simultaneously received materials in physicians' offices and by mail. After the intervention, we conducted a mailed physician survey and individual interviews to assess the impact of the intervention. We compared survey responses for intervention and control physicians, and we analyzed interview transcripts to provide in-depth information about selected topics. RESULTS: Among survey respondents (n = 168), 91% of intervention and 4% of control physicians reported receiving intervention materials. Physicians received information from multiple other sources. More intervention than control physicians reported decreased antibiotic prescribing from 2000-2003 (75% vs 58%, P = .03), but there were no differences between groups in knowledge, attitudes, or behaviors favoring judicious antibiotic use. Both groups were concerned about antibiotic resistance and reported room to reduce their own prescribing. Interviewed physicians suggested frequent repetition of messages, brief written materials on specific topics for themselves and patients, and promotion in the mass media as the most effective strategies to reduce prescribing. CONCLUSIONS: In multiple communities an intervention in physician offices to promote judicious antibiotic prescribing reached its intended audience, but physicians' self-reported attitudes and practices were similar in intervention and control communities. Campaigns that repeat brief, consistent reminders to multiple stakeholder groups may be most effective at assuring judicious antibiotic use.",0,0,
1386,Physician screening for multiple behavioral health risk factors,"BACKGROUND: Screening rates in primary care for single behavioral health risk factors are widely documented. However, such risk factors cluster in individuals and populations. This article examines the number and types of behavioral risk factors that U.S. adults reported, and reported having been screened for in their last routine medical checkup. METHODS: The sample consisted of 16,818 adults from the 1998 National Health Interview Survey who reported having a routine checkup in the past year. Respondents completed questions regarding four behavioral risk factors (physical inactivity, overweight, cigarette smoking, risky drinking), and provider screening for behaviors related to these risk factors. RESULTS: Half of the sample (52.0%) reported having two or more of the four risk factors, and more than half (59.4%) were screened for two or more risk behaviors during their last routine checkup, although 28.6% reported being screened for none of them. Respondents reporting at least one risk factor were screened for an average of 57.7% of their own risk factors. Women, adults with lower levels of income and education, and those aged 65 and older, reported being screened for fewer of their risk factors. CONCLUSIONS: While guidelines for risk factor screening and intervention typically focus on single behavioral risk factors, most primary care patients present with, and are screened for, more than one. Behavioral risk factor screening tools and interventions must be expanded to cover multiple risks. Additionally, efforts are needed to reduce the substantial missed opportunities for screening, and to eliminate demographic disparities in screening practices and accuracy.",0,0,
1387,"Physician, heal thyself: health maintenance behaviors among physicians","The goal of this article is to assess the need for health maintenance intervention programs directed at physicians and patients. We compared the health maintenance behavior compliance of physicians (as patients) to a control patient population. An online survey was sent to the Texas Tech University Health Sciences Center (TTUHSC) medical school clinical and nonclinical basic science faculties and to the non-TTUHSC clinicians of the local county medical society. The survey included questions regarding basic demographics and recent participation in regular health maintenance strategies including annual checkup, influenza vaccination, colonoscopy, Pap smear, and mammogram. Logistic regressions were conducted to determine if being a physician had a significant association with the likelihood of participating in the health maintenance behavior outcomes listed above. This article shows that physicians are less likely than the general population to adhere to specific health maintenance guidelines: namely, annual checkups, colonoscopies, and mammograms. Pap smear rates did not differ between physicians and a control population, but physicians showed an increased likelihood of receiving an influenza vaccine.",0,0,
1388,Physician-Industry Relations. Part 1: Individual Physicians,"This is part 1 of a 2-part paper on ethics and physician-industry relationships. Part 1 offers advice to individual physicians"";"" part 2 gives recommendations to medical education providers and medical professional societies. Physicians and industry have a shared interest in advancing medical knowledge. Nonetheless, the primary ethic of the physician is to promote the patient's best interests, while the primary ethic of industry is to promote profitability. Although partnerships between physicians and industry can result in impressive medical advances, they also create opportunities for bias and can result in unfavorable public perceptions. Many physicians and physicians-in-training think they are impervious to commercial influence. However, recent studies show that accepting industry hospitality and gifts, even drug samples, can compromise judgment about medical information and subsequent decisions about patient care. It is up to the physician to judge whether a gift is acceptable. A very general guideline is that it is ethical to accept modest gifts that advance medical practice. It is clearly unethical to accept gifts or services that obligate the physician to reciprocate. Conflicts of interest can arise from other financial ties between physicians and industry, whether to outside companies or self-owned businesses. Such ties include honorariums for speaking or writing about a company's product, payment for participating in clinic-based research, and referrals to medical resources. All of these relationships have the potential to influence a physician's attitudes and practices. This paper explores the ethical quandaries involved and offers guidelines for ethical business relationships.",0,0,
1389,Physicians and the pharmaceutical industry (update 2001),,0,0,
1390,Physicians' health habits are associated with lifestyle counseling for hypertensive patients,"BACKGROUND: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) recommended lifestyle interventions, either with or without pharmacologic treatment, for all patients with high blood pressure. The objective of this study is to determine the association of physicians' personal habits with their attitudes and behaviors regarding JNC VII lifestyle modification guidelines. METHODS: One thousand primary care physicians completed DocStyles 2010, a voluntary web-based survey designed to provide insight into physician attitudes and behaviors regarding various health issues. RESULTS: The respondents' average age was 45.3 years, and 68% were male. In regards to physician behavior, 4.0% smoked at least once a week, 38.6% ate >/=5 cups of fruits and/or vegetables >/=5 days/week, and 27.4% exercised >/=5 days/week. When asked about specific types of advice offered to their hypertensive patients, physicians reported recommending that their patients eat a healthy diet (92.2%), or cut down on salt (96.1%), or attain or maintain a healthy weight (94.8%), or limit the use of alcohol (75.4%), or be physically active (94.4%). Collectively, 66.5% made all 5 lifestyle modification recommendations. Nonsmoking physicians were more likely to recommend each lifestyle intervention to their hypertensive patients. Those who exercised at least 1 day per week were more likely to recommend limiting alcohol use. CONCLUSIONS: The probability of recommending all 5 JNC VII interventions was greater for physicians who were nonsmoking and who exercised at least 1 day a week.",0,0,
1391,Physicians' response to victims of domestic violence: toward a model of care,"Even though current domestic violence guidelines, such as those published by the AMA in 1992, attempt to relieve physicians of the ""full burden of intervention,"" they continue to call upon physicians to play a large role in identifying, intervening in, and following up on case of partner abuse. In this paper, we define a limited domestic violence role for physicians which furthers the direction recommended by the AMA and which complements exemplary programs. We propose simplifying and limiting physicians' tasks to Asking patients about abuse""; providing Validating messages, acknowledging that battering is wrong and confirming patient worth; Documenting presenting signs, symptoms, and disclosures; and Referring victims to domestic violence specialists (AVDR). By drawing on the literature and our own experience, we show how focusing the physician's role on these four taks is consistent with exemplary programs and expands on ideas put forth by experts for addressing domestic violence in health care settings; reduces barriers for physician interventions with victims; offers a realistic approach for physicians, reducing unrealistic educational demands;"" and complements managed care trends in contemporary health care.",0,0,
1392,Physicians' understanding of consent requirements for phase I clinical trials in cognitively impaired or highly vulnerable populations,"We investigated physicians' attitudes about entering patients who cannot give informed consent or who are of a vulnerable population into clinical trials. A survey instrument asked a nationwide sample of practicing physicians about whether ten hypothetical patients could be enrolled in a phase I clinical trials. The impact of demographic variables on the number of scenarios viewed as completely or somewhat acceptable was analyzed via student's T tests or analysis of variance (ANOVA) as applicable. All significant (p<0.01) variables were entered into a multiple logistic regression model. Eighty-four percent of respondents indicated that at least one case scenario was acceptable. A majority of those who conduct clinical trials (62%), who had training in the ethics of clinical research (78%), and who sit on institutional review boards (IRBs) (83%) approved of at least one case scenario. Physicians approved of the entry of some patients who cannot give informed consent or who are of a vulnerable population into clinical trials. More effective education on the guidelines involving clinical research should be available to practicing physicians, residents, and medical students. There should also be assurance that physicians who conduct clinical trials or who sit on IRBs have the requisite knowledge about the ethics of clinical research.",0,0,
1393,Pinning down the diagnosis in breast cancer,,0,0,
1394,Point-of service reminders for prescribing cardiovascular medications.,"OBJECTIVES: To provide physicians with evidence-based recommendations for care at the point of service, using an automated system, and to evaluate its effectiveness in promoting prescriptions to prevent cardiovascular events. STUDY DESIGN: Randomized controlled trial. METHODS: Patients at risk for cardiovascular events who might benefit from angiotensin-converting enzyme inhibitors or 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) were identified from electronic data in a managed care organization and randomly assigned into 2 groups. Physicians seeing outpatients in the intervention group were faxed a sheet with pertinent patient data, including a recommendation to prescribe the indicated medication. In the control group, the data sheet did not include the recommendation. Dispensed prescriptions were compared between groups. RESULTS: More than 4000 visits were observed for each medication type. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were dispensed in 7.1% of visits in the intervention group versus 5.7% in the control group (P = .048) following the first patient-physician encounter. No significant difference was observed for statins (intervention, 8.1% vs control, 7.7%). Data for all patient-physician encounters and both medications were combined in logistic regression analysis. The odds ratio was 1.19 for a dispensed prescription in the intervention group and 1.54 for 2 or more visits versus 1 visit. CONCLUSIONS: An automated system that provides pertinent data and tailored recommendations for care at the point of service modestly increased prescription dispensing rates. Targeting patient-provider encounters to change provider behavior is challenging"";"" however, even small effects can produce clinically important results over time.",0,1,
1395,"Point-of-care electronic prompts: an effective means of increasing compliance, demonstrating quality, and improving outcome","BACKGROUND: Incentives based on quality indicators such as the Surgical Care Improvement Project core measures (SCIP 1) encourage implementation of evidence-based guidelines consistently into clinical practice. Information systems with point-of-care electronic prompts (POCEPs) can facilitate adoption of processes and benchmark performance. We evaluated the effectiveness of POCEPs on rates of antibiotic administration within 60 minutes of surgical incision and effect on outcome in a prospective observational trial. METHODS: SCIP 1 compliance and the corresponding outcome variable (surgical site infection [SSI]) were examined prospectively over 2 consecutive 6-month periods before (A) and after (B) POCEPs implementation at a regional health system. Secondary analysis extended the observation to two 12-month periods (A' and B'). A 2-year (C and D) sustainability phase followed. RESULTS: The 19,744 procedures included 9127 and 10,617 procedures before (A) and after (B) POCEPs implementation, respectively. POCEPs increased compliance with SCIP indicators in period B by 31% (95% CI, 30.0%-32.2%) from 62% to 92% (P 95% with mean SSI rates lower for all periods compared with pre-POCEPs SSI rates (0.8%, 0.7%, and 0.5% vs 1.1%"";"" P 30% and were associated with a 0.4% absolute risk reduction in the incidence of SSI. POCEPs may be useful to modulate provider behavior and demonstrate intraoperative quality and value.",1,1,
1396,"Population-based interventions for reducing sexually transmitted infections, including HIV infection","BACKGROUND: Sexually transmitted infections (STI) are common in developing countries. The World Health Organisation (WHO) estimates that in 1999, 340 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred. Human immunodeficiency virus (HIV) infection is also common in developing countries. UNAIDS estimates that over 95% of the 40 million people infected with HIV by December 1999 live in developing countries (UNAIDS 2003). The STI and HIV epidemics are interdependent. Similar behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of both infections, and there is clear evidence that conventional STIs increase the likelihood of HIV transmission. Several studies have demonstrated a strong association between both ulcerative and non-ulcerative STIs and HIV infection (Cameron 1989, Laga 1993). There is biological evidence, too, that the presence of an STI increases shedding of HIV, and that STI treatment reduces HIV shedding (Cohen 1997, Robinson 1997). Therefore, STI control may have the potential to contribute substantially to HIV prevention. OBJECTIVES: To determine the impact of population-based STI interventions on the frequency of HIV infection, frequency of STIs and quality of STI management. SEARCH STRATEGY: The following electronic databases were searched for relevant randomised trials or reviews:1) MEDLINE for the years 1966 to 2003 using the search terms ""sexually transmitted diseases"" and ""human immunodeficiency virus infection""2) The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register, in the most recent issue of the Cochrane Library3) The specialist registry of trials maintained by the Cochrane Infectious Diseases Group.4) EMBASE The abstracts of relevant conferences were searched, and reference lists of all review articles and primary studies were scanned. Finally, authors of included trials and other experts in the field were contacted as appropriate. SELECTION CRITERIA: Randomised controlled trials in which the unit of randomisation is either a community or a treatment facility. Studies where individuals are randomised were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. Trials were examined for completeness of reporting. The methodological quality of each trial was assessed by the same two reviewers, with details recorded of randomisation method, blinding, use of intention-to-treat analysis and the number of patients lost to follow-up, using standard guidelines of the Cochrane Infectious Diseases Group. MAIN RESULTS: Five trials were included. Frequency of HIV infection: In Rakai, after 3 rounds of treatment of all community members for STIs, the rate ratio of incident HIV infection was 0.97 (95%CI 0.81 to 1.16), indicating no effect of the intervention. In Mwanza, the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (OR=0.58, 95% CI 0.42-0.70), corresponding to a 38% reduction (95%CI 15% to 55%) in HIV incidence in the intervention group. In the newest trial by Kamali et al, the rate ratio of behavioral intervention & STI management compared to control on HIV incidence was 1.00 (0.63-1.58, p=.98). These are consistent with Rakai data showing no effect of intervention. Frequency of STIs: In both Mwanza and Rakai, there was no significant reduction in gonorrhoea, chlamydia, urethritis, or reported STI symptoms among intervention communities. The prevalence ratio of syphilis between intervention and control groups in Rakai was 0.8 (95%CI 0.71-0.89), of trichmoniasis was 0.59 (0.38-0.91), and of bacterial vaginosis was 0.87 (0.74-1.02). In Mwanza, the prevalence of serologically diagnosed syphilis in the intervention community was 5% compared with 7% in the control community at the end of the trial (adjusted re7% in the control community at the end of the trial (adjusted relative risk 0.71 (95%CI 0.54-0.93). In Kamali et al, there was a significant decrease in gonorrhoea and active syphilis cases. Rate ratio for gonorrhoea was 0.29(0.12-0.71, p=0.016), active syphilis was 0.53(0.33-0.84,p=0.016). There was a trend towards significance with intervention on the use of condoms with the last casual partner"";"" the rate ratio was 1.27(1.02-1.56,p=0.036). Quality of treatment: In Lima, following training of pharmacy assistants in STI syndromic management, symptoms were recognised as being due to an STI in 65% of standardised simulated patients (SSPs) visiting intervention and 60% of SSPs visiting control pharmacies (p=0.35). Medication was offered without referral to a doctor in most cases (83% intervention and 78% control, p=0.61). Of those SSPs offered medication, only 1.4% that visited intervention pharmacies and only 0.7% of those that visited control pharmacies (p=0.57) were offered a recommended regimen. Similarly in only 15% and 16% of SSP visits respectively was any recommended drug offered. However, education and counseling were more likely to be given to SSPs visiting intervention pharmacies (40% vs 27%, p=0.01). No SSPs were given partner cards or condoms. In Hlabisa, following the intervention targeting primary care clinic nurses (strengthened STI syndromic management and provision of STI syndrome packets containing recommended drugs, condom, partner cards and patient information leaflets), SSPs were more likely to be given recommended drugs in intervention clinics (83% vs 12%, p<0.005) and more likely to be correctly case managed [given correct drugs, partner cards and condoms] (88% vs 50%, p<0.005). There were no significant differences in the proportions adequately counseled (68% vs 46%, p=0.06), experiencing good staff attitude (84% vs 58%, p=0.07), and being consulted in privacy (92% vs 86%, p=0.4). There was no strong evidence of any impact on treatment-seeking behaviour, utilisation of services, or sexual behaviour in any of the four trials. REVIEWERS' CONCLUSIONS: There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. The addition of the Kamali trial to the existing evidence supports the data from the Rakai trial of no effect. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. The Kamali trial shows an increase in the use of condoms, a marker for improved risk behaviors. Further community-based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment, as well as HIV, STI and other biological endpoints.",0,0,
1397,"Population-based interventions for reducing sexually transmitted infections, including HIV infection","BACKGROUND: Sexually transmitted infections (STI) are common in developing countries. The World Health Organisation (WHO) estimates that in 1995, 333 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred. Human immunodeficiency virus (HIV) infection is also common in developing countries. UNAIDS estimates that over 90% of the 33 million people infected with HIV by December 1999 live in developing countries (UNAIDS 1999). The STI and HIV epidemics are interdependent. Similar behaviours, such as frequent unprotected intercourse with different partners, place people at high risk of both infections, and there is clear evidence that conventional STIs increase the likelihood of HIV transmission. Several studies have demonstrated a strong association between both ulcerative and non-ulcerative STIs, and HIV infection (Cameron 1989, Laga 1993) and there is biological evidence that the presence of an STI increases shedding of HIV and that STI treatment reduces HIV shedding (Cohen 1997, Robinson 1997). Therefore, STI control may have the potential to contribute substantially to HIV prevention. OBJECTIVES: To determine the impact of population-based STI interventions on the frequency of HIV infection, frequency of STIs and quality of STI management. SEARCH STRATEGY: The following electronic databases were searched for relevant randomised trials or reviews: 1) MEDLINE for the years 1966 to current using the search terms sexually transmitted diseases and human immunodeficiency virus infection 2) The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register in the most recent issue of the Cochrane Library 3) The specialist register of trials maintained by the Cochrane Infectious Diseases Group. 4) EMBASE The abstracts of relevant conferences were searched and reference lists of all review articles and primary studies were scanned. Finally, authors of included trials and other experts in the field were contacted as appropriate. SELECTION CRITERIA: Randomised controlled trials in which the unit of randomisation is either a community or a treatment facility. Studies where individuals are randomised were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied the inclusion criteria to potential studies with any disagreements resolved by discussion. Trials were examined for completeness of reporting. The methodological quality of each trial was assessed by the same two reviewers with details recorded of randomisation method, blinding, use of intention-to-treat analysis and the number of patients lost to follow-up using standard guidelines of the Cochrane Infectious Diseases Group. MAIN RESULTS: Four trials were included. Frequency of HIV infection: In Rakai, after 3 rounds of treatment of all community members for STIs the rate ratio of incident HIV infection was 0.97 (95%CI 0.81 to 1.16), indicating no effect of the intervention. In Mwanza, the incidence of HIV infection in the intervention groups (strengthened syndromic management of STIs in primary care clinics) was 1.2% compared with 1.9% in the control groups (OR=0.58, 95% CI 0.42-0.70), corresponding to a 38% reduction (95%CI 15% to 55%) in HIV incidence in the intervention group. Frequency of STIs: In both Mwanza and Rakai, there was no significant reduction in gonorrhoea, chlamydia, urethritis, or reported STI symptoms among intervention communities. The prevalence ratio of syphilis between intervention and control groups in Rakai was 0.8 (95%CI 0.71-0.89), of trichmoniasis was 0.59 (0.38-0.91), and of bacterial vaginosis was 0.87 (0.74-1.02). In Mwanza, the prevalence of serologically diagnosed syphilis in the intervention community was 5% compared with 7% in the control community at the end of the trial (adjusted relative risk 0.71 (95%CI 0.54-0.93). Quality of treatment: In Lima, following training of pharmacy assistants in STI syndromic management, symptoms were recognised as being due to an STI in 65% of standardised simulated patients (SSPs) visiting intervention and 60% of SSPs visiting control pharmacies (p=0.35). Medication was offered without referral to a doctor in most cases (83% intervention and 78% control, p=0.61). Of those SSPs offered medication, only 1.4% that visited intervention pharmacies and only 0.7% of those that visited control pharmacies (p=0.57) were offered a recommended regimen. Similarly in only 15% and 16% of SSP visits respectively was any recommended drug offered. However, education and counseling were more likely to be given to SSPs visiting intervention pharmacies (40% vs 27%, p=0.01). No SSPs were given partner cards or condoms. In Hlabisa, following the intervention targeting primary care clinic nurses (strengthened STI syndromic management and provision of STI syndrome packets containing recommended drugs, condom, partner cards and patient information leaflets), SSPs were more likely to be given recommended drugs in intervention clinics (83% vs 12%, p <0.005) and more likely to be correctly case managed [given correct drugs, partner cards and condoms] (88% vs 50%, p <0.005). There were no significant difference in the proportions adequately counseled (68% vs 46%, p=0.06), experiencing good staff attitude (84% vs 58%, p=0.07), and being consulted in privacy (92% vs 86%, p=0.4). There was no strong evidence of any impact on treatment seeking behaviour, utilisation of services, or sexual behaviour in any of the four trials. REVIEWERS' CONCLUSIONS: There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. There are however other compelling reasons why STI treatment services should be strengthened and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. Further community based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment as well as HIV, STI and other biological endpoints.",0,0,1396
1398,Population-level intervention strategies and examples for obesity prevention in children,"With obesity affecting approximately 12.5 million American youth, population-level interventions are indicated to help support healthy behaviors. The purpose of this review is to provide a summary of population-level intervention strategies and specific intervention examples that illustrate ways to help prevent and control obesity in children through improving nutrition and physical activity behaviors. Information is summarized within the settings where children live, learn, and play (early care and education, school, community, health care, home). Intervention strategies are activities or changes intended to promote healthful behaviors in children. They were identified from (a) systematic reviews""; (b) evidence- and expert consensus-based recommendations, guidelines, or standards from nongovernmental or federal agencies;"" and finally (c) peer-reviewed synthesis reviews. Intervention examples illustrate how at least one of the strategies was used in a particular setting. To identify interventions examples, we considered (a) peer-reviewed literature as well as (b) additional sources with research-tested and practice-based initiatives. Researchers and practitioners may use this review as they set priorities and promote integration across settings and to find research- and practice-tested intervention examples that can be replicated in their communities for childhood obesity prevention.",0,0,
1399,Positron emission tomography in gynecologic cancer,"Most positron emission tomography (PET) imaging studies in gynecologic cancer are performed using (18)F-fluorodeoxyglucose (FDG). It contributes valuable information in primary staging of untreated advanced cervical cancer, in the post-treatment surveillance with unexplained tumor marker (such as squamous cell carcinoma antigen [SCC-Ag]) elevation or suspicious of recurrence, and restaging of potentially curable recurrent cervical cancer. Its value in early-stage resectable cervical cancer is questionable. In ovarian cancer, FDG-PET provides benefits for those with plateaued or increasing abnormal serum CA 125 (>35 U/mL), computed tomography and/or magnetic resonance imaging (CT-MRI) defined localized recurrence feasible for local destructive procedures (such as surgery, radiotherapy, or radiofrequency ablation), and clinically suspected recurrent or persistent cancer for which CT-guide biopsy cannot be performed. The role of FDG-PET in endometrial cancer is relatively less defined because of the lack of data in the literature. In our prospective study, FDG-PET coupled with MRI-CT may facilitate optimal management of endometrial cancer in well-selected cases. The clinical impact was positive in 29 (48.3%) of the 60 scans, 22.2% for primary staging, 73.1% for post-therapy surveillance, and 57.1% after salvage therapy, respectively. Scant studies have been reported in the management of vulvar cancer using FDG-PET. More data are needed. Gestational trophoblastic neoplasia is quite unique in biological behavior and clinical management. Our preliminary results suggest that FDG-PET is potentially useful in selected gestational trophoblastic neoplasia by providing a precise metastatic mapping of tumor extent up front, monitoring response, and localizing viable tumors after chemotherapy. The evaluation of a diagnostic tool, such as PET, is usually via comparing the diagnostic efficacy (sensitivity, specificity, etc), by using a more sophisticated receiver operating curve method, or the proportion of treatment been modified. Evaluating PET by clinical benefit is specific to the individual tumor and an attractive new endpoint.",0,0,
1400,Postnatal depression and infant development,,0,0,
1401,Postphlebitic syndrome after fractures of the leg,,0,0,
1402,Potential of trans fats policies to reduce socioeconomic inequalities in mortality from coronary heart disease in England: cost effectiveness modelling study,"OBJECTIVES To determine health and equity benefits and cost effectiveness of policies to reduce or eliminate trans fatty acids from processed foods, compared with consumption remaining at most recent levels in England. DESIGN Epidemiological modelling study. SETTING Data from National Diet and Nutrition Survey, Low Income Diet and Nutrition Survey, Office of National Statistics, and health economic data from other published studies PARTICIPANTS Adults aged ≥25, stratified by fifths of socioeconomic circumstance. INTERVENTIONS Total ban on trans fatty acids in processed foods""; improved labelling of trans fatty acids; bans on trans fatty acids in restaurants and takeaways. MAIN OUTCOME MEASURES Deaths from coronary heart disease prevented or postponed; life years gained; quality adjusted life years gained. Policy costs to government and industry;"" policy savings from reductions in direct healthcare, informal care, and productivity loss. RESULTS A total ban on trans fatty acids in processed foods might prevent or postpone about 7200 deaths (2.6%) from coronary heart disease from 2015-20 and reduce inequality in mortality from coronary heart disease by about 3000 deaths (15%). Policies to improve labelling or simply remove trans fatty acids from restaurants/fast food could save between 1800 (0.7%) and 3500 (1.3%) deaths from coronary heart disease and reduce inequalities by 600 (3%) to 1500 (7%) deaths, thus making them at best half as effective. A total ban would have the greatest net cost savings of about £265m (€361m, $415m) excluding reformulation costs, or £64m if substantial reformulation costs are incurred outside the normal cycle. CONCLUSIONS A regulatory policy to eliminate trans fatty acids from processed foods in England would be the most effective and equitable policy option. Intermediate policies would also be beneficial. Simply continuing to rely on industry to voluntary reformulate products, however, could have negative health and economic outcomes.",0,0,
1403,Practical clinical trials in psychopharmacology: a systematic review,"Practical clinical trials (PCTs) are randomized experiments under typical practice conditions with the aim of testing the ""real-life"" benefits and risks of therapeutic interventions. Influential PCTs have been conducted in cardiology, oncology, and internal medicine. Psychotropic medications are widely and increasingly used in medical practice. This review examines recent progress in conducting PCTs in psychopharmacology. The January 2000 to October 2014 MEDLINE, Scopus, and ClinicalTrials.gov databases were searched for peer-reviewed publications of PCTs with at least 100 subjects per treatment arm. Most PCTs in psychiatry evaluated mental health services or psychosocial interventions rather than specific pharmacotherapies. Of 157 PCTs in psychiatry, 30 (19%) were in psychopharmacology, with a median of 2 publications per year and no increase during the period of observation. Sample size ranged from 200 to 18,154"";"" only 11 studies randomized 500 patients or more. Psychopharmacology PCTs were equally likely to be funded by industry as by public agencies. There were 10 PCTs of antidepressants, for a total of 4206 patients (in comparison with at least 46 PCTs of antihypertensive medications, for a total of 208,014 patients). Some psychopharmacology PCTs used suicidal behavior, treatment discontinuation, or mortality as primary outcome and produced effectiveness and safety data that have influenced both practice guidelines and regulatory decisions. Practical clinical trials can constitute an important source of information for clinicians, patients, regulators, and policy makers but have been relatively underused in psychopharmacology. Electronic medical records and integrated practice research networks offer promising platforms for a more efficient conduct of PCTs.",0,0,
1404,Practical implementation of the coronary revascularization heart team,,0,0,
1405,Practice changes associated with the Department of Veterans Affairs' Family Care Collaborative,"BACKGROUND: The Department of Veterans Affairs (VA) provides rehabilitation for veterans with moderate to severe war injuries through four regional Polytrauma Rehabilitation Centers (PRCs). To standardize and improve care provided to these veterans' family members, health services researchers partnered with program leaders and rehabilitation specialists to implement a family care quality improvement collaborative. OBJECTIVE: To describe practice changes associated with the Family Care Collaborative's intervention. DESIGN: Cross-site, mixed-method evaluation. PARTICIPANTS: Rehabilitation interdisciplinary team members (n = 226) working at the four participating sites. INTERVENTIONS: The collaborative developed and implemented in a 6-month pilot a web-based tool to standardize and promote family-centered care. OUTCOMES: Provider survey of family care, satisfaction with family care, and perceived competence in working with families""; specific practice changes at each site; provider and facilitator perceptions of the collaborative work;"" and a validated measure to predict likelihood of success of the selected intervention. MAIN RESULTS: Family-centered practices and satisfaction improved at sites with lower baseline scores (P < 0.05) and was equivalent across sites after the pilot. Providers initiated specific family-centered practices that often began at one site and spread to the others through the collaborative. Sites standardized family education and collaboration. Providers believed that the collaborative produced a ""culture change"" from patient-centered to family-centered care and viewed program leadership and health services researchers' involvement as crucial for success. Scores on the measure to predict successful implementation of the intervention beyond the pilot were promising. CONCLUSIONS: Collaboratives that bring together clinicians, program leaders, and researchers may be useful for fostering complex change involving interdisciplinary teams.",0,1,
1406,Practice development: bridging the research-practice divide through the appointment of a research lead,"Research suggests that while most clinicians endorse the importance of evidence-based practice, without the right culture of support and encouragement it can be difficult to achieve such practice. This paper presents an outline of one method to enhance evidence-based practice. It reports on the evaluation of a new type of occupational therapy post, a research lead based in clinical practice, and suggests that the post has the potential to bridge the research-practice divide. Based on feedback from clinicians, research outputs and the impact on practice, the results offer an insight into the role of the research lead in contributing to and enhancing the use of evidence-based practice. It is hoped that these findings may be beneficial to other areas that are considering the strategies and support required to enhance and invest in evidence-based practice.",0,1,
1407,Practice Doesn't Always Make Perfect: A Qualitative Study Explaining Why a Trial of an Educational Toolkit Did Not Improve Quality of Care,"BACKGROUND: Diabetes is a chronic disease commonly managed by family physicians, with the most prevalent complication being cardiovascular disease (CVD). Clinical practice guidelines have been developed to support clinicians in the care of diabetic patients. We conducted a pragmatic cluster randomized controlled trial (RCT) of a printed educational toolkit aimed at improving CVD management in diabetes in primary care, and found no effect, and indeed, the possibility of some harm. We conducted a qualitative evaluation to study the strategy for guideline implementation employed in this trial, and to understand its effects. This paper focuses solely on the qualitative findings, as the RCT's quantitative results have already been reported elsewhere. METHODS AND FINDINGS: All family practices in the province of Ontario had been randomized to receive the educational toolkit by mail, in either the summer of 2009 (intervention arm) or the spring of 2010 (control arm).A subset of 80 family physicians (representing approximately 10% of the practices randomized and approached, with records on 1,592 randomly selected patients with diabetes at high risk for CVD) then took part in a chart audit and reflective feedback exercise related to their own practice in comparison to the guideline recommendations. They were asked to complete two forms (one pre- and one post-audit) in order to understand their awareness of the guidelines pre-trial, their expectations regarding their individual performance pre-audit, and their reflections on their audit results. In addition, individual interviews with thirteen other family physicians were conducted. Textual data from interview transcripts and written commentary from the pre- and post-audit forms underwent qualitative descriptive analysis to identify common themes and patterns. Analysis revealed four main themes: impressions of the toolkit, awareness was not the issue, 'it's not me it's my patients', and chart audit as a more effective intervention than the toolkit. Participants saw neither the toolkit content nor its dissemination strategy to be effective, indicating they perceived themselves to be aware of the guidelines pre-trial. However, their accounts also indicated that they may be struggling to prioritize CVD management in the midst of competing demands for their attention. Upon receiving their chart audit results, many participants expressed surprise that they had not performed better. They reported that the audit results would be an important motivator for behaviour change. CONCLUSIONS: The qualitative findings outlined in this paper offer important insights into why the intervention was not effective. They also demonstrate that physicians have unperceived needs relative to CVD management and that the chart audit served to identify shortcomings in their practice of which they had been hitherto unaware. The findings also indicate that new methods of intervention development and implementation should be explored. This is important given the high prevalence of diabetes worldwide"";"" appropriate CVD management is critical to addressing the morbidity and mortality associated with the disease.",0,0,
1408,Practice Feedback Interventions: 15 Suggestions for Optimizing Effectiveness,"Electronic practice data are increasingly being used to provide feedback to encourage practice improvement. However, evidence suggests that despite decades of experience, the effects of such interventions vary greatly and are not improving over time. Guidance on providing more effective feedback does exist, but it is distributed across a wide range of disciplines and theoretical perspectives.Through expert interviews""; systematic reviews;"" and experience with providing, evaluating, and receiving practice feedback, 15 suggestions that are believed to be associated with effective feedback interventions have been identified. These suggestions are intended to provide practical guidance to quality improvement professionals, information technology developers, educators, administrators, and practitioners who receive such interventions. Designing interventions with these suggestions in mind should improve their effect, and studying the mechanisms underlying these suggestions will advance a stagnant literature.",0,0,
1409,Practice guidelines developed by specialty societies: the need for a critical appraisal,"BackgroundThere is increasing concern about the quality, reliability, and independence of practice guidelines. Because no information is available on the methodological quality of the guidelines developed by specialty societies, we undertook a survey on those published in peer-reviewed journals."";"" BackgroundThere is increasing concern about the quality, reliability, and independence of practice guidelines. Because no information is available on the methodological quality of the guidelines developed by specialty societies, we undertook a survey on those published in peer-reviewed journals.",0,0,
1410,Practice nurses' intentions to use clinical guidelines,"BACKGROUND: Evidence indicates that, although nurses are increasingly using clinical guidelines to ensure higher quality of care, there is a wide variance in their adherence to them. The utility of the Theory of Planned Behaviour (TPB) has not been previously investigated in explaining this variance in community nursing. AIM: This paper reports a study whose primary aim was to examine the utility of the TPB in explaining variations in practice nurses' intentions to offer smoking cessation advice in accordance with coronary heart disease guidelines. METHODS: A cross-sectional survey using a postal questionnaire was carried out. A 52-item questionnaire was administered to 48 practice nurses in England. The questionnaire was designed to assess the components of the TPB, and included measures of intentions to offer smoking cessation advice, self-reported past behaviour, attitudes, subjective norms, perceived behavioural controls (PBCs), behavioural beliefs and evaluations, normative beliefs and motivation to comply, and control beliefs and evaluations. RESULTS: The TPB explained up to 40% of variance in intentions to offer smoking cessation advice. Attitudes and PBCs were the most important predictors of intention. Among other elements of the TPB, indirect attitudes and indirect PBCs made significant positive contributions to explaining variance in intention. DISCUSSION: Future trials of interventions to increase practice nurses' adherence to clinical guidelines could attempt to address the elements identified in this study as important factors. Further studies are required to examine the utility of the TPB in predicting practice nurses' behaviour.",0,0,
1411,Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine,"Insomnia is the most common sleep complaint reported to physicians. Treatment has traditionally involved medication. Behavioral approaches have been available for decades, but lack of physician awareness and training, difficulty in obtaining reimbursements, and questions about efficacy have limited their use. These practice parameters review the current evidence with regards to a variety of nonpharmacologic treatments for insomnia. Using a companion paper which provides a background review, the available literature was analyzed. The evidence was graded by previously reported criteria of the American Academy of Sleep Medicine with references to American Psychological Association criteria. Treatments considered include: stimulus control, progressive muscle relaxation, paradoxical intention, biofeedback, sleep restriction, multicomponent cognitive behavioral therapy, sleep hygiene education, imagery training, and cognitive therapy. Improved experimental design has significantly advanced the process of evaluation of nonpharmacologic treatments for insomnia using guidelines outlined by the American Psychological Association (APA). Recommendations for individual therapies using the American Academy of Sleep Medicine recommendation levels for each are: Stimulus Control (Standard)""; Progressive Muscle Relaxation, Paradoxical Intention, and Biofeedback (Guidelines); Sleep Restriction, and Multicomponent Cognitive Behavioral Therapy (Options);"" Sleep Hygiene Education, Imagery Training, and Cognitive Therapy had insufficient evidence to be recommended as a single therapy. Optimal duration of therapy, who should perform the treatments, long term outcomes and safety concerns, and the effect of treatment on quality of life are questions in need of future research.",0,0,
1412,Practice-level effects of interventions to improve asthma care in primary care settings: the Pediatric Asthma Care Patient Outcomes Research Team.,"Objective. To assess the practice-level effects of (1) a physician peer leader intervention and (2) peer leaders in combination with the introduction of asthma education nurses to facilitate care improvement. And, to compare findings with previously reported patient-level outcomes of trial enrollees.  Study Setting. Data were included on children 5–17 years old with asthma in 40 primary care practices, affiliated with managed health care plans enrolled in the Pediatric Asthma Care Patient Outcomes Research Team (PORT) randomized trial.  Study Design. Primary care practices were randomly assigned to one of two care improvement arms or to usual care. Automated claims data were analyzed for 12-month periods using a repeated cross-sectional design. The primary outcome was evidence of at least one controller medication dispensed among patients with persistent asthma. Secondary outcomes included controller dispensing among all identified asthmatics, evidence of chronic controller use, and the dispensing of oral steroids. Health service utilization outcomes included numbers of ambulatory visits and hospital-based events.  Principal Findings. The proportion of children with persistent asthma prescribed controllers increased in all study arms. No effect of the interventions on the proportion receiving controllers was detected (peer leader intervention effect 0.01, 95 percent confidence interval [CI]: -0.07, 0.08"";"" planned care intervention effect -0.03, 95 percent CI: -0.09, 0.02). A statistical trend was seen toward an increased number of oral corticosteroid bursts dispensed in intervention practices. Significant adjusted increases in ambulatory visits of 0.08–0.10 visits per child per year were seen in the first intervention year, but only a statistical trend in these outcomes persisted into the second year of follow-up. No differences in hospital-based events were detected.  Conclusions. This analysis showed a slight increase in ambulatory asthma visits as a result of asthma care improvement interventions, using automated data. The absence of detectable impact on medication use at the practice level differs from the positive intervention effect observed in patient self-reported data from trial enrollees. Analysis of automated data on nonenrollees adds information about practice-level impact of care improvement strategies. Benefits of practice-level interventions may accrue disproportionately to the subgroup of trial enrollees. The effect of such interventions may be less apparent at the level of practices or health plans.",0,1,
1413,Preclinical research in Rett syndrome: setting the foundation for translational success,"In September of 2011, the National Institute of Neurological Disorders and Stroke (NINDS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the International Rett Syndrome Foundation (IRSF) and the Rett Syndrome Research Trust (RSRT) convened a workshop involving a broad cross-section of basic scientists, clinicians and representatives from the National Institutes of Health (NIH), the US Food and Drug Administration (FDA), the pharmaceutical industry and private foundations to assess the state of the art in animal studies of Rett syndrome (RTT). The aim of the workshop was to identify crucial knowledge gaps and to suggest scientific priorities and best practices for the use of animal models in preclinical evaluation of potential new RTT therapeutics. This review summarizes outcomes from the workshop and extensive follow-up discussions among participants, and includes: (1) a comprehensive summary of the physiological and behavioral phenotypes of RTT mouse models to date, and areas in which further phenotypic analyses are required to enhance the utility of these models for translational studies""; (2) discussion of the impact of genetic differences among mouse models, and methodological differences among laboratories, on the expression and analysis, respectively, of phenotypic traits;"" and (3) definitions of the standards that the community of RTT researchers can implement for rigorous preclinical study design and transparent reporting to ensure that decisions to initiate costly clinical trials are grounded in reliable preclinical data.",0,0,
1414,Precommittingto choose wisely about low-value services: a stepped wedge cluster randomised trial.,"Background Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.  Methods We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.  Results The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.  Conclusion Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.",1,1,
1415,Predicting physician guideline compliance: an assessment of motivators and perceived barriers,"BACKGROUND: Although clinical practice guidelines are widely accepted as ""best practices,"" provider compliance remains low. OBJECTIVES: To examine the relationship between providers' behavioral intentions and their compliance with practice guidelines""; to assess the impact of perceived barriers that were most inhibiting to compliance;"" and to examine the ability of factors in the Physician Guideline Compliance Model to predict intention to comply and compliance with guidelines implemented at specific practice sites. METHODS: Survey research methods were used to assess effects of antecedents (attitudes, subjective norms, past behavior, and perceived behavioral control) on providers' intentions to comply and compliance with clinical practice guidelines. Provider survey I was conducted at the time of guideline introduction and survey II 4 months after implementation. RESULTS: Scores for the antecedents to behavior and behavioral intention reflected favorable responses toward the use of guidelines. The mean self-reported compliance behavior was 65%, whereas compliance as assessed by chart review was 54%. Approximately 68% of the variance in the physicians' behavioral intentions was accounted for by variables included in the Physician Guideline Compliance Model. A significant negative correlation was found between perceived barriers and self-reported behavior but not between perceived barriers and chart-review-assessed behavior. CONCLUSIONS: Some variables, particularly perceived barriers to guideline implementation, predicted a provider's practice intentions and self-reported behavior. Future guideline intervention efforts should identify and reduce these barriers to guideline compliance prior to implementation.",0,0,
1416,Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore,"OBJECTIVE To develop and validate a new diabetes risk algorithm (the QDScore) for estimating 10 year risk of acquiring diagnosed type 2 diabetes over a 10 year time period in an ethnically and socioeconomically diverse population. DESIGN Prospective open cohort study using routinely collected data from 355 general practices in England and Wales to develop the score and from 176 separate practices to validate the score. PARTICIPANTS 2 540 753 patients aged 25-79 in the derivation cohort, who contributed 16 436 135 person years of observation and of whom 78 081 had an incident diagnosis of type 2 diabetes""; 1 232 832 patients (7 643 037 person years) in the validation cohort, with 37 535 incident cases of type 2 diabetes. OUTCOME MEASURES A Cox proportional hazards model was used to estimate effects of risk factors in the derivation cohort and to derive a risk equation in men and women. The predictive variables examined and included in the final model were self assigned ethnicity, age, sex, body mass index, smoking status, family history of diabetes, Townsend deprivation score, treated hypertension, cardiovascular disease, and current use of corticosteroids;"" the outcome of interest was incident diabetes recorded in general practice records. Measures of calibration and discrimination were calculated in the validation cohort. RESULTS A fourfold to fivefold variation in risk of type 2 diabetes existed between different ethnic groups. Compared with the white reference group, the adjusted hazard ratio was 4.07 (95% confidence interval 3.24 to 5.11) for Bangladeshi women, 4.53 (3.67 to 5.59) for Bangladeshi men, 2.15 (1.84 to 2.52) for Pakistani women, and 2.54 (2.20 to 2.93) for Pakistani men. Pakistani and Bangladeshi men had significantly higher hazard ratios than Indian men. Black African men and Chinese women had an increased risk compared with the corresponding white reference group. In the validation dataset, the model explained 51.53% (95% confidence interval 50.90 to 52.16) of the variation in women and 48.16% (47.52 to 48.80) of that in men. The risk score showed good discrimination, with a D statistic of 2.11 (95% confidence interval 2.08 to 2.14) in women and 1.97 (1.95 to 2.00) in men. The model was well calibrated. CONCLUSIONS The QDScore is the first risk prediction algorithm to estimate the 10 year risk of diabetes on the basis of a prospective cohort study and including both social deprivation and ethnicity. The algorithm does not need laboratory tests and can be used in clinical settings and also by the public through a simple web calculator (www.qdscore.org).",0,0,
1417,Prediction of hip fracture in elderly women: a prospective study,"OBJECTIVE To assess the relative importance of osteoporosis of the os calcis, cognisance, and mobility in the risk of subsequent fracture of the hip in elderly women. DESIGN Prospective study of elderly women in residential care over two years. SETTING 21 Private or 38 local authority residential homes for the elderly and 4 geriatric hospitals in Doncaster and Hull. SUBJECTS 1414 Ambulant women aged over 69, in private or local authority residential care or geriatric care. Those who had had bilateral hip surgery were excluded. MAIN OUTCOME MEASURES Broad band ultrasonic attenuation (BUA) index, Clifton assessment procedures for the elderly test (for cognisance), and mobility on a six point scale, and fracture of the hip in the subsequent two year period. RESULTS 73 Women fractured their hip during the two years. Their mean age was not significantly different from that of the women who did not have a fracture (85.3 (SD 5.6) v 83.9 (6.3)""; p = 0.07), but their mean BUA index (40.3 (19.3) v 50.9 (22.2) db/MH2), and score for cognisance (median 19 (interquartile range 10.5-27.0) v 24 (17-30)) were significantly lower (both p less than 0.001). These variables had independent associations with fracture of the hip. Women with fractures had a significantly lower score for the psychomotor component of the cognisance test (4.5 (1-8) v 7 (2-10); p less than 0.0025 and were significantly more mobile (1(1-3) v 3 (1-6); p less than 0.02). Subdividing women according to high, medium, and low scores for BUA index and cognisance testing disclosed a high risk group (118 women) with low BUA index and cognisance score, whose incidence of fracture was 12.8%;"" in the group at lowest risk (136 women) with high BUA index and cognisance score, the incidence of fracture was only 1.5% (relative risk 8.4 (95% confidence interval -2.0 to 35.5]. Further analysis showed that those most at risk were, additionally, most mobile but that less mobile women with good cognisance had a low incidence of fractures, regardless of the BUA index, (1.2%, high index, v 0.9%, low index). CONCLUSIONS Elderly women most at risk of sustaining hip fractures were those with low BUA index, low cognisance test score, and high mobility. Improving bone strength and cognisance in elderly women may reduce their incidence of hip fracture.",0,0,
1418,Predictors of colorectal cancer screening from patients enrolled in a managed care health plan,"BACKGROUND: Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests. METHODS: Using results from independent cross-sectional telephone surveys with patients aged>or=50 years performed before (2000""; n=498) and after (2003; n=482) a quality improvement intervention for CRC screening within a large managed care health plan, the trends and predictors of CRC screening with fecal occult blood test (FOBT) and/or endoscopy (flexible sigmoidoscopy/colonoscopy) were examined from a patient perspective. RESULTS: In 2000, patient reported screening rates within guidelines were 38% for any test, 23% for endoscopy, and 22% for FOBT. In 2003, screening rates increased to 50% for any test, 39% for endoscopy, and 24% for FOBT. Having discussed CRC with a doctor significantly increased the odds of being screened (FOBT: odds ratio [OR], 2.09 [95% confidence interval (95% CI), 1.47-2.96]; endoscopy: OR, 2.33 [95% CI, 1.67-3.26]; and any test: OR, 2.86 [95% CI, 2.06-3.96]), and reporting barriers to CRC in general decreased the odds of being screened (FOBT: OR, 0.76 [95% CI, 0.60-0.95]; endoscopy: OR, 0.74 [95% CI, 0.60-0.92];"" and any test: OR, 0.66 [95% CI, 0.54-0.80]). CONCLUSIONS: Although screening rates increased over the 3-year period, evidence was found of ongoing underutilization of CRC screening. The 2 strongest determinants of obtaining CRC screening were provider influence and patient barriers related to CRC screening in general, pointing to the need for multilevel interventions that target both the provider and patient.",0,0,
1419,Predictors of fatigue 30 days after completing anthracycline plus taxane adjuvant chemotherapy for breast cancer,"PURPOSES/OBJECTIVES: To identify the predictors of fatigue 30 days after completing adjuvant chemotherapy for breast cancer and whether differences are observed between a behavioral sleep intervention and a healthy-eating attention control group in predicting fatigue. DESIGN: Descriptive, exploratory, secondary analysis of a randomized clinical trial. SETTING: Outpatient oncology patients in a midwestern U. S. city. SAMPLE: 96 women, ages 29-83 years, 72% married, 95% white, diagnosed with stage I-IIIA breast cancer, receiving adjuvant anthracycline and taxane chemotherapy. METHODS: Participants were randomized to a behavioral sleep intervention group or an attention control group. Participants completed data collection prior to and during the peak and rebound days of the initial chemotherapy treatment cycle and after the last treatment. MAIN RESEARCH VARIABLES: Fatigue, circadian rhythms of activity, objective and subjective sleep-wake, and objective and subjective activity-rest. FINDINGS: Predictors of fatigue were less total sleep time prior to treatment, higher fatigue prior to treatment and at the peak, and less energy upon awakening on rebound days. In the control group, predictors of higher fatigue were higher fatigue prior to treatment, higher body mass index, higher number of positive lymph nodes, and less daytime dysfunction. For the intervention group, lower peak activity at the peak of initial treatment differentially predicted fatigue. CONCLUSIONS: Results suggest the sleep intervention group participants who maintained activity balanced with sleep at the peak of the initial treatment benefited most from the intervention. IMPLICATIONS FOR NURSING: Nurses should screen for fatigue prior to initial chemotherapy treatment and at regular intervals, further assess for poor sleep in patients who report fatigue of 4 or higher (on a 0-10 scale), and use evidence-based guidelines to select appropriate interventions.",0,0,
1420,Predictors of provider recommendation for HPV vaccine among young adult men and women: findings from a cross-sectional survey,"BACKGROUND: Although physician recommendation is one of the strongest predictors of human papillomavirus (HPV) vaccination, it is unclear for whom physicians are recommending the vaccine. To help guide intervention efforts, this study investigated predictors of participant-reported physician recommendation for HPV vaccine among young adults in the USA. METHODS: Women and men (N=223) aged 18-26 years were recruited online through Craigslist, a popular classified advertisements website. Ads were posted in the 25 largest US cities from September 2013 to March 2014. Participants completed a survey that assessed demographic and sociopolitical characteristics, sexual history, HPV vaccination history, and whether they had ever received a recommendation for HPV vaccine from a physician or healthcare provider. RESULTS: Fifty-three per cent reported receiving a recommendation for HPV vaccine and 45% had received >/=1 dose of HPV vaccine. Participants who received a recommendation were over 35 times more likely to receive >/=1 dose of HPV vaccine relative to participants without a recommendation. Bivariable and multivariable correlates of provider recommendation were identified. Results from the multivariable model indicated that younger (aged 18-21 years), female, White participants with health insurance (ie, employer-sponsored or some other type such as military-sponsored) were more likely to report receiving a recommendation for HPV vaccine. CONCLUSIONS: Results suggest that physician recommendation practices for HPV vaccination vary by characteristics of the patient. Findings underscore the key role of the healthcare provider in promoting HPV vaccination and have important implications for future HPV vaccine interventions with young adults.",0,0,
1421,Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation,"Protocols of systematic reviews and meta-analyses allow for planning and documentation of review methods, act as a guard against arbitrary decision making during review conduct, enable readers to assess for the presence of selective reporting against completed reviews, and, when made publicly available, reduce duplication of efforts and potentially prompt collaboration. Evidence documenting the existence of selective reporting and excessive duplication of reviews on the same or similar topics is accumulating and many calls have been made in support of the documentation and public availability of review protocols. Several efforts have emerged in recent years to rectify these problems, including development of an international register for prospective reviews (PROSPERO) and launch of the first open access journal dedicated to the exclusive publication of systematic review products, including protocols (BioMed Central's Systematic Reviews). Furthering these efforts and building on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, an international group of experts has created a guideline to improve the transparency, accuracy, completeness, and frequency of documented systematic review and meta-analysis protocols--PRISMA-P (for protocols) 2015. The PRISMA-P checklist contains 17 items considered to be essential and minimum components of a systematic review or meta-analysis protocol.This PRISMA-P 2015 Explanation and Elaboration paper provides readers with a full understanding of and evidence about the necessity of each item as well as a model example from an existing published protocol. This paper should be read together with the PRISMA-P 2015 statement. Systematic review authors and assessors are strongly encouraged to make use of PRISMA-P when drafting and appraising review protocols.",0,0,
1422,Prescribing habits of general practitioners in choosing an empirical antibiotic regimen for lower respiratory tract infections in adults in Sicily,"The survey was carried out, between September 1995 and May 1996, in order to describe the prescriptive behaviour among Sicilian general practitioners (GPs) in choosing an empirical antibiotic regimen for LRTIs in adult patients and begin an educational process which involves the same GPs in decisions regarding their prescriptions and in performing local guidelines. Each practitioner filled out a questionnaire for each therapeutic intervention which ended with an antibiotic prescription. The questionnaire also enquired into the patient's characteristics, diseases to be treated and drug prescription. Doctors were asked to give an opinion about the severity assessment of the infectious disease before choosing the antibiotic treatment, in order to evaluate the prescriptive behaviour of physicians related to the patient's symptoms. Of all Sicilian GPs approached, 76 physicians from 25 Sicilian towns, with a patient population of 96,630, agreed to participate. The GPs used 49 different molecules and six different associations of two antibiotics. The most frequently used antibacterial agents were cephalosporins (55.0%). Penicillins (11.7%), fluoroquinolones (11. 4%), macrolides (10.1%) and combinations of penicillins with beta-lactamase inhibitors (7.9%), together, represented 41.1% of the remaining antibiotic prescriptions. The choice of the route of administration was significantly influenced by age of the patients, by symptoms and signs of the disease and by the presence of concurrent diseases rather than by bacteria suspected of causing the disease. The rather marked variation in antibiotic prescribing pattern for LRTIs among Sicilian GPs reflects lack of availability or knowledge of any local or national guidelines about the management of these diseases.",0,0,
1423,Prescription data as a tool in pharmacotherapy audit (I). General considerations,"This article discusses how prescription data that are available from pharmacies can be used as a tool to support the improvement of prescribing behaviour. For the optimal use of prescription data in pharmacotherapeutic audit, the specific aim of the audit meeting must be clear. Next, appropriate measures (quality of drug choice, volume, cost) have to be selected for the presentation and discussion of prescribing. For several aims of audit meetings, suggestions for adequate measures are given. For each stage of behavioural change the article describes why and how prescription data can provide a useful contribution. Finally, recommendations are given regarding prerequisites for the optimal use of prescription data. Important factors are that the prescription data should sufficiently cover the physicians' patient population, information regarding the extent of repeat prescribing is needed, and the prescribing of drugs with multiple indications can cause difficulties with the interpretation of the graphs. With this information in mind, feedback on prescribing can be tailored to the audit groups' needs and targeted to the intervention that is pursued.",0,0,
1424,Prescription of Non-Occupational Post-Exposure HIV Prophylaxis by Emergency Physicians: An Analysis on Accuracy of Prescription and Compliance,"We conducted a retrospective analysis of data from a prospective nPEP (non-Occupational Post Exposure Prophylaxis) registry based on patients consulting at one academic Emergency department located in Brussels, Belgium. We review here 1,357 cases consulting from January 2011 to December 2013.The objective of the study is to determine whether emergency physicians prescribe nPEP according to national guideline with support from IDS (infectious disease specialists). As this intervention has a high cost we wanted to verify correct allocation of treatment to high risk patients. Moreover we wanted to determine whether compliance to nPEP when prescribed by an Emergency Physician was different from literature reports. Finally we wanted to describe the population consulting for nPEP at our center. Emergency physicians prescribed nPEP more frequently in high risk exposures (98.6%) compared to intermediate risk exposures (53.2%)"";"" adequately allocating resources from a public health perspective. Appropriateness of prescription when evaluated according to nPEP Belgian guidelines was 98.8%.Compliance with nPEP prescribed by Emergency physicians was 60% in our study. Compliance was the highest in MSM (Men who have Sex with Men) while sexual assault victims showed the lowest compliance. Altogether this study suggests that Emergency physicians can safely and adequately prescribe nPEP when supported by a comprehensive guideline. Recognizing intrinsic differences within heterogeneous populations consulting for nPEP may improve compliance to this high-cost public health intervention.",0,0,
1425,Prescription omega-3s: an overview for nurse practitioners,"Nurse practitioners (NPs) often take a multidisciplinary approach when treating and educating patients. Collaboration with a registered dietitian is not uncommon when treating patients with severe hypertriglyceridemia (triglycerides [TGs] >/=500 mg/dL). Patients with severe hypertriglyceridemia should be treated and managed to normalize TG levels (TG level <150 mg/dL). Treatment for severe hypertriglyceridemia is often 3-fold, including lifestyle changes, diet modification, and pharmacotherapy. Therapeutic lifestyle changes are generally the first step in lowering TG levels. Registered dietitians promote a heart-healthy diet rich in fruits and vegetables. Evidence has been mounting to support consumption of eicosapentaenoic acid and docosahexaenoic acid to decrease TGs. When lifestyle and diet changes do not effectively decrease TGs, NPs will recommend pharmacological therapy as a next step. A viable pharmacological option includes prescription omega-3 (P-OM3) fatty acid ethyl esters. Each 4-g/d dose of P-OM3 provides 465 mg of eicosapentaenoic acid and 375 mg of docosahexaenoic acid. Clinical trials show that P-OM3 can safely and effectively decrease TGs by 45% in patients with severe hypertriglyceridemia. Nurse practitioners play an important role in the treatment of severe hypertriglyceridemia and in the education of patients about lifestyle and diet changes that can greatly impact patients' health.",0,0,
1426,Pressure sore treatment: Clinical guidelines,"Clinical guidelines, like any intervention, can and should be appraised systematically. Evaluation is essential since an intervention that appears as if it will improve care may not do so in practice. Furthermore, guidelines rely on a change in behaviour on the part of practitioners and failure to achieve this may undermine potential health gains. The key areas considered here are evaluation of guidelines themselves and assessment of their impact on care.",0,0,
1427,"Prevalence of a Healthy Lifestyle Among Individuals With Cardiovascular Disease in High-, Middle- and Low-Income Countries The Prospective Urban Rural Epidemiology (PURE) Study","Importance Little is known about adoption of healthy lifestyle behaviors among individuals with a coronary heart disease (CHD) or stroke event in communities across a range of countries worldwide.  Objective To examine the prevalence of avoidance or cessation of smoking, eating a healthy diet, and undertaking regular physical activities by individuals with a CHD or stroke event.  Design, Setting, and Participants Prospective Urban Rural Epidemiology (PURE) was a large, prospective cohort study that used an epidemiological survey of 153 996 adults, aged 35 to 70 years, from 628 urban and rural communities in 3 high-income countries (HIC), 7 upper-middle-income countries (UMIC), 3 lower-middle-income countries (LMIC), and 4 low-income countries (LIC), who were enrolled between January 2003 and December 2009.  Main Outcome Measures Smoking status (current, former, never), level of exercise (low, <600 metabolic equivalent task [MET]-min/wk""; moderate, 600-3000 MET-min/wk; high, >3000 MET-min/wk), and diet (classified by the Food Frequency Questionnaire and defined using the Alternative Healthy Eating Index).  Results Among 7519 individuals with self-reported CHD (past event: median, 5.0 [interquartile range {IQR}, 2.0-10.0] years ago) or stroke (past event: median, 4.0 [IQR, 2.0-8.0] years ago), 18.5% (95% CI, 17.6%-19.4%) continued to smoke; only 35.1% (95% CI, 29.6%-41.0%) undertook high levels of work- or leisure-related physical activity, and 39.0% (95% CI, 30.0%-48.7%) had healthy diets; 14.3% (95% CI, 11.7%-17.3%) did not undertake any of the 3 healthy lifestyle behaviors and 4.3% (95% CI, 3.1%-5.8%) had all 3. Overall, 52.5% (95% CI, 50.7%-54.3%) quit smoking (by income country classification: 74.9% [95% CI, 71.1%-78.6%] in HIC; 56.5% [95% CI, 53.4%-58.6%] in UMIC; 42.6% [95% CI, 39.6%-45.6%] in LMIC; and 38.1% [95% CI, 33.1%-43.2%] in LIC). Levels of physical activity increased with increasing country income but this trend was not statistically significant. The lowest prevalence of eating healthy diets was in LIC (25.8%; 95% CI, 13.0%-44.8%) compared with LMIC (43.2%;"" 95% CI, 30.0%-57.4%), UMIC (45.1%, 95% CI, 30.9%-60.1%), and HIC (43.4%, 95% CI, 21.0%-68.7%).  Conclusion and Relevance Among a sample of patients with a CHD or stroke event from countries with varying income levels, the prevalence of healthy lifestyle behaviors was low, with even lower levels in poorer countries.",0,0,
1428,Prevalence of Chlamydia trachomatis infection in women having cervical smear tests,"OBJECTIVE To determine the prevalence of sexually transmitted diseases in patients with normal and abnormal cervical smears. DESIGN A prospective study of asymptomatic women with normal cervical smears attending their general practitioner and newly referred patients with abnormal smears attending a colposcopy clinic. SETTING A hospital based colposcopy clinic and an urban general practice (list size 5500) in north west Glasgow. SUBJECTS 197 asymptomatic women attending their general practitioner for cervical smear tests and 101 randomly selected patients attending the colposcopy clinic for investigation of abnormal smears. MAIN OUTCOME MEASURES Presence of various sexually transmitted infections as determined by culture and serological tests. RESULTS Of the 101 women with cytological abnormalities, six had current chlamydial infection proved by culture and none had gonococcal infection"";"" of the 197 women with normal smears, 24 (12%) had a chlamydial infection and two had gonorrhoea. Serological studies for Chlamydia trachomatis specific antibody also indicated that a large proportion of patients had been exposed to this agent in both groups. There was no significant difference between the groups in the prevalence of any sexually transmitted disease studied. CONCLUSION A high prevalence of chlamydial infection is present in women in north west Glasgow irrespective of their cervical cytological state.",0,0,
1429,Prevalence of Nonpolypoid (Flat and Depressed) Colorectal Neoplasms in Asymptomatic and Symptomatic Adults,"Context Colorectal cancer is the second leading cause of cancer death in the United States. Prevention has focused on the detection and removal of polypoid neoplasms. Data are limited on the significance of nonpolypoid colorectal neoplasms (NP-CRNs).  Objectives To determine the prevalence of NP-CRNs in a veterans hospital population and to characterize their association with colorectal cancer.  Design, Setting, and Patients Cross-sectional study at a veterans hospital in California with 1819 patients undergoing elective colonoscopy from July 2003 to June 2004.  Main Outcome Measures Endoscopic appearance, location, size, histology, and depth of invasion of neoplasms.  Results The overall prevalence of NP-CRNs was 9.35% (95% confidence interval [95% CI], 8.05%-10.78%""; n = 170). The prevalence of NP-CRNs in the subpopulations for screening, surveillance, and symptoms was 5.84% (95% CI, 4.13%-8.00%; n = 36), 15.44% (95% CI, 12.76%-18.44%; n = 101), and 6.01% (95% CI, 4.17%-8.34%; n = 33), respectively. The overall prevalence of NP-CRNs with in situ or submucosal invasive carcinoma was 0.82% (95% CI, 0.46%-1.36%; n = 15); in the screening population, the prevalence was 0.32% (95% CI, 0.04%-1.17%; n = 2). Overall, NP-CRNs were more likely to contain carcinoma (odds ratio, 9.78; 95% CI, 3.93-24.4) than polypoid lesions, irrespective of the size. The positive size-adjusted association of NP-CRNs with in situ or submucosal invasive carcinoma was also observed in subpopulations for screening (odds ratio, 2.01; 95% CI, 0.27-15.3) and surveillance (odds ratio, 63.7;"" 95% CI, 9.41-431). The depressed type had the highest risk (33%). Nonpolypoid colorectal neoplasms containing carcinoma were smaller in diameter as compared with the polypoid ones (mean [SD] diameter, 15.9 [10.2] mm vs 19.2 [9.6] mm, respectively). The procedure times did not change appreciably as compared with historical controls.  Conclusion In this group of veteran patients, NP-CRNs were relatively common lesions diagnosed during routine colonoscopy and had a greater association with carcinoma compared with polypoid neoplasms, irrespective of size.",0,0,
1430,"Prevalence of War-Related Mental Health Conditions and Association With Displacement Status in Postwar Jaffna District, Sri Lanka","Context Nearly 2.7 million individuals worldwide are internally displaced (seeking refuge in secure areas of their own country) annually by armed conflict. Although the psychological impact of war has been well documented, less is known about the mental health symptoms of forced displacement among internally displaced persons.  Objectives To estimate the prevalence of the most common war-related mental health conditions, symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression, and to assess the association between displacement status and these conditions in postwar Jaffna District, Sri Lanka.  Design, Setting, and Participants Between July and September 2009, a cross-sectional multistage cluster sample survey was conducted among 1517 Jaffna District households including 2 internally displaced persons camps. The response rate was 92% (1448 respondents, 1409 eligible respondents). Two percent of participants (n = 80) were currently displaced, 29.5% (n = 539) were recently resettled, and 68.5% (n = 790) were long-term residents. Bivariable analyses followed by multivariable logistic regression models were performed to determine the association between displacement status and mental health.  Main Outcome Measures Symptom criteria of PTSD, anxiety, and depression as measured by the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist¨C25.  Results The overall prevalences of symptoms of PTSD, anxiety, and depression were 7.0% (95% confidence interval [CI], 5.1%-9.7%), 32.6% (95% CI, 28.5%-36.9%), and 22.2% (95% CI, 18.2%-26.5%), respectively. Currently displaced participants were more likely to report symptoms of PTSD (odds ratio [OR], 2.71""; 95% CI, 1.28-5.73), anxiety (OR, 2.91; 95% CI, 1.89-4.48), and depression (OR, 4.55; 95% CI, 2.47-8.39) compared with long-term residents. Recently resettled residents were more likely to report symptoms of PTSD (OR, 1.96;"" 95% CI, 1.11-3.47) compared with long-term residents. However, displacement was no longer associated with mental health symptoms after controlling for trauma exposure.  Conclusion Among residents of Jaffna District in Sri Lanka, prevalence of symptoms of war-related mental health conditions was substantial and significantly associated with displacement status and underlying trauma exposure.",0,0,
1431,Preventing and managing unprofessionalism in medical school faculties,"Professionalism is a required competency for medical students, residents, practicing physicians, and academic faculty. Faculty members must adhere to codes of conduct or risk discipline. The authors describe issues of unprofessionalism that culminate in allegations of faculty misconduct or filing of grievances in academic medicine and outline strategies for early intervention and prevention. The authors, vice and associate deans and executive director of the office of faculty affairs at a large U.S. medical school, have handled many allegations of unprofessional conduct over the past decade. They present case examples based on behaviors such as lack of respect, inappropriate language and behavior, failure to cooperate with members of the health care team, and sexual harassment/discrimination. They discuss factors complicating evaluation of these behaviors, including variable definitions of respect, different cultural norms, and false allegations. The authors make recommendations for prevention and intervention, including early identification, performance management, education about sexual harassment, and referrals to professional coaches, anger management classes, and faculty-staff assistance programs.",0,0,
1432,Preventing caries in young children of immigrant Bangladeshi families in New York: perspectives of mothers and paediatricians,"OBJECTIVE: Childhood caries is common in South Asian immigrant families. Few children visit a dentist by 12 months, as recommended by current guidelines. The paediatric visit has important potential for linking children to preventive care. The aim of this study was to understand the barriers and facilitators to caries prevention for young children of immigrant Bangladeshi families in New York. Qualitative data were collected as a preliminary step in the development of an oral health counselling intervention for South Asian children. BASIC DESIGN: Qualitative interviews on child feeding and oral health prevention were conducted with Bangladeshi mothers. Qualitative interviews were conducted with paediatricians regarding their experiences with providing care. The data were analysed using standard qualitative approaches. SETTING: Paediatric practices serving low income Bangladeshi immigrants in New York City. PARTICIPANTS: 26 mothers of children aged 6-24 months receiving services in five paediatric settings and 15 paediatricians providing care in these settings. RESULTS: Both mothers and their paediatricians described risky feeding practices, communication problems and a lack of compliance. Oral health for young children was a low priority for some mothers. Most, however, were concerned about childhood caries but lacked skills or resources to decrease caries risk. CONCLUSIONS: Results support our plan to develop an empowerment-based counselling intervention to address caries risk in children. Paediatric dentists should be aware of the barriers to caries prevention in this group.",0,0,
1433,Preventing child abuse and neglect with a program of nurse home visitation: The limiting effects of domestic violence,"Context Home visitation to families with young children has been promoted as an effective way to prevent child maltreatment, but few studies have examined the conditions under which such programs meet this goal.  Objective To investigate whether the presence of domestic violence limits the effects of nurse home visitation interventions in reducing substantiated reports of child abuse and neglect.  Design Fifteen-year follow-up study of a randomized trial.  Setting Semirural community in upstate New York.  Participants Of 400 socially disadvantaged pregnant women with no previous live births enrolled consecutively between April 1978 and September 1980, 324 mothers and their children participated in the follow-up study.  Interventions Families were randomly assigned to receive routine perinatal care (control group"";"" n = 184 participated in follow-up), routine care plus nurse home visits during pregnancy only (n = 100), or routine care plus nurse home visits during pregnancy and through the child's second birthday (n = 116).  Main Outcome Measures Number of substantiated reports over the entire 15-year period involving the study child as subject regardless of the identity of the perpetrator or involving the mother as perpetrator regardless of the identity of the child abstracted from state records and analyzed by treatment group and level of domestic violence in the home as measured by the Conflict Tactics Scale.  Results Families receiving home visitation during pregnancy and infancy had significantly fewer child maltreatment reports involving the mother as perpetrator (P = .01) or the study child as subject (P = .04) than families not receiving home visitation. The number of maltreatment reports for mothers who received home visitation during pregnancy only was not different from the control group. For mothers who received visits through the child's second birthday, the treatment effect decreased as the level of domestic violence increased. Of women who reported 28 or fewer incidents of domestic violence (79% of sample), home-visited mothers had significantly fewer child maltreatment reports during the 15-year period than mothers not receiving the longer-term intervention (P = .01). However, this intervention did not significantly reduce child maltreatment among mothers reporting more than 28 incidents of domestic violence (21% of sample).  Conclusions The presence of domestic violence may limit the effectiveness of interventions to reduce incidence of child abuse and neglect.",0,0,
1434,Preventing coronary heart disease and stroke with aggressive statin therapy in older adults using a team management model,"PURPOSES: The purposes of this review were to highlight recent clinical trial results on the safety and efficacy of statin therapy in adults aged 65 years and older and to examine how nurse practitioners (NPs) and physician assistants (PAs) working together with physicians as a team can better serve the needs of this fastest growing subset of the U.S. population who are at high risk for cardiovascular events including stroke. DATA SOURCES: This report was compiled by reviewing the scientific literature on the safety and efficacy of statin therapy, including effects on cardiovascular, coronary, and stroke endpoints, with particular reference to clinical trial results in older patients. CONCLUSIONS: Recent guidelines emphasize that age alone is not a reason to withhold treatment with statin therapy in older adults. However, despite the evidence highlighted in this review demonstrating that older patients can safely achieve substantial benefit from statin therapy, studies have consistently shown an inverse relationship between age and treatment propensity. Often, older patients have multiple risk factors and many chronic comorbid conditions that seem to complicate and hinder treatment in many busy clinic practices. More extensive guidelines for the use of statin therapy in older patients, incorporating recommendations for treatment targets and developing a framework for the use of statins in stroke prevention, would assist care providers in the management of this high-risk population. Finally, NPs and PAs are both well educated and well placed to manage patients with chronic stable cardiovascular disease (CVD). IMPLICATIONS FOR PRACTICE: The implementation of a multidisciplinary team approach to identify at-risk individuals and provide them with education, counseling, and effective statin treatment will aid efforts to reduce the increased risk for morbidity and mortality associated with CVD in older adults.",0,0,
1435,Prevention of depression in at-risk adolescents: a randomized controlled trial,"Context Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings.  Objective To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression.  Design, Setting, and Participants A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase.  Intervention Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone.  Main Outcome Measure Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of ¡Ý4) for at least 2 weeks as diagnosed by clinical interviewers.  Results Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%""; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, ?1.1; z = ?2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43;"" 95% CI, 0.76-2.67).  Conclusion The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent.",0,0,
1436,Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement,"DESCRIPTION: Update of the 1996 U.S. Preventive Services Task Force (USPSTF) recommendation statement on counseling to prevent household and recreational injuries, including falls. METHODS: The USPSTF reviewed new evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls in community-dwelling older adults. The interventions were grouped into 5 main categories: multifactorial clinical assessment (with or without direct intervention), clinical management (with or without screening), clinical education or behavioral counseling, home hazard modification, and exercise or physical therapy. RECOMMENDATIONS: The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (Grade B recommendation)The USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (Grade C recommendation).",0,0,
1437,Preventive Care Advised (PCA)/Operative Care Advised (OCA)--categorising caries by the management option,"Currently a range of systems and classifications are used by clinicians, epidemiologists and clinical research workers to sub-divide carious lesions into different grades. These systems are based on the depth of the lesion and/or the presence/absence of macroscopic cavitation. In order to improve upon the meaningfulness and comparability of such systems in the light of increasing knowledge about the disease process, lesion behaviour and caries management options, the authors propose a new system of categorisation that differentiates between lesions which normally require operative intervention and those which do not. In future, it is proposed that in addition to existing conventional criteria, diagnostic systems should also allow results to be expressed in terms of 1) lesions for which appropriate non-invasive Preventive Care Is Advised (PCA lesions) and 2) lesions for which Operative Care Is Advised (OCA lesions). Locally acceptable sub-divisions may have to be developed and agreed for certain specific applications. The adoption of this additional nomenclature and approach in the future should aid communications between the different groups involved in caries diagnosis and research. It may facilitate the dissemination of research findings, as well as helping to ""drive"" researchers working on caries diagnostic methods to focus on techniques which will aid in the accurate assessment of lesion activity and behaviour. Such a focus should also increase our understanding of treatment decision making and promote the development of clinical guidelines. The facility to retain existing criteria in parallel, for local and other purposes, would preserve comparability with data collected previously.",0,0,
1438,Preventive evidence into practice (PEP) study: implementation of guidelines to prevent primary vascular disease in general practice protocol for a cluster randomised controlled trial,"BACKGROUND: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession. METHODS: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%)""; and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care;"" and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews. DISCUSSION: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.",0,0,
1439,Preventive interventions for postnatal psychosis,"BACKGROUND: Postnatal psychosis is a worldwide life-threatening condition that affects one to two in every 1000 new mothers. It has an abrupt onset within a month of childbirth. Affected new mothers rapidly develop frank psychosis, cognitive impairment, and disorganised behaviours. Factors that increase the risk of postnatal psychosis include primiparous mothers who are single, women who are older, or with a past psychiatric history and family history of affective psychosis, prenatal depression and autoimmune thyroid dysfunction. The risk of a future postnatal recurrence is 25% to 57%. Preventive interventions for postnatal psychosis aim at identifying women with risk factors, early recognition of imminent psychosis through screening, and preventive drug therapy. Mood stabilisers, antipsychotic drugs and hormone therapy may be beneficial in the prevention of postnatal psychotic episodes in women at risk. OBJECTIVES: To investigate the best available evidence for interventions aimed at preventing postnatal psychosis. SEARCH METHODS: We searched the Cochrane Schizophrenia Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2012 using the search strategy of the Cochrane Schizophrenia Group. SELECTION CRITERIA: All randomised controlled trials relevant to the prevention of postnatal psychosis. DATA COLLECTION AND ANALYSIS: Two review authors inspected all citations to ensure reliable selection. If we had included relevant trials, we planned to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors would have independently extracted data. For homogenous dichotomous data, we planned to calculate the risk ratio (RR), 95% confidence interval (CI), and the number needed to treat to benefit/harm (NNTB/NNTH) on an intention-to-treat basis. MAIN RESULTS: There are no included studies in this review. The electronic search produced three relevant references, among which we identified two old planned trials that seem never to have started, and one which we excluded a study because it was a report of a case series. AUTHORS' CONCLUSIONS: This is not an empty review - it is a review full of unanswered questions. Despite growing interest in women's mental health, the literature in the area of postnatal psychosis is still very limited. It seems that clinicians have no choice but to continue with their current practices guided solely by varied clinical judgement. Women at risk of postnatal psychosis and their relatives are justified to be disappointed in the medical/research fraternity. A post hoc PubMed topic (not methodology-specific) search identified mainly case series. Policy makers have no trial-based evidence upon which to base their guidelines. Certainly, preventive interventions for postnatal psychosis are difficult to justify with confidence without well-designed, well-conducted, and well-reported randomised studies. Available publications suggest that such studies are possible and funders of research may wish to make this work a priority.",0,0,
1440,Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain,"OBJECTIVE: We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team. METHODS: To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (>/=30% decrease in Roland-Morris Disability Questionnaire score). RESULTS: Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively). CONCLUSIONS: As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.",0,0,
1441,Primary care clinicians' experiences prescribing HIV pre-exposure prophylaxis at a specialized community health centre in Boston: lessons from early adopters,"INTRODUCTION: An estimated 1.2 million Americans have indications for using antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. For many of these at-risk individuals, the best opportunity to learn about and receive PrEP will be during routine visits to their generalist primary care clinicians. However, few generalist clinicians have prescribed PrEP, primarily because of practical concerns about providing PrEP in primary care settings. The experiences of specialized primary care clinicians who have prescribed PrEP can inform the feasibility of PrEP provision by generalists. METHODS: During January to February 2015, 35 primary care clinicians at a community health centre in Boston that specializes in the care of sexual and gender minorities completed anonymous surveys about their experiences and practices with PrEP provision. Responses were analyzed with descriptive statistics. RESULTS AND DISCUSSION: Thirty-two clinicians (response rate=91%) completed the surveys. Nearly all clinicians (97%) had prescribed PrEP (median 20 patients, interquartile range 11-33). Most clinicians reported testing and risk-reduction counselling practices concordant with U.S. Centers for Disease Control and Prevention guidelines for PrEP. Clinicians indicated that patients using PrEP experienced medication toxicities infrequently and generally reported high adherence. However, some clinicians' practices differed from guideline recommendations, and some clinicians observed patients with increased risk behaviours. Most clinicians (79%) rated PrEP provision as easy to accomplish, and 97% considered themselves likely to prescribe PrEP in the future. CONCLUSIONS: In a primary care clinic with specialized expertise in HIV prevention, clinicians perceived that PrEP provision to large numbers of patients was safe, feasible and potentially effective. Efforts to engage generalist primary care clinicians in PrEP provision could facilitate scale-up of this efficacious intervention.",0,0,
1442,Primary care guidelines on consultation practices: the effectiveness of computerized versus paperbased versions. A cluster randomized controlled trial among newly qualified primary care physicians.,"Objective: To compare the effects of computerized and paper-based versions of guidelines on recently qualified physicians' consultation practices.  Methods: Two arm cluster randomized controlled trial. Physicians were randomized to receive computerized or textbook-based versions of the same guidelines for a 4-week study period. Physicians' compliance with guideline recommendations about laboratory, radiological, physical and other examinations, procedures, nonpharmacologic and pharmacologic treatments, physiotherapy, and referrals were measured by case note review.  Results: There were 139 recently qualified physicians working in 96 primary healthcare centers in Finland who participated in the study. Data on 4,633 patient encounters were abstracted, of which 3,484 were suitable for further analysis. Physicians' compliance with guidelines was high (over 80% for use of laboratory, radiology, physical examinations, and referrals). There were no significant differences in physicians' consultation practices in any of the measured outcomes between the computerized and textbook group.  Conclusion: Guidelines are a useful source of information for recently qualified physicians working in primary care. However, the method of presentation of the guidelines (electronic or paper) does not have an effect on guideline use or their impact on decisions. Other factors should be considered when choosing the method of presentation of guidelines, such as information-seeking time, ease of use during the consultation, ability to update, production costs, and the physicians' own preferences.",1,1,
1443,Primary care physicians' response to dissemination of practice guidelines,"BACKGROUND: Much effort has gone into producing clinical practice guidelines, but relatively few studies address dissemination issues. Unless guidelines are used, little is gained. This study evaluates the effect of three methods to disseminate asthma guidelines on physicians' behavior and attitudes toward education strategies. METHODS: Asthma guidelines were mailed to 60 physicians in three Area Health Education Centers in Arkansas. Dissemination efforts at one site featured a short summary, telephone calls by ""detailing"" physicians, and a continuing medical education conference. Computer strategies were used at the second site, and a multimedia approach with facsimile messages, posters, videocassettes, audiocassettes, and a continuing medical education conference was used at the third site. A fourth site with 22 participants served as a comparison. Data were collected by mailed questionnaires, outpatient chart reviews, and physician interviews. Changes between baseline and posttest assessments following a 4-month intervention were calculated for medication use, and peak flow monitoring use was compared with the control group (general linear model). Regression analyses were used to identify physician and practice factors associated with particular education techniques. RESULTS: Each site improved in the use of medications or peak flow monitoring, but none improved in all areas. The multimedia, continual reminder approach was well accepted but there was little support for the computer strategies. CONCLUSIONS: Further efforts to disseminate clinical guidelines should include a variety of formats with an emphasis on short, concise summaries and frequent reminders. Social influence appears to play a role and will be a fruitful area for further research.",0,1,
1444,Primary care physicians' use of lumbar spine imaging tests: effects of guidelines and practice pattern feedback,"OBJECTIVE: To reduce variability in primary care physicians' use of procedures for imaging the lumbar spine. DESIGN: Controlled intervention using clinical practice guideline and practice pattern feedback. STUDY SAMPLE: Sixty-seven internists and 28 family practitioners in a large, group-model HMO. MEASUREMENTS AND MAIN RESULTS: Intervention group physicians received the clinical practice guideline for low back pain, followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine. Control group physicians received neither the guideline nor the feedback reports. Automated radiology utilization data were used to compare intervention and control group physicians' changes in use rates and variability in use rates over the course of the study period. Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study. CONCLUSIONS: Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed.",0,0,
1445,Primary care provider attitudes are associated with smoking cessation counseling and referral,"OBJECTIVE: Most primary care providers (PCPs) endorse the importance of smoking cessation, but counseling rates are low. We evaluated the consistency of PCP's attitudes toward smoking cessation counseling and corresponding smoking-cessation behaviors. DESIGN: This was a postintervention analysis of a population-based sample from a group randomized controlled trial to improve adherence to smoking cessation guidelines. SETTING: A total of 18 VA sites in Southwestern and Western United States participated. PARTICIPANTS: A total of 280 PCPs completed a survey at 12 months after the implementation of a smoking-cessation quality improvement (QI) program. Their patients also completed 12- (n = 1080) and 18-month (n = 924) follow-up surveys. INTERVENTION: The quality improvement intervention included local priority setting, quality improvement plan development, implementation, and monitoring. MEASUREMENTS AND MAIN RESULTS: PCPs at intervention sites were more likely to report counseling patients about smoking cessation (P = 0.04) but not referral. PCP attitude toward smoking-cessation counseling was strongly associated with reported counseling (P < 0.001) and with referral (P = 0.01). Other associations with counseling were the perceived barrier ""patients are not interested in quitting"" (P = 0.01) and fewer years in practice (P = 0.03)"";"" other associations with referral were specialty consultation (P < 0.0001) and the perceived barrier ""referral not convenient"" (P = 0.001) (negative association). PCP attitudes were associated with higher rates of counseling, referral, and program attendance. CONCLUSIONS: PCPs, regardless of intervention participation, had attitudes consistent with their reported smoking-cessation behaviors and more favorable attitudes were associated with higher rates of patient-reported smoking cessation behavior. Findings suggest that PCPs who endorse smoking-cessation counseling and referral may provide more treatment recommendations and have higher patient quit rates.",0,1,
1446,Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial,"IMPORTANCE: The National Lung Screening Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown. OBJECTIVE: To determine the association between the reported clinician-delivered 5As (ask, advise, assess, assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and arrange follow-up) after lung screening and smoking behavior changes. DESIGN, SETTING, AND PARTICIPANTS: A matched case-control study (cases were quitters and controls were continued smokers) of 3336 NLST participants who were smokers at enrollment examined participants' rates and patterns of 5A delivery after a lung screen and reported smoking cessation behaviors. MAIN OUTCOMES AND MEASURES: Prevalence of the clinician-delivered 5As and associated smoking cessation after lung screening. RESULTS: Delivery of the 5As 1 year after screening were as follows: ask, 77.2%""; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%. Receipt of ask, advise, and assess was not significantly associated with quitting in multivariate models that adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit. Assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% CI, 1.21-1.63), and arrange was associated with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% CI, 1.19-1.79). CONCLUSIONS AND RELEVANCE: Assist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting;"" less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.",0,0,
1447,Primary care providers' responsiveness to health-risk behaviors reported by adolescent patients,"OBJECTIVE: To assess clinicians' responsiveness to health-risk behaviors reported by adolescent patients during a comprehensive clinical preventive services visit. DESIGN: Nonprobability sample of adolescent patients scheduled for a routine physical examination. SETTING: Seven clinical sites in the Chicago, Ill, area. PARTICIPANTS: Fifteen primary care providers and 95 adolescent patients between 11 and 18 years of age. INTERVENTION: Providers delivered comprehensive clinical preventive services to adolescent patients using the Guidelines for Adolescent Preventive Services model. This model includes screening, guidance, a physical examination, and immunizations. Prior to the visit, adolescent patients completed a screening questionnaire that included a 52-item health-risk behavior profile. Responses on the screening questionnaire were discussed during the visit. MAIN OUTCOME MEASURES: Each provider's responsiveness to reported health-risk behaviors was determined by comparing the adolescent patient's responses on the screening questionnaire with those reported during a debriefing interview with the adolescent about whether specific subjects were discussed. Responsiveness to highly sensitive behaviors was determined by comparing the screening questionnaire and the medical record. RESULTS: On average, each adolescent patient reported 10 risk behaviors, of which 7 were discussed. The severity of the reported risk behavior, the number of reported biological health concerns, and the adolescent patient's sex were significant predictors of the provider's responsiveness. The number of reported health-risk behaviors, visit duration, provider's professional role and sex, whether the adolescent was a new patient, and the adolescent patient's age were unrelated to responsiveness. CONCLUSIONS: Providers addressed most health-risk behaviors reported during a single visit, but responsiveness declined when 3 or more biological health concerns or relatively severe problems were reported. Steps can be taken to increase providers' responsiveness.",0,0,
1448,"Primary care, generalism, public good: déjà vu? Again!",,0,0,
1449,"Primary care-based multifaceted, interdisciplinary medical educational intervention for patients with systolic heart failure: lessons learned from a cluster randomised controlled trial","BACKGROUND: Chronic (systolic) heart failure (CHF) is a common and disabling condition. Adherence to evidence-based guidelines in primary care has been shown to improve health outcomes. The aim was to explore the impact of a multidisciplinary educational intervention for general practitioners (GPs) (Train the trainer = TTT) on patient and performance outcomes. METHODS: This paper presents the key findings from the trial and discusses the lessons learned during the implementation of the TTT trial. Primary care practices were randomly assigned to the TTT intervention or to the control group. 37 GPs (18 TTT, 19 control) were randomised and 168 patients diagnosed with ascertained CHF (91 TTT, 77 control) were enrolled. GPs in the intervention group attended four meetings addressing clinical practice guidelines and pharmacotherapy feedback. The primary outcome was patient self-reported quality of life at seven months, using the SF-36 Physical Functioning scale. Secondary outcomes included other SF-36 scales, the Kansas City Cardiomyopathy Questionnaire (KCCQ), total mortality, heart failure hospital admissions, prescribing, depressive disorders (PHQ-9), behavioural change (European Heart Failure Self-Care Behaviour Scale), patient-perceived quality of care (EUROPEP) and improvement of heart failure using NT-proBNP-levels. Because recruitment targets were not achieved an exploratory analysis was conducted. RESULTS: There was high baseline achievement in both groups for many outcomes. At seven months, there were no significant mean difference between groups for the primary outcome measure (-3.3, 95%CI -9.7 to 3.1, p = 0.30). The only difference in secondary outcomes related to the prescribing of aldosterone antagonists by GPs in the intervention group, with significant between group differences at follow-up (42 vs. 24%, adjusted OR = 4.0, 95%CI 1.2-13"";"" p = 0.02). CONCLUSION: The intervention did not change the primary outcome or most secondary outcomes. Recruitment targets were not achieved and the under-recruitment of practices and patients alongside a selection bias of participating GPs, prohibit definite conclusions, but the CI indicates a non-effectiveness of the intervention in this sample. We describe the lessons learned from conducting the trial for the future planning and conduct of confirmatory trials in primary care. TRIAL REGISTRATION: ISRCTN08601529.",0,0,
1450,Primary care-based smoking interventions,"The primary care setting is an important place for promoting smoking cessation. Randomized clinical trials (RCTs) testing the effect of brief smoking interventions and comprehensive programs delivered in a primary care setting present excellent evidence that such interventions significantly increase patients' smoking cessation rates and that as the dose of intervention increases, the effect increases. Unfortunately, despite widespread dissemination of preventive services guidelines and positive physician attitudes towards such services, the current level of delivery of smoking cessation intervention by physicians in real-world settings is not high, making this a major research and public health concern. Interventions to increase the rate of implementation provider-delivered brief smoking interventions can be grouped broadly into: provider education""; clinical systems and procedures (e.g., screening and tracking of patients);"" and organizational policy (e.g., reimbursement, coverage, performance measures). Given the significant effect that primary care-based interventions can have on smoking cessation, it is important to investigate methods to increase their rate of delivery and their effect. Examples of research to motivate to intervene questions include: what are the best incentives or combination of incentives for physicians? What are the most effective strategies to remind providers to intervene? How can each of these be best implemented in different types of settings and systems? How can a stepped-care and patient-treatment matching model be used? The study of factors such as reimbursement policies and covered benefits do not lend themselves well to tightly-controlled randomized trials. Therefore, use of quasi-experimental designs, and application of qualitative strategies are needed. These designs represent a different challenge to the research community.",0,0,
1451,Primary Coronary Intervention (PCI) within the myocardial infarction network system in a German city (Essen),"In a German city (Essen, 490,000 people), a new network system for patients with ST elevation myocardial infarction (STEMI) was established in 2004. This included a so-called integrated care model (IV model) by participation of insurance companies. In a cooperative structure between invasive and noninvasive hospitals, general practitioners and cardiologists as well as emergency systems it could be realized, that every patient with STEMI will be treated by primary percutaneous coronary intervention (PCI) as soon as possible according to the current guidelines. The patient characteristics (age, gender, comorbidity, medication) were comparable to other trials and registries. The primary success rate was high (96.4%). The acute in-hospital results demonstrated a low mortality (7.6%). The time periods of delay were comparable to other registries. The symptom-to-balloon time was 239 min, the medical contact-to-balloon time 95 min, the door-to-balloon time 60 min, and the puncture-to-balloon time 18 min (median values). The STEMI network system in Essen demonstrates the possibility of modern therapy in patients with myocardial infarction (primary PCI) in a cooperative modality between all participants in the health-care system.",0,0,
1452,Primary prevention of diabetes mellitus type 2 and cardiovascular diseases using a cognitive behavior program aimed at lifestyle changes in people at risk: Design of a randomized controlled trial,"BACKGROUND: The number of people with cardiovascular disease (CVD) and diabetes mellitus type 2 (T2DM) is growing rapidly. To a large extend, this increase is due to lifestyle-dependent risk factors, such as overweight, reduced physical activity, and an unhealthy diet. Changing these risk factors has the potential to postpone or prevent the development of T2DM and CVD. It is hypothesized that a cognitive behavioral program (CBP), focused in particular on motivation and self-management in persons who are at high risk for CVD and/or T2DM, will improve their lifestyle behavior and, as a result, will reduce their risk of developing T2DM and CVD. METHODS: 12,000 inhabitants, 30-50 years of age living in several municipalities in the semi-rural region of West-Friesland will receive an invitation from their general practitioner (n = 13) to measure their own waist circumference with a tape measure. People with abdominal obesity (male waist >/= 102 cm, female waist >or= 88 cm) will be invited to participate in the second step of the screening which includes blood pressure, a blood sample and anthropometric measurements. T2DM and CVD risk scores will then be calculated according to the ARIC and the SCORE formulae, respectively. People with a score that indicates a high risk of developing T2DM and/or CVD will then be randomly assigned to the intervention group (n = 300) or the control group (n = 300).Participants in the intervention group will follow a CBP aimed at modifying their dietary behavior, physical activity, and smoking behavior. The counseling methods that will be used are motivational interviewing (MI) and problem solving treatment (PST), which focus in particular on intrinsic motivation for change and self-management of problems of the participants. The CBP will be provided by trained nurse practitioners in the participant's general practice, and will consists of a maximum of six individual sessions of 30 minutes, followed by 3-monthly booster sessions by phone. Participants in the control group will receive brochures containing health guidelines regarding physical activity and diet, and how to stop smoking. The primary outcome measures will be changes in T2DM and CVD risk scores. Secondary outcome measures will be changes in lifestyle behavior and cost-effectiveness and cost-utility ratios. All relevant direct and indirect costs will be measured, and there will be a follow-up of 24 months. DISCUSSION: Changing behaviors is difficult, requires time, considerable effort and motivation. Combining the two counseling methods MI and PST, followed by booster sessions may result in sustained behavioral change. TRIAL REGISTRATION: Current Controlled Trials ISRCTN59358434.",0,0,
1453,Priming Hand Hygiene Compliance in Clinical Environments,"Introduction: Effective hand hygiene is the single most important procedure in preventing hospital-acquired infections. Traditional information/education-based interventions have shown only modest benefits on compliance. This study set out to investigate whether priming via olfactory and visual cues influences hand hygiene compliance. Method: Randomized controlled trial set in a surgical intensive care unit (SICU) at a teaching hospital in Miami, Florida. The primary outcome data involved observations—a mix of health professionals and service users were observed entering the SICU by 2 trained observers and their hand hygiene compliance was independently verified. Interventions included either an olfactory prime (clean, citrus smell) or visual prime (male or female eyes). The primary outcome measure was hand hygiene compliance (HHC) measured by the visitor using the hand gel dispenser. Results: At a 5% level there was significant evidence that a clean, citrus smell significantly improves HHC (46.9% vs. 15.0%, p = .0001). Compared to the control group, a significant improvement in HHC was seen when a picture of “male eyes” was placed over the hand gel dispenser (33.3% vs. 15.0%, p < .038). No significant improvement in HHC was seen when a picture of female eyes was placed over the same hand gel dispenser (10.0% vs. 15.0%, p = .626). Conclusions: This is one of the first studies to demonstrate that priming can influence HHC in a clinical setting. The findings suggest that priming interventions could be used to change other behaviors relevant to public health. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",1,1,
1454,Printed educational materials: effects on professional practice and health care outcomes,"BACKGROUND: Printed educational materials (PEMs) are widely used passive dissemination strategies to improve knowledge, awareness, attitudes, skills, professional practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines and appear to be the most frequently adopted method for disseminating information. OBJECTIVES: To determine the effectiveness of PEMs in improving process outcomes (including the behaviour of healthcare professionals) and patient outcomes. To explore whether the effect of characteristics of PEMs (e.g., source, content, format, mode of delivery, timing/frequency, complexity of targeted behaviour change) can influence process outcomes (including the behaviour of healthcare professionals and patient outcomes). SEARCH STRATEGY: The following electronic databases were searched up to July 2006: (a) The EPOC Group Specialised Register (including the database of studies awaiting assessment (see 'Specialised Register'under 'Group Details')""; (b) The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness;"" (c) MEDLINE, EMBASE, CINAHL and CAB Health. An updated search of MEDLINE was done in March 2007. SELECTION CRITERIA: We included randomised controlled trials (RCTs) , controlled clinical trials (CCT), controlled before and after studies (CBAs) and interrupted time series analyses (ITS) that evaluated the impact of printed educational materials on healthcare professionals' practice and/or patient outcomes. There was no language restriction. Any objective measure of professional performance (sch as number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g., blood pressure, number of caesarean sections) were included. DATA COLLECTION AND ANALYSIS: Four reviewers undertook data abstraction independently using a modified version of the EPOC data collection checklist. Any disagreement was resolved by discussion among the reviewers and arbitrators. Statistical analysis was based upon consideration of dichotomous process outcomes, continuous process outcomes, patient outcome dichotomous measures and patient outcome continuous measures. We presented the results for all comparisons using a standard method of presentation where possible. We reported separately for each study the median effect size for each type of outcome, and the median of these effect sizes across studies. MAIN RESULTS: Twenty-three studies were included for this review. Evidence from this review showed that PEMs appear to have small beneficial effects on professional practice. RCTs comparing PEMs to no intervention observed an absolute risk difference median: +4.3% on categorical process outcomes (e.g., x-ray requests, prescribing and smoking cessation activities) (range -8.0% to +9.6%, 6 studies), and a relative risk difference +13.6% on continuous process outcomes (e.g., medication change, x-rays requests per practice) (range -5.0% to +26.6%, 4 studies). These findings are similar to those reported for the ITS studies, although significantly larger effect sizes were observed (relative risk difference range from 0.07% to 31%). In contrast, the median effect size was -4.3% for patient outcome categorical measures (e.g., screening, return to work, quit smoking) (range -0.4% to -4.6%, 3 studies)). Two studies reported deteriorations in continuous patient outcome data (e.g., depression score, smoking cessation attempts) of -10.0% and -20.5%. One study comparing PEMs with educational workshops observed minimal differences. Two studies comparing PEMs and education outreach did not have statistically significant differences between the groups. It was not possible to explore potential effect modifiers across studies. AUTHORS' CONCLUSIONS: The results of this review suggest that when compared to no intervention, PEMs when used alone may have a beneficial effect on process outcomes but not on patient outcomes. Despite this wide of range of effects reported for PEMs, clinical significance of the observed effect sizes is not known. There is insufficient information about how to optimise educational materials. The effectiveness of educational materials compared to other interventions is uncertain.",0,1,
1455,Printed educational messages fail to increase use of thiazides as first-line medication for hypertension in primary care: a cluster randomized controlled trial [ISRCTN72772651,"BACKGROUND: Evidence on the effectiveness of printed educational messages in contributing to increasing evidence-based clinical practice is contradictory. Nonetheless, these messages flood physician offices, in an attempt to promote treatments that can reduce costs while improving patient outcomes. This study evaluated the ability of printed educational messages to promote the choice of thiazides as the first-line treatment for individuals newly diagnosed with hypertension, a practice supported by good evidence and included in guidelines, and one which could reduce costs to the health care system. METHODS: The study uses a pragmatic, cluster randomized controlled trial (randomized by physician practice group). SETTING: The setting involves all Ontario general/family practice physicians. Messages advising the use of thiazides as the first-line treatment of hypertension were mailed to each physician in conjunction with a widely read professional newsletter. Physicians were randomized to receive differing versions of printed educational messages: an ""insert"" (two-page evidence-based article) and/or one of two different versions of an ""outsert"" (short, directive message stapled to the outside of the newsletter). One outsert was developed without an explicit theory and one with messages developed targeting factors from the theory of planned behaviour or neither (newsletter only, with no mention of thiazides). The percentage of patients aged over 65 and newly diagnosed with hypertension who were prescribed a thiazide as the sole initial prescription medication. The effect of the intervention was estimated using a logistic regression model estimated using generalized estimating equation methods to account for the clustering of patients within physician practices. RESULTS: Four thousand five hundred four physicians (with 23,508 patients) were randomized, providing 97 % power to detect a 5 % absolute increase in prescription of thiazides. No intervention effect was detected. Thiazides were prescribed to 27.6 % of the patients who saw control physicians, 27.4 % for the insert, 26.8 % for the outsert and 28.3 % of the patients who saw insert + outsert physicians, p = 0.54. CONCLUSIONS: The study conclusively failed to demonstrate any impact of the printed educational messages on increasing prescribing of thiazide diuretics for first-line management of hypertension. TRIAL REGISTRATION: ISRCTN72772651.",0,1,
1456,Private enterprise and public good: ethical issues in the funding of clinical research,"Health-care centres, universities, and the researchers and clinicians working in them are encouraged to procure research funding through the development of commercial relationships. There are positive, practical, and morally relevant arguments in support of this initiative, but the move also raises ethical issues concerning potential conflicts of interest. These include conflicts between an institution's or researcher's responsibilities to each other, to research subjects, and to the public, and competing financial interests. This article examines developments in research funding and ethical difficulties that may arise in the present administrative context. It provides suggestions for the development of guidelines by institutions that are supportive of investigators in their endeavors to enhance clinical care through crucial external funding and the implementation of research.",0,0,
1457,Pro re nata medication for psychiatric inpatients: time to act,"Pro re nata (PRN""; 'as needed') medication is an archetypal mainstay for managing acute psychiatric inpatient symptoms and behaviours. Psychiatric and mental health nursing practices have circumnavigated the development of a uniform medical-ethical standard for the administration of PRN psychotropic medication. This paper examines the evidence for administration of PRN psychotropic medications and, in the context of evidence-based best practice, current mental health policy and professional ethics, proposes a standardized Australian PRN administration protocol. The procedures and circumstances leading to a nurse administering psychotropic PRN medication are divided into five simple steps, namely (i) medical prescription; (ii) nurse evaluation of patient indications for an intervention; (iii) nurse consideration of therapeutic options; (iv) obtaining patient informed consent;"" and (v) documentation of outcomes of PRN administration. The literature associated with each step is reviewed, along with national and international professional ethics, guidelines and patient rights documents pertaining to the care of mental health patients. Recommendations for best-practise care are discussed for each step. There is a lacuna of published evidence supporting the use of PRN medications in psychiatric inpatients. Yet there is published evidence that PRN medications are associated with increased risks of morbidity, inappropriate use, may result in above-recommended dosages or polypharmacy, and complicate the assessment of efficacy of regular scheduled medicines. Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects. There are no national explicit standards, operational criteria or quality assurance for the use of PRN medication in inpatient psychiatric units. Contemporary PRN practices are largely unregulated and driven by essentially anecdotal evidence, leaving the clinicians and the service open to claims of poor accountability and misuse (intentional and unintentional) of psychotropic medications. Development of best practice guidelines for the use of PRN administration is essential.",0,0,
1458,Proactive asthma care in childhood: general practice based randomised controlled trial.,"Objectives To assess the feasibility and effectiveness of a general practice based, proactive system of asthma care in children.  Design Randomised controlled trial with cluster sampling by general practice.  Setting General practices in the northern region of the Australian Capital Territory.  Participants 174 children with moderate to severe asthma who attended 24 general practitioners.  Intervention System of structured asthma care (the 3+ visit plan), with participating families reminded to attend the general practitioner.  Main outcome measures Process measures: rates for asthma consultations with general practitioner, written asthma plans, completion of the 3+ visit plan""; clinical measures: rates for emergency department visits for asthma, days absent from school, symptom-free days, symptoms over the past year, activity limitation over the past year, and asthma drug use over the past year; spirometric lung function measures before and after cold air challenge.  Results Intervention group children had significantly more asthma related consultations (odds ratio for three or more asthma related consultations 3.8 (95% confidence interval 1.9 to 7.6; P = 0.0001), written asthma plans (2.2 (1.2 to 4.1); P = 0.01), and completed 3+ visit plans (24.2 (5.7 to 103.2); P = 0.0001) than control children and a mean reduction in measurements of forced expiratory volume in one second after cold air challenge of 2.6% (1.7 to 3.5); P = 0.0001) less than control children. The number needed to treat (benefit) for one additional written asthma action plan was 5 (3 to 41) children. Intervention group children had lower emergency department attendance rates for asthma (odds ratio 0.4 (0.2 to 1.04); P = 0.06) and less speech limiting wheeze (0.2 (0.1 to 0.4); P = 0.0001) than control children and were more likely to use a spacer (2.8 (1.6 to 4.7);"" P = 0.0001). No differences occurred in number of days absent from school or symptom-free day scores.  Conclusions Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.",0,1,
1459,Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia,"OBJECTIVE: To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals. DESIGN: Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour. SETTING: Southampton and South West Hampshire Health District, United Kingdom. SUBJECTS: 179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group. MAIN MEASURES: Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines. RESULTS: Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents. CONCLUSION: Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.",0,0,
1460,Proceedings from the 9th annual conference on the science of dissemination and implementation,,0,0,
1461,Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science,,0,0,
1462,Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation,,0,0,
1463,Process and outcome in the National Health Service,,0,0,
1464,Process evaluation of an occupational health guideline aimed at preventing weight gain among employees,"OBJECTIVE: To evuate the process of an occupational health guideline aimed at preventing weight gain. METHODS: Quantitative data on seven process items were assessed and linked to effects on employees' waist circumference and body weight at 6 months. RESULTS: Occupational physicians (n = 7) implemented the guideline partly with respect to the environmental level, but performed well at the individual level. Behavioral change counseling was performed ""to some extent."" Employees (n = 274) showed high reach (86%), satisfaction (7.1), and attendance rates (4.4 of 5 sessions). Significant effects were found on waist circumference (-1.5 cm to -2.1 cm) and body weight (-0.9 kg to -1.4 kg) among employees with higher attendance and satisfaction rates. CONCLUSIONS: Workplace health promotion via an occupational health guideline is feasible, but the environmental component and behavioral change counseling need revisions before practical application.",0,0,
1465,Process evaluation of complex interventions: Medical Research Council guidance,"Process evaluation is an essential part of designing and testing complex interventions. New MRC guidance provides a framework for conducting and reporting process evaluation studies Attempts to tackle problems such as smoking and obesity increasingly use complex interventions. These are commonly defined as interventions that comprise multiple interacting components, although additional dimensions of complexity include the difficulty of their implementation and the number of organisational levels they target.1 Randomised controlled trials are regarded as the gold standard for establishing the effectiveness of interventions, when randomisation is feasible. However, effect sizes do not provide policy makers with information on how an intervention might be replicated in their specific context, or whether trial outcomes will be reproduced. Earlier MRC guidance for evaluating complex interventions focused on randomised trials, making no mention of process evaluation.2 Updated guidance recognised the value of process evaluation within trials, stating that it “can be used to assess fidelity and quality of implementation, clarify causal mechanisms and identify contextual factors associated with variation in outcomes.”3 However, it did not provide guidance for carrying out process evaluation. #### Summary points In 2010, a workshop funded by the MRC Population Health Science Research Network discussed the need for guidance on process evaluation.4 There was consensus that researchers, funders, and …",0,0,
1466,"Procrastination, Deadlines, and Performance: Self-Control by Precommitment","Procrastination is all too familiar to most people. People delay writing up their research (so we hear!), repeatedly declare they will start their diets tomorrow, or postpone until next week doing odd jobs around the house. Yet people also sometimes attempt to control their procrastination by setting deadlines for themselves. In this article, we pose three questions: (a) Are people willing to self-impose meaningful (i.e., costly) deadlines to overcome procrastination? (b) Are self-imposed deadlines effective in improving task performance? (c) When self-imposing deadlines, do people set them optimally, for maximum performance enhancement? A set of studies examined these issues experimentally, showing that the answer is “yes” to the first two questions, and “nO'’ to the third. People have self-control problems, they recognize them, and they try to control them by self-imposing costly deadlines. These deadlines help people control procrastination, but they are not as effective as some externally imposed deadlines in improving task performance.",0,0,
1467,Professional and lay social support for hysterectomy patients,"This paper describes a study of social support for women undergoing hysterectomy, and shows how original research plans had to be modified when early interviews revealed women's need for basic information and their desire to obtain this from the researcher. The modified design allowed comparisons between one group of women receiving information as part of the research interview and a second group receiving no such help. Post-hysterectomy follow-up at 3 months showed significant differences between the 2 groups, with the 'information group' being less hostile but more critical of their hospital treatment. The study also confirms previous findings by the same author of generally high levels of satisfaction, health and resumption of activities after hysterectomy. With regard to social support, it is suggested that full-time housewives are in particular need of support from nurses due to their relative isolation from other sources of support and information. However, all interviewees would have liked more information and support from health care professionals. Despite the acknowledged limitations of the study, some guidelines are offered for nurses attempting to increase levels of lay and professional support for their patients.",0,0,
1468,Professional interventions for general practitioners on the management of musculoskeletal conditions,"BACKGROUND: Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs. OBJECTIVES: To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2""; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions. MAIN RESULTS: Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10;"" 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low. AUTHORS' CONCLUSIONS: There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.",0,1,
1469,Prognosis research strategy (PROGRESS) 1: a framework for researching clinical outcomes,"Understanding and improving the prognosis of a disease or health condition is a priority in clinical research and practice. In this article, the authors introduce a framework of four interrelated themes in prognosis research, describe the importance of the first of these themes (understanding future outcomes in relation to current diagnostic and treatment practices), and introduce recommendations for the field of prognosis research In clinical medicine, the term prognosis refers to the risk of future health outcomes in people with a given disease or health condition. Prognosis research is thus the investigation of the relations between future outcomes (endpoints) among people with a given baseline health state (startpoint) in order to improve health (see supplementary figure on bmj.com). The study of prognosis has never been more important, as globally more people are living with one or more disease or health impairing condition than at any previous time.1 For this reason, governments across the world are increasing their interest in the outcomes of healthcare currently provided for people with disease.2 Similarly, research funders and researchers are increasingly focused on translating new interventions and technologies from the laboratory to clinical practice and then healthcare policy in order to establish and implement new standards of high quality care and improve patient outcomes. Prognosis research findings should thus be integral to clinical decision making, healthcare policy, and discovering and evaluating new approaches to patient management. However, there is a concerning gap between the potential and actual impact of prognosis research on health. Prognosis research studies too often fall a long way short of the high standards required in other fields, such as therapeutic trials and genetic epidemiology. In the PROGnosis RESearch Strategy (PROGRESS) series (www.progress-partnership.org), we propose a framework of four distinct but inter-related prognosis research themes:",0,0,
1470,Promising developments in neuropsychological approaches for the detection of preclinical Alzheimer's disease: a selective review,"Recently published guidelines suggest that the most opportune time to treat individuals with Alzheimer's disease is during the preclinical phase of the disease. This is a phase when individuals are defined as clinically normal but exhibit evidence of amyloidosis, neurodegeneration and subtle cognitive/behavioral decline. While our standard cognitive tests are useful for detecting cognitive decline at the stage of mild cognitive impairment, they were not designed for detecting the subtle cognitive variations associated with this biomarker stage of preclinical Alzheimer's disease. However, neuropsychologists are attempting to meet this challenge by designing newer cognitive measures and questionnaires derived from translational efforts in neuroimaging, cognitive neuroscience and clinical/experimental neuropsychology. This review is a selective summary of several novel, potentially promising, approaches that are being explored for detecting early cognitive evidence of preclinical Alzheimer's disease in presymptomatic individuals.",0,0,
1471,Promoting evidence-based psychosocial care for cancer patients,"With numerous studies demonstrating that psychosocial care reduces distress and improves quality of life, practitioners have an obligation to treat cancer patients in a manner consistent with this evidence. Although the rationale is straightforward, major challenges exist in achieving the goal of translating research into clinical practice. One challenge has been the nature of the evidence, with many studies of psychosocial interventions characterized by poor methodological quality, absence of eligibility criteria specifying heightened distress, and minimal consideration of dissemination potential. A second challenge has been to make practitioners aware of relevant evidence. Targeted efforts at dissemination, such as the issuance of clinical practice guidelines and evidence-based recommendations and the distribution of intervention materials via the Internet, appear to be more effective than passive efforts in providing practitioners with useful information. Perhaps the most challenging aspect has been to persuade practitioners to change how they practice. One approach currently under development would allow practitioners and health-care organizations to perform self-evaluations of the quality of their psychosocial care based on review of medical records. Feedback showing quality of care to be less than optimal is likely to motivate change, especially if the quality indicators assessed are considered to be important and reliable and point to specific actions that can be taken. The use of evidence to promote changes in clinical practice represents one of the major ways in which the field of psycho-oncology can fully realize its potential to positively affect the lives of people with cancer.",0,0,
1472,Promoting Hand Hygiene Compliance,"BACKGROUND: The German ""Clean Hands Campaign"" (an adaptation of the WHO ""Clean Care is Safer Care"" programme) to promote hand hygiene among hospital personnel at Hannover Medical School (MHH, Medizinische Hochschule Hannover), known as Aktion Saubere Hande (ASH), met with initial success. By 2013, however, compliance rates with hygienic hand disinfection in the hospital's ten intensive care units (ICUs) and two hematopoietic stem cell transplantation units (HSCTUs) had relapsed to their initial levels (physicians: 48%"";"" nurses: 56%). The cluster- randomized controlled trial PSYGIENE was conducted to investigate whether interventions tai - lored in ways suggested by research in behavioral psychology might bring about more sustainable improvements than the ASH. METHODS: The ""Health Action Process Approach"" (HAPA) compliance model specifies key psychological determinants of compliance. These determinants were assessed among health care workers in the ICUs and HSCTUs of the MHH by questionnaire (response rates: physicians: 71%""; nurses: 63%) and by interviews of the responsible ward physicians and head nurses (100%). In 2013, 29 tailored behavior change techniques were implemented in educational training sessions and feedback discussions in the six wards that constituted the intervention arm of the trial, while ASH training sessions were provided in the control arm. The compliance rates for 2014 and 2015 (the primary outcomes of the trial) were determined by nonparticipating observation of hygienic hand disinfection, in accordance with the World Health Organization's gold standard. RESULTS: The two groups did not differ in their baseline compliance rates in 2013 (intervention: 54%, control: 55%, p = 0.581). The tailored interventions led to increased compliance in each of the two follow-up years (2014: 64%, p<0.001;"" 2015: 70%, p = 0.001), while the compliance in the control arm increased to 68% in 2014 (p<0.001) but fell back to 64% in 2015 (p = 0.007). The compliance increases from 2013-2015 and the compliance rate in 2015 were higher in the intervention arm (p<0.005). This was mainly attributable to the nurses' behavior, as the corresponding parameters for physicians did not differ significantly between the two study arms in stratified analysis. CONCLUSION: Tailored interventions based on behavioral psychology principles led to more sustainable increases in compliance with hand hygiene guidelines than ASH training sessions did. This was true among nurses, and thus also for hospital ward personnel as a whole (i.e., nurses and physicians combined). Further studies are needed to identify more target group-specific interventions that may improve compliance among physicians.",0,1,
1473,Promoting recovery of schizophrenic patients: discrepancy between routine practice and evidence. The SIEP-DIRECT'S Project,"AIMS: The aim of this work is to present the main discrepancies, as evidenced by the SIEP-DIRECT'S Project, between the evidence-based NICE guidelines for schizophrenia and the usual practices of the Italian mental health services in order to promote the recovery of patients with schizophrenia. METHODS: Starting from the main NICE recommendations on recovery promotion, 41 indicators were developed. These were experimented in 19 participating Italian Mental Health Departments (MHD) or Psychiatric Services through self-evaluation of the activities carried out to promote patient recovery with the aim of assessing the level of adherence to the recommendations. The data required by most of the indicators were obtained from the psychiatric informative system or from the Direction of the MHD. Moreover, specific research was carried out on the clinical records and on representative patient samples. Furthermore, for 14 indicators, there was requested an assessment by the part of ""multidisciplinary"" or ""specialistic"" focus groups who then attributed a score according to a defined ""ad hoc"" scale. RESULTS: According to the data obtained, although the mental health services seem to care about the physical condition of their patients, they do not routinely examine principle parameters such as blood pressure, glycaemia etc., and collaboration with general practitioners is often complex or not uniformly practiced. Most psychiatrists and psychologists possess the basic communication skills but not enough competences in cognitive-behavioural treatments"";"" such treatments, and every other form of structured individual psychotherapy, are seldom carried out and seem to have become marginal activities within the Services. Also family psycho-educational interventions are under-used. The Services are very active in the care of multi-problem schizophrenia patients, who make up a large percentage (almost a quarter, on average) of the patients in their care. These patients are offered specific and integrated treatment plans with the involvement of other health services and social agencies operating in the territory. The strategies adopted by the services for the pharmacological treatment in the prevention of relapses and for patients with frequent crises or with treatment-resistant schizophrenia are all in line with the NICE recommendations. Finally, the Services promote activities of vocational training and supported employment, but the outcomes of these are often unsatisfactory. CONCLUSIONS: The results of the study show a picture of the Italian mental health services with bright yet also dark areas as regards recovery promotion activities. The Services seem to guarantee adequate pharmacological evidence-based treatments, an integrated assistance and good management of multi-problem patients. They have difficulty, however, with respect to the monitoring of the physical health of the patients, psychotherapeutic activities, including those for families, and the promotion of supported employment. Moreover, they still show problems regarding the structuring and formalizing of care processes. To improve this situation, they should make greater use of professional guidelines, protocols and written procedures.",0,0,
1474,Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography,"In a one-year randomized controlled trial, we assessed the effectiveness of a computerized mammography reminder system as a component of a program to increase the use of screening mammography in three health care organizations serving inner-city women in Detroit, Michigan (two sites of a health department, one HMO site, and two sites of a private hospital). Four thousand four hundred and one women older than 40 who had visited a study site in the preceding year were randomly assigned to one of two treatment groups. Limited intervention (LI) included physician and staff breast cancer control education, facilitated mammography appointment scheduling procedures, and elimination of out-of-pocket patient cost for mammography (at three of five sites). Full intervention (FI) included all components of limited intervention plus an additional series of ""cues-to-action."" These included a mammography reminder form inserted in the medical record of women who were due to have mammography, intended to increase physician referral for mammography appointments, and patient reminders intended to increase completion of mammography among referred women. During the one-year intervention period 2,725 randomized women visited a study site. The 6-month mammography appointment rates among FI women vary from 38% to 65% and the FI rate exceeds the LI rate at each site with differences from 13% (95% CI, 6 to 20) to 29% (21 to 38). The annual completed mammography rate among FI women extends from 43% to 64% and exceeds the LI rate at each site by 12% (5 to 19) to 25% (16 to 34). After age-adjustment, the mammography intervention effect sizes among the five sites were not significantly different. The average increase in FI compared to LI was 18%. The computerized reminder system is effective in increasing the use of mammography in each of the study institutions and the major effect is on physician referral for mammography.",0,1,
1475,Promoting self-management through adherence among heart failure patients discharged from rural hospitals: a study protocol,"UNLABELLED: Background Heart failure is one of the most prevalent chronic conditions in adults, leading to prolonged morbidity, repeated hospitalizations, and placing tremendous economic burden on the healthcare system. Heart failure patients discharged from rural hospitals, or primarily critical access hospitals, have higher 30-day readmission and mortality rates compared to patients discharged from urban hospitals. Self-management improves heart failure patients' health outcomes and reduces re-hospitalizations, but adherence to self-management guidelines is low. We propose a home based post-acute care service managed by advanced practice nurses to enhance patient activation and lead to the improvement of self-management adherence in heart failure patients discharged from rural hospitals. Objective This article describes the study design and research methods used to implement and evaluate the intervention. Method Our intervention is a 12-week patient activation (Patient AcTivated Care at Home [PATCH]) to improve self-management adherence. Patients were randomized into two parallel groups (12-week PATCH intervention + usual care vs. usual care only) to evaluate the effectiveness of this intervention. Outcomes were measured at baseline, 3 and 6 months. Discussion This study aimed to examine the effectiveness of a rural theory based, advance practice nurse led, activation enhancing intervention on the self-management adherence in heart failure patients residing in rural areas. Our expectation is to facilitate adherence to self-management behaviors in heart failure patients following discharge from rural hospitals and decrease complications and hospital readmissions, leading to the reduction of economic burden. CLINICAL TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov"";"" https://register.clinicaltrials.gov/ NCT01964053.",0,0,
1476,Promoting use of colorectal cancer screening tests,"BACKGROUND: Colorectal cancer (CRC) screening is underutilized despite evidence that screening reduces mortality.  OBJECTIVE: To assess the effect of an intervention targeting physicians and their patients on rates of CRC screening.  DESIGN: A randomized clinical trial of community physicians and their patients.  PARTICIPANTS: Ninety-four community primary care physicians randomly assigned to an intervention consisting of academic detailing and direct mailings to patients or a control group. Patients aged 50 to 79 years in the intervention group physicians received a letter from their physician, a brochure on CRC screening, and a packet of fecal occult blood test (FOBT) cards.  MEASUREMENTS: After 1 year we measured receipt of the following: (1) FOBT in the past 2 years, (2) flexible sigmoidoscopy (SIG) or colonscopy (COL) in the previous 5 years, and (3) any CRC screening. We report the percent change from baseline in both groups.  RESULTS: 9,652 patients were enrolled for 2 years, and 3,732 patients were enrolled for 5 years. There was no increase in any CRC screening that occurred in the intervention group for patients enrolled for 2 years (12.7 increase vs 12.5%, P=.51). Similar results were seen for any CRC screening among patients enrolled for 5 years (9.7% increase vs 8.6%, P=.45). The only outcome on which the intervention had an effect was on patient rates of screening SIG (7.4% increase vs 4.4%, P<.01).  CONCLUSION: With the exception of an increase in rates of SIG in the intervention group, the intervention had no effect on rates of CRC screening. Future interventions should assess innovative approaches to increase rates of CRC screening.",0,1,
1477,Promotion and prescribing of hormone therapy after report of harm by the Women's Health Initiative,"Context Little is known about how the pharmaceutical industry responds to evidence of harm associated with its products, such as the publication in July 2002 of the Women¡¯s Health Initiative Estrogen Plus Progestin Trial (WHI E+P) report demonstrating that standard-dose Prempro produced significant harm and lacked net benefits.  Objective To examine pharmaceutical industry response to the WHI E+P results by analyzing promotional expenditures for hormone therapy before and after July 2002.  Design and Setting Nationally representative and prospectively collected longitudinal data (January 2001 through December 2003) on prescribing and promotion of hormone therapies were obtained from IMS Health and Consumer Media Reports.  Main Outcome Measures Trends in quarterly prescriptions for hormone therapy and expenditures on 5 modes of drug promotion: samples, office-based detailing, hospital-based promotion, journal advertisements, and direct-to-consumer advertising.  Results Prior to the WHI E+P report, prescribing rates and promotional spending for hormone therapy were stable. In the quarter before the WHI E+P report (April-June 2002), 22.4 million prescriptions for hormone therapy were dispensed and $71 million was spent on promotion (in annual terms, $350 per year per US physician). Within 9 months of the report¡¯s publication (quarter 1 of 2003), there was a 32% decrease in hormone therapy prescriptions, and a nadir had been reached for promotional spending (37% decrease compared with pre-WHI E+P levels). Spending decreased for all promotional activities and most hormone therapies. Overall, the greatest declines were for samples (36% decrease as of quarter 1 of 2003) and direct-to-consumer advertising (100% decrease). The greatest declines in promotion occurred for standard-dose Prempro (61% decrease as of quarter 1 of 2003), the agent implicated by the WHI E+P report. More recently, promotional efforts have increased, particularly for lower-dose Prempro, a resurgence associated with modestly increased prescriptions for this newer agent.  Conclusions Concordant with its widespread use, hormone therapy was among the most heavily promoted medications prior to the WHI E+P report. Following reporting of the evidence of harm from this trial, there was a substantial decline in promotional spending for hormone therapy, particularly for the agents most directly implicated in the trial. Interrelated with the impact of the trial results themselves and the ensuing media coverage, reduced promotion may have contributed to a substantial decline in hormone therapy prescriptions.",0,0,
1478,Proper antibiotic therapy. From penicillin to pharmacogenomic,"Antibiotics have always been considered one of the wonder discoveries of the 20th century. The use of penicillin by Flaming, opened up the golden era of antibiotics and now is hard to imagine the practice of medicine without antibiotics. Life-threatening infections, such as meningitis, endocarditis, bacteremic pneumonia sepsis, would again prove fatal. Also aggressive chemotherapy and transplant procedures would prove impossible. Another real wonder has been the rise of antibiotic resistance soon after the clinical use of penicillin in hospitals and communities. Several study demonstrated an excessive amount of antibiotic prescribing for communities patients and inpatients and in some hospital up to 50% of antibiotic usage is inappropriate: the benefits of antibiotic treatment come with the risk of antibiotic resistance development. In hospitals, infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. A variety of strategies has been proposed to reduce the cost and improve the quality of medication use. Education, guidelines and evidence based recommendations are considered to be essential elements of any program designed to influence prescribing behavior and can provide a foundation of knowledge that will enhance and increase the acceptance of stewardship strategies. Evidence-based recommendations, an approach to clinical practice helping to make decisions based on clinical expertise and on intimate knowledge of the individual patient's situations, beliefs, and priorities, enhance antimicrobial stewardship, that include appropriate selection, dosing, route, and duration of antimicrobial therapy can maximize clinical cure or prevention of infection while limiting the unintended consequences, such as the emergence of resistance, adverse drug events, and cost. These evidence-based guidelines are not a substitute for clinical judgment, and clinical discretion is always required in their application. Genome studies have identified hundreds of genetic polymorphism important determinants of the efficacy of therapy and several trial demonstrated the successful use of pharmacogenomic testing to reduce the incidence of hypersensitivity reactions in patients. Knowing the phenotype of a patient prior to therapy, optimal dose and type drugs can be prescribed to achieve better management of patients.",0,0,
1479,Prophylaxis of infection after appendicectomy: a survey of current surgical practice,"Two hundred and eighty questionnaires were sent to junior surgical staff throughout England inquiring about their use of systemic antibiotic prophylaxis, topical antibacterial agents, and surgical drainage in appendicectomy. One hundred and seventy-five (63%) replies were received from 81 of the 87 hospitals included in the survey. Prophylactic systemic antibiotics were used by 78 surgeons (46%) when operating on a normal appendix but by 168 (99%) when the organ had perforated. Most surgeons started antibiotics before operation, but proportionately fewer did so when the appendix was gangrenous or perforated. Patients with severe contamination tended to receive longer courses of antibiotics, although the duration of administration varied considerably. Metronidazole was included in over 95% of all the prophylactic regimens and was often combined with other drugs when the appendix was gangrenous and perforated. Topical antibacterial agents were applied to the wound routinely by only 45 surgeons (26%), although 106 (61%) used them sometimes. Povidone-iodine was the agent most commonly used. Only 98 surgeons (56%) ever drained appendicectomy wounds, while 135 (77%) sometimes drained the peritoneal cavity. Evidence suggests that present methods of giving systemic antibiotic prophylaxis should continue, but that topical agents and surgical drainage are perhaps unnecessary when surgeons are confident of the efficacy of the systemic treatment used.",0,0,
1480,Prophylaxis of surgical wound sepsis,,0,0,
1481,Proposed guidelines for the participation of persons with dementia as research subjects,,0,0,
1482,Proposed revision of the Declaration of Helsinki,,0,0,
1483,Prospective comparative study of computer programs used for management of warfarin.,"AIMS--To compare the effectiveness of three computerised systems that are currently used for assisting warfarin control in outpatients with the customary dosing method used by experienced medical staff. METHODS--A pilot randomised study of three systems with a follow up independently randomised study of two of these was made on 186 patients receiving long term treatment or who had recently started warfarin treatment and had been discharged from hospital. RESULTS--All three computerised systems seemed to give satisfactory control compared with the traditional dosing method. For patients receiving more intensive treatment with an assigned target range of 3.0-4.5 computerised dosage programs achieved significantly better control"";"" the medical staff undertreated such patients almost 50% of the time. CONCLUSION--Computer based programs can assist outpatient anticoagulant control with warfarin during both early and long term treatment. For most patients the control achieved is as good as that obtained by the customary method of dosing, by experienced clinic doctors, although the latter tend to be too conservative when dosing patients within the intense target range of 3.0 to 4.5 International Normalised Ratio (INR). The computers were significantly more successful in this higher range.",0,1,
1484,Prospective study of quality of life before and after coronary artery bypass grafting,"OBJECTIVES Measurement of changes in patients' perceptions of how differing states of health affect their lives and determination of the ability of preoperative variables to predict outcome after coronary artery bypass grafting. DESIGN Prospective study with completion of questionnaires before coronary artery bypass grafting and at three months, one year, and five years afterwards. SETTING Regional cardiothoracic centre. PATIENTS 100 Male patients all aged below 60 at the time of operation, who were patients of two cardiothoracic surgeons. MAIN OUTCOME MEASURES Patients' assessment of their health state in terms of functional capacity and aspects of distress, according to the Nottingham health profile and outcome of operation in terms of changes in symptoms, working life, and daily activities determined by self completed study questionnaires before operation and at three and six months afterwards. RESULTS Intermediate one year results are reported. The differences between the Nottingham health profile scores before operation and at three months afterwards were significantly different (p less than 0.01), indicating an appreciable improvement in general health state, and at one year compared favourably with those from a normal male population. Analysis of responses to the study questionnaire showed that 65 of 89 patients (73%) were working at one year after operation with a further seven (8%) maintaining that they were fit to work but unable to find employment. The proportion of patients complaining of chest pain fell from 90% (88/98) before grafting to 19% (17/89) at one year after coronary artery bypass grafting, when 91% (81/89) patients maintained that their condition was either completely better or definitely improved. The significant positive factors affecting return to work and home activities were working before operation, short wait for operation, absence of breathlessness, and low physical mobility score in the Nottingham health profile (all p less than 0.001). CONCLUSIONS Improvements were evident in general health state, symptoms, and activity at three months and one year after coronary artery bypass graft surgery. Interventions likely to influence outcomes included reduction in waiting times for operation""; rehabilitation initiatives;"" and more attention to the quality of information given to patients, their relatives, and the community.",0,0,
1485,Prospective trial of real-time electronic surveillance to expedite early care of severe sepsis.,"Study objective An automated, real-time electronic medical record query and caregiver notification system was developed and examined for its utility in improving sepsis care. We hypothesize that the algorithm will increase the rate and timeliness of sampling of blood lactate and blood cultures, performance of chest radiography, and provision of antibiotics.  Methods A before-and-after, prospective study with consecutive enrollment examined an algorithm that automatically identified adult patients accumulating 2 or more systemic inflammatory response syndrome (SIRS) criteria and 2 or more blood pressure measurements less than or equal to 90 mm Hg during their emergency department (ED) stay. In phase 1, the system collected information but did not alert caregivers. In phase 2, caregivers were notified by alphanumeric paging and a text entry into the electronic medical record of the patients' potential illness and were provided with specific recommendations.  Results Patients (33,460) were screened during 6 months""; 398 patients activated the system, including 184 (46%) appropriately identified as severely septic. The algorithm had a 54% positive predictive value and 99% negative predictive value in detecting severe infection with acute organ dysfunction. The median time for patients to accumulate SIRS and blood pressure criteria was 152 minutes (interquartile range [IQR] 71 to 284 minutes), underscoring the dynamic nature of diagnosing critical illness in the emergency setting and the need for detection algorithms to repeatedly assess patients during their evaluation. After implementation, 2 interventions were performed more frequently, chest radiograph before admission (odds ratio 3.2; 95% confidence interval 1.1 to 9.5) and collection of blood cultures (odds ratio 2.9; 95% confidence interval 1.1 to 7.7). Only blood culture testing was performed significantly faster in the presence of decision support (median time to culture before intervention 86 minutes, IQR 31, 296 minutes; median time to culture after intervention 81 minutes, IQR 37, 245 minutes;"" P=.032 by Cox proportional hazards modeling). The predominant shortcoming of the strategy was failing to detect severely septic cases before caregivers.  Conclusion An automated algorithm for detecting potential sepsis increased the frequency and timeliness of some ED interventions for severe sepsis. Future efforts need to identify patient features present earlier in ED evaluation than SIRS and hypotension.",1,1,
1486,Protecting rights of human subjects,"A significant problem exists with the volume of human subjects research that is being carried out by investigators who are not in compliance with the Belmont Report's guidelines for the protection of human subjects. Numerous reasons exist for noncompliance, which may create dilemmas for resolving this issue. However, it is important that health care organizations-regardless of size-take a proactive position in addressing this problem. This article has briefly described the nature, scope, and underlying dilemmas of this issue and has suggested a strategy for resolving the issue at an organizational level. As patient advocates by virtue of their professional licenses, nurses in any role can and must take a lead in protecting human subjects' rights.",0,0,
1487,Protection of children involved in research studies,,0,0,
1488,"Protection of human subjects""; informed consent;"" proposed rule",,0,0,
1489,Protocol for a pragmatic cluster randomised controlled trial for reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China,"INTRODUCTION: Irrational use of antibiotics is a serious issue within China and internationally. In 2012, the Chinese Ministry of Health issued a regulation for antibiotic prescriptions limiting them to <20% of all prescriptions for outpatients, but no operational details have been issued regarding policy implementation. This study aims to test the effectiveness of a multidimensional intervention designed to reduce the use of antibiotics among children (aged 2-14 years old) with acute upper respiratory infections in rural primary care settings in China, through changing doctors' prescribing behaviours and educating parents/caregivers. METHODS AND ANALYSIS: This is a pragmatic, parallel-group, controlled, cluster-randomised superiority trial, with blinded evaluation of outcomes and data analysis, and un-blinded treatment. From two counties in Guangxi Province, 12 township hospitals will be randomised to the intervention arm and 13 to the control arm. In the control arm, the management of antibiotics prescriptions will continue through usual care via clinical consultations. In the intervention arm, a provider and patient/caregiver focused intervention will be embedded within routine primary care practice. The provider intervention includes operational guidelines, systematic training, peer review of antibiotic prescribing and provision of health education to patient caregivers. We will also provide printed educational materials and educational videos to patients' caregivers. The primary outcome is the proportion of all prescriptions issued by providers for upper respiratory infections in children aged 2-14 years old, which include at least one antibiotic. ETHICS AND DISSEMINATION: The trial has received ethical approval from the Ethics Committee of Guangxi Provincial Centre for Disease Control and Prevention, China. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION NUMBER: ISRCTN14340536"";"" Pre-results.",0,0,
1490,Protocol for a systematic review of evaluation research for adults who have participated in the 'SMART recovery' mutual support programme,"INTRODUCTION: Self-Management and Recovery Training (SMART Recovery) offers an alternative to predominant 12-step approaches to mutual aid (eg, alcoholics anonymous). Although the principles (eg, self-efficacy) and therapeutic approaches (eg, motivational interviewing and cognitive behavioural therapy) of SMART Recovery are evidence based, further clarity regarding the direct evidence of its effectiveness as a mutual aid package is needed. Relative to methodologically rigorous reviews supporting the efficacy of 12-step approaches, to date, reviews of SMART Recovery have been descriptive. We aim to address this gap by providing a comprehensive overview of the evidence for SMART Recovery in adults with problematic alcohol, substance and/or behavioural addiction, including a commentary on outcomes assessed, potential mediators, feasibility (including economic outcomes) and a critical evaluation of the methods used. METHODS AND ANALYSIS: Methods are informed by the Cochrane Guidelines for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. 6 electronic peer-reviewed and 4 grey literature databases have been identified. Preliminary searches have been conducted for SMART Recovery literature (liberal inclusion criteria, not restricted to randomised controlled trials (RCTs), qualitative-only designs excluded). Eligible 'evaluation' articles will be assessed against standardised criteria and checked by an independent assessor. The searches will be re-run just before final analyses and further studies retrieved for inclusion. A narrative synthesis of the findings will be reported, structured around intervention type and content, population characteristics, and outcomes. Where possible, 'summary of findings' tables will be generated for each comparison. When data are available, we will calculate a risk ratio and its 95% CI (dichotomous outcomes) and/or effect size according to Cohen's formula (continuous outcomes) for the primary outcome of each trial. ETHICS AND DISSEMINATION: No ethical issues are foreseen. Findings will be disseminated widely to clinicians and researchers via journal publication and conference presentation(s). PROSPERO REGISTRATION NUMBER: CRD42015025574.",0,0,
1491,"Protocol for a systematic review of telephone delivered psychosocial interventions on relapse prevention, adherence to psychiatric medication and health risk behaviours in adults with a psychotic disorder","INTRODUCTION: The mental and physical health of individuals with a psychotic illness are typically poor. When adhered to, medication can reduce relapse. However, despite adherence, relapse remains common and functional outcomes often remain compromised. Compliance is also typically low. Cardiovascular-related morbidity and mortality is also elevated, along with several important modifiable health risk behaviours. Access to psychosocial interventions is therefore important, but currently limited. Telephone delivered interventions represent a promising solution, although further clarity is needed. Accordingly, we aim to provide an overview and critical analysis of the current state of evidence for telephone delivered psychosocial interventions targeting key health priorities in adults with a psychotic disorder, including (1) relapse, (2) adherence to psychiatric medication and/or (3) modifiable cardiovascular health risk behaviours. METHODS AND ANALYSIS: Our methods are informed by published guidelines. The review is registered and any protocol amendments will be tracked. Ten electronic peer-reviewed and four grey literature databases have been identified. Preliminary searches have been conducted for literature on psychosocial telephone interventions targeting relapse, medication adherence and/or health risk behaviours in adults with a psychotic disorder. Articles classified as 'evaluation' will be assessed against standardised criteria and checked by an independent assessor. The searches will be re-run just before final analyses and further studies retrieved for inclusion. A narrative synthesis will be reported, structured around intervention type and content, population characteristics and outcomes. Where possible, 'summary of findings' tables will be generated for each comparison. For the primary outcome of each trial, when data are available, we will calculate a risk ratio and its 95% CI (dichotomous outcomes) and/or effect size according to Cohen's formula (continuous outcomes). ETHICS AND DISSEMINATION: No ethical issues are foreseen. Findings will be disseminated widely to clinicians and researchers via journal publication and conference presentation(s). TRIAL REGISTRATION NUMBER: PROSPERO CRD42015025402.",0,0,
1492,Protocol processing system (ProtoVIEW) to support residents at the emergency ward.,"This paper describes the design, implementation and evaluation of a prototype protocol processing system (ProtoVIEW). ProtoVIEW provides protocol information for diagnostic and therapeutic purposes. The developed system described here is used as a research instrument to investigate the impact of automated protocols on the medical decision making of physicians. A first evaluation indicates that residents like to use the system and that usage of the system leads to a more uniform working strategy.",0,1,
1493,"Provider attitudes toward oral preexposure prophylaxis for HIV prevention among high-risk men who have sex with men in Lima, Peru","Oral preexposure prophylaxis (PrEP) was the first biomedical intervention to demonstrate efficacy in preventing HIV infection among men who have sex with men (MSM). Healthcare providers' attitudes toward PrEP will be critical in translating this finding into effective public health rollout programs. In a convenience sample of 186 healthcare providers in Peru, we assessed knowledge, barriers, and attitudes to prescribe and monitor HIV PrEP for high-risk MSM and transgender women, the populations with the highest HIV incidence in this setting. A total of 57.5% reported awareness of PrEP, and awareness was independently associated with caring for more than 50 MSM (OR: 3.67, p<0.002). Lack of local guidelines, concern about increased high-risk behavior, antiretroviral drug resistance, and limited availability of antiretrovirals for HIV-infected individuals were the most common barriers to prescribing PrEP. Of all physicians 44.6% indicated that they would be likely to prescribe oral PrEP now"";"" likelihood to prescribe was higher if PrEP were supported by local guidelines (70.3%, p<0.001), if more trials supported its effectiveness (68.5%, p<0.001), and if intermittent use were shown to be effective (62.2%, p=0.019). Physicians were more likely to prescribe PrEP now if they care for more than 50 MSM (OR: 6.62, p=0.010). Infectious disease specialists were less likely to prescribe PrEP (OR: 0.10, p=0.003) than nonspecialists. Successful large-scale implementation of PrEP in Peru will require focused educational campaigns to increase awareness and address concerns among healthcare providers.",0,0,
1494,Provider detailing: an intervention to decrease prescription opioid deaths in Utah,"BACKGROUND: Utah undertook a multipronged effort to reverse an epidemic of deaths among patients taking prescription opioids. This article describes the provider detailing portion of the effort. METHODS: Presentations highlighting six recommended prescribing practices were developed and presented to health care workers. Participants were encouraged to utilize the state prescription database and to complete a series of surveys assessing confidence and behavior changes at 0, 1, and 6 months post-presentation. Continuing medical education credits incentivized participation. RESULTS: Utah's medication-related overdose deaths dropped 14.0% in 2008 compared with 2007 following program implementation. A total of 581 physicians and numerous nonphysician health care workers were reached during 46 presentations. Follow-up surveys regarding the degree of adoption of practice changes were completed by 366 participants at 0 months, 82 participants at 1 month, and 29 participants at 6 months. Combined results for all three evaluations showed that 60-80% of responding providers reported no longer prescribing long-acting opioids for acute pain or with sedatives""; 50% noted using Utah's controlled substances database during patient care and utilizing lower starting doses and slower escalations;"" and 30-50% reported obtaining EKGs and sleep studies on appropriate patients, using patient education tools, and implementing Utah's prescribing guidelines. CONCLUSIONS: Provider detailing was associated with a decrease in Utah's prescription opioid death rate and improvements in provider self-reported prescribing behaviors. Other simultaneous interventions may have contributed to the decline in death rates. This intervention's effect was limited by short-term funding.",0,0,
1495,Provider education to promote implementation of clinical practice guidelines,"STUDY OBJECTIVES: Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education. METHODS: Experience and data from relevant randomized clinical trials within an educational framework are reviewed. OBSERVATIONS: Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation. CONCLUSIONS: To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.",0,0,
1496,Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial.,"Background Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England.  Methods In this randomised, 2?×?2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed.  Findings Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126·98 (95% CI 125·68–128·27) in the feedback intervention group and 131·25 (130·33–132·16) in the control group, a difference of 4·27 (3·3%""; incidence rate ratio [IRR] 0·967 [95% CI 0·957–0·977]; p<0·0001), representing an estimated 73?406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135·00 [95% CI 133·77–136·22] in the patient-focused intervention group and 133·98 [133·06–134·90] in the control group; IRR for difference between groups 1·01, 95% CI 1·00–1·02; p=0·105).  Interpretation Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale;"" this outcome makes it a worthwhile addition to antimicrobial stewardship programmes.",1,1,
1497,Provision of taped conversations with neonatologists to mothers of babies in intensive care: randomised controlled trial,"OBJECTIVE To determine whether providing mothers of babies in neonatal intensive care units with audiotapes of their conversations with a neonatologist improves recall of information and psychological wellbeing. DESIGN Randomised, single blinded trial. SETTING Neonatal intensive care unit, North Queensland, Australia. PARTICIPANTS 200 mothers of babies in a neonatal intensive care unit. INTERVENTIONS Mothers given (n=102) or not given (n=98) audiotapes of their conversations with a neonatologist. MAIN OUTCOME MEASURES Recall of information, attitudes to and use of the tape, satisfaction with conversations, postnatal depression, anxiety, general health, and stress about parenting, at 10 days and four and 12 months. RESULTS 91% (n=93) of mothers in the tape group listened to the tape (once by day 10, twice by four months, and three times by 12 months""; range 1-10). At 10 days and four months, mothers in the tape group recalled significantly more information about diagnosis, treatment, and outcome than mothers in the control group. At four months mothers in the tape group were 75% more likely to recall all of the information about treatment than mothers in the control group (59% v 34%;"" risk ratio 1.75, 95% confidence interval 1.27 to 2.4). Six mothers, all in the control group, could not recall their conversations. No statistically significant differences were found between the groups in satisfaction with conversations (10 days), postnatal depression and anxiety scores (10 days, four and 12 months), and stress about parenting (12 months). CONCLUSION Providing the mothers of babies in neonatal intensive care units with audiotapes of conversations with a neonatologist enhanced their recall of information (up to four months). The taped conversations did not affect the mothers' wellbeing or satisfaction with the neonatologist. TRIAL REGISTRATION Australian Clinical Trials Registry 12606000478516.",0,0,
1498,Psychiatric experimentation: the lessons of history,,0,0,
1499,Psychoeducation: improving outcomes in bipolar disorder,"BACKGROUND: A relevant paradigm shift in the treatment of bipolar disorder started a few years ago"";"" crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and ""real world"" effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients. METHODS: A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. ""Bipolar"", ""Psychotherapy"", ""Psychoeducation"", ""Cognitive-behavioral"" and ""Relapse prevention"" were entered as keywords. RESULTS: Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions"";"" almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs - stressing the importance of life-style regularity - and exploring patients' health beliefs and illness-awareness. CONCLUSIONS: The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents.",0,0,
1500,Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians,"BACKGROUND: Psychological and behavioral interventions are frequently used for insomnia disorder.PURPOSE: To assess benefits and harms of psychological and behavioral interventions for insomnia disorder in adults.DATA SOURCES: Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and PsycINFO through September 2015, supplemented with hand-searching.STUDY SELECTION: Randomized, controlled trials of psychological or behavioral interventions that were published in English and enrolled adults with insomnia disorder lasting 4 or more weeks.DATA EXTRACTION: Data extraction by single investigator confirmed by a second reviewer""; dual investigator assessment of risk of bias;"" consensus determination of strength of evidence.DATA SYNTHESIS: Sixty trials with low to moderate risk of bias compared psychological and behavioral interventions with inactive controls or other psychological and behavioral interventions. Cognitive behavioral therapy for insomnia (CBT-I) improved posttreatment global and most sleep outcomes, often compared with information or waitlist controls (moderate-strength evidence). Use of CBT-I improved several sleep outcomes in older adults (low- to moderate-strength evidence). Multicomponent behavioral therapy improved several sleep outcomes in older adults (low- to moderate-strength evidence). Stimulus control improved 1 or 2 sleep outcomes (low-strength evidence). Evidence for other comparisons and for harms was insufficient to permit conclusions.LIMITATIONS: A wide variety of comparisons limited the ability to pool data. Trials did not always report global outcomes and infrequently conducted remitter or responder analysis. Comparisons were often information or waitlist groups, and publication bias was possible.CONCLUSION: Use of CBT-I improves most outcomes compared with inactive controls. Multicomponent behavioral therapy and stimulus control may improve some sleep outcomes. Evidence on other outcomes, comparisons, and long-term efficacy were limited.",0,0,
1501,Psychological treatments for posttraumatic stress disorder: recommendations for the clinician based on a review of the literature,"This article reviews available research data supporting the use of psychotherapy in the treatment of posttraumatic stress disorder (PTSD). The authors highlight how this evidence might inform clinical choices in treating PTSD, as well as demonstrating how assumptions based on gaps in the available literature may be misleading. The authors first discuss findings concerning a number of interventions that are commonly used in the treatment of trauma victims or patients with PTSD: critical incident stress debriefing, psychoeducation, exposure therapy, eye movement desensitization reprocessing, stress inoculation therapy, trauma management therapy, cognitive therapy, psychodynamic psychotherapy, and hypnotherapy. They also discuss a number of treatment strategies that have recently been studied in PTSD, including imagery rehearsal, memory structure intervention, interpersonal psychotherapy, and dialectical behavior therapy. PTSD is associated with significant symptomatic morbidity, although desired outcomes in clinical practice are typically related more to reduction in social, interpersonal, and occupational impairment. The most methodologically robust studies, which have typically examined cognitive or behavioral treatments, indicate that psychotherapy helps to relieve symptom severity"";"" however, there is no consistent information about whether these interventions are helpful in improving other domains of impairment and associated disability, even though these problems are often the greatest concern to patients. Nor does the available evidence indicate when, and for whom, various psychotherapeutic interventions should be provided, or whether different modalities of treatment can and should be combined, or sequentially offered, as is often done in specialized treatment programs. Clinicians should keep these issues in mind in reviewing the literature on current (and future) clinical research. Unfortunately, the current evidence base on psychotherapy for PTSD gives only limited guidance concerning clinical choices in managing PTSD. The authors therefore provide some clinical guidelines based on the literature for clinicians treating patients with PTSD.",0,0,
1502,Psychometric Analysis of the Three-Factor Eating Questionnaire-R18V2 in Adolescent and Young Adult-Aged Central Nervous System Tumor Survivors,"PURPOSE: Adolescent and young adult (AYA)-aged central nervous system (CNS) tumor survivors are an understudied population that is at risk of developing adverse health outcomes, such as obesity. Long-term follow-up guidelines recommend monitoring those at risk of obesity, thus motivating the need for an eating behavior questionnaire. An abbreviated online version of the Three-Factor Eating Questionnaire (TFEQ-R18v2) has been developed, but its applicability to this population is not yet known. This study investigated the instrument's factor structure and reliability in this population. METHODS: AYA-aged CNS tumor survivors (n = 114) aged 15-39 years completed the TFEQ-R18V2 questionnaire online. Confirmatory factor analysis was used to examine the fit of the three-factor structure (uncontrollable eating, cognitive restraint, and emotional eating [EE]) and reliability (internal consistency of the TFEQ-R18v2). Associations between the three factors and body mass index (BMI) were assessed by linear regression. RESULTS: The theorized three-factor structure was supported in our population (RMSEA = 0.056 and CFI = 0.98) and demonstrated good reliability (alpha of 0.81-0.93). EE (beta = 0.07, 95% CI 0.02-0.13) was positively associated with BMI, whereas the other two subscale scores were not. CONCLUSION: The TFEQ-R18v2 instrument holds promise for research and clinical use among AYA-aged CNS tumor survivors. The instrument may be a useful tool for researchers to develop tailored weight management strategies. It also may be a valuable tool for clinicians to monitor survivors who are at risk of obesity and to facilitate referral. Our results also suggest that EE in this population should be further investigated as a potential target for intervention.",0,0,
1503,Psychopharmacology in pregnancy,"Clinicians are confronted with challenging situations when working with women who are pregnant and have a co-existing mental illness. A risk benefit assessment is helpful when identifying possible care interventions. Psychopharmaceutical intervention is a consideration when nonpharmacological interventions are ineffective or inappropriate. Informed consent based on known and unknown risks to the mother and fetus should be obtained. Literature and case reports are contradictory and not conclusive about the risks of medications used for psychiatric illnesses. This article reviews the literature and provides clinical guidelines for antipsychotic medications, antidepressant medications, mood stabilizing medications, and antianxiety medications.",0,0,
1504,Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology,"A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.",0,0,
1505,Pulmonary oedema precipitated by nifedipine,,0,0,
1506,Putting evidence into practice: evidence-based interventions for sleep-wake disturbances,"Symptom management is a vital aspect of the practice of oncology nursing. The Oncology Nursing Society has identified outcomes sensitive to nursing intervention, known as nursing-sensitive patient outcomes. This article presents information about sleep-wake disturbances that occur in patients with cancer and makes recommendations for evidence-based interventions to improve sleep for patients. Sleep-wake disturbances occur in 30%-75% of people with cancer and have a negative impact on other symptoms and quality of life. Despite the frequency and severity of sleep-wake disturbances, limited research has tested interventions to improve sleep-wake outcomes. Although no interventions currently receive the highest recommendations for implementation into practice, several nonpharmacologic interventions show initial positive findings in promoting high-quality sleep and daytime functioning. Oncology nurses can screen for sleep-wake disturbances and suggest tailored interventions. Four categories of promising interventions are cognitive-behavioral therapy, complementary therapies, psychoeducation and information, and exercise. Clinicians can use the Putting Evidence Into Practice (PEP) card and PEP resources at www.ons.org/outcomes to improve sleep-wake outcomes.",0,0,
1507,Putting prevention into practice,"In primary medical care settings, disease prevention services are delivered at lower rates than recommended. Furthermore, practitioners tend to overestimate the rate at which they perform them. There are essentially two steps in delivering evidence-based preventive services: (1) knowing what the evidence is for performing various detection and intervention manoeuvres, and (2) integrating the preventive services into daily practice. The first is a scientific process and is carried out in Canada by the Canadian Task Force on the Periodic Health Examination. However, after a decade of experience with evidence-based guidelines, we now know that guidelines are not enough. Integrating clinical prevention into busy practices is a political and logistical process. This truth is best captured by the quip, ""An ounce of prevention requires a pound of office system change"". A number of studies have demonstrated that continuing medical education (CME) courses and workshops for physicians are not enough to ensure that clinical preventive services are incorporated into practice. According to Lomas, the traditional CME educational approaches need to be complemented by strategies from such paradigms as the social influence model, the diffusion of innovation model and the adult learning model. Battista, in ""From Science to Practice,"" points out the complexity of the communication process required for the diffusion of innovation into practice. Walsh's Systems Model of Clinical Preventive care best captures the interacting factors that mediate between practitioners' intentions and their actions when it comes to delivering clinical prevention services. This paper reports on a practical example of helping family practitioners develop a ""sustaining office system in prevention"" that minimizes barriers, focuses energy and integrates clinical prevention into office routines. The key components are (i) a practice coordinator for prevention, (ii) clear clinical prevention-related job descriptions for all persons who deal with patients, (iii) an information management system that reinforces prevention, and (iv) a practice feedback and problem solving strategy.",0,0,
1508,Qualitative data collection and analysis methods: the INSTINCT trial,"Patient care practices often lag behind current scientific evidence and professional guidelines. The failure of such knowledge translation (KT) efforts may reflect inadequate assessment and management of specific barriers confronting both physicians and patients at the point of treatment level. Effective KT in this setting may benefit from the use of qualitative methods to identify and overcome these barriers. Qualitative methodology allows in-depth exploration of the barriers involved in adopting practice change and has been infrequently used in emergency medicine research. The authors describe the methodology for qualitative analysis within the INcreasing Stroke Treatment through INteractive behavioral Change Tactics (INSTINCT) trial. This includes processes for valid data collection and reliable analysis of the textual data from focus group and interview transcripts. INSTINCT is a 24-hospital, randomized, controlled study that is designed to evaluate a system-based barrier assessment and interactive educational intervention to increase appropriate tissue plasminogen activator (tPA) use in ischemic stroke. Intervention hospitals undergo baseline barrier assessment using both qualitative as well as quantitative (survey) techniques. Investigators obtain data on local barriers to tPA use, as well as information on local attitudes, knowledge, and beliefs regarding acute stroke treatment. Targeted groups at each site include emergency physicians, emergency nurses, neurologists, radiologists, and hospital administrators. Transcript analysis using NVivo7 with a predefined barrier taxonomy is described. This will provide both qualitative insight on thrombolytic use and importance of specific barrier types for each site. The qualitative findings subsequently direct the form of professional education efforts and system interventions at treatment sites.",0,0,
1509,Qualitative research within trials: developing a standard operating procedure for a clinical trials unit,"BACKGROUND: Qualitative research methods are increasingly used within clinical trials to address broader research questions than can be addressed by quantitative methods alone. These methods enable health professionals, service users, and other stakeholders to contribute their views and experiences to evaluation of healthcare treatments, interventions, or policies, and influence the design of trials. Qualitative data often contribute information that is better able to reform policy or influence design. METHODS: Health services researchers, including trialists, clinicians, and qualitative researchers, worked collaboratively to develop a comprehensive portfolio of standard operating procedures (SOPs) for the West Wales Organisation for Rigorous Trials in Health (WWORTH), a clinical trials unit (CTU) at Swansea University, which has recently achieved registration with the UK Clinical Research Collaboration (UKCRC). Although the UKCRC requires a total of 25 SOPs from registered CTUs, WWORTH chose to add an additional qualitative-methods SOP (QM-SOP). RESULTS: The qualitative methods SOP (QM-SOP) defines good practice in designing and implementing qualitative components of trials, while allowing flexibility of approach and method. Its basic principles are that: qualitative researchers should be contributors from the start of trials with qualitative potential""; the qualitative component should have clear aims;"" and the main study publication should report on the qualitative component. CONCLUSIONS: We recommend that CTUs consider developing a QM-SOP to enhance the conduct of quantitative trials by adding qualitative data and analysis. We judge that this improves the value of quantitative trials, and contributes to the future development of multi-method trials.",0,0,
1510,Quality assessment in surgical care departments: proposal for a scoring system in terms of structure and process,"Objective To build a score able to reflect and rank surgical departments according to a definition of “quality” in terms of structure and process.  Methods Collaborative design of a quality score in the framework of the French clinical research project NosoQual. Feasibility and observational study in 46 surgical departments visited between November 2002 and March 2003 according to standardised procedures. A bibliographic review followed by expert consultations, a field test, analysis and a final reconsideration leading to the definition of a consensual score.  Results 138 variables comprised the score. They were classified into seven dimensions, each representing a different aspect of quality of care in surgery. According to the threshold and weight attributed to every variable, scores were calculated for each department. The average level of achievement of the scores varied from 42% to 71% of theoretical maxima. The variability of the scores related to the seven dimensions was larger and more significant than the one expressed by the overall score (coefficient of variation=0.1).  Conclusion This analytical work contributed to the design of a quality score for surgery. However, the progress of the score should continue to take into account all the obstacles that were observed and to meet the high requirements of the actual patient safety issue.",0,0,
1511,Quality improvement and changes in diabetic patient outcomes in an academic nurse practitioner primary care practice,"PURPOSE: To examine a set of system interventions in the management of patients with diabetes and the outcomes of their care. DATA SOURCES: Preintervention and postintervention data collected from electronic medical records. CONCLUSIONS: The sample size was smaller than expected, contributing to a lack of statistical significance from preintervention to postintervention in the patient outcome measures. The systems-level variables that were under the direct control of the clinic staff (e.g., pneumococcal vaccine given) showed great improvement. In the preintervention period, the percentage of ""yes"" responses to the system-level variables ranged from 8 to 24 and jumped to 16 to 95 after the intervention. IMPLICATIONS FOR PRACTICE: Unequivocally, this project demonstrated that systems-level changes result in improved care being provided to patients"";"" however, these had minimal impact on the patient outcome variables. Promoting change in patient behavior is difficult, which may have contributed to the lack of significance in this area, while the variables under the direct control of the clinic staff were more easily changed.",0,0,
1512,Quality improvement of medical records in a teaching hospital,"INTRODUCTION: The aim of this study was to evaluate the quality of the MR compilation in some Operative Units of the ""Azienda Ospedaliera Universitaria--II Universita di Napoli"" (AOU- SUN)-Italy, before and after an intervention of quality improvement, underlining the potential differences in the behaviour of different specialists (physicians vs. surgeons). METHODS: Two random samples of 660 MRs were reviewed. A four-step program was developed: (1) first assessment of the MR""; (2) implementation of the MR quality, sending a letter with the purpose of the study, the results obtained in the first step from that ward, the guidelines to correctly fill out the MR; (3) follow-up step four months later;"" (4) comparison of the data before and after the distribution of the guidelines using indicators of completeness of all sections of MR, clarity of handwriting and presence and clarity of signature. RESULTS: The main concerns were related to the signature of the duty physician (present in 2.0% and legible in only 15.4%), the presence of the letter of discharge (18.0%) and the clarity of the days of hospital stay (32.0%). After the intervention the improvement of the quality of compilation was modest and regarded mainly medical rather than surgical wards. DISCUSSION AND CONCLUSIONS: The improvement was not satisfying since from a medical and a legal point of view the indicators should reach 100% of clarity and completeness. A further study is being carried out to improve the involvement of health care professional, so that such requirements will be perceived as a common goal, not as mere bureaucratic initiatives.",0,0,
1513,"Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment","BackgroundMajor concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States."";"" BackgroundMajor concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States.",0,0,
1514,Quality of pharmaceutical advertisements in medical journals: a systematic review,"BACKGROUND: Journal advertising is one of the main sources of medicines information to doctors. Despite the availability of regulations and controls of drug promotion worldwide, information on medicines provided in journal advertising has been criticized in several studies for being of poor quality. However, no attempt has been made to systematically summarise this body of research. We designed this systematic review to assess all studies that have examined the quality of pharmaceutical advertisements for prescription products in medical and pharmacy journals. METHODS AND FINDINGS: Studies were identified via searching electronic databases, web library, search engine and reviewing citations (1950 - February 2006). Only articles published in English and examined the quality of information included in pharmaceutical advertisements for prescription products in medical or pharmacy journals were included. For each eligible article, a researcher independently extracted the data on the study methodology and outcomes. The data were then reviewed by a second researcher. Any disagreements were resolved by consensus. The data were analysed descriptively. The final analysis included 24 articles. The studies reviewed advertisements from 26 countries. The number of journals surveyed in each study ranged from four to 24 journals. Several outcome measures were examined including references and claims provided in advertisements, availability of product information, adherence to codes or guidelines and presentation of risk results. The majority of studies employed a convenience-sampling method. Brand name, generic name and indications were usually provided. Journal articles were commonly cited to support pharmaceutical claims. Less than 67% of the claims were supported by a systematic review, a meta-analysis or a randomised control trial. Studies that assessed misleading claims had at least one advertisement with a misleading claim. Two studies found that less than 28% of claims were unambiguous clinical claims. Most advertisements with quantitative information provided risk results as relative risk reduction. Studies were conducted in 26 countries only and then the generalizability of the results is limited. CONCLUSIONS: Evidence from this review indicates that low quality of journal advertising is a global issue. As information provided in journal advertising has the potential to change doctors' prescribing behaviour, ongoing efforts to increase education about drug promotion are crucial. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines.",0,0,
1515,Quantitative comparison of cognitive behavioral therapy and music therapy research: a methodological best-practices analysis to guide future investigation for adult psychiatric patients,"While the music therapy profession is relatively young and small in size, it can treat a variety of clinical populations and has established a diverse research base. However, although the profession originated working with persons diagnosed with mental illnesses, there is a considerable lack of quantitative research concerning the effects of music therapy with this population. Music therapy clinicians and researchers have reported on this lack of evidence and the difficulty in conducting psychosocial research on their interventions (Choi, 1997"";"" Silverman, 2003a). While published studies have provided suggestions for future research, no studies have provided detailed propositions for the methodology and design of meticulous high quality randomized controlled psychiatric music therapy research. How do other psychotherapies accomplish their databases and could the music therapy field borrow from their rigorous ""methodological best practices"" to strengthen its own literature base? Therefore, as the National Institutes of Mental Health state the treatment of choice for evidence-based psychotherapy is cognitive behavioral therapy (CBT), aspects of this psychotherapy's literature base were analyzed. The purpose of this literature analysis was to (a) analyze and identify components of high-quality quantitative CBT research for adult psychiatric consumers, (b) analyze and identify the variables and other elements of existing quantitative psychiatric music therapy research for adult consumers, and (c) compare the two data sets to identify the best methodological designs and variables for future quantitative music therapy research with the mental health population. A table analyzing randomized and thoroughly controlled studies involving the use of CBT for persons with severe mental illnesses is included to determine chief components of high-quality experimental research designs and implementation of quantitative clinical research. The table also shows the same analyzed components for existing quantitative psychiatric music therapy research with adult consumers, thus highlighting potential areas and elements for future investigations. A second table depicts a number of potential dependent measures and their sources to be evaluated in future music therapy studies. A third table providing suggestions for future research is derived from a synthesis of the tables and is included to guide researchers and encourage the advancement and expansion of the current literature base. The body of the paper is a discussion of the results of the literature analysis derived from the tables, meta-analyses, and reviews of literature. It is hoped that this report will lead to the addition of future high-quality quantitative research to the psychiatric music therapy literature base and thus provide evidence-based services to as many persons with mental illnesses as possible.",0,0,
1516,Quest for quality care and patient safety: the case of Singapore,"Quality of care in Singapore has seen a paradigm shift from a traditional focus on structural approaches to a broader multidimensional concept which includes the monitoring of clinical indicators and medical errors. Strong political commitment and institutional capacities have been important factors for making the transition. What is still lacking, however, is a culture of rigorous programme evaluation, public involvement, and patient empowerment. Despite these imperfections, Singapore has made considerable strides and its experience may hold lessons for other small developing countries in the common quest for quality care and patient safety.",0,0,
1517,Quetiapine augmentation for depression: dosing pattern in routine practice,"This study investigated the dosing patterns of quetiapine augmentation (QA) for major depressive disorder (MDD) in routine practice. Between 1 January 2009 and 31 May 2013, patients with a diagnosis of MDD who were receiving QA in conjunction with an ongoing antidepressant were recruited into this study. The electronic medical records and clinical data for a total of 977 patients were reviewed up to a year. Almost half the patients maintained QA treatment for more than 3 months. The mean duration of QA was approximately 6 months, and the mean initial and maintenance doses were 23.6 and 40.7 mg/day, respectively (range=12.5-400 mg/day). The most frequent adverse events observed were somnolence, followed by dry mouth and lethargy. Our results indicate that the actual doses of QA for MDD in routine practice should be lower than the doses used in placebo-controlled clinical trials and those recommended by a regulatory agency. Adequately powered and well-controlled prospective studies are needed to better understand the exact role of low doses of QA in the treatment of MDD, particularly in routine practice.",0,0,
1518,Randomised controlled trial of a complex intervention by primary care nurses to increase walking in patients aged 60-74 years: protocol of the PACE-Lift (Pedometer Accelerometer Consultation Evaluation - Lift) trial,"BACKGROUND: Physical activity is essential for older peoples' physical and mental health and for maintaining independence. Guidelines recommend at least 150 minutes weekly, of at least moderate intensity physical activity, with activity on most days. Older people's most common physical activity is walking, light intensity if strolling, moderate if brisker. Less than 20% of United Kingdom 65-74 year olds report achieving the guidelines, despite most being able to. Effective behaviour change techniques include strategies such as goal setting, self-monitoring, building self-efficacy and relapse prevention. Primary care physical activity consultations allow individual tailoring of advice. Pedometers measure step-counts and accelerometers measure physical activity intensity. This protocol describes an innovative intervention to increase walking in older people, incorporating pedometer and accelerometer feedback within a primary care nurse physical activity consultation, using behaviour change techniques. METHODS/DESIGN: DESIGN: Randomised controlled trial with intervention and control (usual care) arms plus process and qualitative evaluations. PARTICIPANTS: 300 people aged 60-74 years registered with 3 general practices within Oxfordshire and Berkshire West primary care trusts, able to walk outside and with no restrictions to increasing their physical activity. INTERVENTION: 3 month pedometer and accelerometer based intervention supported by practice nurse physical activity consultations. Four consultations based on behaviour change techniques, physical activity diary, pedometer average daily steps and accelerometer feedback on physical activity intensity. Individual physical activity plans based on increasing walking and other existing physical activity will be produced. OUTCOMES: Change in average daily steps (primary outcome) and average time spent in at least moderate intensity physical activity weekly (secondary outcome) at 3 months and 12 months, assessed by accelerometry. Other outcomes include quality of life, mood, exercise self-efficacy, injuries. Qualitative evaluations will explore reasons for trial non-participation, the intervention's acceptability to patients and nurses and factors enhancing or acting as barriers for older people in increasing their physical activity levels. DISCUSSION: The PACE-Lift trial will determine the feasibility and efficacy of an intervention for increasing physical activity among older primary care patients. Steps taken to minimise bias and the challenges anticipated will be discussed. Word count 341. TRIAL REGISTRATION NUMBER: ISRCTN42122561.",0,0,
1519,"Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain","OBJECTIVE To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain. DESIGN Factorial randomised trial. SETTING 64 general practices in England. PARTICIPANTS 579 patients with chronic or recurrent low back pain""; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons;"" half of each of these groups were randomised to exercise prescription. INTERVENTIONS Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling. MAIN OUTCOME MEASURES Roland Morris disability score (number of activities impaired by pain) and number of days in pain. RESULTS Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage -0.58, 95% confidence interval -1.94 to 0.77, six lessons -1.40, -2.77 to -0.03, 24 lessons -3.4, -4.76 to -2.03, and exercise -1.29, -2.25 to -0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score -2.98 and -4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons -18, six lessons -10, massage -7) and quality of life improved significantly. No significant harms were reported. CONCLUSIONS One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons. TRIAL REGISTRATION National Research Register N0028108728.",0,0,
1520,"Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation","OBJECTIVE An economic evaluation of therapeutic massage, exercise, and lessons in the Alexander technique for treating persistent back pain. DESIGN Cost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial randomised controlled trial. PARTICIPANTS 579 patients with chronic or recurrent low back pain recruited from primary care. INTERVENTIONS Normal care (control), massage, and six or 24 lessons in the Alexander technique. Half of each group were randomised to a prescription for exercise from a doctor plus behavioural counselling from a nurse. MAIN OUTCOME MEASURES Costs to the NHS and to participants. Comparison of costs with Roland-Morris disability score (number of activities impaired by pain), days in pain, and quality adjusted life years (QALYs). Comparison of NHS costs with QALY gain, using incremental cost effectiveness ratios and cost effectiveness acceptability curves. RESULTS Intervention costs ranged from pound30 for exercise prescription to pound596 for 24 lessons in Alexander technique plus exercise. Cost of health services ranged from pound50 for 24 lessons in Alexander technique to pound124 for exercise. Incremental cost effectiveness analysis of single therapies showed that exercise offered best value ( pound61 per point on disability score, pound9 per additional pain-free day, pound2847 per QALY gain). For two-stage therapy, six lessons in Alexander technique combined with exercise was the best value (additional pound64 per point on disability score, pound43 per additional pain-free day, pound5332 per QALY gain). CONCLUSIONS An exercise prescription and six lessons in Alexander technique alone were both more than 85% likely to be cost effective at values above pound20 000 per QALY, but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique lessons followed by exercise was the most effective and cost effective option.",0,0,
1521,Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life,"OBJECTIVE To evaluate the effectiveness of an integrated care programme, combining a patient directed and a workplace directed intervention, for patients with chronic low back pain. DESIGN Population based randomised controlled trial. SETTING Primary care (10 physiotherapy practices, one occupational health service, one occupational therapy practice) and secondary care (five hospitals). PARTICIPANTS 134 adults aged 18-65 sick listed for at least 12 weeks owing to low back pain. INTERVENTION Patients were randomly assigned to usual care (n=68) or integrated care (n=66). Integrated care consisted of a workplace intervention based on participatory ergonomics, involving a supervisor, and a graded activity programme based on cognitive behavioural principles. MAIN OUTCOME MEASURES The primary outcome was the duration of time off work (work disability) due to low back pain until full sustainable return to work. Secondary outcome measures were intensity of pain and functional status. RESULTS The median duration until sustainable return to work was 88 days in the integrated care group compared with 208 days in the usual care group (P=0.003). Integrated care was effective on return to work (hazard ratio 1.9, 95% confidence interval 1.2 to 2.8, P=0.004). After 12 months, patients in the integrated care group improved significantly more on functional status compared with patients in the usual care group (P=0.01). Improvement of pain between the groups did not differ significantly. CONCLUSION The integrated care programme substantially reduced disability due to chronic low back pain in private and working life. Trial registration Current Controlled Trials ISRCTN28478651.",0,0,
1522,Randomised controlled trial of tailored strategies to implement guidelines for the management of patients with depression in general practice,"BACKGROUND: Various methods are available for implementing change in the clinical behaviour of general practitioners (GPs). Although passive dissemination of information is generally ineffective, other methods can be variably effective. Few studies have investigated the impact of tailored methods. AIM: To determine whether methods tailored to overcome obstacles to change using psychological theories are more effective than dissemination alone in the implementation of guidelines for depression among GPs. DESIGN OF STUDY: Randomised controlled trial. SETTING: Sixty general practices in England""; 30 GPs in the control group, 34 in the intervention group. METHOD: Practitioners identified patients presenting with depression before and after the implementation of guidelines (control group n = 192 in the first data collection, n = 181 in the second; intervention group n = 210 in the first data collection and n = 197 in the second). The main outcome measures were: record of adherence to guideline recommendations in clinical records;"" proportion of patients with Beck Depression Inventory (BDI) score less than 11 at 16 weeks after diagnosis. RESULTS: In comparison with the control group, in the group of GPs receiving tailored implementation, there were increases in the proportions of patients assessed for suicide risk. In the intervention group, the proportion of patients with BDI scores of less than 11 at 16 weeks increased. CONCLUSION: Obstacles to implementation can be identified and strategies tailored to address them. The findings indicate a new approach for research to understand and develop methods of implementation.",0,1,
1523,Randomised controlled trial to change the hospital management of unstable angina,"OBJECTIVES: To examine the benefits of a guideline-based educational program to improve management of unstable angina pectoris (UAP) in hospital patients. DESIGN: Randomised controlled trial. SETTING: 37 public hospitals across New South Wales. PATIENTS: 1,872 patients admitted with a diagnosis of UAP between 1 February and 30 June 1996 (baseline survey), and 1,368 patients with the same diagnosis admitted between 1 July and 31 December 1998 (follow-up survey). INTERVENTION: Educational sessions run by local opinion leaders, presenting guidelines on management of UAP from the National Health and Medical Research Council and feedback on local practice using data from the baseline survey. Sessions were run between March and June 1998. MAIN OUTCOME MEASURES: Use of evidence-based practice, identified by review of medical records. RESULTS: Use of beta-blockers increased in intervention and control hospitals, although the increase was significant only in the former. Use of calcium-channel blockers decreased significantly in both intervention and control hospitals. However, the change in drug use between baseline and follow-up did not differ significantly between intervention and control hospitals. CONCLUSIONS: Despite some appropriate changes in drug use for UAP management between 1996 and 1998, there was no evidence that a guideline-based educational program was of benefit in changing management. This reaffirms the difficulty of changing doctors' behaviour through practice guidelines. Alternative methods of encouraging evidence-based practice should be considered.",0,0,
1524,Randomised trial of an integrated educational strategy to reduce investigation rates in young women with dysfunctional uterine bleeding,"OBJECTIVES: To assess the effectiveness of an integrated educational strategy to change clinician behaviour and reduce the number of hysteroscopies and/or dilatation and curettages for women 40 years or less with dysfunctional uterine bleeding (DUB). DESIGN: Randomised controlled trial with six-month follow-up. SETTING: Public teaching hospital gynaecology units with 12,000-13,000 relevant procedures per year. PARTICIPANTS: Six public gynaecology units made up of 62 gynaecologists or trainees allocated at random to intervention group - three, or control group - 3. Intervention An educational strategy that included dissemination of evidence-based guidelines via a problem-based interactive workshop facilitated by an opinion leader and a laminated algorithm and guidelines. MAIN OUTCOME MEASURES: The number of hysteroscopies and/or dilatation and curettages performed for DUB on women 40 years or less, clinician behaviour change and perceived booking rates of the procedure. RESULTS: At six months, there was no significant effect on the number of hysteroscopies and/or dilatation and curettages performed but there was an increase in evidence-based behaviour. CONCLUSIONS: While the evidence-based educational strategy for the appropriate investigation of young women with DUB resulted in clinician behaviour change when applied to theoretical cases, it did not result in a reduction in hysteroscopy/D&C rates at six months.",0,0,
1525,Randomized clinical trial of a customized electronic alert requiring an affirmative response compared to a control group receiving a commercial passive CPOE alert: NSAID—warfarin co-prescribing as a test case.,"Background Studies that have looked at the effectiveness of computerized decision support systems to prevent drug–drug interactions have reported modest results because of low response by the providers to the automated alerts.  Objective To evaluate, within an inpatient computerized physician order entry (CPOE) system, the incremental effectiveness of an alert that required a response from the provider, intended as a stronger intervention to prevent concurrent orders of warfarin and non-steroidal anti-inflammatory drugs (NSAIDs).  Design Randomized clinical trial of 1963 clinicians assigned to either an intervention group receiving a customized electronic alert requiring affirmative response or a control group receiving a commercially available passive alert as part of the CPOE. The study duration was 2 August 2006 to 15 December 2007.  Measurements Alert adherence was compared between study groups.  Results The proportion of desired ordering responses (ie, not reordering the alert-triggering drug after firing) was lower in the intervention group (114/464 (25%) customized alerts issued) than in the control group (154/560 (28%) passive alerts firing). The adjusted OR of inappropriate ordering was 1.22 (95% CI 0.69 to 2.16).  Conclusion A customized CPOE alert that required a provider response had no effect in reducing concomitant prescribing of NSAIDs and warfarin beyond that of the commercially available passive alert received by the control group. New CPOE alerts cannot be assumed to be effective in improving prescribing, and need evaluation.",1,1,
1526,Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer,"PURPOSE: Persistent insomnia is a common complaint in cancer survivors, but is seldom satisfactorily addressed. The adaptation to cancer care of a validated, cost-effective intervention may offer a practicable solution. The aim of this study was to investigate the clinical effectiveness of protocol-driven cognitive behavior therapy (CBT) for insomnia, delivered by oncology nurses. PATIENTS AND METHODS: Randomized, controlled, pragmatic, two-center trial of CBT versus treatment as usual (TAU) in 150 patients (103 females""; mean age, 61 years.) who had completed active therapy for breast, prostate, colorectal, or gynecological cancer. The study conformed to CONSORT guidelines. Primary outcomes were sleep diary measures at baseline, post-treatment, and 6-month follow-up. Actigraphic sleep, health-related quality of life (QOL), psychopathology, and fatigue were secondary measures. CBT comprised five, small group sessions across consecutive weeks, after a manualized protocol. TAU represented normal clinical practice;"" the appropriate control for a clinical effectiveness study. RESULTS: CBT was associated with mean reductions in wakefulness of 55 minutes per night compared with no change in TAU. These outcomes were sustained 6 months after treatment. Standardized relative effect sizes were large for complaints of difficulty initiating sleep, waking from sleep during the night, and for sleep efficiency (percentage of time in bed spent asleep). CBT was associated with moderate to large effect sizes for five of seven QOL outcomes, including significant reduction in daytime fatigue. There was no significant interaction effect between any of these outcomes and baseline demographic, clinical, or sleep characteristics. CONCLUSION: CBT for insomnia may be both clinically effective and feasible to deliver in real world practice.",0,0,
1527,Randomized controlled trial of a computer strategy to increase general practitioner preventive care,"BACKGROUND: Previous interventions targeting primary care practitioners with the aim of increasing preventive care delivery have demonstrated limited effectiveness. The primary aim of this study was to assess the effectiveness of a computerized continuing medical education program to increase rates of three screening behaviors (cholesterol, blood pressure, and cervical screening) and to identify three risk behaviors (smoking, alcohol consumption, benzodiazepine use) in general practice. METHODS: Nineteen general practitioners were randomly allocated to intervention or control conditions. Those given the intervention received a computerized feedback system. The intervention was delivered using a touch-screen computer located in the surgery waiting area. The preventive behaviors of interest were patient smoking, alcohol use, benzodiazepine use, and blood pressure, cholesterol and cervical screening using the Papanicolou test. Differences in performance by group in each of the outcomes was measured at baseline and 3-month follow-up. Logistic regression analyses with generalized estimating equations were conducted as the main analyses. RESULT: At 3-month follow-up, statistically significant differences were evident in the following outcome measures: accurate classification of benzodiazepine users (z = 2.8540, P < 0.05)""; accurate classification of non-benzodiazepine users (z = 2.7339, P < 0.05); accurate classification of hazardous or harmful alcohol drinkers (z = 2.3079, P < 0.02); blood pressure screening (z = 3.4136, P < 0.001);"" and cholesterol screening (z = 6.6313, P < 0.001). CONCLUSION: A computerized system of performance-specific feedback was effective at increasing some preventive care services in general practice.",0,1,
1528,Randomized controlled trial of a computer-tailored multiple health behaviour intervention in general practice: 12-month follow-up results,"BACKGROUND: Effective strategies to address risk factors of non-communicable diseases are required to curtail the expanding costs of health care. This trial tested the effectiveness over one year of a minimal intervention targeting multiple health behaviours (diet, physical activity, alcohol and smoking) in a general practice setting, through the provision of personalised, computer-tailored feedback. METHODS: Patients who had attended a general practice in the previous 6 months were recruited from 21 general practitioners in Brisbane, Australia. Baseline data were collected using self-reports on adherence to ten health behaviours and summarised into a health score from 0 to 10. This randomised controlled trial used a 2x2 factorial design, with one arm randomising subjects to the intervention or control group. The other arm was either feedback at baseline (single contact) or an additional assessment with feedback at 3 months (dual contact). As such, 4 study groups created were, to which participants were randomised blindly: A. Intervention with single contact""; B. Intervention with dual contact; C. Control with single contact and D. Control with dual contact. All participants were assessed again at 12 months. RESULTS: Of the 4676 participants randomised, 3065 completed questionnaires at 12 months. Both single and dual contact groups improved their 10 item health scores (+0.31 and +0.49 respectively) relative to control group outcomes (+0.02; p<0.01). Improvement in adherence to guidelines for fish intake, type of milk consumed, vegetable and fruit intake, and alcohol intake were observed in single and dual contact intervention groups (p<0.01). Both intervention groups showed greater improvement than controls for individual health behaviours, apart from red meat intake, smoking behaviour, physical activity and body weight. Interestingly, there was an improvement in reported non-smoking rates in both intervention and control groups (3% single contact;"" 4.5% dual contact). CONCLUSIONS: Small but meaningful long-term changes in health behaviours can be achieved with a low-intensity intervention, which may reduce health care costs if implemented on a large scale. Further research is needed to better understand the mechanism by which maintenance of behaviour change can be achieved. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry: ACTRN12611001213932.",0,0,
1529,Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain,"OBJECTIVE: The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain. DESIGN: Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation. PARTICIPANTS: Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices. INTERVENTIONS: Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain. MAIN RESULTS: The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P =.04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior. CONCLUSIONS: Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings.",0,0,
1530,Randomized controlled trial on cardiovascular risk management by practice nurses supported by self-monitoring in primary care,"UNLABELLED: BACKGROUND: Treatment goals for cardiovascular risk management are generally not achieved. Specialized practice nurses are increasingly facilitating the work of general practitioners and self-monitoring devices have been developed as counseling aid. The aim of this study was to compare standard treatment supported by self-monitoring with standard treatment without self-monitoring, both conducted by practice nurses, on cardiovascular risk and separate risk factors. METHODS: Men aged 50-75 years and women aged 55-75 years without a history of cardiovascular disease or diabetes, but with a SCORE 10-year risk of cardiovascular mortality >/= 5% and at least one treatable risk factor (smoking, hypertension, lack of physical activity or overweight), were randomized into two groups. The control group received standard treatment according to guidelines, the intervention group additionally received pro-active counseling and self-monitoring (pedometer, weighing scale and/ or blood pressure device). After one year treatment effect on 179 participants was analyzed. RESULTS: SCORE risk assessment decreased 1.6% (95% CI 1.0-2.2) for the control group and 1.8% (1.2-2.4) for the intervention group, difference between groups was .2% (-.6-1.1). Most risk factors tended to improve in both groups. The number of visits was higher and visits took more time in the intervention group (4.9 (SD2.2) vs. 2.6 (SD1.5) visits p< .001 and 27 (P25 -P75:20-33) vs. 23 (P25 -P75:19-30) minutes/visit p= .048). CONCLUSIONS: In both groups cardiovascular risk decreased significantly after one year of treatment by practice nurses. No additional effect of basing the pro-active counseling on self-monitoring was found, despite the extra time investment. TRIAL REGISTRATION: trialregister.nl NTR2188.",0,0,
1531,Randomized controlled trial to assess the effectiveness of a primary health care liaison worker in promoting shared care for opiate users,"BACKGROUND: Recent national guidelines emphasize the requirement for all general practitioners to manage drug users within a shared care scheme and suggest that a primary health care liaison worker (PHCLW) may facilitate these arrangements. We undertook a group-randomized, randomized controlled trial to determine the effectiveness of a PHCLW in promoting shared care. METHODS: Primary health care teams in Stockport Health Authority, North West England, were randomly allocated to either an intervention arm, who were offered the services of a PHCLW, or to a control arm, who were offered standard support from the community drug team (CDT). The proportion of CDT clients with a history of regular opiate misuse who were in shared care 12 months after randomization was compared across study arms. RESULTS: Eighteen (24.0 per cent) of the 75 CDT clients in the intervention arm but none of the 80 CDT clients in the control arm were in shared care at 12 months (chi2 = 9.37, df = 1, p < 0.01"";"" 95 per cent confidence interval 8.6-39.4 per cent). CONCLUSION: A PHCLW can significantly increase the number of CDT clients in shared care arrangements.",0,0,
1532,Randomized controlled trial: effect of nutritional counselling in general practice,"OBJECTIVES: To investigate the effectiveness of a non-structured 15-min educational intervention by general practitioners (GPs) on modifications of daily diet among healthy adults. DESIGN: Two arms randomized trial lasting 12 months. SETTING: Italian general practitioner wards. Subjects A total of 3,186 men and women aged 18-65 years recruited in the medical ward by their GPs. INTERVENTIONS: An educational intervention and a brochure on the basics of a healthy diet based on the Italian Guidelines for a Correct Nutrition, 1998. The main study goal was to attain an intake of fruits and vegetables >5 servings per day. Follow-up visit every 6 months. Main outcome measures Weight, blood pressure, and a 40-items Food Frequency Questionnaire. RESULTS: The intervention group showed a slightly reduced net intake of meat and a slightly increased net intake of fruits and vegetables, fish products, and olive oil. Body mass index (BMI) changed only in the treatment arm [-0.41 95% confidence interval (95% CI) -0.11 to -0.53]. The net change at 1 year in the intervention arm was +1.31 (CI 0.90-4.39) for fruits and vegetables, and -0.22 (-0.11 to -0.69) for meat (portions per week). We also computed a 'healthy diet score' reflecting compliance with recommended dietary habits. In the intervention group, the mean score at recruitment was significantly lower than the mean score at the end of follow-up (Crude score change = 0.29""; CI 0.19-0.48). No differences were observed in the control group (Crude score change = -0.04;"" CI -0.22-0.02). The difference in score from baseline to the final visit, comparing the intervention vs the control group, was statistically significant (P < 0.001) (MANOVA adjusted by sex, BMI, education, and time). CONCLUSIONS: A brief educational intervention by GPs can induce multiple diet changes that may lower BMI and potentially reduce chronic disease risk in generally healthy adults.",0,0,
1533,Randomized study of online vaccine reminders in adult primary care,"Online immunization reminders were implemented in an adult medicine setting in which all immunization history, vaccine ordering and charting were required online. Physicians were randomized to one of two arms in a cross-over design. Each arm was shown online recommendations for vaccines indicated by nationally accepted guidelines either during the first or during the second part of the study period. The main purpose of the study was to assess the impact of reminders on correct decisions related to prescribing vaccines. Online reminders had the following impact on physician behavior: 1) Physicians used the application almost 3 times as often when shown reminders. 2) Physicians in the reminder group were 27% less likely to order a vaccine in the reminder group (P- value 0.0005). 3) Compliance with guidelines was improved significantly for Tetanus and for Hepatitis B in several analyses. No such effects were found for Pneumoccocal, Measles, or Influenza vaccines.",1,1,
1534,Randomized trial of a clinical decision support system: impact on the management of children with fever without apparent source.,"Objective: To assess compliance with a clinical decision support system (CDSS) for diagnostic management of children with fever without apparent source and to study the effects of application of the CDSS on time spent in the emergency department (ED) and number of laboratory tests. Design: The CDSS was used by ED nursing staff to register children presenting with fever. The CDSS identified children that met inclusion criteria (1–36 months and fever without apparent source (FWS)) and provided patientspecific diagnostic management advice. Children at high risk for serious bacterial infection were randomized for the ‘intervention’ (n 
 74) or the ‘control’ (n 
 90) group. In the intervention group, the CDSS provided the advice to immediately order laboratory tests and in the control group the ED physician first assessed the children and then decided on ordering laboratory tests. Results: Compliance with registration of febrile children was 50% (683/1,399). Adherence to the advice to order laboratory tests was 82% (61/74). Children in the intervention group had a median (25th–75th percentile) length of stay at the ED of 138 (104 –181) minutes. The median length of stay at the ED in the control group was 123 (83–179) minutes. Laboratory tests were significantly more frequently ordered in the intervention group (82%) than in the control group (44%, p  0.001, 
2 test). Conclusion: Implementation of a CDSS for diagnostic management of young children with fever without apparent source was successful regarding compliance and adherence to CDSS recommendations, but had unexpected effects on patient outcome in terms of ED length of stay and number of laboratory tests. The use of the current CDSS was discontinued.",1,1,
1535,Randomized trial of model predictive control for improved anemia management,"Background and objectives: Variable hemoglobin (Hb) response to erythropoiesis stimulating agents may result in adverse outcomes. The utility of model predictive control for drug dosing was previously demonstrated.  Design, setting, participants, & measurements: This was a double-blinded, randomized, controlled trial to test model predictive control for dosing erythropoietin in ESRD patients. The trial included 60 hemodialysis patients who were randomized into a treatment arm (30 subjects) that received erythropoietin doses on the basis of the computer recommendations or a control arm (30 subjects) that received erythropoietin doses on the basis of recommendations from a standard anemia management protocol (control). The subjects were followed for 8 months, and the proportions of measured Hb within the target of 11 to 12 g/dl and outside 9 to 13 g/dl were measured. Variability of the Hb level was measured by the absolute difference between the achieved Hb and the target Hb of 11.5 g/dl as well as the area under the Hb curve.  Results: Model predictive control resulted in 15 observations >13 or <9 g/dl (outliers), a mean absolute difference between achieved Hb and 11.5 g/dl of 0.98 ± 0.08 g/dl, and an area under the Hb curve of 2.86 ± 1.46. The control group algorithm resulted in 30 Hb outliers (P = 0.051), produced a mean absolute difference between achieved Hb and 11.5 g/dl of 1.18 ± 0.18 g/dl (P < 0.001 difference in variance), and an area under the Hb curve of 3.38 ± 2.69 (P = 0.025 difference in variance).  Conclusions: Model predictive control of erythropoietin administration improves anemia management.",0,1,
1536,Randomized trial of problem-based versus didactic seminars for disseminating evidence-based guidelines on asthma management to primary care physicians,"INTRODUCTION: This randomized controlled trial (RCT) investigated the effectiveness of and satisfaction with small-group problem-based learning (PBL) versus a didactic lecture approach to guideline dissemination in asthma management controlling for confounders common in comparative educational interventions. METHODS: Sites were selected as either lecture or PBL using simple randomization. All participants were exposed to similar educational resources to ensure treatment equivalency. Instruments included standardized program/speaker evaluation forms and a validated case-based questionnaire with a visual analogue scale measuring the level of confidence of responses. The latter was presented immediately pre- and post-intervention and 3 months later. The statistician was blinded to intervention groups. RESULTS: Overall, 52 family physicians agreed to participate, 23 in the PBL sessions (mean 4.6 per group) and 29 in the didactic lecture sessions (mean 7.25). There was no significant difference between the groups with respect to the knowledge gained at each test administration. Participants rated the lecturer or facilitator equally well as having established a positive learning environment. PBL participants rated the perceived educational value of the program higher than did lecture participants (4.36 vs. 3.93"";"" p = .04). Both groups experienced a significant increase in asthma-related knowledge post-intervention. Attrition rates for the 3-month post-test were 14% for PBL participants versus 32% for lecture-based participants. DISCUSSION: PBL was as effective in knowledge uptake and retention as lecture-based continuing medical education (CME) programs. Further study is warranted to investigate whether the assessment of higher educational value or an increase in response rate to delayed testing is replicable in other RCTs addressing common confounders and if these factors influence future CME participation, changes in physician clinical behavior, or patient health outcomes.",0,0,
1537,Randomized trial to improve prescribing safety in ambulatory elderly patients.,"OBJECTIVES: To determine whether a computerized tool that alerted pharmacists when patients aged 65 and older were newly prescribed potentially inappropriate medications was effective in decreasing the proportion of patients dispensed these medications.  DESIGN: Prospective, randomized trial.  SETTING: U.S. health maintenance organization.  PARTICIPANTS: All 59,680 health plan members aged 65 and older were randomized to intervention (n=29,840) or usual care (n=29,840). Pharmacists received alerts on all patients randomized to intervention who were newly prescribed a targeted medication.  INTERVENTION: Prescription and age information were linked to alert pharmacists when a patient aged 65 and older was newly prescribed one of 11 medications that are potentially inappropriate in older people.  MEASUREMENTS: Physicians and pharmacists collaborated to develop the targeted medication list, indications for medication use for which an intervention should occur, intervention guidelines and scripts, and to implement the intervention.  RESULTS: Over the 1-year study, 543 (1.8%) intervention group patients aged 65 and older were newly dispensed prescriptions for targeted medications, compared with 644 (2.2%) usual care group patients (P=.002). For medication use indications in which an intervention should occur, dispensings of amitriptyline (P<.001) and diazepam (P=.02) were reduced.  CONCLUSIONS: This study demonstrated the effectiveness of a computerized pharmacy alert system plus collaboration between healthcare professionals in decreasing potentially inappropriate medication dispensings in elderly patients. Coupling data available from information systems with the knowledge and skills of physicians and pharmacists can improve prescribing safety in patients aged 65 and older.",1,1,
1538,"Randomized, controlled trial of the effectiveness of simulation education: A 24-month follow-up study in a clinical setting","BACKGROUND: Critical care nurses' knowledge and skills in adhering to evidence-based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited. We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses. MATERIAL AND METHODS: A randomized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finland during the period February 2012-March 2014. Thirty out of 40 initially randomized critical care nurses participated in a 24-month follow-up study. Behavior and cognitive development was evaluated through a validated Ventilator Bundle Observation Schedule and Questionnaire at the baseline measurement and repeated 3 times during simulation and real-life clinic settings. RESULTS: After simulation education, the average skills score increased from 46.8%-58.8% of the total score in the final postintervention measurement (Ptime < .001, Ptime x group = .040, and Pgroup = .11). The average knowledge scores within groups did not change significantly. The average between-group difference in skills scores was significant only at the measurement taken at 6 months (P = .006). CONCLUSIONS: Critical care nurses' skills in adhering to evidence-based guidelines improved in both groups over time, but the improvements between the study groups was significantly different only at 6 months and was no longer evident after 2 years following a single simulation education.",0,0,
1539,Rapid change in prescribing behavior in hospitals participating in get with the guidelines-stroke after release of the management of atherothrombosis with clopidogrel in high-risk patients (MATCH) clinical trial results,"BACKGROUND AND PURPOSE: Physician prescribing patterns change slowly despite published randomized trials and consensus guidelines. We measure the effect of Management of Atherothrombosis With Clopidogrel in High-Risk Patients (MATCH) trial on discharge prescribing patterns for patients with stroke and those with transient ischemic attack in the Get With The Guidelines (GWTG)-Stroke Program. METHODS: We analyzed discharge prescribing patterns of antithrombotic medications for patients admitted with ischemic stroke or transient ischemic attack at hospitals participating in GWTG-Stroke between October 2002 to January 2006. Clinical information by quarter was analyzed in relation to publication of the MATCH study. Frequency of discharge prescription of aspirin+clopidogrel post-MATCH publication was compared with the pre-MATCH period after adjusting for patient and hospital characteristics and clustering by hospital. RESULTS: A total of 107 872 patients at 632 sites were eligible to receive antithrombotic therapy at discharge. Use of aspirin+clopidogrel therapy declined from 22.4% to 15.4% of patients after the publication of MATCH (adjusted OR 0.62, 95% CI 0.56 to 0.70, P<0.0001). Analysis by quarter revealed a rapid and sustained decrease in use of aspirin+clopidogrel therapy for the remainder of the study period. CONCLUSIONS: A rapid and sustained reduction in the frequency of aspirin+clopidogrel use in ischemic stroke and transient ischemic attack was observed after publication of the MATCH trial in the absence of MATCH-specific GWTG-Stroke initiatives and preceding an American Heart Association guideline update.",0,0,
1540,Rational prescribing in primary care (RaPP): economic evaluation of an intervention to improve professional practice.,"Background Interventions designed to narrow the gap between research findings and clinical practice may be effective, but also costly. Economic evaluations are necessary to judge whether such interventions are worth the effort. We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs. The tailored intervention was evaluated in a randomized trial, and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication, but had little or no impact on other outcomes. The increased use of thiazides was not expected to have an impact on health outcomes.  Methods and Findings We performed cost-minimization and cost-effectiveness analyses on data from a randomized trial involving 146 general practices from two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices""; 257 physicians) or control group (69 practices;"" 244 physicians). Only patients that were being started on antihypertensive medication were included in the analyses. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders. Pharmacists conducted the visits. A cost-minimization framework was adopted, where the costs of intervention were set against the reduced treatment costs (principally due to increased use of thiazides rather than more expensive medication). The cost-effectiveness of the intervention was estimated as the cost per additional patient being started on thiazides. The net annual cost (cost minimization) in our study population was US$53,395, corresponding to US$763 per practice. The cost per additional patient started on thiazides (cost-effectiveness) was US$454. The net annual savings in a national program was modeled to be US$761,998, or US$540 per practice after 2 y. In this scenario the savings exceeded the costs in all but two of the sensitivity analyses we conducted, and the cost-effectiveness was estimated to be US$183.  Conclusions We found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial. A major reason to promote the use of thiazides is their lower price compared to other drugs. The cost of the intervention was more than twice the savings within the time frame of our study. However, we predict modest savings over a 2-y period.",0,1,
1541,"Rationale and design of the Study Assessing the Effect of Cardiovascular Medications Provided as Low-cost, Evidence-based Generic Samples (SAMPLES) trial","BACKGROUND: Highly effective generic cardiovascular medications are frequently underused, leading to greater overall drug costs and cost-related nonadherence. OBJECTIVE: We sought to assess an intervention to stimulate appropriate generic cardiovascular drug use without creating administrative or financial barriers that may impede essential medication use. TRIAL DESIGN: The SAMPLES (Study Assessing the Effect of Cardiovascular Medications Provided as Low-cost, Evidence-based Generic Samples) trial is a clustered, randomized controlled trial of the effect of providing physicians with free generic samples of hydrochlorothiazide for hypertensive patients and simvastatin for patients with hyperlipidemia. We will randomize 660 primary care physicians in Pennsylvania, clustered by physician practice, to receive free samples for both conditions or to receive no samples. We will use data on filled prescriptions obtained from a state-sponsored prescription drug assistance program to perform an intention-to-treat evaluation of the impact of the intervention on physician prescribing behavior (proportion of prescriptions that are generic) and patient adherence. Secondary outcomes will include physician adherence to established guidelines and overall prescription drug costs. CONCLUSION: This trial will define the potential role of an innovative approach to stimulate clinically appropriate cost-effective prescribing. We will determine whether free generic samples can reduce overall drug costs as well as out-of-pocket costs to the patient without sacrificing efficacy and whether this approach results in improved adherence to essential cardiovascular medications. This intervention may also improve adherence to practice guidelines and improve the quality of care received. If effective, this strategy could be used broadly by private insurers or government payers aiming to stimulate more cost-effective and higher-quality care.",0,0,
1542,Reasons and consequences of low adherence to standard precautions by the nursing team,"Standard precautions (SP) are recommendations to prevent infection and protect health care workers during the provision of care, however, still exists low adherence to these recommendations. Objective To analyze the reasons and consequences of low adherence to standard precautions by the nursing staff. Method integrative literature review, search in seven databases, from 2005 to 2014. Results 30 articles were selected for analysis. The reasons for low adherence evidenced relate to deficient practices of lifelong learning, risk behaviors of workers, inadequate provision of equipment and protective equipment and inadequate working conditions. The consequences are accidents and occupational diseases. There are few intervention studies, which merely provide guidance to professionals. Conclusions The low adhesion to standard precautions is linked to individual aspects of workers, employers and educational institutions. Intervention strategies carried out have shown little efficient by only focusing on the worker.",0,1,
1543,Recall intervals for oral health in primary care patients,"BACKGROUND: The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate for almost 3 decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, 6-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries. OBJECTIVES: To determine the beneficial and harmful effects of different fixed recall intervals (for example 6 months versus 12 months) for the following different types of dental check-up: a) clinical examination only""; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish. To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval. To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals. To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals. SEARCH STRATEGY: We searched the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. Date of most recent searches: 5th March 2007. SELECTION CRITERIA: Trials were selected if they met the following criteria: design - random allocation of participants; participants - all children and adults receiving dental check-ups in primary care settings, irrespective of their level of risk for oral disease; interventions - recall intervals for the following different types of dental check-ups: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus scale and polish plus preventive advice; e) no recall interval/patient driven attendance (which may be symptomatic); f) clinician risk-based recall intervals; outcomes - clinical status outcomes for dental caries (including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores, caries increment, filled teeth (including replacement restorations), early carious lesions arrested or reversed); periodontal disease (including, but not limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth, attachment level);"" oral mucosa (presence or absence of mucosal lesions, potentially malignant lesions, cancerous lesions, size and stage of cancerous lesions at diagnosis). In addition the following outcomes were considered where reported: patient-centred outcomes, economic cost outcomes, other outcomes such as improvements in oral health knowledge and attitudes, harms, changes in dietary habits and any other oral health-related behavioural change. DATA COLLECTION AND ANALYSIS: Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted, where deemed necessary and where possible, for further details regarding study design and for data clarification. A quality assessment of the included trial was carried out. The Cochrane Collaboration's statistical guidelines were followed. MAIN RESULTS: Only one study (with 188 participants) was included in this review and was assessed as having a high risk of bias. This study provided limited data for dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported time taken to provide examinations and treatment). AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials (RCTs) to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is insufficient evidence to support or refute the practice of encouraging patients to attend for dental check-ups at 6-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.",0,0,
1544,Recall intervals for oral health in primary care patients,"BACKGROUND: The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate for almost 3 decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, 6-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries. OBJECTIVES: To determine the beneficial and harmful effects of different fixed recall intervals (for example 6 months versus 12 months) for the following different types of dental check-up: a) clinical examination only""; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish. To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval. To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals. To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals. SEARCH STRATEGY: We searched the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. Date of most recent searches: 9th April 2003. SELECTION CRITERIA: Trials were selected if they met the following criteria: design- random allocation of participants; participants - all children and adults receiving dental check-ups in primary care settings, irrespective of their level of risk for oral disease; interventions -recall intervals for the following different types of dental check-ups: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus scale and polish plus preventive advice; e) no recall interval/patient driven attendance (which may be symptomatic); f) clinician risk-based recall intervals; outcomes - clinical status outcomes for dental caries (including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores, caries increment, filled teeth (including replacement restorations), early carious lesions arrested or reversed); periodontal disease (including, but not limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth, attachment level);"" oral mucosa (presence or absence of mucosal lesions, potentially malignant lesions, cancerous lesions, size and stage of cancerous lesions at diagnosis). In addition the following outcomes were considered where reported: patient-centred outcomes, economic cost outcomes, other outcomes such as improvements in oral health knowledge and attitudes, harms, changes in dietary habits and any other oral health-related behavioural change. DATA COLLECTION AND ANALYSIS: Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two authors. Authors were contacted, where deemed necessary and where possible, for further details regarding study design and for data clarification. A quality assessment of the included trial was carried out. The Cochrane Oral Health Group's statistical guidelines were followed. MAIN RESULTS: Only one study (with 188 participants) was included in this review and was assessed as having a high risk of bias. This study provided limited data for dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported time taken to provide examinations and treatment). AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials (RCTs) to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is insufficient evidence to support or refute the practice of encouraging patients to attend for dental check-ups at 6-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.",0,0,1543
1545,Recent Trends in Violence-Related Behaviors Among High School Students in the United States,"Context Violence-related behaviors such as fighting and weapon carrying are associated with serious physical and psychosocial consequences for adolescents.  Objective To measure trends in nonfatal violent behaviors among adolescents in the United States between 1991 and 1997.  Design, Setting, and Participants Nationally representative data from the 1991, 1993, 1995, and 1997 Youth Risk Behavior Surveys were analyzed to describe the percentage of students in grades 9 through 12 who engaged in behaviors related to violence. Overall response rates for each of these years were 68%, 70%, 60%, and 69%, respectively. To assess the statistical significance of time trends for these variables, logistic regression analyses were conducted that controlled for sex, grade, and race or ethnicity and simultaneously assessed linear and higher-order effects.  Main Outcome Measures Self-reported weapon carrying, physical fighting, fighting-related injuries, feeling unsafe, and damaged or stolen property.  Results Between 1991 and 1997, the percentage of students in a physical fight decreased 14%, from 42.5% (95% confidence interval [CI], 40.1%-44.9%) to 36.6% (95% CI, 34.6%-38.6%)""; the percentage of students injured in a physical fight decreased 20%, from 4.4% (95% CI, 3.6%-5.2%) to 3.5% (95% CI, 2.9%-4.1%); and the percentage of students who carried a weapon decreased 30%, from 26.1% (95% CI, 23.8%-28.4%) to 18.3% (95% CI, 16.5%-20.1%). Between 1993 and 1997, the percentage of students who carried a gun decreased 25%, from 7.9% (95% CI, 6.6%-9.2%) to 5.9% (95% CI, 5.1%-6.7%); the percentage of students in a physical fight on school property decreased 9%, from 16.2% (95% CI, 15.0%-17.4%) to 14.8% (95% CI, 13.5%-16.1%);"" and the percentage of students who carried a weapon on school property decreased 28%, from 11.8% (95% CI, 10.4%-13.2%) to 8.5% (95% CI, 7.0%-10.0%). All of these changes represent significant linear decreases.  Conclusions Declines in fighting and weapon carrying among US adolescents between 1991 and 1997 are encouraging and consistent with declines in homicide, nonfatal victimization, and school crime rates. Further research should explore why behaviors related to interpersonal violence are decreasing and what types of interventions are most effective.",0,0,
1546,Recommendations for treating depression in community-based older adults,"OBJECTIVE: To present recommendations for community-based treatment of late-life depression to public health and aging networks. METHODS: An expert panel of mental health and public health researchers and community-based practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness from a systematic literature review of articles published through 2005. RESULTS: The expert panel strongly recommended depression care management-modeled interventions delivered at home or at primary care clinics. The panel recommended individual cognitive behavioral therapy. Interventions not recommended as primary treatments for late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, including group psychotherapy and psychotherapies other than cognitive behavioral therapy. CONCLUSIONS: This interdisciplinary expert panel determined that recommended interventions should be disseminated throughout the public health and aging networks, while acknowledging the challenges and obstacles involved. Interventions that were not recommended or had insufficient evidence often did not treat depression primarily and/or did not include a clinically depressed sample while attempting to establish efficacy. These interventions may provide other benefits, but should not be presumed to effectively treat depression by themselves. Panelists also identified primary prevention of depression as a much under-studied area. These findings should aid individual clinicians as well as public health decision makers in the delivery of population-based mental health services in diverse community settings.",0,0,
1547,Recommendations service for chronic disease patient in multimodel sensors home environment,"With advanced technologies in hand, there exist potential applications and services built around monitoring activities of daily living (ADL) of elderly people at nursing homes. Most of the elderly people in these facilities are suffering from different chronic diseases such as dementia. Existing technologies are mainly focusing on non-medication interventions and monitoring of ADL for addressing loss of autonomy or well-being. Monitoring and managing ADL related to cognitive behaviors for non-medication intervention are very effective in improving dementia patients' conditions. However, cognitive functions of patients can be improved if appropriate recommendations of medications are delivered at a particular time. Previously we developed the Secured Wireless Sensor Network Integrated Cloud Computing for Ubiquitous-Life Care (SC(3)). SC(3) services were limited to monitoring ADL of elderly people with Alzheimer's disease and providing non-medication recommendations to the patient. In this article, we propose a system called the Smart Clinical Decision Support System (CDSS) as an integral part of the SC(3) platform. Using the Smart CDSS, patients are provided with access to medication recommendations of expert physicians. Physicians are provided with an interface to create clinical knowledge for medication recommendations and to observe the patient's condition. The clinical knowledge created by physicians as the knowledge base of the Smart CDSS produces recommendations to the caregiver for medications based on each patient's symptoms.",0,0,
1548,Recruiting hospitalized patients for research: how do participants differ from eligible nonparticipants?,"BACKGROUND: Randomized controlled trials provide strong evidence for guidelines and interventions. Yet, much of the eligible population declines to be studied. OBJECTIVE: To identify differences between participants and eligible nonparticipants in (1) perceived stress, (2) self-efficacy, (3) recovery expectations, (4) discussing advance directives, and (5) understanding a standard prescription label (health literacy). DESIGN: Quasi-experimental prospective cohort study in 5 acute-care hospitals. METHODS: We approached 295 hospital inpatients as they were being recruited for a behavioral intervention and asked them to answer 5 screening questions. We matched respondents' answers to their acceptance of the behavioral intervention and to Medicare claims and enrollment data. We used multivariate logistic regression to compare consent rates based on screening-question responses. SETTING/PATIENTS: Hospitalized fee-for-service Medicare patients. RESULTS: Patients were less likely to consent to the behavioral intervention when they reported feeling unable to control important things in their lives (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.14-0.92), had low recovery expectations (OR: 0.17, 95% CI: 0.06-0.45), or were confused by any question (OR: 0.11, 95% CI: 0.05-0.24). Conversely, individuals who answered the medication question incorrectly were more likely to consent to the behavioral intervention (OR: 3.82, 95% CI: 1.12-13.03). There were no significant differences in consent for patients who reported feeling overwhelmed or reported discussing advance care planning with family members or doctors. CONCLUSIONS: Hospitalized eligible nonparticipants differ in constructs related to perceived stress, recovery expectation, and health literacy. Recognizing such characteristics may inform strategies to improve intervention recruitment in the hospital and representation in clinical trials.",0,0,
1549,Recruitment and retention of elderly patients in clinical trials: issues and strategies,"Clinicians and researchers alike are shifting their focus to elderly patients in order to target the most effective treatments for a variety of psychiatric conditions. Clinical trials with elderly patients are the necessary because they consume the largest number of prescription medications. There are special challenges and considerations in designing and conducting clinical studies. The authors review the various phases of such research, including recruitment of appropriate patients and retention of those enrolled, and they make suggestions, using examples from already completed research studies, illustrating the methods found to be most successful.",0,0,
1550,Recurrence after surgical treatment of hidradenitis suppurativa,"From six to 89 months after surgery 82 patients who had been treated by radical surgery (118 excisions) for intractable hidradenitis suppurativa were reviewed. Local recurrence rates varied greatly with the disease site, being low after axillary (3%) and perianal surgery (0%) and high after inguinoperineal (37%) and submammary (50%) excision. Recurrence results from inadequate excision or an unusually wide distribution of apocrine glands, but physical factors such as obesity, local pressure, and skin maceration played a part in a few patients. Recurrence due to inadequate surgery tended to be the most troublesome. At follow up 75 (91%) of the patients were pleased with the results of their operation. A quarter of the patients developed disease at a new anatomical site after operation. Radical surgery gives good symptomatic control of severe hidradenitis suppurativa of the axilla, inguinoperineal, and perianal regions but is less satisfactory for submammary disease.",0,0,
1551,Redesigning the ‘choice architecture’of hospital prescription charts: a mixed methods study incorporating in situ simulation testing.,"Objectives To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors.  Design A mixed-methods approach was taken in the development phase of the project""; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart.  Setting A London teaching hospital.  Interventions/methods A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation.  Results Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29;"" p<0.0001) were more likely to be completed using the IDEAS chart.  Conclusions In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts.  This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/",1,1,
1552,Reducing cardiovascular disease risk in patients with diabetes: a message from the National Diabetes Education Program,"PURPOSE: To provide nurse practitioners (NPs) a review of current practice guidelines that help clinicians' efforts to reduce the morbidity and mortality associated with diabetes and its major macrovascular complications. DATA SOURCES: This paper presents data from major evidence-based studies and clinical trials that define the scope of the problem, the rationale for risk reduction, and a patient-centered action plan for NPs to effectively manage cardiovascular risk factors in people with diabetes. CONCLUSIONS: NPs are active partners with the National Diabetes Education Program and play a key role in efforts to effectively manage cardiovascular risk factors in people with diabetes and improve their awareness of the link between diabetes and heart disease and stroke. IMPLICATIONS FOR PRACTICE: The action plan to reduce cardiovascular risk in people with diabetes will help NPs to implement the most effective management strategies for medical nutrition therapy, physical activity, and pharmacological therapy required for patient-centered proactive management of hyperglycemia, hypertension, and lipid abnormalities.",0,0,
1553,Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians' transfusion practices,"BACKGROUND: Transfusion services have used various techniques to reduce blood product utilization. Given the potential adverse effects of transfusions and the resources consumed in implementing strategies to reduce transfusions, there is a need to understand their effectiveness. Therefore, we performed a systematic review of the literature to examine the effectiveness of behavioral interventions to reduce blood product utilization. METHODS: We identified all relevant articles through the use of electronic searches of MEDLINE and EMBASE, as well as hand searches of review articles and personal files. The electronic searches included articles published between January 1966 and May 2003. The searches included the terms blood transfusion, plasma exchange, guidelines, education, practice patterns, and professional practice. The outcomes of interest were the number of units transfused and the proportion of patients who received transfusions. RESULTS: Nineteen studies examining the effectiveness of single (guidelines, prospective audits, retrospective audits, and reminders) or multifaceted interventions in reducing red blood cell, platelet, plasma, cryoprecipitate, and albumin transfusions met the inclusion criteria. Eighteen studies demonstrated a relative reduction in the number of units given (range, 9%-77%) or the proportion of patients receiving transfusions (range, 17%-79%). The reported reductions were qualitatively similar for the different blood products studied. No particular intervention or combination of interventions appeared more effective in reducing utilization. CONCLUSIONS: Behavioral interventions, including simple interventions, appear to be effective in changing physician transfusion practices and reducing blood utilization. Appropriately designed clinical trials are still needed to determine the relative effectiveness of different interventions to change practices.",0,1,
1554,Reducing the Risk of Alcohol Use Disorders in Women,"Nurses and other clinicians help women to examine their lifestyles and consider changes to promote optimum health. When the question is about drinking alcohol, what is appropriate to recommend? While moderate intake may be beneficial for cardiovascular and bone health, drinking more than the recommended amount increases the risk of harmful effects. This column examines guidelines for moderate alcohol consumption for women, reviews the assessment process and demonstrates an example of a brief intervention. A program of screening, brief intervention and referral to treatment (termed SBIRT by the Substance Abuse and Mental Health Services Administration) should be part of the standard assessment for every woman. Ongoing assessment of alcohol consumption can help to better target behaviors for early intervention.",0,0,
1555,"Reducing therapeutic injection overuse through patients-prescribers interaction group discussions in Kinondoni District, Dar es Salaam, Tanzania","Inappropriately prescription of injections has been reported in developing and developed countries. Previous studies in Tanzania showed that over 70% of patients attending out- patient clinics at private dispensaries received at least one injection per consultation, a value higher than WHO recommended target of 10%. This is of concern considering the likelihood of adverse effects of possible use of unsafe syringes to transmit HIV, hepatitis B and C, poliomyelitis and added economic impact on the patient and the healthcare system. This study aimed to investigate the impact of Interaction Group Discussion on behavioural change on injection prescribing practices in ten selected public dispensaries in Kinondoni District, Dar es Salaam, Tanzania. Patient records of injection prescriptions were obtained covering the period three months prior to the study from 5 randomly selected control and 5 randomly selected intervention facilities. At each health facility IGDs were conducted for one month on mothers and prescribers followed by a survey 3 months after IGD to determine the impact of IGDs. Chi-square statistical calculations were made to compare data on the percent of prescriptions with an injection prescribed and in those conforming to national standard treatment guidelines (STG) between baseline and 3 months follow up. Results showed no significant difference between the percentage of prescriptions with an injection prescribed at baseline and 3 months follow-up in public dispensaries (P>0.05, X2 test). Prescribed injections that complied with STG was low at baseline and did not significantly improve 3 months after (P>0.05, X2 test). Comprehensive studies and sensitization of compliance to STG by prescribers are recommended.",0,0,
1556,Reducing ventilator-associated pneumonia rates through a staff education programme,"Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in patients on mechanical ventilation and results in increases in mortality, prolonged hospitalization and costs. Preventive measures for VAP are well-documented and evidence-based, yet remain poorly implemented in most intensive care units. We undertook an observational pre and post-intervention study to assess whether an educational programme focusing on preventive practices for VAP could reduce the incidence. Six hundred and seventy-seven adult patients, mechanically ventilated for >48 h were included in the study population. An evidence-based guideline for preventive practices at the bedside was developed and disseminated to the intensive care unit staff. VAP incidence rates before and after implementation of the educational programme were compared. VAP infection rates reduced by 51%, from a mean of 13.2+/-1.2 in the pre-intervention period to 6.5+/-1.5/1000 device days in the post-intervention period (mean difference 6.7"";"" 95% CI: 2.9-10.4, P =0.02). A multidisciplinary educational programme geared towards intensive care unit staff can successfully reduce the incidence rates of VAP. Further studies will be needed to assess the impact on broader outcome measures such as costs or mortality.",0,0,
1557,"Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial","OBJECTIVE: To evaluate the effect of a patient, health care provider, and systems intervention on the prevalence of risk factors for lower extremity amputation in patients with non-insulin-dependent diabetes. DESIGN: Blinded, randomized, controlled trial. SETTING: Academic general medicine practice. PARTICIPANTS: Of the 395 patients with non-insulin-dependent diabetes who underwent the initial patient assessment, 352 completed the study. INTERVENTION: The 12-month intervention was multifaceted. Patients received foot-care education and entered into a behavioral contract for desired self-foot care, which was reinforced through telephone and postcard reminders. Health care providers were given practice guidelines and informational flow sheets on foot-related risk factors for amputation in diabetic patients. In addition, the folders for intervention patients had special identifiers that prompted health care providers to: 1) ask that patients remove their footwear, 2) perform foot examinations, and 3) provide foot-care education. RESULTS: Patients receiving the intervention were less likely than control patients to have serious foot lesions (baseline prevalence, 2.9%""; odds ratio, 0.41 [95% CI, 0.16 to 1.00]; P = 0.05) and other dermatologic abnormalities. Also, they were more likely to report appropriate self-foot-care behaviors, to have foot examinations during office visits (68% compared with 28%; P < 0.001), and to receive foot-care education from health care providers (42% compared with 18%; P < 0.001). Physicians assigned to intervention patients were more likely than physicians assigned to control patients to examine patients' feet for ulcers, pulses, and abnormal dermatologic conditions and to refer patients to the podiatry clinic (10.6% compared with 5.0%;"" P = 0.04). CONCLUSIONS: An intervention designed to reduce risk factors for lower extremity amputations positively affected patient self-foot-care behavior as well as the foot care given by health care providers and reduced the prevalence of lower extremity clinical disease in patients with diabetes.",0,0,
1558,Referral for fertility preservation counselling in female cancer patients,"STUDY QUESTION: What changes can be detected in fertility preservation (FP) counselling (FPC) over time and what are the determinants associated with the referral of newly diagnosed female cancer patients, aged 0-39 years, to a specialist in reproductive medicine for FPC? SUMMARY ANSWER: Although the absolute number of patients receiving FPC increased over time, only 9.8% of all potential patients (aged 0-39 years) were referred in 2011 and referral disparities were found with respect to patients' age, cancer diagnosis and healthcare provider-related factors. WHAT IS KNOWN ALREADY: Referral rates for FPC prior to the start of gonadotoxic cancer treatment are low. Determinants associated with low referral and referral disparities have been identified in previous studies, although there are only scarce data on referral practices and determinants for FPC referral in settings with reimbursement of FP(C). STUDY DESIGN, SIZE, DURATION: We conducted a retrospective observational and questionnaire study in a Dutch university hospital. Data on all female cancer patients counselled for FP in this centre (2001-2013), as well as all newly diagnosed female cancer patients aged 0-39 years in the region (2009-2011) were collected. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were retrieved from medical records (FPC patients), cancer incidences reported by the Dutch Cancer Registry (to calculate referral percentages) and referring professionals (to identify reasons for the current referral behaviour). MAIN RESULTS AND THE ROLE OF CHANCE: In 2011, a total of 9.8% of the patients were referred for FPC. Patients aged 20-29 years or diagnosed with breast cancer or lymphoma were referred more frequently compared with patients under the age of 20 years or patients diagnosed with other malignancies. The absolute numbers of patients receiving FPC increased over time. Healthcare provider-related determinants for low referral were not starting a discussion about fertility-related issues, not knowing where to refer a patient for FPC and not collaborating with patients' associations. LIMITATIONS, REASONS FOR CAUTION: Actual referral rates may slightly differ from our estimation as there may have been patients who did not wish to receive FPC. Sporadically, patients might have been directly referred to other regions or may have received ovarian transposition without FPC. By excluding skin cancer patients, we will have underestimated the group of women who are eligible for FPC as this group also includes melanoma patients who might have received gonadotoxic therapy. WIDER IMPLICATIONS OF THE FINDINGS: The low referral rates and referral disparities reported in the current study indicate that there are opportunities to improve referral practices. Future research should focus on the implementation and evaluation of interventions to improve referral practices, such as information materials for patients at oncology departments, discussion prompts or methods to increase the awareness of physicians and patients of FP techniques and guidelines. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the Radboud university medical center and the Radboud Institute for Health Sciences. The authors have declared no conflicts of interest with respect to this work. TRIAL REGISTRATION NUMBER: Not applicable.",0,0,
1559,Regeneration of peripheral nerves after injury,,0,0,
1560,Regulating and legislating safety: the case for candour,,0,0,
1561,"Regulatory models for human embryo cloning: the free market, professional guidelines, and government restrictions","Both experimental and therapeutic uses of the new reproductive technologies have been governed not by the medical ideology of the best interests of patients and their children, but by the market ideology of profit maximization under the guise of ""reproductive liberty."" Government in our constitutional, democratic society has the authority and obligation to make and enforce reasonable regulations to manage the new reproductive market in order to protect the interests of the public, prospective parents, and their future children. The ""cloning"" debate provides a useful opportunity to compare and contrast the competing regulatory models of the free market, professional guidelines, and government restrictions.",0,0,
1562,Rehabilitating antisocial personalities: treatment through self-governance strategies,"Offenders with antisocial personality disorder (ASPD) are widely assumed to reject psychotherapeutic intervention. Some commentators, therefore, argue that those with the disorder are better managed in the criminal justice system, where, following the introduction of indeterminate sentences, engagement with psychological treatment is coercively linked to the achievement of parole. By comparison, National Institute of Clinical Excellence guidelines on the management and treatment of ASPD recommend that those who are treatment seeking should be considered for admission to specialist psychiatric hospitals. The rationale is that prison-based interventions are underresourced, and the treatment of ASPD is underprioritised. The justification is that offenders with ASPD can be rehabilitated, if they are motivated. One problem, however, is that little is known about why offenders with ASPD seek treatment or what effect subsequent treatment has on their self-understanding. The aim of this paper is to address these unresolved issues. It draws on the findings of Economic and Social Research Council (ESRC) funded qualitative study examining the experiences of sentenced male offenders admitted to a specialist personality disorder ward within the medium secure estate and the medical practitioners who treat them. The data are analysed with reference to Michel Foucault's work on governmentality and strategy in power relations. Two arguments are advanced: first, offenders with ASPD are motivated by legal coercive pressures to implement a variety of Foucauldian-type strategies to give the false impression of treatment progress. Second, and related, treatment does not result in changes in self-understanding in the resistive client with ASPD. This presupposes that, in respect of this group at least, Foucault was mistaken in his claim that resistive behaviours merely mask the effectiveness of treatment norms over time. Nevertheless, the paper concludes that specialist treatment in the hospital setting can effect changes in the resistive offender's self-understanding, but not if the completion of treatment results, as is commonplace, in his prison readmission.",0,0,
1563,Rehabilitation of children and adolescents,"In recent years a significant increase in most chronic mental and physical illnesses among children and adolescents was reported. Thus, medical child and adolescent rehabilitation plays a major role. Therefore, early diagnosis and multimodal intervention in childhood and adolescence is necessary, to prevent a chronic course of disease. Patient education programs have been shown to be effective in the treatment of chronic illnesses. Those programs are mostly aimed to improve the compliant behavior and disease management. Consecutively, the health status and quality of life should be improved. Due to the implementation of guidelines and evaluation studies the quality of rehabilitation programs was ameliorated during the past 15 years. However, future research should develop flexible rehabilitation programs in particular (rehabilitation duration, rehabilitation near or far from place of residence, rehabilitation chain with in-patient, partially out-patient, and out-patient programs), whose effectiveness has to be proven.",0,0,
1564,Relapse of successfully treated anxiety and fear: theoretical issues and recommendations for clinical practice,"Despite the existence of effective interventions for anxiety disorders, relapse--or the return of fear--presents a significant problem for patients and clinicians in the longer term. The present paper draws on the experimental and clinical behavioural literature, reviewing the mechanisms by which the return of fear can occur. The aim of the paper was to generate a list of treatment recommendations for clinicians aimed at reducing relapse in successfully treated anxiety disorders. Clinical and experimental literature on the mechanisms of renewal, reinstatement, spontaneous recovery and reacquisition are reviewed. These are linked with the clinical and experimental literature on the return of fear in successfully treated anxiety. A list of recommendations to assist in reducing the probability of relapse in successfully treated anxiety is presented. This list includes methods for use in behavioural (exposure) treatment of anxiety disorders that aim to enhance clinical outcomes. Despite the significant problem of relapse in successfully treated anxiety, there are methods available to reduce the probability of relapse through return of fear. Clinicians engaging in treatment of anxiety disorders should be mindful of these methods to ensure optimal patient outcome.",0,0,
1565,Relation of completeness of reporting of health research to journals' endorsement of reporting guidelines: systematic review,"OBJECTIVE To assess whether the completeness of reporting of health research is related to journals' endorsement of reporting guidelines. DESIGN Systematic review. DATA SOURCES Reporting guidelines from a published systematic review and the EQUATOR Network (October 2011). Studies assessing the completeness of reporting by using an included reporting guideline (termed ""evaluations"") (1990 to October 2011""; addendum searches in January 2012) from searches of either Medline, Embase, and the Cochrane Methodology Register or Scopus, depending on reporting guideline name. STUDY SELECTION English language reporting guidelines that provided explicit guidance for reporting, described the guidance development process, and indicated use of a consensus development process were included. The CONSORT statement was excluded, as evaluations of adherence to CONSORT had previously been reviewed. English or French language evaluations of included reporting guidelines were eligible if they assessed the completeness of reporting of studies as a primary intent and those included studies enabled the comparisons of interest (that is, after versus before journal endorsement and/or endorsing versus non-endorsing journals). DATA EXTRACTION Potentially eligible evaluations of included guidelines were screened initially by title and abstract and then as full text reports. If eligibility was unclear, authors of evaluations were contacted; journals' websites were consulted for endorsement information where needed. The completeness of reporting of reporting guidelines was analyzed in relation to endorsement by item and, where consistent with the authors' analysis, a mean summed score. RESULTS 101 reporting guidelines were included. Of 15,249 records retrieved from the search for evaluations, 26 evaluations that assessed completeness of reporting in relation to endorsement for nine reporting guidelines were identified. Of those, 13 evaluations assessing seven reporting guidelines (BMJ economic checklist, CONSORT for harms, PRISMA, QUOROM, STARD, STRICTA, and STROBE) could be analyzed. Reporting guideline items were assessed by few evaluations. CONCLUSIONS The completeness of reporting of only nine of 101 health research reporting guidelines (excluding CONSORT) has been evaluated in relation to journals' endorsement. Items from seven reporting guidelines were quantitatively analyzed, by few evaluations each. Insufficient evidence exists to determine the relation between journals' endorsement of reporting guidelines and the completeness of reporting of published health research reports. Journal editors and researchers should consider collaborative prospectively designed, controlled studies to provide more robust evidence. SYSTEMATIC REVIEW REGISTRATION Not registered;"" no known register currently accepts protocols for methodology systematic reviews.",0,0,
1566,Reminiscence therapy for dementia,"BACKGROUND: Reminiscence Therapy (RT) has been defined as vocal or silent recall of events in a person's life, either alone, or with another person or group of people. It typically involves group meetings, at least once a week, in which participants are encouraged to talk about past events, often assisted by aids such as photos, music, objects and videos of the past. There is, often, little consistent application of psychological therapies in dementia services. A number of these 'therapies' were greeted with enthusiasm by health care practitioners in under stimulating care environments. They were expected to work miracles and their 'failure' to do this has led to their widespread disuse. A systematic review of the available evidence is important in order to identify the effectiveness of the different therapies. Subsequently, guidelines for their use can be made on a sound evidence base. OBJECTIVES: RT involves groups of elderly people talking of past events, assisted by aids such as videos, pictures and archives, as a means of communicating and reflecting upon their life experiences. The objective of the review is to assess the effects of RT for dementia. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, MEDLINE, PSYCHLIT, EMBASE, OMNI, BIDS, Dissertation Abstracts International, SIGLE and reference lists of relevant articles up to 1998, and we contacted specialists in the field. We also searched relevant Internet sites and we hand searched Aging and Mental Health, the Gerontologist, Journal of Gerontology, Current Opinion in Psychiatry, Current Research in Britain: Social Sciences, British Psychological Society conference proceedings and Reminiscence database. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised trials of RT for dementia in elderly people. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed trial quality. MAIN RESULTS: Two trials are included in the review, but only one trial with 15 participants had extractable data. The results were statistically non-significant for both cognition and behaviour. REVIEWER'S CONCLUSIONS: No firm conclusions could be reached regarding the effectiveness of RT for dementia. The review highlighted the urgent need for more systematic research in the area.",0,0,
1567,"Remission, residual symptoms, and nonresponse in the usual treatment of major depression in managed clinical practice","BACKGROUND: Although published guidelines recommend the continuation of treatment for depression until full remission of symptoms and restoration of functioning, little is known about how often remission is achieved in usual practice and the precipitants of treatment termination when treatment outcome has not been optimal. METHOD: A naturalistic study design examined 1859 patients receiving treatment for DSM-III-R major depression between 1995 and 1997 in the national provider network of a managed behavioral health organization (MBHO). Symptom and impairment ratings by clinicians were used to group patients into full remission, partial remission, and no response. Claims data were used to characterize treatment and identify comorbid medical conditions. RESULTS: According to clinician ratings, approximately 27% to 39% of patients achieved full remission. Medical and substance use comorbidity and hospital admission were more common in those with a partial response to treatment. Only half of patients without a treatment response received a trial of medication during their treatment. Patient choice was the most common reason for termination of treatment, although nearly 40% of clinicians concurred with patients' decisions even when symptoms had not improved. CONCLUSION: Although rates of full remission were comparable to those in clinical trials of antidepressants, results suggest that clinicians may fail to recommend continuation and maintenance treatment consistent with best practice guidelines and that unsuccessful treatment often does not include antidepressant medication.",0,0,
1568,Replantation of the foot,,0,0,
1569,Report from the PHLS Communicable Disease Surveillance Centre,"An outbreak of legionnaires' disease was reported among holidaymakers returning from Yugoslavia between August and September""; there were further outbreaks of gastrointestinal illness associated with shellfish; influenza received much publicity after a suggestion that an epidemic might occur during the coming winter;"" and two tropical diseases were in the news, leishmaniasis and cercarial dermatitis.",0,0,
1570,Report of the NIH Panel To Define Principles of Therapy of HIV Infection*,"Recent research advances have afforded substantially improved understanding of the biology of human immunodeficiency virus (HIV) infection and the pathogenesis of the acquired immunodeficiency syndrome (AIDS). With the advent of sensitive tools for monitoring HIV replication in infected persons, the risk of disease progression and death can be assessed accurately and the efficacy of anti-HIV therapies can be determined directly. Furthermore, when used appropriately, combinations of newly available, potent antiviral therapies can effect prolonged suppression of detectable levels of HIV replication and circumvent the inherent tendency of HIV to generate drug-resistant viral variants. However, as antiretroviral therapy for HIV infection has become increasingly effective, it has also become increasingly complex. Familiarity with recent research advances is needed to ensure that newly available therapies are used in ways that most effectively improve the health and prolong the lives of HIV-infected persons. To enable practitioners and HIV-infected persons to best use rapidly accumulating new information about HIV disease pathogenesis and treatment, the Office of AIDS Research of the National Institutes of Health sponsored the NIH Panel to Define Principles of Therapy of HIV Infection. This Panel was asked to define essential scientific principles that should be used to guide the most effective use of antiretroviral therapies and viral load testing in clinical practice. Based on detailed consideration of the most current data, the Panel delineated eleven principles that address issues of fundamental importance for the treatment of HIV infection. These principles provide the scientific basis for the specific treatment recommendations made by the Panel on Clinical Practices for the Treatment of HIV Infection sponsored by the Department of Health and Human Services and the Henry J. Kaiser Family Foundation. The reports of both of these panels are provided in this publication. Together, they summarize new dta and provide both the scientific basis and specific guidelines for the treatment of HIV-infected persons. This information will be of interest to health-care providers, HIV-infected persons, HIV/AIDS educators, public health educators, public health authorities, and all organizations that fund medical care of HIV-infected persons.",0,0,
1571,Reproductive rights and the medical care system: a plea for rational health policy,"Recently, there have been many challenges to women's reproductive rights and freedoms: court-ordered cesarean sections""; criminal cases against women for prenatal child abuse; and attempts to limit the practice of mid-wifery, home birth, and the operation of alternative birth centers. In these cases, medicine has been complicit or proactive in attempts to control the behavior or health care options of pregnant women. We discuss medicine's role as an agent of social control, the medical reconstruction of problems that are social in nature, and the need for a more coherent policy framework to guide physician practices.;"" PIP: Reproduction issues are highly controversial. Women's legal right to abortion continues to be challenged, women's rights are being pitted against fetal rights, and there is concern about teen pregnancy, the appropriate use of reproductive technology, and drug and alcohol use during pregnancy. There has been, however, little attention to medicine's role as an agent of social control and arbiter of reproductive behavior, the medical reconstruction of and intervention in problems which are essentially social in nature, or of equity and social justice in reproductive health care. The authors discuss these latter issues in light of historical and more recent attempts to control the behavior of pregnant women. In the absence of current reproductive health policy, the medical profession makes arbitrary decisions in individual cases which may or may not reflect patient or community wishes. A more coherent policy framework and regulatory mechanisms to guide physician practice are needed. The authors discuss the problem in context, key questions, social discrimination in reproductive health care, choosing which services to provide, coercion and choice, and reproductive health policy as a solution.",0,0,
1572,Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols.,"Objective: To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing.  Design: Six-month prospective, randomized, controlled trial.  Setting: Academic primary care general internal medicine practice.  Subjects: Thirty-one general internal medicine faculty, 145 residents, and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocols.  Intervention: Primary care teams of internal medicine residents and faculty received either routine computer reminders (control) or the same reminders to which they were required to circle one of four responses: 1) “done/order today,” 2) “not applicable to this patient,” 3) “patient refused,” or 4) “next visit.”  Results: Intervention physicians complied more frequently than control physicians with all reminders combined (46% vs 38%, respectively, p=0.002) and separately with reminders for FOBT (61% vs 49%, p=0.0007) and mammography (54% vs 47%, p=0.036) but not cervical Pap testing (21% vs 18%, p=0.2). Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing. There was no significant difference between intervention and control faculty, but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing. The intervention’s effect was greatest for patients =70 years old, with significant results for all tests, together and singly, for residents but not faculty. Intervention physicians felt that the reminders were not applicable 21% of the time (due to inadequate data in patients’ electronic medical records) and stated that their patients refused 10% of the time.  Conclusions: Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocols, especially for elderly patients for whom control physicians’ compliance was the lowest. However, 100% compliance with cancer screening reminders will be unattainable due to incomplete data and patient refusal.",0,1,
1573,Research based on archived information and samples. Recommendations from the Royal College of Physicians Committee on Ethical Issues in Medicine,In 1996 the College published Guidelines on the Practice of Ethics committees in Medical Research involving Human Subjects (3rd edition) which includes a section on unintrusive research. The recommendations published here are intended to clarify the issues surrounding this category of research as they relate to consent to the use of archived information and samples.,0,0,
1574,Research in the field of psychiatry,,0,0,
1575,"Research into practice: Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Nottinghamshire, Derbyshire, Lincolnshire (NDL)","Background To address the problem of translation from research-based evidence to routine healthcare practice, the Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire, and Lincolnshire (CLAHRC-NDL) was funded by the National Institute for Health Research as one of nine CLAHRCs across England. This paper outlines the underlying theory and its application that CLAHRC-NDL has adopted, as a case example that might be generalised to practice outside the CLAHRC, in comparison to alternative models of implementation.  Discussion Conventional approaches to health research frequently generate evidence in isolation from the environment in which it is intended for use. The premise of the CLAHRC-NDL model is that barriers to implementation can be overcome if knowledge is co-produced by academic and clinical service staff, taking account of the organisational context in which it is to be applied. This approach is founded on organisational learning theory, recognising that change is a social and political phenomenon. Evidence is produced in real time, taking full account of the environment in which it is to be implemented. To support this process, senior health service staff are seconded to the CLAHRC as ¡®diffusion fellows¡¯ (DFs) to actively bridge the research to practice gap by being a full member of both the research team and their area of clinical practice. To facilitate innovation and embed change in the local health community, existing communities of practice are enhanced and new ones are fostered around specific themes. Our approach has been adopted by 16 clinical research studies in the areas of mental health, children and young people, primary care, and stroke rehabilitation.  Summary The CLAHRC-NDL model of implementation applies organisational learning theory by addressing the social and situational barriers and enablers to implementation, and adopting a philosophy of co-production. Two key mechanisms for translation of innovation have been utilised: DFs, to actively bridge the research to practice gap, and communities of practice, to underpin and sustain improvements in healthcare. The model shows promising results in putting research into practice, which may be transferable to other healthcare contexts.",0,0,
1576,Research opportunities in the area of early childhood: birth through 5 years,"The American Occupational Therapy Association (AOTA) Evidence-Based Practice Project has developed a table summarizing the research opportunities on early childhood. The table provides an overview of the state of current available evidence on interventions within the scope of occupational therapy practice and is based on the systematic reviews from the AOTA Evidence-Based Practice Guidelines Series. Researchers, students, and clinicians can use this information in developing innovative research to answer important questions within the occupational therapy field.",0,0,
1577,Research priorities for public health nursing,"The Association of Community Health Nursing Educators (ACHNE) Research Committee initiated a revision of the ACHNE Research Priorities for public health nursing practice in 2006, following those developed in 1992 and in 2000. The committee (a) reviewed public health nursing research abstracts (n=485) from 7 selected nursing journals to evaluate progress in addressing the 2000 Priorities""; (b) identified research methods used, health issues and health behaviors addressed, and demographics of study populations in the abstracts;"" and (c) reviewed research priorities from key federal funding agencies and journal editors. Overall, progress toward meeting previous priorities was modest, with a limited range of methods, topics, and samples described. The 2009 ACHNE Research Priorities for public health nursing include: (1) Population-Focused Outcomes, and (2) Public Health Nursing Workforce. Multisite studies, clinical trials, community-based participatory research, development and/or analysis of existing large data sets, and development of valid and reliable methods are needed to address these priorities. Collaboration among educators, researchers, and practitioners is crucial to develop the scientific evidence base for population-based nursing practice.",0,0,
1578,"Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial","Background The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices.  Methods/design The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle.  The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital.  Discussion Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals.",0,0,
1579,Responding flexibly but not gullibly to drug addiction,,0,0,
1580,Responding to patient-initiated humor: guidelines for practice,"Over the past few decades, increasing evidence has shown the beneficial effects of humor. The use of caregiver-initiated humor as an intervention in healthcare settings has both physiological and emotional benefits. Little has been written, however, about another very important aspect of humor, patient-initiated humor. When patients use humor to relieve their feelings of stress, uncertainty, or embarrassment, they are trying to communicate with their caregiver. This use of humor by patients is not to ""make light"" of the situation, but rather a way to reduce their feelings of dehumanization. Humor is an interactive process of sharing and an important aspect of communication. Patients will observe the caregiver for a response. An open, accepting response signals understanding"";"" a negative or null response, however, may serve to isolate the patient. The guidelines discussed in this article for recognizing, interpreting, and responding to patient-initiated humor will help home care and hospice nurses to foster increased open patient/caregiver communication and create a supportive humanistic atmosphere for patient care.",0,0,
1581,Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing,"OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status""; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0.52, CI 0.28 to 0.96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0.66, CI 0.46 to 0.96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1;"" OR 0.40, CI 0.20 to 0.80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.",0,0,
1582,Response to intervention: Principles and strategies for effective practice.,"Meeting a key need, this is the first comprehensive guide to implementing a schoolwide response to intervention (RTI) program. The book is geared to helping practitioners understand and respond to No Child Left Behind and to the new special education eligibility guidelines outlined in IDEIA 2004. Presented are the theoretical and empirical foundations of the approach and a clear, 10-step model for conducting RTI procedures with students experiencing learning difficulties. Special features include reproducible planning and implementation worksheets and more than two dozen overhead transparency masters for use in RTI training sessions, with lay-flat binding to facilitate photocopying. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
1583,Responsibility of the educator,,0,0,
1584,Results of a physician and respiratory therapist collaborative effort to improve long-term metered-dose inhaler technique in a pediatric asthma clinic,"BACKGROUND: Despite advances in therapy, asthma continues to be the chronic condition most responsible for school absenteeism and pediatric hospitalizations. This is especially true for inner-city children. We operate an inner-city Pediatric Asthma Compliance and Technique (PACT) clinic in which physicians and respiratory therapists collaborate to improve metered-dose inhaler (MDI) technique and outcomes among asthmatic children. OBJECTIVE: To determine the efficacy of our strategy for improving MDI technique and asthma outcomes. METHODS: Children referred to the PACT clinic underwent standardized assessment based on the Expert Panel Guidelines of the National Heart, Lung, and Blood Institute (NHLBI). Clinicians demonstrated and reinforced correct MDI technique at each visit. Using a standardized format we prospectively collected, at the patient's first visit (T1) and most recent visit (T2), data on demographics, MDI-technique scores (MDI steps done correctly"";"" scale of 0-8), pulmonary function, and asthma severity (NHLBI classification scale: 1 = mild intermittent to 4 = severe persistent). Statistical analyses were performed using parametric and non-parametric tests. RESULTS: Of the 60 patients who attended the PACT clinic between 1999 and 2002, 15 were excluded from the study because of incomplete data recording. Mean duration from T1 to T2 was 11.8 +/- 9.5 months. At T1 and T2, respectively, the mean MDI-technique scores were 53% and 81%, the mean overall asthma severity scores were 2.6 and 2.3, and the mean overall pulmonary function severity scores were 2.4 and 2.1. MDI-technique scores significantly improved between TI and T2 (p < 0.001). The black patients had the largest improvement in MDI technique (p < 0.001), but their pulmonary function test results, overall asthma severity, and pulmonary function severity did not improve significantly. The white patients significantly improved both their MDI technique (p = 0.004) and their overall asthma severity scores (p = 0.005). CONCLUSION: In our PACT clinic asthmatic children showed sustained improvement in MDI technique, and some of the patients improved in pulmonary function and overall asthma severity score.",0,0,
1585,Results that matter: structured vs. unstructured self-monitoring of blood glucose in type 2 diabetes,"Self-monitoring of blood glucose (SMBG) is one component of diabetes management. SMBG presents information about current glycemic status and provides the ability to obtain immediate feedback regarding the impact of behavioral and pharmacological interventions on glucose levels. However, SMBG is useful only when the glucose information is understood correctly, data are accurately interpreted, and results prompt appropriate therapeutic actions. The International Diabetes Federation (IDF) recently published guidelines for SMBG use in non-insulin treated people with diabetes, recommending that SMBG should be used only when patients and/or their clinicians possess the ability and willingness to incorporate SMBG monitoring and therapy adjustment into their diabetes care plan. If SMBG is used, the IDF also recommends that structured SMBG be performed utilizing defined regimens to meet individual needs. Structured SMBG can be performed as daily glucose profiles that are representative of daily glucose excursions. Measuring preprandial/postprandial blood glucose (bG) levels on consecutive or alternating days (""testing in pairs"") also provides impactful glucose information for daily diabetes management. This article reviews recent studies that appropriately utilized structured SMBG as an integral component of comprehensive diabetes management and discusses how their findings support the IDF recommendations. Our goal is to help clinicians make more informed decisions about the value and utility of SMBG in diabetes management.",0,0,
1586,"Rethinking pragmatic randomised controlled trials: introducing the ""cohort multiple randomised controlled trial"" design","Pragmatic trials are important for informing routine clinical practice, but current designs have shortcomings. Clare Relton and colleagues outline the new “cohort multiple randomised controlled trial” design, which could help address the problems associated with existing approaches Randomised controlled trials are generally held to be the “gold standard” for establishing how well an intervention works. Trials that aim to determine the efficacy of a treatment by using a double blind, placebo controlled design (that is, explanatory trials) are, however, sometimes criticised. For example, although the design of explanatory trials results in strong internal validity—we can depend upon the results of a given trial—such trials may have limited external validity: we can’t be confident that we can apply the results to routine clinical practice. Pragmatic trials,1 2 which aim to inform healthcare decision making in practice, have been offered as a solution in that they retain the rigour of randomisation (thus eliminate selection bias) but retain the characteristics of normal clinical practice. The implementation and interpretation of both pragmatic and explanatory randomised controlled trials are associated with significant problems. This article describes a trial design that helps address these problems—the “cohort multiple randomised controlled trial” approach. Existing clinical trial designs can have shortcomings in four areas: recruitment""; ethics; patient preferences;"" and treatment comparisons. ### Recruitment The majority of randomised controlled trials have difficulty recruiting sufficient numbers of patients. For example, one investigation found that less than a third of 114 multicentre, publicly funded UK trials recruited their original target number of patients within the time originally specified.3 Failure to recruit to target may have implications for the power and generalisability of trial results. Moreover, many clinical trials exclude hard to reach groups and ethnic minorities,4 resulting in disparities between the “with need” (reference) population and the trial population.5 6 …",0,0,
1587,Review of legal instruments and codes on medical experimentation with children,"Medical research with children has been the subject of ongoing debate. The reason for controversy is clear. As with research on adults, one must strike a balance between two goals – promoting the health of children through advances in scientific knowledge and protecting child research subjects from exploitation and harm. However, because of their age and relative immaturity, children cannot protect their own interests as well as adult subjects can. Yet as they progress toward adulthood, increasing care must be taken to involve children in decisions that affect them, even to the extent of allowing them to make choices that may have serious and long-term consequences.",0,0,
1588,Revising the Declaration of Helsinki: a fresh start,,0,0,
1589,Revising the history of Cold War research ethics,"President Clinton's charge to the Advisory Committee on Human Radiation Experiments included the identification of ethical and legal standards for evaluating government-sponsored radiation experiments conducted during the Cold War. In this paper, we review the traditional account of the history of American research ethics, and then highlight and explain the significance of a number of the Committee's historical findings as they relate to this account. These findings include both the national defense establishment's struggles with legal and insurance issues concerning human experiments, and the medical profession's perspective on human experimentation in the years following the Nuremberg Medical Trials. We conclude that the Committee's work both enriches the traditional view of the history of research ethics and opens important new areas for study.",0,0,
1590,RHEUMATISM AND ARTHRITIS: REVIEW OF AMERICAN AND ENGLISH LITERATURE OF RECENT YEARS: (ELEVENTH RHEUMATISM REVIEW): Part II,,0,0,
1591,Rheumatism and Arthritis: Review of American and English Literature of Recent Years: (Sixteenth Rheumatism Review),"SINCE 1935, fifteen issues of the Rheumatism Reviews have been published periodically in the ANNALS OF INTERNAL MEDICINE under the auspices of the American Rheumatism Association. This sixteenth issue contains an analysis of selected articles from American and English literature dealing with the fundamental and clinical aspects of the connective tissue diseases for 1961 and 1962. The American Rheumatism Association (ARA) with the assistance of the editors of the ANNALS OF INTERNAL MEDICINE will continue to publish—at intervals of approximately two years—an analysis of the significant contributions in this field with emphasis upon subjects of interest to clinicians. The American Rheumatism Association, in cooperation with the National Library of Medicine, is preparing a recurrent bibliography on rheumatic diseases on computer tape. By utilizing this method of retrieval of literature, the ""Current Bibliographic Listings in Arthritis and Rheumatism"" will be prepared and made available to all of those interested in the connective tissue diseases. Future Rheumatism Reviews will be prepared by a committee of the American Rheumatism Association to provide a single comprehensive analysis of both the fundamental and clinical aspects in the field of rheumatology. These will be published in the journal Arthritis and Rheumatism.",0,0,
1592,RHEUMATISM AND ARTHRITIS:: REVIEW OF AMERICAN AND ENGLISH LITERATURE OF RECENT YEARS: (THIRTEENTH RHEUMATISM REVIEW),"CONTENTS PART I General Incidence of Rheumatic Diseases 2 Classification of Diseases of Joints and Related Structures 5 Diseases Primarily Related to Trauma 5 Arthritis Due to Specific Infectious Agents 8 Rheumatic Fever 19 Sydenham's Chorea 29 Rheumatoid Arthritis 30 Rheumatoid (Ankylosing) Spondylitis 81 Osteoarthritis (Degenerative Joint Disease) 88 PART II Backache and Sciatica 95 Gout and Gouty Arthritis 119 The Uric Acid Problem 144 ""Collagen Diseases"" 149 Psoriatic Arthritis 162 Reiter's Syndrome 163 Neurotrophic Arthropathy: Charcot's Joints 165 Rheumatic Purpura (Sch?nlein-Henoch Syndrome) 166 Hemophilic Arthritis 167 Allergic Arthritis 168 Pharmacologic Arthritis and Arthralgia 168 Alkaptonuria, Ochronosis and Ochronic Arthritis",0,0,
1593,Richard Cabot: Medical Reformer during the Progressive Era (1890-1920),"Richard Cabot's (1868-1939) decision to leave full-time medical work in 1920 to teach social ethics illustrates some of the tensions inherent in twentieth-century medicine's transformation from clinical practice to a biomedical science. Cabot, then one of America's best known physicians, practiced medicine in an era in which science redefined medical practice and thinking. Although a champion of medical science, Cabot's primary concerns were clinical and humanistic. He emphasized the importance of ambulatory medicine, advocated group practice, founded hospital social work, did clinical epidemiologic research, lobbied for preventive medicine, created the Clinical-Pathologic Conference, and wrote extensively on medical ethics. In 1912, despite Cabot's great talents, a top professorship at Harvard Medical School was instead given to David Edsall, a clinician with more extensive basic science training. Cabot's efforts to define the physician's, as well as the health care system's, role in human well-being, however, presaged medicine's current attempts to emphasize the social context of the patient.",0,0,
1594,Ridding the world of hydroxyquinolines,,0,0,
1595,Riding the knowledge translation roundabout: lessons learned from the Canadian Institutes of Health Research Summer Institute in knowledge translation,"Background Funding the education and training of the next generation of health researchers is a key mandate of the Canadian Institutes of Health Research (CIHR) knowledge translation (KT) portfolio. The field of KT is growing daily"";"" thus, the training and development of a new generation of KT researchers is essential.  Methods Using curriculum documents, participant evaluations, and self-reflection, this paper describes a unique Summer Institute hosted by the CIHR in Cornwall, Ontario, Canada. We outline the key aspects of a successful training initiative that could inform organizations and agencies worldwide with an interest in or who have a mandate for KT.  Results This work provides potential funders, faculty, and students with an inside look into the purpose, process, and outcomes of such training initiatives.  Conclusion National and international KT organizations, research institutions, and funding agencies are encouraged to consider replicating the training model employed here, as investment into KT personnel will foster the advancement of the field within and beyond local borders.  'To the individual who devotes his/her life to science, nothing can give more happiness than when the results immediately find practical application. There are not two sciences. There is science and the application of science, and these two are linked as the fruit is to the tree.' ¨C Louis Pasteur, 1871 (from presentation by Ian Graham, 2008 CIHR Knowledge Translation Summer Institute)",0,0,
1596,Risk communication in clinical trials: a cognitive experiment and a survey,"BACKGROUND: A Royal Statistical Society Working Party recently recommended that ""Greater use should be made of numerical, as opposed to verbal, descriptions of risk"" in first-in-man clinical trials. This echoed the view of many clinicians and psychologists about risk communication. As the clinical trial industry expands rapidly across the globe, it is important to understand risk communication in Asian countries. METHODS: We conducted a cognitive experiment about participation in a hypothetical clinical trial of a pain relief medication and a survey in cancer and arthritis patients in Singapore. In part 1 of the experiment, the patients received information about the risk of side effects in one of three formats (frequency, percentage and verbal descriptor) and in one of two sequences (from least to most severe and from most to least severe), and were asked about their willingness to participate. In part 2, the patients received information about the risk in all three formats, in the same sequence, and were again asked about their willingness to participate. A survey of preference for risk presentation methods and usage of verbal descriptors immediately followed. RESULTS: Willingness to participate and the likelihood of changing one's decision were not affected by the risk presentation methods. Most patients indicated a preference for the frequency format, but patients with primary school or no formal education were indifferent. While the patients used the verbal descriptors ""very common"", ""common"" and ""very rare"" in ways similar to the European Commission's Guidelines, their usage of the descriptors ""uncommon"" and ""rare"" was substantially different from the EU's. CONCLUSION: In this sample of Asian cancer and arthritis patients, risk presentation format had no impact on willingness to participate in a clinical trial. However, there is a clear preference for the frequency format. The lay use of verbal descriptors was substantially different from the EU's.",0,0,
1597,"Risk Factors for Methotrexate-Induced Lung Injury in Patients with Rheumatoid Arthritis: A Multicenter, Case-Control Study","BACKGROUND: Toxicity limits the use of methotrexate. OBJECTIVE: To identify risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis. DESIGN: Case-control study. SETTING: One private and five academic rheumatology practices. PARTICIPANTS: Methotrexate recipients with rheumatoid arthritis with and without lung injury. MEASUREMENTS: Potential risk factors examined were sociodemographic and lifestyle characteristics, medical history, clinical and ancillary features and treatment of rheumatoid arthritis before methotrexate therapy, and characteristics of methotrexate therapy. Cases of lung injury were defined according to the modified criteria of Searles and McKendry. RESULTS: Ninety-four percent of the study participants were white, and 67% were women. Case-patients (n = 29) were older than controls (n = 82) (61.5 compared with 54.5 years of age). The strongest predictors of lung injury, after adjustment for other variables, were older age (odds ratio [OR], 5.1 [95% CI, 1.2 to 21.1]), diabetes (OR, 35.6 [CI, 1.3 to infinity]), rheumatoid pleuropulmonary involvement (OR, 7.1 [CI, 1.1 to 45.4]), previous use of disease-modifying antirheumatic drugs (OR, 5.6 [CI, 1.2 to 27.0]), and hypoalbuminemia (OR, 19.5 [CI, 3.5 to 109.7]). Previous use of disease-modifying antirheumatic drugs and hypoalbuminemia had very large attributable risks. CONCLUSION: Knowledge of the risk factors that predispose patients with rheumatoid arthritis to the toxic effects of methotrexate on the lung may provide a rationale for monitoring high-risk patients and may facilitate their management.",0,0,
1598,"Risk for Hospitalized Heart Failure Among New Users of Saxagliptin, Sitagliptin, and Other Antihyperglycemic Drugs","Background: Recent postmarketing trials produced conflicting results about the risk for hospitalized heart failure (hHF) associated with dipeptidyl peptidase-4 (DPP-4) inhibitors, creating uncertainty about the safety of these antihyperglycemic agents. Objective: To examine the associations of hHF with saxagliptin and sitagliptin. Design: Population-based, retrospective, new-user cohort study. Setting: 18 health insurance and health system data partners in the U.S. Food and Drug Administration's Mini-Sentinel program. Patients: Patients aged 18 years or older with type 2 diabetes who initiated therapy with saxagliptin, sitagliptin, pioglitazone, second-generation sulfonylureas, or long-acting insulin products from 2006 to 2013. Measurements: Hospitalized HF, identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 402.x1, 404.x1, 404.x3, and 428.xx recorded as the principal discharge diagnosis. Results: 78 553 saxagliptin users and 298 124 sitagliptin users contributed an average of 7 to 9 months of follow-up data to 1 or more pairwise comparisons. The risk for hHF was not higher with DPP-4 inhibitors than with the other study drugs. The hazard ratios from the disease risk score (DRS)¨Cstratified analyses were 0.83 (95% CI, 0.70 to 0.99) for saxagliptin versus sitagliptin, 0.63 (CI, 0.47 to 0.85) for saxagliptin versus pioglitazone, 0.69 (CI, 0.54 to 0.87) for saxagliptin versus sulfonylureas, and 0.61 (CI, 0.50 to 0.73) for saxagliptin versus insulin. The DRS-stratified hazard ratios were 0.74 (CI, 0.64 to 0.85) for sitagliptin versus pioglitazone, 0.86 (CI, 0.77 to 0.95) for sitagliptin versus sulfonylureas, and 0.71 (CI, 0.64 to 0.78) for sitagliptin versus insulin. Results from the 1:1 propensity score¨Cmatched analyses were similar. Results were also similar in subgroups of patients with and without prior cardiovascular disease and in a subgroup defined by the 2 highest DRS deciles. Limitation: Residual confounding and short follow-up. Conclusion: In this large cohort study, a higher risk for hHF was not observed in users of saxagliptin or sitagliptin compared with other selected antihyperglycemic agents. Primary Funding Source: U.S. Food and Drug Administration.",0,0,
1599,Risk prevalence and screening for cancer by general practitioners,"BACKGROUND: This study presents cancer risk prevalence and screening rates of patients attending general practitioners. Conditions addressed include smoking, skin cancer, Pap smears, clinical breast examinations, and mammography. METHODS: A cross-sectional study of 7,160 patients 18-75 years presenting to 230 general practitioners in a metropolitan and country region in Queensland, Australia, was used. Risk prevalence was assessed from patients' self-report of risk behaviors and screening prior to the consultation. Details of preventive care provided in the consultation were based on doctors' self-report at the conclusion of the consultation. RESULTS: Twenty-seven percent of men and 23% of women smoked, rates being highest in the younger age groups. Using national guidelines, prior screening had not occurred as recommended for men and women as follows: skin cancer screening--66% of men, 70% of women""; cervical cancer screening--27%; clinical breast examination--45%;"" mammography--75%. These patients were thus categorized as ""at risk,"" and screening rates for these patients in the consultation were as follows: smokers--34%""; skin cancer--5%; cervical cancer--16%; mammography--4%;"" clinical breast examination--8%. CONCLUSIONS: Significant numbers of patients presenting to general practitioners were at risk of developing cancer, according to national guidelines. Of these, only small proportions of all groups had a preventive intervention by their GP at the consultation identified in this study. While GPs generally see their role in prevention as important, these results raise questions for future cancer prevention policies and training of GPs.",0,0,
1600,Role and interactions of the cardiologist in a regional institutional project of primary prevention,"BACKGROUND: Evidence is available in support of the policies for a population-wide approach to shifting risk factor distribution""; on the other side, setting up enduring projects of primary prevention is difficult, as well as gathering the right experts. METHODS: In 1999 the Piedmont Region's Administration set up a multi-year intervention with the aim at reducing risk factors and increasing protective factors of oncologic and cardiovascular diseases in the general population, particularly in disadvantage groups. The cardiologists played a primary role by supporting the project of evidence-based guidelines, producing bibliographic reviews and spreading coronary risk maps. A main group of trainers was set up in each Local Health Service to promote a system of counseling lifestyles, with the central reference of the general practitioner activity. As a second step, a mass-media campaign has been set up using health advertisements on newspapers, television, public transports, notice-boards on the following subjects: nutrition, hypertension, tobacco, physical activity, stress;"" warehouses, food markets, trains and squares were involved. Moreover, a newsletter review has been published since January 2000, to produce basic models, most effective interventions and recommendations for their implementation. RESULTS: A new care for the primary prevention and counseling arguments as well as the need for continuous training to promote preventive actions were shown to general practitioners. A system to identify the best channels, communication ways and the most effective messages for healthy lifestyles was settled. A model of monitoring risk factor changes and protective behaviors in the population, describing social differences, was established to better plan and assess effective interventions. CONCLUSIONS: After more than half a century of productive public health science, there is an urgent need that Government Administrations steer their health policies towards determinants of health and create the best conditions to make citizens to improve their lifestyle.",0,0,
1601,"Role of ""external facilitation"" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration","Background Facilitation has been identified in the literature as a potentially key component of successful implementation. It has not, however, either been well-defined or well-studied. Significant questions remain about the operational definition of facilitation and about the relationship of facilitation to other interventions, especially to other change agent roles when used in multi-faceted implementation projects.  Researchers who are part of the Quality Enhancement Research Initiative (QUERI) are actively exploring various approaches and processes, including facilitation, to enable implementation of best practices in the Veterans Health Administration health care system ¨C the largest integrated healthcare system in the United States. This paper describes a systematic, retrospective evaluation of implementation-related facilitation experiences within QUERI, a quality improvement program developed by the US Department of Veterans Affairs.  Methods A post-hoc evaluation was conducted through a series of semi-structured interviews to examine the concept of facilitation across several multi-site QUERI implementation studies. The interview process is based on a technique developed in the field of education, which systematically enhances learning through experience by stimulating recall and reflection regarding past complex activities. An iterative content analysis approach relative to a set of conceptually-based interview questions was used for data analysis.  Findings Findings suggest that facilitation, within an implementation study initiated by a central change agency, is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation was described primarily as a distinct role with a number of potentially crucial behaviors and activities. Data further suggest that external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role.  Preliminary Conclusions This evaluation provides evidence to suggest that facilitation could be considered a distinct implementation intervention, just as audit and feedback, educational outreach, or similar methods are considered to be discrete interventions. As such, facilitation should be well-defined and explicitly evaluated for its perceived usefulness within multi-intervention implementation projects. Additionally, researchers should better define the specific contribution of facilitation to the success of implementation in different types of projects, different types of sites, and with evidence and innovations of varying levels of strength and complexity.",0,0,
1602,Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders,"BACKGROUND: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. METHOD: A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. TREATMENT RECOMMENDATIONS: This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability"";"" however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.",0,0,
1603,Royal College calls for central research ethics committee,,0,0,
1604,Royal College of Physicians Intercollegiate Stroke Working Party evidence-based guidelines for the secondary prevention of stroke through nutritional or dietary modification,"BACKGROUND: Each year, 15 million people worldwide and 110,000 people in England have a stroke. Having a stroke increases the risk of having another. There are a number of additional known risk factors that can be modified by diet. The present study aimed to systematically review key nutrients and diets and their role in secondary prevention, as well as provide evidence-based guidelines for use in clinical practice. The work was conducted as part of the process to develop the 4th edition of the Royal College of Physicians' (RCP) National Clinical Guideline (NCG) for Stroke. METHODS: Questions were generated by the research team, in consultation with the Virtual Stroke Group, an online professional interest group, and the RCP Intercollegiate Stroke Working Party Guideline Development Group. Nine questions covering several individual nutrients and diet combinations were defined and searches conducted up until 31 October 2011 using five electronic databases (Embase, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and Web of Science). All included studies were assessed for quality and risk of bias using van Tulder criteria for randomised controlled trials (RCTs) and Quality of Reporting of Meta-analyses (QUORUM) criteria for systematic reviews. RESULTS: Of 4287 abstracts were identified, 79 papers were reviewed and 29 systematic reviews and RCTs were included to provide evidence for the secondary prevention components of the guidelines. For each question, evidence statements, recommendations and practical considerations were developed. CONCLUSIONS: This systematic review process has resulted in the development of evidence-based guidelines for use in clinical practice and has identified areas for further research.",0,0,
1605,Saccadic eye movement metrics reflect surgical residents' fatigue,"OBJECTIVE: Little is known about the effects of surgical residents' fatigue on patient safety. We monitored surgical residents' fatigue levels during their call day using (1) eye movement metrics, (2) objective measures of laparoscopic surgical performance, and (3) subjective reports based on standardized questionnaires. BACKGROUND: Prior attempts to investigate the effects of fatigue on surgical performance have suffered from methodological limitations, including inconsistent definitions and lack of objective measures of fatigue, and nonstandardized measures of surgical performance. Recent research has shown that fatigue can affect the characteristics of saccadic (fast ballistic) eye movements in nonsurgical scenarios. Here we asked whether fatigue induced by time-on-duty (~24 hours) might affect saccadic metrics in surgical residents. Because saccadic velocity is not under voluntary control, a fatigue index based on saccadic velocity has the potential to provide an accurate and unbiased measure of the resident's fatigue level. METHODS: We measured the eye movements of members of the general surgery resident team at St. Joseph's Hospital and Medical Center (Phoenix, AZ) (6 males and 6 females), using a head-mounted video eye tracker (similar configuration to a surgical headlight), during the performance of 3 tasks: 2 simulated laparoscopic surgery tasks (peg transfer and precision cutting) and a guided saccade task, before and after their call day. Residents rated their perceived fatigue level every 3 hours throughout their 24-hour shift, using a standardized scale. RESULTS: Time-on-duty decreased saccadic velocity and increased subjective fatigue but did not affect laparoscopic performance. These results support the hypothesis that saccadic indices reflect graded changes in fatigue. They also indicate that fatigue due to prolonged time-on-duty does not result necessarily in medical error, highlighting the complicated relationship among continuity of care, patient safety, and fatigued providers. CONCLUSIONS: Our data show, for the first time, that saccadic velocity is a reliable indicator of the subjective fatigue of health care professionals during prolonged time-on-duty. These findings have potential impacts for the development of neuroergonomic tools to detect fatigue among health professionals and in the specifications of future guidelines regarding residents' duty hours.",0,0,
1606,Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England,"Background Substantial sums of money are being invested worldwide in health information technology. Realising benefits and mitigating safety risks is however highly dependent on effective integration of information within systems and/or interfacing to allow information exchange across systems. As part of an English programme of research, we explored the social and technical challenges relating to integration and interfacing experienced by early adopter hospitals of standalone and hospital-wide multimodular integrated electronic prescribing (ePrescribing) systems.  Methods We collected longitudinal qualitative data from six hospitals, which we conceptualised as case studies. We conducted 173 interviews with users, implementers and software suppliers (at up to three different times), 24 observations of system use and strategic meetings, 17 documents relating to implementation plans, and 2 whole-day expert round-table discussions. Data were thematically analysed initially within and then across cases, drawing on perspectives surrounding information infrastructures.  Results We observed that integration and interfacing problems obstructed effective information transfer in both standalone and multimodular systems, resulting in threats to patient safety emerging from the lack of availability of timely information and duplicate data entry. Interfacing problems were immediately evident in some standalone systems where users had to cope with multiple log-ins, and this did not attenuate over time. Multimodular systems appeared at first sight to obviate such problems. However, with these systems, there was a perceived lack of data coherence across modules resulting in challenges in presenting a comprehensive overview of the patient record, this possibly resulting from the piecemeal implementation of modules with different functionalities. Although it was possible to access data from some primary care systems, we found poor two-way transfer of data between hospitals and primary care necessitating workarounds, which in turn led to the opportunity for new errors associated with duplicate and manual information transfer. Extending ePrescribing to include modules with other clinically important information needed to support care was still an aspiration in most sites, although some advanced multimodular systems had begun implementing this functionality. Multimodular systems were, however, seen as being difficult to interface with external systems.  Conclusions The decision to pursue a strategy of purchasing standalone systems and then interfacing these, or one of buying hospital-wide multimodular systems, is a pivotal one for hospitals in realising the vision of achieving a fully integrated digital record, and this should be predicated on a clear appreciation of the relative trade-offs between these choices. While multimodular systems offered somewhat better usability, standalone systems provided greater flexibility and opportunity for innovation, particularly in relation to interoperability with external systems and in relation to customisability to the needs of different user groups.",0,0,
1607,"Salivary cortisol response after a medical interview: the impact of physician communication behaviour, depressed affect and alexithymia","OBJECTIVE: To explore if - and possibly how - a medical interview may affect adrenocortical activity in musculo-skeletal pain patients with and without alexithymia. METHODS: Female patients (N = 54) recruited from a patient organization for fibromyalgia completed the Toronto Alexithymia Scale (TAS-20) and subgroups with, respectively, low and high scores were selected for participation. Seven physicians conducted consultations attempting to vary their communication in accordance with given guidelines. All consultations were videotaped and analysed by The Roter Interaction Analysis System (RIAS) to evaluate the actual content of the consultations. RESULTS: An increase in depressed affect from pre- to post-interview was associated with relatively high cortisol levels 24 h after the consultation, but only in patients with alexithymia. Psychosocial questions from the physician were associated with increased depressed affect immediately following the interview, but not with cortisol responses at any time. CONCLUSION: In patients with deficient affect regulation, increase in depressed affect after a medical interview may be associated with delayed effects in adrenocortical activity, possibly mediated by rumination. PRACTICE IMPLICATIONS: Providers should be sensitive to potential deficits of affect regulation in their patients.",0,0,
1608,"Salt, hypertension and cardiovascular risk","For more than a century salt and blood pressure have been linked. Prospective randomized clinical trials and meta-analyses provided evidence that a reduction of daily salt intake of 100 mmol will lower systolic blood pressure by 3-5 mm Hg, whereas diastolic blood pressure can be reduced by 1 mm Hg. The effect of salt restriction depends strongly on individual salt sensitivity. Whether a reduction of salt intake will ultimately result in a decline of cardiovascular morbidity and mortality remains to be determined in future studies.",0,0,
1609,Scanning for satisfaction or digging for dismay? Comparing findings from a postal survey with those from a focus group-study,"BACKGROUND: Despite growing support for mixed methods approaches we still have little systematic knowledge about the consequences of combining surveys and focus groups. While the methodological aspects of questionnaire surveys have been researched extensively, the characteristics of focus group methodology are understudied. We suggest and discuss whether the focus group setting, as compared to questionnaire surveys, encourages participants to exaggerate views in a negative direction. DISCUSSION: Based on an example from our own research, where we conducted a survey as a follow up of a focus group study, and with reference to theoretical approaches and empirical evidence from the literature concerning survey respondent behaviour and small group dynamics, we discuss the possibility that a discrepancy in findings between the focus groups and the questionnaire reflects characteristics of the two different research methods. In contrast to the survey, the focus group study indicated that doctors were generally negative to clinical guidelines. We were not convinced that this difference in results was due to methodological flaws in either of the studies, and discuss instead how this difference may have been the result of a general methodological phenomenon. SUMMARY: Based on studies of how survey questionnaires influence responses, it appears reasonable to claim that surveys are more likely to find exaggerated positive views. Conversely, there are some indications in the literature that focus groups may result in complaints and overly negative attitudes, but this is still an open question. We suggest that while problematic issues tend to be under-communicated in questionnaire surveys, they may be overstated in focus groups.We argue for the importance of increasing our understanding of focus group methodology, for example by reporting interesting discrepancies in mixed methods studies. In addition, more experimental research on focus groups should be conducted to advance the methodology and to test our hypothesis.",0,0,
1610,School-Based Mental Health Intervention for Children Affected by Political Violence in Indonesia,"Context Little is known about the efficacy of mental health interventions for children exposed to armed conflicts in low- and middle-income settings. Childhood mental health problems are difficult to address in situations of ongoing poverty and political instability.  Objective To assess the efficacy of a school-based intervention designed for conflict-exposed children, implemented in a low-income setting.  Design, Setting, and Participants A cluster randomized trial involving 495 children (81.4% inclusion rate) who were a mean (SD) age of 9.9 (1.3) years, were attending randomly selected schools in political violence–affected communities in Poso, Indonesia, and were screened for exposure (=1 events), posttraumatic stress disorder, and anxiety symptoms compared with a wait-listed control group. Nonblinded assessment took place before, 1 week after, and 6 months after treatment between March and December 2006.  Intervention Fifteen sessions, over 5 weeks, of a manualized, school-based group intervention, including trauma-processing activities, cooperative play, and creative-expressive elements, implemented by locally trained paraprofessionals.  Main Outcome Measures We assessed psychiatric symptoms using the Child Posttraumatic Stress Scale, Depression Self-Rating Scale, the Self-Report for Anxiety Related Disorders 5-item version, and the Children's Hope Scale, and assessed function impairment as treatment outcomes using standardized symptom checklists and locally developed rating scales.  Results Correcting for clustering of participants within schools, we found significantly more improvement in posttraumatic stress disorder symptoms (mean change difference, 2.78""; 95% confidence interval [CI], 1.02 to 4.53) and maintained hope (mean change difference, -2.21; 95% CI, -3.52 to -0.91) in the treatment group than in the wait-listed group. Changes in traumatic idioms (stress-related physical symptoms) (mean change difference, 0.50; 95% CI, -0.12 to 1.11), depressive symptoms (mean change difference, 0.70; 95% CI, -0.08 to 1.49), anxiety (mean change difference, 0.12; 95% CI, -0.31 to 0.56), and functioning (mean change difference, 0.52;"" 95% CI, -0.43 to 1.46) were not different between the treatment and wait-listed groups.  Conclusions In this study of children in violence-affected communities, a school-based intervention reduced posttraumatic stress symptoms and helped maintain hope, but did not reduce traumatic-stress related symptoms, depressive symptoms, anxiety symptoms, or functional impairment.",0,0,
1611,"Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial","BACKGROUND: Obesity is a common cause of non-communicable disease. Guidelines recommend that physicians screen and offer brief advice to motivate weight loss through referral to behavioural weight loss programmes. However, physicians rarely intervene and no trials have been done on the subject. We did this trial to establish whether physician brief intervention is acceptable and effective for reducing bodyweight in patients with obesity. METHODS: In this parallel, two-arm, randomised trial, patients who consulted 137 primary care physicians in England were screened for obesity. Individuals could be enrolled if they were aged at least 18 years, had a body-mass index of at least 30 kg/m2 (or at least 25 kg/m2 if of Asian ethnicity), and had a raised body fat percentage. At the end of the consultation, the physician randomly assigned participants (1:1) to one of two 30 s interventions. Randomisation was done via preprepared randomisation cards labelled with a code representing the allocation, which were placed in opaque sealed envelopes and given to physicians to open at the time of treatment assignment. In the active intervention, the physician offered referral to a weight management group (12 sessions of 1 h each, once per week) and, if the referral was accepted, the physician ensured the patient made an appointment and offered follow-up. In the control intervention, the physician advised the patient that their health would benefit from weight loss. The primary outcome was weight change at 12 months in the intention-to-treat population, which was assessed blinded to treatment allocation. We also assessed asked patients' about their feelings on discussing their weight when they have visited their general practitioner for other reasons. Given the nature of the intervention, we did not anticipate any adverse events in the usual sense, so safety outcomes were not assessed. This trial is registered with the ISRCTN Registry, number ISRCTN26563137. FINDINGS: Between June 4, 2013, and Dec 23, 2014, we screened 8403 patients, of whom 2728 (32%) were obese. Of these obese patients, 2256 (83%) agreed to participate and 1882 were eligible, enrolled, and included in the intention-to-treat analysis, with 940 individuals in the support group and 942 individuals in the advice group. 722 (77%) individuals assigned to the support intervention agreed to attend the weight management group and 379 (40%) of these individuals attended, compared with 82 (9%) participants who were allocated the advice intervention. In the entire study population, mean weight change at 12 months was 2.43 kg with the support intervention and 1.04 kg with the advice intervention, giving an adjusted difference of 1.43 kg (95% CI 0.89-1.97). The reactions of the patients to the general practitioners' brief interventions did not differ significantly between the study groups in terms of appropriateness (adjusted odds ratio 0.89, 95% CI 0.75-1.07, p=0.21) or helpfulness (1.05, 0.89-1.26, p=0.54)"";"" overall, four (<1%) patients thought their intervention was inappropriate and unhelpful and 1530 (81%) patients thought it was appropriate and helpful. INTERPRETATION: A behaviourally-informed, very brief, physician-delivered opportunistic intervention is acceptable to patients and an effective way to reduce population mean weight. FUNDING: The UK National Prevention Research Initiative.",0,0,
1612,"Screening and Intervention for Comorbid Substance Disorders, PTSD, Depression, and Suicide: A Trauma Center Survey","OBJECTIVE: Few investigations have examined screening and intervention procedures for comorbid substance use and mental disorders at trauma centers in the United States, although these disorders are endemic among survivors of traumatic injury. In 2006, the American College of Surgeons (ACS) mandated that level I and level II trauma centers screen for alcohol use problems and that level I centers provide brief intervention for those who screen positive. The ACS is expected to recommend best practice policy guidelines for screening for drug use problems and posttraumatic stress disorder (PTSD). This study examined screening and intervention procedures for the full spectrum of comorbid mental and substance use disorders at U.S. trauma centers. METHODS: Respondents at all level I and level II trauma centers (N=518) in the United States were asked to complete a survey describing screening and intervention procedures for alcohol and drug use problems, suicidality, depression, and PTSD. RESULTS: There were 391 (75%) respondents. Over 80% of trauma centers routinely screened for alcohol and drug use problems. Routine screening and intervention for suicidality, depression, and PTSD were markedly less common"";"" in fact, only 7% of centers reported routine screening for PTSD. Consistent with ACS policy, level I centers were significantly more likely than level II centers to provide alcohol intervention. CONCLUSIONS: Alcohol screening and intervention occurred frequently at U.S. trauma centers and appeared to be responsive to ACS mandates. In the future, efforts to orchestrate clinical investigation and policy could enhance screening and intervention procedures for highly prevalent, comorbid mental disorders.",0,0,
1613,Screening and interventions for overweight in children and adolescents: recommendation statement,"The U.S. Preventive Services Task Force (USPSTF) is an independent panel of non-federal experts in prevention and primary care that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This recommendation addresses the evidence for the accuracy of screening children and adolescents using BMI, the effectiveness of behavioral and pharmacologic interventions in improving health outcomes in these children, and the potential harms of routine screening and intervention. Using USPSTF methodology, an analytic framework with key questions was developed to guide the systematic review, which serves as the basis for this recommendation. The number of children and adolescents who are overweight has more than doubled in the last 25 years. Childhood and adolescent overweight is associated with increased health risks. The USPSTF found insufficient evidence for the effectiveness of behavioral counseling or other preventive interventions with overweight children and adolescents that can be conducted in primary care settings. Currently, available studies are limited by factors such as small sample sizes, poor generalizability, and variable follow-up. Based upon this critical gap in the evidence for effectiveness, the USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes (""I"" recommendation). There are several gaps in the research evidence on screening and interventions for overweight children and adolescents in the primary care setting. Research is needed to provide well-defined and effective approaches to medical and psychological screening in children, as well as effective clinical approaches for the prevention and treatment of overweight in children that can be implemented by primary care clinicians.",0,0,
1614,Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force,"Background: In 2009, suicide accounted for 36 897 deaths in the United States. Purpose: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care. Data Sources: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012)""; gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012). Study Selection: Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings. Data Extraction: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality. Data Synthesis: Evidence was insufficient to determine the benefits of screening in primary care populations;"" very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths. Limitation: Treatment evidence was derived from high-risk rather than screening-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited. Conclusion: Primary care¨Cfeasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. Primary Funding Source: Agency for Healthcare Research and Quality.",0,0,
1615,Screening for colorectal cancer by once only sigmoidoscopy: a feasibility study in Turin,"Objectives –To assess the impact on compliance of three invitation methods, as well as the acceptability and efficacy of two bowel preparation regimens, for endoscopic screening in the general population.  Methods –1170 subjects (men and women aged 55 to 59, in the rosters of a sample of general practitioners (GPs) in Turin), were randomly allocated to one of three invitation groups (A: personal letter, signed by GP, with a pre-fixed appointment""; B: same as for A + letter supporting the study by a well known scientist; C: letter signed by the study coordinator, NS) and two preparation regimens (i: one enema, self administered at home two hours before the test; ii: two enemas, administered the night before and two hours before the test). A postal reminder was mailed to non-attenders. A sample of non-responders was contacted for a telephone interview by a trained nurse. Written consent was obtained from all subjects undergoing the test.  Results –A total of 278 subjects attended for sigmoidoscope screening. An invitation from the GP alone produced the highest response rate (compliance: A = 29.3%; B = 24.9%;"" C = 26.8%). A single enema was as effective as two enemas in achieving satisfactory preparation for the test: the proportion of subjects invited to repeat the test was 8.1% in the single enema group, and 9.6% in the group receiving two enemas.  Conclusions –Compliance with this screening procedure tends to be low. One enema, self administered two hours before sigmoidoscopy, can ensure a satisfactory bowel preparation.",0,1,
1616,Screening for colorectal cancer on the front line,"OBJECTIVE: The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. METHODS: We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. RESULTS: Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong. CONCLUSIONS: Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.",0,0,
1617,Screening for Dementia in Primary Care: A Summary of the Evidence for the U.S. Preventive Services Task Force,"BACKGROUND: Dementia is a large and growing problem but is often not diagnosed in its earlier stages. Screening and earlier treatment could reduce the burden of suffering of this syndrome.PURPOSE: To review the evidence of benefits and harms of screening for and earlier treatment of dementia.DATA SOURCES: MEDLINE, PsycINFO, EMBASE, the Cochrane Library, experts, and bibliographies of reviews.STUDY SELECTION: The authors developed eight key questions representing a logical chain between screening and improved health outcomes, along with eligibility criteria for admissible evidence for each question. Admissible evidence was obtained by searching the data sources.DATA EXTRACTION: Two reviewers abstracted relevant information using standardized abstraction forms and graded article quality according to U.S. Preventive Services Task Force criteria.DATA SYNTHESIS: No randomized, controlled trial of screening for dementia has been completed. Brief screening tools can detect some persons with early dementia (positive predictive value < or =50%). Six to 12 months of treatment with cholinesterase inhibitors modestly slows the decline of cognitive and global clinical change scores in some patients with mild to moderate Alzheimer disease. Function is minimally affected, and fewer than 20% of patients stop taking cholinesterase inhibitors because of side effects. Only limited evidence indicates that any other pharmacologic or nonpharmacologic intervention slows decline in persons with early dementia. Although intensive multicomponent caregiver interventions may delay nursing home placement of patients who have caregivers, the relevance of this finding for persons who do not yet have caregivers is uncertain. Other potential benefits and harms of screening have not been studied.CONCLUSIONS: Screening tests can detect undiagnosed dementia. In persons with mild to moderate clinically detected Alzheimer disease, cholinesterase inhibitors are somewhat effective in slowing cognitive decline. The effect of cholinesterase inhibitors or other treatments on persons with dementia detected by screening is uncertain.",0,0,
1618,Screening for Depression in Adult Patients in Primary Care Settings: A Systematic Evidence Review,"Background: In primary care settings, prevalence estimates of major depressive disorder range from 5% to 13% in all adults, with lower estimates in those older than 55 years (6% to 9%). In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems to ensure accurate diagnosis, effective treatment, and follow-up. Purpose: To conduct a targeted, updated systematic review for the U.S. Preventive Services Task Force about the benefits and harms of screening adult patients for depression in a primary care setting, the benefits of depression treatment in older adults, and the harms of depression treatment with antidepressant medications. Data Sources: MEDLINE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PsycINFO (1998 to 2007), expert suggestions, and bibliographies of recent systematic reviews. Study Selection: Fair- to good-quality randomized clinical trials or controlled clinical trials""; systematic reviews; meta-analyses;"" and large observational studies of serious adverse events and early discontinuation due to adverse effects. All studies were published in English. Data Extraction: Two investigators abstracted, critically appraised, and synthesized 33 articles that met inclusion criteria. Data Synthesis: Nine fair- or good-quality trials indicate that primary care depression screening and care management programs with staff assistance, such as case management or mental health specialist involvement, can increase depression response and remission. Benefit was not evident in screening programs without staff assistance in depression care. Seven regulatory reviews or meta-analyses and 3 large cohort studies indicate no increased risk for completed suicide deaths with antidepressant treatment. Risk for suicidal behaviors was increased in young adults (aged 18 to 29 years) who received antidepressants, particularly those who received paroxetine, but was reduced in older adults. Limitation: Examination of harms was limited to serious adverse events, and existing systematic reviews were primarily used. Additional studies published from 2007 to 2008 extend this review. Conclusion: Depression screening programs without substantial staff-assisted depression care supports are unlikely to improve depression outcomes. Close monitoring of all adult patients who initiate antidepressant treatment, particularly those younger than 30 years, is important both for safety and to ensure optimal treatment.",0,0,
1619,Screening for Hypertension,"Purpose: To review the evidence on four questions about screening asymptomatic adults for arterial hypertension: Is hypertension a significant health problem? Is it detectable at an early, presymptomatic stage? Is treatment available and effective? Do the benefits of screening outweigh the costs and risks? Data Identification and Selection: We did a computerized search of the MEDLARS data base to identify communitybased trials of drug therapy for mild hypertension"";"" other relevant citations are included when appropriate. Data Synthesis: We approached the preliminary questions in our analysis by narrative review and argument. The estimates of therapeutic efficacy are based on previously published meta-analyses. The cost-effectiveness of screening was addressed by formal mathematical modeling of the effect of screening on various U.S. populations. Results of Analysis: Hypertension is clearly a significant health problem. It can be detected early, and effective treatment is available. Screening asymptomatic adults for hypertension has benefits that compare favorably to the risks and costs involved. According to our estimates, screening is most cost-effective for older adults compared with younger adults and for men compared with women and is highly sensitive to the cost of therapy for mild hypertension. Conclusions: We recommend hypertension screening for all adults. We also discuss the frequency and setting of screening activities. When a low-cost therapy is used, the cost-effectiveness of screening for hypertension compares favorably with other cardiovascular interventions.",0,0,
1620,Screening for postnatal depression in primary care: cost effectiveness analysis,"OBJECTIVE To evaluate the cost effectiveness of routine screening for postnatal depression in primary care. DESIGN Cost effectiveness analysis with a decision model of alternative methods of screening for depression, including standardised postnatal depression and generic depression instruments. The performance of screening instruments was derived from a systematic review and bivariate meta-analysis at a range of instrument cut points"";"" estimates of other relevant parameters were derived from literature sources and relevant databases. A decision tree considered the full treatment pathway from the possible onset of postnatal depression through identification, treatment, and possible relapse. SETTING Primary care. PARTICIPANTS A hypothetical population of women assessed for postnatal depression either via routine care only or supplemented by use of formal identification methods six weeks postnatally, as recommended in recent guidelines. MAIN OUTCOME MEASURES Costs expressed in 2006-7 prices and impact on health outcomes expressed in terms of quality adjusted life years (QALYs). The time horizon of the analysis was one year. RESULTS The routine application of either postnatal or general depression questionnaires did not seem to be cost effective compared with routine care only. The Edinburgh postnatal depression scale (at a cut point of 16) had an incremental cost effectiveness ratio (ICER) of pound 41,103 (euro 45,398, $67,130) per QALY compared with routine care only. The ICER for all other strategies ranged from pound 49,928 to pound 272,463 per QALY versus routine care only, while the probability that no formal identification strategy was cost effective was 88% (59%) at a cost effectiveness threshold of pound 20,000 ( pound 30,000) per QALY. While sensitivity analysis indicated that the cost of managing incorrectly identified depression (false positive result) was an important driver of the model, formal identification approaches did not seem to be cost effective at any feasible estimate of this cost. CONCLUSIONS Formal identification methods for postnatal depression do not seem to represent value for money for the NHS. The major determinant of cost effectiveness seems to be the potential additional costs of managing women incorrectly diagnosed as depressed. Formal identification methods for postnatal depression do not currently satisfy the National Screening Committee's criteria for the adoption of a screening strategy as part of national health policy.",0,0,
1621,Screening for speech and language delay in preschool children: systematic evidence review for the US Preventive Services Task Force,"BACKGROUND: PEDIATRICS (ISSN Numbers: Print, 0031-4005"";"" Online, 1098-4275). Published in the public domain by the American Academy of Pediatrics. Speech and language development is a useful indicator of a child's overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age, when the chances for improvement are best. However, optimal methods for screening for speech and language delay have not been identified, and screening is practiced inconsistently in primary care. PURPOSE: We sought to evaluate the strengths and limits of evidence about the effectiveness of screening and interventions for speech and language delay in preschool-aged children to determine the balance of benefits and adverse effects of routine screening in primary care for the development of guidelines by the US Preventive Services Task Force. The target population includes all children up to 5 years old without previously known conditions associated with speech and language delay, such as hearing and neurologic impairments. METHODS: Studies were identified from Medline, PsycINFO, and CINAHL databases (1966 to November 19, 2004), systematic reviews, reference lists, and experts. The evidence review included only English-language, published articles that are available through libraries. Only randomized, controlled trials were considered for examining the effectiveness of interventions. Outcome measures were considered if they were obtained at any time or age after screening and/or intervention as long as the initial assessment occurred while the child was or =2 screening techniques in 1 population, and comparisons of a single screening technique across different populations are lacking. Fourteen good- and fair-quality randomized, controlled trials of interventions reported significantly improved speech and language outcomes compared with control groups. Improvement was demonstrated in several domains including articulation, phonology, expressive language, receptive language, lexical acquisition, and syntax among children in all age groups studied and across multiple therapeutic settings. Improvement in other functional outcomes such as socialization skills, self-esteem, and improved play themes were demonstrated in some, but not all, of the 4 studies that measured them. In general, studies of interventions were small and heterogeneous, may be subject to plateau effects, and reported short-term outcomes based on various instruments and measures. As a result, long-term outcomes are not known, interventions could not be compared directly, and generalizability is questionable. CONCLUSIONS: Use of risk factors to guide selective screening is not supported by studies. Several aspects of screening have been inadequately studied to determine optimal methods, including which instrument to use, the age at which to screen, and which interval is most useful. Trials of interventions demonstrate improvement in some outcome measures, but conclusions and generalizability are limited. Data are not available addressing other key issues including the effectiveness of screening in primary care settings, role of enhanced surveillance by primary care physicians before referral for diagnostic evaluation, non-speech and language and long-term benefits of interventions, and adverse effects of screening and interventions.",0,0,
1622,Screening Surgeons for HIV Infection: A Cost-effectiveness Analysis,"OBJECTIVE. To determine the cost-effectiveness of a policy to screen surgeons for human immunodeficiency virus (HIV) infection to prevent transmission of HIV to patients having invasive procedures. DESIGN:  Cost-effectiveness analysis. RESULTS:  A one-time national screening program would identify approximately 137 surgeons with HIV infection (range, 28 to 423 surgeons) and would prevent approximately 4.3 infections (range, 1.9 to 21.3 infections) in patients treated by infected surgeons and 0.9 infections (range, 0 to 12.9 infections) in sexual partners of infected surgeons at a direct cost of $8.1 million and an induced cost of approximately $44 million. It would result in expenditures of $458,000 per year of life saved (range, $147,000 to $687,000 per year of life saved), whereas an annual screening program would result in expenditures of approximately $1.1 million per year of life saved (range, $338,000 to $1,886,000 per year of life saved). If the prevalence of HIV infection in surgeons is estimated to be three times our base-case estimate (an increase from 0.1% to 0.3%), annual screening would result in expenditures of approximately $741,000 per year of life saved. If the probability of seroconversion after a patient is exposed to a contaminated instrument is increased to 5.0% from our base-case estimate of 0.29%, an annual screening program would still cost more than $228,000 per year of life saved. CONCLUSION:  Screening surgeons for HIV to prevent transmission of HIV to patients having invasive procedures requires expenditures per year of life saved that are considerably in excess of those of most accepted health interventions. Surveillance studies of patients treated by surgeons infected with HIV should be continued to confirm that transmission of HIV to patients having invasive procedures is rare.",0,1,
1623,"Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units: cost effectiveness evaluation","OBJECTIVE To assess the cost effectiveness of screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus (MRSA) in intensive care units. DESIGN Economic evaluation based on a dynamic transmission model. SETTING England and Wales. Population Theoretical population of patients on an intensive care unit. MAIN OUTCOME MEASURES Infections, deaths, costs, quality adjusted life years (QALYs), incremental cost effectiveness ratios for alternative strategies, and net monetary benefits. RESULTS All decolonisation strategies improved health outcomes and reduced costs. Although universal decolonisation (regardless of MRSA status) was the most cost effective in the short term, strategies using screening to target MRSA carriers may be preferred owing to the reduced risk of selecting for resistance. Among such targeted strategies, universal admission and weekly screening with polymerase chain reaction coupled with decolonisation using nasal mupirocin was the most cost effective. This finding was robust to the size of intensive care units, prevalence of MRSA on admission, proportion of patients classified as high risk, and precise value of willingness to pay for health benefits. All strategies using isolation but not decolonisation improved health outcomes but costs were increased. When the prevalence of MRSA on admission to the intensive care unit was 5% and the willingness to pay per QALY gained was between £20,000 (€23,000"";"" $32,000) and £30,000, the best such strategy was to isolate only those patients at high risk of carrying MRSA (either pre-emptively or after identification by admission and weekly screening for MRSA using chromogenic agar). Universal admission and weekly screening using polymerase chain reaction based detection of MRSA coupled with isolation was unlikely to be cost effective unless prevalence was high (10% of patients colonised with MRSA on admission). CONCLUSIONS MRSA control strategies that use decolonisation are likely to be cost saving in an intensive care unit setting provided resistance is lacking, and combining universal screening using polymerase chain reaction with decolonisation is likely to represent good value for money if untargeted decolonisation is considered unacceptable. In intensive care units where decolonisation is not implemented, evidence is insufficient to support universal screening for MRSA outside high prevalence settings.",0,0,
1624,Secondary prevention after minor stroke and TIA - usual care and development of a support program,"BACKGROUND: Effective methods of secondary prevention after stroke or TIA are available but adherence to recommended evidence-based treatments is often poor. The study aimed to determine the quality of secondary prevention in usual care and to develop a stepwise modeled support program. METHODS: Two consecutive cohorts of patients with acute minor stroke or TIA undergoing usual outpatient care versus a secondary prevention program were compared. Risk factor control and medication adherence were assessed in 6-month follow-ups (6M-FU). Usual care consisted of detailed information concerning vascular risk factor targets given at discharge and regular outpatient care by primary care physicians. The stepwise modeled support program additionally employed up to four outpatient appointments. A combination of educational and behavioral strategies was employed. RESULTS: 168 patients in the observational cohort who stated their openness to participate in a prevention program (mean age 64.7 y, admission blood pressure (BP): 155/84 mmHg) and 173 patients participating in the support program (mean age 67.6 y, BP: 161/84 mmHg) were assessed at 6 months. Proportions of patients with BP according to guidelines were 50% in usual-care and 77% in the support program (p<0.01). LDL<100 mg/dl was measured in 62 versus 71% (p = 0.12). Proportions of patients who stopped smoking were 50 versus 79% (p<0.01). 72 versus 89% of patients with atrial fibrillation were on oral anticoagulation (p = 0.09). CONCLUSIONS: Risk factor control remains unsatisfactory in usual care. Targets of secondary prevention were met more often within the supported cohort. Effects on (cerebro-)vascular recurrence rates are going to be assessed in a multicenter randomized trial.",0,0,
1625,Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial,"OBJECTIVE To determine whether a combination of a selective serotonin reuptake inhibitor (SSRIs) and cognitive behaviour therapy (CBT) together with clinical care is more effective in the short term than an SSRI and clinical care alone in adolescents with moderate to severe major depression. DESIGN Pragmatic randomised controlled superiority trial. SETTING 6 outpatient clinics in Manchester and Cambridge. PARTICIPANTS 208 adolescents, aged 11-17, with moderate to severe major or probable major depression who had not responded to a brief initial intervention. Adolescents with suicidality, depressive psychosis, or conduct disorder were included. INTERVENTIONS 103 adolescents received an SSRI and routine care"";"" 105 received an SSRI, routine care, and CBT. The trial lasted 12 weeks, followed by a 16 week maintenance phase. MAIN OUTCOME MEASURES Change in score on the Health of the Nation outcome scales for children and adolescents (primary outcome) from baseline with 12 weeks as the primary and 28 weeks as the follow-up end point. Secondary measures were change in scores on the mood and feelings questionnaire, the revised children's depression rating scale, the children's global assessment scale, and the clinical global impression improvement scale. RESULTS At 12 weeks the treatment effect for the primary outcome was -0.64 (95% confidence interval -2.54 to 1.26, P=0.50). In a longitudinal analysis, there was no difference in effectiveness of treatment for the primary (average treatment effect 0.001, -1.52 to 1.52, P=0.99) or secondary outcome measures. On average there was a decrease in suicidal thoughts and self harm. There was no evidence of a protective effect of cognitive behaviour therapy on suicidal thinking or action. By 28 weeks, 57% were much or very much improved with 20% remaining unimproved. CONCLUSIONS For adolescents with moderate to severe major depression there is no evidence that the combination of CBT plus an SSRI in the presence of routine clinical care contributes to an improved outcome by 28 weeks compared with the provision of routine clinical care plus an SSRI alone. TRIAL REGISTRATION Current Controlled Trials ISRCNT 83809224.",0,0,
1626,Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data,"BackgroundQuestions concerning the safety of selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression in children led us to compare and contrast published and unpublished data on the risks and benefits of these drugs."";"" BackgroundQuestions concerning the safety of selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression in children led us to compare and contrast published and unpublished data on the risks and benefits of these drugs.",0,0,
1627,Self-formulated conditional plans for changing health behaviour among healthcare consumers and health professionals.,"This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:  Our primary objective is to assess the effects of self-formulated conditional plans to change the health-related behaviours of health consumers and healthcare professionals. Our secondary objective is to explore if the effects of self-formulated conditional plans are modified by: (i) the form of the plan (e.g., implementation intention, action plan, coping plan)""; (ii) fidelity to plan development (did the individual participate in its development as planned?); and, (iii) complexity of the targeted behaviour (e.g., number of actions required;"" regularity of the behaviour).",0,1,
1628,Self-help books for depression: how can practitioners and patients make the right choice?,"BACKGROUND: Depression is a common and important public health problem most often treated by GPs. A self-help approach is popular with patients, yet little is known about its effectiveness. AIM: Our primary aim was to review and update the evidence for the clinical effectiveness of bibliotherapy in the treatment of depression. Our secondary aim was to identify which of these self-help materials are generally available to buy and to examine the evidence specific to these publications. METHOD: Medline, CINAHL, EMBASE, PsycINFO, CCTR, PsiTri and the National Research Register were searched for randomised trials that evaluated self-help books for depression which included participants aged over 16 years with a diagnosis or symptoms of depression. Clinical symptoms, quality of life, costs or acceptability to users were the required outcome measures. Papers were obtained and data extracted independently by two researchers. A meta-analysis using a random effects model was carried out using the mean score and standard deviation of the Hamilton Rating Scale for Depression at the endpoint of the trial. RESULTS: Eleven randomised controlled trials were identified. None fulfilled CONSORT guidelines and all were small, with the largest trial having 40 patients per group. Nine of these evaluated two current publications, Managing Anxiety and Depression (UK) and Feeling Good (US). A meta-analysis of 6 trials evaluating Feeling Good found a large treatment effect compared to delayed treatment (standardised mean difference = -1.36"";"" 95% confidence interval [CI] = -1.76 to -0.96). Five self-help books were identified as being available and commonly bought by members of the public in addition to the two books that had been evaluated in trials. CONCLUSION: There are a number of self-help books for the treatment of depression readily available. For the majority, there is little direct evidence for their effectiveness. There is weak evidence that suggests that bibliotherapy, based on a cognitive behavioural therapy approach is useful for some people when they are given some additional guidance. More work is required in primary care to investigate the cost-effectiveness of self-help and the most suitable format and presentation of materials.",0,0,
1629,Self-management programmes for COPD: moving forward,"Self-management is of increasing importance in chronic obstructive pulmonary disease (COPD) management. However, there is confusion over what processes are involved, how the value of self-management should be determined, and about the research priorities. To gain more insight into and agreement about the content of programmes, outcomes, and future directions of COPD self-management, a group of interested researchers and physicians, all of whom had previously published on this subject and who had previously collaborated on other projects, convened a workshop. This article summarises their initial findings. Self-management programmes aim at structural behaviour change to sustain treatment effects after programmes have been completed. The programmes should include techniques aimed at behavioural change, be tailored individually, take the patient's perspective into account, and may vary with the course of the patient's disease and co-morbidities. Assessment should include process variables. This report is a step towards greater conformity in the field of self-management. To enhance clarity regarding effectiveness, future studies should clearly describe their intervention, be properly designed and powered, and include outcomes that focus more on the acquisition and practice of new skills. In this way more evidence and a better comprehension on self-management programmes will be obtained, and more specific formulation of guidelines on self-management made possible.",0,0,
1630,Self-reported use of personal protective equipment among Chinese critical care clinicians during 2009 H1N1 influenza pandemic,"BACKGROUND: Critically ill patients with 2009 H1N1 influenza are often treated in intensive care units (ICUs), representing significant risk of nosocomial transmission to critical care clinicians and other patients. Despite a large body of literature and guidelines recommending infection control practices, numerous barriers have been identified in ICUs, leading to poor compliance to the use of personal protective equipment (PPE). The use of PPE among critical care clinicians has not been extensively evaluated, especially during the pandemic influenza. This study examined the knowledge, attitudes, and self-reported behaviors, and barriers to compliance with the use of PPE among ICU healthcare workers (HCWs) during the pandemic influenza. METHODOLOGY/PRINCIPAL FINDINGS: A survey instrument consisting of 36 questions was developed and mailed to all HCWs in 21 ICUs in 17 provinces in China. A total of 733 physicians, nurses, and other professionals were surveyed, and 650 (88.7%) were included in the analysis. Fifty-six percent of respondents reported having received training program of pandemic influenza before they cared for H1N1 patients, while 77% reported to have adequate knowledge of self and patient protection. Only 18% of respondents were able to correctly identify all components of PPE, and 55% reported high compliance (>80%) with PPE use during patient care. In multivariate analysis, vaccination for 2009 H1N1 influenza, positive attitudes towards PPE use, organizational factors such as availability of PPE in ICU, and patient information of influenza precautions, as well as reprimand for noncompliance by the supervisors were associated with high compliance, whereas negative attitudes towards PPE use and violation of PPE use were independent predictors of low compliance. CONCLUSION/SIGNIFICANCE: Knowledge and self-reported compliance to recommended PPE use among Chinese critical care clinicians is suboptimal. The perceived barriers should be addressed in order to close the significant gap between perception and knowledge or behavior.",0,0,
1631,Self-reported versus actual test ordering behavior among primary care clinicians,"To determine the accuracy of clinician self-reports, 38 clinicians were surveyed in a university-based health maintenance organization (HMO) practice on their thyroid function testing (TFT) patterns one year after the distribution of an educational intervention (the intervention). The mean of the absolute difference between self-reported and actual test ordering rates was 12%"";"" the difference was greater than 20% for only 3 of 33 clinicians who ordered TFT for at least five patients during the study period. A strong association was found between self-reported change and the actual mean change in TFT postintervention ordering rates (p less than 0.0001). Results suggest that clinicians, at least in certain settings, can accurately estimate their utilization patterns and the effect of practice guidelines.",0,0,
1632,Self-reported violations during medication administration in two paediatric hospitals,"Content Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process.  Objective To assess the extent of violations in the medication administration process among nurses.  Design, setting and participants Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process.  Main outcome measure Self-reported violations of three medication administration protocols were made using a seven-point 0–6 scale from ‘not at all’ to ‘a great deal’.  Results Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant three-way interaction among violation situation, step in the process, and unit.  Conclusions Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital unit, step in the process, and violation situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol to accomplish job tasks.",0,0,
1633,"Self-study from web-based and printed guideline materials. A randomized, controlled trial among resident physicians","BACKGROUND: On-line physician education is increasing, but its efficacy in comparison with existing self-study methods is unknown. OBJECTIVE: To compare knowledge, learning efficiency, and learner satisfaction produced by self-study of World Wide Web-based and print-based guidelines for care after acute myocardial infarction. DESIGN: Randomized, controlled trial. SETTING: 12 family medicine and internal medicine residency programs at four universities. PARTICIPANTS: 162 residents. INTERVENTIONS: In proctored sessions, participants were randomly assigned to study from printed materials or from SAGE (Self-Study Acceleration with Graphic Evidence), a Web-based tutorial system. Both methods used identical self-assessment questions and answers and guideline text, but SAGE featured hyperlinks to specific guideline passages and graphic evidence animations. MEASUREMENTS: Scores on multiple-choice knowledge tests, score gain per unit of study time, and ratings on a learner satisfaction scale. RESULTS: Immediate post-test scores on a 20-point scale were similar in the SAGE and control groups (median score, 15.0 compared with 14.5""; P>0.2), but SAGE users spent less time studying (median, 27.0 compared with 38.5 minutes; P<0.001) and therefore had greater learning efficiency (median score gain, 8.6 compared with 6.7 points per hour; P = 0.04). On a scale of 5 to 20, SAGE users were more satisfied with learning (median rating, 17.0 compared with 15.0; P<0.001). After 4 to 6 months, knowledge had decreased to the same extent in the SAGE and control groups (median score, 12.0 compared with 11.0;"" P = 0.12). CONCLUSIONS: On-line tutorials may produce greater learning efficiency and satisfaction than print materials do, but one self-study exposure may be insufficient for long-term knowledge retention. Further research is needed to identify instructional features that motivate greater final learning and retention.",0,1,
1634,Sertraline as monotherapy in the treatment of psychotic and nonpsychotic depression,"BACKGROUND: Previous studies suggest that selective serotonin reuptake inhibitors (SSRIs) are effective when used alone in the treatment of unipolar depression with psychotic features. The purpose of the present study was to examine the response to sertraline for patients with and without psychotic features using standard criteria such as recovery and remission. METHOD: An 8-week open-label trial of sertraline in depressed inpatients was conducted. Twenty-five subjects had DSM-IV major depressive disorder with psychotic features, and 25 had DSM-IV major depressive disorder without psychotic features. After a 1-week open washout, all subjects were rated using the Hamilton Rating Scale for Depression (HAM-D) and Brief Psychiatric Rating Scale (BPRS) at baseline. The HAM-D was administered weekly, and the BPRS was administered again only at the end of the 8-week trial. Medication dosage was started at 50 mg/day, increased to 100 mg/day after 1 week, and then increased up to 200 mg/day if subjects had not remitted. RESULTS: Depressed patients without psychosis responded significantly better than did depressed patients with psychosis using the criteria of remission (HAM-D score - 7""; p =.001), response (HAM-D score - 50% of baseline score; p =.011), referral for electroconvulsive therapy (HAM-D score >/= 15;"" p =.011), or change in HAM-D scores (p =.016). Baseline HAM-D score and psychosis independently predicted response, whereas baseline BPRS scores did not, regardless of whether psychotic status was entered into the analyses. CONCLUSION: Psychotic depression responds more poorly than depression without psychosis to sertraline alone. Psychosis was a predictor of response independent of degree of depression and general psychopathology. Limitations due to an open-label design are discussed, as are differences between this study and others using SSRIs for psychotic depression.",0,0,
1635,Services for children with developmental co-ordination disorder: an evaluation against best practice principles,"PURPOSE: The National Health Service in Scotland published a best practice framework to support occupational therapists and physiotherapists to deliver effective services for children with developmental co-ordination disorder (DCD)"";"" however, adherence is variable. To highlight areas for development, this study compared the care pathway within a paediatric DCD service against the NHS Scotland framework. METHODS: A partnership of researchers and clinicians based in the United Kingdom conducted a qualitative study with 37 participants (N = 13 interview participants, N = 24 workshop participants). In-depth interviews and/or workshops were used to map the DCD service against the NHS framework. Identified gaps were aligned with four key stages of the care pathway. Qualitative analysis software was used to analyse the data. RESULTS: Core principles to guide future development were identified for each phase of the pathway. These core principles related to the NHS framework and focused on issues such as involving the family, defining clear pathways and enhancing children's participation. Participants identified potential strategies for service improvement such as developing community-based interventions and information provision. CONCLUSION: Challenges when providing services for children with DCD include confusing service pathways and poor partnership working. It is, therefore, important that clinicians utilise collaborative working strategies that support children's participation. IMPLICATIONS FOR REHABILITATION: There are numerous challenges related to the implementation of best practice principles into the provision of therapy services for children with developmental coordination disorder (DCD). It is important that AHPs seek ways of engaging parents and educational professionals at all stages of the care pathway in order to ensure optimum service provision for the child. Addressing participation is an important aspect and community-based strategies may be particularly beneficial, both as a preventative activity and as an intervention approach.",0,0,
1636,Sex in the MD's office,"KIE: A case study explores the dilemma of a doctor confronted with a colleague's serious violation of professional norms. Dr. Jones, a psychiatrist, learns from a patient that she voluntarily is sexually involved with her internist, who has threatened to harm her if she takes action against him. Though distraught and suicidal, the woman insists on protecting the internist, and Jones must decide on his own what course to take. Shapiro, a psychiatrist, points out in her commentary that Jones's actions depend on those of his patient, to whom he has obligations of confidentiality. He also has moral and fraternal obligations toward his collegague that may involve contacting an impaired physicians committee. Morrow, a sociologist, aruges that Jones is morally and legally obligated to intervene to protect patients and the integrity of the medical profession. This intervention should probably take the form of notifying an agency that investigates problem doctors.",0,0,
1637,"Sex, stroke, and inflammation: The potential for estrogen-mediated immunoprotection in stroke.","Stroke is the third leading cause of death and the primary cause of disability in the developed world. Experimental and clinical data indicate that stroke is a sexually dimorphic disease, with males demonstrating an enhanced intrinsic sensitivity to ischemic damage throughout most of their lifespan. The neuroprotective role of estrogen in the female brain is well established, however, estrogen exposure can also be deleterious, especially in older women. The mechanisms for this remain unclear. Our current understanding is based on studies examining estrogen as it relates to neuronal injury, yet cerebral ischemia also induces a robust sterile inflammatory response involving local and systemic immune cells. Despite the potent anti-inflammatory effects of estrogen, few studies have investigated the contribution of estrogen to sex differences in the inflammatory response to stroke. This review examines the potential role for estrogen-mediated immunoprotection in ischemic injury. (PsycINFO Database Record (c) 2017 APA, all rights reserved)",0,0,
1638,"Sexual activity and counseling in the first month after acute myocardial infarction among younger adults in the United States and Spain: a prospective, observational study","BACKGROUND: United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients' experience with counseling about sexual activity after AMI. METHODS AND RESULTS: The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07""; 95% confidence interval, 1.03-1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02-1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08-1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk;"" 1.36, 95% confidence interval, 1.11-1.66). CONCLUSIONS: Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.",0,0,
1639,Sexual health curricula in U.S. medical schools: current educational objectives,"OBJECTIVE: The authors identify the explicit and implicit objectives that shape decisions about what medical schools teach regarding human sexuality. METHODS: The authors reviewed relevant articles in journals, physician licensing examinations, and publications by professional organizations to identify learning objectives for human sexuality in undergraduate medical curricula. RESULTS: There is consensus about many of the attitudinal objectives and some of the skills medical students should acquire in sexual health. There is less consensus on the sexuality-related information student physicians need to master. The few common informational objectives focus narrowly on diagnosing sexual dysfunction and disease. CONCLUSION: The model sexual health curricula, licensing exams, and guidelines from professional organizations mainly focus on the pathological aspects of sexuality. Student physicians should master fundamental information on healthy sexual function and become familiar with the roles of practitioners in various therapeutic disciplines in addressing sexual concerns and enhancing patients' sexual functioning and well-being. Instruction should also address ways to incorporate this important topic in time-limited interactions with patients.",0,0,
1640,Sexually Transmitted Diseases Among Users of Erectile Dysfunction Drugs: Analysis of Claims Data,"BackgroundPharmacologic treatments for erectile dysfunction (ED) have gained widespread popularity among middle-aged and older males in recent years. Increased sexual activity among users of these treatments raises concerns about sexually transmitted diseases(STDs).ObjectiveTo examine the association between STDs and ED drug s.DesignLongitudinal analysis of users and non-users of ED drugs.Data sourcesMedical and drug claims from 1997 to 2006 of 1,410,806 male employees above the age of 40 with private insurance from 44 large companies.ResultsUsers of ED drugs had higher baseline rates of STDs compared to non-users even prior to initiating ED drug therapy (288 v. 156 annually per 100,000 people, p < 0.005). Adjusting for these baseline rates, users of ED drugs had higher rates of STDs in the year after first ED drug use when compared to non-users in the same period (OR 2.06, p < 0.05). Within users of ED drugs, STD rates were higher in the year following first ED drug use compared to the year before (327 vs 289 annually per 100,000 people, p < 0.05).LimitationsSelection bias precludes firm conclusions about whether use of ED treatments directly leads to increases in STDs.ConclusionsCompared to non-users, users of ED drugs have higher rates of STDs both prior to initiation of treatment and one year after. At a minimum, this relationship suggests that men using ED drugs may benefit from early discussions about safe sexual practices and closer monitoring for STDs. It is also possible that availability of ED drugs may increase STD rates.",0,0,
1641,Shared decision making does not influence physicians against clinical practice guidelines,"BACKGROUND: While shared decision making (SDM) and adherence to clinical practice guidelines (CPGs) are important, some believe they are incompatible. This study explored the mutual influence between physicians' intention to engage in SDM and their intention to follow CPGs. METHODS: Embedded within a clustered randomized trial to assess the impact of training physicians in SDM about using antibiotics to treat acute respiratory tract infections, this study evaluated physicians' intentions to both engage in SDM and follow CPGs. A self-administered questionnaire based on the theory of planned behavior evaluated both behavioral intentions and their respective determinants (attitude, subjective norm and perceived behavioral control) at study entry and exit. We used path analysis to explore the relationships between the intentions. We conducted statistical analyses using the maximum likelihood method and the variance-covariance matrix. Goodness of fit indices encompassed the chi-square statistic, the comparative fit index and the root mean square error of approximation. RESULTS: We analyzed 244 responses at entry and 236 at exit. In the control group, at entry we observed that physicians' intention to engage in SDM (r = 0, t = 0.03) did not affect their intention to follow CPGs""; however, their intention to follow CPGs (r = -0.31 t = -2.82) did negatively influence their intention to engage in SDM. At exit, neither behavioral intention influenced the other. In the experimental group, at entry neither behavioral intention influenced the other;"" at exit, the intention to engage in SDM still did not influence the intention to use CPGs, although the intention to follow CPGs (r = -0.15 t = -2.02) slightly negatively influenced the intention to engage in SDM, but this was not clinically significant. CONCLUSION: Physicians' intention to engage in SDM does not affect their intention to adopt CPGs even after SDM training. Physicians' intention to adopt CPGs had no clinically significant influence on intention to engage in SDM. TRIAL REGISTRATION: ClinicalTrials.gov NCT01116076.",0,0,
1642,"Short course of cognitive behavioural therapy may reduce health anxiety, say researchers","A short course of cognitive behavioural therapy delivered by nurses with minimal training would be an effective and relatively cheap way to reduce health anxiety in general medical clinics, researchers claim. Health anxiety or hypochondriasis places a substantial burden on health services because it leads to multiple consultations and investigations. Cognitive behavioural therapy is known to be an effective treatment for other anxiety disorders, but there are shortages of specialist therapists and long waiting lists for treatment. The Cognitive Behaviour Therapy for Health Anxiety in Medical Patients (CHAMP) study randomised 445 people with abnormal health anxiety who were attending gastroenterological, neurological, and respiratory medicine clinics in …",0,0,
1643,Should future interventional neuroradiologists be screened for mutations that impair radiation-induced DNA repair?,"In our current medical practice, an increasing number of specialists now have access to radiology technical platforms in order to perform imaging-guided procedures. Although knowledge about the current guidelines and radiation protection devices is a pre-requisite for the use of radiation, the preventive measures are often more or less strictly followed, leading to chronic daily exposure to significant doses of radiation and large accumulated lifetime exposures. Aortic intervention, electrophysiology, and neuro intervention in particular can result in large doses to the operators. Interventionalists might try to rationalize their dismissal of the exposure risks with various excuses: they don't know where they left their badges (even though, guiltily, they would readily admit it is good practice to always wear them), the estimated short duration of the procedure, significant muscular strain and spasm caused by the heaviness of lead aprons, decreased dexterity with lead gloves, or discomfort in wearing lead protective glasses. But their dismissive attitude is most likely due to the inherent inability to feel threatened by something they cannot see or feel, a commitment to the patient at all cost, and a culture of bravado that reinforces their behavior.",0,0,
1644,Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study,"BackgroundLow-dose inhaled corticosteroids (ICS) are highly effective for reducing asthma exacerbations and mortality. Conventionally, ICS treatment is recommended for patients with symptoms on more than 2 days per week, but this criterion has scant evidence. We aimed to assess the validity of the previous symptom-based cutoff for starting ICS by establishing whether there was a differential response to budesonide versus placebo for severe asthma exacerbations, lung function, and asthma symptom control across subgroups identified by baseline asthma symptom frequency."";"" BackgroundLow-dose inhaled corticosteroids (ICS) are highly effective for reducing asthma exacerbations and mortality. Conventionally, ICS treatment is recommended for patients with symptoms on more than 2 days per week, but this criterion has scant evidence. We aimed to assess the validity of the previous symptom-based cutoff for starting ICS by establishing whether there was a differential response to budesonide versus placebo for severe asthma exacerbations, lung function, and asthma symptom control across subgroups identified by baseline asthma symptom frequency.",0,0,
1645,Should women take part in clinical trials in breast cancer? Issues and some solutions,"PURPOSE: The purpose of this review is to consider the issues for women related to participation in clinical trials that evaluate the management of breast cancer and provide some recommendations for future initiatives to address the identified areas of concern. METHODS: The National Health and Medical Research Council (NHMRC) National Breast Cancer Centre hosted an international workshop to address the question ""Clinical Trials in Breast Cancer: Should Women Take Part?"" We also reviewed the literature on informed participation in clinical trials that was identified in a broadly based search that covered Medline, PsycLIT, and HealthPlan from 1986 to 1996. RESULTS AND CONCLUSION: When women are asked to participate in a clinical trial, they are faced with a number of questions and dilemmas. These include issues related to the conduct and ethical considerations of the trial""; the effect of participation or nonparticipation on treatment; the roles of the doctor as clinician and as researcher; the process of informed consent; the timing of the request for participation; and the benefits and costs of participation. A number of steps are identified that could help women decide whether to participate in clinical trials. These include provision of community information about clinical trials; establishment of independent brokers and registers for clinical trials; consumer review of information and protocols and involvement in trials; review of the role of ethics committees; collection of data about the proportion of women currently recruited to clinical trials, their reasons for participating or declining, and their views about the process of recruitment and participation; models for optimal practice in recruiting women to clinical trials and encouraging ongoing participation in trials; evidence-based communication skills training for clinicians to teach skills to inform women adequately of clinical trial participation;"" and auspicing and promotion of trials by an independent agency.",0,0,
1646,Significance of the chronic fatigue syndrome in rehabilitation medicine--status and perspectives,"It appears that from a clinical point of view chronic exhaustion or fatigue is an important factor in rehabilitation. This is, however, first of all a phenomenon that can be described as a function in accordance with the International Classification of Functioning, Disability and Health (JCF), caused by chronic illnesses or chronic excessive stress. The clinical and sociomedical ranking of chronic fatigue or exhaustion in respect of rehabilitation was discussed in the framework of a Workshop at the 12th Rehabilitation Science Colloquium, 2003 from the viewpoints of psychiatric rehabilitation, methodology, sociology and practical rehabilitation, and conclusions for future research were drawn. The definition of chronic fatigue is first of all mainly based on the feeling of chronic tiredness but also on phenomena of disturbed concentration, physical discomfort, headache and disorders of ""drive"" and mood. A psychiatric diagnosis linked with symptoms of chronic fatigue is neurasthenia, which is arrived at according to precisely defined criteria. Depressive disorder is one of the most important differential diagnoses in this sphere. Examinations by general practitioners revealed that about 90 % of the patients who had been diagnosed as suffering from psychovegetative disorders completely agreed with the diagnosis of neurasthenia. Neurasthenia resulted more often in work disability periods than disorders of somatisation and other psychosomatic diagnoses. Basing on the ""IRES"" scale ""vital exhaustion"", singular of even serious changes become evident in about 50 % to 90 % of the patients undergoing rehabilitation, depending on their individual range of indications. As was to be expected, the majority of pathologic findings concerns patients undergoing psychosomatic rehabilitation, since in such cases there is an overlapping with symptoms of psychosomatic diseases. It is, however, remarkable that also in somatically oriented orthopaedic rehabilitation symptoms of fatigue are seen in up to 50 % of the patients. Preliminary studies have shown that these symptoms can be definitely ameliorated within the rehabilitation framework, although pathological signs are still abundantly apparent in follow-up examinations. Markedly severe degrees of ""vital exhaustion"" and ""vocational exhaustion"" are also seen in rheumatology patients undergoing somatic rehabilitation. This agrees with case history details related by many female and male patients. Hence, it appears necessary to adapt rehabilitative intervention to both the psychovegetative and the medical behavioural aspects of this symptom. Scientific classification of the entire sphere of chronic fatigue in respect of rehabilitation requires classification of the relevant functions within the ICF framework. To this end it would be necessary to conduct patient inquiries within cross-sectional studies on the one hand and, on the other, a systematic consensus process among experts would have to be used for allocation to the relevant functions. This is the basis for development of suitable assessment tools for use in prospective studies in order to systematically evaluate the impact on functions and especially their effects on activities and participation.",0,0,
1647,Simplifying care: when is the treatment burden too much for patients living in poverty?,,0,0,
1648,Simulation education as a single intervention does not improve hand hygiene practices: A randomized controlled follow-up study,"BACKGROUND: To evaluate how critical nurses' knowledge of and adherence to current care hand hygiene (HH) guidelines differ between randomly allocated intervention and control groups before and after simulation education in both a simulation setting and clinical practice during a 2-year follow-up period. It was hypothesized that intervention group knowledge of and adherence to current HH guidelines might increase compared with a control group after simulation education. METHODS: A prospective, parallel, randomized controlled trial with repeated measurements was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Oulu, Finland. Thirty out of 40 initially randomized critical care nurses participated in the baseline measurements"";"" of these, 17 completed all the study procedures. Participants' HH adherence was observed only in high-risk contact situations prior to and postendotracheal suctioning events using a direct, nonparticipatory method of observation. Participants' HH knowledge was evaluated at the end of each observational session. RESULTS: The overall HH adherence increased from a baseline value of 40.8% to 50.8% in the final postintervention measurement at 24 months (P = .002). However, the linear mixed model did not identify any significant group (P = .77) or time-group interactions (P = .17) between the study groups after 2 years of simulation education. In addition, simulation education had no impact on participants' HH knowledge. CONCLUSIONS: After a single simulation education session, critical care nurses' knowledge of and adherence to current HH guidelines remained below targeted behavior rates.",0,0,
1649,Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice,"Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.",0,0,
1650,"Smoking among emergency chest pain patients: motivation to quit, risk perception and physician intervention","The feasibility of the emergency department (ED) as a setting for smoking interventions was examined among 159 adult patients presenting with chest pain (38% were smokers). Subjects had been admitted to a 24-h observation unit (OU) to rule out myocardial infarction. We examined the frequency and extent of physician interventions for smoking using the AHCPR guidelines as a model. We also assessed patients' perceptions of risk from smoking and motivation to quit. Results indicate that ED physicians provided incomplete and inconsistent intervention. While most patients were asked if they smoked, only half were advised to quit, and few were offered assistance with quitting. Perceived risk from smoking was low among almost half of all smokers. However, over three-quarters were willing to receive smoking cessation counseling while in the ED. The ED may be an opportune setting in which to initiate smoking cessation counseling for certain high-risk populations.",0,0,
1651,Smoking cessation activities by general practitioners and practice nurses,"OBJECTIVES: To assess general practitioners' and practice nurses' self reported behaviour, attitudes, and knowledge in relation to smoking cessation. DESIGN AND SETTING: Two postal surveys of random national samples of 303 GPs (survey 1) and 459 practice nurses (survey 2) covering England and Wales""; effective response rates were 75% and 96%, respectively. RESULTS: Survey 1 found that 96% of GPs accepted that intervening against smoking was part of their role and almost all (99%) said that they recorded smoking status when patients registered; 57% reported that they routinely updated their records on smoking status, 50% said they advised smokers to stop during most or all consultations, and 76% said they advised smokers to cut down if they cannot stop. A large majority (83%) said they either recommended or prescribed nicotine replacement therapy (NRT). Although most GPs (86%) thought that NRTs were effective, only a minority thought they were worth the cost (47%) or should be on National Health Service (NHS) prescription (32%). There was little evidence that previous training in smoking cessation was associated with more activity, more positive attitudes, or greater knowledge. Survey 2 found that almost all practice nurses (99%) agreed that intervening against smoking was part of their role and 95% said they advised patients to stop at least occasionally;"" 71% said they advised smokers to stop at most or all consultations. A majority (74%) said that they recommended NRT to their patients. As with the GPs most practice nurses thought that nicotine replacement was effective (79%), but fewer (42%) thought the cost was justified, and only about half (53%) thought it should be available on NHS prescription. Nurses who said they had been trained in smoking cessation engaged in more activity relating to smoking cessation, had more positive attitudes, and were more knowledgeable. CONCLUSION: GPs and practice nurses accepted that intervening with smoking was an important part of their role and a large majority reported that they intervened at least with some smokers. This represents a promising baseline from which to proceed in terms of implementation of the new smoking cessation guidelines, but it is hoped that improvements can be made in terms of the frequency of updating records and intervening, and acceptance of the cost-effectiveness of NRT as a life preserving intervention.",0,0,
1652,Smoking cessation counseling beliefs and behaviors of outpatient oncology providers,"PURPOSE: Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the ""teachable moment"" of cancer diagnosis to provide smoking cessation assistance. PROVIDERS AND METHODS: Physicians and midlevel providers (n = 74) who provide outpatient oncology services completed an online survey regarding smoking cessation counseling behaviors, beliefs, and perceived barriers. Outpatient medical records for 120 breast, lung, head and neck, colon, prostate, and acute leukemia cancer patients were reviewed to assess current smoking cessation assessment and intervention documentation practices. RESULTS: Providers reported commonly assessing smoking in new patients (82.4% frequently or always), but rates declined at subsequent visits for both current smokers and recent quitters. Rates of advising patients to quit smoking were also high (86.5% frequently or always), but <30% of providers reported frequently or always providing intervention to smoking patients (e.g., nicotine replacement therapy or other medications, self-help materials, and/or referrals). Only 30% of providers reported that they frequently or always followed up with patients to assess progress with quitting. Few providers (18.1%) reported high levels of confidence in their ability to counsel smoking patients. Patients' lack of motivation was identified as the most important barrier to smoking cessation. CONCLUSIONS: Although beliefs about providing cessation services to smoking patients were generally positive, few providers reported commonly providing interventions beyond advice to quit. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.",0,0,
1653,Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers,"OBJECTIVES: This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers. METHODS: WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis. RESULTS: Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance. CONCLUSIONS: Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.",0,0,
1654,"Smoking cessation from office to bedside. An evidence-based, practical approach","Cigarette smoking continues to be a national healthcare crisis and is responsible for unacceptable levels of suffering, disease, and death. The barriers to effective intervention such as training, time, and reimbursement are formidable, although the situation is improving as the proper behavioral approaches and medications become clearly defined. Application of these practical points is an acquired skill that takes time. Incorporating these suggestions into daily practice ensures that your smoking patients have the best opportunity to quit and the highest level of care.",0,0,
1655,Smoking cessation in family medicine: effects of an area health education center training program,"BACKGROUND AND OBJECTIVES: Many clinicians have not received adequate training in smoking cessation. We examined the effects of a tobacco training program on clinician behavior, attitudes, knowledge, and comfort related to smoking cessation. METHODS: In a prospective cohort study, family medicine residents and faculty completed a pretest, followed by an educational intervention that encompassed presentations on smoking cessation resources, motivational interviewing, and the neurobiology of addiction and pharmacotherapy. After 3 months, participants completed a postintervention survey. Results were analyzed using chi-square tests to examine the effects of training. RESULTS: Thirty-three residents and faculty completed the pretraining survey and 25 completed the posttraining survey. Following training, participants were more familiar and comfortable with Public Health Service Clinical Practice Guidelines (P < .0001). No significant differences were found in performance of the 5 As (Ask, Advise, Assess, Assist, and Arrange) or other behaviors, including providing assistance with counseling, cessation plans, resources, or pharmacotherapy. There were no improvements in knowledge of specific intervention plans or attitudes related to identifying and counseling smokers. CONCLUSION: A multidisciplinary tobacco training program increases clinician familiarity and comfort with practice guidelines, and may contribute to improving care activities that promote a healthy lifestyle. Future research should explore other interventions that have the potential of changing practice patterns on a larger scale. Future studies should also assess the effect of training programs on patient-oriented outcomes.",0,0,
1656,Smoking cessation--a central role for physicians,"Physicians are in a unique position to advice smokers to quit by the ability to integrate the various aspects of nicotine dependence. This review provides an overview of intervention with smokers presenting in a primary care setting. Strategies used for smoking cessation counseling differed according to patient's readiness to quit. For smokers who do not intend to quit smoking, physicians should inform and sensitize patients about tobacco use and cessation, especially by personalizing benefits to quit and challenging smokers 'beliefs. For smokers who are dissonant, physicians should use motivational strategies, such as discussing barriers to cessation and their solutions. For smokers ready to quit, the physician should show strong support, help set a quit date, prescribe pharmaceutical therapies for nicotine dependence, such as replacement therapy and/or bupropion, with instructions for use, and suggest behavioral strategies to prevent relapse.",0,0,
1657,Smoking: can we really make a difference?,"The enormous health benefits of stopping smoking are now well established. Doctors have a vital role in motivating smokers and initiating quit attempts. The mainstay of National Health Service smoking cessation strategy should be the routine provision of brief opportunistic intervention in primary care, backed up by referral to a specialist smoking cessation service. There is an urgent need to increase substantially the numbers of smokers referred by general practitioners, other members of the primary care team, and those working in acute hospital trusts, to specialist smoking cessation services and for better channels of communication between the various agencies. Use of pharmacotherapy (nicotine replacement therapy or bupropion) in combination with behavioural support achieves higher cessation rates than either component alone and is the most effective way of helping smokers to stop. Smokers who quit often relapse and hence will need repeated help.",0,0,
1658,Social Status and Mortality,,0,0,
1659,Societal preferences for the return of incidental findings from clinical genomic sequencing: a discrete-choice experiment,"BACKGROUND: An important challenge with the application of next-generation sequencing technology is the possibility of uncovering incidental genomic findings. A paucity of evidence on personal utility for incidental findings has hindered clinical guidelines. Our objective was to estimate personal utility for complex information derived from incidental genomic findings. METHODS: We used a discrete-choice experiment to evaluate participants' personal utility for the following attributes: disease penetrance, disease treatability, disease severity, carrier status and cost. Study participants were drawn from the Canadian public. We analyzed the data with a mixed logit model. RESULTS: In total, 1200 participants completed our questionnaire (available in English and French). Participants valued receiving information about high-penetrance disorders but expressed disutility for receiving information on low-penetrance disorders. The average willingness to pay was $445 (95% confidence interval [CI] $322-$567) to receive incidental findings in a scenario where clinicians returned information about high-penetrance, medically treatable disorders, but only 66% of participants (95% CI 63%-71%) indicated that they would choose to receive information in that scenario. On average, participants placed an important value ($725, 95% CI $600-$850) on having a choice about what type of findings they would receive, including receipt of information about high-penetrance, treatable disorders or receipt of information about high-penetrance disorders with or without available treatment. The predicted uptake of that scenario was 76% (95% CI 72%-79%). INTERPRETATION: Most participants valued receiving incidental findings, but personal utility depended on the type of finding, and not all participants wanted to receive incidental results, regardless of the potential health implications. These results indicate that to maximize benefit, participant-level preferences should inform the decision about whether to return incidental findings.",0,0,
1660,Society for Adolescent Medicine Position Paper on Reproductive Health Care for Adolescents,"PIP: This article is a revision of a 1983 position paper of the Society for Adolescent Medicine with inclusion of the newest medical advances in research on adolescent sexuality""; i.e., contraceptive compliance, promotion of behavior change, relationships of ethnicity and pregnancy, and male reproductive health. The issues for the 1990's will be sexually transmitted diseases' morbidity and mortality. Topics identified are sexual activity and adolescent pregnancy, care of the pregnant teen, sexually transmitted diseases, HIV infection, the male adolescent, sexual abuse in adolescents, gay and lesbian youth, interventions, reproductive health care of adolescents with disabilities and chronic illnesses, and training of primary care physicians. The HIV/AIDS epidemic has focused attention on the reproductive behavior of males. Sexual activity varies by racial/ethnic group. Interventions to delay sexual initiation needs to be examined, although condom use has increased among 17-19 year olds from 21% to 58% in metropolitan areas. However condom use is lowest among the group of men at highest risk of STDs: those who had ever used drugs, those who had ever had sex with a prostitute, and those that had 5 or more partners/year. Male beliefs about contraception have been infrequently examined. There are misconceptions about heterosexual transmission of HIV. Better screening is needed for STD detection. Fathers are more involved in prenatal care and postnatal intervention programs. 7% of children have been subjected to nonvoluntary sexual intercourse between the ages of 18-21. ;"" i.e., 12.7% of white women, 9% of black women, 1.9% of white males, and 6.1% of black males. Risk factors for white women were living apart form parents at 16 years, poverty, physical and emotional limitations, parental alcohol and smoking and drug use. Sexual assault was associated with hitchhiking and alcohol and drug use in 1 study cited. Physicians need to be sensitive to this issue and probe for information. The sexual needs of those unsure of orientation or who a re homosexual or lesbian are gradually becoming recognized. Among 12th graders. 1% of males and 1% of females viewed themselves as mostly or completely homosexual or lesbian, and 10% were unsure. Psychological and medical problems are encountered. Interventions needed are reproductive and STd information, multiple approaches in a variety of settings, adolescent clinics, and outreach.",0,0,
1661,"Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults","Context.¡ª A prominent hypothesis regarding social inequalities in mortality is that the elevated risk among the socioeconomically disadvantaged is largely due to the higher prevalence of health risk behaviors among those with lower levels of education and income.  Objective.¡ª To investigate the degree to which 4 behavioral risk factors (cigarette smoking, alcohol drinking, sedentary lifestyle, and relative body weight) explain the observed association between socioeconomic characteristics and all-cause mortality.  Design.¡ª Longitudinal survey study investigating the impact of education, income, and health behaviors on the risk of dying within the next 7.5 years.  Participants.¡ª A nationally representative sample of 3617 adult women and men participating in the Americans' Changing Lives survey.  Main Outcome Measure.¡ª All-cause mortality verified through the National Death Index and death certificate reviews.  Results.¡ª Educational differences in mortality were explained in full by the strong association between education and income. Controlling for age, sex, race, urbanicity, and education, the hazard rate ratio of mortality was 3.22 (95% confidence interval [CI], 2.01-5.16) for those in the lowest-income group and 2.34 (95% CI, 1.49-3.67) for those in the middle-income group. When health risk behaviors were considered, the risk of dying was still significantly elevated for the lowest-income group (hazard rate ratio, 2.77""; 95% CI, 1.74-4.42) and the middle-income group (hazard rate ratio, 2.14;"" 95% CI, 1.38-3.25).  Conclusion.¡ª Although reducing the prevalence of health risk behaviors in low-income populations is an important public health goal, socioeconomic differences in mortality are due to a wider array of factors and, therefore, would persist even with improved health behaviors among the disadvantaged.",0,0,
1662,Sources of Variation and Bias in Studies of Diagnostic Accuracy,"Background: Studies of diagnostic accuracy are subject to different sources of bias and variation than studies that evaluate the effectiveness of an intervention. Little is known about the effects of these sources of bias and variation.  Purpose: To summarize the evidence on factors that can lead to bias or variation in the results of diagnostic accuracy studies.  Data Sources: MEDLINE, EMBASE, and BIOSIS, and the methodologic databases of the Centre for Reviews and Dissemination and the Cochrane Collaboration. Methodologic experts in diagnostic tests were contacted.  Study Selection: Studies that investigated the effects of bias and variation on measures of test performance were eligible for inclusion, which was assessed by one reviewer and checked by a second reviewer. Discrepancies were resolved through discussion.  Data Extraction: Data extraction was conducted by one reviewer and checked by a second reviewer.  Data Synthesis: The best-documented effects of bias and variation were found for demographic features, disease prevalence and severity, partial verification bias, clinical review bias, and observer and instrument variation. For other sources, such as distorted selection of participants, absent or inappropriate reference standard, differential verification bias, and review bias, the amount of evidence was limited. Evidence was lacking for other features, including incorporation bias, treatment paradox, arbitrary choice of threshold value, and dropouts.  Conclusions: Many issues in the design and conduct of diagnostic accuracy studies can lead to bias or variation"";"" however, the empirical evidence about the size and effect of these issues is limited.",0,0,
1663,Spotting the malignant melanoma,,0,0,
1664,Stability of Attitudes to the Ethical Issues Raised by the Return of Incidental Genomic Research Findings in Children: A Follow-Up Study,"OBJECTIVE: We explore the stability of parental attitudes to the ethical issues raised by the return of genomic research results. METHODS: A 19-item questionnaire was mailed to participants in a large genome research consortium 18 months following a baseline survey. We describe the stability of parental attitudes to (a) sharing of genomic research results, (b) endorsement of children in genomic research, (c) responsibilities of researchers, and (d) responsibilities to extended family. We also explore their experience in receiving results. RESULTS: Of 170 original participants, 154 (91%) responded. Most participants expressed positive rights to receive incidental genomic research findings (85%), including when ameliorative therapy was unknown (85%). Only 3% found it acceptable to delegate the decision to return results to an independent committee. Researchers, either with a parent (42%) or physician (17%), were felt to be responsible to convey research results to children when they reach adulthood. Most participants (74%) indicated that results should be shared with potentially affected extended family. These results are very similar to those of the baseline survey. All participants who received genomic results would do so again and reported actions similar to their expressed attitudes. CONCLUSIONS: The opinions of parents regarding genomic research remain stable over time. Guidelines on the return of results should incorporate these findings.",0,0,
1665,Staged diabetes management: computerizing a disease state management program,"Recently, the Diabetes Control and Complication Trial (DCCT) and other similar studies have demonstrated that near-normalization of blood glucose in diabetes will reduce complications up to 75% but translation of these results into practice has been difficult. In an attempt to help provide the best possible control of patients with diabetes, we have produced an attempt to help provide the best possible control of patients with diabetes, we have produced a new disease state management system for diabetes, called ""Staged Diabetes Management"" (SDM), implemented it in over 100 sites worldwide, and developed a computer program to simplify its use. SDM, designed to change the way we deal with patients with diabetes, is based upon five principles: (1) community involvement in setting care guidelines""; (2) negotiation of goals with patients; (3) appropriate timelines for therapeutic success; (4) use of flowcharts for medical decisions;"" and (5) evaluation of the program. SDM is designed to be altered by a community to meet its needs and resources. It encourages primary care physicians to deliver better diabetes care using a team approach and to refer patients with diabetes to specialists when appropriate. It has a complete set of materials for communities, individual health care providers and patients. SDM has been tested for changes in structure, process and outcomes. A meta-analysis of seven clinical trials with over 500 patients has shown a time-weighted average fall in hemoglobin A1c of 1.7 points (equivalent to a drop in mean blood glucose of about 3.5 mM or 60 mg/dL). Preliminary pharmacoeconomic analysis demonstrates a lifetime cost saving of over $27,000 per patient. A computer program has been developed for the Microsoft Windows environment that contains a client-server database, based upon DiabCare, for the data file structure.",0,0,
1666,Standard operating procedure changed pre-hospital critical care anaesthesiologists' behaviour: a quality control study,"INTRODUCTION: The ability of standard operating procedures to improve pre-hospital critical care by changing pre-hospital physician behaviour is uncertain. We report data from a prospective quality control study of the effect on pre-hospital critical care anaesthesiologists' behaviour of implementing a standard operating procedure for pre-hospital controlled ventilation. MATERIALS AND METHODS: Anaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region prospectively registered pre-hospital advanced airway-management data according to the Utstein-style template. We collected pre-intervention data from February 1st 2011 to January 31st 2012, implemented the standard operating procedure on February 1st 2012 and collected post intervention data from February 1st 2012 until October 31st 2012. We included transported patients of all ages in need of controlled ventilation treated with pre-hospital endotracheal intubation or the insertion of a supraglottic airways device. The objective was to evaluate whether the development and implementation of a standard operating procedure for controlled ventilation during transport could change pre-hospital critical care anaesthesiologists' behaviour and thereby increase the use of automated ventilators in these patients. RESULTS: The implementation of a standard operating procedure increased the overall prevalence of automated ventilator use in transported patients in need of controlled ventilation from 0.40 (0.34-0.47) to 0.74 (0.69-0.80) with a prevalence ratio of 1.85 (1.57-2.19) (p = 0.00). The prevalence of automated ventilator use in transported traumatic brain injury patients in need of controlled ventilation increased from 0.44 (0.26-0.62) to 0.85 (0.62-0.97) with a prevalence ratio of 1.94 (1.26-3.0) (p = 0.0039). The prevalence of automated ventilator use in patients transported after return of spontaneous circulation following pre-hospital cardiac arrest increased from 0.39 (0.26-0.48) to 0.69 (0.58-0.78) with a prevalence ratio of 1.79 (1.36-2.35) (p = 0.00). CONCLUSION: We have shown that the implementation of a standard operating procedure for pre-hospital controlled ventilation can significantly change pre-hospital critical care anaesthesiologists' behaviour.",0,1,
1667,Standards for Reporting Implementation Studies (StaRI) Statement,"Implementation studies are often poorly reported and indexed, reducing their potential to inform initiatives to improve healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aimed to develop guidelines for transparent and accurate reporting of implementation studies. Informed by the findings of a systematic review and a consensus-building e-Delphi exercise, an international working group of implementation science experts discussed and agreed the StaRI Checklist comprising 27 items. It prompts researchers to describe both the implementation strategy (techniques used to promote implementation of an underused evidence-based intervention) and the effectiveness of the intervention that was being implemented. An accompanying Explanation and Elaboration document (published in BMJ Open, doi:10.1136/bmjopen-2016-013318) details each of the items, explains the rationale, and provides examples of good reporting practice. Adoption of StaRI will improve the reporting of implementation studies, potentially facilitating translation of research into practice and improving the health of individuals and populations.",0,0,
1668,State of the science: beta-blockers and reduction of perioperative cardiac events,"This article evaluates the current literature concerning the use of perioperative beta-blockade to reduce cardiac events in hopes that it may provide direction to clinicians or demonstrate gaps in medical knowledge, thus revealing areas suitable for future study. The current standard of practice for the use of perioperative beta-blockade in preoperative patients is outlined in the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines. Findings differ as to the risk and benefit of using beta-blockers perioperatively to reduce cardiac events. Further research is needed to support the ACC/AHA recommendations. It is essential that the decision to use beta-blockade be made on a case-by-case basis with adequate risk stratification as part of the criteria.",0,0,
1669,Sticking to minimum standards: implementing antibiotic stewardship in intensive care,"BACKGROUND: In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers. AIM: This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital. METHODS: We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record. RESULTS: Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) (P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice. CONCLUSION: A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices.",0,0,
1670,Stimulant drugs,"Stimulants are a key element in the treatment of ADHD. Carefully designed trials of stimulants have found substantial improvement in ADHD core behaviours in 65-75 % of subjects with ADHD. Most standard stimulants are rapidly absorbed, with their behavioural effects appearing within 30 minutes, reaching a peak within one to three hours and disappearing within five hours. Doses at school are often necessary, in spite of the risk of peer ridicule and added adult supervision requirements. The mechanism by which stimulants act to reduce hyperactivity is not completely understood, but they improve impulsivity and activity levels. Several controlled evaluations made over periods of time greater than a year show a clear persistence of medication effects over time. A carefully crafted programme of treatment with methylphenidate is more effective in the reduction of hyperactivity symptoms than an intensive programme of behavioural and cognitive intervention. The combination of stimulants with psychosocial interventions in ADHD offers few advantages over medication alone. Unchallengeable guides to practice that would be appropriate everywhere are difficult to propose. It is imperative that clinicians prescribing stimulants should monitor the use of the drug properly, making sure that it is not being abused by the child's family, peers or those dispensing medication at school. Polypharmacy should only be embarked on by a specialist service and the combination of methylphenidate and clonidine should be used cautiously. Apart from ADHD, stimulants are useful in narcolepsy, resistant depression and partial syndromes of attention and hyperactivity. Major gaps in knowledge remain"";"" pharmacokinetics, pharmacodynamics and pharmacogenetics of stimulant effects need further study. Details of stimulant administration regimes seem to have a major effect on the response achieved. Further research is needed, preferably in realistic practice settings, comparing different forms of combination with psychological interventions, investigating the effects in groups of children outside the core of schoolaged children with typical ADHD: preschool children, adults, those with partial syndromes (such as inattentiveness) and those with co-morbid disorders.",0,0,
1671,Strangling the future,,0,0,
1672,Strategies for rehabilitation professionals to move evidence-based knowledge into practice: a systematic review,"RATIONALE: Rehabilitation clinicians need to stay current regarding best practices, especially since adherence to clinical guidelines can significantly improve patient outcomes. However, little is known about the benefits of knowledge translation interventions for these professionals. OBJECTIVES: To examine the effectiveness of single or multi-component knowledge translation interventions for improving knowledge, attitudes, and practice behaviors of rehabilitation clinicians. METHODS: Systematic review of 7 databases conducted to identify studies evaluating knowledge translation interventions specific to occupational therapists and physical therapists. RESULTS: 12 studies met the eligibility criteria. For physical therapists, participation in an active multi-component knowledge translation intervention resulted in improved evidence-based knowledge and practice behaviors compared with passive dissemination strategies. These gains did not translate into change in clinicians' attitudes towards best practices. For occupational therapists, no studies have examined the use of multi-component interventions"";"" studies of single interventions suggest limited evidence of effectiveness for all outcomes measured. CONCLUSION: While this review suggests the use of active, multi-component knowledge translation interventions to enhance knowledge and practice behaviors of physical therapists, additional research is needed to understand the impact of these strategies on occupational therapists. Serious research gaps remain regarding which knowledge translation strategies impact positively on patient outcomes.",0,1,
1673,Strengthening general practice,,0,0,
1674,Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and Elaboration,"Much medical research is observational. The reporting of observational studies is often of insufficient quality. Poor reporting hampers the assessment of the strengths and weaknesses of a study and the generalisability of its results. Taking into account empirical evidence and theoretical considerations, a group of methodologists, researchers, and editors developed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations to improve the quality of reporting of observational studies. The STROBE Statement consists of a checklist of 22 items, which relate to the title, abstract, introduction, methods, results and discussion sections of articles. Eighteen items are common to cohort studies, case-control studies and cross-sectional studies and four are specific to each of the three study designs. The STROBE Statement provides guidance to authors about how to improve the reporting of observational studies and facilitates critical appraisal and interpretation of studies by reviewers, journal editors and readers. This explanatory and elaboration document is intended to enhance the use, understanding, and dissemination of the STROBE Statement. The meaning and rationale for each checklist item are presented. For each item, one or several published examples and, where possible, references to relevant empirical studies and methodological literature are provided. Examples of useful flow diagrams are also included. The STROBE Statement, this document, and the associated Web site (http://www.strobe-statement.org/) should be helpful resources to improve reporting of observational research.",0,0,
1675,Stress as a cardiovascular risk factor,"Stress is a reaction of the organism to a stressor with various negative health consequences including the development of arteriosclerosis. Stress may cause myocardial ischemia, rhythm disturbances, platelet stimulation, increased blood viscosity through hemoconcentration as well as endothelial dysfunction and coronary vasoconstriction in the presence of arteriosclerosis of the coronary arteries. Psychosocial risk factors may also lead to the development and to clinical consequences of arteriosclerosis. The five most important psychosocial risk factors are: depression, anxiety, personality factors, social isolation and chronic life stress. Various components are responsible for the fact that life events or certain psychosocial factors can lead to a stress reaction. Psychosocial risk factors have direct pathophysiologic effects but also influence life style and behavior Various stress management intervention programs have proven to be effective. Psychosocial intervention in conjunction with cardiac rehabilitation programs has shown to reduce cardiovascular morbidity and mortality.",0,0,
1676,Stress echocardiography in heart failure,"Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.",0,0,
1677,Structured follow-up by general practitioners after deliberate self-poisoning: a randomised controlled trial,"BACKGROUND: General Practitioners (GPs) play an important role in the follow-up of patients after deliberate self-poisoning (DSP). The aim was to examine whether structured follow-up by GPs increased the content of, adherence to, and satisfaction with treatment after discharge from emergency departments. METHODS: This was a multicentre, randomised trial with blinded assignment. Five emergency departments and general practices in the catchment area participated. 202 patients discharged from emergency departments after DSP were assigned. The intervention was structured follow-up by the GP over a 6-month period with a minimum of five consultations, accompanied by written guidelines for the GPs with suggestions for motivating patients to follow treatment, assessing personal problems and suicidal ideation, and availability in the case of suicidal crisis. Outcome measures were data retrieved from the Register for the control and payment of reimbursements to health service providers (KUHR) and by questionnaires mailed to patients and GPs. After 3 and 6 months, the frequency and content of GP contact, and adherence to GP consultations and treatment in general were registered. Satisfaction with general treatment received and with the GP was measured by the EUROPEP scale. RESULTS: Patients in the intervention group received significantly more consultations than the control group (mean 6.7 vs. 4.5 (p = 0.004)). The intervention group was significantly more satisfied with the time their GP took to listen to their personal problems (93.1% vs. 59.4% (p = 0.002)) and with the fact that the GP included them in medical decisions (87.5% vs. 54. 8% (p = 0.009)). The intervention group was significantly more satisfied with the treatment in general than the control group (79% vs. 51% (p = 0.026)). CONCLUSIONS: Guidelines and structured, enhanced follow-up by the GP after the discharge of the DSP patient increased the number of consultations and satisfaction with aftercare in general practice. Consistently with previous research, there is still a need for interventional studies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01342809. Registered 18 April 2011.",0,0,
1678,Structured smoking cessation training for health professionals on cardiology wards: a prospective study,"BACKGROUND: Smoking is a major cardiovascular risk factor, and smoking cessation is imperative for patients hospitalized with a cardiovascular event. This study aimed to evaluate a systems-based approach to helping hospitalized smokers quit and to identify implementation barriers. DESIGN: Prospective intervention study followed by qualitative analysis of staff interviews. METHODS: The prospective intervention study assessed the effects of implementing standard operating procedures (SOPs) for the provision of counselling and pharmacotherapy to smokers admitted to cardiology wards on counselling frequency. In addition, a qualitative analysis of staff interviews was undertaken to examine determinants of physician and nurse behaviour"";"" this sought to understand barriers in terms of motivation, capability, and/or opportunity. RESULTS: A total of 150 smoking patients were included in the study (75 before and 75 after SOP implementation). Before the implementation of SOPs, the proportion of patients reporting to have received cessation counselling from physicians and nurses was 6.7% and 1.3%, respectively. Following SOP implementation, these proportions increased to 38.7% (p < 0.001) and 2.7% (p = 0.56), respectively. Qualitative analysis revealed that lack of motivation, e.g. role incongruence, appeared to be a major barrier. CONCLUSIONS: Introduction of a set of standard operating procedures for smoking cessation advice was effective with physicians but not nurses. Analysis of barriers to implementation highlighted lack of motivation rather than capability or opportunity as a major factor that would need to be addressed.",0,1,
1679,Study confirms value of STD treatment in curbing HIV transmission,"PIP: An intervention was conducted in the Mwanza Region of Tanzania to determine whether the improved treatment at rural health centers and dispensaries of sexually transmitted diseases (STD) other than HIV/AIDS could reduce the incidence of new HIV infections. Medical assistants and nurses in six rural health centers were trained in the syndromic management of STDs, and health center staff were encouraged to counsel their patients, offer them condoms, and ask for referrals of sex partners for treatment. The centers received the least expensive effective drugs for treating the major STD syndromes. Health workers trained as supervisors visited each center every 8 weeks to check drug supplies and patient records, provide refresher training, and ensure adherence to the syndromic management guidelines. Moreover, a cohort of 1000 adults in the communities served by the six health centers was interviewed and tested for HIV at the beginning of the study and 2 years after the intervention was introduced. The number of new cases of HIV infection occurring in the cohort was then compared with that occurring in another cohort selected from communities served by health centers where improved STD treatment had not been provided. 11,632 cases of STD were treated at the centers during the 2-year study period. It was determined that the intervention reduced by 42% the number of new HIV infections occurring over the study period. That reduction was across both sexes and all age groups, but evident especially among women aged 15-24 years. Survey results indicate that the reductions in HIV incidence were the result of improved STD treatment rather than changes in sexual behavior. Preliminary calculations indicate a cost of approximately US$300 per HIV infection averted.",0,0,
1680,Study of a novel curriculum on electronic communication in family medicine residencies,"Electronic communication between physicians and patients is common but can carry risks to users--both patients and physicians. Little is known about electronic communication between physicians and patients and even less about electronic communication during residency. We studied knowledge and practices before and after a controlled test of a novel curriculum teaching e-mail communication with patients using residents and faculty in 16 family medicine residencies in the United States. Both faculty and residents showed a lack of knowledge of confidentiality and encryption, little familiarity with published guidelines for physician-patient e-mail, and noncompliance with documentation requirements before the curriculum was presented. Posttests revealed a greater improvement in knowledge and appropriate behaviors related to patient-physician e-mail in the intervention group compared to control sites (mean intervention increase is 13 points[t=-4.065, P<.01], mean control increase is 5 points [t=-2.015, P<.05]). An increased uncertainty about comfort with patient e-mail among intervention residents is an interesting result that could be due to heightened awareness of issues but limited time devoted to absorbing the topic. Suggestions for delivering the curriculum are provided.",0,0,
1681,Study protocol for a randomized controlled trial: the feasibility and impact of cardiovascular absolute risk assessment in Australian general practice,"BACKGROUND: Although cardiovascular absolute risk (CVAR) assessment has been recommended for use in Australian general practice for a number of years, there is continuing uncertainty about its implementation and impact. Our previous work has developed a multifaceted implementation model. This study aims to investigate both the feasibility of using this model and the impact of CVAR assessment and management on general practice clinical processes and patient care. STUDY DESIGN: This cluster randomized controlled trial will be conducted in general practices in Sydney, involving general practitioners (GPs), other practice staff, and patients aged 45 to 69 years without existing cardiovascular disease. METHODS: A total of 32 practices (40 GPs) and 1,320 patients will be recruited. Randomization will be conducted at the practice level. The intervention group of GPs will be trained to use a CVAR implementation model, whereas the control group of GPs will continue usual care. Study outcomes include clinical processes, patient risk, use of lifestyle intervention, and prescription of antihypertensive and lipid-lowering medications. Data will be collected and analyzed using mixed methods. Study outcomes before and after the intervention will be compared, and the 2 groups will also be compared after adjusting for baseline difference and clustering factors. DISCUSSION: This trial will be the first study in Australian general practice and one of few international studies to evaluate the impact of implementing CVAR assessment and management. Results of this study will help improve the primary prevention of cardiovascular disease and inform guidelines for clinical practice and the implementation of other health initiatives.",0,0,
1682,Studying de-implementation in health: an analysis of funded research grants,"Background Studying de-implementation¡ªdefined herein as reducing or stopping the use of a health service or practice provided to patients by healthcare practitioners and systems¡ªhas gained traction in recent years. De-implementing ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices is important for mitigating patient harm, improving processes of care, and reducing healthcare costs. A better understanding of the state-of-the-science is needed to guide future objectives and funding initiatives. To this end, we characterized de-implementation research grants funded by the United States (US) National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).  Methods We used systematic methods to search, identify, and describe de-implementation research grants funded across all 27 NIH Institutes and Centers (ICs) and AHRQ from fiscal year 2000 through 2017. Eleven key terms and three funding opportunity announcements were used to search for research grants in the NIH Query, View and Report (QVR) system. Two coders identified eligible grants based on inclusion/exclusion criteria. A codebook was developed, pilot tested, and revised before coding the full grant applications of the final sample.  Results A total of 1277 grants were identified through the QVR system"";"" 542 remained after removing duplicates. After the multistep eligibility assessment and review process, 20 grant applications were coded. Many grants were funded by NIH (n?=?15), with fewer funded by AHRQ, and a majority were funded between fiscal years 2015 and 2016 (n?=?11). Grant proposals focused on de-implementing a range of health services and practices (e.g., medications, therapies, screening tests) across various health areas (e.g., cancer, cardiovascular disease) and delivery settings (e.g., hospitals, nursing homes, schools). Grants proposed to use a variety of study designs and research methods (e.g., experimental, observational, mixed methods) to accomplish study aims.  Conclusions Based on the systematic portfolio analysis of NIH- and AHRQ-funded research grants over the past 17 years, relatively few have focused on studying the de-implementation of ineffective, unproven, harmful, overused, inappropriate, and/or low-value health services and practices provided to patients by healthcare practitioners and systems. Strategies for raising the profile and growing the field of research on de-implementation are discussed.",0,0,
1683,Success after treatment of periprosthetic joint infection: a Delphi-based international multidisciplinary consensus,"BACKGROUND: The lack of agreement regarding what constitutes successful treatment for periprosthetic joint infections (PJI) makes it difficult to compare the different strategies of management that are used in clinical practice and in research studies. QUESTIONS/PURPOSES: The aims of this study were to create a consensus definition for success after PJI treatment, and to provide a universal, multidimensional framework for reporting of studies regarding PJI treatment. METHODS: A two-round basic Delphi method was used to reach a consensus definition. We invited 159 international experts (orthopaedic surgeons, infectious disease specialists, and clinical researchers) from 17 countries to participate""; 59 participated in the first round, and 42 participated in the second round. The final definition consisted of all statements that achieved strong agreement (80% or greater of participants considering a criterion relevant for defining success). RESULTS: The consensus definition of a successfully treated PJI is: (1) infection eradication, characterized by a healed wound without fistula, drainage, or pain, and no infection recurrence caused by the same organism strain; (2) no subsequent surgical intervention for infection after reimplantation surgery;"" and (3) no occurrence of PJI-related mortality (by causes such as sepsis, necrotizing fasciitis). The Delphi panel agreed to defining midterm results as those reported 5 or more years after the definitive PJI surgery, and long-term results as those reported 10 or more years after surgery. Although no consensus was reached on the definition of short-term results, 71% of the participants agreed that 2 years after the definitive PJI surgery is acceptable to define it. CONCLUSIONS: This multidimensional definition of success after PJI treatment may be used to report and compare results of treatment of this catastrophic complication. LEVEL OF EVIDENCE: Level V, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.",0,0,
1684,"Successful implementation of a guideline by peer comparisons, education, and positive physician feedback","The objective of this study was to determine if peer comparisons, an educational intervention, and positive physician feedback would decrease ordering of knee X-ray studies. We prospectively studied the ordering of knee X-ray studies for patients presenting with knee injuries before and after an educational program to encourage use of the Ottawa decision rule for knee radiography. Physicians were able to privately compare their individual baseline X-ray utilization data with that of their colleagues. Although acceptance of the rule was voluntary, both oral and written feedback encouraged consideration of the rule in clinical decision-making. The percentage of knee injury patients who received X-ray studies, as well as the Percentage Abnormal Results (PAR, defined as the percentage of X-ray studies demonstrating a fracture or effusion), were calculated before and after the educational meeting. Results of the study showed that the percentage of patients presenting with knee injuries who received X-ray studies decreased 23%. In addition, the PAR increased 58.4% between the two study periods. In conclusion, physician behavior can be altered positively with reinforcement. Peer comparisons, education, and positive physician feedback decreased test ordering by physicians even without mandating use of a protocol. PAR is a useful outcome measure to track physician utilization.",0,1,
1685,Successful implementation of a neonatal pain and sedation protocol at 2 NICUs,"OBJECTIVE: To evaluate the implementation of a neonatal pain and sedation protocol at 2 ICUs. METHODS: The intervention started with the evaluation of local practice, problems, and staff satisfaction. We then developed and implemented the Vienna Protocol for Neonatal Pain and Sedation. The protocol included well-defined strategies for both nonpharmacologic and pharmacologic interventions based on regular assessment of a translated version of the Neonatal Pain Agitation and Sedation Scale and titration of analgesic and sedative therapy according to aim scores. Health care staff was trained in the assessment by using a video-based tutorial and bedside teaching. In addition, we performed reevaluation, retraining, and random quality checks. Frequency and quality of assessments, pharmacologic therapy, duration of mechanical ventilation, and outcome were compared between baseline (12 months before implementation) and 12 months after implementation. RESULTS: Cumulative median (interquartile range) opiate dose (baseline dose of 1.4 [0.5-5.9] mg/kg versus intervention group dose of 2.7 [0.4-57] mg/kg morphine equivalents""; P = .002), pharmacologic interventions per episode of continuous sedation/analgesia (4 [2-10] vs 6 [2-13]; P = .005), and overall staff satisfaction (physicians: 31% vs 89%; P < .001; nurses: 17% vs 55%;"" P < .001) increased after implementation. Time on mechanical ventilation, length of stay at the ICU, and adverse outcomes were similar before and after implementation. CONCLUSIONS: Implementation of a neonatal pain and sedation protocol at 2 ICUs resulted in an increase in opiate prescription, pharmacologic interventions, and staff satisfaction without affecting time on mechanical ventilation, length of intensive care stay, and adverse outcomes.",0,0,
1686,Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal.,"Background Despite using sterile technique for catheter insertion, closed drainage systems, and structured daily care plans, catheter-associated urinary tract infections (CAUTIs) regularly occur in acute care hospitals. We believe that meaningful reduction in CAUTI rates can only be achieved by reducing urinary catheter use.  Methods We used an interventional study of a hospital-wide, multidisciplinary program to reduce urinary catheter use and CAUTIs on all patient care units in a 300-bed, community teaching hospital in Connecticut. Our primary focus was the implementation of a nurse-directed urinary catheter removal protocol. This protocol was linked to the physician’s catheter insertion order. Three additional elements included physician documentation of catheter insertion criteria, a device-specific charting module added to physician electronic progress notes, and biweekly unit-specific feedback on catheter use rates and CAUTI rates in a multidisciplinary forum.  Results We achieved a 50% hospital-wide reduction in catheter use and a 70% reduction in CAUTIs over a 36-month period, although there was wide variation from unit to unit in catheter reduction efforts, ranging from 4% (maternity) to 74% (telemetry).  Conclusion Urinary catheter use, and ultimately CAUTI rates, can be effectively reduced by the diligent application of relatively few evidence-based interventions. Aggressive implementation of the nurse-directed catheter removal protocol was associated with lower catheter use rates and reduced infection rates.",0,1,
1687,Suicidality: procedure in emergency cases,"Emergency physicians (EP), paramedics and the staff of the emergency room play an increasingly important role in the medical and psychological emergency treatment of patients after suicide attempts, as well as in the crisis intervention of persons with acute suicidal tendencies. This article aims to give an overview of the prevalence rates, methods of suicide or attempted suicide and the problems faced by EPs when treating these patients. In addition, concepts are presented which allow an adequate risk assessment of suicidality and the options for primary crisis intervention. Paramedics and intensive care clinicians are increasingly confronted with this complex process with social, personal and medical aspects. In order to treat people in suicidal crises and/or after a suicide attempt and to provide a safe and optimal care for this often heterogeneous group of patients, clear guidelines are a prerequisite. The first assessment of the acute danger of suicide is of particular importance due to the resulting consequences and a clear approach is demonstrated for dealing with suicidal people. Furthermore, the legal principles are presented.",0,0,
1688,Suicide and violence assessment in psychiatry,"Psychiatrists are increasingly expected to predict and prevent the suicidal and violent/homicidal impulses of their clients. This article reviews the current literature and research in these areas. While the debate continues on whether the clinician can successfully predict either violence or suicidal behavior in their patients, the preponderance of studies weighs in that predicting suicide and violence in the individual may not be possible currently given present knowledge. To compensate for forecasting limitations, conservative clinicians deliberately overpredict suicide or violence to help insure the safety of their patients and the greater communities in which they reside. In addition, clinicians need to perform thorough assessments and make logical clinical decisions that are in line with the perceived risks. Preventive measures for violence remain complex, but clinicians can maximize treatment effects by following specific intervention guidelines. Minimally, documentation concerning violence needs to focus on the rationale for why treatment interventions were or were not implemented. The chart does not require lengthy notations but should include a reasonable assessment of risk and the delineation of a prudent course of action.",0,0,
1689,Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior,"These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.",0,0,
1690,Supporting clinical practice at the bedside using wireless technology.,"Objectives: Despite studies that show improvements in both standards of care and outcomes with the judicious application of clinical practice guidelines (CPGs), their clinical utilization remains low. This randomized controlled trial examined the use of a wirelessly networked mobile computer (MC) by physicians at the bedside with access to an emergency department information system, decision support tools (DSTs), and other software options. Methods: Each of ten volunteer emergency physicians was randomized using a matched‐pair design to work five shifts in standard fashion (desktop computer [DC] access) and five shifts with a wirelessly networked MC. Work pattern issues and electronic CPG/DST use were compared using end‐of‐shift satisfaction questionnaires and review of a CPG/DST database. Repeated‐measures analysis of variance was used to examine between‐shift differences. Results: A total of 100 eight‐hour shifts were evaluated""; 99% compliance with postshift questionnaires was achieved. Using a seven‐point Likert scale (MC values first), MCs were rated as being as fast (5.04 vs. 4.54; p = 0.13) and convenient (5.08 vs. 4.14; p = 0.07) as DCs. Overall, physicians rated MCs to be less efficient (3.18 vs. 4.30; p = 0.02) but encouraged more frequent use of DSTs (4.10 vs. 3.47; p = 0.03) without impacting doctor–patient communication (2.78 vs. 2.96; p = 0.51). During the study period, physician use of an intranet Web application (eCPG) was more frequent during shifts assigned to the MC when compared with the DC (eCPG uses/shift, 3.6 vs. 2.0;"" p = 0.033). Conclusions: The MC technology permitted physicians to access information at the bedside and increased the use of CPG/DST tools. According to physicians, patients appeared to accept their use of information technology to assist in decision making. Development of improved computer technology may address the major limitation of MC portability.",0,1,
1691,Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial,"Objective To compare the effectiveness of a novel model of care (""Stepping Up"") with usual primary care in normalising insulin initiation for type 2 diabetes, leading to improved glycated haemoglobin (HbA1c) levels.Design Cluster randomised controlled trial.Setting Primary care practices in Victoria, Australia, with a practice nurse and at least one consenting eligible patient (HbA1c ≥7.5% with maximal oral treatment).Participants 266 patients with type 2 diabetes and 74 practices (mean cluster size 4 (range 1-8) patients), followed up for 12 months.Intervention The Stepping Up model of care intervention involved theory based change in practice systems and reorientation of the roles of health professionals in the primary care diabetes team. The core components were an enhanced role for the practice nurse in leading insulin initiation and mentoring by a registered nurse with diabetes educator credentials.Main outcome measures The primary endpoint was change in HbA1c. Secondary endpoints included the proportion of participants who transitioned to insulin, proportion who achieved target HbA1c, and a change in depressive symptoms (patient health questionnaire, PHQ-9), diabetes specific distress (problem areas in diabetes scale, PAID), and generic health status (assessment of quality of life instrument, AQoL-8D).Results HbA1c improved in both arms, with a clinically significant between arm difference (mean difference -0.6%, 95% confidence interval -0.9% to -0.3%), favouring the intervention. At 12 months, in intervention practices, 105/151 (70%) of participants had started insulin, compared with 25/115 (22%) in control practices (odds ratio 8.3, 95% confidence interval 4.5 to 15.4, P<0.001). Target HbA1c (≤7% (53 mmol/mol)) was achieved by 54 (36%) intervention participants and 22 (19%) control participants (odds ratio 2.2, 1.2 to 4.3, P=0.02). Depressive symptoms did not worsen at 12 months (PHQ-9: -1.1 (3.5) v -0.1 (2.9), P=0.05). A statistically significant difference was found between arms in the mean change in mental health (AQoL mental component summary: 0.04 (SD 0.16) v -0.002 (0.13), mean difference 0.04 (95% confidence interval 0.002 to 0.08), P=0.04), favouring the intervention, but no significant difference in physical health (AQoL physical component summary: 0.03 (0.15) v 0.02 (0.13)) nor diabetes specific distress (5.6 (15.5) v -2.4 (15.4)). No severe hypoglycaemia events were reported.Conclusions The Stepping Up model of care was associated with increased insulin initiation rates in primary care, and improvements in glycated haemoglobin without worsening emotional wellbeing.Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12612001028897.",0,0,
1692,Supporting middle-cadre health care workers in Malawi: lessons learned during implementation of the PALM PLUS package,"BACKGROUND: The government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector"";"" however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package. METHODS: A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings. RESULTS: Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances. CONCLUSIONS: The PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.",0,0,
1693,Surgical decision making and behavior. Social psychology explanations and research perspectives,"Social psychology is the discipline that investigates thought processes, emotions, and behaviors in the interpersonal context. There are three broad topic domains: understanding oneself and other persons, interpersonal relations, and group influence. The most important method is the experiment. The value of the social psychological perspective is illustrated with regard to the following surgical research questions: How do surgeons arrive at their decisions? How do surgeons confirm their decisions? Why do decision aids (computer support, guidelines) receive so little acceptance? How should patients be informed? Which group processes play a role in the operating theatre? What are the determinants of patient outcomes? Social psychology can extend surgical research in three respects: better understanding of everyday phenomena in the clinical and surgical arena, methodologically refined and stronger patient-oriented study designs, and new perspectives for improved patient outcomes.",0,0,
1694,Surgical treatments for men with benign prostatic enlargement: cost effectiveness study,"OBJECTIVE To determine which surgical treatment for lower urinary tract symptoms suggestive of benign prostate enlargement is cost effective. DESIGN Care pathways describing credible treatment strategies were decided by consensus. Cost-utility analysis used Markov modelling and Monte Carlo simulation. DATA SOURCES Clinical effectiveness data came from a systematic review and an individual level dataset. Utility values came from previous economic evaluations. Costs were calculated from National Health Service (NHS) and commercial sources. METHODS The Markov model included parameters with associated measures of uncertainty describing health states between which individuals might move at three monthly intervals over 10 years. Successive annual cohorts of 25,000 men were entered into the model and the probability that treatment strategies were cost effective was assessed with Monte Carlo simulation with 10,000 iterations. RESULTS A treatment strategy of initial diathermy vaporisation of the prostate followed by endoscopic holmium laser enucleation of the prostate in case of failure to benefit or subsequent relapse had an 85% probability of being cost effective at a willingness to pay value of pound20,000 (euro21,595, $28,686)/quality adjusted life year (QALY) gained. Other strategies with diathermy vaporisation as the initial treatment were generally cheaper and more effective than the current standard of transurethral resection repeated once if necessary. The use of potassium titanyl phosphate laser vaporisation incurred higher costs and was less effective than transurethral resection, and strategies involving initial minimally invasive treatment with microwave thermotherapy were not cost effective. Findings were unchanged by wide ranging sensitivity analyses. CONCLUSION The outcome of this economic model should be interpreted cautiously because of the limitations of the data used. The finding that initial vaporisation followed by holmium laser enucleation for failure or relapse might be advantageous both to men with lower urinary tract symptoms and to healthcare providers requires confirmation in a good quality prospective clinical trial before any change in current practice. Potassium titanyl phosphate laser vaporisation was unlikely to be cost effective in our model, which argues against its unrestricted use until further evidence of effectiveness and cost reduction is obtained.",0,0,
1695,Surrogate decision making for severely cognitively impaired research subjects: the continuing debate,"As research into Alzheimer's disease and other dementing disorders becomes more complex, risky, invasive, and commonplace, the need intensifies for discussion of the ethics of involving persons with dementia in research, specifically research of greater than minimal risk and of no expected direct benefit to the subject. (It is beyond the scope of this paper to consider the ethical issues related to research involvement of cognitively impaired children or children or adults with intermittent and/or reversible cognitive or psychiatric impairments. For such discussions, refer to the references in notes 1–6.) Reviewing such studies pushes our traditional analysis tools to their limits. Simply balancing and prioritizing the basic ethical principles of respect for persons, beneficence, and justice that serves us well in reviewing the vast majority of studies is inadequate when reviewing research of such ethical complexities as studies with marked risks and no expectation of direct benefit to subjects unable to consent or withdraw. Moving up to the level of theory, placing these principles within the commonly applied frameworks of consequentialism, deontology, or virtue ethics bring us no closer to reducing the tensions such research creates between upholding individual autonomy and advancing society's need to learn how to treat and cure these devastating diseases. What is needed is the introduction of more contemporary moral analyses. Specifically, we need to become more inclusive of the diversity of values perspectives of our general citizenry. In more theoretical terms, we ought to elevate to a more central role a communitarian perspective and a feminist ethics emphasis on relationships and context as we rush to keep in step, ethically, with this rapidly expanding area of medical inquiry.",0,0,
1696,Survivorship care plans and adherence to lifestyle recommendations among breast cancer survivors,"PURPOSE: The effectiveness of survivorship care plans has not been widely tested. We evaluated whether a one-time brief lifestyle consultation as part of a broader survivorship care plan was effective at changing diet and lifestyle patterns. METHODS: A diverse sample of women with stage 0-III breast cancer were randomized to control or intervention groups within 6 weeks of completing adjuvant treatment. Both groups received the National Cancer Institute publication, ""Facing Forward: Life after Cancer Treatment."" The intervention group also met with a nurse (1 h) and a nutritionist (1 h) to receive personalized lifestyle recommendations based upon national guidelines. Diet, lifestyle, and perceived health were assessed at baseline, 3 and 6 months. Linear regression analyses evaluated the effects of the intervention adjusted for covariates. RESULTS: A total of 126 women completed the study (60 control/66 intervention, 61 Hispanic/65 non-Hispanic). At 3 months, the intervention group reported greater knowledge of a healthy diet (P = 0.047), importance of physical activity (P = 0.03), and appropriate use of dietary supplements (P = 0.006) and reported lower frequency of alcohol drinking (P = 0.03) than controls. At 6 months, only greater knowledge of a healthy diet (P = 0.01) persisted. The intervention was more effective among non-Hispanics than Hispanics on improving attitude towards healthy eating (P = 0.03) and frequency of physical activity (P = 0.006). CONCLUSIONS: The intervention changed lifestyle behaviors and knowledge in the short-term, but the benefits did not persist. IMPLICATIONS FOR CANCER SURVIVORS: Culturally competent long-term behavioral interventions should be tested beyond the survivorship care plan to facilitate long-term behavior change among breast cancer survivors.",0,0,
1697,Syndrome resembling kwashiorkor after partial gastrectomy,,0,0,
1698,Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States,"Background: Each year millions of Americans enroll in commercial and self-help weight loss programs. Health care providers and their obese patients know little about these programs because of the absence of systematic reviews. Purpose: To describe the components, costs, and efficacy of the major commercial and organized self-help weight loss programs in the United States that provide structured in-person or online counseling. Data Sources: Review of company Web sites, telephone discussion with company representatives, and search of the MEDLINE database. Study Selection: Randomized trials at least 12 weeks in duration that enrolled only adults and assessed interventions as they are usually provided to the public, or case series that met these criteria, stated the number of enrollees, and included a follow-up evaluation that lasted 1 year or longer. Data Extraction: Data were extracted on study design, attrition, weight loss, duration of follow-up, and maintenance of weight loss. Data Synthesis: We found studies of eDiets.com, Health Management Resources, Take Off Pounds Sensibly, OPTIFAST, and Weight Watchers. Of 3 randomized, controlled trials of Weight Watchers, the largest reported a loss of 3.2% of initial weight at 2 years. One randomized trial and several case series of medically supervised very-low-calorie diet programs found that patients who completed treatment lost approximately 15% to 25% of initial weight. These programs were associated with high costs, high attrition rates, and a high probability of regaining 50% or more of lost weight in 1 to 2 years. Commercial interventions available over the Internet and organized self-help programs produced minimal weight loss. Limitations: Because many studies did not control for high attrition rates, the reported results are probably a best-case scenario. Conclusions: With the exception of 1 trial of Weight Watchers, the evidence to support the use of the major commercial and self-help weight loss programs is suboptimal. Controlled trials are needed to assess the efficacy and cost-effectiveness of these interventions.",0,0,
1699,Systematic Review: Elective Induction of Labor Versus Expectant Management of Pregnancy,"BACKGROUND: The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature.PURPOSE: To compare the benefits and harms of elective induction of labor and expectant management of pregnancy.DATA SOURCES: MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews.STUDY SELECTION: Experimental and observational studies of elective induction of labor reported in English.DATA EXTRACTION: Two authors abstracted study design""; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity.DATA SYNTHESIS: Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09]).LIMITATIONS: There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice.CONCLUSION: RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice;"" thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.",0,0,
1700,Systematic Review: The Long-Term Effects of False-Positive Mammograms,"BACKGROUND: Although abnormal screening mammograms deleteriously affect the psychological well-being of women during the time immediately surrounding the tests, their long-term effects are poorly understood.PURPOSE: To characterize the long-term effects of false-positive screening mammograms on the behavior and well-being of women 40 years of age or older.DATA SOURCES: English-language studies from the MEDLINE, Web of Science, EMBASE, CINAHL, PsycINFO, and ERIC databases through August 2006.STUDY SELECTION: Studies were identified that examined the effects of false-positive results of routine screening mammography on women's behavior, well-being, or beliefs.DATA EXTRACTION: Two investigators independently coded study characteristics, quality, and effect sizes.DATA SYNTHESIS: 23 eligible studies (n = 313,967) were identified. A random-effects meta-analysis showed that U.S. women who received false-positive results on screening mammography were more likely to return for routine screening than those who received normal results (risk ratio, 1.07 [95% CI, 1.02 to 1.12]). The effect was not statistically significant among European women (risk ratio, 0.97 [CI, 0.93 to 1.01]), and Canadian women were less likely to return for routine screening because of false-positive results (risk ratio, 0.63 [CI, 0.50 to 0.80]). Women who received false-positive results conducted more frequent breast self-examinations and had higher, but not apparently pathologically elevated, levels of distress and anxiety and thought more about breast cancer than did those with normal results.LIMITATIONS: Correlational study designs, a small number of studies, a lack of clinical validation for many measures, and possible heterogeneity.CONCLUSIONS: Some women with false-positive results on mammography may have differences in whether they return for mammography, occurrence of breast self-examinations, and levels of anxiety compared with women with normal results. Future research should examine how false-positive results on mammography affect other outcomes, such as trust and health care use.",0,0,
1701,Systematic Review: The Value of the Periodic Health Evaluation,"Background:The periodic health evaluation (PHE) has been a fundamental part of medical practice for decades despite a lack of consensus on its value.Purpose:To synthesize the evidence on benefits and harms of the PHE.Data Sources:Electronic searches of such databases as MEDLINE and the Cochrane Library, review of reference lists, and hand- searching of journals through September 2006.Study Selection:Studies (English-language only) assessing the delivery of preventive services, clinical outcomes, and costs among patients receiving the PHE versus those receiving usual care.Data Extraction:Study design and settings, descriptions of the PHE, and clinical outcomes associated with the PHE.Data Synthesis:The best available evidence assessing benefits or harms of the PHE consisted of 21 studies published from 1973 to 2004. The PHE had a consistently beneficial association with patient receipt of gynecologic examinations and Papanicolaou smears, cholesterol screening, and fecal occult blood testing. The PHE also had a beneficial effect on patient “worry” in 1 randomized, controlled trial but had mixed effects on other clinical outcomes and costs.Limitations:Descriptions of the PHE and outcomes were heterogeneous. Some trials were performed before U.S. Preventive Services Task Force guidelines were disseminated, limiting their applicability to modern practice.Conclusions:Evidence suggests that the PHE improves delivery of some recommended preventive services and may lessen patient worry. Although additional research is needed to clarify the long-term benefits, harms, and costs of receiving the PHE, evidence of benefits in this study justifies implementation of the PHE in clinical practice.""",0,0,
1702,Systematic reviews examining implementation of research into practice and impact on population health are needed,"OBJECTIVES: To examine the research translation phase focus (T1-T4) of systematic reviews published in the Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE). Briefly, T1 includes reviews of basic science experiments""; T2 includes reviews of human trials leading to guideline development; T3 includes reviews examining how to move guidelines into policy and practice;"" and T4 includes reviews describing the impact of changing health practices on population outcomes. STUDY DESIGN AND SETTING: A cross-sectional audit of randomly selected reviews from CDSR (n = 500) and DARE (n = 500) was undertaken. The research translation phase of reviews, overall and by communicable disease, noncommunicable disease, and injury subgroups, were coded by two researchers. RESULTS: A total of 898 reviews examined a communicable, noncommunicable, or injury-related condition. Of those, 98% of reviews within CDSR focused on T2, and the remaining 2% focused on T3. In DARE, 88% focused on T2, 8.7% focused on T1, 2.5% focused on T3, and 1.3% focused on T4. Almost all reviews examining communicable (CDSR 100%, DARE 93%), noncommunicable (CDSR 98%, DARE 87%), and injury (CDSR 95%, DARE 88%) were also T2 focused. CONCLUSION: Few reviews exist to guide practitioners and policy makers with implementing evidence-based treatments or programs.",0,0,
1703,Systemic inflammatory rheumatic diseases competence network,"The foundation of the competence network for rheumatology, which is funded by the ""Bundesministerium fur Bildung und Forschung"" (BMBF) since 1999, succeeded to create a unique research structure in Germany: medical doctors and scientists from six university rheumatology centres (Berlin, Dusseldorf, Erlangen, Freiburg, Hannover und Lubeck/Bad Bramstedt) work closely together with scientists doing basic research at the Deutsches Rheuma-Forschungszentrum (DRFZ), with rheumatological hospitals, reha-clinics, and rheumatologists. Jointly they are searching for causes of systemic inflammatory rheumatic diseases and try to improve therapies-nationwide and with an interdisciplinary approach. The primary objective of this collaboration is to transfer new scientific insights more rapidly in order to improve methods for diagnosis and patients treatment.",0,0,
1704,Systems of care for ST-segment-elevation myocardial infarction: a report From the American Heart Association's Mission: Lifeline,"BACKGROUND: National guidelines call for participation in systems to rapidly diagnose and treat ST-segment-elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States. METHODS AND RESULTS: A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website. Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%)""; single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%);"" and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%). CONCLUSIONS: This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.",0,0,
1705,Tailored information increases patient/physician discussion of colon cancer risk and testing: The Cancer Risk Intake System trial,"Assess whether receipt of tailored printouts generated by the Cancer Risk Intake System (CRIS) - a touch-screen computer program that collects data from patients and generates printouts for patients and physicians - results in more reported patient-provider discussions about colorectal cancer (CRC) risk and screening than receipt of non-tailored information. Cluster-randomized trial, randomized by physician, with data collected via CRIS prior to visit and 2-week follow-up telephone survey among 623 patients. Patients aged 25-75 with upcoming primary-care visits and eligible for, but currently non-adherent to CRC screening guidelines. Patient-reported discussions with providers about CRC risk and testing. Tailored recipients were more likely to report patient-physician discussions about personal and familial risk, stool testing, and colonoscopy (all p < 0.05). Tailored recipients were more likely to report discussions of: chances of getting cancer (+ 10%)""; family history (+ 15%); stool testing (+ 9%);"" and colonoscopy (+ 8%) (all p < 0.05). CRIS is a promising strategy for facilitating discussions about testing in primary-care settings.",0,1,
1706,Tailored skills training for practitioners to enhance assessment of prognostic factors for persistent and disabling back pain: four quasi-experimental single-subject studies,"The well-known gap between guidelines and behaviour in clinical practice calls for effective behaviour change interventions. One example showing this gap is physiotherapists' insufficient assessment of psychosocial prognostic factors in back pain (i.e., yellow flags). The present study aimed to evaluate an educational model by performing a tailored skills training intervention for caregivers and studying changes over time in physiotherapists' assessment of prognostic factors in telephone consultations. A quasi-experimental single-subject design over 36 weeks was used, with repeated measurements during baseline, intervention, and postintervention phases. Four physiotherapists in primary health care audiorecorded a total of 63 consultations with patients. The tailored intervention included individual goal setting, skills training, and feedback on performance. The primary outcome was the number of assessed prognostic factors (0-10). Changes were seen in all four participants. The amount of assessed prognostic factors increased from between 0 and 2 at baseline to between 6 and 10 at postintervention. Time spent on assessment of psychosocial factors increased, and time spent on discussions about biomedical pain symptoms decreased. Knowledge and biopsychosocial attitudes toward back pain were congruent with guidelines at inclusion and did not change markedly during the intervention. Self-efficacy for assessment of cognitive and emotional prognostic factors increased during the study phases. The results suggest that a tailored skills training intervention using behaviour change techniques, such as individual goal setting, skills training, and feedback on performance, is effective in producing change in specific clinical behaviours in physiotherapists.",0,1,
1707,Targeted intervention programs: creating a customized practice model to improve the treatment of allergic rhinitis in a managed care population,"OBJECTIVE: To develop an intervention program to improve health outcomes among patients with allergic rhinitis in a managed care environment. STUDY DESIGN: The Episodes of Care (EOC) team at Lovelace Health Systems selected allergic rhinitis for an intervention program because it was identified as one of the top 10 reasons for visits to primary care clinics. The intervention program was based on a multidisciplinary team process designed to create a customized provider and patient education program to alter inconsistence or deficiencies in the treatment of allergic rhinitis. PATIENTS AND METHODS: The EOC team researched literature and current practices and then identified inconsistencies in diagnostic and treatment patterns. Based on this research, the team developed guidelines and a provider education program. Intervention strategies were structured around decision points in a treatment protocol. More than 500 patients were monitored throughout the allergy season by using written and telephone surveys, symptom diaries, and encounter data. Measurable outcomes were established for provider and patient behavior. Patient outcomes were derived from a preventive behavior index and administrative data reporting usage of 5 classes of medication. RESULTS: Approximately 50% of providers altered their practice patterns as a result of the intervention program. Patient outcomes showed a decrease in the use of rescue medications, particularly antibiotics, and an increase in preventive measures in the treatment group compared with the control group. CONCLUSION: The EOC model resulted in positive changes in provider and patient behavior. The multidisciplinary approach resulted in broad provider participation.",0,0,
1708,Targeting cognitive deficits in schizophrenia: a review of the development of a new class of medicines from the perspective of community mental health researchers,"INTRODUCTION: Schizophrenia is a chronic disorder associated with positive and negative symptoms and wide-ranging deficits in neurocognitive function. Neurocognitive deficits are considered to be the core pathophysiological symptoms of the illness. Neurocognitive deficits are also closely associated with functional outcome. At present, cognitive deficits remain one of the most important unmet therapeutic needs in schizophrenia. AREAS COVERED: Neuroscientific discoveries over the past decades have enriched our understanding of the neurobiological mechanism underlying cognitive deficits in schizophrenia. This research has identified new molecular mechanisms and processes as promising pharmacological targets. However, in spite of extensive efforts to develop a new class of cognitive-enhancing medicines for the treatment of schizophrenia over the past 5 years, no novel pharmacological agents have received the regulatory approvals required by the Food and Drug Administration. The efficacy and safety outcomes from selective Phase II clinical trials are reviewed. EXPERT OPINION: The evolving concept of neurocognition and the current guidelines for the design and methodology of clinical trials of cognitive-enhancing drugs for the treatment of individuals with schizophrenia are critically examined. The future directions in the development of cognitive-enhancing medicines for the treatment of schizophrenia from the perspective of clinicians and researchers from community mental health settings are discussed.",0,0,
1709,Task force VI: Self-monitoring of the blood pressure,"BACKGROUND: Self-monitoring of the blood pressure by patients at home or in other nonclinical settings has become increasingly common in recent years. This phenomenon has been fueled in part by the increase in availability of automatic sphygmomanometers, which are now both affordable and easy for patients to use. BENEFITS OF SELF-MONITORING: Self-monitoring of the blood pressure can be an important adjunct to management of hypertension. The technique allows patients to participate more in their care. Self-measured values of blood pressure are more likely to be representative of the average daily blood pressure than is a clinic measurement and may be better related to hypertensive involvement of target organs and cardiovascular morbidity than is the clinic blood pressure. Finally, the self-monitoring of blood pressure has the potential to reduce the costs of hypertension-related care. LIMITATIONS OF SELF-MONITORING: There are several issues that prevent the more widespread use of self-monitoring of the blood pressure in clinical practice. First, devices marketed for use by patients have advanced technically during the 1990s, but many have not been subjected to rigorous clinical validation for precision and reliability (e.g. in terms of Association for the Advancement of Medical Instrumentation and British Hypertension Society guidelines). It is recommended that devices for measuring blood pressure used by patients at home be subjected to the same validation processes as those that are applied to ambulatory recordings. Second, although the upper limits of normal for self-monitored blood pressure of a general population can be defined statistically (it is approximately 135/85 mmHg), it is not yet possible to determine the normal self-monitored blood pressure because these values must be linked to classical clinical cardiovascular endpoints or outcomes. Third, the relationships among self-monitored, clinic, and ambulatory blood pressures are defined for some populations but their behaviors according to age, sex, ethnicity, and treatment status require further study. Fourth, several different schedules for self-monitoring of the blood pressure by patients have been used in clinical research and practice. It will be necessary to determine the optimal schedule and number of recordings required when patients perform self-monitoring of the blood pressure. Fifth, self-monitoring of the blood pressure in clinical trials of antihypertensive therapies is certainly feasible but has typically not been included in their design, either by investigators or by the pharmaceutical sponsors. Sixth, there have been data suggesting that self-monitoring of the blood pressure reduces the comprehensive costs associated with hypertension care on an annual basis. However, since most work on the economic impact of self-monitoring of the blood pressure has been performed in managed-care environments in the USA, it is not known whether this reduction in health-care costs would be applicable to other types of practice environments on a worldwide basis. CONCLUSIONS: Self-monitoring of the blood pressure is at present useful as an adjunct measurement for the management of hypertensive patients and might provide benefits in clinical trials of antihypertensive therapy. Nevertheless, the available data on self-monitoring of the blood pressure are inadequate as grounds for clinicians to make primary diagnostic or therapeutic decisions and should not override the blood pressure obtained by clinical measurement or via ambulatory monitoring.",0,0,
1710,Teaching appropriate interactions with pharmaceutical company representatives: the impact of an innovative workshop on student attitudes,"BACKGROUND: Pharmaceutical company representatives (PCRs) influence the prescribing habits and professional behaviour of physicians. However, the skills for interacting with PCRs are not taught in the traditional medical school curriculum. We examined whether an innovative, mandatory workshop for third year medical students had immediate effects on knowledge and attitudes regarding interactions with PCRs. METHODS: Surveys issued before and after the workshop intervention solicited opinions (five point Likert scales) from third year students (n = 75) about the degree of bias in PCR information, the influence of PCRs on prescribing habits, the acceptability of specific gifts, and the educational value of PCR information for both practicing physicians and students. Two faculty members and one PCR led the workshop, which highlighted typical physician-PCR interactions, the use of samples and gifts, the validity and legal boundaries of PCR information, and associated ethical issues. Role plays with the PCR demonstrated appropriate and inappropriate strategies for interacting with PCRs. RESULTS: The majority of third year students (56%, 42/75) had experienced more than three personal conversations with a PCR about a drug product since starting medical school. Five percent (4/75) claimed no previous personal experience with PCRs. Most students (57.3%, 43/75) were not aware of available guidelines regarding PCR interactions. Twenty-eight percent of students (21/75) thought that none of the named activities/gifts (lunch access, free stethoscope, textbooks, educational CD-ROMS, sporting events) should be restricted, while 24.0% (8/75) thought that students should be restricted only from sporting events. The perceived educational value of PCR information to both practicing physicians and students increased after the workshop intervention from 17.7% to 43.2% (chi square, p = .0001), and 22.1% to 40.5% (p = .0007), respectively. Student perceptions of the degree of bias of PCR information decreased from 84.1% to 72.9% (p = .065), but the perceived degree of influence on prescribing increased (44.2% to 62.1% (p = .02)). CONCLUSIONS: Students have exposure to PCRs early in their medical training. A single workshop intervention may influence student attitudes toward interactions with PCRs. Students were more likely to acknowledge the educational value of PCR interactions and their impact on prescribing after the workshop intervention.",0,0,
1711,Teaching hospital medical staff to handwash,"Objective To increase the frequency of handwashing by medical staff.  Design A prospective study of handwashing before and after patient contact.  Setting A paediatric intensive care unit in a tertiary hospital.  Participants 61 intensive care unit medical staff and visiting medical staff.  Interventions A five-phase behaviour modification program: (i) unobtrusive observation for four weeks to obtain a baseline handwashing rate""; (ii) overt observation for five weeks (preceded by written advice); (iii) overt observation continued for four weeks with performance feedback; (iv) all observation and feedback discontinued for seven weeks;"" and (v) unobtrusive observation for five weeks to obtain a residual rate.  Results 939 patient contacts were observed. The baseline handwashing rates before and after patient contact were 12.4% and 10.6%, respectively. During overt observation, the respective rates increased and plateaued at 32.7% and 33.3%, but increased further (to 68.3% and 64.8%) during the period of performance feedback. The residual handwashing rates, observed unobtrusively seven weeks after the cessation of performance feedback, were 54.6% before and 54.9% after patient contact.  Conclusions Performance feedback is moderately effective in training hospital medical staff to handwash.",0,1,
1712,Teasing apart “the tangled web” of influence of policy dialogues: lessons from a case study of dialogues about healthcare reform options for Canada,"Background The knowledge exchange literature suggests that policy dialogues are intended to enhance short-, medium- and long-term capacities of individuals, organizations and health systems to use evidence to inform policy-making. Key features of effective dialogues have been suggested, but the linkages between these features and the realization of improved capacities for evidence-informed policy-making among dialogue attendees and the subsequent influence on policy-making activities are not well understood.  Methods We conducted a qualitative case study of a series of four policy dialogues that were convened in Canada among national, provincial and regional stakeholders on topics pertaining to healthcare financing and funding in 2011. Data sources included videos of participant perspectives captured during or immediately following each event and follow-up key informant interviews among dialogue participants held 4 years later in 2015. Three conceptual frameworks pertaining to (i) policy dialogues and capacities for evidence use, (ii) factors shaping policy-making across the policy cycle and (iii) factors shaping implementation of evidence guided the thematic analysis. We then synthesized the findings across the three frameworks.  Results The results suggest the potential benefits of policy dialogues described in the literature were developed among the participants at these dialogues. Informants elaborated on how dialogue features influenced their capacities to use evidence, the ideas, interests and institutions during the agenda-setting and policy formulation stages of policy-making and how implementation was affected by characteristics of policy options, individuals, organizations, the external environment and processes.  Conclusions We present a conceptual framework that furthers our understanding of the potential influence of policy dialogues on the content and mechanisms of policy development and illustrate pathways of influence on various stages of the policy cycle from agenda setting through formulation and implementation. The framework highlights important factors for consideration in designing and evaluating policy dialogues and in supporting post-dialogue knowledge exchange efforts.",0,0,
1713,Teleconferenced educational detailing: diabetes education for primary care physicians,"INTRODUCTION: Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed. METHODS: A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated. RESULTS: Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians. DISCUSSION: CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.",0,0,
1714,Telehealth for patients at high risk of cardiovascular disease: pragmatic randomised controlled trial,"OBJECTIVE  To assess whether non-clinical staff can effectively manage people at high risk of cardiovascular disease using digital health technologies. DESIGN  Pragmatic, multicentre, randomised controlled trial. SETTING  42 general practices in three areas of England. PARTICIPANTS  Between 3 December 2012 and 23 July 2013 we recruited 641 adults aged 40 to 74 years with a 10 year cardiovascular disease risk of 20% or more, no previous cardiovascular event, at least one modifiable risk factor (systolic blood pressure ≥140 mm Hg, body mass index ≥30, current smoker), and access to a telephone, the internet, and email. Participants were individually allocated to intervention (n=325) or control (n=316) groups using automated randomisation stratified by site, minimised by practice and baseline risk score. INTERVENTIONS  Intervention was the Healthlines service (alongside usual care), comprising regular telephone calls from trained lay health advisors following scripts generated by interactive software. Advisors facilitated self management by supporting participants to use online resources to reduce risk factors, and sought to optimise drug use, improve treatment adherence, and encourage healthier lifestyles. The control group comprised usual care alone. MAIN OUTCOME MEASURES  The primary outcome was the proportion of participants responding to treatment, defined as maintaining or reducing their cardiovascular risk after 12 months. Outcomes were collected six and 12 months after randomisation and analysed masked. Participants were not masked. RESULTS  50% (148/295) of participants in the intervention group responded to treatment compared with 43% (124/291) in the control group (adjusted odds ratio 1.3, 95% confidence interval 1.0 to 1.9""; number needed to treat=13); a difference possibly due to chance (P=0.08). The intervention was associated with reductions in blood pressure (difference in mean systolic -2.7 mm Hg (95% confidence interval -4.7 to -0.6 mm Hg), mean diastolic -2.8 (-4.0 to -1.6 mm Hg);"" weight -1.0 kg (-1.8 to -0.3 kg), and body mass index -0.4 ( -0.6 to -0.1) but not cholesterol -0.1 (-0.2 to 0.0), smoking status (adjusted odds ratio 0.4, 0.2 to 1.0), or overall cardiovascular risk as a continuous measure (-0.4, -1.2 to 0.3)). The intervention was associated with improvements in diet, physical activity, drug adherence, and satisfaction with access to care, treatment received, and care coordination. One serious related adverse event occurred, when a participant was admitted to hospital with low blood pressure. CONCLUSIONS  This evidence based telehealth approach was associated with small clinical benefits for a minority of people with high cardiovascular risk, and there was no overall improvement in average risk. The Healthlines service was, however, associated with improvements in some risk behaviours, and in perceptions of support and access to care.Trial registration Current Controlled Trials ISRCTN 27508731.",0,0,
1715,Telephone Care Management To Improve Cancer Screening among Low-Income Women,"BackgroundMinority and low-income women receive fewer cancer screenings than other women.ObjectiveTo evaluate the effect of a telephone support intervention to increase rates of breast, cervical, and colorectal cancer screening among minority and low-income women.DesignRandomized, controlled trial conducted between November 2001 and April 2004.Setting11 community and migrant health centers in New York City.Patients1413 women who were overdue for cancer screening.InterventionOver 18 months, women assigned to the intervention group received an average of 4 calls from prevention care managers and women assigned to the control group received usual care. Follow-up data were available for 99% of women, and 91% of the intervention group received at least 1 call.MeasurementsMedical record documentation of mammography, Papanicolaou testing, and colorectal cancer screening according to U.S. Preventive Services Task Force recommendations.ResultsThe proportion of women who had mammography increased from 0.58 to 0.68 with the intervention and decreased from 0.60 to 0.58 with usual care""; the proportion who had Papanicolaou testing increased from 0.71 to 0.78 with the intervention and was unchanged with usual care;"" and the proportion who had colorectal screening increased from 0.39 to 0.63 with the intervention and from 0.39 to 0.50 with usual care. The difference in the change in screening rates between groups was 0.12 for mammography (95% CI, 0.06 to 0.19), 0.07 for Papanicolaou testing (CI, 0.01 to 0.12), and 0.13 for colorectal screening (CI, 0.07 to 0.19). The proportion of women who were up to date for 3 tests increased from 0.21 to 0.43 with the intervention.LimitationsParticipants were from 1 city and had access to a regular source of care. Medical records may not have captured all cancer screenings.ConclusionsTelephone support can improve cancer screening rates among women who visit community and migrant health centers. The intervention seems to be well suited to health plans, large medical groups, and other organizations that seek to increase cancer screening rates and to address disparities in care.",0,0,
1716,"Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial","Context Although guideline-concordant depression treatment is clearly effective, treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective.  Objective To evaluate the effects of a depression outreach-treatment program on workplace outcomes, a concern to employers.  Design, Setting, and Participants A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded.  Intervention A telephonic outreach and care management program encouraged workers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy.  Main Outcome Measures Depression severity (Quick Inventory of Depressive Symptomatology, QIDS) and work performance (World Health Organization Health and Productivity Questionnaire [HPQ], a validated self-report instrument assessing job retention, time missed from work, work performance, and critical workplace incidents).  Results Combining data across 6- and 12-month assessments, the intervention group had significantly lower QIDS self-report scores (relative odds of recovery, 1.4""; 95% confidence interval, 1.1-2.0; P = .009), significantly higher job retention (relative odds, 1.7; 95% confidence interval, 1.1-3.3; P = .02), and significantly more hours worked among the intervention (ß=2.0; P=.02;"" equivalent to an annualized effect of 2 weeks of work) than the usual care groups that were employed.  Conclusions A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes. The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers.",0,0,
1717,Telephone-Delivered Collaborative Care for Treating Post-CABG Depression,"Context Depressive symptoms commonly follow coronary artery bypass graft (CABG) surgery and are associated with less positive clinical outcomes.  Objective To test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs usual physician care.  Design, Setting, and Participants Single-blind effectiveness trial at 7 university-based and community hospitals in or near Pittsburgh, Pennsylvania. Participants were 302 post-CABG patients with depression (150, intervention""; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression recruited between March 2004 and September 2007 and observed as outpatients until June 2008.  Intervention Eight months of telephone-delivered collaborative care provided by nurses working with patients' primary care physicians and supervised by a psychiatrist and primary care physician from this study.  Main Outcome Measures Mental health–related quality of life (HRQL) measured by the Short Form-36 Mental Component Summary (SF-36 MCS) at 8-month follow-up; secondary outcome measures included assessment of mood symptoms (Hamilton Rating Scale for Depression [HRS-D]), physical HRQL (SF-36 PCS), and functional status (Duke Activity Status Index [DASI]); and hospital readmissions.  Results The intervention patients reported greater improvements in mental HRQL (all P = .02) (SF-36 MCS: ?, 3.2 points; 95% confidence interval [CI], 0.5-6.0), physical functioning (DASI: ?, 4.6 points; 95% CI, 1.9-7.3), and mood symptoms (HRS-D: ?, 3.1 points; 95% CI, 1.3-4.9); and were more likely to report a 50% or greater decline in HRS-D score from baseline (50.0% vs 29.6%; number needed to treat, 4.9 [95% CI, 3.2-10.4]) than usual care patients (P < .001). Men with depression were particularly likely to benefit from the intervention (SF-36 MCS: ?, 5.7 points; 95% CI, 2.2-9.2;"" P = .001). However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group.  Conclusion Compared with usual care, telephone-delivered collaborative care for treatment of post-CABG depression resulted in improved HRQL, physical functioning, and mood symptoms at 8-month follow-up.",0,0,
1718,Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review,"OBJECTIVE: Studies involving the use of telepractice in the delivery of services to individuals with autism spectrum disorders (ASD) were reviewed with the intent to inform practice and identify areas for future research. METHODS: Systematic searches of electronic databases, reference lists and journals identified eight studies that met pre-determined inclusion criteria. These studies were analysed and summarized in terms of the: (a) characteristics of the participants, (b) technology utilized, (c) services delivered via telepractice, (d) research methodology and (e) results of the study. RESULTS: Telepractice was used by university-based researchers, behaviour analysts, psychiatrists and psychologists to assist caretakers and educators in the delivery of services to 46 participants with ASD. The services delivered included behavioural and diagnostic assessments, educational consulting, guidance and supervision of behavioural interventions and coaching/training in the implementation of a comprehensive early intervention programme. CONCLUSIONS: Results suggests telepractice is a promising service delivery approach in the treatment of individuals with ASD that warrants additional research. Guidelines for practitioners and potential directions for future research are discussed.",0,0,
1719,Test ordering guidelines can alter ordering patterns in an academic emergency department,"To determine the impact of an educational program designed to modify test ordering behavior in an academic Emergency Department (ED), an observational, before-and-after study was conducted at a university tertiary referral center and Emergency Medicine (EM) residency site. Test ordering standards were developed by EM faculty, RNs, and NPs based upon group consensus and published data. The standards were given to all ED staff beginning February 1996, and included in the evidence-based medicine orientation and educational program for all residents and medical students prior to beginning their rotation. No restrictions were placed on actual test ordering. The number of laboratory tests (total and individual) ordered per 100 patients decreased significantly after the educational program began for: total testing, CBC, and liver function test (LFT). In addition, declines during individual months for these tests were statistically significant. Prothrombin time and blood culture testing showed no significant decreases in test ordering frequency. Chemistry test ordering frequency showed statistically significant increases. Overall, approximately $50,000 was saved by decreasing test ordering. Test ordering behavior can be modified and maintained by an educational program and may have significant economic effects.",0,0,
1720,Testimony of LeRoy Walters,,0,0,
1721,"Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: the UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761","BACKGROUND: Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines. Few randomised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control. All these trials have used a cluster design and most have methodological flaws. None specifically focus upon practitioner behaviour towards LBP patients. Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results. Although numerous LBP guidelines have been developed worldwide, there is a paucity of data on whether their dissemination actually changes practitioner behaviour. Primarily because of its low unit cost, sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy. The effect size of such a strategy, at an individual practitioner level, is likely to be small. However, if large numbers of practitioners are targeted, this strategy might achieve meaningful changes at a population level. METHODS: The primary aim of this prospective, pragmatic randomised controlled trial is to test the short-term effectiveness (six-months following intervention) of a directly-posted information package on the reported clinical behaviour (primary outcome), attitudes and beliefs of UK chiropractors, osteopaths and musculoskeletal physiotherapists. We sought to randomly allocate a combined sample of 1,800 consenting practitioners to receive either the information package (intervention arm) or no information above that gained during normal practice (control arm). We collected questionnaire data at baseline and six-months post-intervention. The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity, work and bed-rest, that fall within categories previously defined by an expert consensus exercise as either 'guideline-consistent' and 'guideline-inconsistent'.",0,0,
1722,Testing the implementation of clinical guidelines,,0,1,
1723,Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder,"OBJECTIVE: To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking. METHOD: A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents. RESULTS: Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment. CONCLUSIONS: Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.",0,0,
1724,The ACC/AHA 2013 guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: the good the bad and the uncertain: a comparison with ESC/EAS guidelines for the management of dyslipidaemias 2011,"Atherosclerotic cardiovascular disease is the most important public health problem of our time in both Europe and the rest of the world, accounting for the greatest expenditure in most healthcare budgets. Achieving consistency of clinical care, incorporating new evidence and their synthesis into practical recommendations for clinicians is the task of various guideline committees throughout the world. Any change in a set of guidelines therefore can have far reaching consequences, particularly if they appear to be at variance with the existing guidelines. The present article discusses the recent American College of Cardiology (ACC)/American Heart Association (AHA) guidelines 2013 on the control of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults. When compared with the ESC/EAS guidelines on lipid modification in 2011, the ACC/AHA guidelines of 2013 differ markedly. Specifically, (i) the scope is limited to randomized trials only, which excludes a significant body of data and promotes essentially a statin centric approach only""; (ii) the abolition of low-density lipoprotein cholesterol (LDL-C) targets in favour of specific statin regimens that produce a 30-50% reduction in LDL-C we believe will confuse many physicians and miss the opportunity for medication adherence and patient engagement in self-management; (iii) the absence of target LDL-C levels in very high-risk patients with high absolute risk or residual risk factors will discourage clinicians to consider the addition of lipid modification treatments and individualize patient care; (iv) a reduction in the threshold for treatment in primary prevention will result in a greater number of patients being prescribed statin therapy, which is potentially good in young patients with high life time risk, but will result in a very large number of older patients offered therapy;"" and (v) the mixed pool risk calculator used to asses CVD risk in the guidelines for primary prevention has not been fully evaluated. This article discusses the potential implications of adopting the ACC/AHA guidelines on patient care in Europe and beyond and concludes with the opinion that the ESC/EAS guidelines from 2011 seem to be the most wide ranging, pragmatic and appropriate choice for European countries.",0,0,
1725,The aggressive child,"Acute assessment and management of the aggressive or violent child or adolescent are a challenge for clinicians. Early recognition of signs of impending violence and a clear understanding of the progression of violent behavior are essential to ensure safety of patients and staff. The management of violent and aggressive patients using behavioral interventions tailored to the stage of violence or aggression is critical to reducing the likelihood that the child or adolescent will attack staff or injure self or others. The indications and risks of chemical and physical restraints and hospital standards and guidelines that govern the use of behavioral and experience regarding the prevalence, presentation, and differential diagnosis of psychotic disorders in juveniles. The clinician must rapidly disentangle which elements of the clinical presentation indicate true psychotic thought processes versus elements that represent misunderstood developmentally appropriate phenomena, symptoms of nonpsychotic illnesses, or harbingers of an underlying primary medical illness. A thorough assessment is required before appropriate treatment can begin.",0,0,
1726,The AHCPR guidelines on heart failure: comparison of a family medicine and an internal medicine practice with the guidelines and an educational intervention to modify behavior,"OBJECTIVES: The objectives of this study were to apply the Agency for Health Care Policy and Research (AHCPR) guideline for heart failure to the measurement of quality of care in the ambulatory setting, to compare the results for two large practices and to design an educational intervention for the two practices being studied. METHODS: A retrospective chart review was conducted on a random sample of 50 patients with heart failure selected from each of two outpatient practices: the general internal medicine practice and the family medicine practice at a large academic medical center. Five medical review criteria were developed from the AHCPR guideline for heart failure to compare the two practices with each other and the guidelines. An educational intervention was developed to modify physician behavior in regard to compliance with guidelines. RESULTS: Assessment of left ventricular function occurred in 79% of all cases. Of eligible patients, 68% were treated with angiotensin-converting enzyme inhibitors (ACE-Is). Of those patients treated with enalapril and captopril, 30% and 12%, respectively, were receiving the target dose as defined in the AHCPR guidelines. Of patients not eligible for treatment with ACE-Is, none were treated with hydralazine and nitrates. When the ejection fraction was less than or equal to 40%, 81% of eligible patients were treated with ACE-Is, whereas 59% were treated with ACE-Is when the ejection fraction was greater than 40%. Calcium channel blockers were used in the treatment of 42% of patients. A statistical difference (P = .05) was found between the two practices for documentation of left ventricular function, the use of ACE-Is for patients with ejection fraction less than or equal to 40%, and the use of calcium channel blockers and beta blockers. CONCLUSIONS: In the practices studied, there is underutilization of the documentation of left ventricular function, ACE-Is in eligible patients, target doses of ACE-Is, and the use of hydralazine and nitrates for ineligible patients. A higher proportion of patients receive ACE-I therapy when the ejection fraction is less than or equal to 40%. There may be inappropriate use of calcium channel blockers in some patients. There is unexplained clinical variation between the two practices studied.",0,0,
1727,The altruistic medical researcher: gone and forgotten?,"With increasing economic, political, and bureaucratic involvement in research, there is little focus on the medical researcher's idealistic and benevolent intentions. Benevolence is a pillar of ethical human-subjects research, and altruism is a form of benevolence that is difficult to quantify. It is interest in the welfare of others without personal benefit. This article examines the extent of altruism in medical research from philosophical, psychological, and practical points of view. With the emergence of experimental human trials in the first half of the century, the fame and recognition of physicians largely precluded altruistic motivation. From the philosophical perspective, altruism is at best an optional moral principle. It is not evident in ethical guidelines. In the scientific process, altruism can exist only in ethical and properly designed research. Egoism, scientific misconduct, and conflicts of interest undermine it"";"" but altruism is also a potential solution for these problems. Research is not globally oriented and has an unjust distribution. In an evolutionary model, altruism cannot thrive due to its lack of rewards and feedback, particularly in the economic climate of today's science. Anonymity is decreasing, selfishness is increasing. Research has become an industry, and virtuous ideals are a romantic notion. If we use altruism as an indicator, then its rarity and fragility indicate research's unhealthy state.",0,0,
1728,The American Society of Clinical Psychopharmacology Survey of Psychopharmacologists' Practice Patterns for the Treatment of Mood Disorders,"BACKGROUND: Optimal successive treatment decisions are not well established after an initial medication nonresponse in major depressive disorder or bipolar disorder. While practice guidelines offer consensus-based expert treatment recommendations, little is known about ""real world"" pharmacology decision making by practicing psychopharmacologists. MATERIALS AND METHODS: We surveyed via Internet the national membership of the American Society of Clinical Psychopharmacology (ASCP) to study preferred pharmacotherapy strategies and factors that influence medication choices for patients with mood disorders. RESULTS: Surveys were returned by 154/752 ASCP members (21%). After nonresponse to a serotonin reuptake inhibitor in major depressive disorder, participants equally favored switching within or across antidepressant classes. After a partial response, adjunctive bupropion was the preferred intervention, followed by changing antidepressant classes. Atypical antipsychotic augmentation was only a fourth-line consideration, even though moderate or marked efficacy was perceived in most instances with olanzapine, aripiprazole, and quetiapine. Respondents favored avoiding antidepressants in bipolar I patients with mixed/cycling features or prior antidepressant-associated mania/hypomania. In rapid cyclers, they advocated antidepressant cessation and preferred the use of atypical antipsychotics and lamotrigine. CONCLUSIONS: Participating psychopharmacologists treating adults with mood disorders report prescribing medications that largely mirror the evidence base with only a few notable exceptions, in consideration of the characteristics of definable clinical subpopulations.",0,0,
1729,The anticipated clinical and economic effects of 90–90–90 in South Africa,"Background The UNAIDS “90-90-90” global treatment target aims to achieve 73% virologic suppression among HIV-infected persons worldwide by 2020. Objective Using a microsimulation model of HIV detection, disease and treatment, we estimate the clinical and economic value of reaching this ambitious goal in South Africa. Design We model: the Current Pace strategy, simulating existing scale-up efforts and gradual increases in overall virologic suppression from 24% to 36% in 5 years"";"" and the UNAIDS Target strategy, simulating 73% suppression in 5 years. Data Sources Published estimates and South African survey data inform HIV transmission rates (0.16–9.03/100PY), HIV-specific age-stratified fertility rates (1.0–9.1/100PY), and costs (ART: $11–31/month, routine care: $20–157/month). Target population South African HIV-infected population, including incident infections over the next ten years Perspective Modified societal perspective, excluding time and productivity costs Time Horizon Five and ten years Interventions Aggressive HIV case-detection, efficient linkage to care, rapid treatment scale-up and adherence/retention interventions toward the UNAIDS Target strategy Outcome Measures HIV transmissions, deaths, years of life saved (YLS), maternal orphans, costs (2014USD), and cost-effectiveness Base Case Analysis Compared to Current Pace over (5- and) 10-years, the UNAIDS Target strategy would avert (873,000) 2,051,000 HIV transmissions, (1,174,000) 2,478,000 deaths, and (726,000) 1,689,000 maternal orphans, while saving (3,002,000) 13,340,000 life-years. The additional budget required for the UNAIDS Target strategy would be ($7.965) $15.979 billion, yielding an incremental cost-effectiveness ratio (ICER) of ($2,720/YLS) $1,260/YLS, (<50%) <20% of South Africa per capita GDP. Results of Sensitivity Analysis Outcomes generally varied <20% from base case outcomes when we varied key input parameters within plausible ranges. Limitations Several pathways may lead to 73% overall suppression which were examined in sensitivity analysis. Conclusions Reaching the “90-90-90” HIV suppression target would be costly but both extraordinarily effective and cost-effective in South Africa. Global health policy makers should mobilize the political and economic support to make the 90-90-90 aspiration a reality.",0,0,
1730,The application of an occupational health guideline reduces sedentary behaviour and increases fruit intake at work: results from an RCT,"OBJECTIVE: To evaluate the effectiveness of a draft occupational health practice guideline aimed at preventing weight gain on employees' physical activity, sedentary behaviour and dietary behaviour and on body weight-related outcomes. METHODS: A randomised controlled trial was performed comparing guideline-based care to usual care among 16 occupational physicians and 523 employees in the Netherlands between 2009 and 2011. Occupational physicians in the intervention group followed the draft guideline by providing advice to employers on how to assess and intervene on the obesogenic work environment and conducted five face-to-face behavioural change counselling sessions with employees to improve their lifestyle. Data of employees were collected by questionnaire and physical measurements at baseline and 6-months follow-up. Linear and logistic regression analyses were performed to determine effects. RESULTS: The intervention showed significant effects on sedentary behaviour at work (beta -28 min/day, 95% CI -2 to -54) and on fruit intake (beta 2.1 pieces/week"";"" 95% CI 0.6 to 3.6). No significant intervention effects were found for physical activity, sedentary behaviour in leisure time or during weekend days, snack intake and body weight-related outcomes. CONCLUSION: Guideline-based care resulted in a more favourable sedentary behaviour at work and increased fruit intake but did not improve employees' physical activity, snack intake or body weight-related outcomes. Trial registration number ISRCTN/73545254 and NTR/1190.",0,0,
1731,The assessment of attention-deficit/hyperactivity disorder in rural primary care: the portability of the American Academy of Pediatrics guidelines to the “real world”. ,"Objective. To examine the implementation of a protocol for the assessment of attention-deficit/ hyperactivity disorder (ADHD) in rural pediatric practices. The protocol was designed to provide an efficient means for pediatricians to learn and use the ADHD guidelines put forth by the American Academy of Pediatrics (AAP). Methods. Primary care staff (physicians, nurses, etc) from 2 rural pediatric practices were trained to use the ADHD-assessment protocol. Medical records for 101 patients were reviewed from 1 to 2 years before the introduction of the protocol and for 86 patients during the subsequent 2 to 3 years to assess compliance with the AAP guidelines. In addition, 34% of the scales scored by the staff were rescored to check for scoring accuracy. Results. Before the availability of the AAP guidelines and the implementation of the assessment protocol, neither primary care site was consistently collecting the comprehensive information that is now recommended for an ADHD assessment. Parent and/or teacher rating scales were collected for only 0% to 21% of assessments across sites. When provided with brief training and supporting materials, medical records reflected significant improvement in the ascertainment of clinically necessary ADHD information, with parent and teacher rating scales present 88% to 100% of the time. Staff demonstrated an ability to score rating scales with a high degree of accuracy. The integrity of protocol collection and management was maintained 2 to 3 years after training. Conclusions. An efficient system for conducting ADHD assessments according to AAP guidelines in rural pediatrics clinics can be initiated and maintained with integrity. Additional research is needed to determine if this system improves diagnostic decision-making and patient outcomes. Pediatrics 2005"";115:e120–e126. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2004-1521;"" attention-deficit/hyperactivity disorder, assessment, guidelines, pediatric",0,1,
1732,The Behavioral Economics of Health and Health Care,"People often make decisions in health care that are not in their best interest, ranging from failing to enroll in health insurance to which they are entitled, to engaging in extremely harmful behaviors. Traditional economic theory provides a limited tool kit for improving behavior because it assumes that people make decisions in a rational way, have the mental capacity to deal with huge amounts of information and choice, and have tastes endemic to them and not open to manipulation. Melding economics with psychology, behavioral economics acknowledges that people often do not act rationally in the economic sense. It therefore offers a potentially richer set of tools than provided by traditional economic theory to understand and influence behaviors. Only recently, however, has it been applied to health care. This article provides an overview of behavioral economics, reviews some of its contributions, and shows how it can be used in health care to improve people's decisions and health.",0,1,
1733,The behaviour change wheel: A new method for characterising and designing behaviour change interventions,"Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations.  Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity.  Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions"";"" around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity.  Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.",0,0,
1734,The Black report on socioeconomic inequalities in health 10 years on,,0,0,
1735,The Bold Promise Project: a system change in primary care to support cardiovascular risk screening,"AIMS: To develop a series of system changes in primary care to facilitate cardiovascular risk screening of all eligible patients identified according to the current New Zealand Cardiovascular Guidelines (NZGG), and to provide the ability to measure and track clinical management of high risk patients. METHODS: Several system changes were developed within primary care practice management software to identify the patient cohort eligible for cardiovascular risk screening, to calculate cardiovascular disease risk (CVR), and to extract the data for reporting on screening outcomes and clinical management indicators in high risk patients. Following a baseline audit, the system changes were piloted over 12 months in three general practices with a combined enrolled patient population of 30,963. RESULTS: A total of 6570 NZGG eligible patients were identified"";"" 20.1% of these were Maori and 19.7% were Pacific people (mostly of Samoan, Tongan, Niuean, or Cook Islands origin). Over 12 months, screening rates for cardiovascular risk assessment increased from 4.7% to 53.5% for the cohort. Of the 3516 patients screened, 482 (13.7%) had established cardiovascular disease. A further 230 (6.5%) had diabetes without CVD and 646 (18.4%) had a 5-year CVD risk of > or = to 15% Management data was available in 232 (48.1%) of those with CVD, 74%, 65%, and 79% were on aspirin, statins, and blood pressure-lowering medication, respectively. Fifty-five percent exceeded the low density lipoprotein (LDL) target of 2.5 mmol/L, 62% had a systolic blood pressure (BP) above the target of 130 mmHg, 18% were still smoking, and only 9% met all clinical targets recommended in the guideline. Of 646 with a 5-year CVD risk > or = to 15%, management data was available in 347 (53.7%). Only 34% were prescribed aspirin, 40% were prescribed statins, and 57% were on blood pressure lowering medication. Forty percent of this group had a systolic BP >140 mmHg, 36% an LDL >3.5 mmol/L, with only 7% of patients meeting all the guideline clinical targets. CONCLUSIONS: The system changes comprising this intervention have dramatically increased cardiovascular risk assessment rates in a primary care setting, and will facilitate appropriate targeting of intensive cardiovascular prevention measures to close the treatment gap observed.",0,1,
1736,The challenge for preventive cardiology,,0,0,
1737,The challenge of transferring an implementation strategy from academia to the field: a process evaluation of local quality improvement collaboratives in Dutch primary care using the normalization process theory,"RATIONALE, AIMS AND OBJECTIVES: A quality improvement strategy consisting of comparative feedback and peer review embedded in available local quality improvement collaboratives proved to be effective in changing the test-ordering behaviour of general practitioners. However, implementing this strategy was problematic. We aimed for large-scale implementation of an adapted strategy covering both test ordering and prescribing performance. Because we failed to achieve large-scale implementation, the aim of this study was to describe and analyse the challenges of the transferring process. METHODS: In a qualitative study 19 regional health officers, pharmacists, laboratory specialists and general practitioners were interviewed within 6 months after the transfer period. The interviews were audiotaped, transcribed and independently coded by two of the authors. The codes were matched to the dimensions of the normalization process theory. RESULTS: The general idea of the strategy was widely supported, but generating the feedback was more complex than expected and the need for external support after transfer of the strategy remained high because participants did not assume responsibility for the work and the distribution of resources that came with it. CONCLUSION: Evidence on effectiveness, a national infrastructure for these collaboratives and a general positive attitude were not sufficient for normalization. Thinking about managing large databases, responsibility for tasks and distribution of resources should start as early as possible when planning complex quality improvement strategies. Merely exploring the barriers and facilitators experienced in a preceding trial is not sufficient. Although multifaceted implementation strategies to change professional behaviour are attractive, their inherent complexity is also a pitfall for large-scale implementation.",0,0,
1738,The clinical effectiveness and cost-effectiveness of low-intensity psychological interventions for the secondary prevention of relapse after depression: a systematic review,"BACKGROUND: Depression is the most common mental disorder in community settings and a major cause of disability across the world. The objective of treatment is to achieve remission or at least adequate control of depressive symptoms""; however, even after successful treatment, the risk of relapse after remission is significant. Although the effectiveness of low-intensity interventions has been extensively evaluated to treat primary symptoms of psychological difficulties, there has been substantially less research examining the use of these interventions as a relapse prevention strategy. OBJECTIVE: To systematically review the clinical effectiveness and cost-effectiveness of low-intensity psychological or psychosocial interventions to prevent relapse or recurrence in patients with depression. As the broader definition of 'low-intensity' psychological intervention is somewhat contested, the review was conducted in two parts: A, a systematic review of all evaluations of 'low-intensity' interventions that were delivered by para-professionals, peer supporters or psychological well-being practitioners as defined by the Improving Access to Psychological Therapies programme; and B, a scoping review of relevant evaluations of interventions involving qualified mental health professionals (e.g. psychiatrists, clinical psychologists, cognitive behavioural therapists) involving < 6 hours of contact per patient. DATA SOURCES: Comprehensive literature searches were developed; electronic databases were searched from inception until September 2010 (including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, EMBASE, The Cochrane Library), internet resources were used to identify guidelines on the treatment of depression, and the bibliographies of relevant reviews, guidelines and included studies were scrutinised. REVIEW METHODS: Two reviewers independently screened titles and abstracts; data were extracted independently by one reviewer using a standardised data extraction form and checked by another. Discrepancies were resolved by consensus, with involvement of a third reviewer when necessary. The inclusion criteria were population - adults or adolescents who had received treatment for depression; intervention - part A, low-intensity interventions, specifically any unsupported psychological/psychosocial interventions or any supported interventions that did not involve highly qualified mental health professionals, and, part B, interventions carried out by qualified mental health professionals that involved < 6 hours of contact per patient; comparator - any, including no treatment, placebo, psychological or pharmacological interventions; outcomes - relapse or recurrence, other outcomes (e.g. social function, quality of life) were recorded where reported; and study design - for clinical effectiveness, randomised, quasi-randomised and non-randomised studies with concurrent control patients. For cost-effectiveness, full economic evaluations that compared two or more treatment options and considered both costs and consequences. No studies met the main part A inclusion criteria. RESULTS: For the clinical effectiveness review, 17 studies (14 completed, three ongoing), reported in 27 publications, met the part B inclusion criteria. These studies were clinically and methodologically diverse, and reported differing degrees of efficacy for the evaluated interventions. One randomised controlled trial (RCT), which evaluated a collaborative care-type programme, was potentially relevant to part A; this study reported no difference between patients receiving the intervention and those receiving usual care in terms of relapse of depression over 12 months. For the cost-effectiveness review, two studies met the criteria for part B. One of these was an economic evaluation of the RCT above, which was potentially relevant to part A. This evaluation found that the intervention may be a cost-effective use of resources when compared with usual care; however, it was unclear how valid these estimates were for the NHS. LIMITATIONS: Although any definition of 'brief' is likely to be somewhat arbitrary, an inclusion threshold of 6 hours contact per patient was used to select brief high-intensity intervention studies. Most excluded studies evaluated clearly resource-intensive interventions, though occasionally, studies were excluded on the basis of having only slightly more than 6 hours contact per patient. CONCLUSIONS: There is inadequate evidence to determine the clinical effectiveness or cost-effectiveness of low-intensity interventions for the prevention of relapse or recurrence of depression. A scoping review of brief high-intensity therapies indicates that some approaches have shown promise in some studies, but findings have not been consistent. Many uncertainties remain and further primary research is required. Careful consideration should be given to the scope of such research; it is important to evaluate the broader patient pathway accounting for the heterogeneous patient groups of interest. Future RCTs conducted in a UK primary care setting should include adult participants in remission or recovery from depression, and evaluate the quality of the intervention and consistency of delivery across practitioners where appropriate. The occurrence of relapse or recurrence should be measured using established methods, and functional outcomes as well as symptoms should be measured;"" data on quality of life using a generic instrument, such as the European Quality of Life-5 Dimensions (EQ-5D), should be collected. FUNDING: The National Institute for Health Research Health Technology Assessment programme.",0,0,
1739,The Clinical Effectiveness and Cost-effectiveness of Screening for Anal Squamous Intraepithelial Lesions in Homosexual and Bisexual HIV-Positive Men,"Context Homosexual and bisexual men infected with human immunodeficiency virus (HIV) are at increased risk for human papillomavirus¨Crelated anal neoplasia and anal squamous cell carcinoma (SCC).  Objective To estimate the clinical benefits and cost-effectiveness of screening HIV-positive homosexual and bisexual men for anal squamous intraepithelial lesions (ASIL) and anal SCC.  Design Cost-effectiveness analysis performed from a societal perspective that used reference case recommendations from the Panel on Cost-Effectiveness in Health and Medicine. A state-transition Markov model was developed to calculate lifetime costs, life expectancy, and quality-adjusted life expectancy for no screening vs several screening strategies for ASIL and anal SCC using anal Papanicolaou (Pap) testing at different intervals. Values for incidence, progression, and regression of anal neoplasia""; efficacy of screening and treatment; natural history of HIV; health-related quality of life;"" and costs were obtained from the literature.  Setting and Participants Hypothetical cohort of homosexual and bisexual HIV-positive men living in the United States.  Main Outcome Measures Life expectancy, quality-adjusted life expectancy, quality-adjusted years of life saved, lifetime costs, and incremental cost-effectiveness ratio.  Results Screening for ASIL increased quality-adjusted life expectancy at all stages of HIV disease. Screening with anal Pap tests every 2 years, beginning in early HIV disease (CD4 cell count >0.50¡Á109/L), resulted in a 2.7-month gain in quality-adjusted life expectancy for an incremental cost-effectiveness ratio of $13,000 per quality-adjusted life year saved. Screening with anal Pap tests yearly provided additional benefit at an incremental cost of $16,600 per quality-adjusted life year saved. If screening was not initiated until later in the course of HIV disease (CD4 cell count <0.50¡Á109/L), then yearly Pap test screening was preferred due to the greater amount of prevalent anal disease (cost-effectiveness ratio of less than $25,000 per quality-adjusted life year saved compared with no screening). Screening every 6 months provided little additional benefit over that of yearly screening. Results were most sensitive to the rate of progression of ASIL to anal SCC and the effectiveness of treatment of precancerous lesions.  Conclusions Screening HIV-positive homosexual and bisexual men for ASIL and anal SCC with anal Pap tests offers quality-adjusted life expectancy benefits at a cost comparable with other accepted clinical preventive interventions.",0,0,
1740,The clinician-investigator: unavoidable but manageable tension,"The ""difference position"" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The ""similarity position"" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine--specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions.",0,0,
1741,The CLUES study: a cluster randomized clinical trial for the evaluation of cardiovascular guideline implementation in primary care,"BACKGROUND: The appropriate care for people with cardiovascular risk factors can reduce morbidity and mortality. One strategy for improving the care for these patients involves the implementation of evidence-based guidelines. To date, little research concerning the impact of such implementation strategies in our setting has been published. Aims. To evaluate the effectiveness of a multifaceted tailored intervention in the implementation of three cardiovascular risk-related guidelines (hypertension, type 2 diabetes and dyslipidemia) in primary care in the Basque Health Service compared with usual implementation. METHODS/DESIGN: A two-year cluster randomized clinical trial in primary care in two districts in the Basque Health Service. All primary care units are randomized. Data from all patients with diabetes, hypertension and those susceptible to coronary risk screening will be analyzed.Interventions. The control group will receive standard implementation. The experimental group will receive a multifaceted tailored implementation strategy, including a specific web page and workshops for family physicians and nurses.Endpoints. Primary endpoints: annual request for glycosylated hemoglobin, basic laboratory tests for hypertension, cardiovascular risk screening (women between 45-74 and men between 40-74 years old). Secondary endpoints: other process and clinical guideline indicators. ANALYSIS: Data will be extracted from centralized computerized medical records. ANALYSIS will be performed at a primary care unit level weighted by cluster size. DISCUSSION: The main contribution of our study is that it seeks to identify an effective strategy for cardiovascular guideline implementation in primary care in our setting. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN88876909.",0,0,
1742,The Colorado Asthma Toolkit Program: a practice coaching intervention from the High Plains Research Network,"INTRODUCTION: Asthma is often under-diagnosed and under-treated in primary care. The Colorado Asthma Toolkit Program was initiated to establish a method for improving asthma care by providing to primary care practices coaching, training, and support for (1) evidence-based asthma diagnosis and treatment, and (2) education and activation of patients toward effective self-management of their illness. METHODS: A collaborative program was initiated involving 2 academic medical institutions and the High Plains Research Network, a primary care practice-based research network in eastern Colorado. Focus groups were conducted with rural Colorado patients and health care clinicians to assess need and determine the most effective intervention strategies. Two intertwined training programs, or ""toolkits,"" were subsequently developed, one each for health care clinicians and patients. Clinicians received 3 coaching sessions conducted by 2 nurses in the practice that included training in guideline-based methods for evaluation and treatment of asthma, coaching to assist practices in implementing these methods, and training in communication techniques to promote asthma self-management. Practices were also given a spirometer and trained in its use and interpretation. Patient self-management toolkits were provided to clinicians, who were trained to use the materials to educate patients and increase treatment adherence. Evaluations were based on practice interviews 1 to 3 months after coaching. RESULTS: Coaching occurred in 57 of the 58 primary care offices in eastern rural and semirural Colorado. Practices reported changes in their asthma management behaviors: (1) 40.4% of practices increased their use of inhaled corticosteroids, with the median percent of patients taking inhaled corticosteroids rising from 25% to 50%""; (2) 53.2% of practices increased their use of asthma action plans, with the median percent of patients with action plans rising from 0% to 20%;"" and (3) 78.7% of practices initiated or increased their use of spirometry, resulting in a rise in median use from 0% to 30%. CONCLUSION: The Colorado Asthma Toolkit Program successfully disseminated asthma care training into a majority of area rural health care practices. Acceptance by practices was attributable to flexible, in-office coaching and provision of spirometry. Significant shifts seen in asthma-management practices are likely to reduce hospitalizations and emergency department visits.",0,0,
1743,The Community Physicians' Network (CPN): an academic-community partnership to eliminate healthcare disparities,"INTRODUCTION: Disparities in health care are maintained by three primary factors: 1) patient factors which include multiple risk factors and comorbidities""; 2) healthcare practitioner factors comprising inconsistent application of practice guidelines due to a limited database of clinical trials of effective therapies in African Americans and other underrepresented minorities; and 3) barriers in the healthcare delivery system resulting in poor access to care. The Morehouse School of Medicine Community Physicians' Network (CPN) was established to address disparities in health care by focusing on provider-specific strategies. OBJECTIVES: To: 1) use disease-specific registries to identify treatment gaps and facilitate quality improvement processes among CPN practices; 2) develop practice-specific and guideline-based educational messages to promote quality care; 3) engage and train CPN-physicians for participation in approved NIH, other government, and industry-supported clinical protocols; and 4) develop a data repository of all CPN-sponsored clinical trials that include significant numbers of African Americans and other underrepresented minorities. METHODS: The disease-specific outpatient registries will have the following features: 1) data structures and data elements will use standard database codes and a data dictionary; 2) HIPPA-compliant data abstraction and data transfer tool; 3) baseline chart review to establish practice patterns and provide practice-specific feedback; 4) annual update of registry; 5) data registry and repository maintained on Morehouse School of Medicine's secure servers; 6) registry publications will include only aggregate data, without identification of contributing practices; 7) an electronic medical records platform will be encouraged as the ultimate data management tool for CPN practices. In addition, up to three continuing medical education (CME) programs each year will feature national speakers and promote evidence-based practice guidelines. RESULTS: Eighty-five primary care and subspecialty practices are actively enrolled in CPN with a total of 385,000 annual outpatient visits. The makeup of insurance status is: HMO/PPO (45%); Medicare only (19%); Medicare HMO (11%); Medicare plus (8%); Medicaid (6%);"" Uninsured (11%). CONCLUSIONS: The Community Physicians' Network will address specific gaps in the health care of African-American and other minority patients by promoting quality care among its members and by facilitating participation in approved clinical trial protocols. The unique academic community partnership is consistent with the NIH roadmap goal of eliminating healthcare disparities.",0,0,
1744,The compensation of patients injured in clinical trials,"The problem of 'no fault' compensation for patients who suffer adverse effects as a result of their participation in clinical trials is discussed in the light of the guidelines issued by the Association of the British Pharmaceutical Industry (ABPI) and our recent experiences in reviewing protocols submitted to the local ethics of surgical research sub-committee. We have found a variety of qualifications being applied by pharmaceutical firms which are not in the spirit of the guidelines, let alone the interests of the patient, and we suggest a means whereby the patients can be assured of fair treatment in the event of 'no fault' injury.",0,0,
1745,The Context of Antibiotic Overuse,,0,0,
1746,The Cost-Effectiveness and Population Outcomes of Expanded HIV Screening and Antiretroviral Treatment in the United States,"Background Although recent guidelines call for expanded routine screening for HIV, resources for antiretroviral treatment (ART) are limited and all eligible people are not currently being treated.Objective To evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.DesignDynamic mathematical model of HIV transmission and disease progression, and cost-effectiveness analysis.Data SourcesPublished literature.Target PopulationHigh-risk (injection drug users, men who have sex with men) and low-risk individuals aged 15 to 64 in the U.S.Time Horizon20 years and lifetime (costs and QALYs).PerspectiveSocietal.InterventionsExpanded HIV screening and counseling, treatment with ART, or both.Outcome MeasuresNew HIV infections, discounted costs and quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.Results Base-Case AnalysisOne-time HIV screening of low-risk individuals coupled with annual screening of high-risk individuals could prevent 6.7% of a projected 1.23 million new infections and cost $22,382/QALY gained, assuming a 20% reduction in sexual activity post-screening. Expanding ART utilization to 75% of eligible individuals prevents 10.3% of infections and costs $20,300/QALY gained. A combination strategy prevents 17.3% of infections and costs $21,580/QALY gained.Results Sensitivity AnalysisWith no reduction in sexual activity, expanded screening prevents 3.7% of infections. Earlier ART initiation when CD4>350 cells/mL prevents 20¨C28% of infections. Additional efforts to halve high-risk behavior could reduce infections by 65%.LimitationsSimplified model of disease progression and treatment"";"" exclusion of acute HIV screening.ConclusionsExpanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without significant reductions in risk behavior.Primary Funding SourceNational Institute on Drug Abuse, United States National Institutes of Health (R-01-DA-15612) and the United States Department of Veterans Affairs.",0,0,
1747,"The Costs, Clinical Benefits, and Cost-Effectiveness of Screening for Cervical Cancer in HIV-Infected Women","Background:Women with HIV infection have a higher risk for cervical squamous intraepithelial lesions than do women without HIV infection, and the optimal regimen for cervical cancer screening in these women is uncertain.Objective:To assess the net health consequences, costs, and cost-effectiveness of various screening strategies for cervical neoplasia and cancer in HIV-infected women.Design:A cost-effectiveness analysis from a societal perspective done by using a state-transition Markov model. Values for incidence, progression, and regression of cervical neoplasia""; efficacy of screening and treatment; progression of HIV disease; mortality from HIV infection and cancer; quality of life;"" and costs were obtained from the literature.Setting:Simulated clinical practice in the United States.Patients:HIV-infected women representative of the U.S. population.Intervention:Six main screening strategies¡ªno screening, annual Papanicolaou smears, annual Papanicolaou smears after two negative smears obtained 6 months apart (recommended by the Centers for Disease Control and Prevention), semiannual Papanicolaou smears, annual colposcopy, and semiannual colposcopy¡ªwere considered.Measurements:Quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness.Results:Annual Papanicolaou smear screening resulted in a 2.1-month gain in quality-adjusted life expectancy for an incremental cost of $12 800 per QALY saved. Annual Papanicolaou smear screening after two negative smears obtained 6 months apart provided an additional 0.04 QALYs at a cost of $14 800 per QALY saved. Semiannual Papanicolaou smear screening provided a further 0.17 QALYs at a cost of $27 600 per QALY saved. Annual colposcopy cost more but provided no additional benefit compared with that given by semiannual Papanicolaou smear screening, and semiannual colposcopy exceeded $375 000 per QALY saved. Results were most sensitive to the rate of progression of neoplasia to invasive cancer.Conclusions:In HIV-infected women, cervical cancer screening with annual Papanicolaou smears after two negative smears obtained 6 months apart offers quality-adjusted life expectancy benefits at a cost comparable to that of other clinical preventive interventions.",0,0,
1748,The current situation of health research and ethics in Sudan,"At the beginning of the twentieth century, health research in the Sudan developed primarily as a function of the colonial British administration. Ethical issues in the medical profession in the Sudan are governed by the Sudan Medical Council. To address these issues, the Sudan Medical Council issued Medico-legal and Ethical Guidelines in 1967. This important document has focused principally on ethical issues arising in clinical medicine. Throughout the history of health research in Sudan it is very difficult to find any reference to research ethics. Nevertheless, there have been a few attempts to articulate ethics in health research. In 1979, Sudan witnessed the establishment of the first ethical review committee, which was established by the initiative of a group of doctors and scientists from the national health research laboratory. This committee got neither political nor institutional recognition. Therefore, it was not developed and came to an end shortly after its inception. Yet, in 2000 the FMOH established an ethical review committee (ERC). The functions of this committee were to review proposals of health research to be carried out in the country for ethical issues irrespective to the funding agents. Unfortunately, the committee devoted all the jobs in reviewing only externally-sponsored health research and research carried out by expatriate researchers or international organisations.",0,0,
1749,The demonstration of a theory-based approach to the design of localized patient safety interventions.,"Background There is evidence of unsafe care in healthcare systems globally. Interventions to implement recommended practice often have modest and variable effects. Ideally, selecting and adapting interventions according to local contexts should enhance effects. However, the means by which this can happen is seldom systematic, based on theory, or made transparent. This work aimed to demonstrate the applicability, feasibility, and acceptability of a theoretical domains framework implementation (TDFI) approach for co-designing patient safety interventions.  Methods We worked with three hospitals to support the implementation of evidence-based guidance to reduce the risk of feeding into misplaced nasogastric feeding tubes. Our stepped process, informed by the TDF and key principles from implementation literature, entailed: involving stakeholders""; identifying target behaviors; identifying local factors (barriers and levers) affecting behavior change using a TDF-based questionnaire; working with stakeholders to generate specific local strategies to address key barriers; and supporting stakeholders to implement strategies. Exit interviews and audit data collection were undertaken to assess the feasibility and acceptability of this approach.  Results Following audit and discussion, implementation teams for each Trust identified the process of checking the positioning of nasogastric tubes prior to feeding as the key behavior to target. Questionnaire results indicated differences in key barriers between organizations. Focus groups generated innovative, generalizable, and adaptable strategies for overcoming barriers, such as awareness events, screensavers, equipment modifications, and interactive learning resources. Exit interviews identified themes relating to the benefits, challenges, and sustainability of this approach. Time trend audit data were collected for 301 patients over an 18-month period for one Trust, suggesting clinically significant improved use of pH and documentation of practice following the intervention.  Conclusions The TDF is a feasible and acceptable framework to guide the implementation of patient safety interventions. The stepped TDFI approach engages healthcare professionals and facilitates contextualization in identifying the target behavior, eliciting local barriers, and selecting strategies to address those barriers. This approach may be of use to implementation teams and policy makers, although our promising findings confirm the need for a more rigorous evaluation;"" a balanced block evaluation is currently underway.",0,1,
1750,The design and evaluation of a graphical display for laboratory data,"Objective Advances in healthcare information technology have provided opportunities to present data in new, more effective ways. In this study, we designed a laboratory display that features small, data-dense graphics called sparklines, which have recently been promoted as effective representations of medical data but have not been well studied. The effect of this novel display on physicians' interpretation of data was investigated.  Design Twelve physicians talked aloud as they assessed laboratory data from four patients in a pediatric intensive care unit with the graph display and with a conventional table display.  Measurements Verbalizations were coded based on the abnormal values and trends identified for each lab variable. The correspondence of interpretations of variables in each display was evaluated, and patterns were investigated across participants. Assessment time was also analyzed.  Results Physicians completed assessments significantly faster with the graphical display (3.6 min vs 4.4 min, p=0.042). When compared across displays, 37% of interpretations did not match. Graphs were more useful when the visual cues in tables did not provide trend information, while slightly abnormal values were easier to identify with tables.  Conclusions Data presentation format can affect how physicians interpret laboratory data. Graphic displays have several advantages over numeric displays but are not always optimal. User, task and data characteristics should be considered when designing information displays.",0,1,
1751,The development of an intervention to promote adherence to national guidelines for suspected viral encephalitis,"BACKGROUND: Central nervous system infections can have devastating clinical outcomes if not diagnosed and treated promptly. There is a documented gap between recommended and actual practice and a limited understanding of its causes. We identified and explored the reasons for this gap, focusing on points in the patient pathway most amenable to change and the development of a tailored intervention strategy to improve diagnosis and treatment. METHODS: Using theoretically-informed semi-structured interviews, we explored barriers and enablers to diagnosing and managing patients with suspected encephalitis, specifically performing lumbar punctures and initiating antiviral therapy within 6 h. We purposively sampled hospitals and hospital staff in the UK. We audio recorded and transcribed all interviews prior to a framework analysis. We mapped identified barriers and enablers to the patient pathway. We matched behaviour change techniques targeting clinicians to the most salient barriers and enablers and embedded them within an intervention package. RESULTS: We interviewed 43 staff in six hospitals. Clinical staff expressed uncertainty when and how to perform lumbar punctures and highlighted practical difficulties in undertaking them within busy clinical settings. Once treatment need was triggered, clinicians generally felt able to take appropriate therapeutic action, albeit within organisational and resource constraints. Matched behaviour change techniques largely targeted antecedents of treatment. These included decision support to prompt recognition, highlighting the consequences of missed diagnoses for clinicians and patients, and practical support for lumbar punctures. We subsequently devised an evidence-informed package comprising 'core' interventions and, to allow for local flexibility, 'optional' interventions. CONCLUSIONS: We identified several points in the patient pathway where practice could improve, the most critical being around clinical suspicion and initial investigation. Interventions targeting professional beliefs and behaviours whilst optimising their clinical environment were amongst the most promising approaches to improve the care of suspected encephalitis. TRIAL REGISTRATION: Randomised trial registered with Controlled Trials ISRCTN06886935 .",0,1,
1752,The development of an intervention to promote adherence to national guidelines for suspected viral encephalitis.,"Background Central nervous system infections can have devastating clinical outcomes if not diagnosed and treated promptly. There is a documented gap between recommended and actual practice and a limited understanding of its causes. We identified and explored the reasons for this gap, focusing on points in the patient pathway most amenable to change and the development of a tailored intervention strategy to improve diagnosis and treatment.  Methods Using theoretically-informed semi-structured interviews, we explored barriers and enablers to diagnosing and managing patients with suspected encephalitis, specifically performing lumbar punctures and initiating antiviral therapy within 6 h. We purposively sampled hospitals and hospital staff in the UK. We audio recorded and transcribed all interviews prior to a framework analysis. We mapped identified barriers and enablers to the patient pathway. We matched behaviour change techniques targeting clinicians to the most salient barriers and enablers and embedded them within an intervention package.  Results We interviewed 43 staff in six hospitals. Clinical staff expressed uncertainty when and how to perform lumbar punctures and highlighted practical difficulties in undertaking them within busy clinical settings. Once treatment need was triggered, clinicians generally felt able to take appropriate therapeutic action, albeit within organisational and resource constraints. Matched behaviour change techniques largely targeted antecedents of treatment. These included decision support to prompt recognition, highlighting the consequences of missed diagnoses for clinicians and patients, and practical support for lumbar punctures. We subsequently devised an evidence-informed package comprising ‘core’ interventions and, to allow for local flexibility, ‘optional’ interventions.  Conclusions We identified several points in the patient pathway where practice could improve, the most critical being around clinical suspicion and initial investigation. Interventions targeting professional beliefs and behaviours whilst optimising their clinical environment were amongst the most promising approaches to improve the care of suspected encephalitis.",0,1,1751
1753,The development of evidence-based psychotherapy for use in alcoholism. A review,"Past decades have seen enormous advances in the development and validation of evidence-based approaches to psychotherapy for alcoholism. While psychoanalytic and early behavioral techniques were the original basis of psychotherapy in this field, evidence-based approaches are now built up on the principles of motivational interviewing and cognitive-behavior therapy. Different techniques have been developed to modify preceding and persisting conditions favoring problem behavior, e.g., training in coping/social skills and the community reinforcement approach. According to the results of the project MATCH, one of the largest treatment trials, ""cognitive-behavioral intervention"" combines motivational enhancement therapy, the 12-step approach, and cognitive-behavior therapy, with the aim of providing new and even more efficacious psychotherapy for alcohol dependent patients. These very promising developments are beset with huge problems, however, insofar as few of the new evidence-based treatment approaches are accepted as standard treatment in Germany, in addition to which only a fraction of all alcohol-dependent persons in the country find their way into the care system, for various reasons. Early diagnosis and facilitation of access to the various treatment options available could be a future task for general practitioners and also for company / industrial medical schemes.",0,0,
1754,The dirty dozen: 12 sources of bias in forensic neuropsychology with ways to mitigate.,"The ever expanding role of a forensic neuropsychologist in civil litigation has rightfully led to a higher level of expectation for this expert, in realms such as clinical and courtroom knowledge, objectivity, and work product utility. The onus is on forensic neuropsychologists to ensure that these expectations are met. Recognizing that bias is inherent in clinical and forensic work, it is imperative that in high stakes situations such as forensic neuropsychological assessment, the evaluator is proactively conscientious in recognizing, and minimizing, the effects of these biases. This article highlights 12, of many, common biases about which the prudent forensic neuropsychologist should always be mindful of, during evaluation as well as the provision of deposition or trial testimony. Role, cognitive, and practice biases are defined and illustrated with examples. Specific suggestions are extracted from both empirical literature and forensic experience on how to recognize and mitigate these biases. The information contained in this article is intended to provide sound and practical strategies that can be useful for forensic neuropsychological practitioners. Attorneys will also find the content useful when working with such experts, including during deposition and cross examination preparation. (PsycINFO Database Record (c) 2017 APA, all rights reserved)",0,0,
1755,The economy-wide impact of pandemic influenza on the UK: a computable general equilibrium modelling experiment,"OBJECTIVES To estimate the potential economic impact of pandemic influenza, associated behavioural responses, school closures, and vaccination on the United Kingdom. DESIGN A computable general equilibrium model of the UK economy was specified for various combinations of mortality and morbidity from pandemic influenza, vaccine efficacy, school closures, and prophylactic absenteeism using published data. SETTING The 2004 UK economy (the most up to date available with suitable economic data). MAIN OUTCOME MEASURES The economic impact of various scenarios with different pandemic severity, vaccination, school closure, and prophylactic absenteeism specified in terms of gross domestic product, output from different economic sectors, and equivalent variation. RESULTS The costs related to illness alone ranged between 0.5% and 1.0% of gross domestic product ( pound8.4bn to pound16.8bn) for low fatality scenarios, 3.3% and 4.3% ( pound55.5bn to pound72.3bn) for high fatality scenarios, and larger still for an extreme pandemic. School closure increases the economic impact, particularly for mild pandemics. If widespread behavioural change takes place and there is large scale prophylactic absence from work, the economic impact would be notably increased with few health benefits. Vaccination with a pre-pandemic vaccine could save 0.13% to 2.3% of gross domestic product ( pound2.2bn to pound38.6bn)""; a single dose of a matched vaccine could save 0.3% to 4.3% ( pound5.0bn to pound72.3bn);"" and two doses of a matched vaccine could limit the overall economic impact to about 1% of gross domestic product for all disease scenarios. CONCLUSION Balancing school closure against ""business as usual"" and obtaining sufficient stocks of effective vaccine are more important factors in determining the economic impact of an influenza pandemic than is the disease itself. Prophylactic absence from work in response to fear of infection can add considerably to the economic impact.",0,0,
1756,The EDUCATE Study: a continuing education exemplar for Clinical Practice Guideline Implementation,"Cancer care is evolving from a solo practitioner care delivery system based on tradition and anecdotal experience to a multidisciplinary, collaborative, science-driven paradigm. Evidence-based practice facilitates optimal care quality for patients with cancer and is effected for medical and nursing practitioners through clinical practice guideline implementation. Clinician education based on principles of adult learning is one method of implementing clinical practice guidelines in clinical practice. However, research demonstrates that conventional static methods of education do little to change behavior"";"" instead, effective education incorporates interactive formats, provides feedback, and includes reminder and reinforcement strategies. The EDUCATE (Educating Clinicians to Achieve Treatment Guideline Effectiveness) Study offers one model for clinical practice guideline implementation using educational methods. A faculty of nurse educators, together with practice champions, carried out an intensive educational intervention comprised of multiple teaching/learning activities during a 12-month period in community oncology practices throughout the United States. In addition to an overview of clinical practice guidelines and educational methods that can be used for implementation of clinical practice guidelines, the obstacles faced and lessons learned through the EDUCATE Study are presented, along with recommendations for implementation in the practice setting.",0,0,
1757,The effect of a computerized reminder system on the prevention of postoperative venous thromboembolism,"Study objective To measure the effect of an altered process of care, directed by a computerized reminder system, on rates of symptomatic postoperative venous thromboembolism.  Design Comparisons of preintervention and postintervention measurements.  Setting A university-affiliated community hospital in Utah.  Patients Two-thousand seventy-seven consecutive patients who underwent major operations in four surgical divisions between January 1, 1997, and October 31, 1997 (preintervention), and 2,093 consecutive patients who underwent the same procedures between January 1, 1998, and October 31,1998 (postintervention).  Intervention A program to prevent venous thromboembolism developed from American College of Chest Physicians guidelines, and an altered work process directed by a computerized reminder system.  Measurements Rates of symptomatic, objectively confirmed deep vein thrombosis (DVT), pulmonary embolism (PE), and death attributable to venous thromboembolism occurring within 90 days of the date of surgery.  Results The preintervention and postintervention cohorts did not differ with respect to age, severity of illness, number of risk factors for venous thromboembolism, or individual risk factors for venous thromboembolism. The overall prophylaxis rate increased from 89.9% before implementation of the computerized reminder system to 95.0% after implementation (p < 0.0001). The combined 90-day rate of symptomatic DVT, PE, and death attributable to PE remained the same (preintervention, 1.0%""; postintervention, 1.2%; odds ratio, 1.21;"" 95% confidence interval, 0.67 to 2.20). Forty of 46 venous thromboembolic complications (87%) occurred despite the delivery of American College of Chest Physicians-recommended measures to prevent venous thromboembolism.  Conclusions Computerized reminder systems combined with altered care procedures increase the rate of prophylaxis against venous thromboembolism without decreasing the rate of symptomatic venous thromboembolism when the baseline rate of prophylaxis is high. A population of surgical patients exists who are resistant to American College of Chest Physicians-recommended prophylactic measures against venous thromboembolism. New strategies are needed to address prophylaxis-resistant venous thromboembolism.",1,1,
1758,The effect of a mobile clinical decision support system on the diagnosis of obesity and overweight in acute and primary care encounters.,"The purpose of the study was to compare the proportion of obesity-related diagnoses in clinical encounters (N = 1874) documented by nurses using a personal digital assistant-based log with and without obesity decision support features. The experimental group encounters in the randomized controlled trial had significantly more (P = .000) obesity-related diagnoses (11.3%) than did the control group encounters (1%) and a significantly lower false negative rate (24.5% vs 66.5%, P = .000). The study findings provide evidence that integration of a decision support feature that automatically calculates an obesity-related diagnosis increases diagnoses and decreases missed diagnoses and suggest that such systems have the potential to improve the quality of obesity-related care.   OBESITY AND OVERWEIGHT are challenging public health issues and the target of public health prevention goals in the United States.1 Obesity and overweight have been underrecognized conditions, which has led to many obese patients not receiving appropriate interventions.2,3 Prevention and management of obesity and overweight encompasses a set of complex and dynamic processes,4 and integration of relevant evidence into practice is needed to improve obesity management.5,6 Clinical practice guidelines can serve as a tool for provision of evidence-based practice"";"" however, few studies have been conducted with nurses, and methodological issues limit generalizability of their results.7 Although advanced practice nurses have the potential to play pivotal roles in the prevention and management of obesity and overweight, there is little empirical evidence about their adherence to guidelines, and thus research is needed to explore effective strategies that support guideline implementation.8 The purpose of this study was to compare the proportion of obesity-related diagnoses (obesity and overweight) in clinical encounters documented using a personal digital assistant-based clinical decision support system as compared with a personal digital assistant-based clinical log without obesity decision support features.",0,1,
1759,The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial,"BACKGROUND: Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality. OBJECTIVE: To evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients. DESIGN: Pragmatic cluster randomised trial. SETTING: Eight tertiary referral hospitals with >200 beds each in three Australian states. PARTICIPANTS: 1600 patients (200/hospital) were recruited. Patients were eligible if they were: >/=18 years old""; at risk of pressure ulcer because of limited mobility; expected to stay in hospital >/=48h and able to read English. METHODS: Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. RESULTS: Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33;"" p=0.198). No adverse events or harms were reported. CONCLUSIONS: Although the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.",0,0,
1760,The effect of adding Pap smear information to a mammography reminder system in an HMO: results of randomized controlled trial.,"Background While reminders can promote cancer screening in primary care, little is known about the potential interaction between multiple reminders.  Methods We conducted a randomized controlled trial to compare the effect of combined Pap smear plus mammogram reminders and mammogram-only reminders among 2471 women 40 years of age or older enrolled in a health maintenance organization serving a predominately Medicaid-eligible population. Reminders included both a mailed letter for the woman and a medical record prompt.  Results Intervention assignment was unassociated with differences in rates of visitation to family medicine or internal medicine or completion of mammography during the study year. Compared to women assigned to mammogram-only reminder treatment, those assigned to the combined Pap smear plus mammogram reminder intervention were more likely to visit a gynecologist (34% compared to 29%, adjusted odds ratio = 1.33, 95% confidence interval 1.08–1.63) and to complete a Pap smear (30% compared to 23%, adjusted odds ratio = 1.39, 95% confidence interval 1.07–1.89).  Conclusions In the study setting, the addition of Pap smear to mammography reminders has a procedure-specific effect, increasing gynecology visits and Pap smear use while neither increasing nor decreasing other primary care visits or mammography. We find no evidence of reinforcement or competition between these reminders.",0,1,
1761,The effect of computer reminders on GPs' prescribing behaviour: a cluster-randomised trial,"OBJECTIVE: It is difficult to control drug-prescribing behaviour in general practice, despite the development and distribution of guidelines. The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system (CRS). DESIGN: Cluster-randomised controlled trial with an incomplete block design in the south of the Netherlands: 25 GPs (7 GP practices) received reminders about antibiotics and asthma/COPD prescriptions, 28 GPs (7 GP practices) received reminders about cholesterol prescriptions. Prescription guidelines were integrated into the computerised GP information system. MEASUREMENTS: Both performance indicators and prescription volumes were calculated as the main outcome measures. Next to individual volume measure, sum scores were constructed on the volume measures per drug group (antibiotics, asthma/COPD and cholesterol). RESULTS: Variation between GPs turned out to be larger and more skewed than expected. No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs. Although there was a tendency towards clinically relevant results for prescription volumes that were supposed to drop, the difference in sum score between the groups was not significant. For antibiotic prescriptions that were supposed to drop, the sum score for the intervention group was 28.2 (95% CI: 20.8-44.5) prescriptions per 1000 patients per GP, while this was 39.7 (95% CI: 29.7-64.1) for the control group (p 0.2). For prescriptions asthma/COPD that were supposed to drop, the sum score for the intervention group was 1.1 (95% CI: 0.6-2.6) prescriptions per 1000 patients per GP, while this was 2.2 (95% CI: 1.4-4.3) for the control group (p 0.1). On three specific recommendations (on quinolones for cystitis, corticosteroids for CPOD, and antibiotics for acute sore throat) significant differences were found. CONCLUSIONS: This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour. Nevertheless, computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice.",1,1,
1762,The Effect of Educational Intervention on Medical Diagnosis Recording among Residents,"INTRODUCTION: Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians' performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS). METHODS: This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians' knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test. RESULTS: Change in physicians' knowledge before and after education was not statistically significant (p = 0.15). Residents' behavior did not have statistically significant changes during three phases of the study. CONCLUSION: Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians' behavior about chart documentation.",0,0,
1763,The effect of external feedback on the management of medicare inpatients with congestive heart failure,"The purpose of this study was to compare the effect of 2 feedback strategies on the adherence to congestive heart failure (CHF) guidelines. Thirty-two hospitals in 4 states were randomized to receive either a written feedback intervention (low-intensity intervention [LII]) or an intervention involving feedback, a physician liaison, and quality improvement tools (high-intensity intervention [HII]). CHF quality indicators were assessed, and quality managers were interviewed at baseline and remeasurement. No significant changes in quality indicators were found as a result of either intervention. Seventy-eight percent of quality managers indicated that hospital project implementation had not begun until shortly before remeasurement. HII quality managers perceived the CHF project as significantly more successful compared with LII quality managers (63% versus 13%, P < .01). Evaluation of the effects of external feedback on practice behavior requires sufficient time for organizational and individual clinician change to occur. Physician liaisons may play a role in facilitating this change.",0,1,
1764,The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial. ,"Background Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya.  Methods From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636.  Findings 119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23·7 percentage-points (95% CI 7·6–40·0""; p=0·004) immediately after intervention and by 24·5 percentage-points (8·1–41·0;"" p=0·003) 6 months later.  Interpretation In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices.",1,1,
1765,The effect of orthodontic referral guidelines: a randomised controlled trial,"OBJECTIVE: To develop and evaluate the effectiveness of referral guidelines for the referral of orthodontic patients to consultant and specialist practitioner orthodontists. DESIGN: Single centre randomised controlled trial with random allocation of referral guidelines for orthodontic treatment to general dental practitioners. SETTING: Hospital orthodontic departments and specialist orthodontic practices in Manchester and Stockport. SUBJECTS: General dental practitioners and the patients they referred for orthodontic treatment. MAIN OUTCOME MEASURE: Appropriateness of referral, defined as whether the patient was accepted for orthodontic treatment. RESULTS: The referral guidelines did not reduce the number of inappropriate referrals. CONCLUSIONS: Referral guidelines for orthodontic referrals did not influence the behaviour of the general dental practitioners. More research into the optimum methods of dissemination and implementation of referral guidelines for use in the general dental service is needed.",0,0,
1766,The effect of registry-based performance feedback via short text messages and traditional postal letters on prescribing parenteral steroids by general practitioners—A randomized controlled trial,"Background It is conjectured that providing feedback on physicians’ prescribing behavior improves quality of drug prescriptions. However, the effectiveness of feedback provision and mode of feedback delivery is not well understood. The objective of this study was to assess and compare the effect of traditional paper letters (TPL) and short text message (STM) feedback on general practitioners’ prescribing behavior of parenteral steroids (PSs).  Methods In a single-blind randomized controlled trial, 906 general practitioners (GPs) having at least 10 monthly prescriptions were randomly recruited into two interventions and one control study arms with 1:1 allocation, stratified by percentage of prescriptions. The intervention was the provision of 3 feedback messages containing prescribing indices in TPL and STM (in the first two arms) versus the control arm (CG) with an interval of 3 months between these messages. We calculated the PS Defined Daily Dose (DDD) for every GP, every month, and compared between the 3 arms, before and after the interventions. The expected primary outcome was to reduce prescription of parenteral steroids by participants. The study was performed in the Kerman Social Security Organization in Iran.  Results A total of 906 GPs were selected for the trial, but only 721 of them (TPL = 191, STM = 228, CG = 302) were recruited for the 1st feedback. The mean age of GPs was 44 and 59% of them were male. The prescribed parenteral steroid DDDs at baseline were similar (TPL = 121.62, STM = 127.49, CG = 115.68, P > 0.5). At the end of the study, DDDs in the TPL and STM arms were similar (TPL = 104.38, STM = 101.90, P > 0.9) but DDDs in each intervention arm was statistically significantly lower than in CG (CG = 156.17, P < 0.0001). Being in TPL and STM arms resulted in 36.1 and 41.7 units of decrease in DDD respectively, compared to the control arm (P < 0.02 and P < 0.005) after the one-year duration of the study.  Conclusion Feedback by TPLs and STMs on prescribing performance effectively reduced prescribing PSs by GPs. STM, being a cheap and fast tool, is potentially powerful and efficient for drug prescription rationalization.",1,1,
1767,The effect of the Vermont Diabetes Information System on inpatient and emergency room use: results from a randomized trial.,"Objective To describe the effect of the Vermont Diabetes Information System (VDIS) on hospital and emergency department use.  Data Source Statewide discharge database.  Study Design Randomized controlled trial of a decision support system for 7412 adults with diabetes and their 64 primary care providers.  Data Collection/Data Extraction Charges and dates for hospital admissions and emergency department care in Vermont during an average of 32 months of observation. Data from New York hospitals were not available.  Results Patients randomized to VDIS were admitted to the hospital less often than control subjects (0.17 admissions vs 0.20""; P = .01) and generated lower hospital charges ($3113 vs $3480; P = .019). VDIS patients also had lower emergency department utilization (0.27 visits vs 0.36; P <.0001) and charges ($304 vs $414;"" P <.0001). The intervention was particularly effective in men and in older subjects.  Conclusions Despite data limitations that tended to reduce the apparent effect of the system, this randomized, controlled trial showed that VDIS reduces hospitalization and emergency department utilization and expenses.",0,1,
1768,The effectiveness and cost effectiveness of dark chocolate consumption as prevention therapy in people at high risk of cardiovascular disease: best case scenario analysis using a Markov model,"OBJECTIVE To model the long term effectiveness and cost effectiveness of daily dark chocolate consumption in a population with metabolic syndrome at high risk of cardiovascular disease. DESIGN Best case scenario analysis using a Markov model. SETTING Australian Diabetes, Obesity and Lifestyle study. PARTICIPANTS 2013 people with hypertension who met the criteria for metabolic syndrome, with no history of cardiovascular disease and not receiving antihypertensive therapy. MAIN OUTCOME MEASURES Treatment effects associated with dark chocolate consumption derived from published meta-analyses were used to determine the absolute number of cardiovascular events with and without treatment. Costs associated with cardiovascular events and treatments were applied to determine the potential amount of funding required for dark chocolate therapy to be considered cost effective. RESULTS Daily consumption of dark chocolate (polyphenol content equivalent to 100 g of dark chocolate) can reduce cardiovascular events by 85 (95% confidence interval 60 to 105) per 10,000 population treated over 10 years. $A40 (£25""; €31;"" $42) could be cost effectively spent per person per year on prevention strategies using dark chocolate. These results assume 100% compliance and represent a best case scenario. CONCLUSIONS The blood pressure and cholesterol lowering effects of dark chocolate consumption are beneficial in the prevention of cardiovascular events in a population with metabolic syndrome. Daily dark chocolate consumption could be an effective cardiovascular preventive strategy in this population.",0,0,
1769,The effectiveness and cost-effectiveness of lay counsellor-delivered psychological treatments for harmful and dependent drinking and moderate to severe depression in primary care in India: PREMIUM study protocol for randomized controlled trials,"BACKGROUND: The leading mental health causes of the global burden of disease are depression in women and alcohol use disorders in men. A major hurdle to the implementation of evidence-based psychological treatments in primary care in developing countries is the non-availability of skilled human resources. The aim of these trials is to evaluate the effectiveness and cost-effectiveness of two psychological treatments developed for the treatment of depression and alcohol use disorders in primary care in India. METHODS/DESIGN: This study protocol is for parallel group, randomized controlled trials (Healthy Activity Program for moderate to severe depression, Counselling for Alcohol Problems for harmful and dependent drinking) in eight primary health centres in Goa, India. Adult primary care attendees will be screened with the Patient Health Questionnaire for depression and, in men only, the Alcohol Use Disorders Identification Test for drinking problems. Screen-positive attendees will be invited to participate""; men who screen positive for both disorders will be invited to participate in the Counselling for Alcohol Problems trial. Those who consent will be allocated in a 1:1 ratio to receive either the respective psychological treatment plus enhanced usual care or enhanced usual care only using a computer generated allocation sequence, stratified by primary health centre and, for depression, by sex. The enhanced usual care comprises providing primary health centre doctors with contextualized World Health Organization guidelines and screening results. Psychological treatments will be delivered by lay counsellors, over a maximum period of three months. Primary outcomes are severity of disorder and remission rates at three months post-enrolment and, for the Counselling for Alcohol Problems trial, drinking and the impact of drinking on daily lives. Secondary outcomes include severity of disorder and remission rates at 12 months, disability scores, suicidal behaviour and economic impact, and cost-effectiveness at three and 12 months. 500 participants with depression and 400 participants with harmful drinking will be recruited. Primary analyses will be intention-to-treat. DISCUSSION: These trials may offer a new approach for the treatment of moderate-severe depression and drinking problems in primary care that is potentially scalable as it relies on delivery by a single pool of lay counsellors. TRIAL REGISTRATION: Both trials are registered with the International Society for the Registration of Clinical Trials (Healthy Activity Programme registration number ISRCTN95149997;"" Counselling for Alcohol Problems registration number ISRCTN76465238).",0,0,
1770,"The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) randomized trial","STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners (chiropractors, osteopaths, and musculoskeletal physiotherapists) across the United Kingdom. SUMMARY OF BACKGROUND DATA: A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations. METHODS: In total, 1758 practitioners were randomly allocated to either of the 2 study arms. One arm was posted a printed information package containing guideline recommendations for the management of LBP (n = 876) and the other received no intervention (n = 882). The primary outcome measure consisted of 3 ""quality indicators"" (activity, work, and bed-rest) relating to a vignette of a patient with LBP, in which responses were dichotomized into either ""guideline-inconsistent"" or ""guideline-consistent."" The secondary outcome was the practitioners' LBP-related beliefs, measured using the Health Care Providers Pain and Impairment Relationship Scale. Outcomes were measured at baseline and at 6 months. RESULTS: Follow-up at 6 months was 89%. The changes in reported behavior on the quality indicators were as follows: activity, odds ratio (OR) 1.29 (95% confidence interval, 1.03-1.61) and number needed to be treated (NNT), 19 (15-28)""; work, OR 1.35 (1.07-1.70) and NNT 19 (14-29); and bed-rest, OR 1.31 (0.97-1.76) and NNT 47 (33-103). The composite NNT for a change from guideline-inconsistent to guideline-consistent behavior on at least 1 of the 3 quality indicators was 10 (9-14). LBP-related beliefs were significantly improved in those who were sent the information package (P = 0.002), but only to a small degree (mean difference, 0.884 scale points;"" 95% confidence interval, 0.319-1.448). CONCLUSION: Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners, toward practice that is more in line with guideline recommendations.",0,0,
1771,"The effectiveness of an intervention in increasing community health clinician provision of preventive care: a study protocol of a non-randomised, multiple-baseline trial","BACKGROUND: The primary behavioural risks for the most common causes of mortality and morbidity in developed countries are tobacco smoking, poor nutrition, risky alcohol use, and physical inactivity. Evidence, guidelines and policies support routine clinician delivery of care to prevent these risks within primary care settings. Despite the potential afforded by community health services for the delivery of such preventive care, the limited evidence available suggests it is provided at suboptimal levels. This study aims to assess the effectiveness of a multi-strategic practice change intervention in increasing clinician's routine provision of preventive care across a network of community health services. METHODS/DESIGN: A multiple baseline study will be conducted involving all 56 community health facilities in a single health district in New South Wales, Australia. The facilities will be allocated to one of three administratively-defined groups. A 12 month practice change intervention will be implemented in all facilities in each group to facilitate clinician risk assessment of eligible clients, and clinician provision of brief advice and referral to those identified as being 'at risk'. The intervention will be implemented in a non-random sequence across the three facility groups. Repeated, cross-sectional measurement of clinician provision of preventive care for four individual risks (smoking, poor nutrition, risky alcohol use, and physical inactivity) will occur continuously for all three facility groups for 54 months via telephone interviews. The interviews will be conducted with randomly selected clients who have visited a community health facility in the last two weeks. Data collection will commence 12 months prior to the implementation of the intervention in the first group, and continue for six months following the completion of the intervention in the last group. As a secondary source of data, telephone interviews will be undertaken prior to and following the intervention with randomly selected samples of clinicians from each facility group to assess the reported provision of preventive care, and the acceptability of the practice change intervention and implementation. DISCUSSION: The study will provide novel evidence regarding the ability to increase clinician's routine provision of preventive care across a network of community health facilities. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12611001284954 UNIVERSAL TRIAL NUMBER (UTN): U1111-1126-3465.",0,0,
1772,The effectiveness of computer reminders for improving quality assessment for point-of-care testing in general practice—A randomized controlled trial,"Background Computer reminders are increasingly being applied in efforts to improve quality and patient safety. However, research is still needed to establish the effectiveness of different kinds of reminders in various settings. This study aimed to evaluate the effectiveness of computer reminders for improving adherence to a quality assessment scheme for point-of-care testing in general practice.  Method The study was conducted as a randomized controlled crossover trial among general practices in the Capital Region of Denmark. The intervention consisted of sending computer reminders (ComRem) to practices not adhering to the guideline recommendations of split testing for hemoglobin and glucose. Practices were randomly allocated into two groups. During the first follow-up period, one of the groups received the ComRem intervention together with the general implementation activities (GIA), while the other group only received the GIA. For the second follow-up period, the intervention was switched between the two groups. Outcomes were measured as split test procedure adherence.  Results A total of 142 practices were randomly allocated to the early intervention group and 144 practices to the late intervention group (the control group in the first follow-up period). In the first intervention period, the mean number of split tests performed in the group receiving ComRem group increased from 1.22 to 3.76 (out of eight possible tests) while the mean number of split tests increased from 1.11 to 2.35 in the group targeted by GIA only (p = 0.0059). After the crossover, a similar effect of reminders was observed. Furthermore, the developments in outcome measures over time showed a strong effect of computer reminders beyond the intervention periods.  Conclusion There was a significant effect of computer reminders on adherence to the quality assessment scheme for point-of-care testing. Thus, computer reminders seem to be useful for supporting the implementation of relatively simple procedures for quality and safety.",1,1,
1773,The effectiveness of computerized clinical guidelines in the process of care: a systematic review,"BACKGROUND: Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines. METHODS: Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care. RESULTS: Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5""; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7;"" 95%CI: 1.3-34.3) were statistically significant predictors. CONCLUSIONS: From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.",0,1,
1774,The effectiveness of interventions to improve laboratory requesting patterns among primary care physicians: a systematic review,"Background Laboratory testing is an integral part of day-to-day primary care practice, with approximately 30 % of patient encounters resulting in a request. However, research suggests that a large proportion of requests does not benefit patient care and is avoidable. The aim of this systematic review was to comprehensively search the literature for studies evaluating the effectiveness of interventions to improve primary care physician use of laboratory tests.  Methods A search of PubMed, Cochrane Library, Embase and Scopus (from inception to 09/02/14) was conducted. The following study designs were considered: systematic reviews, randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analysis (ITSs). Studies were quality appraised using a modified version of the Effective Practice and Organisation of Care (EPOC) checklist. The population of interest was primary care physicians. Interventions were considered if they aimed to improve laboratory testing in primary care. The outcome of interest was a volume of laboratory tests.  Results In total, 6,166 titles and abstracts were reviewed, followed by 87 full texts. Of these, 11 papers were eligible for inclusion in the systematic review. This included four RCTs, six CBAs and one ITS study. The types of interventions examined included education, feedback, guidelines, education with feedback, feedback with guidelines and changing order forms. The quality of included studies varied with seven studies deemed to have a low risk of bias, three with unclear risk of bias and one with high risk of bias. All but one study found significant reductions in the volume of tests following the intervention, with effect sizes ranging from 1.2 to 60 %. Due to heterogeneity, meta-analysis was not performed.  Conclusions Interventions such as educational strategies, feedback and changing test order forms may improve the efficient use of laboratory tests in primary care"";"" however, the level of evidence is quite low and the quality is poor. The reproducibility of findings from different laboratories is also difficult to ascertain from the literature. Some standardisation of both interventions and outcome measures is required to enable formal meta-analysis.",0,1,
1775,"The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial","OBJECTIVE To evaluate whether a new computerised cognitive behavioural therapy intervention (SPARX, Smart, Positive, Active, Realistic, X-factor thoughts) could reduce depressive symptoms in help seeking adolescents as much or more than treatment as usual. DESIGN Multicentre randomised controlled non-inferiority trial. SETTING 24 primary healthcare sites in New Zealand (youth clinics, general practices, and school based counselling services). PARTICIPANTS 187 adolescents aged 12-19, seeking help for depressive symptoms, with no major risk of self harm and deemed in need of treatment by their primary healthcare clinicians: 94 were allocated to SPARX and 93 to treatment as usual. INTERVENTIONS Computerised cognitive behavioural therapy (SPARX) comprising seven modules delivered over a period of between four and seven weeks, versus treatment as usual comprising primarily face to face counselling delivered by trained counsellors and clinical psychologists. OUTCOMES The primary outcome was the change in score on the children's depression rating scale-revised. Secondary outcomes included response and remission on the children's depression rating scale-revised, change scores on the Reynolds adolescent depression scale-second edition, the mood and feelings questionnaire, the Kazdin hopelessness scale for children, the Spence children's anxiety scale, the paediatric quality of life enjoyment and satisfaction questionnaire, and overall satisfaction with treatment ratings. RESULTS 94 participants were allocated to SPARX (mean age 15.6 years, 62.8% female) and 93 to treatment as usual (mean age 15.6 years, 68.8% female). 170 adolescents (91%, SPARX n = 85, treatment as usual n = 85) were assessed after intervention and 168 (90%, SPARX n = 83, treatment as usual n = 85) were assessed at the three month follow-up point. Per protocol analyses (n = 143) showed that SPARX was not inferior to treatment as usual. Post-intervention, there was a mean reduction of 10.32 in SPARX and 7.59 in treatment as usual in raw scores on the children's depression rating scale-revised (between group difference 2.73, 95% confidence interval -0.31 to 5.77""; P=0.079). Remission rates were significantly higher in the SPARX arm (n = 31, 43.7%) than in the treatment as usual arm (n = 19, 26.4%) (difference 17.3%, 95% confidence interval 1.6% to 31.8%; P = 0.030) and response rates did not differ significantly between the SPARX arm (66.2%, n = 47) and treatment as usual arm (58.3%, n = 42) (difference 7.9%, -7.9% to 24%;"" P = 0.332). All secondary measures supported non-inferiority. Intention to treat analyses confirmed these findings. Improvements were maintained at follow-up. The frequency of adverse events classified as ""possibly"" or ""probably"" related to the intervention did not differ between groups (SPARX n = 11"";"" treatment as usual n = 11). CONCLUSIONS SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings and could be used to address some of the unmet demand for treatment. TRIAL REGISTRATION Australian New Zealand Clinical Trials ACTRN12609000249257.",0,0,
1776,The effectiveness of workplace interventions to increase physical activity and decrease sedentary behaviour in adults: protocol for a systematic review,"BACKGROUND: A physically active lifestyle plays a preventative role in the development of various chronic diseases and mental health conditions. Unfortunately, few adults achieve the minimum amount of physical activity and spend excessive time sitting. Developing targeted interventions to increase active living among adults is an important endeavour for public health. One plausible context to reach adults is the workplace. This systematic review aims to review the effectiveness of workplace interventions on increasing physical activity and decreasing sedentary behaviour in the workplace. METHODS: An advisory group of practitioners will work in collaboration with the research team to inform the systematic review and knowledge mobilization. Fifteen electronic databases will be searched to identify studies examining the effectiveness of workplace interventions on physical activity and sedentary behaviour. All experimental designs and observational studies (non-experimental intervention studies) meeting the study criteria will be included. Studies examining generally healthy, employed, adult participants will be included for the review. Interventions will focus on increasing physical activity and/or decreasing sedentary behaviour from the individual to policy level. The primary outcome variables will be reported or observed physical activity and/or sedentary behaviour in the workplace. Secondary outcomes will include variables ranging from return on investment to quality of life. Study quality will be assessed for risk of bias following the protocol identified in the Cochrane Handbook for Systematic Reviews of Interventions and supplemented by the guidelines developed by the Cochrane Effective Practice and Organisation of Care group, using RevMan. The quality of the evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. Meta-analyses, forest plots, and harvest plots will be used where appropriate to assess the direction, size, and consistency of the intervention effect across the studies using similar intervention strategies. Follow-up knowledge mobilization activities and products will be developed to support the use of this knowledge in practice. DISCUSSION: This protocol paper describes a systematic review assessing the effectiveness of various types of workplace interventions on increasing physical activity and decreasing sedentary behaviour at work. Collaborating with an advisory group of potential knowledge users throughout the process postulates a greater use and reach of the information gained from this systematic review by knowledge users. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015019398.",0,0,
1777,The effects of a postgraduate course on opioid-prescribing patterns of general practitioners,"BACKGROUND: The objective of this study is to evaluate whether a single palliative cancer care workshop, which included information about drug prescribing, had an effect on the opioid-prescription patterns of general practitioners in daily practice. METHOD: The opioid-prescription figures of 68 general practitioners who had participated in the workshop were aggregated from the computer system of the Regional Sick Fund. The prescription figures of a year before and a year after the workshop were compared and a control group of non-participants was included. RESULTS: This study showed a limited efficacy of a palliative cancer care workshop on the morphine-prescription figures of the general practitioners in daily practice. This limited effect did not accord with the results of a pre- and post-workshop questionnaire evaluating the attitudes of the same practitioners. CONCLUSION: A single workshop can not effectuate substantial changes in prescription behaviors. Possibilities for more reinforcements are discussed.",0,0,
1778,The effects of a theory-based training program on nurses' self-efficacy and behavior for smoking cessation counseling,"BACKGROUND: Cigarette smoking continues to put Americans at risk for serious health consequences and early death. Nurses play an important role in disseminating smoking cessation interventions to patients in the hospital. However, nurses are not prepared for smoking cessation counseling. METHOD: A quasi-experimental design was used. Fifteen nurses participated in the Clinical Practice Guideline ""5 A's"" brief intervention training program, completing a survey during three time periods. RESULTS: There were several statistically significant changes in the dependent variables for self-efficacy and behavior for smoking cessation counseling. CONCLUSION: Results of this study support further research and theory-based training for nurses.",0,0,
1779,The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials,"BackgroundStatins reduce LDL cholesterol and prevent vascular events, but their net effects in people at low risk of vascular events remain uncertain."";"" BackgroundStatins reduce LDL cholesterol and prevent vascular events, but their net effects in people at low risk of vascular events remain uncertain.",0,0,
1780,"The effects of maternal depression, anxiety, and perceived stress during pregnancy on preterm birth: A systematic review","BACKGROUND: Experiencing psychological distress such as depression, anxiety, and/or perceived stress during pregnancy may increase the risk for adverse birth outcomes, including preterm birth. Clarifying the association between exposure and outcome may improve the understanding of risk factors for prematurity and guide future clinical and research practices. AIM: The aims of the present review were to outline the evidence on the risk of preterm associated with antenatal depression, anxiety, and stress. METHODS: Four electronic database searches were conducted to identify quantitative population-based, multi-centre, cohort studies and randomised-controlled trial studies focusing on the association between antenatal depression, anxiety, and stress, and preterm birth published in English between 1980 and 2013. FINDINGS: Of 1469 electronically retrieved articles, 39 peer-reviewed studies met the final selection criteria and were included in this review following the PRISMA and MOOSE review guidelines. Information was extracted on study characteristics"";"" depression, anxiety and perceived stress were examined as separate and combined exposures. There is strong evidence that antenatal distress during the pregnancy increases the likelihood of preterm birth. CONCLUSION: Complex paths of significant interactions between depression, anxiety and stress, risk factors and preterm birth were indicated in both direct and indirect ways. The effects of pregnancy distress were associated with spontaneous but not with medically indicated preterm birth. Health practitioners engaged in providing perinatal care to women, such as obstetricians, midwives, nurses, and mental health specialists need to provide appropriate support to women experiencing psychological distress in order to improve outcomes for both mothers and infants.",0,0,
1781,"The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care","Background:The benefits of pay-for-performance (P4P) programs are uncertain.Purpose:To update and expand a prior review examining the effects of P4P programs targeted at the physician, group, managerial, or institutional level on process-of-care and patient outcomes in ambulatory and inpatient settings.Data Sources:PubMed from June 2007 to October 2016""; MEDLINE, PsycINFO, CINAHL, Business Economics and Theory, Business Source Elite, Scopus, Faculty of 1000, and Gartner Research from June 2007 to February 2016.Study Selection:Trials and observational studies in ambulatory and inpatient settings reporting process-of-care, health, or utilization outcomes.Data Extraction:Two investigators extracted data, assessed study quality, and graded the strength of the evidence.Data Synthesis:Among 69 studies, 58 were in ambulatory settings, 52 reported process-of-care outcomes, and 38 reported patient outcomes. Low-strength evidence suggested that P4P programs in ambulatory settings may improve process-of-care outcomes over the short term (2 to 3 years), whereas data on longer-term effects were limited. Many of the positive studies were conducted in the United Kingdom, where incentives were larger than in the United States. The largest improvements were seen in areas where baseline performance was poor. There was no consistent effect of P4P on intermediate health outcomes (low-strength evidence) and insufficient evidence to characterize any effect on patient health outcomes. In the hospital setting, there was low-strength evidence that P4P had little or no effect on patient health outcomes and a positive effect on reducing hospital readmissions.Limitation:Few methodologically rigorous studies;"" heterogeneous population and program characteristics and incentive targets.Conclusion:Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.",0,0,
1782,The effects of price information on physicians’ test-ordering behavior: ordering of diagnostic tests.,"This research evaluated the effects of providing physicians with information about the prices of diagnostic tests on their subsequent test-ordering behavior. The study population consisted of 36 second- and third-year residents and 23 clinical faculty in three family practice centers affiliated with the Department of Family Medicine at Wayne State University School of Medicine, Detroit, Michigan. Study participants were asked to review four case studies, each describing a patient with ambiguous symptoms, and to indicate on an attached test order form the tests they would order for each patient. Subjects were randomly assigned either to a group that received test order forms on which the prices of diagnostic tests were printed (price-information group) or to a group that received test order forms with no prices indicated (control group). The study results show that for each of the four cases, the average number of diagnostic tests ordered was significantly lower in the price-information group than in the control group. Our findings also show an average reduction in the cumulative cost of tests ordered per patient of 31.1 per cent related to the provision of price information. The feasibility of regularly providing physicians with price information is discussed and reviewed in light of other approaches that have been developed to modify physician behavior in ordering diagnositc tests.",1,1,
1783,The efficacy of an automated feedback system for general practitioners,"OBJECTIVE: An automated feedback system that produces comments about the non-adherence of general practitioners (GPs) to accepted practice guidelines for ordering diagnostic tests was developed. Before implementing the automated feedback system in daily practice, we assessed the potential effect of the system on the test ordering behaviour of GPs. DESIGN: We used a randomised controlled trial with balanced block design. SETTING: Five times six participant groups of GPs in a computer laboratory setting. INTERVENTION: The GPs reviewed a random sample of 30 request forms they filled in earlier that year. If deemed necessary, they could make changes in the tests requested. Next, the system displayed critical comments about their non-adherence to the guidelines as apparent from the (updated) request forms. SUBJECTS: Twenty-four randomly selected GPs participated. MAIN OUTCOME MEASURES: The number of requested diagnostic tests (17% with 95% confidence interval [CI]: 12-22%) and the fraction of tests ordered that were not in accordance with the practice guidelines (39% with 95% CI: 28-51%) decreased due to the comments of the automated feedback system. The GPs accepted 362 (50%) of the 729 reminders. IMPLICATIONS: Although our experiment cannot predict the size of the actual effect of the automated feedback system in daily practice, the observed effect may be seen as the maximum achievable.",1,1,
1784,The efficacy of computer reminders on external quality assessment for point-of-care testing in Danish general practice: rationale and methodology for two randomized trials,"BACKGROUND: Point-of-care testing (POCT) is increasingly being used in general practice to assist general practitioners (GPs) in their management of patients with diseases. However, low adherence to quality guidelines in terms of split test procedures has been observed among GPs in parts of the Capital Region in Denmark. Computer reminders embedded in GPs electronic medical records (ComRem) may facilitate improved quality control behaviour, but more research is needed to identify what types of reminders work and when. The overall aim of this study is to evaluate the efficacy of ComRem to improve GPs adherence to quality guidelines. This article describes the rationale and methods of the study that constitute this research project. METHODS/DESIGN: The study is conducted as two randomised controlled trials (RCTs) among general practices in two districts of the Capital Region in Denmark. These districts contain a total of 739 GPs in 567 practices with a total of 1.1 million patients allocated to practice lists. In the first RCT (RCT A), ComRem is compared to postal reminder letters. In the second RCT (RCT B), ComRem is compared to usual activities (no reminders) with a crossover approach. In both of these studies, outcomes are measured by the number of split tests received by the laboratory. CONCLUSIONS: This study will contribute to knowledge on the efficacy of ComRem in primary care. Because the study does not explore GPs' perceptions and experiences with regard to ComRem, we will subsequently conduct a qualitative survey focusing on these aspects. TRIAL REGISTRATIONS: Study A: ClinicalTrials.gov identifier: NCT01152151Study B: ClinicalTrials.gov identifier: NCT01152177.",0,0,
1785,The efficacy of visual cues to improve hand hygiene compliance,"BACKGROUND: Guidelines governing healthcare workers' (HCW) hand hygiene (HH) behavior are well established. Despite known hazards of healthcare-associated infection to both HCW and patients, hand hygiene compliance (HHC) rates remain dismally low. To evaluate a potential solution to this ongoing challenge, we used a simulated patient encounter in an actual hospital room to test the efficacy of individual HH triggers. METHODS: One hundred fifty HCW (75 physicians and 75 nurses) participated in this study and were randomly assigned to one of five equal-size groups. Each participant performed a focused physical examination on a standardized patient and was expected to maintain HH before and after the examination. Using two rooms on a medical-surgical unit in a tertiary care teaching hospital, various cues were employed, and the impact on pre- and postexamination HHC was recorded. In the control group, the hand sanitizer dispenser was in its usual location (Baseline). In one group, the dispenser was relocated to direct line of sight (Line-of-Sight) on entering the room""; in another, flashing lights were affixed to the dispenser in its usual location (Baseline & Flicker); and in a third group, the dispenser was relocated to the line of sight, and flashing lights were attached (Line-of-Sight & Flicker). In the last group, a large warning sign (Warning Sign) was affixed to the door, informing the healthcare provider that the room was under electronic surveillance, and failure to perform HHC would trigger an alarm. Data were analyzed using a generalized linear model to perform a repeated measures logistic regression;"" P<0.05 was considered statistically significant. RESULTS: In the control group (Baseline), pre- and postexamination HHC rates were 36.7% and 33.3%, respectively. All interventions improved HHC preintervention compared with baseline (Line-of-Sight=53.3%, Baseline & Flicker=60%, Line-of-Sight & Flicker=66%, Warning Sign=93.3%), but only the Line-of-Sight & Flicker and the Warning Sign produced statistically significant increased pre-examination HHC (P=0.022 and P<0.001, respectively). Only the Warning Sign produced statistically significant increased HHC postexamination (P<0.001). CONCLUSIONS: Visual cues can improve HHC, but their efficacy varies. A warning sign informing of a surveillance system with subsequent reporting of noncompliance resulted in the most significant improvement in HHC. Using a standardized patient in an actual hospital room was a helpful tool in assessing the impact of various interventions designed to improve HHC and patient safety.",1,1,
1786,The employment of ward opinion leaders for continuing education in the hospital.,"Opinion leaders (OLs) are members within a social group with significant social influence over others. A guideline on urinary catheter care was introduced in three groups (A, B and C) of two randomly allocated wards. Two OLs per ward were identifed by nurses in groups A and B, using a sociomem'c method. For education, in-service lectures for 30% of nurses and OLs tutorials for all nurses were used in group A""; OLs tutorials in B, lectures in C and ward nurses were in turn responsible for educating new arrivals of student nurses. Before and after the education programme, the guideline's frequency of practice was assessed by surveying 30% of randomly selected nurses and by direct observation for incorrect practices. A student's quiz on the guideline was also conducted. For all three methods of measurement, the best results were in group A followed by B and C;"" and the differences for the three groups were significant (p<.05). This indicates that continuing education in the hospital can be effectively conducted by the enlistment of ward OLs.",1,1,
1787,The escalating pandemics of obesity and sedentary lifestyle. A call to action for clinicians,"Obesity and sedentary lifestyle are escalating national and global epidemics that warrant increased attention by physicians and other health care professionals. These intricately linked conditions are responsible for an enormous burden of chronic disease, impaired physical function and quality of life, at least 300,000 premature deaths, and at least $90 billion in direct health care costs annually in the United States alone. Clinicians are on the front line of combat, yet these conditions receive minimal attention during a typical office visit. Clinicians often feel overwhelmed by these challenges and point to an absence of clear guidelines and practice tools, minimal training in behavior modification strategies, and lack of time as reasons for failing to confront them. This report provides a ""call to action"" with step-by-step guidelines specifically directed at the pivotal role of physicians and other health care professionals in curbing these dangerous epidemics. This blueprint for action, which requires only a few minutes of a clinician's time to implement, will facilitate more effective intervention related to obesity and inactivity and should favorably impact public health.",0,0,
1788,The Esperance primary prevention of suicide project,"BACKGROUND: Suicide has been a major community concern in Esperance, a geographically isolated port on the south coast of Western Australia. AIMS: To evaluate the effect of three evidence-based initiatives for the primary prevention of suicide: (i) providing suicide awareness sessions for staff members in health, education and social services""; (ii) limiting the sale of over the counter analgesics (aspirin and paracetamol) to packets containing less than the minimum lethal dose;"" and (iii) implementing Commonwealth media guidelines in the reporting of suicides by media. METHODS: Changes in knowledge, awareness, attitudes, comfort and use, before and after each intervention were assessed using standardized instruments and pro forma derived from previous work, such as the Youth Suicide Prevention Training Manual and Suicide Intervention Beliefs Scale. Percentage changes in the number of retail outlets selling over the counter analgesics to less than potentially lethal quantities (less than 8 g of paracetamol or aspirin) were also measured. Media representatives were interviewed to gain their perceptions of Commonwealth Guidelines for the reporting of suicide, and encouraged to consult the project team before reporting suicide related issues. RESULTS: The baseline survey illustrated that mental health staff and general practitioners were more aware of suicide issues, risk factors for suicide and awareness of professional and ethical responses than staff from other services, and were more willing to raise the issue with a person at risk. Thirty-three subjects participated in suicide awareness training of whom 21 (66%) returned questionnaires. There were significant increases in awareness of suicide-related issues and risk factors, as well as reported levels of knowledge of professional and ethical responses and comfort, competence and confidence levels when assisting a person at risk. Only three media representatives were aware of the Commonwealth Health Department Guidelines for reporting suicide and only one believed that the guidelines influenced their reporting. The local newspapers subsequently contacted the researchers to check that their reporting met the guidelines. As regards access to analgesics, one out of seven retailers agreed to implement the strategy (pending agreement from other retailers), another claimed increased awareness of the danger of analgesics, and three maintained that they would attempt to monitor excessive amounts sold to one individual. CONCLUSIONS: Local initiatives can improve the awareness and knowledge of staff in the assessment of suicide risk, as well as of local media. These need to be complemented by initiatives at State or Commonwealth level to produce change in statewide media, or sales of over the counter analgesics.",0,0,
1789,The ethical assessment of innovative therapies: liver transplantation using living donors,"Liver transplantation is the treatment of choice for many forms of liver disease. Unfortunately, the scarcity of cadaveric donor livers limits the availability of this technique. To improve the availability of liver transplantation, surgeons have developed the capability of removing a portion of liver from a live donor and transplanting it into a recipient. A few liver transplants using living donors have been performed worldwide. Our purpose was to analyze the ethics of liver transplants using living donors and to propose guidelines for the procedure before it was introduced in the United States. We used a process of ""research ethics consultation"" that involves a collaboration between clinical investigators and clinical ethicists. We concluded that it was ethically appropriate to perform liver transplantation using living donors in a small series of patients on a trial basis, and we published our ethical guidelines in a medical journal before the procedure was introduced. We recommend this prospective, public approach for the introduction of other innovative therapies in medicine and surgery.",0,0,
1790,The Ethics of Medicine: An Annotated Bibliography of Recent Literature,,0,0,
1791,The European Psychiatric Association (EPA) guidance on suicide treatment and prevention,"UNLABELLED: Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive. DIAGNOSIS: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. TREATMENT: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. TREATMENT with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. TREATMENT with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. SAFETY: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.",0,0,
1792,The evaluation of a tailored intervention to improve the management of suspected viral encephalitis: protocol for a cluster randomised controlled trial,Background Viral encephalitis is a devastating condition for which delayed treatment is associated with increased morbidity and mortality. Clinical audits indicate substantial scope for improved detection and treatment. Improvement strategies should ideally be tailored according to identified needs and barriers to change. The aim of the study is to evaluate the effectiveness and cost-effectiveness of a tailored intervention to improve the secondary care management of suspected encephalitis.  Methods/Design The study is a two-arm cluster randomised controlled trial with allocation by postgraduate deanery. Participants were identified from 24 hospitals nested within 12 postgraduate deaneries in the United Kingdom (UK). We developed a multifaceted intervention package including core and flexible components with embedded behaviour change techniques selected on the basis of identified needs and barriers to change. The primary outcome will be a composite of the proportion of patients with suspected encephalitis receiving timely and appropriate diagnostic lumbar puncture within 12 h of hospital admission and aciclovir treatment within 6 h. We will gather outcome data pre-intervention and up to 12 months post-intervention from patient records. Statistical analysis at the cluster level will be blind to allocation. An economic evaluation will estimate intervention cost-effectiveness from the health service perspective.,0,0,
1793,The evolution of current medical and popular attitudes toward ultraviolet light exposure: part 3,"In the 1930s, attitudes toward ultraviolet (UV) light exposure began to change significantly within the medical profession. UV radiation had been promoted as healthful since the century's start, and particularly after the discovery of its role in vitamin-D metabolism. Increasingly, however, attention would focus on the risks of UV light exposure from sunlamps and sunbathing. During this time, the American Medical Association established guidelines for the approval of UV lamps and the appropriate therapeutic uses of phototherapy. The landmark experiments of Findlay and other researchers, in which malignant skin tumors were induced in rodents after exposure to UV lamps or sunlight, would lead to widespread recognition of the carcinogenicity of UV radiation. The role of sunlight in the etiology of skin cancer was increasingly mentioned in articles in popular magazines in the 1940s and 1950s. There was rapid growth of the sunscreen industry as well, although product efficacy remained highly variable. In the 1950s, interest developed in the use of 8-methoxypsoralen (""the suntan pill"") and dihyroxyacetone (""suntan in a bottle""). In spite of the known risks of UV exposure and attempts by physicians and other health professionals to educate the public and modify behavior, suntanning has remained tenaciously popular. Today, excessive UV light exposure is recognized as the major cause of the approximately 1.3 million cases of skin cancer in the United States each year.",0,0,
1794,The evolution of informed consent in American medicine,,0,0,
1795,"The expert consensus guideline series. Optimizing pharmacologic treatment of psychotic disorders. Introduction: methods, commentary, and summary","OBJECTIVES: A growing number of atypical antipsychotics are available for clinicians to choose from in the treatment of psychotic disorders. However, a number of important questions concerning medication selection, dosing and dose equivalence, and the management of inadequate response, compliance problems, and relapse have not been adequately addressed by clinical trials. To aid clinical decision-making, a consensus survey of expert opinion on the pharmacologic treatment of psychotic disorders was undertaken to address questions not definitively answered in the research literature. METHOD: Based on a literature review, a written survey was developed with 60 questions and 994 options. Approximately half of the options were scored using a modified version of the RAND 9-point scale for rating the appropriateness of medical decisions. For the other options, the experts were asked to write in answers (e.g., average doses) or check a box to indicate their preferred answer. The survey was sent to 50 national experts on the pharmacologic treatment of psychotic disorders, 47 (94%) of whom completed it. In analyzing the responses to items rated on the 9-point scale, consensus on each option was defined as a non random distribution of scores by chi-square ""goodness-of-fit""test. We assigned a categorical rank (first line/preferred choice,second line/alternate choice, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. RESULTS: The expert panel reached consensus on 88% of the options rated on the 9-point scale. The experts overwhelmingly endorsed the atypical antipsychotics for the treatment of psychotic disorders. Risperidone was the top choice for first-episode and multi-episode patients, with the other newer atypicals rated first line or high second line depending on the clinical situation. Clozapine and a long-acting injectable atypical (when available)were other high second line options for multi-episode patients. The expert's dosing recommendations agreed closely with the package inserts for the drugs, and their estimates of dose equivalence among the antipsychotics followed a linear pattern. The experts considered 3-6 weeks an adequate antipsychotic trial, but would wait a little longer (4-10 weeks) before making a major change in treatment regimen if there is a partial response. The experts recommended trying to improve response by increasing the dose of atypical and depot antipsychotics before switching to a different agent"";"" there was less agreement about increasing the dose of conventional antipsychotics before switching, probably because of concern about side effects at higher doses. If it is decided to switch because of inadequate response, risperidone was the expert's first choice to switch to, no matter what drug was initially tried. Although there was some disparity in the expert's recommendations concerning how many agents to try before switching to clozapine, the expert's responses suggest that switching to clozapine should be Clozapine was also the antipsychotic of choice for patients with suicidal behavior. When switching oral antipsychotics,the experts considered cross-titration the preferred strategy. When switching to an injectable antipsychotic, the experts stressed the importance of continuing the oral antipsychotic until therapeutic levels of the injectable agent are achieved. The experts considered psychosocial interventions the first choice strategy for partially compliant patients, with pharmacologic interventions the first choice for patients with clear evidence of noncompliance. However, because it can be difficult to distinguish partially compliant from noncompliant patients, the editors recommended combining psychosocial and pharmacologic interventions to improve compliance whenever possible. When patients relapse because of compliance problems or if there is any doubt about compliance, the experts recommended the use of a long-acting injectable antipsychotic and would select an injectable atypical when this option becomes available. The experts would also consider using an injectable atypical antipsychotic (when available) in many clinical situations that do not involve compliance problems. The experts stressed the importance of monitoring for health problems-especially obesity, diabetes, cardiovascular problems,HIV risk behaviors, medical complications of substance abuse, heavy smoking and its effects, hypertension, and amenorrhea-in patients being treated with antipsychotics. Although many patients are prescribed adjunctive treatments,multiple antipsychotics, and combinations of different classes of drugs (e.g., antipsychotics plus mood stabilizers or antidepressants) in an effort to enhance response, the experts gave little support to any of these strategies, with the exception of antidepressants for patients with dysphoria/depression, antidepressants or ECT for patients with suicidal behavior, and mood stabilizers for patients with aggression/violence. When asked about indicators of remission and recovery, the experts considered acute improvement in psychotic symptoms the most important indicator of remission, whereas they considered more sustained improvement in multiple outcome domains (e.g., occupational/educational functioning, peer relationships,independent living) important in assessing recovery. CONCLUSIONS: The experts reached a high level of consensus on many of the key treatment questions in the survey. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for addressing common clinical dilemmas that arise in the pharmacologic treatment of psychotic disorders. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions. Clinicians should keep in mind that no guidelines can address the complexities involved in the care of each individual patient and that sound clinical judgment based on clinical experience should be used in applying these recommendations.",0,0,
1796,The expert consensus guideline series. Treatment of behavioral emergencies 2005,"OBJECTIVES: Due to inherent dangers and barriers to research in emergency settings, few data are available to guide clinicians about how best to manage behavioral emergencies. Key constructs such as agitation are poorly defined. This lack of empirical data led us to undertake a survey of expert opinion, results of which were published in the 2001 Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. Several second-generation (atypical) antipsychotics (SGAs) are now available in new formulations for treating behavioral emergencies (e.g., intramuscular [i.m.] olanzapine and ziprasidone"";"" rapidly dissolving tablets of olanzapine and risperidone). Critical questions face the field. The SGAs are significantly different from the FGAs and from each other and have not been studied in unselected patients as were the FGAs. Can the SGAs can be thought of as a class, do all antipsychotics have similar anti-agitation effects in different conditions, and, if equally effective, what limits might their safety profiles impose? Should antipsychotics be used more specifically to treat psychotic conditions, while benzodiazepines (BNZs) alone are used nonspecifically? Few data are available concerning combinations of SGAs and BNZs, and findings concerning the traditional combination of haloperidol plus a BNZ may not be relevant to combinations with SGAs. The culture is also evolving with more emphasis on patient involvement in treatment decisions. An international consensus has been developing that calming rather than sedation is the appropriate endpoint of behavioral emergency interventions. We undertook a new survey of expert opinion to update recommendations from the earlier survey. METHOD: A written survey of 61 questions (1,020 options) was mailed to 50 experts in the field, 48 (96%) of whom completed it. The survey sought to define level of agitation at which emergency interventions are appropriate, scope of assessment depending on urgency and patients' ability to cooperate, guiding principles for selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence for a variety of provisional diagnoses and complicating conditions. A modified version of the RAND Corporation's 9-point scale for rating appropriateness of medical decisions was used to score most options. Consensus was defined as a non-random distribution of scores by chi-square ""goodness-of-fit"" test. We assigned a categorical rank (first line/preferred, second line/alternate, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean. Ratings were used to develop guidelines for preferred strategies in key clinical situations. This study received financial support from multiple sponsors, with the panel kept blind to sponsorship to reduce possible bias. Medication ratings were based on responses of only those respondents with direct experience with each drug. In reporting practice patterns, the panel was asked to respond based on actual data rather than estimates. RESULTS: The expert panel reached consensus on 78% of the options rated on the 9-point scale. The responses suggest that physicians can make provisional diagnoses with some confidence and that pharmacological and nonpharmacological interventions are selected differentially based on diagnosis and other salient demographic and medical features. BNZs are recommended when no data are available, when there is no specific treatment (e.g., personality disorder), or when they may have specific benefits (e.g., intoxication). No single SGA emerges as a nonspecific replacement for haloperidol""; instead, different SGAs are preferred in various circumstances consistent with current evidence. To the degree that haloperidol is recommended, it is almost always in combination with a BNZ; haloperidol alone is preferred only in the medically compromised. In contrast, the SGAs are more often recommended for use alone, and the panel would avoid combining BNZs with some SGAs. Oral risperidone alone or combined with a BNZ receives strong support in a variety of situations. Oral olanzapine was rated very similarly to risperidone, with slightly higher ratings than risperidone in situations where it has been studied (e.g., schizophrenia, mania) and slightly lower ratings where it has not been studied or safety may be a concern; there was less support for combining oral olanzapine with a BNZ. For oral treatment of agitation related to schizophrenia or mania, olanzapine alone, risperidone alone or combined with a BNZ, and haloperidol plus a BNZ are first line, with strong support also for combining divalproex with the antipsychotic for presumed mania. Oral ziprasidone and quetiapine generally received similar second-line ratings in most situations. If a parenteral agent is needed, i.m. olanzapine alone received somewhat more support than i.m. ziprasidone alone;"" however, there was more support for i.m. ziprasidone alone or combined with a BNZ than for i.m. olanzapine plus a BNZ, probably reflecting safety concerns. For example, for a provisional diagnosis of schizophrenia, first-line parenteral options are i.m. olanzapine or ziprasidone alone or i.m. haloperidol or ziprasidone combined with a BNZ. Neither of the new parenteral formulations received as much support as traditional agents (i.m. BNZs, i.m. haloperidol) when no data are available or the diagnosis involves medical comorbidity or intoxication. When initial intervention with risperidone, ziprasidone, or haloperidol is unsuccessful, the panel recommended adding a BZD to the antipsychotic. However, when initial treatment with olanzapine or quetiapine is unsuccessful, increasing the dosage is recommended. Perphenazine was consistently rated second line and droperidol and chlorpromazine received third-line ratings throughout. CONCLUSIONS: Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines suggest that the SGAs are now preferred for agitation in the setting of primary psychiatric illnesses but that BNZs are preferred in other situations.",0,0,
1797,The Fit Family Challenge: A Primary Care Childhood Obesity Pilot Intervention,"BACKGROUND: Childhood obesity has increased dramatically over several decades, and the American Academy of Pediatrics has recommended primary care practices as ideal sites for the identification, education, and implementation of therapeutic interventions. The objective of this study was to describe the implementation and results for the Fit Family Challenge (FFC), a primary care-based childhood obesity intervention. METHODS: A single-intervention pilot project that trains primary care practices on childhood obesity guidelines and implementation of a family-focused behavior modification curriculum. A total of 29 family medicine and pediatric community practices in Colorado participated. Participants included 290 patients, aged 6 to 12 years, with a body mass index (BMI) above the 85th percentile. The main outcome measure included the feasibility of implementation of a childhood obesity program in primary care""; secondary outcomes were changes in BMI percentile, BMI z-scores, blood pressure, and changes in lifestyle factors related to childhood obesity. RESULTS: Implementation of FFC is feasible, statically significant changes were seen for decreases in BMI percentile and BMI z-scores for participants who completed 9 to 15 months of follow-up;"" lifestyle factors related to childhood obesity in proved Spanish-speaking families and food insecurity were associated with less follow-up time (P < .01). CONCLUSIONS: A primary care-based childhood obesity intervention may result in significant clinical and lifestyle changes.",0,0,
1798,The future of Britain's mental hospitals,,0,0,
1799,"The Gestational Diabetes Management System (GooDMomS): development, feasibility and lessons learned from a patient-informed, web-based pregnancy and postpartum lifestyle intervention","BACKGROUND: Gestational diabetes mellitus (GDM) contributes to the epidemic of diabetes and obesity in mothers and their offspring. The primary objective of this pilot study was to: 1) refine the GDM Management System (GooDMomS), a web-based pregnancy and postpartum behavioral intervention and 2) assess the feasibility of the intervention. METHODS: In phase 1, ten semi-structured interviews were conducted with women experiencing current or recent GDM mellitus GDM to garner pilot data on the web based intervention interface, content, and to solicit recommendations from women about refinements to enhance the GooDMomS intervention site. Interviews were audiotaped, transcribed and independently reviewed to identify major themes with Atlas.ti v7.0. In phase 2, a single-arm feasibility study was conducted and 23 participants were enrolled in the GooDMomS program. Participants received web lessons, self-tracking of weight and glucose, automated feedback and access to a message board for peer support. The primary outcome was feasibility, including recruitment and retention and acceptability. Secondary outcomes included the proportion of women whose gestational weight gain (GWG) was within the Institute of Medicine (IOM) guidelines and who were able to return to their pre-pregnancy weight after delivery. RESULTS: Comments from semi-structured interviews focused on: 1) usability of the on-line self-monitoring diary and tracking system, 2) access to a safe, reliable social network for peer support and 3) ability of prenatal clinicians to access the on-line diary for clinical management. Overall, 21 (91 %) completed the pregnancy phase. 15/21 (71 %) of participants were within the Institute of Medicine (IOM) guidelines for GWG. Sixteen (70 %) completed the postpartum phase. 7/16 (43 %) and 9/16 (56 %) of participants returned to their pre-pregnancy weight at 6 and 30 weeks postpartum, respectively. CONCLUSIONS: This study documents the feasibility of the GooDMomS program. The results can have implications for web technology in perinatal care and inform the current care paradigm for women with GDM. Findings are supportive of further research with recruitment of a larger sample of participants and comparison of the outcomes with the intervention and standard care. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov on May 15, 2012 under protocol no. NCT01600534 .",0,0,
1800,The impact of a bodyweight and physical activity intervention (BeWEL) initiated through a national colorectal cancer screening programme: randomised controlled trial,"OBJECTIVE To evaluate the impact of a diet and physical activity intervention (BeWEL) on weight change in people with a body mass index >25 weight (kg)/height (m)(2) at increased risk of colorectal cancer and other obesity related comorbidities. DESIGN Multicentre, parallel group, randomised controlled trial. SETTING Four Scottish National Health Service health boards. PARTICIPANTS 329 overweight or obese adults (aged 50 to 74 years) who had undergone colonoscopy after a positive faecal occult blood test result, as part of the national bowel screening programme, and had a diagnosis of adenoma confirmed by histopathology. 163 were randomised to intervention and 166 to control. INTERVENTION Participants were randomised to a control group (weight loss booklet only) or 12 month intervention group (three face to face visits with a lifestyle counsellor plus monthly 15 minute telephone calls). A goal of 7% reduction in body weight was set and participants received a personalised energy prescription (2508 kJ (600 kcal) below that required for weight maintenance) and bodyweight scales. Motivational interviewing techniques explored self assessed confidence, ambivalence, and personal values concerning weight. Behavioural strategies included goal setting, identifying intentions of implementation, self monitoring of body weight, and counsellor feedback about reported diet, physical activity, and weight change. MAIN OUTCOME MEASURES The primary outcome was weight change over 12 months. Secondary outcomes included changes in waist circumference, blood pressure, fasting cardiovascular biomarkers, and glucose metabolism variables, physical activity, diet, and alcohol consumption. RESULTS At 12 months, data on the primary outcome were available for 148 (91%) participants in the intervention group and 157 (95%) in the control group. Mean weight loss was 3.50 kg (SD 4.91) (95% confidence interval 2.70 to 4.30) in the intervention group compared with 0.78 kg (SD 3.77) (0.19 to 1.38) in the control group. The group difference was 2.69 kg (95% confidence interval 1.70 to 3.67). Differences between groups were significant for waist circumference, body mass index, blood pressure, blood glucose level, diet, and physical activity. No reported adverse events were considered to be related to trial participation. CONCLUSIONS Significant weight loss can be achieved by a diet and physical activity intervention initiated within a national colorectal cancer screening programme, offering considerable potential for risk reduction of disease in older adults. TRIAL REGISTRATION Current Controlled Trials ISRCTN53033856.",0,0,
1801,The impact of a nurse-led care programme on events and physical and psychosocial parameters in patients with heart failure with preserved ejection fraction: a randomized clinical trial in primary care in Russia,"BACKGROUND: Disease management programmes (DMPs) improve quality of care for patients with heart failure (HF). However, only a limited number of trials have studied the efficacy of such programmes for patients with heart failure with preserved ejection fraction (HFPEF). OBJECTIVE: To estimate the impact of a structured, nurse-led patient education programme and care plan in general practice on outcome parameters and events in patients with HFPEF. METHODS: Single blinded randomized clinical trial with an intervention over six months and a follow-up during 12 additional months. In the control group, the patients (n = 41) were managed according to Russian national guidelines. Patients in the intervention group (n = 44) received education on individual lifestyle changes and modifications of cardiovascular disease (CVD) risk factors, home-based exercise training and weekly nurse consultations in addition to usual care. RESULTS: Six months after their inclusion, patients in the intervention group significantly improved body mass index, waist circumference, six-min walk test distance, total cholesterol, low-density lipoprotein, left ventricular end-diastolic volume index, quality of life and level of anxiety. After 18 months, there were 11 deaths (25%) or hospitalizations in the intervention group and 12 (29%) in the control group (P = 0.134). Cardiovascular mortality and readmission rate were not reduced significantly after six months of follow-up: the hazard ratio was 0.47 (95% CI: 0.17-1.28""; P = 0.197). After 18 months, this was 0.85 (0.42-1.73;"" P = 0.658). CONCLUSION: This primary care based DMP for patients with HFPEF improved the patients' emotional status and quality of life, positively influenced body weight, functional capacity and lipid profile, and attenuated heart remodelling.",0,0,
1802,The impact of cost displays on primary care physician laboratory test ordering.,"BACKGROUND Physicians are under increased pressure to help control rising health care costs, though they lack information regarding cost implications of patient care decisions.  OBJECTIVE To evaluate the impact of real-time display of laboratory costs on primary care physician ordering of common laboratory tests in the outpatient setting.  DESIGN Interrupted time series analysis with a parallel control group.  PARTICIPANTS Two hundred and fifteen primary care physicians (153 intervention and 62 control) using a common electronic health record between April 2010 and November 2011. The setting was an alliance of five multispecialty group practices in Massachusetts.  INTERVENTION The average Medicare reimbursement rate for 27 laboratory tests was displayed within an electronic health record at the time of ordering, including 21 lower cost tests (< $40.00) and six higher cost tests (> $40.00).  MAIN MEASURES We compared the change-in-slope of the monthly laboratory ordering rate between intervention and control physicians for 12 months pre-intervention and 6 months post-intervention. We surveyed all intervention and control physicians at 6 months post-intervention to assess attitudes regarding costs and cost displays.  KEY RESULTS Among 27 laboratory tests, intervention physicians demonstrated a significant decrease in ordering rates compared to control physicians for five (19 %) tests. This included a significant relative decrease in ordering rates for four of 21 (19 %) lower cost laboratory tests and one of six (17 %) higher cost laboratory tests. A majority (81 %) of physicians reported that the intervention improved their knowledge of the relative costs of laboratory tests.  CONCLUSIONS Real-time display of cost information in an electronic health record can lead to a modest reduction in ordering of laboratory tests, and is well received. Our study demonstrates that electronic health records can serve as a tool to promote cost transparency and reduce laboratory test use.",1,1,
1803,The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization,"This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N = 443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians.",0,0,
1804,"The impact of guidelines, standards and economic restrictions on clinical decision-making processes","Guidelines aim at improving clinical decision-making. Contrary to textbooks and reviews that want to improve medical knowledge, guidelines try to influence medical behaviour. Scientific models of clinical decision-making such as the action theory and empirical data on the effects of guidelines suggest that guidelines will not always reach their goals but can instead even lead to a deterioration in the quality of medical care. Therefore there is a need for controlled clinical trials to investigate whether guideline-exposed physicians yield better patient outcomes than guideline-naive physicians. Guidelines should only be regarded as evidence-based if their positive effects have been empirically demonstrated.",0,0,
1805,The impact of infectious diseases specialist-directed computerized physician order entry antimicrobial stewardship program targeting linezolid use,,0,1,
1806,The impact of medication adherence on lung health outcomes in cystic fibrosis,"PURPOSE OF REVIEW: As new medications continue to come to market to improve health in individuals with cystic fibrosis (CF), patient adherence is increasingly more important to address. Currently, adherence for pulmonary medications is approximately 50% for people with CF. There has been recent research that has demonstrated that poor adherence is linked to worse health outcomes. This review summarizes recent research on the impact of adherence on lung health and highlights future areas of research and clinical practice to address this growing need. RECENT FINDINGS: Recent research has indicated that nonadherence is associated with increased hospitalizations and pulmonary exacerbations, lower baseline lung function, and longer length of stays. However, most of the research has been done using pharmacy refill records as an objective measure of adherence. Electronic monitoring of medications provides more detailed information about patterns of use, which can directly inform clinical care. Furthermore, there have been few published clinical trials evaluating behavioral interventions to promote adherence. SUMMARY: Given the recent research linking adherence to lung health outcomes, there is a growing need to measure and evaluate adherence in clinical care. As new medications are approved for CF, methods to monitor adherence also need to be developed and approved. Clinicians need to continue to assess barriers to adherence to be able to individually tailor interventions to a patient's needs.",0,0,
1807,The impact of supported telemetric monitoring in people with type 2 diabetes: study protocol for a randomised controlled trial,"BACKGROUND: Diabetes prevalence is increasing and current methods of management are unsustainable. Effective approaches to supporting self-management are required. The aim of this randomized controlled trial is to establish whether supported telemetric monitoring of glycemic control and blood pressure results in reductions in glycosylated hemoglobin (HbA1c"";"" the primary outcome of a measure of long-term glycemic control) and secondary outcomes of blood pressure and weight among people with poorly controlled diabetes compared to a control group receiving usual care. METHODS/DESIGN: Design: multi-center, randomized controlled trial with embedded qualitative study. Setting: primary care in Lothian, Kent, Glasgow and Borders regions in the UK. Participants: people with type 2 diabetes and confirmed HbA1c>7.5% (58 mmol/mol). Intervention/comparison: randomization to intervention or control groups will be performed by the Edinburgh Clinical Trials Unit. Participants in the intervention group will be shown how to use blood glucose and blood pressure monitors and weighing scales which use Bluetooth wireless technology to transmit readings via modem to a remote server. These participants will be asked to provide at least twice weekly measurements of morning and evening blood glucose and weekly measurements of weight and blood pressure. Measurements will be checked at least weekly by practice nurses who will contact the patients to adjust therapy according to guidelines and reinforce lifestyle advice. Participants in the control group will receive usual care. All participants will receive an individual education session. Follow-up: measurements will be performed at practices 9 months after randomization by research nurses blinded to allocation. The primary outcome measure is HbA1c and secondary outcomes measure are daytime systolic and diastolic blood pressure, weight and cost per quality-adjusted life year. Analysis: intention-to-treat analyses will be performed. The sample size of 320 participants allows for 20% drop-out and has 80% power at 5% significance to detect a 0.5% absolute (6 mmol/mol) fall in HbA1c in the intervention group. The qualitative study will explore the experiences of patients and professionals using the intervention. TRIAL REGISTRATION: Trial registration number ISRCTN71674628.",0,0,
1808,The importance of managing cardiovascular risk in the treatment of hypertension: the role of ACE inhibitors and ARBs,,0,0,
1809,The importance of the doctor-patient communication in the care of somatizing patients,"The term ""somatization"" refers to the manifestation of multiple somatic complaints not explained by organic changes. According to the literature, 15-25 percent of all medical visits are related to somatization. As medical training does not put enough emphasis on the evaluation of the possible psychological background of certain somatic symptoms, physicians may feel powerless and make unjustified diagnostic and therapeutic efforts. The patients may also feel helpless and frustrated, their anxiety and the intensity of their complaints may increase. As stress is an important factor in the somatization process, stress reduction and improvement of coping are key elements of the treatment guidelines for chronic diseases. Evidence based interventions range from short counselling and medication to cognitive and behavioral psychotherapy. Reattribution, a short (10-30 minutes) structured intervention that can be implemented in primary or secondary care, in certain cases can result in significant decrease in somatic symptoms and anxiety.",0,0,
1810,The improving care in chronic obstructive lung disease study: CAROL improving processes of care and quality of life of COPD patients in primary care: study protocol for a randomized controlled trial,"BACKGROUND: The Swiss health ministry launched a national quality program 'QualiCCare' in 2011 to improve health care for patients with COPD.The aim of this study is to determine whether participation in the COPD quality initiative ('QualiCCare') improves adherence to recommended clinical processes and shows impact on patients' COPD care and on the impact of COPD on a person's life. METHODS: CAROL is a cluster-randomized controlled trial with randomization on the general practioner (GP) level. Thirty GPs will be randomly assigned to equally sized intervention group or control group.Each GP will approach consecutively and regardless of the reason for the current consultation, patients aged 45 years or older, with a smoking history of >/= ten pack-years (PY). Patients with confirmed (by spirometric evaluation) COPD will be included in the study. GPs in the intervention group will receive 'QualiCCare' education, which addresses knowledge, decision-making and behavioural aspects as well as delivery of care according to COPD quality indicators and evidence-based key elements. In the control group, no educational intervention will be applied and COPD patients will be treated as usual. The study period is one year.The primary outcome measure is an aggregated score of relevant clinical processes defining elements in the care of patients with COPD: smoking cessation counseling, influenza vaccination, motivation for physical activity, appropriate pharmacotherapy, patient education and collaborative care. Given a power of 90% and a significance level alpha of 5%, 15 GPs recruiting eight patients each will be necessary in both study arms. With an assumed dropout rate of 20%, 288 patients will need to be included. DISCUSSION: It is important to develop and implement interventions that add value to COPD care considering quality and efficiency. Care pathways modifying the knowledge and behavior of physicians have the potential for improving care by transferring knowledge to clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01921556.",0,0,
1811,The influence of a physician and patient intervention program on dietary intake,"BACKGROUND: Efficient dietary interventions for patients with hypertension in clinical settings are needed. OBJECTIVE: To assess the separate and combined influence of a physician intervention (MD-I) and a patient intervention (PT-I) on dietary intakes of patients with hypertension. DESIGN: A nested 2x2 design, randomized controlled trial conducted over 18 months. PARTICIPANTS: A total of 32 physicians and 574 outpatients with hypertension. INTERVENTION: MD-I included training modules addressing the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure hypertension management guidelines and lifestyle modification. PT-I included lifestyle coaching to adopt the Dietary Approaches to Stop Hypertension (DASH) eating pattern, reduce sodium intake, manage weight, increase exercise, and moderate alcohol intake. MAIN OUTCOME MEASURES: Dietary intakes were measured by the Block Food Frequency Questionnaire. Concordance with the DASH dietary pattern was estimated by a DASH score. STATISTICAL ANALYSES: The main effects of MD-I and PT-I, and their interaction, were evaluated using analysis of covariance. RESULTS: After 6 months of intervention, MD-I participants significantly increased intakes of potassium, fruits, juices, and carbohydrate""; decreased intake of fat;"" and improved overall dietary quality as measured by the Healthy Eating Index. PT-I intervention resulted in increased intakes of carbohydrate, protein, fiber, calcium, potassium, fruits and fruit juices, vegetables, dairy and Healthy Eating Index score, and decreased intakes in fat, saturated fat, cholesterol, sodium, sweets, and added fats/oils/sweets. In addition, PT-I improved overall DASH concordance score. The change in DASH score was significantly associated with the changes in blood pressure and weight at 6 months. At 18 months, most changes reversed back toward baseline levels, including the DASH score. CONCLUSIONS: Both MD-I and PT-I improved eating patterns at 6 months with some sustained effects at 18 months. Even though all dietary changes observed were consistent with the DASH nutrient targets or food group guidelines, only the PT-I intervention was effective in improving the overall DASH concordance score. This finding affirms the role of medical nutrition therapy in long-term intensive interventions for hypertension risk reduction and weight management and underlines the need for development of maintenance strategies. Furthermore, this study emphasizes the importance of collaborations among physicians, registered dietitians and other dietetics practitioners, and lay health advisors while assisting patients to make healthy behavior changes.",0,0,
1812,The influence of patient characteristics on the appropriateness of surgical treatment for breast cancer patients. Progetto Oncologia Femminile,"BACKGROUND: Within the framework of a multi-annual educational intervention sponsored by the Ministry of Health and regional health authorities, patterns of the care delivered to breast cancer patients in Italian general hospitals were monitored in order to identify areas of practice whose quality was in need of improvement. DESIGN: Information on the diagnostic and therapeutic procedures in 63 general hospitals in eight Italian regions performed in 1724 consecutive breast cancer patients were retrospectively gathered from medical records. Quality of care was assessed by a diagnostic and therapeutic score based on the observed degree of compliance with previously established courses of action. RESULTS: The median value of the overall diagnostic and staging score was 60%. About one-third of surgical operations (38%) were inappropriate: one-fourth (24%) of patients with stage I-II disease had unnecessarily radical surgery (i.e., Halsted mastectomy), and limited surgery in patients with small tumors (i.e., < or = 2 cm) was under utilized. Chronological age influenced physicians' behaviour: elderly patients were more likely to have a less intensive diagnostic work-up and less appropriate surgical treatment (with more frequent performance of an unnecessary radical operation and a less frequent utilization of limited surgery), independently of their overall health status. The presence of one or more co-existent diseases was associated with a failure to undergo axillary clearance and with a lower utilization of conservative surgery independently of age. CONCLUSION: In accord with others, this study confirms the existence of a clinically important effect of patient age on diagnostic and therapeutic behaviour and the use of unnecessarily radical surgery procedures. The paper discusses the implications of these findings for the next stage of the educational project, in which practice guidelines will be developed and implemented to improve the quality of care for breast cancer patients.",0,0,
1813,"The intellectual structure and substance of the knowledge utilization field: A longitudinal author co-citation analysis, 1945 to 2004","Background It has been argued that science and society are in the midst of a far-reaching renegotiation of the social contract between science and society, with society becoming a far more active partner in the creation of knowledge. On the one hand, new forms of knowledge production are emerging, and on the other, both science and society are experiencing a rapid acceleration in new forms of knowledge utilization. Concomitantly since the Second World War, the science underpinning the knowledge utilization field has had exponential growth. Few in-depth examinations of this field exist, and no comprehensive analyses have used bibliometric methods.  Methods Using bibliometric analysis, specifically first author co-citation analysis, our group undertook a domain analysis of the knowledge utilization field, tracing its historical development between 1945 and 2004. Our purposes were to map the historical development of knowledge utilization as a field, and to identify the changing intellectual structure of its scientific domains. We analyzed more than 5,000 articles using citation data drawn from the Web of Science?. Search terms were combinations of knowledge, research, evidence, guidelines, ideas, science, innovation, technology, information theory and use, utilization, and uptake.  Results We provide an overview of the intellectual structure and how it changed over six decades. The field does not become large enough to represent with a co-citation map until the mid-1960s. Our findings demonstrate vigorous growth from the mid-1960s through 2004, as well as the emergence of specialized domains reflecting distinct collectives of intellectual activity and thought. Until the mid-1980s, the major domains were focused on innovation diffusion, technology transfer, and knowledge utilization. Beginning slowly in the mid-1980s and then growing rapidly, a fourth scientific domain, evidence-based medicine, emerged. The field is dominated in all decades by one individual, Everett Rogers, and by one paradigm, innovation diffusion.  Conclusion We conclude that the received view that social science disciplines are in a state where no accepted set of principles or theories guide research (i.e., that they are pre-paradigmatic) could not be supported for this field. Second, we document the emergence of a new domain within the knowledge utilization field, evidence-based medicine. Third, we conclude that Everett Rogers was the dominant figure in the field and, until the emergence of evidence-based medicine, his representation of the general diffusion model was the dominant paradigm in the field.",0,0,
1814,"The Irritable Bowel Syndrome Outcome Study (IBSOS): rationale and design of a randomized, placebo-controlled trial with 12 month follow up of self- versus clinician-administered CBT for moderate to severe irritable bowel syndrome","Irritable bowel syndrome is a common, oftentimes disabling, gastrointestinal disorder whose full range of symptoms has no satisfactory medical or dietary treatment. One of the few empirically validated treatments includes a specific psychological therapy called cognitive behavior therapy which, if available, is typically administered over several months by trained practitioners in tertiary care settings. There is an urgent need to develop more efficient versions of CBT that require minimal professional assistance but retain the efficacy profile of clinic based CBT. The Irritable Bowel Syndrome Outcome Study (IBSOS) is a multicenter, placebo-controlled randomized trial to evaluate whether a self-administered version of CBT is, at least as efficacious as standard CBT and more efficacious than an attention control in reducing core GI symptoms of IBS and its burden (e.g. distress, quality of life impairment, etc.) in moderately to severely affected IBS patients. Additional goals are to assess, at quarterly intervals, the durability of treatment response over a 12 month period""; to identify clinically useful patient characteristics associated with outcome as a way of gaining an understanding of subgroups of participants for whom CBT is most beneficial; to identify theory-based change mechanisms (active ingredients) that explain how and why CBT works;"" and evaluate the economic costs and benefits of CBT. Between August 2010 when IBSOS began recruiting subjects and February 2012, the IBSOS randomized 171 of 480 patients. Findings have the potential to improve the health of IBS patients, reduce its social and economic costs, conserve scarce health care resources, and inform evidence-based practice guidelines.",0,0,
1815,The Italian Diabetes and Exercise Study 2 (IDES-2): a long-term behavioral intervention for adoption and maintenance of a physically active lifestyle,"BACKGROUND: Physical activity (PA)/exercise have become an integral part of the management of type 2 diabetes mellitus (T2DM). However, current guidelines are difficult to put into action in this population due to a number of barriers, especially the lack of acceptable, feasible, and validated behavioral intervention strategies. The present manuscript reports the rationale, study design and methods, and design considerations of the Italian Diabetes and Exercise Study (IDES)-2, a randomized controlled trial testing the efficacy of a behavior change strategy in increasing total daily PA and reducing sedentary time (SED-time) in patients with T2DM. METHODS/DESIGN: Starting 7 January 2014, the IDES_2 began enrolling 300 patients with known T2DM of at least 1-year duration in three tertiary referral outpatient Diabetes Clinics in Rome. Additional requirements are age 40 to 80 years, body mass index 27 to 40 kg/m(2), sedentary lifestyle, and physically inactive for at least 6 months, ability to walk 1.6 km without assistance, and eligibility after cardiovascular evaluation. Patients are randomized by center and within each center, by age and type of diabetes treatment to either the intervention or the control group. Patients in the intervention (INT) group (n = 150) receive theoretical and practical exercise counseling consisting of aggregated behavior change techniques (one individual theoretical counseling session plus eight twice-a-week individual theoretical and practical exercise counseling sessions) once a year for 3 years. Patients in the control (CON) group (n = 150), receive standard care, including general physician recommendations for daily PA. The primary outcomes are total daily PA and SED-time, as measured objectively by the use of an accelerometer. Secondary outcomes include physical fitness, modifiable cardiovascular risk factors, musculoskeletal disturbances, well-being/depression, and health-related quality of life. DISCUSSION: The behavioral intervention strategy tested in the IDES_2 is based on solid theoretical grounds and uses several behavioral change techniques, two factors which were found to improve effectiveness of behavioral intervention. In addition, physicians and exercise specialists have been specifically trained for counselling/prescribing and supervising PA/exercise, respectively, in subjects suffering from metabolic disorders. Finally, the large sample size, the long study duration, and the objective measurement of PA allow statistically significant and scientifically robust conclusions to be drawn on the feasibility and efficacy of this intervention in T2DM patients. TRIAL REGISTRATION: ClinicalTrials.gov""; NCT01600937 ;"" 10 October 2012.",0,0,
1816,The knowledge disease,,0,0,
1817,"The lack, need, and opportunities for decision-making and informational tools to educate primary-care physicians and women about breast cancer chemoprevention","This perspective on Vogel et al. (beginning on page 696 in this issue of the journal) examines tamoxifen and raloxifene prescription patterns and why these agents are little used for breast cancer prevention despite their effectiveness in definitive trials, Food and Drug Administration approval, and American Society of Clinical Oncology Guidelines Committee endorsement for this purpose. The complexity of weighing the positive and negative aspects of the drugs and estimating net benefit is discussed, as is the need for informational resources such as interactive Internet-based tools to allow better individualized decisions about the options for chemoprevention.",0,0,
1818,The legal standing of local research ethics committees,,0,0,
1819,The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial,"BACKGROUND: In the Netherlands, 30% of subfertile women are overweight or obese, and at present there is no agreement on fertility care for them. Data from observational and small intervention studies suggest that reduction of weight will increase the chances of conception, decrease pregnancy complications and improve perinatal outcome, but this has not been confirmed in randomised controlled trials. This study will assess the cost and effects of a six-months structured lifestyle program aiming at weight reduction followed by conventional fertility care (intervention group) as compared to conventional fertility care only (control group) in overweight and obese subfertile women. We hypothesize that the intervention will decrease the need for fertility treatment, diminish overweight-related pregnancy complications, and will improve perinatal outcome. METHODS/DESIGN: Multicenter randomised controlled trial in subfertile women (age 18-39 year) with a body mass index between 29 and 40 kg/m2. Exclusion criteria are azoospermia, use of donor semen, severe endometriosis, premature ovarian failure, endocrinopathies or pre-existent hypertensive disorders.In the intervention group the aim is a weight loss of at least 5% to10% in a six-month period, to be achieved by the combination of a diet, increase of physical activity and behavioural modification. After six months, in case no conception has been achieved, these patients will start fertility treatment according to the Dutch fertility guidelines. In the control group treatment will be started according to Dutch fertility guidelines, independently of the patient's weight. OUTCOME MEASURES AND ANALYSIS: The primary outcome measure is a healthy singleton born after at least 37 weeks of gestation after vaginal delivery. Secondary outcome parameters including pregnancy outcome and complications, percentage of women needing fertility treatment, clinical and ongoing pregnancy rates, body weight, quality of life and costs.Data will be analysed according to the intention to treat principle, and cost-effectiveness analysis will be performed to compare the costs and health effects in the intervention and control group. DISCUSSION: The trial will provide evidence for costs and effects of a lifestyle intervention aiming at weight reduction in overweight and obese subfertile women and will offer guidance to clinicians for the treatment of these patients. TRIAL REGISTRATION: Dutch Trial Register NTR1530.",0,0,
1820,"The management of ""psychogenic"" orofacial pain",,0,0,
1821,The management of patients with nicotine dependence - the role of the general practitioners,"The gatekeeper needs a disease management of his patients who smoke. Questionnaires will help to define the diagnosis and grade of nicotine dependence as well as the fingerprint of the patients smoking career. The ICD-10 Code and the Fagerstrom Nicotine Dependence Test are used. There is no therapy indicated without the optimal motivation of the patient. The transtheoretical model of Prochaska and DiClemente ist widely accepted to separate the stadium of motivation into precontemplation, contemplation, preparation and action. Many other factors like earlier experiences, catastrophe scenaries, self-efficacy and selection of therapeutic modality are important for the best outcome. 90 % of the work of a gatekeeper is minimal intervention. This means individually tailored argumentations to shift the motivation of the patient to smoking cessation. The concept is defined in the rules of the five R's with relevance, risks, rewards, roadblocks and repetition. Following these criterias, the gatekeeper gets a positive shift of his motivation in up to 60 % with only one minimal intervention. The smoking cessation guidelines through the world are very similar and show a level A grade for a synergy of behavioural therapy and medication by either nicotine replacement, bupropion or vareniclin. The selection of any other regimen is either less efficient or anecdotally and leads to a further loss of life expectancy of the smoker. The gatekeeper has the infrastructure, the know how and the confidence of his patient to act as disease manager. A successful therapy is possible over six months with about seven consultations, the success rate is expected to be even higher than the values in the medication studies. Smokers should be informed by the health organizations to avoid self therapies and look for specialists help. The gatekeeper is an ideal candidate.",0,0,
1822,The MAURO study: baseline characteristics and compliance with guidelines targets,"BACKGROUND: The Multiple Intervention and Audit in Renal Diseases to Optimize Care (MAURO) study was a cluster randomized controlled trial in 22 renal clinics which aimed to assess the efficacy of a multimodal quality improvement intervention to increase compliance with guideline recommendations for prevention of chronic kidney disease (CKD) progression and cardiovascular (CV) complications. The trial aimed to test whether this multimodal intervention improved adherence to recommended targets for a series of surrogate indicators relevant to blood pressure (BP) control, sodium intake, proteinuria, dyslipidemia, anemia and calcium-phosphate alterations. The trial also tested whether the same intervention slowed CKD progression and prevented CV complications in CKD patients. METHOD: Twenty-two renal clinics were randomized to 2 arms: an intervention arm applying a multimethod quality improvement intervention and a control arm providing standard care. Surrogate indicators were measured to evaluate blood pressure (BP) control, sodium intake, proteinuria, dyslipidemia, anemia and calcium-phosphate alterations. RESULTS: Notwithstanding the fact that the vast majority of patients enrolled in this study (95%) were being treated with antihypertensive drugs, BP goals at baseline (specific for proteinuria level and diabetes) were met only in 45% of nonproteinuric patients and in just 14% and 18% of proteinuric and diabetic patients, respectively. The use of diuretics in hypertensive patients was less than what was needed, and about 80% of patients showed a salt excretion >100 mmol/24 hours. Total and low-density lipoprotein cholesterol levels were out of target in over 40% of patients, but only about 60% of these were on statins. A large majority of CKD patients were obese or overweight. The proportion of smokers was relatively small (13%), and 37% of patients had quit smoking, indicating patients' awareness of the health risks of smoking. CONCLUSIONS: In our cohort, management of modifiable risk factors for CKD progression and CV disease could be substantially improved.",0,0,
1823,The McMaster curriculum: a critique,,0,0,
1824,The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care.,"Background: Adverse drug-related events are common in the elderly, and inappropriate prescribing is a preventable risk factor. Our objective was to determine whether inappropriate prescribing could be reduced when primary care physicians had computer-based access to information on all prescriptions dispensed and automated alerts for potential prescribing problems.  Methods: We randomly assigned 107 primary care physicians with at least 100 patients aged 66 years and older (total 12 560) to a group receiving computerized decision-making support (CDS) or a control group. Physicians in the CDS group had access to information on current and past prescriptions through a dedicated computer link to the provincial seniors' drug-insurance program. When any of 159 clinically relevant prescribing problems were identified by the CDS software, the physician received an alert that identified the nature of the problem, possible consequences and alternative therapy. The rate of initiation and discontinuation of potentially inappropriate prescriptions was assessed over a 13-month period.  Results: In the 2 months before the study, 31.8% of the patients in the CDS group and 33.3% of those in the control group had at least 1 potentially inappropriate prescription. During the study the number of new potentially inappropriate prescriptions per 1000 visits was significantly lower (18%) in the CDS group than in the control group (relative rate [RR] 0.82, 95% confidence interval [CI] 0.69–0.98), but differences between the groups in the rate of discontinuation of potentially inappropriate prescriptions were significant only for therapeutic duplication by the study physician and another physician (RR 1.66, 95% CI 0.99–2.79) and drug interactions caused by prescriptions written by the study physician (RR 2.15, 95% CI 0.98–4.70).  Interpretation: Computer-based access to complete drug profiles and alerts about potential prescribing problems reduces the rate of initiation of potentially inappropriate prescriptions but has a more selective effect on the discontinuation of such prescriptions.",0,1,
1825,The moderating effect of adherence-promoting interventions with clients on evidence-based practices for children and adolescents with mental health problems,"Poor adherence of children and adolescents to evidence-based psychosocial interventions remains a fundamental impediment to treatment effectiveness. To maintain client adherence, researchers and clinicians have employed a number of adherence-promoting strategies, from telephone calls and letters to providing transportation costs and child care to motivational enhancement therapies. However, the influence of adherence promoters on intervention outcomes has not been reported. This study examined the moderating effect of adherence-promoting strategies in a survey and meta-analysis of randomized clinical trials of cognitive behavioral treatments, interpersonal therapy, and psycho-education for children and adolescents with mental health problems (k = 33). Results indicated the type and intensity of adherence promoters' moderated study effect sizes according to client characteristics (age, gender, diagnosis). Preliminary findings suggest that males had higher effect sizes when more intensive adherence-promoting efforts were employed. Adherence-promoting efforts were associated with lower effect sizes for youths who were diagnosed with externalizing disorders. Results of this study suggest directions for future research to clarify clinical guidelines to maximize retention in evidence-based psychotherapy.",0,0,
1826,The myADHDportal.com Improvement Program: An innovative quality improvement intervention for improving the quality of ADHD care among community-based pediatricians,"Though the American Academy of Pediatrics has developed and disseminated clear evidence-based guidelines for ADHD care, community-based pediatricians often have difficulty implementing these guidelines. New strategies are needed to improve the quality of care received by children with ADHD and to improve utilization of the AAP consensus guidelines by pediatricians. An evidence-based quality improvement intervention has been developed that effectively improves the quality of ADHD care delivered by community-based pediatricians. In order to facilitative widespread dissemination of this intervention model, the entire intervention has been modified for online delivery. The intervention is called the myADHDportal.com Improvement Program. The full functionality of this online intervention is described including the collection of online ADHD rating scales from parents and teachers and online communication between parents, teachers, and physicians. In addition, the web portal integrates several innovative quality improvement features including an online wizard for mapping ADHD patient flow, an online report card for monitoring quality of care, and an online wizard for guiding practices through the Plan-Do-Study-Act (PDSA) cycle process. The combination of clinical utility and quality improvement tools facilitates delivery of quality ADHD care and reduces several of the obstacles to implementing AAP-recommended practice behaviors. Initial results with this intervention model are reviewed and goals for dissemination are described.",0,0,
1827,The Nazi doctors trial and the international prohibition on medical involvement in torture,,0,0,
1828,The need for research that is designed to support decisions in the delivery of mental health services,"M.E.P. Seligman (1995) argued that traditional approaches to mental health services research fail to provide useful information to consumers and practitioners, particularly in an environment increasingly dominated by managed care. The authors recommend 4 guidelines for designing a research program so that the results can support the decisions of the major stakeholders (clients-families, practitioners, service managers, and policymakers): (a) Research must be targeted and programmatic and encompass a strategy of complementary efficacy, effectiveness, and cost-effectiveness studies""; (b) study design and measure selection must be sensitive to describe who, and in what context, is best served by which intervention; (c) the design must inform stakeholders as to the type and amount of effort that is required to achieve a behavioral criteria;"" and (d) the strategy should inform researchers how information should be formatted to best support the decisions of the key stakeholders.",0,0,
1829,The NIH report of its review of the Baby Fae case,,0,0,
1830,The Nuremberg Code and medical research,"Addresses the tensions between religious discourse and bioethics. Issues of accessibility and meaning"";"" Addressing differing moral language and concepts.",0,0,
1831,The Nuremberg Code and the Nuremberg Trial. A reappraisal,"The Nuremberg Code includes 10 principles to guide physician-investigators in experiments involving human subjects. These principles, particularly the first principle on ""voluntary consent,"" primarily were based on legal concepts because medical codes of ethics existent at the time of the Nazi atrocities did not address consent and other safeguards for human subjects. The US judges who presided over the proceedings did not intend the Code to apply only to the case before them, to be a response to the atrocities committed by the Nazi physicians, or to be inapplicable to research as it is customarily carried on in medical institutions. Instead, a careful reading of the judgment suggests that they wrote the Code for the practice of human experimentation whenever it is being conducted.",0,0,
1832,The potential of asthma adherence management to enhance asthma guidelines,"OBJECTIVE: Expert Panel Report 3 Guidelines recommend that physicians use adherence management strategies""; however, the evidence for these interventions is weak. Clinicians need effective proven adherence interventions, because approximately 50% of patients with asthma do not follow physician medication recommendations, resulting in unnecessary morbidity. This review examines components of an organized adherence management program that has been successful in uncontrolled trials promoting adherence and reducing morbidity and cost. DATA SOURCES: Literature review was undertaken in the following areas of asthma management: guidelines, cost; morbidity; adherence, monitoring; and communication skills. STUDY SELECTIONS: Studies that examined outcomes from psychoeducational, behavioral, monitoring, and communication interventions. RESULTS: Studies using individual interventions by themselves were modestly effective in promoting adherence. Two uncontrolled studies of children with severe asthma, treated in both inpatient and outpatient rehabilitation settings, used 4 intervention strategies to achieve marked reduction in morbidity and cost. These strategies included: (1) objective adherence monitoring; (2) identification of the cause(s) of nonadherence; (3) delivery of specific strategies for each cause;"" and (4) use of motivational interviewing communication skills to enhance the delivery of the strategy. CONCLUSION: Nonadherence continues to be a significant problem. Physicians need a proven organized approach to improve adherence and reduce morbidity and cost. Evaluation of effective methods in a controlled fashion is warranted to increase adherence management evidence for future asthma guidelines.",0,0,
1833,"The power of clinical trials and guidelines,and the challenge of conflicts of interest",,0,0,
1834,The practice of ethics committees,"KIE: A brief news note welcomes the publication in September 1984 of a useful report, Guidelines on the Practice of Ethics Committees in Medical Research, by the Royal College of Physicians of London. One important recommendation in the Guidelines is that committees should be notified of adverse or unforeseen circumstances arising out of a study and should be sent abstracts or reprints of publications. If it emerges that clinical investigations have been conducted without reference to ethical review concerns, the committee should relay the facts to the institution it serves.",0,0,
1835,The problem with ‘5 whys’,"‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.",0,0,
1836,The problem with survey research.,"The Problem with Survey Research makes a case against survey research as a primary source of reliable information. George Beam argues that all survey research instruments, all types of asking-including polls, face-to-face interviews, and focus groups-produce unreliable and potentially inaccurate results. Because those who rely on survey research only see answers to questions, it is impossible for them, or anyone else, to evaluate the results. They cannot know if the answers correspond to respondents' actual behaviors (objective phenomena) or to their true beliefs and opinions (subjective phenomena). Reliable information can only be acquired by observation, experimentation, multiple sources of data, formal model building and testing, document analysis, and comparison. In fifteen chapters divided into six parts-Ubiquity of Survey Research, The Problem, Asking Instruments, Asking Settings, Askers, and Proper Methods and Research Designs-The Problem with Survey Research demonstrates how asking instruments, settings in which asking and answering take place, and survey researchers themselves skew results and thereby make answers unreliable. The last two chapters and appendices examine observation, other methods of data collection and research designs that may produce accurate or correct information, and show how reliance on survey research can be overcome, and must be. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
1837,The Prussian regulation of 1900: early ethical standards for human experimentation in Germany,,0,0,
1838,The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care,"Background Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression  Design Cluster randomised controlled trial (CRT)  Methods This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education.  The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD.  A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention.",0,0,
1839,The quality of diabetes care to Gullah families of South Carolina,"Empirical evidence from the Diabetes Control and Complication Trial (DCCT) suggests that maintaining normal glycemic control can prevent both micro vascular and macro vascular diseases in persons diagnosed with type 2 diabetes mellitus (T2DM) (DCCT, 1993). Adults with T2DM are also more likely to have hypertension (73% [HTN]) and patients with both are 2 to 4 times more likely to develop diabetic complications compared with the general population (CDC, 2005). The purpose of this descriptive study was to 1) describe the quality of diabetes care received by Gullah families who participated in the Project SuGar research study"";"" and 2) compare the Gullah's quality of care to the national sample in the Center for Disease Control (CDC) Diabetes Report Card using the two indicators of blood pressure and HbA1c. This was a secondary analysis from a parent study that compared selected data to the CDC Diabetes Report Card, the National Health and Nutrition Examination Survey (NHANES III), and the Behavioral Risk Factor Surveillance System (BRFSS). Socio-demographic and clinical data were obtained from 1,057 research participants (N = 1,057). Overall, when compared to the national sample in the CDC Report Card, the HbA1c greater than 9.5% mg/dL was higher among the Gullahs, (30.2% vs. 18%), and blood pressure greater 140/90 mmHg was lower (29% vs. 34%) among the participants. Almost half of the Gullahs (45.9%) self-reported neurovascular complications such as foot pain, claudication, and renal complications of kidney infection and dialysis (7.3%). The Gullah study participants are at risk for diabetes-related complications. Results suggest a quality gap in diabetes care and it suggests health disparities in outcome measures as well. Optimal care that is consistent with clinical guidelines could have a significant impact on decreasing complications and health disparities.",0,0,
1840,The rational patient and beyond: Implications for treatment adherence in people with psychiatric disabilities.,"Objective: Many people with psychiatric disabilities do not benefit from evidence-based practices because they often do not seek out or fully adhere to them. One way psychologists have made sense of this rehabilitation and health decision process and subsequent behaviors (of which adherence might be viewed as one) is by proposing a ""rational patient""""; namely, that decisions are made deliberatively by weighing perceived costs and benefits of intervention options. Social psychological research, however, suggests limitations to a rational patient theory that impact models of health decision making. Design: The research literature was reviewed for studies of rational patient models and alternative theories with empirical support. Special focus was on models specifically related to decisions about rehabilitation strategies for psychiatric disability. Results: Notions of the rational patient evolved out of several psychological models including the health belief model, protection motivation theory, and theory of planned behavior. A variety of practice strategies evolved to promote rational decision making. However, research also suggests limitations to rational deliberations of health. (1) Rather than carefully and consciously considered, many health decisions are implicit, potentially occurring outside awareness. (2) Decisions are not always planful; often it is the immediate exigencies of a context rather than an earlier balance of costs and benefits that has the greatest effects. (3) Cool cognitions often do not dictate the process;"" emotional factors have an important role in health decisions. Each of these limitations suggests additional practice strategies that facilitate a person's health decisions. Conclusion: Old models of rational decision making need to be supplanted by multiprocess models that explain supradeliberative factors in health decisions and behaviors. (PsycINFO Database Record (c) 2016 APA, all rights reserved)",0,0,
1841,"The regulation of gene therapy research in competent adult patients, today and tomorrow: implications of EU Directive 2001/20/EC",,0,0,
1842,"The results of major clinical trials: critical assessment, the circulation of information and media coverage","The round table elected to focus its discussion on trials that, in terms of their importance, are likely to modify medical practices and behaviour. Such trials may be pre- or postmarketing studies. For the findings of a trial to result in a change in practice, they must be credible and fulfil the basic methodological criteria. It is nonetheless appropriate to complete that binary assessment by the use of an assessment checklist appropriate to each category of users, i.e. the Regulatory Agency, prescribing physicians and patients, who are sometimes informed directly by the media. The members of the round table proposed the 'Giens 2003 checklist'. It consists of an interpretative semi-quantitative assessment checklist based on simple messages relevant to practice. Critical assessment is a necessary prelude to the circulation of the results to the various parties involved (healthcare professionals, patients, patient associations, the media and the general public) and the process of informing those parties in readily understandable but accurate terms. The practical implementation of the results, with a change in behaviour and/or the issuing of guidelines, are subsequent stages for which a certain lag time is inevitable. The assessment of implementation programmes, together with an accurate analysis of the obstacles to changing medical practice, should, in the future, improve and accelerate the implementation of important results in order to optimise patient management.",0,0,
1843,"The right stuff for early intervention in psychosis: time, attitude, place, intensity, treatment, & cost","This article shares information about an exciting new approach in psychiatry. During the past 12 years, the authors have worked with young people experiencing their first episode of psychosis. It is clear that intervention at the earliest stages of psychotic illness allows clinicians to make a significant difference in the lives of young people and their families. This article summarizes current intervention strategies, which are considered best practice guidelines for early treatment.",0,0,
1844,The rise in private hospital care,,0,0,
1845,The role of clinical pharmacist on lipid control in dyslipidemic patients in North of Jordan,"OBJECTIVE: The purpose of this study is to investigate the effectiveness of introducing clinical pharmacy services in achieving goal lipid profile in dyslipidemia patients in North of Jordan. Setting the study was carried out in a primary care facility in North of Jordan. METHODS: One hundred fifty two dyslipidemia patients were randomized into intervention and control groups and followed for 6 months period. Intervention group patients were followed intensively by a clinical pharmacist who worked closely with physicians in controlling lipid profiles according to the third edition of recommendations by The National Cholesterol Education Program Adult Treatment Panel, control group patients were provided with standard medical care. Main outcome measure percent of patients at their low density lipoprotein cholesterol target in the intervention group compared to percent of patients at their low density lipoprotein cholesterol target in the control group by the end of the study. RESULTS: One hundred twenty five patients completed the study duration. After 6 months, 94.5% of intervention group patients and 71.2 % of control group patients reached their goal low density lipoprotein cholesterol levels (P value < 0.001, Pearson Chi-Square test) compared to 24.7 and 28.8% respectively at baseline. Majority of pharmacist recommendations (90.4%) were followed by physicians and overall lipid lowering agents use was increased to 91.8% in intervention group patients and 86.5% in control group patients compared to 69.9 and 78.8% respectively at baseline. CONCLUSION: Implementing clinical pharmacy services in Jordan has improved the lipid profiles of dyslipidemic patients.",0,0,
1846,The role of GPs in increasing compliance to colorectal cancer screening: a randomised controlled trial (Italy),"Aims To assess the effect of the provider (GPs versus hospital) on the compliance in returning the faecal occult blood test. To analyse the characteristics of the GP associated with high compliance among his beneficiaries.  Methods A questionnaire about screening attitudes was mailed to the 1192 GPs working in 13 districts of the Lazio region. We asked the GPs to participate in a randomised trial, we sampled 130 GPs and about 1/10 of the GPs’ 50–75 year old beneficiaries (n = 3657) were invited to be screened at the GP office and 1/10 (3675) at the nearest gastroenterology centre.  Results 58.5% of the GPs completed the questionnaire and 22.7% agreed to participate in the trial. The compliance in the GP arm was 50%, in the hospital arm 16% (RR 3.4"";"" 95% CI: 3.13–3.70). There was a high variability in the compliance obtained by the GPs. GPs with more than 25 patients visited/day and those incorrectly recommended screening of colorectal cancer obtained a lower compliance (OR 0.74, 95% CI: 0.57–0.95 and OR 0.76, 95% CI: 0.59–0.97, respectively).  Conclusions The involvement of GPs in colorectal cancer screening can be very effective to enhance the compliance, but the effectiveness is dependent on their willingness to be involved.",0,1,
1847,The role of nurses/social workers in using a multidimensional guideline for diagnosis of anxiety and challenging behaviour in people with intellectual disabilities,"AIMS AND OBJECTIVES: This study seeks (1) to investigate the impact of the implementation of the 'Diagnostic Guideline for Anxiety and challenging behaviours in clients with intellectual disability' on nurses/social workers' knowledge and self-efficacy"";"" and (2) to evaluate the role of nurses/social workers in the diagnostic process when applying the guideline. BACKGROUND: Nurses/social workers have extensive contact with clients with intellectual disabilities. Despite this key position, the contribution of nurses/social workers to the diagnosis of mental health problems and challenging behaviours is rather limited. The authors developed the multidimensional 'Diagnostic Guideline for Anxiety and challenging behaviours'. In this article, the implementation of this guideline is evaluated concerning knowledge and self-efficacy of nurses/social workers, as well the role of nurses/social workers in the diagnostic process. DESIGN: This study employed a comparative multiple case study design. METHODS: Qualitative and quantitative research methods. RESULTS: Working with the 'Diagnostic Guideline for Anxiety and challenging behaviours' led to a statistically significant increase in knowledge and self-efficacy among the nurses/social workers in the experimental condition, compared with nurses/social workers in the control condition. Nurses/social workers and psychologists appreciated the more active contribution of the nurses/social workers in the diagnostic process. CONCLUSIONS: Working with the guideline increased the knowledge and self-efficacy of nurses/social workers, and led to more active participation of nurses/social workers in the diagnostic process. RELEVANCE TO CLINICAL PRACTICE: After following a training programme, nurses/social workers can effectively contribute to the diagnostic process in clients with anxiety and related challenging behaviours.",0,0,
1848,The role of relationship-based developmentally supportive newborn intensive care in strengthening outcome of preterm infants,"This article details the conceptual framework, clinical application, and efficacy of a relationship-based developmentally supportive approach to newborn intensive care referred to as NIDCAP (Newborn Individualized Developmental Care and Assessment Program). Outcomes of the approach are reported in regard to infant health and development, reduction of hospital costs, and family adaptation. The approach is guided by a neurodevelopmental framework for understanding preterm infants and depends on the capacities of professionals to collaborate with one another and with families in support of the infants' medical, developmental, and emotional well-being. The primary vehicle for clinical implementation is detailed behavioral observation with subsequent recommendations for individualized caregiving based on the infant's current functioning and apparent developmental goals. A series of essential components of developmentally oriented caregiving are described, including strategies for coordinated discharge planning, and linkage to community services. The voices of individual clinicians highlight the process of change from protocol-based to relationship-based care.",0,0,
1849,The role of stimulants in the treatment of preschool children with attention-deficit hyperactivity disorder,"The symptoms of attention-deficit hyperactivity disorder (ADHD) can have an early onset, beginning before the age of 6 years. Despite the significant number of preschool-aged children that can be diagnosed with ADHD, there are limited controlled data available on the pharmacological interventions being increasingly used in this population. A 1990 review showed that 34% of paediatricians and 15% of family physicians had prescribed psychostimulant medications to preschoolers with ADHD, and pharmacoepidemiological studies indicate growing use of stimulants in preschoolers during the 1990s. Unfortunately, only six controlled trials, with a total enrollment of less than 200 children, have been conducted using these drugs in preschoolers. While these small studies provide some evidence of benefit from the use of methylphenidate in preschoolers with ADHD, more data are critically needed. Practice parameters developed by the American Academy of Child & Adolescent Psychiatry and the American Academy of Pediatrics provide some guidance regarding the diagnosis and treatment of young children with ADHD, but are mainly based upon research in children of primary-school age. The ongoing PATS (Preschool ADHD Treatment Study), funded by the National Institute of Mental Health, will provide important clinical guidance for diagnostic considerations and intervention strategies for children with ADHD aged 3-5 years. Pending the release of data from the PATS study, clinicians must rely on developmental assessment skills, available standardised rating instruments, reports about the child from multiple informants, and knowledge of the risks and benefits of available pharmacological and behavioural treatments, in order to treat preschool children with ADHD effectively.",0,0,
1850,The role of surveillance in the management of small renal masses,"Incidentally detected, small renal masses (SRMs) have been increasing significantly in recent years due to the widespread use of improved cross-sectional imaging. A significant number of incidental SRMs are diagnosed in elderly patients who are more likely to undergo imaging for other medical issues. The natural history of SRMs has not been historically well understood because most masses are surgically removed soon after diagnosis. Several reports of surveillance of SRMs have been published in the last few years. When followed conservatively with serial imaging, SRMs have variable growth rates with an average of 0.28 cm/year, according to a recent meta-analysis. Larger series with longer follow-up are needed, but a significant number of small tumors seem to have an indolent behavior with a slow growth rate and a limited tendency to progress. The standard of care for enhancing SRMs is surgery. Up to one-third of surgically removed, <4-cm tumors are histologically benign. The outcomes of current surgical treatment of histologically confirmed, <4-cm, renal cell carcinomas are excellent, but this has not led to a decrease in mortality. Based on these considerations and on the available data on the natural history of SRMs, it seems reasonable to consider that we may be overtreating these lesions. This is especially true for elderly or unfit patients who have a decreased life expectancy. In these selected patients and in patients who refuse active treatment, it seems reasonable to propose an initial period of active surveillance for incidental SRMs, with delayed intervention for those tumors that will exhibit fast growth during follow-up. Percutaneous needle biopsies of renal tumors can be safely performed with the use of modern techniques and have the potential to characterize SRMs at histologically diagnosis, thereby allowing a better selection of the conservative or active treatment that is best suited for each individual patient.",0,0,
1851,The role of theory in research to develop and evaluate the implementation of patient safety practices,"Theories provide a way of understanding and predicting the effects of patient safety practices (PSPs), interventions intended to prevent or mitigate harm caused by healthcare or risks of such harm. Yet most published evaluations make little or no explicit reference to theory, thereby hindering efforts to generalise findings from one context to another. Theories from a wide range of disciplines are potentially relevant to research on PSPs. Theory can be used in research to explain clinical and organisational behaviour, to guide the development and selection of PSPs, and in evaluating their implementation and mechanisms of action. One key recommendation from an expert consensus process is that researchers should describe the theoretical basis for chosen intervention components or provide an explicit logic model for ‘why this PSP should work.’ Future theory-driven evaluations would enhance generalisability and help build a cumulative understanding of the nature of change.",0,1,
1852,The social worker and nurse roles in case management: applying the Three Rs,"There are different skill sets that nurse case managers and social workers need in order to have a good patient outcome. The issue is that there is a void in the relationship between social workers and nurses, and this void is founded on factors that can, and must, be addressed. This gap can be minimized by conscious effort, by addressing the issue, and by a willingness to maximize the energy expended in professional relationships to improve patient outcomes. Equally important is the professional experience of each practitioner. The intervention is based on Three Rs: Reciprocity, Responsibility, and Respect.",0,0,
1853,"The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411","BACKGROUND: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland. CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients""; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs;"" and patient-centred consultations accompanied by attention to disease management guidelines. METHODS: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.",0,0,
1854,The Standard of Care: A Case Report and Ethical Analysis,"Physicians increasingly allow their perceived legal responsibilities to displace their clinical judgment. Misunderstandings that surround the term ""standard of care"" have encouraged fears of liability and have led to the practice of defensive medicine. Physicians may consider the standard of care to be a technical or legal obligation, but an optimal standard would be one based on detailed knowledge of a patient's medical history and personal condition. It would include the physician's clinical judgment which integrates specific technical and legal information with clinical experience in caring for patients. Occasionally, such judgment may conflict with the rulings of a court, which considers technical and legal information without the benefit of clinical judgment. Physicians must be prepared to be advocates for their patients, especially when legal proceedings are flawed or injurious. Systematic processes of examination and analysis, such as those used by ethics consultants, can help resolve questions about the standard of care.",0,0,
1855,The state of office-based interventions for youth tobacco use,"Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.",0,0,
1856,"The Study Team for Early Life Asthma Research (STELAR) consortium 'Asthma e-lab': team science bringing data, methods and investigators together","We created Asthma e-Lab, a secure web-based research environment to support consistent recording, description and sharing of data, computational/statistical methods and emerging findings across the five UK birth cohorts. The e-Lab serves as a data repository for our unified dataset and provides the computational resources and a scientific social network to support collaborative research. All activities are transparent, and emerging findings are shared via the e-Lab, linked to explanations of analytical methods, thus enabling knowledge transfer. eLab facilitates the iterative interdisciplinary dialogue between clinicians, statisticians, computer scientists, mathematicians, geneticists and basic scientists, capturing collective thought behind the interpretations of findings.",0,0,
1857,The systematic influence of gain-and loss-framed messages on interest in and use of different types of health behavior,"Framing health messages systematically in terms of either gains or losses influences the behaviors that people adopt. Rothman and Salovey proposed that the relative influence of gain-and loss-framed messages is contingent on people’s perception of the risk or uncertainty associated with adopting the recommended behavior. Specifically, loss-framed messages are more effective when promoting illness-detecting (screening) behaviors, but gain-framed messages are more effective when promoting health-affirming (prevention) behaviors. Two experiments provide a direct test of this conceptual framework. In Experiment 1, participants’ willingness to act after reading about a new disease was a function of how the information was framed and the type of behavior promoted. Experiment 2 replicated and extended these findings with a real health concern—gum disease. Gain-framed pamphlets heightened interest in a plaque-fighting mouth rinse, whereas loss-framed pamphlets heightened interest in a plaque-detecting disclosing rinse. Research on message framing provides a theoretically based guide for the development of effective health messages.",0,1,
1858,The time is now: education and organisation of services,,0,0,
1859,The tools of an evidence-based culture: implementing clinical-practice guidelines in an Israeli HMO,"PURPOSE: Although clinical-practice guidelines (CPGs) are implemented on the assumption that they will improve the quality, efficiency, and consistency of health care, they generally have limited effect in changing physicians' behavior. The purpose of this study was to design and implement an effective program for formulating, promulgating, and implementing CPGs to foster the development of an evidence-based culture in an Israeli HMO. METHOD: The authors implemented a four-stage program of stepwise collaborative efforts with academic institutions composed of developing quantitative tools to evaluate prescribing patterns, updating CPGs, collecting MDs' input via focus groups and quantitative surveys, and conducting a randomized controlled trial of a two-stage, multipronged intervention. The test case for this study was the development, dissemination, and implementation of CPG for the treatment of acute uncomplicated cystitis in adult women. Interventions in the form of a lecture at a conference and a letter with personalized feedback were implemented, both individually and combined, to improve physicians' rates of prescribing the first-line drug, nitrofurantoin, and, in the absence of nitrofurantoin, adhering to the recommended duration of three days of treatment with ofloxacin. RESULTS: The tools and data-generating capabilities designed and constructed in Stage I of the project were integral components of all subsequent stages of the program. Personalized feedback alone was sufficient to improve the rate of adherence to the guidelines by 19.4% (95% CI = 16.7, 22.1). CONCLUSIONS: This study provides a template for introducing the component of experimentation essential for cultivating an evidence-based culture. This process, composed of collaborative efforts between academic institutions and a managed care organization, may be beneficial to other health care systems.",0,1,
1860,The U.S. training institute for dissemination and implementation research in health,"Background The science of dissemination and implementation (D&I) is advancing the knowledge base for how best to integrate evidence-based interventions within clinical and community settings and how to recast the nature or conduct of the research itself to make it more relevant and actionable in those settings. While the field is growing, there are only a few training programs for D&I research""; this is an important avenue to help build the field¡¯s capacity. To improve the United States¡¯ capacity for D&I research, the National Institutes of Health and Veterans Health Administration collaborated to develop a five-day training institute for postdoctoral level applicants aspiring to advance this science.  Methods We describe the background, goals, structure, curriculum, application process, trainee evaluation, and future plans for the Training in Dissemination and Implementation Research in Health (TIDIRH).  Results The TIDIRH used a five-day residential immersion to maximize opportunities for trainees and faculty to interact. The train-the-trainer-like approach was intended to equip participants with materials that they could readily take back to their home institutions to increase interest and further investment in D&I. The TIDIRH curriculum included a balance of structured large group discussions and interactive small group sessions.  Thirty-five of 266 applicants for the first annual training institute were accepted from a variety of disciplines, including psychology (12 trainees); medicine (6 trainees); epidemiology (5 trainees); health behavior/health education (4 trainees); and 1 trainee each from education & human development, health policy and management, health services research, public health studies, public policy and social work, with a maximum of two individuals from any one institution. The institute was rated as very helpful by attendees, and by six months after the institute, a follow-up survey (97% return rate) revealed that 72% had initiated a new grant proposal in D&I research;"" 28% had received funding, and 77% had used skills from TIDIRH to influence their peers from different disciplines about D&I research through building local research networks, organizing formal presentations and symposia, teaching and by leading interdisciplinary teams to conduct D&I research.  Conclusions The initial TIDIRH training was judged successful by trainee evaluation at the conclusion of the week¡¯s training and six-month follow-up, and plans are to continue and possibly expand the TIDIRH in coming years. Strengths are seen as the residential format, quality of the faculty and their flexibility in adjusting content to meet trainee needs, and the highlighting of concrete D&I examples by the local host institution, which rotates annually. Lessons learned and plans for future TIDIRH trainings are summarized.",0,0,
1861,The UPBEAT depression and coronary heart disease programme: using the UK Medical Research Council framework to design a nurse-led complex intervention for use in primary care,"BACKGROUND: Depression is common in coronary heart disease (CHD) and increases the incidence of coronary symptoms and death in CHD patients. Interventions feasible for use in primary care are needed to improve both mood and cardiac outcomes. The UPBEAT-UK programme of research has been funded by the NHS National Institute for Health Research (NIHR) to explore the relationship between CHD and depression and to develop a new intervention for use in primary care. METHODS: Using the Medical Research Council (MRC) guidelines for developing and evaluating complex interventions, we conducted a systematic review and qualitative research to develop a primary care-based nurse-led intervention to improve mood and cardiac outcomes in patients with CHD and depression. Iterative literature review was used to synthesise our empirical work and to identify evidence and theory to inform the intervention. RESULTS: We developed a primary care-based nurse-led personalised care intervention which utilises elements of case management to promote self management. Following biopsychosocial assessment, a personalised care plan is devised. Nurses trained in behaviour change techniques facilitate patients to address the problems important to them. Identification and utilisation of existing resources is promoted. Nurse time is conserved through telephone follow up. CONCLUSIONS: Application of the MRC framework for complex interventions has allowed us to develop an evidence based intervention informed by patient and clinician preferences and established theory. The feasibility and acceptability of this intervention is now being tested further in an exploratory trial.",0,0,
1862,The use of computerized birthday greeting reminders in the management of diabetes.,"BACKGROUND: Although mailed reminders have been used for prevention among general populations, few studies have evaluated their effectiveness among chronically ill populations.  OBJECTIVE: We evaluated the effectiveness of mailed reminders for improving diabetes management. The reminder included a letter from the individual’s primary care physician (PCP), a self-care handbook, a preventive care checklist, and specific recommendations regarding receipt of routine monitoring and screening.  METHODS: Of 195 PCPs practicing with a large group practice, 111 agreed to have their adult patients with diabetes randomized to receive the reminder (n=1,641) or usual care (n=1,668). Using data from automated databases, we fit generalized estimating equations to evaluate the effect of reminder receipt on fasting lipid profile and glycated hemoglobin testing, dilated retinal exam receipt, and visit frequency during the 6 and 12 months following randomization, and glycated hemoglobin and cholesterol levels in the year following randomization.  RESULTS: Reminder and usual care recipients did not differ in sociodemographic, clinical, or prior testing characteristics. In the 6 months following randomization, reminder recipients were more likely to receive a retinal exam (odds ratio [OR], 1.29""; 95% confidence interval [95% CI], 1.12 to 1.49) and diabetes visit (OR, 1.28; 95% CI, 1.12 to 1.47). In the 12 months following randomization, reminder recipients were more likely to receive a glycated hemoglobin test (OR, 1.21; 95% CI, 1.03 to 1.43), retinal exam (OR, 1.23; 95% CI, 1.07 to 1.41), and diabetes visit (OR, 1.25;"" 95% CI, 1.09 to 1.29). In the follow-up year, reminder recipients also tended to have a glycated hemoglobin test that did not reflect poor control (<9.5%).  CONCLUSIONS: We found small but significant improvements in the management of patients with diabetes receiving a computerized mailed reminder.",0,1,
1863,The use of laboratory intervention to stem the flow of fresh-frozen plasma,"Four methods of laboratory intervention were tested by the hospital blood bank in an effort to modify the use of fresh-frozen plasma (FFP). Over a one-year period, a utilization audit was serially initiated with feedback to physicians, a recurrent educational program was introduced for housestaff delineating guidelines for FFP use, a form was introduced requiring justification for FFP orders, and a policy was established requiring pathologist approval of FFP in patients with normal or no coagulation studies. Overall, in comparing the period following all forms of intervention (February 1986-October 1986) to the baseline period prior to any form of intervention (July 1984-March 1985), FFP use dropped 52% in the face of a 17% increase in red blood cell use. It was concluded that blood bankers can dramatically alter the use of this product using established methods for modifying physician ordering behavior.",0,0,
1864,The use of simulation for training teamwork skills in health care: how low can you go?,"High fidelity simulation has become a popular technique for training teamwork skills in high risk industries such as aviation, health care, and nuclear power production. Simulation is a powerful training tool because it allows the trainer to systematically control the schedule of practice, presentation of feedback, and introduction (or suppression) of environmental distractions within a safe, controlled learning environment. Unfortunately, many within the training community have begun to use the terms simulation and high fidelity simulation almost synonymously. This is unfortunate because doing so overemphasises the instructional technology to the detriment of more substantive issues, such as the training’s goals, content, and design. It also perpetuates several myths: simulation fidelity is unidimensional, or higher levels of simulation fidelity lead to increased training effectiveness. The authors propose a typology of simulation fidelity and provide examples of how the different classes of simulation have been successfully used to train teamwork skills in high risk industries. Guidelines are also provided to maximise the usefulness of simulation for training teamwork skills in health care.",0,0,
1865,The use of the nicotine inhaler in smoking cessation,"PURPOSE: To raise awareness among nurse practitioners (NPs) about the nicotine inhaler by providing clinical and practical information about the use of the nicotine inhaler as a treatment option for smoking cessation. DATA SOURCES: This included data-based and review articles in the medical literature, tobacco use and dependence clinical practice guideline, and Medline and Cinahl search engines. Criteria for search keywords were ""nicotine inhaler"" and ""nicotine replacement therapy."" Initial search was done in December 2004. CONCLUSIONS: The nicotine inhaler has been tested as safe and efficacious in the treatment of tobacco cessation. Clinical trials show the nicotine inhaler to be useful alone or as an adjunct to other pharmacological therapies. Current national guidelines recommend that the nicotine inhaler be used in smoking cessation therapy. IMPLICATIONS FOR PRACTICE: The nicotine inhaler is appropriate for many different smokers, including certain types of cardiac patients. NPs can include the nicotine inhaler in a group of nicotine replacement therapies to ensure that smokers are successful in tobacco cessation.",0,0,
1866,The utilization of appropriate osteoporosis medications improves following a multifaceted educational intervention: the Canadian quality circle project (CQC),"BACKGROUND: Osteoporosis is a serious but treatable condition. However, appropriate therapy utilization of the disease remains suboptimal. Thus, the objective of the study was to change physicians' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines. METHODS: The Project was a two year cohort study that consisted of five Quality Circle (QC) phases that included: 1) Training & Baseline Data Collection, 2) First Educational Intervention & First Follow-Up Data Collection 3) First Strategy Implementation Session, 4) Final Educational Intervention & Final Follow-up Data Collection, and 5) Final Strategy Implementation Session. A total of 340 family physicians formed 34 QCs and participated in the study. Physicians evaluated a total of 8376, 7354 and 3673 randomly selected patient charts at baseline, follow-up #1 and the final follow-up, respectively. Patients were divided into three groups"";"" the high-risk, low-risk, and low-risk without fracture groups. The generalized estimating equations technique was utilized to model the change over time of whether physicians RESULTS: The odds of appropriate therapy was 1.29 (95% CI: 1.13, 1.46), and 1.41 (95% CI: 1.20, 1.66) in the high risk group, 1.15 (95% CI: 0.97, 1.36), and 1.16 (95% CI: 0.93, 1.44) in the low risk group, and 1.20 (95% CI: 1.01, 1.43), and 1.23 (95% CI: 0.97, 1.55) in the low risk group without fractures at follow-up #1 and the final follow-up, respectively. CONCLUSION: QCs methodology was successful in increasing physicians' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines.",0,0,
1867,The value of 'gentle reminder' on safe medical behaviour,"Background Based on knowledge and methods from cognitive psychology and behavioural economics we introduced ‘Gentle reminder.’ This procedure calls for public planning of safety norms, and an agreement of all team members to help each other to adhere to this plan.  Methods Team members agree to gently remind their coworkers every time they deviate from the safety norm. For the study, we observed the use of gloves during intravenous insertion and blood withdrawal.  Results and discussion During the 2 years of observation, safe behaviour increased, if safe behaviour before implementation of the ‘gentle reminder’ was 55% in one ward""; it increased after 2 months to above 80%; 2 months later, it was 83% and 90%;"" and finally it stabilised on 90%. A similar pattern was documented in all wards. This is one recommended way to overcome unsafe behaviour.",0,1,
1868,Theory and practice in the management of depressive disorders,"Scientific, professional, and governmental bodies have in recent years intensified efforts to formulate guidelines for the treatment of depression with the goal that medical practice should comply with these standards and thus improve patient care. 'Evidence-based medicine' demands that medical practice should explicitly refer to the best available scientific knowledge. Empirical data on the epidemiology of care suggest that there are major differences between guidelines and routine practice. Failure to detect mental disorders range from 45 to 90%. Only 1 in 10 of those suffering from depression receive adequate treatment. Treatment is insufficient as prescribed dosages are routinely too low, as up to 50% of treatments are ended prematurely and because patient non-compliance interferes with proper treatment application. Psychological treatment is provided only in 60% of cases in need and is mostly unspecific, i.e. listening or giving advice. Furthermore, there are large regional variations in prescribing patterns which show that treatment is influenced by many non-medical factors. Empirical studies show that giving information to physicians or even measures to improve recognition alone are not sufficient to make changes in treatment behaviour. Only if measures are taken to improve treatment interventions directly then, at least for more severe cases, could better illness outcome be shown. If one wants to understand therapist non-compliance with treatment guidelines then one first has to understand the process of medical decision making. Action theory provides a model which brings together theoretical and experimental knowledge, goal setting, medical and emotional assessment, and operational procedures. On the basis of this theory, future guidelines should specify the setting for which they claim to be valid, they should be empirically tested for their feasibility and effects on patient outcome, and they should give proper attention to non-medical factors which have major impact on medical practice.",0,0,
1869,Therapeutic enhancement: nursing intervention category for patients diagnosed with Readiness for Therapeutic Regimen Management,"AIMS: To present a new nursing intervention category called therapeutic enhancement. BACKGROUND: Fewer than half of North Americans follow their physician's recommendations for diet and exercise, even when such are crucial to their health or recovery. It is imperative that nurses consider new ways to promote healthy behaviours. Therapeutic enhancement is intended to provide such a fresh approach. Traditional intervention techniques focusing on education, contracts, social support and more frequent interaction with physicians appear not to be effective when used alone. Successful strategies have been multidisciplinary"";"" and have included interventions by professional nurses who assist patients to understand their disease and the disease process and that helps them to develop disease-management and self-management skills. Therapeutic enhancement incorporates The Stages of Change Theory, Commitment to Health Theory, Motivational Interviewing techniques and instrumentation specifically designed for process evaluation of health-promoting interventions. METHOD: This is a critical review of approaches that, heretofore, have not been synthesised in a single published article. CONCLUSIONS: Based on the commonly used Stages of Change model, therapeutic enhancement is useful for patients who are at the action stage of change. Using therapeutic enhancement as well as therapeutic strategies identified in Stages of Change Theory, such as contingency management, helping relationships, counterconditioning, stimulus control and Motivational Interviewing techniques, nursing professionals can significantly increase the chances of patients moving from action to the maintenance stage of change for a specific health behaviour. RELEVANCE TO CLINICAL PRACTICE: Using the nursing intervention category, therapeutic enhancement can increase caregivers' success in helping patients maintain healthy behaviours.",0,0,
1870,Therapy and supportive care of alcoholics: guidelines for practitioners,"BACKGROUND/AIMS: Alcoholism is a widespread disorder in our societies. However, only a small percentage of alcoholics appear in specific psychotherapeutic treatment programs. The vast majority are seen by general practitioners or experts of other medical specialties where they are treated intensively for their alcohol-induced comorbidities. But the reason for these comorbidities, alcoholism itself, is rarely treated. This article provides a guideline for specialists and non-specialists on how to treat these patients correctly in nonspecific treatment programs and how to increase motivation to stay abstinent. Moreover, the concept can be quickly and easily integrated into the daily routine of any therapeutic team. METHODS: Literature on the therapeutic methods of brief interventions, motivational interviewing as well as pharmacological relapse prevention was reviewed in PubMed for the years 1991-2005. RESULTS/CONCLUSION: The burden of disease of alcoholism and alcohol abuse as primary disorders is highly evident but often underestimated even by therapists of various medical disciplines. Systematic studies of the brief intervention method, motivational interviewing and also pharmacological treatment with acamprosate have shown that these are potent methods that are easily used to increase the duration of abstinence and patients' motivation to take part in further specific treatment.",0,0,
1871,"Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care",,0,0,
1872,Three- and 4-dimensional ultrasound in obstetric practice: does it help?,"OBJECTIVE: The purpose of this article was to review the published literature on 3-dimensional ultrasound (3DUS) and 4-dimensional ultrasound (4DUS) in obstetrics and determine whether 3DUS adds diagnostic information to what is currently provided by 2-dimensional ultrasound (2DUS) and, if so, in what areas. METHODS: A PubMed search was conducted for articles reporting on the use of 3DUS or 4DUS in obstetrics. Seven-hundred six articles were identified, and among those, 525 were actually related to the subject of this review. Articles describing technical developments, clinical studies, reviews, editorials, and studies on fetal behavior or maternal-fetal bonding were reviewed. RESULTS: Three-dimensional ultrasound provides additional diagnostic information for the diagnosis of facial anomalies, especially facial clefts. There is also evidence that 3DUS provides additional diagnostic information in neural tube defects and skeletal malformations. Large studies comparing 2DUS and 3DUS for the diagnosis of congenital anomalies have not provided conclusive results. Preliminary evidence suggests that sonographic tomography may decrease the examination time of the obstetric ultrasound examination, with minimal impact on the visualization rates of anatomic structures. CONCLUSIONS: Three-dimensional ultrasound provides additional diagnostic information for the diagnosis of facial anomalies, evaluation of neural tube defects, and skeletal malformations. Additional research is needed to determine the clinical role of 3DUS and 4DUS for the diagnosis of congenital heart disease and central nervous system anomalies. Future studies should determine whether the information contained in the volume data set, by itself, is sufficient to evaluate fetal biometric measurements and diagnose congenital anomalies.",0,0,
1873,Through the carpal tunnel,,0,0,
1874,Thyroid disease in pregnancy,,0,0,
1875,Tics in the Pediatric Population: Pragmatic Management,"BACKGROUND: Primary tic disorders, notably Tourette syndrome, are very common movement disorders in childhood. However, the management of such patients still poses great therapeutic challenges to medical professionals. METHODS: Based on a synthesis of the available guidelines published in Europe, Canada, and the United States, coupled with more recent therapeutic developments, the authors provide a pragmatic guide to aid clinicians in deciding when and how to treat patients who have primary tic disorders. RESULTS: After a systematic assessment of tics and common neuropsychiatric comorbidities (primarily attention-deficit hyperactivity disorder [ADHD] and obsessive-compulsive disorder [OCD]), the first step in treatment is a comprehensive psychoeducation of patients and families that addresses the protean phenomenology of tics and associated behaviors, coping mechanisms, prognosis, and treatment options. When more active intervention beyond watchful monitoring is indicated, hierarchical evaluation of treatment targets (i.e., tics vs. comorbid behavioral symptoms) is crucial. Behavioral treatments for tics are restricted to older children and are not readily available to all centers, mainly due to the paucity of well-trained therapists. Pharmacological treatments, such as antipsychotics for tics, stimulants and atomoxetine for ADHD, and alpha2A-agonists for children with tics plus ADHD, represent widely available and effective treatment options, but safety monitoring must be provided. Combined polypharmacological and behavioral/pharmacological approaches, as well as neuromodulation strategies, remain under-investigated in this population of patients. CONCLUSIONS: The treatment of children with tics and Tourette syndrome is multifaceted. Multidisciplinary teams with expertise in neurology, psychiatry, psychology, and pediatrics may be helpful to address the complex needs of these children.",0,0,
1876,"Tobacco brief intervention training for chiropractic, acupuncture, and massage practitioners: protocol for the CAM reach study","BACKGROUND: Tobacco use remains the leading cause of morbidity and mortality in the US. Effective tobacco cessation aids are widely available, yet underutilized. Tobacco cessation brief interventions (BIs) increase quit rates. However, BI training has focused on conventional medical providers, overlooking other health practitioners with regular contact with tobacco users. The 2007 National Health Interview Survey found that approximately 20% of those who use provider-based complementary and alternative medicine (CAM) are tobacco users. Thus, CAM practitioners potentially represent a large, untapped community resource for promoting tobacco cessation and use of effective cessation aids. Existing BI training is not well suited for CAM practitioners' background and practice patterns, because it assumes a conventional biomedical foundation of knowledge and philosophical approaches to health, healing and the patient-practitioner relationship. There is a pressing need to develop and test the effectiveness of BI training that is both grounded in Public Health Service (PHS) Guidelines for tobacco dependence treatment and that is relevant and appropriate for CAM practitioners. METHODS/DESIGN: The CAM Reach (CAMR) intervention is a tobacco cessation BI training and office system intervention tailored specifically for chiropractors, acupuncturists and massage therapists. The CAMR study utilizes a single group one-way crossover design to examine the CAMR intervention's impact on CAM practitioners' tobacco-related practice behaviors. Primary outcomes included CAM practitioners' self-reported conduct of tobacco use screening and BIs. Secondary outcomes include tobacco using patients' readiness to quit, quit attempts, use of guideline-based treatments, and quit rates and also non-tobacco-using patients' actions to help someone else quit. DISCUSSION: CAM practitioners provide care to significant numbers of tobacco users. Their practice patterns and philosophical approaches to health and healing are well suited for providing BIs. The CAMR study is examining the impact of the CAMR intervention on practitioners' tobacco-related practice behaviors, CAM patient behaviors, and documenting factors important to the conduct of practice-based research in real-world CAM practices.",0,0,
1877,Tobacco cessation in primary care: maximizing intervention strategies,"The most effective preventive intervention that a clinician can provide for tobacco-using patients against heart disease, cancer, cerebrovascular disease and chronic obstructive pulmonary disease is an empathic, personalized smoking cessation intervention program with extended assistance and follow-up. The goal of the intervention must be complete smoking cessation. Reduction provides no direct health benefits to the individual smoker. Interventions are readily available, but underutilized, in part due to lack of clinician training and organizational support. The present article summarizes the current guidelines for smoking cessation interventions as a framework from which to start. The guidelines incorporate the Transtheoretical Model of patient behavioral change and the ""Five A's"": Ask, Advise, Assess, Assist and Arrange. Pharmacotherapeutic tools, including nicotine replacement therapies (nicotine gums, patches, nasal sprays, inhalers and new therapies) and non-nicotine therapies (bupropion, clonidine, nortriptyline and other antidepressants and anxiolytics) are considered. Adherence validation methods, new approaches to tobacco and addiction treatment that appear in the recent research literature are reviewed. Beyond this framework, specific categories of tobacco users (including smokeless tobacco users), cultural and ethnic minorities, adolescents using snuff and bidis, women, Medicaid recipients, and users of multiple forms of tobacco require special consideration. With this framework and the modifications that may be required for specific categories of patients, practicing clinicians can incorporate into daily practice a successful tobacco cessation intervention program with quit rates approaching 20%.",0,0,
1878,Tobacco cessation in the dental office,"Evidence-based tobacco-cessation guidelines when used by clinicians are effective in reducing tobacco use and obtaining successful quits by patients. Dentists have been encouraged to provide instruction and intervention on tobacco cessation in the dental office. The dental provider is in the unique position to relate oral findings to the patient and to provide advice to tobacco-using patients to quit. In addition, dentists are able to assess patients' self-addiction and level of readiness to quit tobacco use. With this information, dentists can assist in helping patients to stop using tobacco by providing appropriate pharmacotherapeutic aid and thus improve their oral and overall health.",0,0,
1879,Tobacco Cessation Training for Complementary and Alternative Medicine Practitioners: Results of a Practice-Based Trial,"INTRODUCTION: Brief behavioral intervention (BI) is a tobacco-cessation best practice well established among conventional healthcare practitioners. Complementary and alternative medicine (CAM) practitioners treat significant numbers of tobacco users, but do not systematically receive BI training. The CAM Reach study developed and evaluated a tobacco cessation BI training program/practice system intervention adapted specifically for CAM practitioners, and evaluated in real-world CAM practices. STUDY DESIGN: Single-arm intervention. Data were collected in 2010-2014 and analyzed in 2015. SETTING/PARTICIPANTS: Private practices of 30 chiropractors, 27 acupuncturists, 42 massage therapists (N=99), in metropolitan Tucson, Arizona. INTERVENTION: Eight-hour tobacco cessation BI continuing education workshop, in-office BI skills practice/assessment, and system intervention. Training tailored to the CAM practice setting addressed tobacco cessation best practices from the U.S. Public Health Service Guidelines. MAIN OUTCOME MEASURES: Seventeen items (assessing practitioner behavior, motivation, and self-efficacy with tobacco cessation) comprising three factors, Tobacco Cessation Activity, Tobacco Cessation Motivation, and Non-CAM Tobacco Cessation Comfort, were assessed at baseline and 3, 6, 9, and 12 months post-training by practitioner self-report. Research staff visited practices at approximately the same intervals to directly observe changes in clinical practice systems. RESULTS: At 3 months, there were significant increases in practitioners' tobacco cessation activities, motivation and confidence in helping patients quit tobacco, and comfort with providing information and referrals for guideline-based tobacco cessation aids (p<0.0001). Practitioners significantly increased rates of discussing cessation medications with patients (AOR=3.76, 95% CI=1.84, 7.68), and routinely asking about tobacco use in clinical practice (AOR=2.62, 95% CI=1.11, 6.20). Increases occurred across all three practitioner types and were sustained at 12 months-despite heterogeneity in professional training, practice patterns/organization, and practice business models. CONCLUSIONS: Results suggest CAM practitioners are willing and able to offer BIs, and are an important, yet overlooked channel for promoting tobacco cessation and use of evidence-based cessation aids.",0,0,
1880,Tobacco dependence treatment guidelines,"Tobacco dependence causes every sixth death in the Czech Republic and is associated with diseases of the whole body. Treatment of tobacco dependence should be a standard part of clinical care to the extent of time available--from brief intervention at each clinical contact with patients up to intensive treatment. It includes psycho-socio-behavioural support and pharmacotherapy. It should apply to all professions in clinical medicine--as recommended by WHO mainly doctors, nurses, pharmacists and dentists, and should be covered within health care systems. Economically, it is one of the most cost-effective interventions in medicine. In our population over 15 years about 30% smokes (about 2.2 million people), diagnosis F17 relates to approximately 1.75 million people (about 80% of smokers).",0,0,
1881,Tobacco intervention practices of licensed psychologists,"Tobacco dependence is a serious public health concern. The U.S. Department of Health and Human Services has issued a practice guideline of best practices to encourage all health care providers to intervene with tobacco-dependent individuals they encounter. Psychologists may be ideally suited to implement brief tobacco interventions due to their expertise in behavior change strategies and interpersonal counseling skills. This study sought to investigate current tobacco assessment and intervention practices and perceptions of responsibility for tobacco intervention among a regional sample of licensed, practicing psychologists. Results suggest that a majority of psychologists fall far short of the ideal best practices recommended in the practice guideline, and many are unaware of the availability of the guidelines. Further, psychologists in this study perceived tobacco intervention to be a greater responsibility of physicians and other health care providers than of psychologists and other mental health professionals.",0,0,
1882,Tobacco smoking in individuals with attention-deficit hyperactivity disorder: epidemiology and pharmacological approaches to cessation,"The co-occurrence of attention-deficit hyperactivity disorder (ADHD) and nicotine dependence is common. Individuals with ADHD are more likely to initiate smoking and become dependent on nicotine than their non-ADHD counterparts, and recent evidence suggests that they may have more difficulty quitting smoking. Little is known about how to best approach treating these co-morbidities to optimize clinical outcome. Clinicians treating individuals with either ADHD or nicotine dependence should be aware of their common co-occurrence and the need to address both in treatment. This review of ADHD and nicotine dependence provides an overview of relevant epidemiology, bidirectional interactions and implications for pharmacological and adjunctive psychosocial treatment. Incorporating the current evidence base and their clinical experience, the authors propose a stepwise approach to treating patients with co-morbid ADHD and nicotine dependence. Given the potential for ADHD symptoms to interfere with smoking cessation success, the first priority is to stabilize ADHD. The first-line pharmacological approach should be a long-acting psychostimulant. Upon ADHD stabilization, motivational techniques should be used to encourage readiness for a smoking cessation attempt. In the context of behavioural cessation interventions sensitive to the patient's needs and developmental stage, pharmacological intervention targeting smoking cessation may be initiated. The authors recommend varenicline as a first-line agent, given its superior effect size among available medication treatments. Symptoms of ADHD, as well as nicotine withdrawal and craving symptoms, should be monitored closely during the cessation attempt, and adjustments to therapy should be considered if warranted. The authors conclude that, while current treatments may potentially be effective for co-morbid ADHD and nicotine dependence, further research is needed to parse the complex associations between these disorders and prospectively study combined treatments.",0,0,
1883,Tobacco-nicotine education and training for health-care professional students and practitioners: a systematic review,"Introduction: The objective of this systematic review was to investigate what education and training characteristics prepares and supports health-care professionals (HCPs) in the delivery of competent and effective care to clients who use tobacco-nicotine. Methods: A search of eight bibliographic databases for English-language peer-reviewed publications from January 2006 to March 2015. Studies were included if they met the a priori inclusion criteria, which consisted of: 1) quantitative study design, and 2) focus on tobacco-nicotine education or training for HCP students and practitioners. All studies were independently screened for inclusion by two reviewers. Data from included studies were extracted for study characteristics and key outcomes then critically appraised for methodological quality. Results: 59 studies were included for narrative synthesis. Two categories emerged: 1) curriculum characteristics (n=10), and 2) education and training interventions (n=49). Included curriculum studies identified the following themes: content, intensity, competencies evaluation, and barriers. Study findings about education and training interventions were grouped by level of education (pre-licensure, post-licensure, and faculty training), teaching modality, health discipline, and the associated HCP and client outcomes. Conclusion: This comprehensive review suggests that there is a lack of consistency in HCP tobacco-nicotine education and training characteristics. This paper provides valuable categorization of the most frequently utilized components of academic curriculum, and discusses the interventions in relation to HCP and client outcomes. Gaps in the literature are highlighted and the need for standardization of tobacco-nicotine training competencies and evaluation is discussed. Future research investigating the most effective approaches to training is needed. Trial Registration: PROSPERO - protocol number: CRD42015019219 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015019219. IMPLICATIONS: This systematic review summarizes existing tobacco-related curriculum components (content, intensity, competency evaluation, barriers) and training interventions for health-care professionals worldwide and demonstrates that they are associated with positive health-care professional outcomes (knowledge, attitudes, behaviours, skills) and client outcomes (quit attempts and smoking abstinence).",0,0,
1884,Tools for implementing an evidence-based approach in public health practice,"Increasing disease rates, limited funding, and the ever-growing scientific basis for intervention demand the use of proven strategies to improve population health. Public health practitioners must be ready to implement an evidence-based approach in their work to meet health goals and sustain necessary resources. We researched easily accessible and time-efficient tools for implementing an evidence-based public health (EBPH) approach to improve population health. Several tools have been developed to meet EBPH needs, including free online resources in the following topic areas: training and planning tools, US health surveillance, policy tracking and surveillance, systematic reviews and evidence-based guidelines, economic evaluation, and gray literature. Key elements of EBPH are engaging the community in assessment and decision making""; using data and information systems systematically; making decisions on the basis of the best available peer-reviewed evidence (both quantitative and qualitative); applying program-planning frameworks (often based in health-behavior theory); conducting sound evaluation;"" and disseminating what is learned.",0,0,
1885,Topical intranasal corticosteroids in 4-11 year old children with persistent bilateral otitis media with effusion in primary care: double blind randomised placebo controlled trial,"OBJECTIVE To determine the clinical effectiveness of topical intranasal corticosteroids in children with bilateral otitis media with effusion. DESIGN Double blind randomised placebo controlled trial. SETTING 76 Medical Research Council General Practice Research Framework practices throughout the United Kingdom, between 2004 and 2007. PARTICIPANTS 217 children aged 4-11 years who had at least one practice recorded episode of otitis media or a related ear problem in the previous 12 months, and with bilateral otitis media with effusion confirmed by a research nurse using otoscopy plus micro-tympanometry (B/B or B/C2, modified Jerger types). INTERVENTION Mometasone furoate 50 microg or placebo spray given once daily into each nostril for three months. MAIN OUTCOME MEASURES Proportions of children cured of bilateral otitis media with effusion assessed with tympanometry (C1 or A type) at one month (primary end point), three months, and nine months""; adverse events; three month diary symptoms. Results 41% (39/96) of the topical steroid group and 45% (44/98) of the placebo group were cured in one or both ears at one month (difference favouring placebo 4.3% (95% confidence interval -9.3% to 18.1%). Poisson regression was done with adjustment for four pre-specified covariates (clinical severity, P=0.003; atopy, P=0.67; age, P=0.92; season, P=0.71). The adjusted relative risk at one month was 0.97 (95% confidence interval 0.74 to 1.26). At three months, 58% of the topical steroid group and 52% of the placebo group were cured (relative risk 1.23, 0.84 to 1.80). Diary symptoms did not differ between the two groups, and no significant harms were reported. CONCLUSIONS Topical steroids are unlikely to be an effective treatment for otitis media with effusion in general practice. High rates of natural resolution occurred by 1-3 months. TRIAL REGISTRATION Current Controlled Trials ISRCTN38988331; National Research Register NO575123823;"" MREC 03/11/073.",0,0,
1886,Tough-talking journal editor faces accusations of leniency,,0,0,
1887,Toward criteria for pragmatic measurement in implementation research and practice: a stakeholder-driven approach using concept mapping,"Background Advancing implementation research and practice requires valid and reliable measures of implementation determinants, mechanisms, processes, strategies, and outcomes. However, researchers and implementation stakeholders are unlikely to use measures if they are not also pragmatic. The purpose of this study was to establish a stakeholder-driven conceptualization of the domains that comprise the pragmatic measure construct. It built upon a systematic review of the literature and semi-structured stakeholder interviews that generated 47 criteria for pragmatic measures, and aimed to further refine that set of criteria by identifying conceptually distinct categories of the pragmatic measure construct and providing quantitative ratings of the criteria¡¯s clarity and importance.  Methods Twenty-four stakeholders with expertise in implementation practice completed a concept mapping activity wherein they organized the initial list of 47 criteria into conceptually distinct categories and rated their clarity and importance. Multidimensional scaling, hierarchical cluster analysis, and descriptive statistics were used to analyze the data.  Findings The 47 criteria were meaningfully grouped into four distinct categories: (1) acceptable, (2) compatible, (3) easy, and (4) useful. Average ratings of clarity and importance at the category and individual criteria level will be presented.  Conclusions This study advances the field of implementation science and practice by providing clear and conceptually distinct domains of the pragmatic measure construct. Next steps will include a Delphi process to develop consensus on the most important criteria and the development of quantifiable pragmatic rating criteria that can be used to assess measures.",0,0,
1888,Toward Evidence-Based Medical Statistics. 1: The P Value Fallacy,"An important problem exists in the interpretation of modern medical research data: Biological understanding and previous research play little formal role in the interpretation of quantitative results. This phenomenon is manifest in the discussion sections of research articles and ultimately can affect the reliability of conclusions. The standard statistical approach has created this situation by promoting the illusion that conclusions can be produced with certain “error rates,” without consideration of information from outside the experiment. This statistical approach, the key components of which are P values and hypothesis tests, is widely perceived as a mathematically coherent approach to inference. There is little appreciation in the medical community that the methodology is an amalgam of incompatible elements, whose utility for scientific inference has been the subject of intense debate among statisticians for almost 70 years. This article introduces some of the key elements of that debate and traces the appeal and adverse impact of this methodology to the P value fallacy, the mistaken idea that a single number can capture both the long-run outcomes of an experiment and the evidential meaning of a single result. This argument is made as a prelude to the suggestion that another measure of evidence should be used—the Bayes factor, which properly separates issues of long-run behavior from evidential strength and allows the integration of background knowledge with statistical findings.",0,0,
1889,"Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies","Background A wide range of diverse and inconsistent terminology exists in the field of knowledge translation. This limits the conduct of evidence syntheses, impedes communication and collaboration, and undermines knowledge translation of research findings in diverse settings. Improving uniformity of terminology could help address these challenges. In 2012, we convened an international working group to explore the idea of developing a common terminology and an overarching framework for knowledge translation interventions.  Findings Methods included identifying and summarizing existing frameworks, mapping together a subset of those frameworks, and convening a multi-disciplinary group to begin working toward consensus. The group considered four potential approaches to creating a simplified framework: melding existing taxonomies, creating a framework of intervention mechanisms rather than intervention strategies, using a consensus process to expand one of the existing models/frameworks used by the group, or developing a new consensus framework.  Conclusions The work group elected to draft a new, simplified consensus framework of interventions to promote and integrate evidence into health practices, systems and policies. The framework will include four key components: strategies and techniques (active ingredients), how they function (causal mechanisms), how they are delivered (mode of delivery), and what they aim to change (intended targets). The draft framework needs to be further developed by feedback and consultation with the research community and tested for usefulness through application and evaluation.",0,0,
1890,Toxic hepatis during ketoconazole treatment,,0,0,
1891,Tracheostomy and weaning,"No hypothesis relating to respiratory care in the intensive care unit has proved more difficult to study in an objective fashion than the commonly held belief that tracheostomy hastens weaning from ventilatory support. Tracheostomy might facilitate weaning by reducing dead space and decreasing airway resistance, by improving secretion clearance, by reducing the need for sedation, and by decreasing the risk of aspiration. Available evidence indicates that dead space and airway resistance are in fact reduced, although whether the magnitude of these reductions explains the clinical observation of more rapid weaning after tracheotomy is less certain. Most of the data on this subject come from laboratory experiments and short-term physiologic studies on clinically stable patients, and the available evidence from clinical trials with weaning as a primary end point is scant. One large multicenter trial showed no advantage to early tracheotomy but demonstrated how difficult it is to get clinicians to manage their patients with regimens that go against their strongly held opinions. The most recent clinical trial found that percutaneous dilational tracheotomy performed in the first 2 days in patients projected to need > 14 days of ventilatory support greatly reduced ventilator and intensive care unit days, and decreased both the incidence of pneumonia and overall mortality, in comparison with tracheostomy done after day 14. Conducting such trials is difficult because of investigator and clinician bias, the inability to predict which patients will actually require prolonged mechanical ventilation, and several other factors discussed in this article. Tracheotomy probably does aid in liberating some patients from ventilatory support, but this may be as much from its effect on clinician behavior as from any physiologic impact.",0,0,
1892,Tracing the foundations of a conceptual framework for a patient safety ontology,"Background In work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that there was a need to try to understand how the meaning of patient safety and underlying concepts relate to the existing safety and quality frameworks commonly used in healthcare.  Objectives To unfold the concept of patient safety and how it relates to safety and quality frameworks commonly used in healthcare and to trace the evolution of the ICPS framework as a basis of the electronic capture of the component elements of patient safety.  Conclusion The ICPS conceptual framework for patient safety has its origins in existing frameworks and an international consultation process. Although its 10 classes and their semantic relationships may be used as a reference model for different disciplines, it must remain dynamic in the ever-changing world of healthcare. By expanding the ICPS by examining data from all available sources, and ensuring rigorous compliance with the latest principles of informatics, a deeper interdisciplinary approach will progressively be developed to address the complex, refractory problem of reducing healthcare-associated harm.",0,0,
1893,Training for general practitioners in opioid prescribing for chronic pain based on practice guidelines: a randomized pilot and feasibility trial,"UNLABELLED: This study is a pilot and feasibility study that compares 2 training experiences to improve appropriate opioid prescribing for chronic pain. Both training conditions included education in relation to opioid guidelines. Following education, 1 condition included training aimed at improving psychological flexibility and the other included training in practical knowledge and skills related to pain management. Eighty-one general practitioners (GPs) took part in the study, each having been randomly assigned to 1 of the training conditions. It proved easy to recruit GPs to the training. Overall, GPs demonstrated increased knowledge of opioid prescribing for chronic pain and decreases in concerns related to prescribing following training. However, there were no changes observed in reported prescribing practices or in secondary measures of well-being. There were also no significant differences between the training conditions, other than a greater increase in intention to use prescribing guidelines in the psychological flexibility condition. Feasibility and acceptability of the training methods were generally rated high. The psychological flexibility condition was rated higher than the comparison condition in terms of interest and satisfaction. Finally, processes of psychological flexibility before and after training significantly correlated with measures of GP well-being, providing partial support for the relevance of these processes as a focus in GP training. PERSPECTIVE: A training intervention for GPs including education on opioid guidelines for chronic pain and psychological flexibility training increased knowledge of prescribing and reduced concerns but did not change prescribing behavior or well-being. The training was highly acceptable to GPs but may have been too short to produce other effects.",0,0,
1894,Training in internal fixation of fractures,,0,0,
1895,"Training Physicians to Provide High-Value, Cost-Conscious Care","Importance  Increasing health care expenditures are taxing the sustainability of the health care system. Physicians should be prepared to deliver high-value, cost-conscious care.  Objective  To understand the circumstances in which the delivery of high-value, cost-conscious care is learned, with a goal of informing development of effective educational interventions.  Data Sources  PubMed, EMBASE, ERIC, and Cochrane databases were searched from inception until September 5, 2015, to identify learners and cost-related topics.  Study Selection  Studies were included on the basis of topic relevance, implementation of intervention, evaluation of intervention, educational components in intervention, and appropriate target group. There was no restriction on study design.  Data Extraction and Synthesis  Data extraction was guided by a merged and modified version of a Best Evidence in Medical Education abstraction form and a Cochrane data coding sheet. Articles were analyzed using the realist review method, a narrative review technique that focuses on understanding the underlying mechanisms in interventions. Recurrent patterns were identified in the data through thematic analyses. Resulting themes were discussed within the research team until consensus was reached.  Main Outcomes and Measures  Main outcomes were factors that promote education in delivering high-value, cost-conscious care.  Findings  The initial search identified 2650 articles""; 79 met the inclusion criteria, of which 14 were randomized clinical trials. The majority of the studies were conducted in North America (78.5%) using a pre-post interventional design (58.2%; at least 1619 participants); they focused on practicing physicians (36.7%; at least 3448 participants), resident physicians (6.3%; n?=?516), and medical students (15.2%; n?=?275). Among the 14 randomized clinical trials, 12 addressed knowledge transmission, 7 reflective practice, and 1 supportive environment; 10 (71%) concluded that the intervention was effective. The data analysis suggested that 3 factors aid successful learning: (1) effective transmission of knowledge, related, for example, to general health economics and prices of health services, to scientific evidence regarding guidelines and the benefits and harms of health care, and to patient preferences and personal values (67 articles); (2) facilitation of reflective practice, such as providing feedback or asking reflective questions regarding decisions related to laboratory ordering or prescribing to give trainees insight into their past and current behavior (56 articles);"" and (3) creation of a supportive environment in which the organization of the health care system, the presence of role models of delivering high-value, cost-conscious care, and a culture of high-value, cost-conscious care reinforce the desired training goals (27 articles).  Conclusions and Relevance  Research on educating physicians to deliver high-value, cost-conscious care suggests that learning by practicing physicians, resident physicians, and medical students is promoted by combining specific knowledge transmission, reflective practice, and a supportive environment. These factors should be considered when educational interventions are being developed.",0,0,
1896,"Training Physicians to Provide High-Value, Cost-Conscious Care: A Systematic Review","IMPORTANCE: Increasing health care expenditures are taxing the sustainability of the health care system. Physicians should be prepared to deliver high-value, cost-conscious care. OBJECTIVE: To understand the circumstances in which the delivery of high-value, cost-conscious care is learned, with a goal of informing development of effective educational interventions. DATA SOURCES: PubMed, EMBASE, ERIC, and Cochrane databases were searched from inception until September 5, 2015, to identify learners and cost-related topics. STUDY SELECTION: Studies were included on the basis of topic relevance, implementation of intervention, evaluation of intervention, educational components in intervention, and appropriate target group. There was no restriction on study design. DATA EXTRACTION AND SYNTHESIS: Data extraction was guided by a merged and modified version of a Best Evidence in Medical Education abstraction form and a Cochrane data coding sheet. Articles were analyzed using the realist review method, a narrative review technique that focuses on understanding the underlying mechanisms in interventions. Recurrent patterns were identified in the data through thematic analyses. Resulting themes were discussed within the research team until consensus was reached. MAIN OUTCOMES AND MEASURES: Main outcomes were factors that promote education in delivering high-value, cost-conscious care. FINDINGS: The initial search identified 2650 articles""; 79 met the inclusion criteria, of which 14 were randomized clinical trials. The majority of the studies were conducted in North America (78.5%) using a pre-post interventional design (58.2%; at least 1619 participants); they focused on practicing physicians (36.7%; at least 3448 participants), resident physicians (6.3%; n = 516), and medical students (15.2%; n = 275). Among the 14 randomized clinical trials, 12 addressed knowledge transmission, 7 reflective practice, and 1 supportive environment; 10 (71%) concluded that the intervention was effective. The data analysis suggested that 3 factors aid successful learning: (1) effective transmission of knowledge, related, for example, to general health economics and prices of health services, to scientific evidence regarding guidelines and the benefits and harms of health care, and to patient preferences and personal values (67 articles); (2) facilitation of reflective practice, such as providing feedback or asking reflective questions regarding decisions related to laboratory ordering or prescribing to give trainees insight into their past and current behavior (56 articles);"" and (3) creation of a supportive environment in which the organization of the health care system, the presence of role models of delivering high-value, cost-conscious care, and a culture of high-value, cost-conscious care reinforce the desired training goals (27 articles). CONCLUSIONS AND RELEVANCE: Research on educating physicians to deliver high-value, cost-conscious care suggests that learning by practicing physicians, resident physicians, and medical students is promoted by combining specific knowledge transmission, reflective practice, and a supportive environment. These factors should be considered when educational interventions are being developed.",0,0,
1897,Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial,"OBJECTIVES To evaluate the effect of training primary care health professionals in behaviour change counselling on the proportion of patients self reporting change in four risk behaviours (smoking, alcohol use, exercise, and healthy eating). DESIGN Cluster randomised trial with general practices as the unit of randomisation. SETTING General practices in Wales. PARTICIPANTS 53 general practitioners and practice nurses from 27 general practices (one each at all but one practice) recruited 1827 patients who screened positive for at least one risky behaviour. INTERVENTION Behaviour change counselling was developed from motivational interviewing to enable clinicians to enhance patients' motivation to change health related behaviour. Clinicians were trained using a blended learning programme called Talking Lifestyles. MAIN OUTCOME MEASURES Proportion of patients who reported making beneficial changes in at least one of the four risky behaviours at three months. RESULTS 1308 patients from 13 intervention and 1496 from 14 control practices were approached: 76% and 72% respectively agreed to participate, with 831 (84%) and 996 (92%) respectively screening eligible for an intervention. There was no effect on the primary outcome (beneficial change in behaviour) at three months (362 (44%) v 404 (41%), odds ratio 1.12 (95% CI 0.90 to 1.39)) or on biochemical or biometric measures at 12 months. More patients who had consulted with trained clinicians recalled consultation discussion about a health behaviour (724/795 (91%) v 531/966 (55%), odds ratio 12.44 (5.85 to 26.46)) and intended to change (599/831 (72%) v 491/996 (49%), odds ratio 2.88 (2.05 to 4.05)). More intervention practice patients reported making an attempt to change (328 (39%) v 317 (32%), odds ratio 1.40 (1.15 to 1.70)), a sustained behaviour change at three months (288 (35%) v 280 (28%), odds ratio 1.36 (1.11 to 1.65)), and reported slightly greater improvements in healthy eating at three and 12 months, plus improved activity at 12 months. Training cost £1597 per practice. DISCUSSION Training primary care clinicians in behaviour change counselling using a brief blended learning programme did not increase patients reported beneficial behaviour change at three months or improve biometric and a biochemical measure at 12 months, but it did increase patients' recollection of discussing behaviour change with their clinicians, intentions to change, attempts to change, and perceptions of having made a lasting change at three months. Enduring behaviour change and improvements in biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling without additional intervention. TRIAL REGISTRATION ISRCTN 22495456.",0,0,
1898,Transforming assertive community treatment into an integrated care system: the role of nursing and primary care partnerships,"Despite the high rate of co-occurring medical conditions experienced by individuals receiving assertive community treatment (ACT), this comprehensive service model continues to be considered primarily a mental health intervention. Without compromising fidelity to the model, ACT can serve as an ideal platform from which to provide both primary and behavioral health care to those with complex service needs. Using a case example, this article considers the transformation of the ACT mental health care model into an integrated health care delivery system through establishing nursing and primary care partnerships. Specifically, by expanding and explicitly redefining the role of the ACT nurse, well-developed care models, such as Guided Care, can provide additional guidelines and training to ACT nurses who are uniquely trained and oriented to serve as the leader and coordinator of health integration efforts.",0,0,
1899,Transfusion Medicine,"The evolution of transfusion medicine into a clinically oriented discipline emphasising patient care has been accompanied by challenges that need to be faced as specialists look to the future. Emerging issues that affect blood safety and blood supply, such as pathogen inactivation and more stringent donor screening questions, bring new pressures on the availability of an affordable blood supply. Imminent alternatives for management of anaemia, such as oxygen carriers, hold great promise but, if available, will require close oversight. With current estimates of HIV or hepatitis C viral (HCV) transmission approaching one in 2 000 000 units transfused, keeping to a minimum bacterial contamination of platelet products (one in 2000) and errors in transfusion, with its estimated one in 800 000 mortality rate, assume great urgency. Finally, serious difficulties in blood safety and availability for poor, developing countries require innovative strategies and commitment of resources.",0,0,
1900,Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions,"Clinical prediction rules, sometimes called clinical decision rules, have proliferated in recent years. However, very few have undergone formal impact analysis, the standard of evidence to assess their impact on patient care. Without impact analysis, clinicians cannot know whether using a prediction rule will be beneficial or harmful. This paper reviews standards of evidence for developing and evaluating prediction rules""; important differences between prediction rules and decision rules; how to assess the potential clinical impact of a prediction rule before translating it into a decision rule; methodologic issues critical to successful impact analysis, including defining outcome measures and estimating sample size; the importance of close collaboration between clinical investigators and practicing clinicians before, during, and after impact analysis;"" and the need to measure both efficacy and effectiveness when analyzing a decision rule's clinical impact. These considerations should inform future development, evaluation, and use of all clinical prediction or decision rules.",0,1,
1901,Translating evidence-based falls prevention into clinical practice in nursing facilities: Results and lessons from a quality improvement collaborative,"OBJECTIVES: To describe the changes in process of care before and after an evidence-based fall reduction quality improvement collaborative in nursing facilities. DESIGN: Natural experiment with nonparticipating facilities serving as controls. SETTING: Community nursing homes. PARTICIPANTS: Thirty-six participating and 353 nonparticipating nursing facilities in North Carolina. INTERVENTION: Two in-person learning sessions, monthly teleconferences, and an e-mail discussion list over 9 months. The change package emphasized screening, labeling, and risk-factor reduction. MEASUREMENTS: Compliance was measured using facility self-report and chart abstraction (n = 832) before and after the intervention. Fall rates as measured using the Minimum Data Set (MDS) were compared with those of nonparticipating facilities as an exploratory outcome. RESULTS: Self-reported compliance with screening, labeling, and risk-factor reduction approached 100%. Chart abstraction revealed only modest improvements in screening (51% to 68%, P < .05), risk-factor reduction (4% to 7%, P = .30), and medication assessment (2% to 6%, P = .34). There was a significant increase in vitamin D prescriptions (40% to 48%, P=.03) and decrease in sedative-hypnotics (19% to 12%, P = .04) but no change in benzodiazepine, neuroleptic, or calcium use. No significant changes in proportions of fallers or fall rates were observed according to chart abstraction (28.6% to 37.5%, P = .17), MDS (18.2% to 15.4%, P = .56), or self-report (6.1-5.6 falls/1,000 bed days, P = .31). CONCLUSION: Multiple-risk-factor reduction tasks are infrequently implemented, whereas screening tasks appear more easily modifiable in a real-world setting. Substantial differences between self-reported practice and medical record documentation require that additional data sources be used to assess the change-in-care processes resulting from quality improvement programs. Interventions to improve interdisciplinary collaboration need to be developed.",0,0,
1902,Translating guidelines to practice: findings from a multidisciplinary preventive cardiology programme in the west of Ireland,"AIMS: The aim of this observational, descriptive study is to evaluate the impact of an intensive, evidence-based preventive cardiology programme on medical and lifestyle risk factors in patients at high risk of developing cardiovascular disease (CVD). METHODS: Increased CVD risk patients and their family members/partners were invited to attend a 16-week programme consisting of a professional multidisciplinary lifestyle intervention, with appropriate risk factor and therapeutic management in a community setting. Smoking, dietary habits, physical activity levels, waist circumference and body mass index, and medical risk factors were measured at initial assessment, at end of programme, and at 1-year follow up. RESULTS: Adherence to the programme was high, with 375 (87.2%) participants and 181 (84.6%) partners having completed the programme, with 1-year data being obtained from 235 (93.6%) patients and 107 (90.7%) partners. There were statistically significant improvements in both lifestyle (body mass index, waist circumference, physical activity, Mediterranean diet score, fish, fruit, and vegetable consumption, smoking cessation rates), psychosocial (anxiety and depression scales and quality of life indices), and medical risk factors (blood pressure, lipid and glycaemic targets) between baseline and end of programme, with these improvements being sustained at 1-year follow up. CONCLUSIONS: These findings demonstrate how a holistic model of CVD prevention can improve cardiovascular risk factors by achieving healthier lifestyles and optimal medical management.",0,0,
1903,Translation of alcohol screening and brief intervention guidelines to pediatric trauma centers,"BACKGROUND: As part of the American College of Surgeons verification to be a Level 1 trauma center, centers are required to have the capacity to identify trauma patients with risky alcohol use and provide an intervention. Despite supporting scientific evidence and national policy statements encouraging alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT), barriers still exist, which prevent the integration of SBIRT into clinical care. Study objectives of this multisite translational research study were to identify best practices for integrating SBIRT services into routine care for pediatric trauma patients, to measure changes in practice with adoption and implementation of a SBIRT policy, and to define barriers and opportunities for adoption and implementation of SBIRT services at pediatric trauma centers. METHODS: This translational research study was conducted at seven US pediatric trauma centers during a 3-year period. Changes in SBIRT practice were measured through self-report and medical record review at three different study phases, namely, adoption, implementation, and maintenance phases. RESULTS: According to medical record review, at baseline, 11% of eligible patients were screened and received a brief intervention (if necessary) across all sites. After completion of the SBIRT technical assistance activities, all seven participating trauma centers had effectively developed, adopted, and implemented SBIRT policies for injured adolescent inpatients. Furthermore, across all sites, 73% of eligible patients received SBIRT services after both the implementation and maintenance phases. Opportunities and barriers for successful integration were identified. CONCLUSION: This model may serve as method for translating SBIRT services into practice within pediatric trauma centers.",0,0,
1904,Translation of appropriateness criteria into practice guidelines: application of decision table techniques to the RAND criteria for coronary artery bypass graft.,"The process of creating clinical practice guidelines from collected evidence has not been well defined. We have developed a technique for translation of a comprehensive set of appropriateness criteria into a usable set of practice guidelines. The criteria are derived from a formal consensus process conducted by RAND and relate to indications for coronary artery bypass graft in acute myocardial infarction. The clinical indications defined by the expert panel are entered as conditions in a decision table. For each combination of relevant clinical findings, the recommended action is defined from the median ranking of the Rand panel. The fully constructed table is next compacted by conventional decision table techniques and sorted to facilitate parsing the knowledge. Ultimately, 8 narrative statements are derived from 51 rules. Augmented decision tables permit display of detailed data in the summary table and its access on an as-needed basis.",0,1,
1905,Translation of obesity practice guidelines: interprofessional perspectives regarding the impact of public health nurse system-level intervention,"OBJECTIVE: The purpose of the study was to investigate the perceptions of administrators and clinicians regarding a public health facilitated collaborative supporting the translation into practice of the Institute for Clinical Systems Improvement (ICSI) Adult Obesity Guideline. DESIGN AND SAMPLE: This qualitative study was conducted with 10 health care organizations participating in a voluntary, interprofessional obesity management collaborative. A purposive sample of 39 participants included two to three clinicians and an administrator from each organization. Interview analysis focused on how the intervention affected participants and their practices. RESULTS: Four themes described participant experiences of obesity guideline translation: (1) a shift from powerlessness to positive motivation, (2) heightened awareness coupled with improved capacity to respond, (3) personal ownership and use of creativity, and (4) a sense of the importance of increased interprofessional collaboration. CONCLUSIONS: The investigation of interprofessional perspectives illuminates the feelings and perceptions of clinician and administrator participants regarding obesity practice guideline translation. These themes suggest that positive motivation, improved capacity, personal creative ownership, and interprofessional collaboration may be conducive to successful evidence-based obesity guideline implementation. Further research is needed to evaluate these findings relative to translating the ICSI obesity guideline and other guidelines into practice in diverse clinical settings.",0,0,
1906,Translation of obesity practice guidelines: measurement and evaluation,"OBJECTIVE(S): A public health nurse (PHN) in the Midwestern United States (U.S.) led a collaborative system-level intervention to translate the Institute of Clinical Systems Improvement (ICSI) Adult Obesity Guideline into interprofessional practice. This study (1) evaluated the extent of guideline translation across organizations and (2) assessed the Omaha System as a method for translating system-level interventions and measuring outcomes. DESIGN AND SAMPLE: This retrospective, mixed methods study was conducted with a purposeful sample of one administrator (n = 10) and two to three clinicians (n = 29) from each organization (n = 10). MEASURES: Omaha System Problem Rating Scale for Outcomes Knowledge, Behavior, and Status (KBS). KBS ratings gathered from semi-structured interviews and Omaha System documentation were analyzed using standard descriptive and inferential statistics and triangulated findings with participant quotes. RESULTS: KBS ratings and participant quotes revealed intervention effectiveness in creating sustained system-level changes. Self-reported and observed KBS ratings demonstrated improvement across organizations. There was moderate to substantial agreement regarding benchmark attainment within organizations. On average, self-reported improvement exceeded observer improvement. CONCLUSIONS: System-level PHN practice facilitator interventions successfully translated clinical obesity guidelines into interprofessional use in health care organizations. The Omaha System Problem Rating Scale for Outcomes reliably measured system-level outcomes.",0,0,
1907,Trap of trends to statistical significance: likelihood of near significant P value becoming more significant with extra data,"When faced with a P value that has failed to reach some specific threshold (generally P<0.05), authors of scientific articles may imply a “trend towards statistical significance” or otherwise suggest that the failure to achieve statistical significance was due to insufficient data. This paper presents a quantitative analysis to show that such descriptions give a misleading impression and undermine the principle of accurate reporting. P values that fail to reach the conventional significance level of P≤0.05 are regularly reported as if they were moving in that direction. Phrases such as “almost/approaching statistical significance” or, most tellingly, a “trend towards” statistical significance continue to find their way into papers in journals with high impact factors.1 In this article, we examine the mathematical basis for this assumption and assess the extent to which a near significant P value may predict movement towards a future significant P value through the addition of extra data. We also explore the likelihood that extra data would actually result in a significant outcome and, lastly, the confidence one might have that a repeat experiment would independently give statistically significant results. The clearest context in which to consider the correct interpretation of a P value is within a randomised trial. Fisher described how the “simple precaution of randomisation will suffice to guarantee the validity of the test of significance.”2 Random allocation of participants to groups ensures that only the play of chance or a real effect of treatment can explain any difference seen in outcome between the groups. A P value tells us how far chance alone can explain the observed difference and acts as a “snapshot” measure of the strength of evidence at the end of the trial. As evidence accumulates, conclusions become more firmly based. A P value could easily be imagined as following …",0,0,
1908,Treating alcohol problems: making ends meet,,0,0,
1909,"Treating depression within the HIV ""medical home"": a guided algorithm for antidepressant management by HIV clinicians","People living with HIV/AIDS (PLWHA) suffer increased depression prevalence compared to the general population, which negatively impacts antiretroviral (ART) adherence and HIV-related outcomes leading to morbidity and mortality. Yet depression in this population often goes undiagnosed and untreated. The current project sought to design an evidence-based approach to integrate depression care in HIV clinics. The model chosen, measurement-based care (MBC), is based on existing guidelines and the largest randomized trial of depression treatment. MBC was adapted to clinical realities of HIV care for use in a randomized controlled effectiveness trial of depression management at three academic HIV clinics. The adaptation accounts for drug-drug interactions critical to ongoing ART effectiveness and can be delivered by a multidisciplinary team of nonmental health providers. A treatment algorithm was developed that enables clinically supervised, nonphysician depression care managers (DCMs) to track and monitor antidepressant tolerability and treatment response while supporting nonpsychiatric prescribers with antidepressant choice and dosing. Quality of care is ensured through weekly supervision of DCMs by psychiatrists. Key areas of flexibility that have been important in implementation have included flexibility in timing of assessments, accommodation of divergence between algorithm recommendations and provider decisions, and accommodation of delays in implementing treatment plans. This adaptation of the MBC model to HIV care has accounted for critical antidepressant-antiretroviral interactions and facilitated the provision of quality antidepressant management within the HIV medical home.",0,0,
1910,"Treating obesity with a novel hand-held device, computer software program, and Internet technology in primary care: the SMART motivational trial","OBJECTIVE: The purpose of this study was to evaluate the short-term motivational effect of a technology-based weight reduction program for obese adults. METHODS: One hundred and eleven obese (37.0+/-5.8 kg/m(2)) middle aged (45.5+/-10.8 years) adults (62% female) were randomly assigned to a usual care or experimental (SMART: self-monitoring and resting metabolic rate technology) group. The usual care group received a standard nutritional program in accordance to national guidelines. All participants received a comprehensive weight management program consisting of motivational interviewing (MI) sessions and automated e-mail behavioral newsletters. Bodyweight, arterial blood pressure, and psychobehavioral constructs were assessed over 12 weeks. RESULTS: Completer analysis (n=80) indicated a significant improvement in bodyweight (-3.9%), systolic arterial pressure (-4 mmHg), and all motivational constructs following the 12-week study (p<or=.05). However, there were no significant differences between groups at any time period. CONCLUSION: Based on these data, a 12-week comprehensive weight reduction program consisting of MI and automated e-mail behavioral newsletters with or without SMART is efficacious in treating obese adults. PRACTICE IMPLICATIONS: Although both treatment programs were equally effective, clinicians should consider a treatment program that meets the need of the patient. This study was registered at ClinicalTrials.gov NCT00750022.",0,0,
1911,Treatment and prophylaxis of recurrent urinary tract infections,"Recurrent urinary tract infections are typical diseases of sexually active young women. Only elder women show significant rates of underlying, mostly urological diseases. Besides behavioral changes long-term antimicrobial therapy is still the mainstay of both prophylaxis and therapy. This report provides information on the etiology for recurrent urinary tract infections. Strategies for prevention are illustrated. The actual significances of organic remedies and antibiotics respectively are discussed"";"" ineffective therapies are identified. Furthermore an outlook is given on promising novel therapeutics, i.e. vaccines which are already tested in clinical trials.",0,0,
1912,Treatment of anxiety disorders in primary care practice: a randomised controlled trial,"BACKGROUND: Anxiety disorders are prevalent in primary care. Psychological treatment is effective but time-consuming, and there are waiting lists for secondary care. Interest has therefore grown in developing guidelines for treatment that would be feasible in primary care. AIM: To compare the effectiveness and feasibility of guided self-help, the Anxiety Disorder Guidelines of the Netherlands College of General Practitioners and cognitive behavioural therapy (CBT). DESIGN OF STUDY: Randomised controlled study lasting 12 weeks with follow-up at 3 and 9 months for primary care patients with panic disorder and/or generalised anxiety disorder. SETTING: The first two forms of treatment were carried out by 46 GPs who were randomly assigned to one or the other form. CBT was carried out by cognitive behaviour therapists in a psychiatric outpatient clinic. METHOD: Participants (n = 154) were randomly assigned to one of the three forms of treatment. The main outcome measure used was the state subscale of the Spielberger Anxiety Inventory. RESULTS: All three forms of treatment gave significant improvement between pre-test and post-test, and this improvement remained stable between post-test and the follow-ups. The results obtained with the three treatment forms did not differ significantly over time. The feasibility of the Anxiety Disorder Guidelines was low compared with that of guided self-help. CONCLUSION: Our results indicate that primary care patients with prevalent anxiety disorders for whom the GP does not find referral necessary can be adequately treated by the GP. Psychiatric outpatient clinic referral does not give superior results. Guided self-help is easier for the GP to carry out than a less highly-structured treatment like that laid down in the Anxiety Disorder Guidelines.",0,0,
1913,Treatment of childhood memories: theory and practice,"With the growing interest of cognitive behaviour therapy in early developed psychopathology like personality disorders there is an increased need for therapeutic methods for more directly treating pathogenic schemas. Exploring and reinterpreting memories of early childhood experiences that are assumed to have contributed to the pathogenesis are more and more viewed as a promising way to modify core schemas. Experiential methods seem to be the most effective. This article discusses two main forms of these methods: (i) imagery with rescripting and (ii) role play, both of childhood interactions with key figures. For both, protocols are provided as guidelines for clinicians and to stimulate standardization so that this new field can be opened for experimental research. Theoretical views are discussed as to why these methods might be so effective in treating chronic problems that originated in childhood.",0,0,
1914,Treatment of common 'life event' traumas,"BACKGROUND: General practitioners are confronted daily with patients who have experienced distressing 'life events'. Assisting patients through this process can present a significant challenge. OBJECTIVE: This article points to the reactive symptomatology that may be overtly present or concealed in a stressful event and its aftermath reactions, sets the goal of restoring a person's functioning and their self resources, and gives guidelines of what counselling can do for a patient. DISCUSSION: People who are attempting to cope with a distressing 'life event' or the aftermath of a trauma can be effectively helped by early short term counselling. Although this task may not be one that appeals to the busy GP, many accessible interventions can restore a person's coping capacity and avoid the prospect of a continuing and deepening pathology. Many symptoms will not fit the diagnostic categories usually associated with stress disorders. Some may show impaired social engagement and social phobia"";"" others may describe low self worth, states of unwellness, relationship dissatisfaction and maladjustments in key areas of behaviour. The task is to help the person gain a different perspective on the distressing event, their own capacities and the supportive influences around them.",0,0,
1915,Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop,"Background: Myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS) is a debilitating multisystem condition affecting more than 1 million adults in the United States.  Purpose: To determine benefits and harms of treatments for adults with ME/CFS and identify future research needs.  Data Sources: MEDLINE, PsycINFO, and Cochrane databases (January 1988 to September 2014)""; clinical trial registries; reference lists; and manufacturer information.  Study Selection: English-language randomized trials of the effectiveness and adverse effects of ME/CFS treatments.  Data Extraction: Data on participants, study design, analysis, follow-up, and results were extracted and confirmed. Study quality was dual-rated by using prespecified criteria; discrepancies were resolved through consensus.  Data Synthesis: Among 35 treatment trials enrolling participants primarily meeting the 1994 Centers for Disease Control and Prevention and Oxford case definitions of CFS, the immune modulator rintatolimod improved some measures of exercise performance compared with placebo in 2 trials (low strength of evidence). Trials of galantamine, hydrocortisone, IgG, valganciclovir, isoprinosine, fluoxetine, and various complementary medicines were inconclusive (insufficient evidence). Counseling therapies and graded exercise therapy compared with no treatment, relaxation, or support improved fatigue, function, global improvement, and work impairment in some trials;"" counseling therapies also improved quality of life (low to moderate strength of evidence). Harms were rarely reported across studies (insufficient evidence).  Limitation: Trials were heterogeneous and were limited by size, number, duration, applicability, and methodological quality.  Conclusion: Trials of rintatolimod, counseling therapies, and graded exercise therapy suggest benefit for some patients meeting case definitions for CFS, whereas evidence for other treatments and harms is insufficient. More definitive studies comparing participants meeting different case definitions, including ME, and providing subgroup analysis are needed to fill research gaps.",0,0,
1916,Treatment of seasonal affective disorder,"Seasonal affective disorder (SAD), winter type, is characterized by the regular annual onset of major depressive episodes during fall or winter, followed by spontaneous remission and sometimes hypomanic or manic episodes during spring and summer. SAD is clinically important, since approximately 2-5% of the general population in temperate climates are affected. Since the first description of the syndrome, researchers have made attempts to elucidate the pathophysiological background of SAD. Bright light therapy has been proposed as the treatment of choice for this disorder. However, numerous studies have also investigated suitable psychopharmacological treatments for SAD. This report is aimed to provide an overview on the clinical management and current therapeutic options for SAD.",0,0,
1917,Treatment services for children with ADHD: a national perspective,"OBJECTIVE: To summarize knowledge on treatment services for children and adolescents with attention-deficit hyperactivity disorder (ADHD), trends in services from 1989 to 1996, types of services provided, service mix, and barriers to care. METHOD: A review of the literature and analyses from 2 national surveys of physician practices are presented. RESULTS: Major shifts have occurred in stimulant prescriptions since 1989, with prescriptions now comprising three fourths of all visits to physicians by children with ADHD. Between 1989 and 1996, related services, such as health counseling, for children with ADHD increased 10-fold, and diagnostic services increased 3-fold. Provision of psychotherapy, however, decreased from 40% of pediatric visits to only 25% in the same time frame. Follow-up care also decreased from more than 90% of visits to only 75%. Family practitioners were more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or recommend follow-up care. About 50% of children with identified ADHD seen in real-world practice settings receive care that corresponds to guidelines of the American Academy of Child and Adolescent Psychiatry. Physicians reported significant barriers to service provision for these children, including lack of pediatric specialists, insurance obstacles, and lengthy waiting lists. CONCLUSIONS: The trends in treatment services and physician variations in service delivery point to major gaps between the research base and clinical practice. Clinical variations may reflect training differences, unevenness in the availability of specialists and location of services, and changes in health care incentives.",0,0,
1918,Trends in the social control of medical and psychiatric research,,0,0,
1919,Triggering anti-smoking advice by GPs: mode of action of an intervention stimulating smoking cessation advice by GPs,"OBJECTIVE: To assess the mode of action of an intervention (GP desktop resource, GDR) that increased the frequency of general practitioner (GP) advice to stop smoking. METHODS: Analyses were undertaken to differentiate between three hypotheses regarding the mode of action of the GDR. That the GDR acts: (1) by altering GPs' attitudes, (2) independently of attitudes in prompting GPs to intervene with smokers or (3) by altering the relationship between attitudes and behaviour. RESULTS: The GDR was an independent predictor of the number of patients advised to stop smoking (beta = .345, p < .001). Concern about the doctor-patient relationship was the only attitude variable that independently predicted advice giving, in this case negatively (beta = -.465, p < .001). Possession of the GDR did not alter GPs' views on whether intervening with smokers harmed the doctor-patient relationship, but did weaken the relationship between this attitude item and the number of patients advised to stop smoking (beta = .595, p < .001 for the interaction). CONCLUSION: This study is the first to show that concern over the doctor-patient relationship was an independent predictor of advice giving while in other studies it has merely been noted as something that GPs express concern about. A simple device designed to trigger action on the part of GPs appeared to work by mitigating the negative effect of an attitudinal barrier to action. It would be interesting to explore this phenomenon more generally in relation to health promotion activities on the part of health professionals. PRACTICE IMPLICATIONS: Recommendations that GPs engage in health promotion activities with their patients need to consider that GPs' concerns over harming the doctor-patient relationship may deter them from making such interventions. The GDR appears to be effective in prompting GPs to advise their smoking patients to stop and its widespread distribution to GPs should be considered.",0,0,
1920,Tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer worldwide,"Multidisciplinary management tumor boards are now conducted worldwide for the management of patients with cancer. Studies evaluating their influence on decision making and patient outcome are limited"";"" however, single-center studies have reported significant changes in diagnosis and treatment plans. A survey from Arabic countries showed widespread use and reliance on tumor boards for decision making. A recent multi-institutional survey of veteran affairs (VA) hospitals in the United States found limited association between the presence of tumor boards and care and outcomes. The Cancer Care Outcomes Research and Surveillance Consortium looked at the association between tumor board features and measures of quality of care. Results of overall survival among the patients of these physicians participating in tumor boards is ongoing, but preliminary results are outlined along with a recent ASCO survey of international members on the presence, utilization, and influence of tumor boards in this article. Tumor boards allow for implementation of clinical practice guidelines and may help capture cases for clinical trials. Efforts to improve preparations, structure, and conduct of tumor boards, research methods to monitor their performance, teamwork, and outcomes are outlined also in this article. The concept of mini-tumor boards and more efficient methods for MDM in countries with limited resources are also discussed. In suboptimal settings, such as small community hospitals, rural areas, and areas with limited resources, boundaries in diagnosis and management can be overcome, or at least improved, with tumor boards, especially with the use of video-conferencing facilities. Studies from the United Kingdom showed that special training of multidisciplinary teams (MDT) led to better team dynamics and communication, improved patient satisfaction, and improved clinical outcome. The weight of the benefits versus the time and effort spent to improve efficiency, patient care, and better time management in the United States and in the international oncology community is also reviewed in this article.",0,0,
1921,Turning knowledge into action at the point-of-care: the collective experience of nurses facilitating the implementation of evidence-based practice,"BACKGROUND: Facilitation is considered a way of enabling clinicians to implement evidence into practice by problem solving and providing support. Practice development is a well-established movement in the United Kingdom that incorporates the use of facilitators, but in Canada, the role is more obtuse. Few investigations have observed the process of facilitation as described by individuals experienced in guideline implementation in North America. AIM: To describe the tacit knowledge regarding facilitation embedded in the experiences of nurses implementing evidence into practice. METHODS: Twenty nurses from across Canada were purposively selected to attend an interactive knowledge translation symposium to examine what has worked and what has not in implementing evidence in practice. This study is an additional in-depth analysis of data collected at the symposium that focuses on facilitation as an intervention to enhance evidence uptake. Critical incident technique was used to elicit examples to examine the nurses' facilitation experiences. Participants shared their experiences with one another and completed initial data analysis and coding collaboratively. The data were further thematically analyzed using the qualitative inductive approach of constant comparison. RESULTS: A number of factors emerged at various levels associated with the successes and failures of participants' efforts to facilitate evidence-based practice. Successful implementation related to: (a) focus on a priority issue, (b) relevant evidence, (c) development of strategic partnerships, (d) the use of multiple strategies to effect change, and (e) facilitator characteristics and approach. Negative factors influencing the process were: (a) poor engagement or ownership, (b) resource deficits, (c) conflict, (d) contextual issues, and (e) lack of evaluation and sustainability. CONCLUSIONS: Factors at the individual, environmental, organizational, and cultural level influence facilitation of evidence-based practice in real situations at the point-of-care. With a greater understanding of factors contributing to successful or unsuccessful facilitation, future research should focus on analyzing facilitation interventions tailored to address barriers and enhance facilitators of evidence uptake.",0,0,
1922,Two cheers or three for treatment guidelines? Nudging prescribers in right directions,,0,1,
1923,Type 2 diabetes mellitus in youth,"In the United States, the incidence of type 2 diabetes mellitus (DM) in children and adolescents has been increasing at an alarming rate. Early recognition and intervention can delay the onset of type 2 DM and prevent the long-term complications. School nurses have an essential role in implementing the American Diabetes Association (ADA) recommended screening guidelines to identify youth at high risk for type 2 DM and in implementing student health programs that focus positively on the importance of physical activity and healthy eating habits. The purpose of this article is to present an overview of the epidemiology, pathophysiology, complications, diagnosis, and treatment, as well as the recommended screening guidelines for type 2 DM in the pediatric age group. The information provided will enhance awareness, promote screening, and empower the school nurse to more effectively promote healthy lifestyle education.",0,0,
1924,Undergraduate medical education: present state and future needs,,0,0,
1925,Understanding and preventing criminal recidivism among adults with psychotic disorders,"The high prevalence of adults with psychotic disorders in the criminal justice system has received much attention recently, but our understanding of this problem is marked by diverging opinions. Mental health professionals point to deinstitutionalization and our fragmented mental health system as primary causes. Criminologists minimize the role of mental illness and contend that persons with and without mental illness are arrested for the same reasons. Meanwhile, practice guidelines offer little guidance to clinicians about how to address the problem. Drawing upon contemporary crime prevention principles as well as current knowledge of psychotic disorders and their treatment, this article presents a conceptual framework for understanding and preventing criminal recidivism. The framework highlights the importance of individual and service-system risk variables and emphasizes the central role of treatment nonadherence as a mediator between modifiable risk variables and recidivism. On the basis of the conceptual framework described in this article, three necessary elements of intervention are presented for preventing recidivism among adults with psychotic disorders: competent care, access to services, and legal leverage. Research is needed to further define and test these intervention elements as foundations for future service delivery efforts.",0,0,
1926,Understanding and promoting smoking cessation: overview and guidelines for physician intervention,"This chapter outlines requirements for quitting smoking successfully, and for effective treatments. It presents practical guidelines for physicians and allied health care providers with specific recommendations for how to motivate and help patients quit ""on their own"" and how to select more intensive backup treatment if needed. Useful guides, references, and resources are suggested, with recommendations concerning optimal use of nicotine chewing gum.",0,0,
1927,Understanding diagnosis and management of dementia and guideline implementation in general practice: a qualitative study using the theoretical domains framework,"BACKGROUND: Dementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia""; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs' reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines. METHODS: Semi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale. RESULTS: A total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of 'Beliefs about consequences'); discomfort in using validated tools ('Emotion'), possibly due to limited training and confidence ('Skills'; 'Beliefs about capabilities'); limited awareness of the need for, and forgetting to conduct, a depression assessment ('Knowledge'; 'Memory, attention and decision processes'). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment ('Knowledge'); possessing the necessary skills and confidence ('Skills'; 'Beliefs about capabilities');"" and having adequate time and resources ('Environmental context and resources'). CONCLUSIONS: This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs' uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.",0,0,
1928,Understanding how appraisal of doctors produces its effects: a realist review protocol,"INTRODUCTION: UK doctors are now required to participate in revalidation to maintain their licence to practise. Appraisal is a fundamental component of revalidation. However, objective evidence of appraisal changing doctors' behaviour and directly resulting in improved patient care is limited. In particular, it is not clear how the process of appraisal is supposed to change doctors' behaviour and improve clinical performance. The aim of this research is to understand how and why appraisal of doctors is supposed to produce its effect. METHODS AND ANALYSIS: Realist review is a theory-driven interpretive approach to evidence synthesis. It applies realist logic of inquiry to produce an explanatory analysis of an intervention that is, what works, for whom, in what circumstances, in what respects. Using a realist review approach, an initial programme theory of appraisal will be developed by consulting with key stakeholders in doctors' appraisal in expert panels (ethical approval is not required), and by searching the literature to identify relevant existing theories. The search strategy will have a number of phases including a combination of: (1) electronic database searching, for example, EMBASE, MEDLINE, the Cochrane Library, ASSIA, (2) 'cited by' articles search, (3) citation searching, (4) contacting authors and (5) grey literature searching. The search for evidence will be iteratively extended and refocused as the review progresses. Studies will be included based on their ability to provide data that enable testing of the programme theory. Data extraction will be conducted, for example, by note taking and annotation at different review stages as is consistent with the realist approach. The evidence will be synthesised using realist logic to interrogate the final programme theory of the impact of appraisal on doctors' performance. The synthesis results will be written up according to RAMESES guidelines and disseminated through peer-reviewed publication and presentations. TRIAL REGISTRATION NUMBER: The protocol is registered with PROSPERO 2014:CRD42014007092.",0,0,
1929,Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: a study protocol,"BACKGROUND: Canada is among the most prosperous nations in the world, yet the health and wellness outcomes of Canadian children are surprisingly poor. There is some evidence to suggest that these poor health outcomes are partly due to clinical practice variation, which can stem from failure to apply the best available research evidence in clinical practice, otherwise known as knowledge translation (KT). Surprisingly, clinical practice variation, even for common acute paediatric conditions, is pervasive. Clinical practice variation results in unnecessary medical treatments, increased suffering, and increased healthcare costs. This study focuses on improving health outcomes for common paediatric acute health concerns by evaluating strategies that improve KT and reduce clinical practice variation. DESIGN/METHODS: Using a multiple case study design, qualitative and quantitative data will be collected from four emergency departments in western Canada. Data sources will include: pre- and post-implementation focus group data from multidisciplinary healthcare professionals""; individual interviews with the local champions, KT intervention providers, and unit/site leaders/managers; Alberta Context Tool (ACT) survey data;"" and aggregated patient outcome data. Qualitative and quantitative data will be systematically triangulated, and matrices will be built to do cross-case comparison. Explanations will be built about the success or lack of success of the clinical practice guidelines (CPG) and clinical pathways (CPs) uptake based upon the cross-case comparisons. SIGNIFICANCE: This study will generate new knowledge about the potential causal mechanisms and factors which shape implementation. Future studies will track the impact of the CPG/CPs implementation on children's health outcome, and healthcare costs.",0,0,
1930,"Understanding non-compliance to colorectal cancer screening: a case control study, nested in a randomised trial ","Background The major limit to colorectal cancer screening effectiveness is often low compliance. We studied the reasons for non compliance and determinants of compliance to faecal occult blood tests in Lazio, Italy.  Methods This is a case-control study nested within a trial that tested the effect of type of test and provider on colorectal cancer screening compliance. Non compliant trial subjects were classified as cases, and compliant subjects were classified as controls. We sampled 600 cases and 600 controls matched by their general practitioner, half were invited for screening at the hospital, and the other half directly at their general practitioner's office. Cases and controls answered questions on: distance from test provider, logistical problems, perception of colorectal cancer risk, confidence in screening efficacy, fear of results, presence of colorectal cancer in the family, and gastrointestinal symptoms.  Results About 31% of cases never received the letter offering free screening, and 17% of the sampled population had already been screened. The first reported reason for non-compliance was ""lack of time"" (30%)"";"" the major determinant of compliance was the distance from the test provider: odds ratio >30 minutes vs <15 minutes 0.3 (95%CI = 0.2–0.7). The odds ratio for lack of time was 0.16 (95% IC 0.1–0.26). The effect was stronger if the hospital (0.03 95%CI = 0.01–0.1) rather than the general practitioner (0.3 95%CI = 0.2–0.6) was the provider. Twenty-two percent of controls were accompanied by someone to the test.  Conclusion To increase compliance, screening programmes must involve test providers who are geographically close to the target population.",0,1,
1931,Understanding physician acceptance of mobile technology: insights from two telephone interviews in Finland,"This paper sets out to investigate physicians' perceptions and usage regarding a new mobile medical information system in a pilot trial in the Finnish healthcare sector. Two sets of data were gathered in June and October 2003 by telephone interviews. The physicians interviewed had positive perceptions of the mobile system, and started to use it frequently in their work. They showed few negative experiences of using a Nokia Communicator. They favoured using mobile technology as a way to improve spreading medical knowledge. The main contents of the system, the Evidence-Based Medical Guidelines and the Pharmaca Fennica (the pharmacopoeia), were crucial for using the system. Some differences in physicians' behaviour across time were also found. Implications for system improvement are discussed.",0,0,
1932,Understanding practice: the factors that influence management of mild traumatic brain injury in the emergency department--a qualitative study using the Theoretical Domains Framework,"BACKGROUND: Mild traumatic brain injury is a frequent cause of presentation to emergency departments. Despite the availability of clinical practice guidelines in this area, there is variation in practice. One of the aims of the Neurotrauma Evidence Translation program is to develop and evaluate a targeted, theory- and evidence-informed intervention to improve the management of mild traumatic brain injury in Australian emergency departments. This study is the first step in the intervention development process and uses the Theoretical Domains Framework to explore the factors perceived to influence the uptake of four key evidence-based recommended practices for managing mild traumatic brain injury. METHODS: Semi-structured interviews were conducted with emergency staff in the Australian state of Victoria. The interview guide was developed using the Theoretical Domains Framework to explore current practice and to identify the factors perceived to influence practice. Two researchers coded the interview transcripts using thematic content analysis. RESULTS: A total of 42 participants (9 Directors, 20 doctors and 13 nurses) were interviewed over a seven-month period. The results suggested that (i) the prospective assessment of post-traumatic amnesia was influenced by: knowledge""; beliefs about consequences; environmental context and resources; skills; social/professional role and identity; and beliefs about capabilities; (ii) the use of guideline-developed criteria or decision rules to inform the appropriate use of a CT scan was influenced by: knowledge; beliefs about consequences; environmental context and resources; memory, attention and decision processes; beliefs about capabilities; social influences; skills and behavioral regulation; (iii) providing verbal and written patient information on discharge was influenced by: beliefs about consequences; environmental context and resources; memory, attention and decision processes; social/professional role and identity; and knowledge; (iv) the practice of providing brief, routine follow-up on discharge was influenced by: environmental context and resources; social/professional role and identity; knowledge; beliefs about consequences;"" and motivation and goals. CONCLUSIONS: Using the Theoretical Domains Framework, factors thought to influence the management of mild traumatic brain injury in the emergency department were identified. These factors present theoretically based targets for a future intervention.",0,0,
1933,"Understanding the neurobiology, assessment, and treatment of substances of abuse and dependence: a guide for the critical care nurse","What do I as a critical care nurse do? Nurses, by virtue of being trained in health promotion, and also because they interact with patients, families, and communities, have firsthand opportunities to play an active role in practicing primary prevention. To avoid the first occurrence of substance abuse, assess community need, assess facility needs, and identify potential risk. Identify the magnitude of the problem. Intervene early with the youth and at-risk populations. Refer patients and their families to mental health specialists. Provide education to patients, families, communities. To reduce occurrences of substance abuse, practicing secondary prevention requires prompt action in the earliest moments of recognizing a problem and directing patients to early intervention and rehabilitation. Screening your patients, providing brief education, and prompt referral constitutes early intervention. To retard the progress of the disease, practice tertiary prevention by providing education, counseling, and support to the afflicted in achieving and maintaining sobriety through medication compliance and rehabilitative group and counseling work. The goal of intervention in the lives of substance abusers is to stop drug use, avoid relapse, and sustain recovery. After years of research, NIDA has identified 13 fundamental principles to effective drug abuse treatment. 1. Addiction is a complex but treatable disease that affects brain function and behavior. 2. No single treatment is appropriate for everyone. 3. Treatment needs to be readily available. 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Remaining in treatment for an adequate period of time is critical. 6. Counseling--individual and/or group--and other behavioral therapies are the most commonly used forms of drug abuse treatment. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. 8. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure it meets his or her changing needs. 9. Many drug-addicted individuals also have other mental disorders that need treatment. 10. Medically assisted detoxification in the first stage of addiction treatment and by itself does little to change long-term drug abuse. 11. Treatment does not need to be voluntary to be effective. 12. Drug use during treatment must be monitored continuously, because lapses during treatment do occur. 13. Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. To truly impact this disease, there needs to be improvement in the identification of risk factors and early identification and early intervention with children and adolescents. The future of neuroscience is in objective brain scans and genetic testing. Out of these approaches can come more objective measures of addiction and dependence using brain scans and genetic testing. These measures would potentially allow for the development of vaccines for specific drugs of abuse and dependence, as well as increasingly selective and effective pharmacologic approaches for treatment and a new consensus on standard of care for substance dependence.",0,0,
1934,Understanding the performance of community health volunteers involved in the delivery of health programmes in underserved areas: a realist synthesis,"Background The recruitment of community health volunteers (CHVs) to support the delivery of health programmes is an established approach in underserved areas and in particular where there are health inequalities due to the scarcity of trained human resources. However, there is a dearth of evidence about what works to improve CHVs¡¯ performance. This review aimed to synthesise existing literature to explain why, how and under which circumstances intervention approaches to improve the performance of CHVs are more likely to be successful.  Methods We performed a realist synthesis. We identified candidate theories related to our review questions, which then guided the selection, appraisal and analysis of primary studies. Publications of interest dating from 2008 to 2012 were identified by a systematic search in PubMed and IDEAS databases. We considered all study designs that examined the various aspects of CHV performance in the context of formal organisational settings to be eligible and excluded the studies that did not provide explanation about the performance of CHVs neither in the findings nor in the discussion part. Data were arranged according to their reference to context, interventions, outcomes and mechanisms in order to identify the interaction between them. The synthesis of data allowed us to determine explanatory patterns within or across the studies.  Results We identified broad intervention approaches within the 23 papers included in the review: positioning of the CHV within the community, establishment of clear roles, provision of skill-based and ongoing training, incentives, supervision and logistical support for task distribution and implementation. The findings provided information regarding which mechanisms (self-esteem, sense of duty, self-efficacy, sense of being fairly treated) to target when implementing such approaches, and which contextual factors (stable and supportive cultural, political and social context and intervention closely linked to local health services) create the most favourable conditions for these mechanisms to occur, ultimately contributing to CHVs¡¯ better performance. Four main explanatory patterns around these mechanisms emerged as being fundamental to better performance.  Conclusions The patterns identified, combined with the designers¡¯ and other stakeholders¡¯ assumptions on how such interventions are expected to work, can be tested by empirical studies in order to provide useful information to be used by programme implementers, policymakers, donors and the community.",0,0,
1935,"Unemployment and mortality in Denmark, 1970-80","Relative mortality in the period 1970-80 was studied among Danish men and women who were unemployed and employed on the day of the 1970 census. The study population consisted of the total labour force in the age range 20-64 on 9 November 1970--that is, about 2 million employed and 22,000 unemployed people. Relative mortality was analysed by a multiplicative hazard regression model (as a natural extension of the standardised mortality ratio) and a multiplicative regression model with extra-Poisson variation. A significantly increased death rate (40-50%) was found among the unemployed after adjusting for occupation, housing category, geographical region, and marital state. Analysis of five main causes of death showed increased mortality from all causes, but especially from suicide or accidents. In areas where the local unemployment rate was comparatively high the relative mortality among the unemployed was lower. The increased mortality among the unemployed was interpreted as a consequence of health related selection as well as increased susceptibility associated with the psychosocial stress of unemployment.",0,0,
1936,Unequal protection for patient rights: the divide between university and health ethics committees,"Despite recommendations from the Cartwright Report ethical review by health ethics committees has continued in New Zealand without health practitioners ever having to acknowledge their dual roles as health practitioners researching their own patients. On the other hand, universities explicitly identify doctor/research-patient relations as potentially raising conflict of role issues. This stems from the acknowledgement within the university sector itself that lecturer/research-student relations are fraught with such conflicts. Although similar unequal relationships are seen to exist between health resarchers and their patients, the patient/subjects are not afforded the levels of protection that are afforded student/subjects. In this paper we argue that the difference between universities and health research is a result of the failure of the Operational Standard Code for Ethics Committees to explicitly acknowledge the vulnerability of the patient and conflict of interests in the dual roles of health practitioner/researcher. We end the paper recommending the Ministry of Health consider the rewriting of the Operational Standard Code for Ethics Committees, in particular in the rewriting of section 26 of the Operational Standard Code for Ethics Committees. We also identify the value of comparative ethical review and suggest the New Zealand's Health Research Council's trilateral relationship with Australia's NHMRC (National Health and Medical Research Council) and Canada's CIHR (Canadian Institute of Health Research) as a useful starting point for such a process.",0,0,
1937,Unhealthy drinking patterns and receipt of preventive medical services by older adults,"BACKGROUND: Preventive service use among older adults is suboptimal. Unhealthy drinking may constitute a risk factor for failure to receive these services. OBJECTIVES: To determine the relationship between unhealthy drinking and receipt of recommended preventive services among elderly Medicare beneficiaries, applying the framework of current alcohol consumption guidelines. DESIGN/METHODS: The data source is the nationally representative 2003 Medicare Current Beneficiary Survey. The sample included community-dwelling, fee-for-service Medicare beneficiaries 65 years and older (N = 10,523). Based on self-reported drinking, respondents were categorized as nondrinkers, within-guidelines drinkers, exceeding monthly but not daily limits, or heavy episodic drinkers. Using survey and claims data, influenza vaccination, pneumonia vaccination, glaucoma screening, and mammogram receipt were determined. Bivariate and logistic regression analyses were conducted. RESULTS: Overall, 70.3% received flu vaccination and 49% received glaucoma screening during the year, 66.8% received pneumonia vaccination, and 56.2% of women received a mammogram over 2 years. In logistic regression, heavy episodic drinking was associated with lower likelihood of service receipt compared to drinking within guidelines: flu vaccination (OR 0.75, CI 0.59-0.96), glaucoma screening (OR 0.74, CI 0.58-0.95), and pneumonia vaccination (OR 0.75, CI 0.59-0.96). Nondrinkers when compared with those reporting drinking within guidelines were less likely to receive a mammogram (OR 0.83, CI 0.69-1.00). CONCLUSIONS: Heavy episodic drinking is associated with lower likelihood of receiving several preventive services. Practitioners should be encouraged to screen all elders regarding alcohol intake and in addition to appropriate intervention, consider elders reporting heavy episodic drinking at higher risk for non-receipt of preventive services.",0,0,
1938,Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.,"Background  The effectiveness of computerized physician order entry (CPOE) systems has been modest, largely because clinicians frequently override electronic alerts.  Methods  To evaluate the effectiveness of a nearly “hard stop” CPOE prescribing alert intended to reduce concomitant orders for warfarin and trimethoprim-sulfamethoxazole, a randomized clinical trial was conducted at 2 academic medical centers in Philadelphia, Pennsylvania. A total of 1981 clinicians were assigned to either an intervention group receiving a nearly hard stop alert or a control group receiving the standard practice. The study duration was August 9, 2006, through February 13, 2007.  Results  The proportion of desired responses (ie, not reordering the alert-triggering drug within 10 minutes of firing) was 57.2% (111 of 194 hard stop alerts) in the intervention group and 13.5% (20 of 148) in the control group (adjusted odds ratio, 0.12;"" 95% confidence interval, 0.045-0.33). However, the study was terminated early because of 4 unintended consequences identified among patients in the intervention group: a delay of treatment with trimethoprim-sulfamethoxazole in 2 patients and a delay of treatment with warfarin in another 2 patients.  Conclusions  An electronic hard stop alert as part of an inpatient CPOE system seemed to be extremely effective in changing prescribing. However, this intervention precipitated clinically important treatment delays in 4 patients who needed immediate drug therapy. These results illustrate the importance of formal evaluation and monitoring for unintended consequences of programmatic interventions intended to improve prescribing habits.",0,1,
1939,Update on interventions focused on symptom clusters: what has been tried and what have we learned?,"PURPOSE OF REVIEW: Although clinicians and researchers acknowledge symptom clusters, the focus has been on relieving a single symptom. This review summarizes the recent literature on interventions that focus on relief of symptom clusters in patients with cancer. RECENT FINDINGS: Twelve intervention studies meeting inclusion criteria were published in 2011-2012. The timeframe was expanded to 2009-2012 and 24 studies met the criteria: 18 in early stage and 6 in advanced-stage cancer patients. Several cognitive behavioral therapy, complementary therapy, and exercise interventions demonstrated positive outcomes in relieving a variety of symptom clusters in several cancer types. Most psychoeducational interventions using traditional formats or those combined with automated clinician alerts demonstrated effectiveness in reducing a variety of clusters. Clusters that included fatigue and anxiety or depression were reduced by exercise in early stage patients and by methylphenidate in advanced-stage patients. Current NIH R01 funded studies verified the trends in the types of interventions being tested. SUMMARY: Few interventions have been tested and found to be effective in relieving the specific symptom clusters in early and advanced-stage cancer patients. Future research needs to expand our understanding of the mechanisms that initiate co-occurring symptoms. Mechanism-targeted interventions need to be identified and tested in homogeneous samples with specific symptom clusters. Interventions need to be replicated before guidelines can be established.",0,0,
1940,Update on pediatric hyperlipidemia,"PURPOSE OF REVIEW: The purpose of this study is to review the National Heart Lung and Blood Institute (NHBLI) guidelines on screening and management of hyperlipidemia in children and to discuss the critics concerns regarding universal screening. RECENT FINDINGS: Data derived from the National Health and Nutrition Examination Survey has shown favorable trends in serum lipid levels among children and adolescents aged 6-19 years between 1988-1994 and 2007-2010. Mean total cholesterol (TC) decreased from 165 to 160 mg/dl, and the prevalence of elevated TC decreased from 11.3 to 8.1%. However, between 2007 and 2010, approximately 20% of children aged 9-11 years had either low high-density lipoprotein cholesterol (HDL-C) or high non-HDL-C This warrants additional evaluation as per the NHBLI guidelines. SUMMARY: The NHBLI guidelines present physicians with a balanced perspective for screening and managing hyperlipidemia in children. These guidelines provide a schematic approach that helps primary care physicians to make treatment decisions. The hope is that this will lead to decreased healthcare system expense and overall improved health through early identification and intervention.",0,0,
1941,"US medical researchers, the Nuremberg Doctors Trial, and the Nuremberg Code. A review of findings of the Advisory Committee on Human Radiation Experiments","The Advisory Committee on Human Radiation Experiments (ACHRE), established to review allegations of abuses of human subjects in federally sponsored radiation research, was charged with identifying appropriate standards to evaluate the ethics of cold war radiation experiments. One central question for ACHRE was to determine what role, if any, the Nuremberg Code played in the norms and practices of US medical researchers. Based on the evidence from ACHRE's Ethics Oral History Project and extensive archival research, we conclude that the Code, at the time it was promulgated, had little effect on mainstream medical researchers engaged in human subjects research. Although some clinical investigators raised questions about the conduct of research involving human beings, the medical profession did not pursue this issue until the 1960s.",0,0,
1942,Usage and effect of health information exchange: a systematic review,"Background: Health information exchange (HIE) is increasing in the United States, and it is incentivized by government policies. Purpose: To systematically review and evaluate evidence of the use and effect of HIE on clinical care. Data Sources: Selected databases from 1 January 2003 to 31 May 2014. Study Selection: English-language hypothesis-testing or quantitative studies of several types of data exchange among unaffiliated organizations for use in clinical care that addressed health outcomes, efficiency, utilization, costs, satisfaction, HIE usage, sustainability, and attitudes or barriers. Data Extraction: Data extraction was done in duplicate. Data Synthesis: Low-quality evidence from 12 hypothesis-testing studies supports an effect of HIE use on reduced use or costs in the emergency department. Direct evidence that HIEs were used by providers was reported in 21 studies involving 13 distinct HIE organizations, 6 of which were located in New York, and generally showed usage in less than 10% of patient encounters. Findings from 17 studies of sustainability suggest that approximately one quarter of existing HIE organizations consider themselves financially stable. Findings from 38 studies about attitudes and barriers showed that providers, patients, and other stakeholders consider HIE to be valuable, but barriers include technical and workflow issues, costs, and privacy concerns. Limitation: Publication bias, possible selective reporting of outcomes, and a dearth of reporting on context and implementation processes. Conclusion: Health information exchange use probably reduces emergency department usage and costs in some cases. Effects on other outcomes are unknown. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist. A small portion of operational HIEs have been evaluated, and more research is needed to identify and understand success factors.",0,1,
1943,Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup,"Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units, and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA (Best practices in Evaluation and Treatment of Agitation) is noncoercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior. In this article, the authors discuss several aspects of seclusion and restraint, including review of the Centers for Medicare and Medicaid Services guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff, and a review of quality improvement and risk management strategies that have been effective in decreasing their use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment primarily of acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions.",0,0,
1944,Use and care of animals in research and teaching: MMA policy statement,,0,0,
1945,Use of a Clinical Decision Support Tool to improve guideline adherence for the treatment of methicillin-resistant Staphylococcus aureus: Skin and Soft Tissue Infections.,"Skin and Soft Tissue Infections (SSTI's) with abscess are commonly seen in the Emergency Department (ED) setting. Given the increasing prevalence of methicillin-resistant Staphylococcus-aureus (MRSA)-related abscesses, appropriate evidence-based decisions are essential in assuring successful treatment. Provider adherence to clinical guidelines for the treatment of SSTI's with presumed MRSA remains inconsistent in terms of prescriptive practice related to antibiotic selection, culturing wounds, and patient discharge recommendations regarding the use of infection control techniques. Evidence indicates that the use of Clinical Decision Support (CDS) tools is valuable in improving provider awareness and adherence to clinical guidelines. This study was conducted to examine whether the development of a CDS tool to guide order entry for the treatment of MRSA-related SSTI's and embed it into the electronic medical record program would improve provider adherence to the North Carolina Consensus Guideline for Management of Suspected Commmunity-Acquired MRSA Skin and Soft Tissue.",0,1,
1946,Use of a computer to detect and respond to clinical events: its effect on clinician behavior.,"A computer was used to prospectively detect and suggest responses to simple, medication-related events as reflected in a computerized record in a prospective, randomized study of a diabetes clinic with primary-care responsibility. There were two categories of event/suggestions: when the last observation of a test required for medication control was too old, the computer suggested a repeat""; and when an abnormality with therapeutic implications was detected, the computer suggested a specific change in therapeutics. Clinicians responded to 36% of events in the first category with computer reminders and 11% without (P < 0.0001);"" they responded to 28% of events in the second category with computer assistance and 13% without (P < 0.026). For the most clinically significant of these second category events, the difference was even greater: 47% with and 4% without computer assistance (P < 0.0004). I believe that computer detection and response (in the form of reminders) to simple clinical events will change clinician behavior.",1,1,
1947,Use of a computerized guideline for glucose regulation in the intensive care unit improved both guideline adherence and glucose regulation.,"Objective: To measure the impact of a computerized guideline for glucose regulation in an ICU.  Design: A randomized, controlled trial with an off-on-off design.  Methods: We implemented a glucose regulation guideline in an intensive care unit in paper form during the first study period. During the second period, the guideline was randomly applied in either paper or computerized form. In the third period, the guideline was available only in paper form.  Measurements and results: We analyzed data for 484 patients. During the intervention period, the control group included 54 patients and the computerized intervention group included 66 patients. The two guideline-related outcome measures consisted of compliance with: (a) glucose measurement timing recommendations and (b) insulin dose advice. We measured clinical impact as the proportion of time that glucose levels fell within target range. In the first (paper-based) study period, 29.0% of samples occurred with optimal timing""; during the second period, this increased to 35.5% for paper-based and to 40.2% for computerized protocols. The third study period timeliness scores reverted to the first period rates. Late (suboptimal) sampling occurred for 66% of glucose measurements in the first study period, for 42% of paper-based and 28% of computer-based protocol samples in the second period, and for 50.0% of samples in the third study period. In the first study period, insulin-dosing guideline compliance was 56.3%;"" in the second period, it was 64.2% for paper-based and 77.3% for computer-based protocols, and it fell to 42.4% in the third period. For the second study period, the time that a patient's glucose values fell within target range improved for both the control (52.9%) and the computerized groups (54.2%) compared with the first study period (44.3%) and the third period (42.3%).  Conclusion: Implementing a computerized version of a guideline significantly improved timeliness of measurements and glucose level regulation for critically ill patients compared with implementing a paper-based version of the guideline.",1,1,
1948,Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial.,"Background Mammography screening can reduce breast cancer mortality. However, most women are unaware that inconsequential disease can also be detected by screening, leading to overdiagnosis and overtreatment. We aimed to investigate whether including information about overdetection of breast cancer in a decision aid would help women aged around 50 years to make an informed choice about breast screening.  Methods We did a community-based, parallel-group, randomised controlled trial in New South Wales, Australia, using a random cohort of women aged 48–50 years. Recruitment to the study was done by telephone""; women were eligible if they had not had mammography in the past 2 years and did not have a personal or strong family history of breast cancer. With a computer program, we randomly assigned 879 participants to either the intervention decision aid (comprising evidence-based explanatory and quantitative information on overdetection, breast cancer mortality reduction, and false positives) or a control decision aid (including information on breast cancer mortality reduction and false positives). Participants and interviewers were masked to group assignment. The primary outcome was informed choice (defined as adequate knowledge and consistency between attitudes and screening intentions), which we assessed by telephone interview about 3 weeks after random allocation. The primary outcome was analysed in all women who completed the relevant follow-up interview questions fully. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613001035718.  Findings Between January, 2014, and July, 2014, 440 women were allocated to the intervention group and 439 were assigned to the control group. 21 women in the intervention group and 20 controls were lost to follow-up; a further ten women assigned to the intervention and 11 controls did not answer all questions on attitudes. Therefore, 409 women in the intervention group and 408 controls were analysed for the primary outcome. 99 (24%) of 409 women in the intervention group made an informed choice compared with 63 (15%) of 408 in the control group (difference 9%, 95% CI 3–14; p=0·0017). Compared with controls, more women in the intervention group met the threshold for adequate overall knowledge (122/419 [29%] vs 71/419 [17%]; difference 12%, 95% CI 6–18; p<0·0001), fewer women expressed positive attitudes towards screening (282/409 [69%] vs 340/408 [83%]; 14%, 9–20; p<0·0001), and fewer women intended to be screened (308/419 [74%] vs 363/419 [87%]; 13%, 8–19;"" p<0·0001). When conceptual knowledge alone was considered, 203 (50%) of 409 women in the intervention group made an informed choice compared with 79 (19%) of 408 in the control group (p<0·0001).  Interpretation Information on overdetection of breast cancer provided within a decision aid increased the number of women making an informed choice about breast screening. Becoming better informed might mean women are less likely to choose screening.",0,1,
1949,Use of a fall prevention practice guideline for community-dwelling older persons at risk for falling: a feasibility study,"BACKGROUND: Falls among older persons occur frequently and are a common cause of physical and psychological morbidity and healthcare utilization. The problem can be attributed to a complex interaction between health-related, behavioral and environmental factors. To ensure a uniform and evidence-based approach, a practice guideline was developed for fall prevention in community-dwelling older persons at risk for falls. OBJECTIVE: To test the feasibility of integrating a fall prevention practice guideline into the daily practice of 4 primary healthcare disciplines, i.e. general practitioners, nurses, occupational therapists and physiotherapists. METHODS: This was a descriptive study which was carried out by 10 local health networks located throughout Flanders. The subjects involved in the study were 99 primary care workers and 1,142 community-dwelling older patients (65 years or older) who could rise from a chair and transfer independently. For 6 months, primary care workers implemented our fall prevention guideline, which consisted of 3 parts (case finding, multifactorial in-depth assessment and interventions). After the 6-month trial phase, participating primary care workers were asked to complete a semistructured questionnaire to evaluate the feasibility of using the guideline in daily practice. RESULTS: The average time spent on carrying out the guideline was 32.0+/-14.0 min. Healthcare workers from all 4 disciplines considered case finding to be their responsibility. The picture was different for the evaluation of risk factors and interventions. Although 87.5% considered fall prevention to be an important issue, healthcare workers from different disciplines failed to agree about how to integrate the prevention guideline into daily practice. Perceived barriers to implementing the guideline were lack of time (57.3%), poor motivation of the target population (53.3%) and insufficient cooperation between healthcare workers (37.3%). CONCLUSION: A guideline can be used to initiate the integration of prevention strategies into daily practice. Case finding is feasible for all disciplines. Multifactorial assessment and interventions require specific task allocation, multidisciplinary cooperation and clear communication.",0,0,
1950,Use of action planning to increase provision of smoking cessation care by general practitioners: role of plan specificity and enactment,"Background Strategies are needed to help general practitioners (GPs) promote smoking cessation as recommended by guidelines. This study examines whether the quality of action planning among GPs improves their provision of smoking cessation care.  Methods The effectiveness of a 1-h training programme was examined in a cluster randomised controlled trial in which 49 GPs participated. GPs who followed the training (intervention group"";"" n?=?25) formulated action plans related to i) enquiring about smoking, ii) advising to quit smoking, and iii) arranging follow-up for smokers motivated to quit. GPs also formulated a coping plan for encountering smokers not motivated to quit. The quality of these plans (plan specificity) was rated and, 6 weeks after the training, GPs reported on the performance of these plans (plan enactment). Multilevel regression analyses were used to examine the effects of plan specificity and plan enactment on patient-reported smoking cessation activities of the GPs in the intervention group (n?=?1,632 patients) compared with the control group (n?=?1,769 patients).  Results Compared to the control group, GPs who formulated a highly specific action plan during the training asked their patients about smoking more often after the training compared to prior to the training (OR 2.11, 95% CI 1.51–2.95). GPs were most likely to have asked patients about smoking after the training compared to prior to the training when they had enacted a highly specific formulated action plan (OR 3.08, 95% CI 2.04–4.64). The effects of GP plan specificity and plan enactment on asking patient about smoking were most prominent among GPs who, at baseline, intended to provide smoking cessation care.  Conclusions A highly specific action plan formulated by a GP on when, how, and by whom patients will be asked about smoking had a positive effect on GPs’ asking patients about smoking, especially when these professionals also reported to have enacted this plan. This effect was most prominent among GPs who intended to provide smoking cessation care prior to the intervention. Training in devising personalised coping plans is recommended to further increase GPs’ provision of advice to quit smoking and arranging follow-up support to quit smoking.",1,1,
1951,Use of an Internet portal to improve community-based pediatric ADHD care: a cluster randomized trial,"OBJECTIVE: To determine the effectiveness of a quality improvement program to improve pediatricians' adherence to existing, evidence-based, attention-deficit/hyperactivity disorder (ADHD) practice guidelines. METHODS: Forty-nine community-based pediatricians at 8 practices participated in a cluster-randomized trial. Practices were matched according to the numbers of pediatricians and the proportions of patients receiving Medicaid. The medical charts for a random sample of patients with ADHD for each of the participating pediatricians were examined at baseline and 6 months. All practices participated in 4 sessions of training, including didactic lectures and office flow modification workshops. Practices were then given access to an ADHD Internet portal that allowed parents, teachers, and pediatricians to input information (eg, rating scales) about patients, after which information was scored, interpreted, and formatted in a report style that was helpful for assessment and treatment of patients with ADHD. Physicians evaluated their practice behaviors quarterly and addressed underperforming areas. RESULTS: Pediatricians in the intervention group, compared with those in the control group, demonstrated significantly higher rates of many American Academy of Pediatrics-recommended ADHD care practices, including collection of parent (Cohen's d = 0.69) and teacher (d = 0.68) rating scales for assessment of children with ADHD, use of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (d = 0.85), and use of teacher rating scales to monitor treatment responses (d = 1.01). CONCLUSION: A quality improvement intervention that can be widely disseminated by using Internet-based information technology significantly improved the quality of ADHD care in community-based pediatric settings.",0,0,
1952,Use of antibiotics. Septicaemia,,0,0,
1953,Use of evidence in WHO recommendations,"BackgroundWHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisation's guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. We examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments."";"" BackgroundWHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisation's guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. We examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments.",0,0,
1954,Use of Warfarin at Discharge Among Acute Ischemic Stroke Patients With Nonvalvular Atrial Fibrillation in China,"BACKGROUND AND PURPOSE: Guidelines recommend oral anticoagulation for ischemic stroke patients with atrial fibrillation, and previous studies have shown the underuse of anticoagulation for these patients in China. We sought to explore the underlying reasons and factors that currently affect the use of warfarin in China. METHODS: From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with warfarin use at discharge. RESULTS: Among the 952 acute ischemic stroke patients with nonvalvular atrial fibrillation, 19.4% were discharged on warfarin. The risk of bleeding (52.8%) and patient refusal (31.9%) were the main reasons for not prescribing anticoagulation. Larger/teaching hospitals were more likely to prescribe warfarin. Older patients, heavy drinkers, patients with higher National Institutes of Health Stroke Scale score on admission were less likely to be given warfarin, whereas patients with history of heart failure and an international normalized ratio between 2.0 and 3.0 during hospitalization were significantly associated with warfarin use at discharge. CONCLUSIONS: The rate of warfarin use remains low among patients with ischemic stroke and known nonvalvular atrial fibrillation in China. Hospital size and academic status together with patient age, heart failure, heavy alcohol drinking, international normalized ratio in hospital, and stroke severity on admission were each independently associated with the use of warfarin at discharge. There is much room for improvement for secondary stroke prevention in nonvalvular atrial fibrillation patients in China.",0,0,
1955,"User satisfaction and frustration with a handheld, pen-based guideline implementation system for asthma","OBJECTIVE: To evaluate clinicians' satisfaction and frustrations with the use of a handheld computer system that implements a guideline for management of childhood asthma exacerbations. SETTING: Nine primary-care pediatric practices. DESIGN: Survey component of a randomized, prospective before-after trial. INTERVENTION: Newton MessagePad outfitted with custom software (called ""AsthMonitor"") that assists in documentation of clinical findings and provides guideline-based recommendations. RESULTS: Overall, 3 users gave strongly positive global ratings while 6 users were neutral. The majority used the documentation functions concurrently with care. Except for recommendations to administer oxygen (which were unsupported by evidence), users found the recommendations appropriate and appreciated the reminders. Seven of 9 participants believed it took more time to document with AsthMonitor. CONCLUSIONS: Handheld computers are acceptable to some office-based practitioners to provide guideline-based advice within the context of the clinical encounter.",0,1,
1956,Using ‘nudge’principles for order set design: a before and after evaluation of an electronic prescribing template in critical care,"Objective Computerised order sets have the potential to reduce clinical variation and improve patient safety but the effect is variable. We sought to evaluate the impact of changes to the design of an order set on the delivery of chlorhexidine mouthwash and hydroxyethyl starch (HES) to patients in the intensive care unit.  Methods The study was conducted at University Hospitals Bristol NHS Foundation Trust, UK. Our intensive care unit uses a clinical information system (CIS). All drugs and fluids are prescribed with the CIS and drug and fluid charts are stored within a database. Chlorhexidine mouthwash was added as a default prescription to the prescribing template in January 2010. HES was removed from the prescribing template in April 2009. Both interventions were available to prescribe manually throughout the study period. We conducted a database review of all patients eligible for each intervention before and after changes to the configuration of choices within the prescribing system.  Results 2231 ventilated patients were identified as appropriate for treatment with chlorhexidine, 591 before the intervention and 1640 after. 55.3% were prescribed chlorhexidine before the change and 90.4% after (p<0.001). 6199 patients were considered in the HES intervention, 2177 before the intervention and 4022 after. The mean volume of HES infused per patient fell from 630 mL to 20 mL after the change (p<0.001) and the percentage of patients receiving HES fell from 54.1% to 3.1% (p<0.001). These results were well sustained with time.  Conclusions The presentation of choices within an electronic prescribing system influenced the delivery of evidence-based interventions in a predictable way and the effect was well sustained. This approach has the potential to enhance the effectiveness of computerised order sets.",1,1,
1957,Using a behaviour change techniques taxonomy to identify active ingredients within trials of implementation interventions for diabetes care,"BACKGROUND: Methodological guidelines for intervention reporting emphasise describing intervention content in detail. Despite this, systematic reviews of quality improvement (QI) implementation interventions continue to be limited by a lack of clarity and detail regarding the intervention content being evaluated. We aimed to apply the recently developed Behaviour Change Techniques Taxonomy version 1 (BCTTv1) to trials of implementation interventions for managing diabetes to assess the capacity and utility of this taxonomy for characterising active ingredients. METHODS: Three psychologists independently coded a random sample of 23 trials of healthcare system, provider- and/or patient-focused implementation interventions from a systematic review that included 142 such studies. Intervention content was coded using the BCTTv1, which describes 93 behaviour change techniques (BCTs) grouped within 16 categories. We supplemented the generic coding instructions within the BCTTv1 with decision rules and examples from this literature. RESULTS: Less than a quarter of possible BCTs within the BCTTv1 were identified. For implementation interventions targeting providers, the most commonly identified BCTs included the following: adding objects to the environment, prompts/cues, instruction on how to perform the behaviour, credible source, goal setting (outcome), feedback on outcome of behaviour, and social support (practical). For implementation interventions also targeting patients, the most commonly identified BCTs included the following: prompts/cues, instruction on how to perform the behaviour, information about health consequences, restructuring the social environment, adding objects to the environment, social support (practical), and goal setting (behaviour). The BCTTv1 mapped well onto implementation interventions directly targeting clinicians and patients and could also be used to examine the impact of system-level interventions on clinician and patient behaviour. CONCLUSIONS: The BCTTv1 can be used to characterise the active ingredients in trials of implementation interventions and provides specificity of content beyond what is given by broader intervention labels. Identification of BCTs may provide a more helpful means of accumulating knowledge on the content used in trials of implementation interventions, which may help to better inform replication efforts. In addition, prospective use of a behaviour change techniques taxonomy for developing and reporting intervention content would further aid in building a cumulative science of effective implementation interventions.",0,0,
1958,Using a theory of planned behaviour framework to explore hand hygiene beliefs at the '5 critical moments' among Australian hospital-based nurses,"BACKGROUND: Improving hand hygiene among health care workers (HCWs) is the single most effective intervention to reduce health care associated infections in hospitals. Understanding the cognitive determinants of hand hygiene decisions for HCWs with the greatest patient contact (nurses) is essential to improve compliance. The aim of this study was to explore hospital-based nurses' beliefs associated with performing hand hygiene guided by the World Health Organization's (WHO) 5 critical moments. Using the belief-base framework of the Theory of Planned Behaviour, we examined attitudinal, normative, and control beliefs underpinning nurses' decisions to perform hand hygiene according to the recently implemented national guidelines. METHODS: Thematic content analysis of qualitative data from focus group discussions with hospital-based registered nurses from 5 wards across 3 hospitals in Queensland, Australia. RESULTS: Important advantages (protection of patient and self), disadvantages (time, hand damage), referents (supportive: patients, colleagues"";"" unsupportive: some doctors), barriers (being too busy, emergency situations), and facilitators (accessibility of sinks/products, training, reminders) were identified. There was some equivocation regarding the relative importance of hand washing following contact with patient surroundings. CONCLUSIONS: The belief base of the theory of planned behaviour provided a useful framework to explore systematically the underlying beliefs of nurses' hand hygiene decisions according to the 5 critical moments, allowing comparisons with previous belief studies. A commitment to improve nurses' hand hygiene practice across the 5 moments should focus on individual strategies to combat distraction from other duties, peer-based initiatives to foster a sense of shared responsibility, and management-driven solutions to tackle staffing and resource issues. Hand hygiene following touching a patient's surroundings continues to be reported as the most neglected opportunity for compliance.",0,0,
1959,Using Appreciative Inquiry to promote evidence-based practice in nursing: the glass is more than half full,"It is now understood that successful implementation of evidence-based practice (EBP) requires a focus on the context of the care setting. While the focal point of many reports is the limitations and barriers, this paper proposes a new approach to ""making EBP happen."" Appreciative Inquiry (AI), both a method of social research and an organizational development or change intervention, is a novel means to elicit enthusiasm and support for EBP in nursing. Readers will be introduced to the theoretical foundations and assumptions as well as the ""4-D Model"" of AI. It is proposed that the advanced practice nurse (APN) is in a key position to introduce and support this intervention in healthcare organizations to promote the successful implementation of EBP.",0,0,
1960,Using computerized clinical decision support for latent tuberculosis infection screening.,"Background The Centers for Disease Control and Prevention (CDC) has published guidelines recommending screening high-risk groups for latent tuberculosis infection (LTBI). The goal of this study was to determine the impact of computerized clinical decision support and guided web-based documentation on screening rates for LTBI.  Design Nonrandomized, prospective, intervention study.  Setting and participants Participants were 8463 patients seen at two primary care, outpatient, public community health center clinics in late 2002 and early 2003.  Intervention The CDC’s LTBI guidelines were encoded into a computerized clinical decision support system that provided an alert recommending further assessment of LTBI risk if certain guideline criteria were met (birth in a high-risk TB country and aged <40). A guided web-based documentation tool was provided to facilitate appropriate adherence to the LTBI screening guideline and to promote accurate documentation and evaluation. Baseline data were collected for 15 weeks and study-phase data were collected for 12 weeks.  Main outcome measures Appropriate LTBI screening according to CDC guidelines based on chart review.  Results Among 4135 patients registering during the post-intervention phase, 73% had at least one CDC-defined risk factor, and 610 met the alert criteria (birth in a high-risk TB country and aged <40 years) for potential screening for LTBI. Adherence with the LTBI screening guideline improved significantly from 8.9% at baseline to 25.2% during the study phase (183% increase, p < 0.001).  Conclusions This study demonstrated that computerized, clinical decision support using alerts and guided web-based documentation increased screening of high-risk patients for LTBI. This type of technology could lead to an improvement in LTBI screening in the United States and also holds promise for improved care for other preventive and chronic conditions.",0,1,
1961,Using implementation intentions to teach practitioners: changing practice behaviors via continuing education,"OBJECTIVE: This study evaluated the effectiveness of implementation intentions on increasing the use of a practice behavior among mental health practitioners who attended a one-day continuing education class. METHODS: Seventy-eight practitioners were randomly assigned to one of two classes on psychiatric advance directives. One class incorporated instruction in implementation intentions (N=40) and the other class did not (N=38). Implementation intention training involved having the participants describe the best time and place to use a practitioner-guided procedure to assist consumers to complete a psychiatric advance directive. Use of the practitioner-guided procedure was the dependent variable in this study. Use of the procedure in practice was assessed three months after the class via an electronic self-report survey. RESULTS: There were no statistically significant differences between the two class conditions in participant characteristics or preclass or postclass knowledge of and intentions to use the procedure. Fifty-four participants (69%) responded to the three-month follow-up survey, indicating that they had used the practitioner-guided procedure. The results of the follow-up survey showed that overall those attending the class that incorporated implementation intentions used the practitioner-guided procedure significantly more often than those in the other class (80% versus 58%). The effect of implementation intentions on utilization of the practitioner-guided procedure was evident among practitioners whose postclass intentions were high but below the median for the overall sample (chi(2)=7.1, df=1, p<.01). Implementation rates among practitioners with the highest post-class intentions were equivalent in the two class conditions. CONCLUSIONS: Incorporating implementation intentions into continuing education classes can increase the use of practices taught in these classes among well-motivated practitioners.",1,1,
1962,Using implementation intentions to teach practitioners: changing practice behaviours via continuing education.,"Objective: This study evaluated the effectiveness of implementation intentions on increasing the use of a practice behavior among mental health practitioners who attended a one-day continuing education class. Methods: Seventy-eight practitioners were randomly assigned to one of two classes on psychiatric advance directives. One class incorporated instruction in implementation intentions (N=40) and the other class did not (N=38). Implementation intention training involved having the participants describe the best time and place to use a practitioner-guided procedure to assist consumers to complete a psychiatric advance directive. Use of the practitioner-guided procedure was the dependent variable in this study. Use of the procedure in practice was assessed three months after the class via an electronic self-report survey. Results: There were no statistically significant differences between the two class conditions in participant characteristics or preclass or postclass knowledge of and intentions to use the procedure. Fifty-four participants (69%) responded to the three-month follow-up survey, indicating that they had used the practitioner-guided procedure. The results of the follow-up survey showed that overall those attending the class that incorporated implementation intentions used the practitioner-guided procedure significantly more often than those in the other class (80% versus 58%). The effect of implementation intentions on utilization of the practitioner-guided procedure was evident among practitioners whose postclass intentions were high but below the median for the overall sample (?2=7.1, df=1, p<.01). Implementation rates among practitioners with the highest post-class intentions were equivalent in the two class conditions. Conclusions: Incorporating implementation intentions into continuing education classes can increase the use of practices taught in these classes among well-motivated practitioners. (Psychiatric Services 59:747–752, 2008)",1,1,
1963,Using paper chart based clinical reminders to improve guideline adherence to lipid management,"RATIONALE, AIMS AND OBJECTIVES: The objective of this study was to apply a paper-based clinical reminder to improve the adherence to lipid guidelines. METHODS: Patients with coronary heart disease (CHD) without lipid-lowering therapy (LLT) were recruited, and medical records were reviewed. Eligible subjects were randomized"";"" a clinical reminder stating current standards and local insurance policy was stamped on the paper chart in the study group but not in the control. The primary outcome was new LLT subscription in the 6-month follow-up period, and the secondary end point was the composite result of LLT or lipid profile check-up. RESULTS: Ninety-two patients were assigned to the study group and 102 to the control group. The primary outcome showed no difference at the end of 6 months (OR: 1.70, P = 0.248, 95% CI: 0.69-4.19). The secondary end point was significantly higher in the reminder group (OR: 2.81, P = 0.001, 95% CI: 1.57-5.04). CONCLUSION: A paper chart based clinical reminder providing update clinical recommendations could modify the doctor's behaviour and improve the attention to lipid levels. However, its effect cannot be transformed into an increase in LLT or a decrease in low-density lipoprotein level owing to local policy constraint.",1,1,
1964,Using pathology-specific laboratory profiles in clinical pathology to reduce inappropriate test requesting: two completed audit cycles,"BACKGROUND: Systematic reviews have shown that, although well prepared, the Consensus Guidelines have failed to change clinical practice. In the healthcare district of Castelnovo ne Monti (Reggio Emilia, Italy), it became necessary for the GPs and Clinical Pathologists to work together to jointly define laboratory profiles. METHODS: Observational study with two cycles of retrospective audit on test request forms, in a primary care setting. Objectives of the study were to develop pathology-specific laboratory profiles and to increase the number of provisional diagnoses on laboratory test request forms. A Multiprofessional Multidisciplinary Inter-hospital Work Team developed pathology-specific laboratory profiles for more effective test requesting. After 8 training sessions that used a combined strategy with multifaceted interventions, the 23 General Practitioners (GPs) in the trial district (Castelnovo ne Monti) tested the profiles""; the 21 GPs in the Puianello district were the control group; all GPs in both districts participated in the trial. All laboratory tests for both healthcare districts are performed at the Laboratory located in the trial district. A baseline and a 1-year audit were performed in both districts on the GPs' request forms. RESULTS: Seven pathology-specific laboratory profiles for outpatients were developed. In the year after the first audit cycle: 1) the number of tests requested in the trial district was distinctly lower than that in the previous year, with a decrease of about 5% (p < 0.001); 2) the provisional diagnosis on the request forms was 52.8% in the trial district and 42% in the control district (P < 0.001); 3) the decrease of the number of tests on each request form was much more marked in the trial district (8.73 vs. 10.77;"" p < 0.001). CONCLUSIONS: The first audit cycle showed a significant decrease in the number of tests ordered only in the trial district. The combined strategy used in this study improved the prescriptive compliance of most of the GPs involved. The presence of the clinical pathologist is seen as an added value.",0,0,
1965,Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the American College of Physicians,"Description: The American College of Physicians developed this guideline to present the available evidence on the pharmacologic management of the acute, continuation, and maintenance phases of major depressive disorder""; dysthymia; subsyndromal depression; and accompanying symptoms, such as anxiety, insomnia, or neurovegetative symptoms, by using second-generation antidepressants. Methods: Published literature on this topic was identified by using MEDLINE, EMBASE, PsychLit, the Cochrane Central Register of Controlled Trials, and International Pharmaceutical Abstracts from 1980 to April 2007. Searches were limited to English-language studies in adults older than 19 years of age. Keywords for search included terms for depressive disorders and 12 specific second-generation antidepressantsbupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxineand their specific trade names. This guideline grades the evidence and recommendations by using the American College of Physicians clinical practice guidelines grading system. Recommendation 1: The American College of Physicians recommends that when clinicians choose pharmacologic therapy to treat patients with acute major depression, they select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences (Grade: strong recommendation; moderate-quality evidence). Recommendation 2: The American College of Physicians recommends that clinicians assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy (Grade: strong recommendation; moderate-quality evidence). Recommendation 3: The American College of Physicians recommends that clinicians modify treatment if the patient does not have an adequate response to pharmacotherapy within 6 to 8 weeks of the initiation of therapy for major depressive disorder (Grade: strong recommendation; moderate-quality evidence). Recommendation 4: The American College of Physicians recommends that clinicians continue treatment for 4 to 9 months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had 2 or more episodes of depression, an even longer duration of therapy may be beneficial (Grade: strong recommendation;"" moderate-quality evidence).",0,0,
1966,Using shared goal setting to improve access and equity: a mixed methods study of the Good Goals intervention in children's occupational therapy,"Background Access and equity in children¡¯s therapy services may be improved by directing clinicians¡¯ use of resources toward specific goals that are important to patients. A practice-change intervention (titled ¡®Good Goals¡¯) was designed to achieve this. This study investigated uptake, adoption, and possible effects of that intervention in children¡¯s occupational therapy services.  Methods Mixed methods case studies (n?=?3 services, including 46 therapists and 558 children) were conducted. The intervention was delivered over 25?weeks through face-to-face training, team workbooks, and ¡®tools for change¡¯. Data were collected before, during, and after the intervention on a range of factors using interviews, a focus group, case note analysis, routine data, document analysis, and researchers¡¯ observations.  Results Factors related to uptake and adoptions were: mode of intervention delivery, competing demands on therapists¡¯ time, and leadership by service manager. Service managers and therapists reported that the intervention: helped therapists establish a shared rationale for clinical decisions""; increased clarity in service provision; and improved interactions with families and schools. During the study period, therapists¡¯ behaviours changed: identifying goals, odds ratio 2.4 (95% CI 1.5 to 3.8); agreeing goals, 3.5 (2.4 to 5.1);"" evaluating progress, 2.0 (1.1 to 3.5). Children¡¯s LoT decreased by two months [95% CI ?8 to +4?months] across the services. Cost per therapist trained ranged from ¡ê1,003 to ¡ê1,277, depending upon service size and therapists¡¯ salary bands.  Conclusions Good Goals is a promising quality improvement intervention that can be delivered and adopted in practice and may have benefits. Further research is required to evaluate its: (i) impact on patient outcomes, effectiveness, cost-effectiveness, and (ii) transferability to other clinical contexts.",0,1,
1967,Using standardized patients to measure professional performance of physicians,"OBJECTIVE: To determine the nature of inaccuracies likely to occur when standardized patients (SPs) are used to measure physician behaviour and to evaluate the potential impact of these inaccuracies on estimates of physician performance. DESIGN: Secondary analysis from a randomized controlled trial. SETTING: Family physicians' offices. STUDY PARTICIPANTS: Eighteen individuals, each portraying one of two patient scenarios, made a total of 179 visits to 92 family physicians who were participating in a separate randomized controlled trial to evaluate the impact of an educational workshop on implementation of preventive guidelines. MAIN OUTCOME MEASURES: Accuracy of SPs' portrayal of the assigned scenarios and accuracy of their coding of physician performance, determined on the basis of audiotapes of the visits and correlated with indicators of physicians' preventive practices. RESULTS: Accuracy of portrayal of the patient scenario was 84.8% for the male SPs and 93.5% for the female SPs. Inaccuracies in portrayal had no impact on physician performance scores. Accuracy of coding of physician performance was 90.5% for the female SPs (kappa = 0.66) and 90.1% for the male SPs (kappa = 0.68). Coding inaccuracies occurred most frequently for assessment of alcohol consumption and advice against smoking. CONCLUSION: SPs can provide valid information about physicians' professional performance. However, standardization of their activities must not be taken for granted. It may be more difficult to obtain standardized coding for counselling activities, an aspect of physician visits for which SPs are particularly appropriate.",0,0,
1968,Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study,"Background There are recognised gaps between evidence and practice in general practice, a setting posing particular implementation challenges. We earlier screened clinical guideline recommendations to derive a set of ¡®high-impact¡¯ indicators based upon criteria including potential for significant patient benefit, scope for improved practice and amenability to measurement using routinely collected data. Here, we explore health professionals¡¯ perceived determinants of adherence to these indicators, examining the degree to which determinants were indicator-specific or potentially generalisable across indicators.  Methods We interviewed 60 general practitioners, practice nurses and practice managers in West Yorkshire, the UK, about adherence to four indicators: avoidance of risky prescribing""; treatment targets in type 2 diabetes; blood pressure targets in treated hypertension;"" and anticoagulation in atrial fibrillation. Interview questions drew upon the Theoretical Domains Framework (TDF). Data were analysed using framework analysis.  Results Professional role and identity and environmental context and resources featured prominently across all indicators whilst the importance of other domains, for example, beliefs about consequences, social influences and knowledge varied across indicators. We identified five meta-themes representing more general organisational and contextual factors common to all indicators.  Conclusions The TDF helped elicit a wide range of reported determinants of adherence to ¡®high-impact¡¯ indicators in primary care. It was more difficult to pinpoint which determinants, if targeted by an implementation strategy, would maximise change. The meta-themes broadly underline the need to align the design of interventions targeting general practices with higher level supports and broader contextual considerations. However, our findings suggest that it is feasible to develop interventions to promote the uptake of different evidence-based indicators which share common features whilst also including content-specific adaptations.",0,0,
1969,Using the Turning Research Into Practice (TRIP) database: how do clinicians really search?,"OBJECTIVES: Clinicians and patients are increasingly accessing information through Internet searches. This study aimed to examine clinicians' current search behavior when using the Turning Research Into Practice (TRIP) database to examine search engine use and the ways it might be improved. METHODS: A Web log analysis was undertaken of the TRIP database-a meta-search engine covering 150 health resources including MEDLINE, The Cochrane Library, and a variety of guidelines. The connectors for terms used in searches were studied, and observations were made of 9 users' search behavior when working with the TRIP database. RESULTS: Of 620,735 searches, most used a single term, and 12% (n = 75,947) used a Boolean operator: 11% (n = 69,006) used ""AND"" and 0.8% (n = 4,941) used ""OR."" Of the elements of a well-structured clinical question (population, intervention, comparator, and outcome), the population was most commonly used, while fewer searches included the intervention. Comparator and outcome were rarely used. Participants in the observational study were interested in learning how to formulate better searches. CONCLUSIONS: Web log analysis showed most searches used a single term and no Boolean operators. Observational study revealed users were interested in conducting efficient searches but did not always know how. Therefore, either better training or better search interfaces are required to assist users and enable more effective searching.",0,0,
1970,Using theory to improve low back pain care in Australian Aboriginal primary care: a mixed method single cohort pilot study,"BACKGROUND: Low back pain (LBP) care is frequently discordant with research evidence. This pilot study evaluated changes in LBP care following a systematic, theory informed intervention in a rural Australian Aboriginal Health Service. We aimed to improve three aspects of care""; reduce inappropriate LBP radiological imaging referrals, increase psychosocial oriented patient assessment and, increase the provision of LBP self-management information to patients. METHODS: Three interventions to improve care were developed using a four-step systematic implementation approach. A mixed methods pre/post cohort design evaluated changes in the three behaviours using a clinical audit of LBP care in a six month period prior to the intervention and then following implementation. In-depth interviews elicited the perspectives of involved General Practitioners (GPs). Qualitative analysis was guided by the theoretical domains framework. RESULTS: The proportion of patients who received guideline inconsistent imaging referrals (GICI) improved from 4.1 GICI per 10 patients to 0.4 (95% CI for decrease in rate: 1.6 to 5.6) amongst GPs involved in the intervention. Amongst non-participating GPs (locum/part-time GPs who commenced post-interventions) the rate of GICI increased from 1.5 to 4.4 GICI per 10 patients (95 % CI for increase in rate: .5 to 5.3). There was a modest increase in the number of patients who received LBP self-management information from participating GPs and no substantial changes to psychosocial oriented patient assessments by any participants;"" however GPs qualitatively reported that their behaviours had changed. Knowledge and beliefs about consequences were important behavioural domains related to changes. Environmental and resource factors including protocols for locum staff and clinical tools embedded in patient management software were future strategies identified. CONCLUSIONS: A systematic intervention model resulted in partial improvements in LBP care. Determinants of practice change amongst GPs were increased knowledge of clinical guidelines, education delivered by someone considered a trusted source of information, and awareness of the negative consequences of inappropriate practices, especially radiological imaging on patient outcomes. Inconsistent and non-evidence based practices amongst locum GPs was an issue that emerged and will be a significant future challenge. The systematic approach utilised is applicable to other services interested in improving LBP care.",0,0,
1971,"Using Wearable Devices and Smartphones to Track Physical Activity: Initial Activation, Sustained Use, and Step Counts Across Sociodemographic Characteristics in a National Sample","Background: Interest in using wearable devices and smartphones to monitor daily health behaviors, such as physical activity, is growing (1, 2). Many large employers are using these technologies in workplace wellness programs (3). The precision medicine initiative has described how data collected by these technologies can be used to better target interventions. However, the characteristics of persons who use these devices are poorly understood. Objective: To describe rates of initial use of activity trackers, sustained use after 6 months, and step counts across different sociodemographic characteristics from a wellness program offered across the United States. Methods and Findings: Data on activity tracker use, mean daily step counts, and sociodemographic characteristics between 2014 and 2015 were obtained from Humana for insured persons with access to HumanaVitality (now Go365), a wellness program offered across the United States. Median household income from U.S. Census data was linked using ZIP code. Data were received deidentified and deemed exempt from review by the University of Pennsylvania Institutional Review Board.",0,0,
1972,Validating the SF-36 health survey questionnaire: new outcome measure for primary care,"OBJECTIVES To test the acceptability, validity, and reliability of the short form 36 health survey questionnaire (SF-36) and to compare it with the Nottingham health profile. DESIGN Postal survey using a questionnaire booklet together with a letter from the general practitioner. Non-respondents received two reminders at two week intervals. The SF-36 questionnaire was retested on a subsample of respondents two weeks after the first mailing. SETTING Two general practices in Sheffield. PATIENTS 1980 patients aged 16-74 years randomly selected from the two practice lists. MAIN OUTCOME MEASURES Scores for each health dimension on the SF-36 questionnaire and the Nottingham health profile. Response to questions on recent use of health services and sociodemographic characteristics. RESULTS The response rate for the SF-36 questionnaire was high (83%) and the rate of completion for each dimension was over 95%. Considerable evidence was found for the reliability of the SF-36 (Cronbach's alpha greater than 0.85, reliability coefficient greater than 0.75 for all dimensions except social functioning) and for construct validity in terms of distinguishing between groups with expected health differences. The SF-36 was able to detect low levels of ill health in patients who had scored 0 (good health) on the Nottingham health profile. CONCLUSIONS The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity. Its use in other contexts and with different disease groups requires further research.",0,0,
1973,Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes,"Introduction Lung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations.  Methods A factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors (‘patients’). GP participants made management decisions online for six ‘patients’, whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated""; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each ‘patient’ had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression.  Results GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that ‘patients’ had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger ‘patients’ (AOR=0.52; 95% CI 0.39 to 0.7) and black ‘patients’ than white (AOR=0.68;"" 95% CI 0.48 to 0.95).  Conclusions GPs were not more likely to investigate ‘patients’ with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.",0,1,
1974,Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study,"BackgroundInformation about the variation in the risk for venous thromboembolism (VTE) and in prophylaxis practices around the world is scarce. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study is a multinational cross-sectional survey designed to assess the prevalence of VTE risk in the acute hospital care setting, and to determine the proportion of at-risk patients who receive effective prophylaxis."";"" BackgroundInformation about the variation in the risk for venous thromboembolism (VTE) and in prophylaxis practices around the world is scarce. The ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study is a multinational cross-sectional survey designed to assess the prevalence of VTE risk in the acute hospital care setting, and to determine the proportion of at-risk patients who receive effective prophylaxis.",0,0,
1975,"Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings: Updated edition."," This guideline has been developed to advise on the short-term management of violence and aggression in mental health, health and community settings in adults, children (aged 12 years or under) and young people (aged 13 to 17 years). This guideline updates Violence: the Short-term Management of Disturbed/Violent Behaviour in In-Patient Psychiatric Settings and Emergency Departments (NICE clinical guideline 25), which was developed by the National Collaborating Centre for Nursing and Supportive Care and published in 2005. Since the publication of the 2005 guideline, there have been some important advances in our knowledge of the management of violence and aggression, including service users' views on the use of physical intervention and seclusion, and the effectiveness, acceptability and safety of drugs and their dosages for rapid tranquillisation. The previous guideline was restricted to people aged 16 years and over in adult psychiatric settings and emergency departments"";"" this update has been expanded to include some of the previously excluded populations and settings. All areas of NICE clinical guideline 25 have been updated, and this guideline will replace it in full. The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, people with mental health problems who have personally experienced management of violent or aggressive behaviour, their carers and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for the management of violence and aggression, while also emphasising the importance of the experience of these service users' care and the experience of their carers (see Appendix 1 for more details on the scope of the guideline). Although the evidence base is rapidly expanding, there are a number of major gaps. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will assist clinicians, service users and carers, by identifying the merits of particular treatment approaches where evidence from research and clinical experience exists.",0,0,
1976,Violence in general practice: a survey of general practitioners' views,"OBJECTIVE To survey the extent of abuse and violence directed towards general practitioners during the course of their professional duties and to categorize the characteristics of such aggression. DESIGN Retrospective survey of the views of a large sample of general practitioners by using a piloted postal questionnaire. SETTING All medical practices in the west midlands. SUBJECTS A total of 1093 general practitioners (40.6% of the total sample) who responded to the questionnaire. MAIN OUTCOME MEASURE Number of incidents of aggression experienced by the general practitioners during a period of 12 months and the incidence of various precipitating factors. RESULTS Although the response was low at 40.6%, this study is the largest published database on aggression towards family doctors. In all, 687 (62.9%) of the responders had experienced abuse or violence during the previous 12 months, and 191 (17.5%) had experienced some sort of abuse at least once a month and 11 (1%) had experienced verbal abuse every day. Even assuming that all of the non-responders did not experience any violence, then aggression in patients affects 25.5% of general practitioners in the west midlands. For those practitioners who had experienced aggression in patients the annual incidence of an event per general practitioner was 2.42. In all, 96 (14%) of these general practitioners thought that aggression was increasing. A total of 1520 (91.3%) of all incidents comprised verbal abuse or threats with no direct physical act. The surgery was the commonest location for aggression, with 942 (56.6%) incidents"";"" however, 90 (62.5%) of the incidents involving assault or injury occurred during domiciliary visits and 22 (66%) of the injuries were received during night calls. Relatives were the aggressors in 668 (37.6%) cases, anxiety was a precipitant in 435 (25.7%) cases, and a long wait in 183 (10.8%). CONCLUSIONS Violence towards general practitioners is common and may be increasing. Some of the precipitants of aggression are potentially avoidable and practices should make strenuous attempts to identify such factors and remedy them. Staff training in interpersonal skills and recognising anxious or intoxicated patients is essential and should be supplemented by consideration of surgery layout and repair. Doctors should avoid delays for patients by rearranging booking policies or surgery times and lengths. Victims of aggression must be followed up. A prospective study or centralised recording of incidents should be funded.",0,0,
1977,'We can do only what we have the means for' general practitioners' views of primary care for older people with complex health problems,"BACKGROUND: Due to demographic change, general practitioners (GPs) are increasingly required to care for older people with complex health problems. Little is known about the subjective appraisals of GPs concerning the demanded changes. Our objective is to explore how general practitioners view their professional mandates and capacities to provide comprehensive care for older people with complex health problems. Do geriatric training or experience influence viewpoints? Can barriers for the implementation of changes in primary care for older people with complex health problems be detected? METHODS: Preceding a controlled intervention study on case management for older patients in the primary care setting (OMAHA II), this qualitative study included 10 GPs with differing degrees of geriatric qualification. Semi structured interviews were conducted and audio-taped. Full interview transcripts were analyzed starting with open coding on a case basis and case descriptions. The emerging thematic structure was enriched with comparative dimensions through reiterated inter-case comparison and developed into a multidimensional typology of views. RESULTS: Based on the themes emerging from the data and their presentation by the interviewed general practitioners we could identify three different types of views on primary care for older people with complex health problems: 'maneuvering along competence limits', 'Herculean task', and 'cooperation and networking'. The types of views differ in regard to role-perception, perception of their own professional domain, and action patterns in regard to cooperation. One type shows strong correspondence with a geriatrician. Across all groups, there is a shared concern with the availability of sufficient resources to meet the challenges of primary care for older people with complex health problems. CONCLUSIONS: Limited financial resources, lack of cooperational networks, and attitudes appear to be barriers to assuring better primary care for older people with complex health problems. To overcome these barriers, geriatric training is likely to have a positive impact but needs to be supplemented by regulations regarding reimbursement. Most of all, general practitioners' care for older people with complex health problems needs a conceptual framework that provides guidance regarding their specific role and contribution and assisting networks. For example, it is essential that general practice guidelines become more explicit with respect to managing older people with complex health problems.",0,0,
1978,Web-based computer-tailoring for practice nurses aimed to improve smoking cessation guideline adherence: A study protocol for a randomized controlled effectiveness trial,"BACKGROUND: Dutch practice nurses sub-optimally adhere to evidence-based smoking cessation guidelines. Web-based computer-tailoring could be effective in improving their guideline adherence. Therefore, this paper aims to describe the development of a web-based computer-tailored program and the design of a randomized controlled trial testing its (cost-)effectiveness. METHODS: Theoretically grounded in the I-Change Model and Self-Determination Theory, and based on the results of a qualitative needs assessment among practice nurses, a web-based computer-tailored program was developed including three modules with tailored advice, an online forum, modules with up-to-date information about smoking cessation, Frequently Asked Questions (FAQs) and project information, and a counseling checklist. The program's effects are assessed by comparing an intervention group (access to all modules) with a control group (access to FAQs, project information and counseling checklist only). Smoking cessation guideline adherence and behavioral predictors (i.e. intention, knowledge, attitude, self-efficacy, social influence, action and coping planning) are measured at baseline and at 6- and 12-month follow-up. Additionally, the program's indirect effects on smokers' quit rates and the number of quit attempts are assessed after 6 and 12months. DISCUSSION: This paper describes the development of a web-based computer-tailored adherence support program for practice nurses and the study design of a randomized controlled trial testing its (cost-)effectiveness. This program potentially contributes to improving the quality of smoking cessation care in Dutch general practices. If proven effective, the program could be adapted for use by other healthcare professionals, increasing the public health benefits of improved smoking cessation counseling for smokers.",0,0,
1979,Web-based interventions for ulcerative colitis and Crohn's disease: systematic review and future directions,"Behavioral intervention technologies (BITs), the application of psychological and behavioral interventions through the use of technology, provide the opportunity for clinicians to deliver care through a means that overcomes a number of treatment barriers. Web-based interventions are a subset of BITs developing as promising alternatives to face-to-face delivery of treatments and monitoring for patients with ulcerative colitis (UC) and Crohn's disease (CD). A systematic review of literature resulted in five empirical studies of web-based interventions for UC and CD. Additionally, an informal search of a popular search engine yielded limited, currently available, web-based interventions for patients with UC and CD. Despite being an ideal population for the development and dissemination of online interventions, patients with UC and CD have far less treatment options compared to other behavioral health concerns. However, given the growing body of research involving web-based interventions for other conditions, researchers and clinicians targeting UC and CD management and treatment have the benefit of being able to utilize the BIT model, an existing conceptual framework for the development of web-based interventions for both conditions. The BIT model is presented and applied to the treatment of UC and CD, as well as a technology development program, Purple, and usability guidelines to guide clinical researchers in the future development, evaluation, and dissemination of BITs for patients with UC and CD.",0,0,
1980,Weekly E-mail reminders influence emergency physician behavior: a case study using the Joint Commission and Centers for Medicare and Medicaid Services Pneumonia Guidelines,"OBJECTIVES: Improving physician compliance with evidence-based guidelines is challenging. The authors wanted to determine if weekly e-mail reminders to emergency department (ED) staff increase compliance with Joint Commission and the Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia quality measures. METHODS: One nurse administrator reviewed records on a weekly basis for all adult patients admitted to the hospital from the ED with a working diagnosis of pneumonia. An e-mail was then sent to all ED staff indicating the percentage of patients with antibiotic timing less than 4 hours from arrival. The names of individuals who administered antibiotics in less than 1 hour were highlighted. This study compared the time to antibiotics for 11 months before and 11 months after commencing this intervention. RESULTS: There were 281 patients in the control cohort, and 37 met exclusion criteria, leaving 244 for analysis. There were 342 patients in the intervention cohort, and 40 met exclusion criteria, leaving 302 for analysis. The median time from arrival to chest radiograph order decreased significantly from 61 to 47 minutes (p < 0.001). The median time interval from chest radiograph order to antibiotic administration did not change significantly (92 to 88 minutes, p = 0.294). The overall median time from arrival to antibiotic administration decreased significantly from 162 to 146 minutes (p = 0.018). The percentage of patients with antibiotic administration within 4 hours increased from 77.5% to 86.1% (p = 0.009). CONCLUSIONS: Weekly e-mail reminders listing performance on antibiotic administration recommendations are associated with increased compliance with a clinical guideline.",1,1,
1981,Weight Care Project: Health professionals' attitudes and ability to assess body weight status - study protocol,"BACKGROUND: Health professionals working in primary care and public health have opportunities to address body weight status issues with their patients through face-to-face contact. The objectives of this all-Ireland project are: 1. to assess the attitudes, current practices/behaviours and knowledge of key health professional groups on body weight status""; 2. to assess the health professional groups' ability to identify body weight status in both adults and children. The health professional groups are: (a) community related public health nurses; (b) school public health nurses; (c) GPs and practice nurses (primary care);"" and (d) occupational health nurses (workplace) from both Northern Ireland and the Republic of Ireland. METHODS/DESIGN: This all-Ireland multi-disciplinary project follows a mixed methods approach using both quantitative and qualitative methodologies, and consists of four components:1. Literature review - to explore the role of health professionals in managing obesity through spontaneous intervention in a variety of health promotion settings.2. Telephone interviews and focus groups - to gain an in-depth insight into the views of health professionals in assessing body weight status.3. Survey (primarily online but also paper-based) - to determine the attitudes, current practices/behaviours and knowledge of health professionals in assessing body weight status.4. Online evaluation study - an online interactive programme will be developed to assess health professionals' ability to identify the body weight status of adults and children. DISCUSSION: This project will assess and report the attitudes, current practices/behaviours and knowledge of key health professional groups within Northern Ireland and the Republic of Ireland on body weight status, and their ability to identify body weight status in both adults and children. The results of this project will generate recommendations for clinical practice in managing obesity, which may inform policy guidelines.",0,0,
1982,"Weight maintenance: challenges, tools and strategies for primary care physicians","Obesity is recognized as a chronic disease and one of the major healthcare challenges facing us today. Weight loss can be achieved via lifestyle, pharmacological and surgical interventions, but weight maintenance remains a lifetime challenge for individuals with obesity. Guidelines for the management of obesity have highlighted the role of primary care providers (PCPs). This review examines the long-term outcomes of clinical trials to identify effective weight maintenance strategies that can be utilized by PCPs. Because of the broad nature of the topic, a structured PubMed search was conducted to identify relevant research articles, peer-reviewed reviews, guidelines and articles published by regulatory bodies. Trials have demonstrated the benefit of sustained weight loss in managing obesity and its comorbidities. Maintaining 5-10% weight loss for >/=1 year is known to ameliorate many comorbidities. Weight maintenance with lifestyle modification - although challenging - is possible but requires long-term support to reinforce diet, physical activity and behavioural changes. The addition of pharmacotherapy to lifestyle interventions promotes greater and more sustained weight loss. Clinical evidence and recently approved pharmacotherapy has given PCPs improved strategies to support their patients with maintenance of weight loss. Further studies are needed to assess the translation of these strategies into clinical practice.",0,0,
1983,Weighty matters--an approach to childhood overweight in general practice,"BACKGROUND: In Australia, childhood obesity now rivals asthma as the most prevalent chronic child health condition. The past 2 decades have shown a rapidly rising prevalence of childhood overweight and obesity with no sign that this trajectory will plateau. Primary care is increasingly recognised as a forum in which to address this growing public health issue. OBJECTIVE: This article discusses the epidemiology of childhood overweight and obesity in Australia and their associated physical and psychosocial morbidities. It discusses the current evidence base and resources for the definition, investigation and management of childhood obesity and outlines an approach in the primary care setting. It also reports a recently developed general practitioner delivered intervention to reduce overweight in primary school aged children--the Live, Eat and Play (LEAP) project. DISCUSSION: Clear clinical practice guidelines for the assessment and management of overweight and obesity in childhood in primary care now exist. The feasibility of these guidelines, and the availability of resources required to deliver them, is not yet clear. The LEAP project proposes an effective intervention delivered by general practitioners to address this vital and complex issue.",0,0,
1984,Well balanced: 8 steps to wellness for adults with mental illness and diabetes,"Serious mental illness places a tremendous burden on clients, their families, and behavioral and medical health care providers. The co-occurrence of diabetes with mental illness may further compromise daily functioning. Psychiatric nurses can make a significant difference in improving the health and medical outcomes of this client population. A partnership was developed between the University of Rochester School of Nursing and the Western New York Care Coordination Program to evaluate a novel nursing model for adults with both serious mental illness and diabetes mellitus. The Well Balanced program incorporated health promotion, disease management, nursing care management, and evidence-based practice guidelines into 8 Steps to Wellness for a community-based mental health population. During a 16-visit intervention period, psychiatric nurses interacted with 74 clients. As a result of the program, clients experienced improvements in health risk status and in their hemoglobin A1C and reported high satisfaction with the Well Balanced program.",0,0,
1985,WellDoc mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction,"BACKGROUND: Less than 63% of individuals with diabetes meet professional guidelines target of hemoglobin A1c <7.0%, and only 7% meet combined glycemic, lipid, and blood pressure goals. The primary study aim was to assess the impact on A1c of a cell phone-based diabetes management software system used with web-based data analytics and therapy optimization tools. Secondary aims examined health care provider (HCP) adherence to prescribing guidelines and assessed HCPs' adoption of the technology. METHODS: Thirty patients with type 2 diabetes were recruited from three community physician practices for a 3-month study and evenly randomized. The intervention group received cell phone-based software designed by endocrinologists and CDEs (WellDoc Communications, Inc., Baltimore, MD). The software provided real-time feedback on patients' blood glucose levels, displayed patients' medication regimens, incorporated hypo- and hyperglycemia treatment algorithms, and requested additional data needed to evaluate diabetes management. Patient data captured and transferred to secure servers were analyzed by proprietary statistical algorithms. The system sent computer-generated logbooks (with suggested treatment plans) to intervention patients' HCPs. RESULTS: The average decrease in A1c for intervention patients was 2.03%, compared to 0.68% (P < 0.02, one-tailed) for control patients. Of the intervention patients, 84% had medications titrated or changed by their HCP compared to controls (23%, P = 0.002). Intervention patients' HCPs reported the system facilitated treatment decisions, provided organized data, and reduced logbook review time. CONCLUSIONS: Adults with type 2 diabetes using WellDoc's software achieved statistically significant improvements in A1c. HCP and patient satisfaction with the system was clinically and statistically significant.",0,0,
1986,What are specialist mental health clinician attitudes to guideline recommendations for the treatment of depression in young people?,"OBJECTIVES: We sought to examine potential barriers to the use of evidence-based guidelines for youth depression in a tertiary specialist mental health service, as part of an initiative to implement evidence based practice within the service. METHODS: This was a qualitative study adopting a social constructionist perspective using focus groups. The focus groups, conducted with all clinicians (medical and allied health), were audiotaped, transcribed and thematic analysis was undertaken. Clinicians were asked about the barriers to implementing four key recommendations from the National Institute for Health and Clinical Excellence (NICE) guidelines. RESULTS: Barriers existed at (i) the individual clinician level""; (ii) the clinical level in terms of the presentation of young people;"" and (iii) the service level. The key individual clinician level barrier was a stated belief that the guidelines were not relevant to the young people presenting to the service, with little evidence to guide practice. Related, the main barrier with regard to the clinical presentation was the severity and complexity of this presentation, often making the delivery of interventions like cognitive behavioural therapy (CBT) difficult. At the service level, a lack of integration with primary and secondary level care meant sequencing interventions according to guideline recommendations was difficult. CONCLUSIONS: There is a clear imperative to develop the evidence base to ensure that effective treatments for young people aged up to 25 years with severe and complex disorders that include comorbid conditions, suicide risk and psychosocial difficulties are investigated and disseminated. Furthermore, this work has highlighted the need for greater investment in models of care that ensure integration between existing primary and secondary care and enhanced specialist early intervention mental health services for young people.",0,0,
1987,What do general practitioners think and do about prostate cancer screening in Australia?,BACKGROUND: Men seek advice from their general practitioner (GP) on the merits of screening for prostate cancer. This study aimed to examine how the knowledge and clinical experience of GPs influenced their position on prostate cancer screening. METHODS: A total of 13 focus groups were set up with 77 GPs. Focus group discussions were audio-taped and transcribed verbatim. Transcripts were analysed by two investigators via thematic analysis. RESULTS: GPs were evenly divided between those who proactively screen men for prostate cancer and those who do so only at the patient's request. GPs had limited knowledge of recently published evidence from trials on prostate cancer screening. DISCUSSION: Effective methods of increasing GP knowledge about evidence-based recommendations and potentially changing clinical behaviour are required in order to promote evidence-based decision-making by GPs and their patients.,0,0,
1988,What do patients and relatives know about problems and failures in care?,"Objective To understand what patients and family members know about problems and failures in healthcare.  Design Qualitative, semistructured open-ended interviews were conducted with 39 patients and 80 family members about their experiences of incidents in tertiary healthcare. Nineteen interviews involved more than one respondent, yielding 100 interviews in total. Participants were recruited through advertisements in the national broadsheet and tabloid print media (43%), with the help of the health services where the incidents occurred (28%), through invitations sent out by two internet marketing companies (27%) and by consumer organisations (2%).  Setting Interviews were conducted in the homes of the respondents or over the phone. One participant emailed her responses to the questionnaire.  Results Analysis of the interview data revealed: (1) considerable knowledge on the part of patients and relatives about health service risks, problems and incidents""; (2) the insight of interviewees into care improvement opportunities;"" and (3) challenges faced by patients and relatives when trying to negotiate their knowledge and insights with health service staff.  Conclusion Patients (and family members) need access to structured processes ensuring dialogue with health service personnel about perceived risks, problems and incidents. Such dialogue would reveal patients' and family members' questions and knowledge about improvement opportunities, and minimise the risk that their questions and knowledge are ignored.",0,0,
1989,What do persons with mental illnesses need to quit smoking? Mental health consumer and provider perspectives,"OBJECTIVES: Forty-one percent (41%) of persons in the U.S. who reported having recent mental illnesses also smoke cigarettes. Tobacco use among this population is associated with up to 25 less years of life and excess medical comorbidity compared to the general population. While research demonstrates that tobacco interventions can be effective for persons with mental illnesses, they are not commonly utilized in clinical practice. The current study explored how to adapt evidence-based tobacco cessation interventions to meet the unique physiological, psychological, and social challenges facing persons with mental illnesses. METHODS: Ten focus groups were conducted utilizing a semi-structured discussion"";"" 5 for adult mental health consumers (n = 62) and 5 with mental health clinicians and administrators (n = 22). Content analysis was used to organize themes into categories. RESULTS: Five thematic categories were found: (1) Barriers to treatment, (2) Resources and infrastructure, (3) Negative influences on smoking behavior, (4) Knowledge deficits, and (5) Treatment needs. CONCLUSIONS: These findings are instructive in developing appropriate tobacco cessation services for this population. Specifically, these data have been incorporated into a mental health provider toolkit for smoking cessation and have informed the development of a tobacco cessation intervention study.",0,0,
1990,What i would say to the Royal Commission. Our neglected wastelands,,0,0,
1991,What implementation interventions increase cancer screening rates? a systematic review,"Background Appropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. As part of a larger agenda to create an implementation guideline, we conducted a systematic review to evaluate interventions designed to increase the rate of breast, cervical, and colorectal cancer (CRC) screening. The interventions considered were: client reminders, client incentives, mass media, small media, group education, one-on-one education, reduction in structural barriers, reduction in out-of-pocket costs, provider assessment and feedback interventions, and provider incentives. Our primary outcome, screening completion, was calculated as the overall median post-intervention absolute percentage point (PP) change in completed screening tests.  Methods Our first step was to conduct an iterative scoping review in the research area. This yielded three relevant high-quality systematic reviews. Serving as our evidentiary foundation, we conducted a formal update. Randomized controlled trials and cluster randomized controlled trials, published between 2004 and 2010, were searched in MEDLINE, EMBASE and PSYCHinfo.  Results The update yielded 66 studies new eligible studies with 74 comparisons. The new studies ranged considerably in quality. Client reminders, small media, and provider audit and feedback appear to be effective interventions to increase the uptake of screening for three cancers. One-on-one education and reduction of structural barriers also appears effective, but their roles with CRC and cervical screening, respectively, are less established. More study is required to assess client incentives, mass media, group education, reduction of out-of-pocket costs, and provider incentive interventions.  Conclusion The new evidence generally aligns with the evidence and conclusions from the original systematic reviews. This review served as the evidentiary foundation for an implementation guideline. Poor reporting, lack of precision and consistency in defining operational elements, and insufficient consideration of context and differences among populations are areas for additional research.",0,1,
1992,What is the role of the general practitioner towards the family caregiver of a community-dwelling demented relative? A systematic literature review,"OBJECTIVE: To identify the attitudes and perspectives of the family physician towards the caregivers of demented relatives and to describe the caregivers' satisfaction. DESIGN: Systematic review. SUBJECTS: The studied population consisted of dementia family and their general practitioners. MAIN OUTCOME MEASURES: Outcome measures were the generic tasks and skills of the general practitioner to improve home care from the perspective of the family caregiver. Caregivers were assessed on satisfaction regarding the care provided by their general practitioner. RESULTS: The general practitioner is aware of his/her skills and limits in all aspects of dementia care and his/her role towards the family caregiver. They also acknowledged the importance of an adequate diagnostic process, but they felt uncomfortable disclosing the diagnosis to both the patient and the caregiver. They reported having more confidence in treatment matters than in diagnostic stages. Caregivers' reports on the attitude of their general practitioner in the diagnostic process were rated from helpful to poorly empathized. General practitioners found themselves to be highly involved in dementia home care, but caregivers rated their involvement to be insufficient. The lack of appropriate communication skills of general practitioners was also not appreciated by the caregivers. A lack of time and reward was considered by the general practitioner to be a major obstacle in dementia care. CONCLUSION: The key role of general practitioners as care providers and care planners is consolidated by the family caregivers' confidence in their skills. Clear guidelines from early diagnosis to adequate referrals should improve the ability of the general practitioner to support these time and energy-consuming home-care situations. Intervention studies addressing the gaps in the skills of the general practitioners in dementia home care management could be helpful in supporting the family caregiver.",0,0,
1993,"What is the value of the routine use of patient-reported outcome measures toward improvement of patient outcomes, processes of care, and health service outcomes in cancer care? A systematic review of controlled trials","PURPOSE: The systematic use of patient-reported outcome measures (PROMs) has been advocated as an effective way to standardize cancer practice. Yet, the question of whether PROMs can lead to actual improvements in the quality of patient care remains under debate. This review examined whether inclusion of PROM in routine clinical practice is associated with improvements in patient outcomes, processes of care, and health service outcomes during active anticancer treatment. METHODS: A systematic review of five electronic databases (Medline, EMBASE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], PsycINFO, and Psychology and Behavioral Sciences Collection [PBSC]) was conducted from database inception to May 2012 to locate randomized and nonrandomized controlled trials of patients receiving active anticancer treatment or supportive care irrespective of type of cancer. RESULTS: Based on prespecified eligibility criteria, we included 26 articles that reported on 24 unique controlled trials. Wide variability in the design and use of interventions delivered, outcomes evaluated, and cancer- and modality-specific context was apparent. Health service outcomes were only scarcely included as end points. Overall, the number of statistically significant findings were limited and PROMs' intervention effect sizes were predominantly small-to-moderate. CONCLUSION: The routine use of PROMs increases the frequency of discussion of patient outcomes during consultations. In some studies, PROMs are associated with improved symptom control, increased supportive care measures, and patient satisfaction. Additional effort is required to ensure patient adherence, as well as additional support to clinicians who will respond to patient concerns and issues, with clear system guidelines in place to guide their responses. More research is required to support PROM cost-benefit in terms of patient safety, clinician burden, and health services usage.",0,0,
1994,What shall we teach undergraduates?,"The opinions of 600 randomly selected doctors on what should be taught to undergraduates in clinical years were analysed. The respondents gave a high priority to general medicine, paediatrics, general surgery, casualty, and gynaecology, but a low priority to forensic medicine, plastic surgery, radiotherapy, anaesthetics, radiology, and rehabilitation medicine. Doctors thought that these should be taught to postgraduates. The two major groupings of doctors--general practitioners and consultants--gave essentially the same priorities. Undergraduate curricula cannot include all major specialities, so the results of this analysis may provide a useful basis for selecting the most suitable subjects. Criteria for including other specialties might be the ability and enthusiasm of the teachers and well-thought-out and academically sound teaching programmes.",0,0,
1995,What's in a setting?: Influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use,"BACKGROUND: Organizational culture is an important but underinvestigated feature of the work environment that can impact provider behavior, including adherence to clinical practice guidelines. There is substantial evidence that physician assistance to smokers can produce significant reductions in tobacco use. However, this evidence has not been well translated into practice, as only a small proportion of smokers receive recommended treatment during medical visits. PURPOSE: This study examines organizational culture as a contextual feature of primary care clinics and its impact on adherence to evidence-based guidelines for treating tobacco use. METHODOLOGY: Cross-sectional survey data were collected from 500 primary care providers in 60 community clinics located in New York City. Relationships between provider adherence to ""5A"" clinical guidelines, as recommended by the U.S. Public Health Service, and both provider and organizational covariates were described. We used hierarchical linear modeling to examine the associations between clinic culture and provider treatment patterns. FINDINGS: Providers in clinics with stronger ""group/clan,"" ""hierarchical,"" and ""rational"" culture types, as compared with a ""developmental"" culture, reported greater adherence to 5A guidelines (p < .05). System-level structures and care processes were positively associated (p < .01), whereas number of ongoing quality initiatives was negatively associated with 5A delivery (p < .05). Provider familiarity with guidelines (p < .01), confidence with cessation counseling (p < .05), and perceived effectiveness in helping smokers quit were associated with more frequent 5A intervention (p < .01). PRACTICE IMPLICATIONS: Findings suggest that organizational culture can influence provider adherence to cessation treatment guidelines, even when controlling for other factors known to affect practice patterns. Specifically, cultures that emphasize human resources and performance standards are conducive to integrating 5A guidelines into routine practice. Understanding the role of organizational culture enables healthcare managers and practitioners to be strategic when implementing, and also sustaining, use of evidence-based guidelines.",0,0,
1996,What's on YOUR Facebook profile? Evaluation of an educational intervention to promote appropriate use of privacy settings by medical students on social networking sites,"BACKGROUND: The rise of social media has led to growing concerns about the potential implications of 'unprofessional' postings by physicians and medical students on individuals, institutions, and the medical profession. Relevant and effective guidelines have been difficult to develop and enforce, and there is a need for students and physicians to consider how their online activities may be perceived in the context of their professional roles. The purpose of this project was to examine the Internet presence of a graduating Canadian medical school class by scanning students' public profiles on the social media site Facebook, incorporate this information into an educational activity addressing professionalism and social media, and evaluate the impact of this activity on student behavior. METHODS: A systematic search for public Facebook profiles of each member of the class was conducted, and data were collected on the types of publicly visible material. These were presented as part of an educational session on social media and professionalism. One month later, the Facebook search was repeated. RESULTS: Of 152 students in the class, profiles were found for 121 (79.8%). The majority of students used appropriately restrictive privacy settings"";"" however, a significant minority had publicly visible information, including comments, photographs, location, and status as a medical student. The educational innovation was well received with more than 90% of students agreeing that this topic was important and well addressed. A follow-up search found that many students had altered their privacy settings to make less information publicly available. CONCLUSIONS: A small but significant proportion of students share potentially unprofessional content on social media. An interactive educational intervention, which includes specific disclosure of how participants appear to others on social media, resulted in a significant change in student behavior.",0,0,
1997,When is it cost-effective to change the behavior of health professionals?,"Because of the workings of health care systems, new, important, and cost-effective treatments sometimes do not become routine care while well-marketed products of equivocal value achieve widespread adoption. Should policymakers attempt to influence clinical behavior and correct for these inefficiencies? Implementation methods achieve a certain level of behavioral change but cost money to enact. These factors can be combined with the cost-effectiveness of treatments to estimate an overall policy cost-effectiveness. In general, policy cost-effectiveness is always less attractive than treatment cost-effectiveness. Consequently trying to improve the uptake of underused cost-effective care or reduce the overuse of new and expensive treatments may not always make economic sense. In this article, we present a method for calculating policy cost-effectiveness and illustrate it with examples from a recent trial, conducted during 1997 and 1998, of educational outreach by community pharmacists to influence physician prescribing in England.",0,0,
1998,When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making,"For long the medical literature has shown that patients do not always receive appropriate care, including pharmacotherapeutic treatment. To achieve improved patient care, a number of physician-oriented interventions are being delivered internationally in an attempt to implement evidence based medicine in routine daily practice of medical practitioners. The pharmacy profession has taken an active role in the delivery of intervention strategies aimed at promoting evidence based prescribing and improved quality and safety of medicine use. However, the medical literature also supports the notion that valid clinical care recommendations do not always have the desired impact on physician behaviour. We argue that the well-established theory of psychological reactance might at least partially explain instances when physicians do not act upon such recommendations. Reactance theory suggests that when recommended to take a certain action, a motivational state compels us to react in a way that affirms our freedom to choose. Often we choose to do the opposite of what the recommendation is proposing that we do or we just become entrenched in our initial position. The basic concepts of psychological reactance are universal and likely to be applicable to the provision of recommendations to physicians. Making recommendations regarding clinical care, including pharmacotherapy, may carry with it implied threats, as it can be perceived as an attempt to restrict one's freedom of choice potentially generating reactance and efforts to avoid them. By identifying and taking into account factors likely to promote reactance, physician-oriented interventions could become more effective.",0,0,
1999,When the bough breaks: rethinking treatment strategies for perinatal depression,Awareness of depression among OB-GYN physicians has increased with the result that more than 13% of pregnant women in the United States receive prescriptions for antidepressant medications. But the safety and effectiveness of these compounds has been exaggerated while the effectiveness of psychotherapy has been overlooked and distorted and various medical guidelines for treatment of perinatal depression have been downplayed or ignored. This article addresses the common fears and misconceptions surrounding treatment of depression during pregnancy and after childbirth. The effectiveness of strategic cognitive-behavioral therapy enhanced with hypnosis offers excellent results without the risks associated with these medications. Targets for focused intervention are identified and discussed.,0,0,
2000,When to initiate dialysis: effect of proposed US guidelines on survival,"BackgroundRecent guidelines from the US National Kidney Foundation Dialysis Outcomes Quality Initiative recommend an earlier start of dialysis treatment than has been common practice. Their implementation would have a substantial effect on patients' daily lives and would increase costs. The guidelines are largely opinion-based, because evidence is still lacking."";"" BackgroundRecent guidelines from the US National Kidney Foundation Dialysis Outcomes Quality Initiative recommend an earlier start of dialysis treatment than has been common practice. Their implementation would have a substantial effect on patients' daily lives and would increase costs. The guidelines are largely opinion-based, because evidence is still lacking.",0,0,
2001,Where shall John go? Newfoundland,,0,0,
2002,Who wrote the Declaration of Helsinki?,,0,0,
2003,Why are clinicians not embracing the results from pivotal clinical trials in severe sepsis? A bayesian analysis,"BACKGROUND: Five pivotal clinical trials (Intensive Insulin Therapy""; Recombinant Human Activated Protein C [rhAPC]; Low-Tidal Volume; Low-Dose Steroid; Early Goal-Directed Therapy [EGDT]) demonstrated mortality reduction in patients with severe sepsis and expert guidelines have recommended them to clinical practice. Yet, the adoption of these therapies remains low among clinicians. OBJECTIVES: We selected these five trials and asked: Question 1--What is the current probability that the new therapy is not better than the standard of care in my patient with severe sepsis? Question 2--What is the current probability of reducing the relative risk of death (RRR) of my patient with severe sepsis by meaningful clinical thresholds (RRR >15%; >20%; >25%)? METHODS: Bayesian methodologies were applied to this study. Odds ratio (OR) was considered for Question 1, and RRR was used for Question 2. We constructed prior distributions (enthusiastic;"" mild, moderate, and severe skeptic) based on various effective sample sizes of other relevant clinical trials (unfavorable evidence). Posterior distributions were calculated by combining the prior distributions and the data from pivotal trials (favorable evidence). MAIN FINDINGS: Answer 1--The analysis based on mild skeptic prior shows beneficial results with the Intensive Insulin, rhAPC, and Low-Tidal Volume trials, but not with the Low-Dose Steroid and EGDT trials. All trials' results become unacceptable by the analyses using moderate or severe skeptic priors. Answer 2--If we aim for a RRR>15%, the mild skeptic analysis shows that the current probability of reducing death by this clinical threshold is 88% for the Intensive Insulin, 62-65% for the Low-Tidal Volume, rhAPC, EGDT trials, and 17% for the Low-Dose Steroid trial. The moderate and severe skeptic analyses show no clinically meaningful reduction in the risk of death for all trials. If we aim for a RRR >20% or >25%, all probabilities of benefits become lower independent of the degree of skepticism. CONCLUSIONS: Our clinical threshold analysis offers a new bedside tool to be directly applied to the care of patients with severe sepsis. Our results demonstrate that the strength of evidence (statistical and clinical) is weak for all trials, particularly for the Low-Dose Steroid and EGDT trials. It is essential to replicate the results of each of these five clinical trials in confirmatory studies if we want to provide patient care based on scientifically sound evidence.",0,0,
2004,Why do physicians treat their relatives? Exploring the influence of social psychology,"Physicians often receive requests for treatment, medical advice, or other intervention from relatives. Most doctors comply. Reasons for compliance can be categorized by doctors' attitudes toward the relative, colleagues, themselves, ethical guidelines, and the problem. Compliance may be influenced by elements of social psychology as well. Social exchange theory, persuasion techniques, attribution, conformity, desire for approval, and the affinity principle can induce intervention. Future research should explore doctors' attitudes toward relatives, the medium by which requests are made, treatment outcomes, changes in the relationship following treatment, cultural or familial norms, and changes in clinicians' beliefs or behavior that occur when facing opposing requests and guidelines. Awareness of these influences may help physicians to make objective decisions regarding intervention.",0,0,
2005,Why even good physicians do not wash their hands,,0,0,
2006,Why no guidelines for behavior modification?,"This paper reviews the guidelines for behavioral programs published by the National Association of Retarded Children. The review discusses a number of reasons why guidelines should not be enunciated for behavior modification, e.g., the procedures of behavior modification appear to be no more or less subject to abuse and no more or less in need of ethical regulation than intervention procedures derived from any other set of principles and called by other terms. The review recommends alternative methods for protecting the rights of clients who participate in behavioral programs. Specifically, behavioral clinicians, like other therapists, should be governed by the ethics codes of their professions"";"" also, the ethics of all intervention programs should be evaluated in terms of a number of critical issues.",0,0,
2007,Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts,"BACKGROUND: Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines. OBJECTIVE: To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts. DESIGN: Retrospective review. SETTING: Tertiary care hospital. PARTICIPANTS: Inpatient healthcare providers. INTERVENTION: Provider-BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record. MEASUREMENTS: Provider (free-text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by chi(2) analysis and kappa scoring. RESULTS: Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to ""symptomatic"" anemia (11%-12%). Many providers transfused in anticipation of surgical or procedural intervention (10%-15%) or imminent hospital discharge (2%-5%). Resident physicians represented the majority (55%) of providers interacting with BPAs. CONCLUSION: Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors.",0,0,
2008,Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study,"BACKGROUND: Knee arthroscopy has historically been a common treatment for knee osteoarthritis. However, multiple Randomised Controlled Trials along with a Cochrane review has led NICE to recommend that arthroscopy is not used in the vast majority of patients that have knee osteoarthritis. These recommendations have been replicated internationally. The use of arthroscopy for knee osteoarthritis has decreased"";"" however, it is still prevalent. This study examines the factors that are perceived to influence decision-making using a theoretical framework that was developed for behaviour change research (Theoretical Domains Framework). This study will allow future work to develop and evaluate an intervention specifically targeted to the barriers identified. METHODS: A multimodal approach was used including questionnaire research and semi-structured interviews with all grades of physician offering a knee arthroscopy service in a Level One Trauma Centre in the West Midlands, U.K. Focus groups with patients were also conducted. Mixed methods analysis was used, with descriptive statistics for quantitative data, and thematic content analysis for qualitative data. RESULTS: A total of 26 surgeons responded to questionnaires, with 6 semi-structured interviews taking place. All surgical grades were represented. Two focus groups of six patients were performed. The results identified 13 beliefs across 12 domains (some beliefs were represented across domains). The beliefs that there was a pressure from patients to do something, that there were limited other options available, that surgeons wanted to meet patients expectations, and that there was a time pressure in clinic appeared to be the predominant barriers. CONCLUSIONS: Using the Theoretical Domains Framework, this paper has described the relevant barriers and enablers to the implementation of NICE guidance regarding arthroscopy use in patients with knee osteoarthritis. The next step in this process is the development of a targeted intervention, and we discuss the barriers that are most likely to alter practice if targeted through an intervention, and how such an intervention could look. Such an intervention would require evaluation within the clinical setting.",0,0,
2009,Why women do not ask for information on preconception health? A qualitative study,"BACKGROUND: Preconception care involves health promotion to reduce risk factors that might affect women and couples of childbearing age. The risk factors of adverse reproductive outcomes include recognized genetic diseases in the family or the individual, previous congenital diseases, miscarriage, prematurity, fetal growth restriction, infertility, chronic maternal diseases, lifestyle, and occupational or environmental factors. Effective preconception care involves a range of preventive, therapeutic and behavioural interventions. Although in Italy there are national preconception care recommendations concerning the general population, they are usually encouraged informally and only for single risk factors. At present there is increasing interest in offering a global intervention in this field. The aim of this study was to investigate attitudes and behaviours of Italian women of childbearing age and healthcare professionals regarding preconception health. METHODS: We conducted a qualitative study among women of childbearing age and healthcare professionals between February 2014 and February 2015. Five focus groups were held: 2 with non-pregnant women aged 22 to 44 years and 3 with healthcare professionals. Discussion topics included women's questions about preconception health, worries and barriers regarding preconception care interventions, attitudes and behaviours of women and healthcare professionals towards preconception health, women's information sources. In the analysis of the focus groups priority was given to what was said by the women, supplemented by information from the healthcare professionals' focus groups. RESULTS: Fourteen women of childbearing age (8 nulliparae and 6 multiparae) and 12 healthcare professionals (3 nurses, 4 midwives, 5 doctors) participated in the focus groups. The results indicate the presence of many barriers and a lack of awareness of preconception health relating to women, healthcare professionals and policies. Women's knowledge and attitudes towards primary preconception care information are described. The main reference source of information in this field for Italian women seems to be their obstetric-gynaecologist. CONCLUSIONS: The study indicates that several barriers influence preconception care in Italy. Moreover, a lack of awareness of preconception health and care among Italian women of childbearing age and healthcare professionals emerges. The findings might contribute to strategies for the implementation of preconception care guidelines.",0,0,
2010,WIC providers' perspectives on offering smoking cessation interventions,"PURPOSE: To examine the perspectives of WIC clinic providers on offering smoking cessation interventions for pregnant women. STUDY DESIGN AND METHODS: Four focus groups consisting of WIC nurses, dietitians, and social workers (N = 25) were conducted at WIC clinics in eastern Iowa. Researchers developed discussion guidelines to determine how WIC providers currently approached pregnant women who smoke cigarettes and what they considered barriers to providing effective smoking cessation interventions. Code mapping was used to analyze focus group discussions. RESULTS: Factors influencing the ability of WIC staff to provide a smoking cessation intervention for pregnant women included available time, clinic priorities, staff approaches to clients, and staff training. In addition, providers expressed concerns about educational materials for clients as well as additional client issues that prevented smoking cessation. The absence of mechanisms to track clinic outcomes related to smoking cessation was also noted. CLINICAL IMPLICATIONS: WIC providers have time limitations that may necessitate minimal or low-intensity interventions for smoking cessation, but did not know that such approaches are actually effective. WIC providers require more education about the entire issue of smoking cessation in order to become more proactive in their attempts to help pregnant women quit. Training that enhances self-efficacy and understanding of the impact of smoking on mothers, infants, and children should be initiated to motivate staff to intervene. Another strategy to motivate WIC staff in this regard could be tracking clinic outcomes in helping women to quit smoking or prevent relapse.",0,0,
2011,Will mothers of sick children help their husbands to stop smoking after receiving a brief intervention from nurses? Secondary analysis of a randomised controlled trial,"BACKGROUND: Second-hand smoke is a severe health hazard for children. Clinical guidelines suggest that nurses advise smoking parents to quit when they accompany their sick children to paediatric settings, but the guidelines did not mention what nurses can do if the parents are not with the children. This study examines the effectiveness of a low-intensity, nurse-led health instructional initiative for non-smoking mothers, to motivate them to take action to help their husbands stop smoking. METHODS: This was a randomised controlled trial and 1,483 non-smoking women, who were living with husbands who do smoke, were recruited when they accompanied with their sick children on hospital admission in general paediatic wards/outpatient departments of four hospitals in Hong Kong. The women were randomly allocated into intervention and control groups. The former received brief health education counselling from nurses, a purpose-designed health education booklet, a ""no smoking"" sticker, and a telephone reminder one week later"";"" the control group received usual care. The primary outcome was the women""s action to help their smoking husbands stop smoking at 3-, 6- and 12-month follow-ups. RESULTS: A higher proportion of women in the intervention than the control group had taken action to help their husbands stop smoking at the 3-month (76% vs. 65%, P < .001), 6-month (66% vs. 49%, P < .001) and 12-month (52% vs. 40%, P < .001) follow-ups. Women who had received the intervention, had better knowledge of the health hazards of smoking, higher intention to take action, perceived their husbands' willingness to stop/reduce smoking, had previously advised their husbands to give up smoking, were aware of their husbands' history of smoking and, were aware that their husbands had made an earlier quit attempt and intended to help them stop smoking at the follow-ups. CONCLUSIONS: A brief health education intervention by nurses in paediatric settings can be effective in motivating the mothers of sick children to take action to help their husbands quit smoking. We recommend adding the following to the clinical practice guidelines on treating tobacco use and dependence: 'Nurses should offer every non-smoking mother of a sick child brief advice to encourage their husbands to stop smoking'. TRIAL REGISTRATION: Current Controlled Trials ISRCTN72290421.",0,0,
2012,Words matter: increasing the implementation of clinical guidelines.,"Objectives: To determine whether writing clinical guideline recommendations in behaviourally specified “plain English” language increases the likelihood of their implementation by service users (patients).  Design: Randomised controlled trial in which participants received either the original text of the National Institute for Clinical Excellence (NICE) public guidelines for the management of schizophrenia or a behaviourally specified text with the same content.  Setting: Mental health service user networks and voluntary sector organisations within two inner London boroughs.  Participants: Eighty four mental health service users recruited by post or face to face contact at service user meetings.  Intervention: The section of the NICE public guidelines for schizophrenia concerning psychological and pharmacological treatments was rewritten to improve style and behavioural specificity by applying evidence-based and psychologically informed principles of good written communication.  Outcome measures: Cognitive predictors of behaviour, as specified by the evidence based theory of planned behaviour, constituted the primary outcome as it was not possible to measure the actual behaviour of guideline implementation. The predictors were behavioural intentions to implement the guidelines, attitudes towards implementation, and perceived behavioural control over implementation. Satisfaction with the guidelines and perceived comprehension were also measured.  Results: Behaviourally specified “plain English” guidelines led to stronger intentions to implement the guidelines, more positive attitudes towards them, and greater perceived behavioural control over using them. There was no difference in satisfaction or perceived comprehension.  Conclusions: Writing guidelines with high behavioural specificity in conjunction with the use of “plain English” may be a simple and effective method of increasing their implementation. Evaluation with a behavioural outcome is now needed.",0,1,
2013,Working to improve care of hospital hyperglycemia through statewide collaboration: the Georgia Hospital Association Diabetes Special Interest Group,"OBJECTIVE: To review the efforts of the Georgia Hospital Association Diabetes Special Interest Group (DSIG) to develop and disseminate sample clinical guidelines on management of inpatient hyperglycemia. METHODS: Beginning in February 2003, a consortium of physicians and allied health professionals from throughout the state of Georgia began meeting on a frequent basis to formulate a plan to enhance the care of hospitalized patients with hyperglycemia. The immediate goals of the DSIG were the identification and organization of interested stakeholders, the development of consensus sample clinical guidelines, and the dissemination of information. RESULTS: Since its inception, the DSIG has accomplished the following: development of 7 consensus sample clinical guidelines, construction of a Web site that posts these clinical guidelines and other useful related information and educational materials, and sponsorship of workshops throughout the state of Georgia. CONCLUSION: As the importance of glucose control in the hospital setting has become increasingly recognized, institutions must find ways of applying results of clinical trials to ""real-world"" hospital environments. The DSIG is an example of a successful collaboration that could serve as a model for other state hospital organizations that wish to develop programs to enhance the care of inpatients with hyperglycemia.",0,0,
2014,"World Medical Association adopts statements, etc., on miscellaneous matters",,0,0,
2015,World Medical Association declaration of Helsinki. Recommendations guiding physicians in biomedical research involving human subjects,,0,0,
2016,Xenotransplants: proceed with caution,,0,0,
2017,Yoga for chronic low back pain: a randomized trial,"Background: Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain. Objective: To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain. Design: Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604) Setting: 13 non¨CNational Health Service premises in the United Kingdom. Patients: 313 adults with chronic or recurrent low back pain. Intervention: Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months. Measurements: Scores on the Roland¨CMorris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months""; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes). Results: 93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain. Limitation: There were missing data for the primary outcome (yoga group, n = 21;"" usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes. Conclusion: Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care.",0,0,
2018,Youth receiving orthodontic care are not immune to poor diet and overweight: a call for dental providers to participate in prevention efforts,"OBJECTIVES: While obesity is common in the US, disparities exist. Orthodontic samples are assumed to be more affluent than the general population and not in need of assistance in developing or maintaining healthy lifestyles. This paper evaluates the need of the orthodontic population for intervention by examining diet and weight status of an orthodontic patient sample and describes a role for dental clinicians in obesity prevention efforts. METHODS: 552 patients age 8-14 years, 54% female, 51% non-Hispanic white, 26% Hispanic were recruited from orthodontic practices in Southern California to participate in a randomized controlled trial of clinician-delivered health promotion. Height, weight, demographics, and diet were recorded. Chi-Square analyses were used to test for differences at baseline by gender, age, ethnicity, and income. RESULTS: 13% of the sample was overweight and 9% was obese. Males had a higher rate of obesity than females. Lower income youth had a higher rate than higher income youth. Hispanic youth had a higher rate than non-Hispanic white youth. Failure to meet national dietary guidelines was common, differing significantly by demographic group. CONCLUSIONS: Within a sample not typically thought of as needing assistance, nearly 25% were overweight or obese and the majority failed to meet dietary recommendations. While most patients could benefit from intervention, male, Hispanic, and lower income groups were in greatest need of assistance. Dental providers, who see youth frequently and already discuss nutrition in the context of oral health, have the opportunity to contribute to obesity prevention.",0,0,
2019,A Systematic Scoping Review of the Choice Architecture Movement: Toward Understanding When and Why Nudges Work,"In this paper, we provide a domain‐general scoping review of the nudge movement by reviewing 422 choice architecture interventions in 156 empirical studies. We report the distribution of the studies across countries, years, domains, subdomains of applicability, intervention types, and the moderators associated with each intervention category to review the current state of the nudge movement. Furthermore, we highlight certain characteristics of the studies and experimental and reporting practices that can hinder the accumulation of evidence in the field. Specifically, we found that 74% of the studies were mainly motivated to assess the effectiveness of the interventions in one specific setting, while only 24% of the studies focused on the exploration of moderators or underlying processes. We also observed that only 7% of the studies applied power analysis, 2% used guidelines aiming to improve the quality of reporting, no study in our database was preregistered, and the used intervention nomenclatures were non‐exhaustive and often have overlapping categories. Building on our current observations and proposed solutions from other fields, we provide directly applicable recommendations for future research to support the evidence accumulation on why and when nudges work.",0,1,