Ethical concerns in early 21st century organ transplantation

PubMed Central

Waness, Abdelkarim

2011-01-01

Medical ethics is an indispensible and challenging aspect of clinical practice. This is particularly prominent in the field of organ transplantation. In this paper, initially, a clinical case with brain death that ended up as an organ donor will be presented. Following the presentation, important moral challenges which initially formed medical ethics and some highlights of it in organ transplantation will be discussed in detail. The impact of complex modern influential factors that might interfere with the practice of medical ethics in this field such as patients’ vulnerability, financial temptations, and legal regulations will be also dealt with. Finally, we shall propose practical guidelines aiming at improving the practice of medical ethics in the emerging issue of organ transplantation. PMID:23908752

Vertical integration of teaching in Australian general practice--a survey of regional training providers.

PubMed

Stocks, Nigel P; Frank, Oliver; Linn, Andrew M; Anderson, Katrina; Meertens, Sarah

2011-06-06

To examine vertical integration of teaching and clinical training in general practice and describe practical examples being undertaken by Australian general practice regional training providers (RTPs). A qualitative study of all RTPs in Australia, mid 2010. All 17 RTPs in Australia responded. Eleven had developed some vertical integration initiatives. Several encouraged registrars to teach junior doctors and medical students, others encouraged general practitioner supervisors to run multilevel educational sessions, a few coordinated placements, linkages and support across their region. Three RTPs provided case studies of vertical integration. Many RTPs in Australia use vertical integration of teaching in their training programs. RTPs with close associations with universities and rural clinical schools seem to be leading these initiatives.

[What everybody should know about good clinical practices].

PubMed

Osorio, Lyda

2015-01-01

An increasing number of countries are adopting good clinical practices guidelines as part of the regulation of clinical studies to register pharmaceutical products and other health-related products. Consequently, all parties involved in the research and development of these products should know them, implement them and ensure their compliance. However, good clinical practices guidelines are just one of the initiatives seeking to achieve the highest ethical and scientific standards in health research and in other areas where humans are research subjects. This review defines such practices and their objectives presenting in a practical manner their legal framework in Colombia, and clarifying their application in studies where interventions use no medications or those that are not clinical trials. Finally, the work discusses the challenges to ensure that good clinical practices contribute to the protection of research participants, the education of trustworthy health professionals, and a culture of respect for human beings.

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

PubMed

Reddy, Ashok; Sessums, Laura; Gupta, Reshma; Jin, Janel; Day, Tim; Finke, Bruce; Bitton, Asaf

2017-09-01

Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services. © 2017 Annals of Family Medicine, Inc.

Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice.

PubMed

Jacobi, Judith; Ray, Shaunta'; Danelich, Ilya; Dodds Ashley, Elizabeth; Eckel, Stephen; Guharoy, Roy; Militello, Michael; O'Donnell, Paul; Sam, Teena; Crist, Stephanie M; Smidt, Danielle

2016-05-01

This paper describes the goals of the American Society of Health-System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health-system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication-related outcomes and technicians assume greater responsibility for product-related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed. © 2016 Pharmacotherapy Publications, Inc.

Perceptions of Supervision Processes and Practices in Initial Contract, Tenured, and Distinguished-Rated Teachers as They Relate to Self-Learning and Growth in One Large Suburban School District

ERIC Educational Resources Information Center

Watters, Chad M.

2017-01-01

The purpose of this mixed methods study is to examine the perceptions of supervision practices in initial contract, tenured, and distinguished-rated teachers at the elementary level in one large, suburban school district. This study described teacher perceptions of clinical and alternative supervision practices. Six research questions guided this…

Screening for important unwarranted variation in clinical practice: a triple-test of processes of care, costs and patient outcomes.

PubMed

Partington, Andrew; Chew, Derek P; Ben-Tovim, David; Horsfall, Matthew; Hakendorf, Paul; Karnon, Jonathan

2017-03-01

Objective Unwarranted variation in clinical practice is a target for quality improvement in health care, but there is no consensus on how to identify such variation or to assess the potential value of initiatives to improve quality in these areas. This study illustrates the use of a triple test, namely the comparative analysis of processes of care, costs and outcomes, to identify and assess the burden of unwarranted variation in clinical practice. Methods Routinely collected hospital and mortality data were linked for patients presenting with symptoms suggestive of acute coronary syndromes at the emergency departments of four public hospitals in South Australia. Multiple regression models analysed variation in re-admissions and mortality at 30 days and 12 months, patient costs and multiple process indicators. Results After casemix adjustment, an outlier hospital with statistically significantly poorer outcomes and higher costs was identified. Key process indicators included admission patterns, use of invasive diagnostic procedures and length of stay. Performance varied according to patients' presenting characteristics and time of presentation. Conclusions The joint analysis of processes, outcomes and costs as alternative measures of performance inform the importance of reducing variation in clinical practice, as well as identifying specific targets for quality improvement along clinical pathways. Such analyses could be undertaken across a wide range of clinical areas to inform the potential value and prioritisation of quality improvement initiatives. What is known about the topic? Variation in clinical practice is a long-standing issue that has been analysed from many different perspectives. It is neither possible nor desirable to address all forms of variation in clinical practice: the focus should be on identifying important unwarranted variation to inform actions to reduce variation and improve quality. What does this paper add? This paper proposes the comparative analysis of processes of care, costs and outcomes for patients with similar diagnoses presenting at alternative hospitals, using linked, routinely collected data. This triple test of performance indicators extracts maximum value from routine data to identify priority areas for quality improvement to reduce important and unwarranted variations in clinical practice. What are the implications for practitioners? The proposed analyses need to be applied to other clinical areas to demonstrate the general application of the methods. The outputs can then be validated through the application of quality improvement initiatives in clinical areas with identified important and unwarranted variation. Validated frameworks for the comparative analysis of clinical practice provide an efficient approach to valuing and prioritising actions to improve health service quality.

Integrating Bioethics into Clinical and Translational Science Research: A Roadmap

PubMed Central

Shapiro, Robyn S.; Layde, Peter M.

2008-01-01

Abstract Recent initiatives to improve human health emphasize the need to effectively and appropriately translate new knowledge gleaned from basic biomedical and behavioral research to clinical and community application. To maximize the beneficial impact of scientific advances in clinical practice and community health, and to guard against potential deleterious medical and societal consequences of such advances, incorporation of bioethics at each stage of clinical and translational science research is essential. At the earliest stage, bioethics input is critical to address issues such as whether to limit certain areas of scientific inquiry. Subsequently, bioethics input is important to assure not only that human subjects trials are conducted and reported responsibly, but also that results are incorporated into clinical and community practices in a way that promotes and protects bioethical principles. At the final stage of clinical and translational science research, bioethics helps to identify the need and approach for refining clinical practices when safety or other concerns arise. The framework we present depicts how bioethics interfaces with each stage of clinical and translational science research, and suggests an important research agenda for systematically and comprehensively assuring bioethics input into clinical and translational science initiatives. PMID:20443821

Interprofessional communication training: benefits to practicing pharmacists.

PubMed

Luetsch, Karen; Rowett, Debra

2015-10-01

Interprofessional communication skills are important for pharmacists to build collaborative relationships with other health professionals, integrate into healthcare teams, maximise their effectiveness in patient care in addressing complex care needs and meet the demands of health care reforms. This qualitative study explores clinical pharmacists' experiences and reflections after completing a learning and practice module which introduced them to a framework for successful interprofessional communication. The postgraduate clinical pharmacy program at The University of Queensland and the clinical pharmacy practice environments of forty-eight hospital and seven community based pharmacists. A learning and practice module outlining a framework for successful interprofessional communication was designed and integrated into a postgraduate clinical pharmacy program. Enrolled pharmacists applied newly learnt communication skills in pro-actively initiated, clinical discussions with a health professional in their practice environment. They provided written reflections on their experiences which were analysed using thematic analysis. Pharmacists' perceptions of the impact of applying the communication framework during their interaction with a health professional in their practice setting. Themes which emerged from reflections described pharmacists' confidence and capabilities to successfully conduct a clinical discussion with a health professional after initial apprehension and nervousness about the scheduled interaction. The application of the communication framework enhanced their perception of their professional identity, credibility and ability to build a collaborative working relationship with other health professionals. Pharmacists perceived that a learning and practice module for successful interprofessional practice integrated into a postgraduate clinical pharmacy program enhanced their interprofessional communication skills. The development of pro-active, interprofessional communication skills has the potential to increase interprofessional collaboration and pharmacists' personal role satisfaction. Pharmacists also observed it added value to their professional contribution in health care teams when addressing the demands of increasingly complex health care needs and reforms.

Improving the Implementation of Evidence-Based Clinical Practices in Adolescent Reproductive Health Care Services

PubMed Central

Romero, Lisa M.; Middleton, Dawn; Mueller, Trisha; Avellino, Lia; Hallum-Montes, Rachel

2015-01-01

Purpose The purposes of the study were to describe baseline data in the implementation of evidence-based clinical practices among health center partners as part of a community-wide teen pregnancy prevention initiative and to identify opportunities for health center improvement. Methods Health center partner baseline data were collected in the first year (2011) and before program implementation of a 5-year community-wide teen pregnancy prevention initiative. A needs assessment on health center capacity and implementation of evidence-based clinical practices was administered with 51 health centers partners in 10 communities in the United States with high rates of teen pregnancy. Results Health centers reported inconsistent implementation of evidence-based clinical practices in providing reproductive health services to adolescents. Approximately 94.1% offered same-day appointments, 91.1% had infrastructure to reduce cost barriers, 90.2% offered after-school appointments, and 80.4% prescribed hormonal contraception without prerequisite examinations or testing. Approximately three quarters provided visual and audio privacy in examination rooms (76.5%) and counseling areas (74.5%). Fewer offered a wide range of contraceptive methods (67.8%) and took a sexual health history at every visit (54.9%). Only 45.1% reported Quick Start initiation of hormonal contraception, emergency contraception (43.1%), or intrauterine devices (12.5%) were “always” available to adolescents. Conclusions The assessment highlighted opportunities for health center improvement. Strategies to build capacity of health center partners to implement evidence-based clinical practices may lead to accessibility and quality of reproductive health services for adolescents in the funded communities. PMID:26381918

Integrating pharmacogenomics into pharmacy practice via medication therapy management.

PubMed

Reiss, Susan M

2011-01-01

To explore the application and integration of pharmacogenomics in pharmacy clinical practice via medication therapy management (MTM) to improve patient care. Department of Health & Human Services (HHS) Personalized Health Care Initiative, Food and Drug Administration (FDA) pharmacogenomics activity, and findings from the Utilizing E-Prescribing Technologies to Integrate Pharmacogenomics into Prescribing and Dispensing Practices Stakeholder Workshop, convened by the American Pharmacists Association (APhA) on March 5, 2009. Participants at the Stakeholder Workshop included diverse representatives from pharmacy, medicine, pathology, health information technology (HIT), standards, science, academia, government, and others with a key interest in the clinical application of pharmacogenomics. In 2006, HHS initiated the Personalized Health Care Initiative with the goal of building the foundation for the delivery of gene-based care, which may prove to be more effective for large patient subpopulations. In the years since the initiative was launched, drug manufacturers and FDA have begun to incorporate pharmacogenomic data and applications of this information into the drug development, labeling, and approval processes. New applications and processes for using this emerging pharmacogenomics data are needed to effectively integrate this information into clinical practice. Building from the findings of a stakeholder workshop convened by APhA and the advancement of the pharmacist's collaborative role in patient care through MTM, emerging roles for pharmacists using pharmacogenomic information to improve patient care are taking hold. Realizing the potential role of the pharmacist in pharmacogenomics through MTM will require connectivity of pharmacists into the electronic health record infrastructure to permit the exchange of pertinent health information among all members of a patient's health care team. Addressing current barriers, concerns, and system limitations and developing an effective infrastructure will be necessary for pharmacogenomics to achieve its true potential. To achieve integration of pharmacogenomics into clinical practice via MTM, the pharmacy profession must define a process for the application of pharmacogenomic data into pharmacy clinical practice that is aligned with MTM service delivery, develop a viable business model for these practices, and encourage and direct the development of HIT solutions that support the pharmacist's role in this emerging field.

The Pursuit of a Collegial Model of Clinical Practice: The Story of One University

ERIC Educational Resources Information Center

Strieker, Toni S.; Lim, Woong; Hubbard, Daphne; Crovitz, Darren; Gray, Kimberly C.; Holbien, Marie; Steffen, Cherry

2017-01-01

This study addresses the urgent need for change in clinical experiences that better prepare teacher candidates to negotiate the changing landscape of educational and accreditation policies and practices affecting P-12 classrooms. Specifically, the article examines the impact of a comprehensive 4-year initiative to transform traditional student…

Balancing Certainty and Uncertainty in Clinical Practice

ERIC Educational Resources Information Center

Kamhi, Alan G.

2011-01-01

Purpose: In this epilogue, I respond to each of the five commentaries, discussing in some depth a central issue raised in each commentary. In the final section, I discuss how my thinking about certainty and uncertainty in clinical practice has evolved since I wrote the initial article. Method: Topics addressed include the similarities/differences…

Integrated management of depression: improving system quality and creating effective interfaces.

PubMed

Myette, Thomas L

2008-04-01

Depression is a chronic recurrent condition and is a leading cause of work disability. Improving occupational outcomes for depression will require an integrated approach that incorporates best practices from the clinical, community, and workplace systems. This article briefly reviews recent quality improvement initiatives and promising practices in each system and then shifts to the importance of systems integration. An integrated chronic care model uses a sophisticated case management process to support essential relationships, facilitate key plans, and efficiently link the three systems to optimize clinical, economic, and occupational outcomes. An expanded role for employers and their agents in the management of depression and other chronic diseases is seen as fundamental to maintaining a healthy and productive workforce. To improve occupational outcomes for depression by integrating best practices from the clinical, community, and workplace systems. After a brief review of quality improvement initiatives and promising practices in each system, an integrated chronic care model is introduced. A case management process that links critical systems, supports essential relationships, and facilitates key plans is expected to result in improvements in clinical, economic, and occupational outcomes. Employers should be more engaged with clinical and community partners in the prevention and control of depression in affected employees.

Effect of Risk Acceptance for Bundled Care Payments on Clinical Outcomes in a High-Volume Total Joint Arthroplasty Practice After Implementation of a Standardized Clinical Pathway.

PubMed

Kee, James R; Edwards, Paul K; Barnes, Charles L

2017-08-01

The Bundled Payments for Care Improvement (BPCI) initiative and the Arkansas Payment Improvement (API) initiative seek to incentivize reduced costs and improved outcomes compared with the previous fee-for-service model. Before participation, our practice initiated a standardized clinical pathway (CP) to reduce length of stay (LOS), readmissions, and discharge to postacute care facilities. This practice implemented a standardized CP focused on patient education, managing patient expectations, and maximizing cost outcomes. We retrospectively reviewed all primary total joint arthroplasty patients during the initial 2-year "at risk" period for both BPCI and API and determined discharge disposition, LOS, and readmission rate. During the "at risk" period, the average LOS decreased in our total joint arthroplasty patients and our patients discharged home >94%. Patients within the BPCI group had a decreased discharge to home and decreased readmission rates after total hip arthroplasty, but also tended to be older than both API and nonbundled payment patients. While participating in the BPCI and API, continued use of a standardized CP in a high-performing, high-volume total joint practice resulted in maintenance of a low-average LOS. In addition, BPCI patients had similar outcomes after total knee arthroplasty, but had decreased rates of discharge to home and readmission after total hip arthroplasty. Copyright © 2017 Elsevier Inc. All rights reserved.

Evaluation of a community diabetes initiative: Integrating diabetes care.

PubMed

Walsh, Jason Leo; Harris, Benjamin Howell Lole; Roberts, Aled Wyn

2015-06-01

To evaluate the impact of a community diabetes initiative, aiming to improve the efficiency of type 2 diabetes (T2DM) care within the Cardiff and Vale Health Board. In 2012, a community diabetes initiative was introduced in Cardiff and Vale. Ten National Health Service (NHS) consultant diabetologists and three nurse specialists supported 69 general practices in this region. Here we evaluate the impact of this initiative by assessing the number and quality of secondary care diabetes clinic referrals before (2011-2012) and after implementation (2013-2014). Referrals pre and post initiative were audited against Cardiff and Vale T2DM referral guidelines in two 6-month periods. In the 6-months prior to the initiative, 108 referrals were received, 78 of which were in line with local guidance. Approximately one year after embarking on the diabetes initiative (2013-2014) there was a 31% reduction (p<0.01) in the total number of T2DM clinic referrals and a 57% reduction (p<0.01) in referrals outside the guidelines. A decrease in referrals was not seen in the practice noted not to engage with the initiative. The community diabetes initiative intervention has significantly improved the appropriateness of T2DM referrals from GP practices engaged with the initiative. As a result we advocate a move towards integrated diabetes care within the community. Copyright © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Practice development 'without walls' and the quandary of corporate practice.

PubMed

Graham, Iain; Fielding, Carol; Rooke, Debbie; Keen, Steven

2006-08-01

The context of this study is a group of clinical nurse specialists from across a Trust seeking accreditation as a practice development unit. The university was asked to facilitate the accreditation process via 11 2-hour learning sessions (including a one-hour focus group). During initial discussions between the university and practice development unit, the overarching research question for this study was set as: 'what are the main roles and responsibilities of clinical nurse specialists?' Although there is no known study of a practice development unit based beyond a ward or speciality, the central tenet of the practice development unit literature is that units must demonstrate their worth if they are to survive and harness senior management support in doing so. Data gleaned from the transcribed audio tape-recordings of the learning sessions were studied at least three times to ensure transcription accuracy and produce detailed charts. Ethical approval was granted by the appropriate Local Research Ethics Committee and written informed consent obtained from clinical nurse specialists. The study lasted 30 months and ended in October 2004. The four crucial statements that give meaning to specialist practice are: quality care giver; expert; information giver and initiator of change. Further analysis reveals the area of corporate and political practice as being missing from this and other lists of clinical nurse specialist attributes found in the literature. Clinical nurse specialists characterize their relationship with the Trust in terms of dichotomy--differing agendas and perceptions of value. The specialist role requires professional development in the areas of corporate and political acumen and professional business management. While the findings of this study relate to one Trust and a group of 16 clinical nurse specialists, with careful application they may be transferable to other settings and groups of senior nurses.

Learning and teaching clinical communication in the clinical workplace.

PubMed

Brown, Jo; Dearnaley, Jo

2016-08-01

Clinical communication teaching and learning has become increasingly separate from the clinical workplace over the last 20 years in the UK, and in many medical schools is front-loaded to the early years of the curriculum. Many reasons exist to explain this separation, including the increasing use of simulation. However, learning by simulation alone is not ideal, and the literature now points towards a new direction that blends simulation with authentic experiences in the clinical workplace to aid the transition to clinical life. This article presents a practical example of collaboration between a London medical school and a hospital trust to provide an integrated clinical communication learning experience for students by situating teaching on the clinical wards for senior medical students. Clinical communication teaching and learning has become increasingly separate from the clinical workplace We outline a new teaching initiative, the 'Communication on the wards' pilot project, that blends clinical communication teaching with ward-based learning in an authentic environment, with patients, medical students and teachers working together. This teaching initiative was a practical attempt to bridge the theory-practice gap in clinical communication education, and to place learning in the clinical workplace for students. As such, it was enjoyed by all those who took part, and may be the way forward for clinical communication teaching and learning in the future. © 2015 John Wiley & Sons Ltd.

Primary Care Practices’ Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement

PubMed Central

Cohen, Deborah J.; Dorr, David A.; Knierim, Kyle; DuBard, C. Annette; Hemler, Jennifer R.; Hall, Jennifer D.; Marino, Miguel; Solberg, Leif I.; McConnell, K. John; Nichols, Len M.; Nease, Donald E.; Edwards, Samuel T.; Wu, Winfred Y.; Pham-Singer, Hang; Kho, Abel N.; Phillips, Robert L.; Rasmussen, Luke V.; Duffy, F. Daniel; Balasubramanian, Bijal A.

2018-01-01

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports—but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures. PMID:29608365

A case report using the mental state examination scale (MSES): a tool for measuring change in mental state.

PubMed

Fernando, Irosh; Carter, Gregory

2016-02-01

There is a need for a simple and brief tool that can be used in routine clinical practice for the quantitative measurement of mental state across all diagnostic groups. The main utilities of such a tool would be to provide a global metric for the mental state examination, and to monitor the progression over time using this metric. We developed the mental state examination scale (MSES), and used it in an acute inpatient setting in routine clinical work to test its initial feasibility. Using a clinical case, the utility of MSES is demonstrated in this paper. When managing the patient described, the MSES assisted the clinician to assess the initial mental state, track the progress of the recovery, and make timely treatment decisions by quantifying the components of the mental state examination. MSES may enhance the quality of clinical practice for clinicians, and potentially serve as an index of universal mental healthcare outcome that can be used in clinical practice, service evaluation, and healthcare economics. © The Royal Australian and New Zealand College of Psychiatrists 2015.

Emerging Role of Quality Indicators in Physical Therapist Practice and Health Service Delivery

PubMed Central

Klemm, Alexandria; Li, Linda C.; Jones, C. Allyson

2016-01-01

Quality-based care is a hallmark of physical therapy. Treatment effectiveness must be evident to patients, managers, employers, and funders. Quality indicators (QIs) are tools that specify the minimum acceptable standard of practice. They are used to measure health care processes, organizational structures, and outcomes that relate to aspects of high-quality care of patients. Physical therapists can use QIs to guide clinical decision making, implement guideline recommendations, and evaluate and report treatment effectiveness to key stakeholders, including third-party payers and patients. Rehabilitation managers and senior decision makers can use QIs to assess care gaps and achievement of benchmarks as well as to guide quality improvement initiatives and strategic planning. This article introduces the value and use of QIs to guide clinical practice and health service delivery specific to physical therapy. A framework to develop, select, report, and implement QIs is outlined, with total joint arthroplasty rehabilitation as an example. Current initiatives of Canadian and American physical therapy associations to develop tools to help clinicians report and access point-of-care data on patient progress, treatment effectiveness, and practice strengths for the purpose of demonstrating the value of physical therapy to patients, decision makers, and payers are discussed. Suggestions on how physical therapists can participate in QI initiatives and integrate a quality-of-care approach in clinical practice are made. PMID:26089040

Case Report: Activity Diagrams for Integrating Electronic Prescribing Tools into Clinical Workflow

PubMed Central

Johnson, Kevin B.; FitzHenry, Fern

2006-01-01

To facilitate the future implementation of an electronic prescribing system, this case study modeled prescription management processes in various primary care settings. The Vanderbilt e-prescribing design team conducted initial interviews with clinic managers, physicians and nurses, and then represented the sequences of steps carried out to complete prescriptions in activity diagrams. The diagrams covered outpatient prescribing for patients during a clinic visit and between clinic visits. Practice size, practice setting, and practice specialty type influenced the prescribing processes used. The model developed may be useful to others engaged in building or tailoring an e-prescribing system to meet the specific workflows of various clinic settings. PMID:16622168

A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care.

PubMed

Rand, Cynthia M; Tyrrell, Hollyce; Wallace-Brodeur, Rachel; Goldstein, Nicolas P N; Darden, Paul M; Humiston, Sharon G; Albertin, Christina S; Stratbucker, William; Schaffer, Stanley J; Davis, Wendy; Szilagyi, Peter G

2018-03-01

Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs. Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types. outcome measures comprised baseline and postproject measures of 1) MOs (primary outcome), and 2) HPV vaccine initiation and completion. Process measures comprised monthly chart audits of MOs for HPV vaccination for performance feedback, monthly Plan-Do-Study-Act surveys and pre-post surveys about office systems. providers were trained at the start of the project on offering a strong recommendation for HPV vaccination. Practices implemented provider prompts and/or standing orders and/or reminder/recall if desired, and were provided monthly feedback on MOs to assess their progress. chi-square tests were used to assess changes in office practices, and logistic regression used to assess changes in MOs according to visit type and overall, as well as HPV vaccine initiation and completion. MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P < .01, and P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P < .01), and for male patients in continuity clinics (from 68% to 75%; P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03). Office systems changes using a QI model and multicomponent interventions decreased rates of MO for HPV vaccination and increased initiation and completion rates among some gender subgroups. A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery. Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Clinical Evidence: a useful tool for promoting evidence-based practice?

PubMed

Formoso, Giulio; Moja, Lorenzo; Nonino, Francesco; Dri, Pietro; Addis, Antonio; Martini, Nello; Liberati, Alessandro

2003-12-23

Research has shown that many healthcare professionals have problems with guidelines as they would prefer to be given all relevant information relevant to decision-making rather than being told what they should do. This study assesses doctors' judgement of the validity, relevance, clarity and usability of the Italian translation of Clinical Evidence (CE) after its free distribution launched by the Italian Ministry of Health. Opinions elicited using a standardised questionnaire delivered either by mail or during educational or professional meetings. Twenty percent (n = 1350) doctors participated the study. Most of them found CE's content valid, useful and relevant for their clinical practice, and said CE can foster communications among clinicians, particularly among GPs and specialists. Hospital doctors (63%) more often than GPs (48%) read the detailed presentation of individual chapters. Twenty-nine percent said CE brought changes in their clinical practice. Doctors appreciated CE's nature of an evidence-based information compendium and would have not preferred a collection of practice guidelines. Overall, the pilot initiative launched by the Italian Ministry of Health seems to have been well received and to support the subsequent decision to make the Italian edition of Clinical Evidence concise available to all doctors practising in the country. Local implementation initiatives should be warranted to favour doctor's use of CE.

Experience with Fingolimod in Clinical Practice

PubMed Central

Hersh, Carrie M.; Hara-Cleaver, Claire; Rudick, Richard A.; Cohen, Jeffrey A.; Bermel, Robert A.; Ontaneda, Daniel

2015-01-01

Aim To report experience with fingolimod in clinical practice. Design/Methods Patients in an academic medical center who were prescribed fingolimod from October 2010 to August 2011 were identified through the electronic medical record and followed for 12 months after fingolimod initiation. Adverse effects, clinical measures, MRI data, and quality of life measures were assessed. Results Three hundred seventeen patients started fingolimod. Eleven patients were treatment naïve (3.5%) and 76 (24.0%) had remote disease modifying therapy use prior to fingolimod. One hundred fifty-one (47.6%) switched because of patient preference and 79 (24.9%) switched because of breakthrough disease. About 11.6% transitioned from natalizumab. Follow-up data were available for 306 patients (96.5%) with mean follow-up time 332 days. Fingolimod was discontinued in 76 of 306 patients (24.8%) at mean 248 days after fingolimod start. Discontinuation most often was due to adverse effects (n=40) or breakthrough disease (n=22). Among patients who started fingolimod with available 12 month follow-up data, 267 (87.3%) remained relapse free and 256 (83.7%) had no relapses or gadolinium enhancement. Time to first relapse occurred at mean 282 days after fingolimod initiation. Quality of life measures remained stable at follow-up. Conclusions Fingolimod was discontinued at a higher rate in clinical practice than in clinical trials. Discontinuation was primarily due to adverse effects or breakthrough disease. Disease activity was adequately controlled in most patients who started fingolimod. This clinical practice cohort is consistent with efficacy data from phase 3 trials and describes the most common tolerability issues in clinical practice. PMID:25271798

Timing of Initiation of Maintenance Dialysis

PubMed Central

Wong, Susan P. Y.; Vig, Elizabeth K.; Taylor, Janelle S.; Burrows, Nilka R.; Liu, Chuan-Fen; Williams, Desmond E.; Hebert, Paul L.; O’Hare, Ann M.

2016-01-01

IMPORTANCE There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision. OBJECTIVE To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice. DESIGN, SETTING, AND PARTICIPANTS A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014. MAIN OUTCOMES AND MEASURES Central themes related to the timing of initiation of dialysis as documented in patients’ electronic medical records. RESULTS Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0–6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73m2. The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities. CONCLUSIONS AND RELEVANCE The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients’ values, goals, and preferences. PMID:26809745

Developing a business-practice model for pharmacy services in ambulatory settings.

PubMed

Harris, Ila M; Baker, Ed; Berry, Tricia M; Halloran, Mary Ann; Lindauer, Kathleen; Ragucci, Kelly R; McGivney, Melissa Somma; Taylor, A Thomas; Haines, Stuart T

2008-02-01

A business-practice model is a guide, or toolkit, to assist managers and clinical pharmacy practitioners in the exploration, proposal, development and implementation of new clinical pharmacy services and/or the enhancement of existing services. This document was developed by the American College of Clinical Pharmacy Task Force on Ambulatory Practice to assist clinical pharmacy practitioners and administrators in the development of business-practice models for new and existing clinical pharmacy services in ambulatory settings. This document provides detailed instructions, examples, and resources on conducting a market assessment and a needs assessment, types of clinical services, operations, legal and regulatory issues, marketing and promotion, service development and exit plan, evaluation of service outcomes, and financial considerations in the development of a clinical pharmacy service in the ambulatory environment. Available literature is summarized, and an appendix provides valuable citations and resources. As ambulatory care practices continue to evolve, there will be increased knowledge of how to initiate and expand the services. This document is intended to serve as an essential resource to assist in the growth and development of clinical pharmacy services in the ambulatory environment.

National Institutes of Health eliminates funding for national architecture linking primary care research.

PubMed

Peterson, Kevin A

2007-01-01

With the ending of the National Electronic Clinical Trial and Research Network (NECTAR) pilot programs and the abridgement of Clinical Research Associate initiative, the National Institutes of Health Roadmap presents a strategic shift for practice-based research networks from direct funding of a harmonized national infrastructure of cooperating research networks to a model of local engagement of primary care clinics performing practice-based research under the aegis of regional academic health centers through Clinical and Translational Science Awards. Although this may present important opportunities for partnering between community practices and large health centers, for primary care researchers, the promise of a transformational change that brings a unified national primary care community into the clinical research enterprise seems likely to remain unfulfilled.

Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines.

PubMed

Bonilauri Ferreira, Ana Paula Ribeiro; Ferreira, Rodrigo Fernando; Rajgor, Dimple; Shah, Jatin; Menezes, Andrea; Pietrobon, Ricardo

2010-04-20

Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment. This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil. FOUR MAIN THEMES WERE IDENTIFIED: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision. Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration.

Clinical Reasoning in the Real World Is Mediated by Bounded Rationality: Implications for Diagnostic Clinical Practice Guidelines

PubMed Central

Bonilauri Ferreira, Ana Paula Ribeiro; Ferreira, Rodrigo Fernando; Rajgor, Dimple; Shah, Jatin; Menezes, Andrea; Pietrobon, Ricardo

2010-01-01

Background Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment. Method This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil. Results Four main themes were identified: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision. Discussion Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration. PMID:20421920

Crossing the gender boundaries: The gender experiences of male nursing students in initial nursing clinical practice in Taiwan.

PubMed

Liu, Hsing-Yuan; Li, Yun Ling

2017-11-01

The initial nursing clinical practice is the necessary practicum required for nursing students. Because of the changing learning style, many of them are under great pressure for environmental change and therefore their daily routine is severe affected. Interacting directly with patients in a female-dominated occupation, along with the general gender stereotypes, the impact is especially significant to male nursing students than to female nursing students. The purpose of this preliminary qualitative study is to explore the gendered experiences of male nursing students during their first initial nursing clinical practice. Both focus group interviews and individual interviews are conducted with twenty-two sophomore nursing students from a university of technology in northern Taiwan, with ten male students and twelve female students. Two main themes emerge from the gendered experiences shared by the nursing students: Gender consciousness awakening and thus maintaining masculinity, and male advantage in the learning environments. The results identify the specific gendered experiences of nursing students, providing implications for future nursing education and counseling service. Further, this study may serve to promote an active yet gender-sensitive nursing education for training nursing professionals. Published by Elsevier Ltd.

Variables Affecting Pharmacy Students’ Patient Care Interventions during Advanced Pharmacy Practice Experiences

PubMed Central

Patterson, Brandon J.; Sen, Sanchita; Bingham, Angela L.; Bowen, Jane F.; Ereshefsky, Benjamin; Siemianowski, Laura A.

2016-01-01

Objective. To identify the temporal effect and factors associated with student pharmacist self-initiation of interventions during acute patient care advanced pharmacy practice experiences (APPE). Methods. During the APPE, student pharmacists at an academic medical center recorded their therapeutic interventions and who initiated the intervention throughout clinical rotations. At the end of the APPE student pharmacists completed a demographic survey. Results. Sixty-two student pharmacists were included. Factors associated with lower rates of self-initiated interventions were infectious diseases and pediatrics APPEs and an intention to pursue a postgraduate residency. Timing of the APPE, previous specialty elective course completion, and previous hospital experience did not result in any significant difference in self-initiated recommendations. Conclusion. Preceptors should not base practice experience expectations for self-initiated interventions on previous student experience or future intentions. Additionally, factors leading to lower rates of self-initiated interventions on infectious diseases or pediatrics APPEs should be explored. PMID:27756924

Mentoring Clinical Nurses to Write for Publication: Strategies for Success.

PubMed

Oman, Kathleen S; Mancuso, Mary P; Ceballos, Kirtley; Makic, MaryBeth Flynn; Fink, Regina M

2016-05-01

: Clinical nurses often find writing a challenge, but it's important to disseminate clinical practice initiatives that result in notable patient outcomes. Nurses have a responsibility to share what they do to improve patient care. The increased emphasis on the development and evaluation of evidence-based practice has made it necessary for nurses to share best practices that are associated with improved patient outcomes. We developed a six-month Writing for Publication workshop series designed to teach clinical nurses about the writing process and mentor them through the stages of preparing a manuscript to submit for publication. This successful program helped novice nurse authors become published professionals and had a great impact on our organization.

Strengthening care teams to improve adherence in cystic fibrosis: a qualitative practice assessment and quality improvement initiative.

PubMed

Gardner, Allison J; Gray, Alice L; Self, Staci; Wagener, Jeffrey S

2017-01-01

Treatment regimens for patients with cystic fibrosis (CF) are complex, time consuming, and burdensome, and adherence to CF treatment is suboptimal. CF care teams play a critical role in supporting patients' chronic self-management skills, but there is no uniform method for assessing patients' adherence to treatment or standard interventions to help patients improve when necessary. Between May 2015 and March 2016, care team members from 10 CF centers in the USA participated in a practice assessment and quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, personalized continuing medical education (CME)-certified Webconferences with expert study faculty, targeted reinforcement of key practice points, and follow-up online survey and telephone interviews to evaluate the benefits and limitations of the intervention. Responses to the baseline practice assessment survey were received from 50 multidisciplinary care team members representing 10 CF centers. Primary barriers to adherence-related aspects of care in their clinics were motivating patients and caregivers to improve adherence and obtaining accurate information about adherence from patients. At the conclusion of the initiative, participants reported improvements in communication within their care team, implementation of new approaches to asking about adherence, and a renewed commitment to asking patients and caregivers about adherence at each clinic visit. Structured QI interventions that bring multidisciplinary care teams together to reflect on clinic processes and elicit objective insights from outside faculty have the potential to improve practice patterns related to the assessment and improvement of patient adherence in CF.

Initial strides for invent-VTE: Towards global collaboration to accelerate clinical research in venous thromboembolism.

PubMed

Rodger, Marc; Langlois, Nicole; Middeldorp, Saskia; Kahn, Susan; Sandset, Per Morten; Brighton, Timothy; Huisman, Menno V; Meyer, Guy; Konstantinides, Stavros; Ageno, Walter; Morange, Pierre; Garcia, David; Kreuziger, Lisa Baumann; Young, Laura; Key, Nigel; Monreal, Manuel; Jiménez, David

2018-03-01

Venous thromboembolism (VTE) represents a major global burden of disease and requires collaborative efforts to conduct large, high-quality investigator-initiated and academically sponsored studies addressing the most relevant clinical questions. Owing to increasing regulatory requirements, the highly competitive nature of peer-reviewed funding and costs associated with conducting large, multinational clinical trials, completing practice-changing research constitutes a growing challenge for clinical investigators. As clinical trialists interested in VTE, we founded INVENT (International Network of Venous Thromboembolism Clinical Research Networks) in an effort to promote and accelerate patient-oriented, investigator-initiated, international collaborative research, to identify, prioritize and answer key clinical research questions for patients with VTE. We report on our activities to formalize the INVENT network and our accomplishments in our first year. Copyright © 2018 Elsevier Ltd. All rights reserved.

Mapping Evidence-Based Treatments for Children and Adolescents: Application of the Distillation and Matching Model to 615 Treatments from 322 Randomized Trials

ERIC Educational Resources Information Center

Chorpita, Bruce F.; Daleiden, Eric L.

2009-01-01

This study applied the distillation and matching model to 322 randomized clinical trials for child mental health treatments. The model involved initial data reduction of 615 treatment protocol descriptions by means of a set of codes describing discrete clinical strategies, referred to as practice elements. Practice elements were then summarized in…

A qualitative grounded theory study of the conceptions of clinical practice in osteopathy - a continuum from technical rationality to professional artistry.

PubMed

Thomson, Oliver P; Petty, Nicola J; Moore, Ann P

2014-02-01

How practitioners conceive clinical practice influences many aspects of their clinical work including how they view knowledge, clinical decision-making, and their actions. Osteopaths have relied upon the philosophical and theoretical foundations upon which the profession was built to guide clinical practice. However, it is currently unknown how osteopaths conceive clinical practice, and how these conceptions develop and influence their clinical work. This paper reports the conceptions of practice of experienced osteopaths in the UK. A constructivist grounded theory approach was taken in this study. The constant comparative method of analysis was used to code and analyse data. Purposive sampling was employed to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be sampled. Data collection methods involved semi-structured interviews and non-participant observation of practitioners during a patient appointment, which was video-recorded and followed by a video-prompted reflective interview. Participants' conception of practice lay on a continuum, from technical rationality to professional artistry and the development of which was influenced by their educational experience, view of health and disease, epistemology of practice knowledge, theory-practice relationship and their perceived therapeutic role. The findings from this study provide the first theoretical insight of osteopaths' conceptions of clinical practice and the factors which influence such conceptions. Copyright © 2013 Elsevier Ltd. All rights reserved.

Do Clinical Practice Guidelines Improve Quality?

PubMed

Baldassari, Cristina M

2017-07-01

Controversy exists surrounding how to best define and assess quality in the health care setting. Clinical practice guidelines (CPGs) have been developed to improve the quality of medical care by highlighting key clinical recommendations based on recent evidence. However, data linking CPGs to improvements in outcomes in otolaryngology are lacking. Numerous barriers contribute to difficulties in translating CPGs to improvements in quality. Future initiatives are needed to improve CPG adherence and define the impact of CPG recommendations on the quality of otolaryngologic care provided to our patients.

Aligning Documentation With Congenital Muscular Torticollis Clinical Practice Guidelines: Administrative Case Report.

PubMed

Gutierrez, Dennis; Kaplan, Sandra L

2016-01-01

A hospital-based pediatric outpatient center, wanting to weave evidence into practice, initiated an update of knowledge, skills, and documentation patterns with its staff physical therapists and occupational therapists who treat people with congenital muscular torticollis (CMT). This case report describes 2 cycles of implementation: (1) the facilitators and barriers to implementation and (2) selected quality improvement outcomes aligned with published clinical practice guidelines (CPGs). The Pediatric Therapy Services of St Joseph's Regional Medical Center in New Jersey has 4 full-time, 1 part-time, and 3 per diem staff. Chart audits in 2012 revealed variations in measurement, interventions, and documentation that led to quality improvement initiatives. An iterative process, loosely following the knowledge-to-action cycle, included a series of in-service training sessions to review the basic anatomy, pathokinesiology, and treatment strategies for CMT; reading assignments of the available CPGs; journal review; documentation revisions; and training on the recommended measurements to implement 2 published CPGs and measure outcomes. A previous 1-page generic narrative became a 3-page CMT-specific form aligned with the American Physical Therapy Association Section on Pediatrics CMT CPG recommendations. Staff training on the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, classification of severity, type of CMT, prognostication, measures of cervical range of motion, and developmental progression improved documentation consistency from 0% to 81.9% to 100%. Clinicians responded positively to using the longer initial evaluation form. Successful implementation of both clinical and documentation practices were facilitated by a multifaceted approach to knowledge translation that included a culture supportive of evidence-based practice, administrative support for training and documentation redesign, commitment by clinicians to embrace changes aimed at improved care, and clinical guidelines that provide implementable recommendations. © 2016 American Physical Therapy Association.

The activities of a dietitian-led gastroenterology clinic using extended scope of practice.

PubMed

Ryan, Dominique; Pelly, Fiona; Purcell, Elizabeth

2016-10-21

Extending the scope of practice of allied health professionals has been a strategy adopted in the United Kingdom to address issues within the health system. Australia's health system is currently undermined by similar issues, heightening government interest in adopting the extended scope health care model. The aim of the current study was to describe the activities and outcomes of a dietitian-led gastroenterology clinic which operated under an extended scope of practice model in an outpatient gastroenterology department at a tertiary hospital in regional Queensland, Australia, and to assess patient satisfaction with the initiative. A descriptive, cross-sectional case series undertaken over 50 clinics involving 82 category 2 and 3 patients with suspected/confirmed coeliac disease or inflammatory bowel disease; low haemoglobin; gastroesophageal reflux disease, or; malnutrition. Data was analysed using Microsoft Excel 2010, and presented as descriptive statistics. Sixty out of 82 selected patients (median age 51 years) attended an initial appointment with the dietitian. Twenty-four review appointments were attended. Average waiting period for an initial appointment was 148 days (range 31-308 days). A total of 149 management strategies were provided, and 94 (63 %) of these involved the dietitian utilising extended scope of practice. The dietitian managed 47 (78 %) patients without need for gastroenterologist referral, and 25 (42 %) were discharged after dietetic management. Patients reported high levels of satisfaction with the clinic. Seventy-eight percent of category 2 and 3 patients referred to the gastroenterologist could be managed exclusively in the dietitian-led clinic. This extended scope model of care could potentially benefit the efficiency and acceptability of Australia's public health system.

Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives.

PubMed

Pai, Vidya V; Lee, Henry C; Profit, Jochen

2018-06-01

Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts. Copyright © 2018 Elsevier Inc. All rights reserved.

National data elements for the clinical management of acute coronary syndromes.

PubMed

Chew, Derek P B; Allan, Roger M; Aroney, Constantine N; Sheerin, Noella J

2005-05-02

Patients with acute coronary syndromes represent a clinically diverse group and their care remains heterogeneous. These patients account for a significant burden of morbidity and mortality in Australia. Optimal patient outcomes depend on rapid diagnosis, accurate risk stratification and the effective implementation of proven therapies, as advocated by clinical guidelines. The challenge is in effectively applying evidence in clinical practice. Objectivity and standardised quantification of clinical practice are essential in understanding the evidence-practice gap. Observational registries are key to understanding the link between evidence-based medicine, clinical practice and patient outcome. Data elements for monitoring clinical management of patients with acute coronary syndromes have been adapted from internationally accepted definitions and incorporated into the National Health Data Dictionary, the national standard for health data definitions in Australia. Widespread use of these data elements will assist in the local development of "quality-of-care" initiatives and performance indicators, facilitate collaboration in cardiovascular outcomes research, and aid in the development of electronic data collection methods.

Setting up recovery clinics and promoting service user involvement.

PubMed

John, Thomas

2017-06-22

Service user involvement in mental health has gained considerable momentum. Evidence from the literature suggests that it remains largely theoretical rather than being put into practice. The current nature of acute inpatient mental health units creates various challenges for nurses to put this concept into practice. Recovery clinics were introduced to bridge this gap and to promote service user involvement practice within the current care delivery model at Kent and Medway NHS and Social Care Partnership Trust. It has shaped new ways of working for nurses with a person-centred approach as its philosophy. Service users and nurses were involved in implementing a needs-led and bottom-up initiative using Kotter's change model. Initial results suggest that it has been successful in meeting its objectives evidenced through increased meaningful interactions and involvement in care by service users and carers. The clinics have gained wide recognition and have highlighted a need for further research into care delivery models to promote service user involvement in these units.

An examination of the usefulness of repeat testing practices in a large hospital clinical chemistry laboratory.

PubMed

Deetz, Carl O; Nolan, Debra K; Scott, Mitchell G

2012-01-01

A long-standing practice in clinical laboratories has been to automatically repeat laboratory tests when values trigger automated "repeat rules" in the laboratory information system such as a critical test result. We examined 25,553 repeated laboratory values for 30 common chemistry tests from December 1, 2010, to February 28, 2011, to determine whether this practice is necessary and whether it may be possible to reduce repeat testing to improve efficiency and turnaround time for reporting critical values. An "error" was defined to occur when the difference between the initial and verified values exceeded the College of American Pathologists/Clinical Laboratory Improvement Amendments allowable error limit. The initial values from 2.6% of all repeated tests (668) were errors. Of these 668 errors, only 102 occurred for values within the analytic measurement range. Median delays in reporting critical values owing to repeated testing ranged from 5 (blood gases) to 17 (glucose) minutes.

Comparing Usual Care With a Warfarin Initiation Protocol After Mechanical Heart Valve Replacement.

PubMed

Roberts, Gregory; Razooqi, Rasha; Quinn, Stephen

2017-03-01

The immediate postoperative warfarin sensitivity for patients receiving heart valve prostheses is increased. Established warfarin initiation protocols may lack clinical applicability, resulting in dosing based on clinical judgment. To compare current practice for warfarin initiation with a known warfarin initiation protocol, with doses proportionally reduced to account for the increased postoperative sensitivity. We compared the Mechanical Heart Valve Warfarin Initiation Protocol (Protocol group) with current practice (clinical judgment-Empirical group) for patients receiving mechanical heart valves in an observational before-and-after format. End points were the time to achieve a stable therapeutic international normalized ratio (INR), doses held in the first 6 days, and overanticoagulation in the first 6 days. The Protocol group (n = 37) achieved a stable INR more rapidly than the Empirical group (n = 77; median times 5.1 and 8.7 days, respectively; P = 0.002). Multivariable analysis indicated that the Protocol group (hazard ratio [HR] = 2.22; P = 0.005) and men (HR = 1.76; P = 0.043) more rapidly achieved a stable therapeutic INR. Age, serum albumin, amiodarone, presence of severe heart failure, and surgery type had no impact. Protocol patients had fewer doses held (1.1% vs 10.1%, P < 0.001) and no difference in overanticoagulation (2.7% vs 9.1%, P = 0.27). The Mechanical Heart Valve Warfarin Initiation Protocol provided a reliable approach to initiating warfarin in patients receiving mechanical aortic or mitral valves.

Community hospitals and general practice: extended attachments for medical students.

PubMed

Grant, J; Ramsay, A; Bain, J

1997-09-01

The first year experience of an innovative experiment in undergraduate medical education is described. The study investigated the educational effectiveness of prolonged clinical attachments for medical undergraduates in community hospital-based general practice. It has also assessed the ability of students to take some responsibility for their own learning in a clinically challenging environment. A retrospective evaluation of the experience obtained during the 3 month attachments for a self-selected group of fourth year Dundee medical school undergraduates was made. These undergraduates were placed in 10 mainly rural Scottish general practices with attached community hospitals providing a wide spectrum of inpatient and outpatient medical and surgical care. Students were assessed on the satisfactory completion of a portfolio of learning experiences and a practical clinical skills list. They were also required to submit a clinical project based on some aspect of their work during the attachment. The initial results showed a high degree of student and tutor satisfaction with the attachments. The assessment of all 10 of the students' educational achievements in their attachment were regarded as satisfactory and two were assessed as outstanding. Tutor assessment confirmed the validity of the initiative. Prolonged attachments in community hospital-based general practice for medical undergraduates have proved educationally valid and popular with both students and tutors. The development and dissemination of this model on a wider scale has resource issues which require to be addressed.

Net present value approaches for drug discovery.

PubMed

Svennebring, Andreas M; Wikberg, Jarl Es

2013-12-01

Three dedicated approaches to the calculation of the risk-adjusted net present value (rNPV) in drug discovery projects under different assumptions are suggested. The probability of finding a candidate drug suitable for clinical development and the time to the initiation of the clinical development is assumed to be flexible in contrast to the previously used models. The rNPV of the post-discovery cash flows is calculated as the probability weighted average of the rNPV at each potential time of initiation of clinical development. Practical considerations how to set probability rates, in particular during the initiation and termination of a project is discussed.

Testing and screening for chlamydia in general practice: a cross-sectional analysis.

PubMed

Thomson, Allison; Morgan, Simon; Henderson, Kim; Tapley, Amanda; Spike, Neil; Scott, John; van Driel, Mieke; Magin, Parker

2014-12-01

Chlamydia screening is widely advocated. General practice registrars are an important stage of clinical behaviour development. This study aimed to determine rates of, and factors associated with, registrars' chlamydia testing including asymptomatic screening. A cross-sectional analysis of data from Registrars Clinical Encounters in Training (ReCEnT), a cohort study of registrars' consultations. Registrars record details of 60 consecutive consultations in each GP-term of training. Outcome factors were chlamydia testing, asymptomatic screening and doctor-initiated screening. Testing occurred in 2.5% of 29,112 consultations (398 registrars) and in 5.8% of patients aged 15-25. Asymptomatic screening comprised 47.5% of chlamydia tests, and 55.6% of screening tests were doctor-initiated. Chlamydia testing was associated with female gender of doctor and patient, younger patient age, and patients new to doctor or practice. Asymptomatic screening was associated with practices where patients incur no fees, and in patients new to doctor or practice. Screening of female patients was more often doctor-initiated. GP registrars screen for chlamydia disproportionately in younger females and new patients. Our findings highlight potential opportunities to improve uptake of screening for chlamydia, including targeted education and training for registrars, campaigns targeting male patients, and addressing financial barriers to accessing screening services. © 2014 Public Health Association of Australia.

Association Between Complementary and Alternative Medicine Use and Breast Cancer Chemotherapy Initiation: The Breast Cancer Quality of Care (BQUAL) Study.

PubMed

Greenlee, Heather; Neugut, Alfred I; Falci, Laura; Hillyer, Grace Clarke; Buono, Donna; Mandelblatt, Jeanne S; Roh, Janise M; Ergas, Isaac J; Kwan, Marilyn L; Lee, Marion; Tsai, Wei Yann; Shi, Zaixing; Lamerato, Lois; Kushi, Lawrence H; Hershman, Dawn L

2016-09-01

Not all women initiate clinically indicated breast cancer adjuvant treatment. It is important for clinicians to identify women at risk for noninitiation. To determine whether complementary and alternative medicine (CAM) use is associated with decreased breast cancer chemotherapy initiation. In this multisite prospective cohort study (the Breast Cancer Quality of Care [BQUAL] study) designed to examine predictors of breast cancer treatment initiation and adherence, 685 women younger than 70 years with nonmetastatic invasive breast cancer were recruited from Columbia University Medical Center, Kaiser Permanente Northern California, and Henry Ford Health System and enrolled between May 2006 and July 31, 2010. Overall, 306 patients (45%) were clinically indicated to receive chemotherapy per National Comprehensive Cancer Network guidelines. Participants were followed for up to 12 months. Baseline interviews assessed current use of 5 CAM modalities (vitamins and/or minerals, herbs and/or botanicals, other natural products, mind-body self-practice, mind-body practitioner-based practice). CAM use definitions included any use, dietary supplement use, mind-body use, and a CAM index summing the 5 modalities. Chemotherapy initiation was assessed via self-report up to 12 months after baseline. Multivariable logistic regression models examined a priori hypotheses testing whether CAM use was associated with chemotherapy initiation, adjusting for demographic and clinical covariates, and delineating groups by age and chemotherapy indication. A cohort of 685 women younger than 70 years (mean age, 59 years; median age, 59 years) with nonmetastatic invasive breast cancer were recruited and followed for up to 12 months to examine predictors of breast cancer treatment initiation. Baseline CAM use was reported by 598 women (87%). Chemotherapy was initiated by 272 women (89%) for whom chemotherapy was indicated, compared with 135 women (36%) for whom chemotherapy was discretionary. Among women for whom chemotherapy was indicated, dietary supplement users and women with high CAM index scores were less likely than nonusers to initiate chemotherapy (odds ratio [OR], 0.16; 95% CI, 0.03-0.51; and OR per unit, 0.64; 95% CI, 0.46-0.87, respectively). Use of mind-body practices was not related to chemotherapy initiation (OR, 1.45; 95% CI, 0.57-3.59). There was no association between CAM use and chemotherapy initiation among women for whom chemotherapy was discretionary. CAM use was high among patients with early-stage breast cancer enrolled in a multisite prospective cohort study. Current dietary supplement use and higher number of CAM modalities used but not mind-body practices were associated with decreased initiation of clinically indicated chemotherapy. Oncologists should consider discussing CAM with their patients during the chemotherapy decision-making process.

Measuring impact of JAMA Dermatology Practice Gaps section on training in US dermatology residency programs.

PubMed

Britton, Kristina M; Stratman, Erik J

2013-07-01

JAMA Dermatology Practice Gaps commentaries are intended to aid in the interpretation of the literature to make it more practical and applicable to daily patient care. Practice Gaps commentaries have had an impact on physician clinical practice and dermatology residency curricula. To assess the impact of JAMA Dermatology Practice Gaps commentaries on dermatology residency training programs in the United States, including journal club discussions and local quality improvement activities. A web-based questionnaire of 17 questions was sent via e-mail to US dermatology residency program directors (PDs) in February 2012. Program director report of incorporating Practice Gaps themes and discussions into resident journal club activities, clinical practice, quality improvement activities, or research projects in the residency programs, as a result of a Practice Gaps commentary. Of the 114 surveys distributed to US dermatology residency PDs, 48 were completed (42% response rate). Sixty percent of PDs reported familiarity with the Practice Gaps section of JAMA Dermatology, and 56% discuss these commentaries during resident journal club activities. Quality improvement and research projects have been initiated as a result of Practice Gaps commentaries. Practice Gaps commentaries are discussed during most dermatology residency journal club activities. Practice Gaps have had an impact on physician practice and dermatology residency curricula and can serve as a tool for enhanced continuing medical education and quality improvement initiatives.

Centres for Leadership: a strategy for academic integration.

PubMed

King, Gillian; Parker, Kathryn; Peacocke, Sean; Curran, C J; McPherson, Amy C; Chau, Tom; Widgett, Elaine; Fehlings, Darcy; Milo-Manson, Golda

2017-05-15

Purpose The purpose of this paper is to describe how an Academic Health Science Centre, providing pediatric rehabilitation services, research, and education, developed a Centres for Leadership (CfL) initiative to integrate its academic functions and embrace the goal of being a learning organization. Design/methodology/approach Historical documents, tracked output information, and staff members' insights were used to describe the ten-year evolution of the initiative, its benefits, and transformational learnings for the organization. Findings The evolutions concerned development of a series of CfLs, and changes over time in leadership and management structure, as well as in operations and targeted activities. Benefits included enhanced clinician engagement in research, practice-based research, and impacts on clinical practice. Transformational learnings concerned the importance of supporting stakeholder engagement, fostering a spirit of inquiry, and fostering leaderful practice. These learnings contributed to three related emergent outcomes reflecting "way stations" on the journey to enhanced evidence-informed decision making and clinical excellence: enhancements in authentic partnerships, greater innovation capacity, and greater understanding and actualization of leadership values. Practical implications Practical information is provided for other organizations interested in understanding how this initiative evolved, its tangible value, and its wider benefits for organizational collaboration, innovation, and leadership values. Challenges encountered and main messages for other organizations are also considered. Originality/value A strategy map is used to present the structures, processes, and outcomes arising from the initiative, with the goal of informing the operations of other organizations desiring to be learning organizations.

Attitudes to the public release of comparative information on the quality of general practice care: qualitative study.

PubMed

Marshall, Martin N; Hiscock, Julia; Sibbald, Bonnie

2002-11-30

To examine the attitudes of service users, general practitioners, and clinical governance leads based in primary care trusts to the public dissemination of comparative reports on quality of care in general practice, to guide the policy and practice of public disclosure of information in primary care. Qualitative focus group study using mock quality report cards as prompts for discussion. 12 focus groups held in an urban area in north west England and a semirural area in the south of England. 35 service users, 24 general practitioners, and 18 clinical governance leads. There was general support for the principle of publishing comparative information, but all three stakeholder groups expressed concerns about the practical implications. Attitudes were strongly influenced by experience of comparative reports from other sectors-for example, school league tables. Service users distrusted what they saw as the political motivation driving the initiative, expressed a desire to "protect" their practices from political and managerial interference, and were uneasy about practices being encouraged to compete against each other. General practitioners focused on the unfairness of drawing comparisons from current data and the risks of "gaming" the results. Clinical governance leads thought that public disclosure would damage their developmental approach to implementing clinical governance. The initial negative response to the quality reports seemed to diminish on reflection. Despite support for the principle of greater openness, the planned publication of information about quality of care in general practice is likely to face considerable opposition, not only from professional groups but also from the public. A greater understanding of the practical implications of public reporting is required before the potential benefits can be realised.

Sick leave and disability pension before and after initiation of antirheumatic therapies in clinical practice.

PubMed

Neovius, M; Simard, J F; Klareskog, L; Askling, J

2011-08-01

To investigate sick leave and disability pension in rheumatoid arthritis (RA) in relation to the initiation of biological and non-biological antirheumatic therapies in clinical practice. Patients aged 19-60 years initiating non-biological mono (n=2796) or combination disease-modifying antirheumatic drug (DMARD) therapy (n=973), or biological agents (n=4787) were identified in the Swedish Rheumatology Quality Register between 1999 and 2007. Sick leave and disability pension data (1995-2010) were retrieved from national registers. During the year before the start of mono DMARD, combination DMARD and biological treatment, 10%, 12% and 43% of patients received disability pension benefits, respectively. The corresponding combined annual sick leave and disability pension days were 78 (54+25), 132 (105+27) and 190 (79+111). Irrespective of treatment type, initiators were characterised by a history of increasing sick leave and disability pension. Treatment start was associated with a break in this trajectory: sick leave decreased while disability pension increased, resulting in a net stabilisation of total days. Higher levels of days on sick leave and disability pension at treatment start were observed in patients initiating biologics in 1999 (236 days/year) compared with 2007 (150 days/year; p<0.001), but the trajectory thereafter remained largely similar and contrasted markedly with the level in the general population. Sick leave and disability pension increased rapidly before the initiation of antirheumatic therapy, which was associated with a halt but not a reversal of this development. Work ability is a metric of importance for clinical practice, signalling large remaining needs in the RA population, and the need for intervention earlier in the disease process.

Medical nutrition therapy in adults with chronic kidney disease: integrating evidence and consensus into practice for the generalist registered dietitian nutritionist.

PubMed

Beto, Judith A; Ramirez, Wendy E; Bansal, Vinod K

2014-07-01

Chronic kidney disease is classified in stages 1 to 5 by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative depending on the level of renal function by glomerular filtration rate and, more recently, using further categorization depending on the level of glomerular filtration rate and albuminuria by the Kidney Disease Improving Global Outcomes initiative. Registered dietitian nutritionists can be reimbursed for medical nutrition therapy in chronic kidney disease stages 3 to 4 for specific clients under Center for Medicare and Medicaid Services coverage. This predialysis medical nutrition therapy counseling has been shown to both potentially delay progression to stage 5 (renal replacement therapy) and decrease first-year mortality after initiation of hemodialysis. The Joint Standards Task Force of the American Dietetic Association (now the Academy of Nutrition and Dietetics), the Renal Nutrition Dietetic Practice Group, and the National Kidney Foundation Council on Renal Nutrition collaboratively published 2009 Standards of Practice and Standards of Professional Performance for generalist, specialty, and advanced practice registered dietitian nutritionists in nephrology care. The purpose of this article is to provide an update on current recommendations for screening, diagnosis, and treatment of adults with chronic kidney disease for application in clinical practice for the generalist registered dietitian nutritionist using the evidence-based library of the Academy of Nutrition and Dietetics, published clinical practice guidelines (ie, National Kidney Foundation Council on Renal Nutrition, Renal Nutrition Dietetic Practice Group, Kidney Disease Outcomes Quality Initiative, and Kidney Disease Improving Global Outcomes), the Nutrition Care Process model, and peer-reviewed literature. Copyright © 2014 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.

Translating U-500R Randomized Clinical Trial Evidence to the Practice Setting: A Diabetes Educator/Expert Prescriber Team Approach

PubMed Central

Bergen, Paula M.; Kruger, Davida F.; Taylor, April D.; Eid, Wael E.; Bhan, Arti; Jackson, Jeffrey A.

2017-01-01

Purpose The purpose of this article is to provide recommendations to the diabetes educator/expert prescriber team for the use of human regular U-500 insulin (U-500R) in patients with severely insulin-resistant type 2 diabetes, including its initiation and titration, by utilizing dosing charts and teaching materials translated from a recent U-500R clinical trial. Conclusions Clinically relevant recommendations and teaching materials for the optimal use and management of U-500R in clinical practice are provided based on the efficacy and safety results of and lessons learned from the U-500R clinical trial by Hood et al, current standards of practice, and the authors’ clinical expertise. This trial was the first robustly powered, randomized, titration-to-target trial to compare twice-daily and three-times-daily U-500R dosing regimens. Modifications were made to the initiation and titration dosing algorithms used in this trial to simplify dosing strategies for the clinical setting and align with current glycemic targets recommended by the American Diabetes Association. Leveraging the expertise, resources, and patient interactions of the diabetes educator who can provide diabetes self-management education and support in collaboration with the multidisciplinary diabetes team is strongly recommended to ensure patients treated with U-500R receive the timely and comprehensive care required to safely and effectively use this highly concentrated insulin. PMID:28427304

Translating U-500R Randomized Clinical Trial Evidence to the Practice Setting: A Diabetes Educator/Expert Prescriber Team Approach.

PubMed

Bergen, Paula M; Kruger, Davida F; Taylor, April D; Eid, Wael E; Bhan, Arti; Jackson, Jeffrey A

2017-06-01

Purpose The purpose of this article is to provide recommendations to the diabetes educator/expert prescriber team for the use of human regular U-500 insulin (U-500R) in patients with severely insulin-resistant type 2 diabetes, including its initiation and titration, by utilizing dosing charts and teaching materials translated from a recent U-500R clinical trial. Conclusions Clinically relevant recommendations and teaching materials for the optimal use and management of U-500R in clinical practice are provided based on the efficacy and safety results of and lessons learned from the U-500R clinical trial by Hood et al, current standards of practice, and the authors' clinical expertise. This trial was the first robustly powered, randomized, titration-to-target trial to compare twice-daily and three-times-daily U-500R dosing regimens. Modifications were made to the initiation and titration dosing algorithms used in this trial to simplify dosing strategies for the clinical setting and align with current glycemic targets recommended by the American Diabetes Association. Leveraging the expertise, resources, and patient interactions of the diabetes educator who can provide diabetes self-management education and support in collaboration with the multidisciplinary diabetes team is strongly recommended to ensure patients treated with U-500R receive the timely and comprehensive care required to safely and effectively use this highly concentrated insulin.

A Clinical Nurse Specialist-Led Interprofessional Quality Improvement Project to Reduce Hospital-Acquired Pressure Ulcers.

PubMed

Fabbruzzo-Cota, Christina; Frecea, Monica; Kozell, Kathryn; Pere, Katalin; Thompson, Tamara; Tjan Thomas, Julie; Wong, Angela

2016-01-01

The purpose of this clinical nurse specialist-led interprofessional quality improvement project was to reduce hospital-acquired pressure ulcers (HAPUs) using evidence-based practice. Hospital-acquired pressure ulcers (PUs) have been linked to morbidity, poor quality of life, and increasing costs. Pressure ulcer prevention and management remain a challenge for interprofessional teams in acute care settings. Hospital-acquired PU rate is a critical nursing quality indicator for healthcare organizations and ties directly with Mount Sinai Hospital's (MSH's) mission and vision, which mandates providing the highest quality care to patients and families. This quality improvement project, guided by the Donabedian model, was based on the Registered Nurses' Association of Ontario Best Practice Guideline Risk Assessment & Prevention of Pressure Ulcers. A working group was established to promote evidence-based practice for PU prevention. Initiatives such as documentation standardization, development of staff education and patient and family educational resources, initiation of a hospital-wide inventory for support surfaces, and procurement of equipment were implemented to improve PU prevention and management across the organization. An 80% decrease in HAPUs has been achieved since the implementation of best practices by the Best Practice Guideline Pressure Ulcer working group. The implementation of PU prevention strategies led to a reduction in HAPU rates. The working group will continue to work on building interprofessional awareness and collaboration in order to prevent HAPUs and promote an organizational culture that supports staff development, teamwork and communication. This quality improvement project is a successful example of an interprofessional clinical nurse specialist-led initiative that impacts patient/family and organization outcomes through the identification and implementation of evidence-based nursing practice.

Syncope Best Practices: A Syncope Clinical Practice Guideline to Improve Quality.

PubMed

Phelps, Heather M; Sachdeva, Ritu; Mahle, William T; McCracken, Courtney E; Kelleman, Michael; McConnell, Michael; Fischbach, Peter S; Cardis, Brian M; Campbell, Robert M; Oster, Matthew E

2016-05-01

To determine whether implementation of a standardized clinical practice guideline (CPG) for the evaluation of syncope would decrease practice variability and resource utilization. A retrospective review of medical records of patients presenting to our practice for outpatient evaluation of syncope before and after implementation of the CPG. The guideline included elements of history, physical exam, electrocardiogram, and "red flags" for further testing. Outpatient pediatric cardiology offices of a large pediatric cardiology practice. All new patients between 3 and 21 years old, who presented to cardiology clinic with a chief complaint of syncope. The CPG for the evaluation of pediatric syncope was presented to the providers. Resource utilization was determined by the tests ordered by individual physicians before and after initiation of the CPG. Patient final diagnoses were recorded and the medical records were subsequently reviewed to determine if any patients, who presented again to the system, were ultimately diagnosed with cardiac disease. Of the 1496 patients with an initial visit for syncope, there was no significant difference in the diagnosis of cardiac disease before or after initiation of the CPG: (0.6% vs. 0.4%, P = .55). Electrocardiography provides the highest yield in the evaluation of pediatric syncope. Despite high compliance (86.9%), there were no overall changes in costs ($346.31 vs. $348.53, P = .85) or in resource utilization. There was, however, a decrease in the variability of ordering of echocardiograms among physicians, particularly among those at the extremes of utilization. Although the CPG did not decrease already low costs, it did decrease the wide variability in echo utilization. Evaluation beyond detailed history, physical exam, and electrocardiography provides no additional benefit in the evaluations of pediatric patients presenting with syncope. © 2015 Wiley Periodicals, Inc.

Developing a framework to guide the de-adoption of low-value clinical practices in acute care medicine: a study protocol.

PubMed

Parsons Leigh, Jeanna; Niven, Daniel J; Boyd, Jamie M; Stelfox, Henry T

2017-01-19

Healthcare systems have difficulty incorporating scientific evidence into clinical practice, especially when science suggests that existing clinical practices are of low-value (e.g. ineffective or harmful to patients). While a number of lists outlining low-value practices in acute care medicine currently exist, less is known about how best to initiate and sustain the removal of low-value clinical practices (i.e. de-adoption). This study will develop a comprehensive list of barriers and facilitators to the de-adoption of low-value clinical practices in acute care facilities to inform the development of a framework to guide the de-adoption process. The proposed project is a multi-stage mixed methods study to develop a framework to guide the de-adoption of low-value clinical practices in acute care medicine that will be tested in a representative sample of acute care settings in Alberta, Canada. Specifically, we will: 1) conduct a systematic review of the de-adoption literature to identify published barriers and facilitators to the de-adoption of low-value clinical practices in acute care medicine and any associated interventions proposed (Phase one); 2) conduct focus groups with acute care stakeholders to identify important themes not published in the literature and obtain a comprehensive appreciation of stakeholder perspectives (Phase two); 3) extend the generalizability of focus group findings by conducting individual stakeholder surveys with a representative sample of acute care providers throughout the province to determine which barriers and facilitators identified in Phases one and two are most relevant in their clinical setting (Phase three). Identified barriers and facilitators will be catalogued and integrated with targeted interventions in a framework to guide the process of de-adoption in each of four targeted areas of acute care medicine (Emergency Medicine, Cardiovascular Health and Stroke, Surgery and Critical Care Medicine). Analyses will be descriptive using a combination of qualitative and quantitative analyses. There is a growing body of literature suggesting that the de-adoption of ineffective or harmful practices from patient care is integral to the delivery of high quality care and healthcare sustainability. The framework developed in this study will map barriers and facilitators to de-adoption to the most appropriate interventions, allowing stakeholders to effectively initiate, execute and sustain this process in an evidence-based manner.

Clinical pharmacists in general practice: an initial evaluation of activity in one English primary care organisation.

PubMed

Bush, Joseph; Langley, Christopher A; Jenkins, Duncan; Johal, Jaspal; Huckerby, Clair

2017-12-27

This aim of this research was to characterise the breadth and volume of activity conducted by clinical pharmacists in general practice in Dudley Clinical Commissioning Group (CCG), and to provide quantitative estimates of both the savings in general practitioner (GP) time and the financial savings attributable to such activity. This descriptive observational study retrospectively analysed quantitative data collected by Dudley CCG concerning the activity of clinical pharmacists in GP practices during 2015. Over the 9-month period for which data were available, the 5.4 whole time equivalent clinical pharmacists operating in GP practices within Dudley CCG identified 23 172 interventions. Ninety-five per cent of the interventions identified were completed within the study period saving the CCG in excess of £1 000 000. During the 4 months for which resource allocation data were available, the clinical pharmacists saved 628 GP appointments plus an additional 647 h that GPs currently devote to medication review and the management of repeat prescribing. This research suggests that clinical pharmacists in general practice in Dudley CCG are able to deliver clinical interventions efficiently and in high volume. In doing so, clinical pharmacists were able to generate considerable financial returns on investment. Further work is recommended to examine the effectiveness and cost-effectiveness of clinical pharmacists in general practice in improving outcomes for patients. © 2017 Royal Pharmaceutical Society.

Leadership Practices of Clinical Trials Office Leaders in Academic Health Centers

ERIC Educational Resources Information Center

Naser, Diana D.

2012-01-01

In the ever-changing clinical research environment, academic health centers seek leaders who are visionary and innovative. Clinical trials offices across the country are led by individuals who are charged with promoting growth and change in order to maximize performance, develop unique research initiatives, and help institutions achieve a…

Clinical Transition Framework: Integrating Coaching Plans, Sampling, and Accountability in Clinical Practice Development.

PubMed

Boyer, Susan A; Mann-Salinas, Elizabeth A; Valdez-Delgado, Krystal K

The clinical transition framework (CTF) is a competency-based practice development system used by nursing professional development practitioners to support nurses' initial orientation or transition to a new specialty. The CTF is applicable for both new graduate and proficient nurses. The current framework and tools evolved from 18 years of performance improvement and research projects engaged in both acute and community care environments in urban and rural settings. This article shares core CTF concepts, a description of coaching plans, and a professional accountability statement as experienced within the framework.

Application of an Electronic Medical Record in Space Medicine

NASA Technical Reports Server (NTRS)

McGinnis, Patrick J.

2000-01-01

Electronic Medical Records (EMR) have been emerging over the past decade. Today, they are replacing the paper chart in clinics throughout the nation. Approximately three years ago, the NASA-JSC Flight Medicine Clinic initiated an assessment of the EMRs available on the market. This assessment included comparing these products with the particular scope of practice at JSC. In 1998, the Logician EMR from Medicalogic was selected for the JSC Flight Medicine Clinic. This presentation reviews the process of selection and implementation of the EMR into the unique practice of aerospace medicine at JSC.

Guidelines on treatment of perinatal depression with antidepressants: An international review

PubMed Central

Kamperman, Astrid M; Boyce, Philip; Bergink, Veerle

2018-01-01

Objective: Several countries have developed Clinical Practice Guidelines regarding treatment of perinatal depressive symptoms and perinatal use of antidepressant. We aimed to compare guidelines to guide clinicians in best clinical practice. Methods: An extensive search in guideline databases, MEDLINE and PsycINFO was performed. When no guidelines were (publicly) available online, we contacted psychiatric-, obstetric-, perinatal- and mood disorder societies of all first world countries and the five largest second world countries. Only Clinical Practice Guidelines adhering to quality criteria of the Appraisal of Guidelines for Research and Evaluation instrument and including a systematic review of evidence were included. Data extraction focussed on recommendations regarding continuation or withdrawal of antidepressants and preferred treatment in newly depressed patients. Results: Our initial search resulted in 1094 articles. After first screening, 40 full-text articles were screened. Of these, 24 were excluded for not being an official Clinical Practice Guidelines. In total, 16 Clinical Practice Guidelines were included originating from 12 countries. Eight guidelines were perinatal specific and eight were general guidelines. Conclusion: During pregnancy, four guidelines advise to continue antidepressants, while there is a lack of evidence supporting this recommendation. Five guidelines do not specifically advise or discourage continuation. For new episodes, guidelines agree on psychotherapy (especially cognitive behavioural therapy) as initial treatment for mild to moderate depression and antidepressants for severe depression, with a preference for sertraline. Paroxetine is not preferred treatment for new episodes but switching antidepressants for ongoing treatment is discouraged (three guidelines). If mothers use antidepressants, observation of the neonate is generally recommended and breastfeeding encouraged. PMID:29506399

Guidelines on treatment of perinatal depression with antidepressants: An international review.

PubMed

Molenaar, Nina M; Kamperman, Astrid M; Boyce, Philip; Bergink, Veerle

2018-04-01

Several countries have developed Clinical Practice Guidelines regarding treatment of perinatal depressive symptoms and perinatal use of antidepressant. We aimed to compare guidelines to guide clinicians in best clinical practice. An extensive search in guideline databases, MEDLINE and PsycINFO was performed. When no guidelines were (publicly) available online, we contacted psychiatric-, obstetric-, perinatal- and mood disorder societies of all first world countries and the five largest second world countries. Only Clinical Practice Guidelines adhering to quality criteria of the Appraisal of Guidelines for Research and Evaluation instrument and including a systematic review of evidence were included. Data extraction focussed on recommendations regarding continuation or withdrawal of antidepressants and preferred treatment in newly depressed patients. Our initial search resulted in 1094 articles. After first screening, 40 full-text articles were screened. Of these, 24 were excluded for not being an official Clinical Practice Guidelines. In total, 16 Clinical Practice Guidelines were included originating from 12 countries. Eight guidelines were perinatal specific and eight were general guidelines. During pregnancy, four guidelines advise to continue antidepressants, while there is a lack of evidence supporting this recommendation. Five guidelines do not specifically advise or discourage continuation. For new episodes, guidelines agree on psychotherapy (especially cognitive behavioural therapy) as initial treatment for mild to moderate depression and antidepressants for severe depression, with a preference for sertraline. Paroxetine is not preferred treatment for new episodes but switching antidepressants for ongoing treatment is discouraged (three guidelines). If mothers use antidepressants, observation of the neonate is generally recommended and breastfeeding encouraged.

Knowledge Translation in Audiology

PubMed Central

Kothari, Anita; Bagatto, Marlene P.; Seewald, Richard; Miller, Linda T.; Scollie, Susan D.

2011-01-01

The impetus for evidence-based practice (EBP) has grown out of widespread concern with the quality, effectiveness (including cost-effectiveness), and efficiency of medical care received by the public. Although initially focused on medicine, EBP principles have been adopted by many of the health care professions and are often represented in practice through the development and use of clinical practice guidelines (CPGs). Audiology has been working on incorporating EBP principles into its mandate for professional practice since the mid-1990s. Despite widespread efforts to implement EBP and guidelines into audiology practice, gaps still exist between the best evidence based on research and what is being done in clinical practice. A collaborative dynamic and iterative integrated knowledge translation (KT) framework rather than a researcher-driven hierarchical approach to EBP and the development of CPGs has been shown to reduce the knowledge-to-clinical action gaps. This article provides a brief overview of EBP and CPGs, including a discussion of the barriers to implementing CPGs into clinical practice. It then offers a discussion of how an integrated KT process combined with a community of practice (CoP) might facilitate the development and dissemination of evidence for clinical audiology practice. Finally, a project that uses the knowledge-to-action (KTA) framework for the development of outcome measures in pediatric audiology is introduced. PMID:22194314

Liberating the Oppressed: Research Knowledge Differentials and Ethical Investigation in Special Operations Forces Clinical Science.

PubMed

Kemplin, Kate Rocklein; Bowling, F Young

Special Operations Forces (SOF) medics do not have preparation in research knowledge that enables them to independently initiate or generate their own studies. Thus, medics rely on evidence generated by others, who are removed from medics' practice environment. Here, salient literature on research self-efficacy and the genesis of institutional review boards (IRBs) are reviewed and interpreted for contextual applications to medics' practice and initiation of studies. More publications delving into research methods are warranted to promote medics' participation and initiation of selfdirected scientific investigation, in collaboration with research scientists. 2017.

Identifying opportunities to advance practice at a large academic medical center using the ASHP Ambulatory Care Self-Assessment Tool.

PubMed

Martirosov, Amber Lanae; Michael, Angela; McCarty, Melissa; Bacon, Opal; DiLodovico, John R; Jantz, Arin; Kostoff, Diana; MacDonald, Nancy C; Mikulandric, Nancy; Neme, Klodiana; Sulejmani, Nimisha; Summers, Bryant B

2018-05-29

The use of the ASHP Ambulatory Care Self-Assessment Tool to advance pharmacy practice at 8 ambulatory care clinics of a large academic medical center is described. The ASHP Ambulatory Care Self-Assessment Tool was developed to help ambulatory care pharmacists assess how their current practices align with the ASHP Practice Advancement Initiative. The Henry Ford Hospital Ambulatory Care Advisory Group (ACAG) opted to use the "Practitioner Track" sections of the tool to assess pharmacy practices within each of 8 ambulatory care clinics individually. The responses to self-assessment items were then compiled and discussed by ACAG members. The group identified best practices and ways to implement action items to advance ambulatory care practice throughout the institution. Three recommended action items were common to most clinics: (1) identify and evaluate solutions to deliver financially viable services, (2) develop technology to improve patient care, and (3) optimize the role of pharmacy technicians and support personnel. The ACAG leadership met with pharmacy administrators to discuss how action items that were both feasible and deemed likely to have a medium-to-high impact aligned with departmental goals and used this information to develop an ambulatory care strategic plan. This process informed and enabled initiatives to advance ambulatory care pharmacy practice within the system. The ASHP Ambulatory Care Self-Assessment Tool was useful in identifying opportunities for practice advancement in a large academic medical center. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

A nurse-led 'stop smoking' initiative.

PubMed

McGowan, E; MacAuley, D; Anderson, U

A one-week smoking awareness initiative and subsequent audit in a general practice are described. All patients attending morning surgery during the study period were offered the opportunity to discuss smoking habits at a smoking awareness clinic: 84 smokers attended. They were interviewed by the practice preventive care nurse who took a smoking history, monitored carbon monoxide (CO Hb) levels and offered a follow-up appointment. CO Hb provided immediate feedback on the effect of smoking and patients who smoked 20 or more cigarettes per day had an average CO Hb of 16.1 per cent. Fifteen per cent of smokers made a commitment to stop smoking and agreed to attend follow-up clinics. A random sample (50) of attenders at the initial Smoking Awareness Clinic (84) were followed up by questionnaire six months later. There were 29 replies (58 per cent); 19 patients (65 per cent) found the visit to the clinic helpful, 14 (48 per cent) reduced the number of cigarettes they smoked, and 11 (38 per cent) altered some other aspect of their lifestyle, of whom four modified their diet and four increased exercise. Five patients claimed they had given up smoking.

How can primary care providers manage pediatric obesity in the real world?

PubMed

Hopkins, Kristy F; Decristofaro, Claire; Elliott, Lydia

2011-06-01

To provide information regarding evidence-based interventions and clinical practice guidelines as a basis for a clinical toolkit utilizing a step management approach for the primary care provider in managing childhood obesity. Evidence-based literature including original clinical trials, literature reviews, and clinical practice guidelines. Interventions can be stratified based on initial screening of children and adolescents so that selection of treatment options is optimized. For all treatments, lifestyle modifications include attention to diet and activity level. Levels of initial success, as well as maintenance of target body mass index, may be related to the intensity and duration of interventions; involvement of family may increase success rates. For failed lifestyle interventions, or for patients with extreme obesity and/or certain comorbidities, pharmacologic or surgical options should be considered. Many intensive programs have shown success, but the resources required for these approaches may be unavailable to the typical community provider and family. However, using current guidelines, the primary care provider can initiate and manage ongoing interventions in pediatric obesity. A toolkit for primary care implementation and maintenance interventions is provided. ©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia.

PubMed

Lavoie, Kim L; Rash, Joshua A; Campbell, Tavis S

2017-01-06

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

A continuous quality improvement approach to improving clinical practice in the areas of sedation, analgesia, and neuromuscular blockade.

PubMed

Arbour, Richard

2003-01-01

Practice concerns associated with the medical prescription and nurses' administration and monitoring of sedatives, analgesics, and neuromuscular blocking agents were identified by the clinical nurse specialist within a surgical intensive care unit of a large, tertiary-care referral center. These concerns were identified using a variety of needs assessment strategies. Results of the needs assessment were used to develop a program of care, including a teaching initiative, specific to these practice areas. The teaching initiative incorporated principles of andragogy, the theory of adult learning. Educational techniques included inservice education, bedside instruction using "teaching moments," competency-based education modules, and integration of instruction into critical care orientation. Content and approach were based on the background and level of experience of participants. Educational program outcomes included increased consistency in monitoring neuromuscular blockade by clinical assessment and peripheral nerve stimulation. A second outcome was more accurate patient assessment leading to the provision of drug therapy specific to the patients' clinical states, including anxiety or pain. The continuous quality improvement approach offers a model for improving patient care using individualized needs assessment, focused educational interventions, and program evaluation strategies.

The PBRN Initiative

PubMed Central

Curro, F.A.; Vena, D.; Naftolin, F.; Terracio, L.; Thompson, V.P.

2012-01-01

The NIDCR-supported Practice-based Research Network initiative presents dentistry with an unprecedented opportunity by providing a pathway for modifying and advancing the profession. It encourages practitioner participation in the transfer of science into practice for the improvement of patient care. PBRNs vary in infrastructure and design, and sustaining themselves in the long term may involve clinical trial validation by regulatory agencies. This paper discusses the PBRN concept in general and uses the New York University College of Dentistry’s Practitioners Engaged in Applied Research and Learning (PEARL) Network as a model to improve patient outcomes. The PEARL Network is structured to ensure generalizability of results, data integrity, and to provide an infrastructure in which scientists can address clinical practitioner research interests. PEARL evaluates new technologies, conducts comparative effectiveness research, participates in multidisciplinary clinical studies, helps evaluate alternative models of healthcare, educates and trains future clinical faculty for academic positions, expands continuing education to include “benchmarking” as a form of continuous feedback to practitioners, adds value to dental schools’ educational programs, and collaborates with the oral health care and pharmaceutical industries and medical PBRNs to advance the dental profession and further the integration of dental research and practice into contemporary healthcare (NCT00867997, NCT01268605). PMID:22699662

How we used a patient visit tracker tool to advance experiential learning in systems-based practice and quality improvement in a medical student clinic.

PubMed

Chen, Chen Amy; Park, Ryan J; Hegde, John V; Jun, Tomi; Christman, Mitalee P; Yoo, Sun M; Yamasaki, Alisa; Berhanu, Aaron; Vohra-Khullar, Pamela; Remus, Kristin; Schwartzstein, Richard M; Weinstein, Amy R

2016-01-01

Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student-Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.

Measuring the cost implications of the Collaborative Accountable Care initiative in Texas.

PubMed

Ho, Vivian; Allen, Timothy K; Kim, Urie; Keenan, William P; Ku-Goto, Meei-Hsiang; Sanderson, Mark

2016-09-01

We analyzed changes in healthcare spending associated with the implementation of Cigna's Collaborative Accountable Care (CAC) initiative in a large multi-clinic physician practice. We compared claims from 2009, prior to the CAC initiative, against claims for 2010 to 2011, contrasting the patients covered by Cigna's CAC initiative with patients in other practices in the same geographic area covered by Cigna's medical plan. We used a propensity weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the CAC. The CAC initiative resulted in a 5.7% reduction in net spending per patient for 2010 to 2011, relative to what spending would have been without the initiative. This reduced spending was evident in multiple service categories: evaluation and management, procedures, imaging, tests, and durable medical equipment. Professional payments, inpatient facility, and outpatient facility payments for Medical Clinic of North Texas enrollees all experienced significant cost savings relative to the control group. About half of the savings resulted from using lower-priced sources. The CAC initiative, which includes an embedded care coordinator and a list of recommended providers, was associated with cost savings similar to those reported by other initiatives, such as global budgets and risk-based contracts.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices.

PubMed

Stevens, David P; Bowen, Judith L; Johnson, Julie K; Woods, Donna M; Provost, Lloyd P; Holman, Halsted R; Sixta, Constance S; Wagner, Ed H

2010-09-01

There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. To improve training for residents who provide chronic illness care in teaching practice settings. US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure

A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices

PubMed Central

Bowen, Judith L.; Johnson, Julie K.; Woods, Donna M.; Provost, Lloyd P.; Holman, Halsted R.; Sixta, Constance S.; Wagner, Ed H.

2010-01-01

BACKGROUND There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. OBJECTIVE To improve training for residents who provide chronic illness care in teaching practice settings. DESIGN US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives—either a national Collaborative, or a subsequent California Collaborative—to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures—HbA1c <7%, LDL <100 mg/dL, and blood pressure ≤130/80—and three process measures—retinal and foot examinations, and patient self-management goals—were tracked. PARTICIPANTS Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives. INTERVENTIONS Teaching-practice teams—faculty, residents and staff—participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly. RESULTS Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives. CONCLUSIONS These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable. PMID:20737232

Patient-reported outcomes to initiate a provider-patient dialog for the management of hip and knee osteoarthritis.

PubMed

Golightly, Yvonne M; Allen, Kelli D; Nyrop, Kirsten A; Nelson, Amanda E; Callahan, Leigh F; Jordan, Joanne M

2015-10-01

Although many treatment guidelines exist for hip and knee osteoarthritis (OA), uptake in clinical practice is typically low. Valid patient-reported outcome measures (PROs) that can be easily used in the clinic could aid implementation and evaluation of treatment recommendations, and the tracking of symptoms and function over time. This project responded to a 2012 Call to Action of the Chronic Osteoarthritis Management Initiative of the United States Bone and Joint Initiative; we aimed to develop a tiered list of recommended PROs that could be feasibly applied in common clinical settings, across four domains of pain, function, fatigue, and sleep. PROs were identified through a focused literature review. Clinicians and researchers with OA expertise evaluated each measure' feasibility for use in routine clinical practice, followed by meaningfulness in assessing OA outcomes. Eligible PROs were categorized by domain and ranked into Tiers One (very brief measures for initial use in clinical settings), Two (brief measures with more in-depth assessment), and Three (most detailed assessment). Total PROs identified were 172 for pain, 160 for function, 55 for fatigue, and 60 for sleep. Of these, 9 pain, 7 function, 7 fatigue, and 8 sleep PROs were ranked into one of three tiers. This three-tiered list of recommended PROs provides a basis for tools to systematically track outcomes, facilitate provider-patient dialog, and guide treatment for hip or knee OA. Research is needed to test the utility and feasibility of systematic implementation of these measures in primary care and specialty clinical settings. Copyright © 2015 Elsevier Inc. All rights reserved.

Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative

PubMed Central

Visser, K; Katchamart, W; Loza, E; Martinez-Lopez, J A; Salliot, C; Trudeau, J; Bombardier, C; Carmona, L; van der Heijde, D; Bijlsma, J W J; Boumpas, D T; Canhao, H; Edwards, C J; Hamuryudan, V; Kvien, T K; Leeb, B F; Martín-Mola, E M; Mielants, H; Müller-Ladner, U; Murphy, G; Østergaard, M; Pereira, I A; Ramos-Remus, C; Valentini, G; Zochling, J; Dougados, M

2009-01-01

Objectives: To develop evidence-based recommendations for the use of methotrexate in daily clinical practice in rheumatic disorders. Methods: 751 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2007–8 consisting of three separate rounds of discussions and Delphi votes. Ten clinical questions concerning the use of methotrexate in rheumatic disorders were formulated. A systematic literature search in Medline, Embase, Cochrane Library and 2005–7 American College of Rheumatology/European League Against Rheumatism meeting abstracts was conducted. Selected articles were systematically reviewed and the evidence was appraised according to the Oxford levels of evidence. Each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed. Results: A total of 16 979 references was identified, of which 304 articles were included in the systematic reviews. Ten multinational key recommendations on the use of methotrexate were formulated. Nine recommendations were specific for rheumatoid arthritis (RA), including the work-up before initiating methotrexate, optimal dosage and route, use of folic acid, monitoring, management of hepatotoxicity, long-term safety, mono versus combination therapy and management in the perioperative period and before/during pregnancy. One recommendation concerned methotrexate as a steroid-sparing agent in other rheumatic diseases. Conclusions: Ten recommendations for the use of methotrexate in daily clinical practice focussed on RA were developed, which are evidence based and supported by a large panel of rheumatologists, enhancing their validity and practical use. PMID:19033291

Use of email in a family practice setting: opportunities and challenges in patient- and physician-initiated communication

PubMed Central

Virji, Ayaz; Yarnall, Kimberly SH; Krause, Katrina M; Pollak, Kathryn I; Scannell, Margaret A; Gradison, Margaret; Østbye, Truls

2006-01-01

Background Electronic mail (email) has the potential to improve communication between physicians and patients. Methods We conducted two research studies in a family practice setting: 1) a brief, anonymous patient survey of a convenience sample to determine the number of clinic patients receptive to communicating with their physician via email, and 2) a randomized, controlled pilot study to assess the feasibility of providing health education via email to family practice patients. Results Sixty-eight percent of patients used email, and the majority of those (80%) were interested in using email to communicate with the clinic. The majority also reported that their email address changed less frequently than their home address (65%, n = 173) or telephone number (68%, n = 181). Forty-two percent were willing to pay an out-of-pocket fee to have email access to their physicians. When evaluating email initiated by the clinic, 26% of otherwise eligible patients could not participate because they lacked email access; those people were more likely to be black and to be insured through Medicaid. Twenty-four subjects agreed to participate, but one-third failed to return the required consent form by mail. All participants who received the intervention emails said they would like to receive health education emails in the future. Conclusion Our survey results show that patients are interested in email communication with the family practice clinic. Our feasibility study also illustrates important challenges in physician-initiated electronic communication. The 'digital divide' – decreased access to electronic technologies in lower income groups – is an ethical concern in the use of email for patient-physician communication. PMID:16911780

Management of testosterone therapy in adolescents and young men with hypogonadism: are we following adult clinical practice guidelines?

PubMed

Nahata, Leena; Yu, Richard N; Bhasin, Shalender; Cohen, Laurie E

2015-05-01

Male hypogonadism is a common disorder that is associated with low bone density, poor muscle mass, anemia, and sexual dysfunction. The Endocrine Society recently published a Clinical Practice Guideline for testosterone therapy in androgen-deficient men. Because treatment is frequently initiated in adolescence, the goal of this quality improvement initiative was to assess whether pediatric endocrinologists at a large tertiary care center follow these guidelines and to identify opportunities for improvement. We performed a retrospective chart review at Boston Children's Hospital. Inclusion criteria were as follows: current age ≥16 years, diagnosis of hypogonadism, and testosterone replacement therapy. Data were collected about current age, age at treatment initiation, diagnoses, pre- and on-treatment testosterone levels, route of testosterone administration and dose, bone density, hematocrit levels, and adherence with therapy. Fifty-nine patients were included. Fourteen (24%) were prescribed lower testosterone doses than those recommended in the Clinical Practice Guideline. Seven (12%) had no pre-treatment testosterone levels, and 10 (17%) had no on-treatment levels. In 49 patients with on-treatment testosterone levels, 36 had at least one value that was lower than the adult reference range. Ten (28%) of the 36 men with low testosterone levels had no dose adjustments. Thirty-seven (63%) of the 59 patients had no dual-energy X-ray absorptiometry scans, and 18 (31%) did not have hematocrit levels. Pediatric endocrinologists in this review did not consistently follow the Clinical Practice Guideline for testosterone therapy in hypogonadal adult males. Strategies that improve adherence to guidelines could help maximize the benefits of therapy and minimize treatment-associated risks.

Comprehensive Psychopathological Assessment Based on the Association for Methodology and Documentation in Psychiatry (AMDP) System: Development, Methodological Foundation, Application in Clinical Routine, and Research.

PubMed

Stieglitz, Rolf-Dieter; Haug, Achim; Fähndrich, Erdmann; Rösler, Michael; Trabert, Wolfgang

2017-01-01

The documentation of psychopathology is core to the clinical practice of the psychiatrist and clinical psychologist. However, both in initial as well as further training and specialization in their fields, this particular aspect of their work receives scanty attention only. Yet, for the past 50 years, the Association for Methodology and Documentation in Psychiatry (AMDP) System has been in existence and available as a tool to serve precisely the purpose of offering a systematic introduction to the terminology and documentation of psychopathology. The motivation for its development was based on the need for an assessment procedure for the reliable documentation of the effectiveness of newly developed psychopharmacological substances. Subsequently, the AMDP-System began to be applied in the context of investigations into a number of methodological issues in psychiatry (e.g., the frequency and specificity of particular symptoms, the comparison of rating scales). The System then became increasingly important also in clinical practice and, today, represents the most used instrument for the documentation of psychopathology in the German-speaking countries of Europe. This paper intends to offer an overview of the AMDP-System, its origins, design, and functionality. After an initial account of the history and development of the AMDP-System, the discussion will in turn focus on the System's underlying methodological principles, the transfer of clinical skills and competencies in its practical application, and its use in research and clinical practice. Finally, potential future areas of development in relation to the AMDP-System are explored.

Comprehensive Psychopathological Assessment Based on the Association for Methodology and Documentation in Psychiatry (AMDP) System: Development, Methodological Foundation, Application in Clinical Routine, and Research

PubMed Central

Stieglitz, Rolf-Dieter; Haug, Achim; Fähndrich, Erdmann; Rösler, Michael; Trabert, Wolfgang

2017-01-01

The documentation of psychopathology is core to the clinical practice of the psychiatrist and clinical psychologist. However, both in initial as well as further training and specialization in their fields, this particular aspect of their work receives scanty attention only. Yet, for the past 50 years, the Association for Methodology and Documentation in Psychiatry (AMDP) System has been in existence and available as a tool to serve precisely the purpose of offering a systematic introduction to the terminology and documentation of psychopathology. The motivation for its development was based on the need for an assessment procedure for the reliable documentation of the effectiveness of newly developed psychopharmacological substances. Subsequently, the AMDP-System began to be applied in the context of investigations into a number of methodological issues in psychiatry (e.g., the frequency and specificity of particular symptoms, the comparison of rating scales). The System then became increasingly important also in clinical practice and, today, represents the most used instrument for the documentation of psychopathology in the German-speaking countries of Europe. This paper intends to offer an overview of the AMDP-System, its origins, design, and functionality. After an initial account of the history and development of the AMDP-System, the discussion will in turn focus on the System’s underlying methodological principles, the transfer of clinical skills and competencies in its practical application, and its use in research and clinical practice. Finally, potential future areas of development in relation to the AMDP-System are explored. PMID:28439242

Using a Critical Appraisal Assignment to Infuse Evidence-Based Practice into a Therapeutic Modality Course

ERIC Educational Resources Information Center

Zwart, Mary Beth; Olson, Bernadette

2014-01-01

Context: It is the responsibility of athletic training educators, through curriculum and clinical experiences, to engage students towards adopting evidence-based practice (EBP) into their practice. The initial task of implementing EBP into a curriculum or course can seem like a large task for educators and students. As a way to start scaffolding…

Promoting Good Clinical Laboratory Practices and Laboratory Accreditation to Support Clinical Trials in Sub-Saharan Africa

PubMed Central

Shott, Joseph P.; Saye, Renion; Diakité, Moussa L.; Sanogo, Sintry; Dembele, Moussa B.; Keita, Sekouba; Nagel, Mary C.; Ellis, Ruth D.; Aebig, Joan A.; Diallo, Dapa A.; Doumbo, Ogobara K.

2012-01-01

Laboratory capacity in the developing world frequently lacks quality management systems (QMS) such as good clinical laboratory practices, proper safety precautions, and adequate facilities; impacting the ability to conduct biomedical research where it is needed most. As the regulatory climate changes globally, higher quality laboratory support is needed to protect study volunteers and to accurately assess biological parameters. The University of Bamako and its partners have undertaken a comprehensive QMS plan to improve quality and productivity using the Clinical and Laboratory Standards Institute standards and guidelines. The clinical laboratory passed the College of American Pathologists inspection in April 2010, and received full accreditation in June 2010. Our efforts to implement high-quality standards have been valuable for evaluating safety and immunogenicity of malaria vaccine candidates in Mali. Other disease-specific research groups in resource-limited settings may benefit by incorporating similar training initiatives, QMS methods, and continual improvement practices to ensure best practices. PMID:22492138

Basic principles to consider when opening a nurse practitioner-owned practice in Texas.

PubMed

Watson, Michael

2015-12-01

Advanced Practice Registered Nurse (APRN)-owned clinics in Texas are becoming more common and because of the success of these early clinics, more APRNs are considering opening their own practice; but Texas remains one of the most restrictive states for APRN practice and many questions remain. What are the regulations about physician delegation? Will you get reimbursed from insurance companies and at what rates? Can you be a primary care provider (PCP)? Changes enacted after the adoption of Senate Bill 406 improved the opportunities for APRNs in Texas yet several requirements must be met and early consultation with a lawyer and accountant can facilitate the initial business setup. The Prescriptive Authority Agreement simplified the delegation requirements and allows the APRN increased flexibility in obtaining and consulting with a delegating physician. Becoming credentialed as a PCP with private insurance companies is often complicated; however, utilizing the Council for Affordable Quality Healthcare's Universal Provider Data source for initial credentialing can facilitate this. Although this article does not discuss the financial implications of opening a practice, it does cover many aspects including legislative and regulatory requirements for practice, credentialing process and challenges, business structure, and tax implications. ©2015 American Association of Nurse Practitioners.

Clinical leadership in contemporary clinical practice: implications for nursing in Australia.

PubMed

Davidson, P M; Elliott, D; Daly, J

2006-04-01

Leadership in the clinical practice environment is important to ensure both optimal patient outcomes and successive generations of motivated and enthusiastic clinicians. The present paper seeks to define and describe clinical leadership and identify the facilitators and barriers to clinical leadership. We also describe strategies to develop clinical leaders in Australia. Key drivers to the development of nursing leaders are strategies that recognize and value clinical expertise. These include models of care that highlight the importance of the nursing role; evidence-based practice and measurement of clinical outcomes; strategies to empower clinicians and mechanisms to ensure participation in clinical decision-making. Significant barriers to clinical leadership are organizational structures that preclude nurses from clinical decision making; the national shortage of nurses; fiscal constraints; absence of well evaluated models of care and trends towards less skilled clinicians. Systematic, strategic initiatives are required to nurture and develop clinical leaders. These strategies need to be collegial collaborations between the academic and health care sectors in order to provide a united voice for advancing the nursing profession.

Measuring Costs to Community-Based Agencies for Implementation of an Evidence-Based Practice.

PubMed

Lang, Jason M; Connell, Christian M

2017-01-01

Healthcare reform has led to an increase in dissemination of evidence-based practices. Cost is frequently cited as a significant yet rarely studied barrier to dissemination of evidence-based practices and the associated improvements in quality of care. This study describes an approach to measuring the incremental, unreimbursed costs in staff time and direct costs to community-based clinics implementing an evidence-based practice through participating in a learning collaborative. Initial implementation costs exceeding those for providing "treatment as usual" were collected for ten clinics implementing trauma-focused cognitive behavioral therapy through participation in 10-month learning collaboratives. Incremental implementation costs of these ten community-based clinic teams averaged the equivalent of US$89,575 (US$ 2012). The most costly activities were training, supervision, preparation time, and implementation team meetings. Recommendations are made for further research on implementation costs, dissemination of evidence-based practices, and implications for researchers and policy makers.

Implementing elements of evidence-based practice into scientist-practitioner training at the University of Nebraska-Lincoln.

PubMed

DiLillo, David; McChargue, Dennis

2007-07-01

Evidence-based practice (EBP) has become the predominant model of training and is emerging as a common model of practice for many non-psychology health care professions. Recognizing the relevance of EBP to psychology, the American Psychological Association (APA) developed and endorsed an official policy statement on EBP for the practice of professional psychology. There is now a pressing need to consider ways that EBP can inform scientist-practitioner training. The present article proposes clinical competencies associated with the practice of EBP, and describes initial efforts to implement elements of EBP into training at the University of Nebraska-Lincoln. These efforts have occurred in both the classroom and practicum training experiences, and are geared toward helping students become more effective users of the evidence base through their clinical work. Challenges to the implementation of EBP in clinical psychology training are discussed as well.

The Practicum Script Concordance Test: An Online Continuing Professional Development Format to Foster Reflection on Clinical Practice

ERIC Educational Resources Information Center

Hornos, Eduardo H.; Pleguezuelos, Eduardo M.; Brailovsky, Carlos A.; Harillo, Leandro D.; Dory, Valerie; Charlin, Bernard

2013-01-01

Introduction: Judgment in the face of uncertainty is an important dimension of expertise and clinical competence. However, it is challenging to conceive continuing professional development (CPD) initiatives aimed at helping physicians enhance their clinical judgment skills in ill-defined situations. We present an online script concordance-based…

A Study of Critical Reflection in Health Professional Education: "Learning Where Others Are Coming from"

ERIC Educational Resources Information Center

Delany, Clare; Watkin, Deborah

2009-01-01

A dominant focus of clinical education for health professional students is experiential learning through an apprentice model where students are exposed to a range of clinical scenarios and conditions through observation initially, and then through supervised clinical practice. However experiential learning may not be enough to meet the need for…

The utah beacon experience: integrating quality improvement, health information technology, and practice facilitation to improve diabetes outcomes in small health care facilities.

PubMed

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J; North, Christie

2014-01-01

The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010-2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC(3) was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients' diabetes outcomes at 21 participating smaller, independent clinics. Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC(3) helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients' diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC(3) Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC(3) Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC(3) Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape.

The Utah Beacon Experience: Integrating Quality Improvement, Health Information Technology, and Practice Facilitation to Improve Diabetes Outcomes in Small Health Care Facilities

PubMed Central

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J.; North, Christie

2014-01-01

Purpose: The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010–2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC3 was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients’ diabetes outcomes at 21 participating smaller, independent clinics. Innovation: Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC3 helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients’ diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Findings: Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC3 Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Conclusion and Discussion: Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC3 Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC3 Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape. PMID:25848624

Operationalizing quality improvement in a pediatric surgical practice.

PubMed

Arca, Marjorie J; Enters, Jessica; Christensen, Melissa; Jeziorczak, Paul; Sato, Thomas T; Thielke, Robert; Oldham, Keith T

2014-01-01

Quality improvement (QI) is critical to enhancing patient care. It is necessary to prioritize which QI initiatives are relevant to one's institution and practice, as implementation is resource-intensive. We have developed and implemented a streamlined process to identify QI opportunities in our practice. We designed a web-based Pediatric and Infant Case Log and Outcomes (PICaLO) instrument using Research Electronic Data Capture (REDCap™) to record all surgical procedures for our practice. At the time of operation, a surgeon completes a case report form. An administrative assistant enters the data in PICaLO within 5-7days. Outcomes such as complications, deaths, and "occurrences" (readmissions, reoperations, transfers to ICU, ER visit, additional clinic visits) are recorded at the time of encounter, during M & M Conferences, and during follow-up clinic visits. Variables were chosen and defined based on national standards from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), and Patient Based Learning Log. Occurrences are queried for potential QI initiatives. In 2012, 3597 patients were entered, totaling 5177 procedures. There were 220 complications, 278 occurrences, and 16 deaths. Specific QI opportunities were identified and put into place. Data on procedures and outcomes can be collected effectively in a pediatric surgery practice to delineate pertinent QI initiatives. PICaLO is recognized by the American Board of Surgery as a mechanism to meet Maintenance of Certification 4 criteria. © 2014.

Philanthropy as a source of funding for nursing initiatives.

PubMed

Kleinpell, Ruth M; Start, Rachel; McIntosh, Erik; Worobec, Sophia; Llewellyn, Jane

2014-01-01

Nurse leaders are challenged with ensuring that research and evidence-based practices are being integrated into clinical care. Initiatives such as the Magnet Recognition Program have helped reinforce the importance of advancing nursing practices to integrate best practices, conduct quality improvement initiatives, improve performance metrics, and involve bedside nurses in conducting research and evidence-based practice projects. While seeking research funding is an option for some initiatives, other strategies such as seeking funding from grateful patients or from philanthropic resources are becoming important options for nurse leaders to pursue, as the availability of funding from traditional sources such as professional organizations or federal funding becomes more limited. In addition, more institutions are seeking and applying for funding, increasing the pool of candidates who are vying for existing funding. Seeking alternative sources of funding, such as through philanthropy, becomes a viable option. This article reviews important considerations in seeking funding from philanthropic sources for nursing initiatives. Examples from a multiyear project that focused on promoting a healthy work environment and improving nursing morale are used to highlight strategies that were used to solicit, obtain, and secure extension funding from private foundation funding to support the initiative.

Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline.

PubMed

Slinin, Yelena; Greer, Nancy; Ishani, Areef; MacDonald, Roderick; Olson, Carin; Rutks, Indulis; Wilt, Timothy J

2015-11-01

In 2006, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) published clinical practice guidelines for hemodialysis adequacy. Recent studies evaluating hemodialysis adequacy as determined by initiation timing, frequency, duration, and membrane type and prompted an update to the guideline. Systematic review and evidence synthesis. Patients with advanced chronic kidney disease receiving hemodialysis. We screened publications from 2000 to March 2014, systematic reviews, and references and consulted the NKF-KDOQI Hemodialysis Adequacy Work Group members. We included randomized or controlled clinical trials in patients undergoing long-term hemodialysis if they reported outcomes of interest. Early versus late dialysis therapy initiation; more frequent (>3 times a week) or longer duration (>4.5 hours) compared to conventional hemodialysis; low- versus high-flux dialyzer membranes. All-cause and cardiovascular mortality, myocardial infarction, stroke, hospitalizations, quality of life, depression or cognitive function scores, blood pressure, number of antihypertensive medications, left ventricular mass, interdialytic weight gain, and harms or complications related to vascular access or the process of dialysis. We included 32 articles reporting on 19 trials. Moderate-quality evidence indicated that earlier dialysis therapy initiation (at estimated creatinine clearance [eClcr] of 10-14mL/min) did not reduce mortality compared to later initiation (eClcr of 5-7mL/min). More than thrice-weekly hemodialysis and extended-length hemodialysis during a short follow-up did not improve clinical outcomes compared to conventional hemodialysis and resulted in a greater number of vascular access procedures (very low-quality evidence). Hemodialysis using high-flux membranes did not reduce all-cause mortality, but reduced cardiovascular mortality compared to hemodialysis using low-flux membranes (moderate-quality evidence). Few studies were adequately powered to evaluate mortality. Heterogeneity of study designs and interventions precluded pooling data for most outcomes. Limited data indicate that earlier dialysis therapy initiation and more frequent and longer hemodialysis did not improve clinical outcomes compared to conventional hemodialysis. Published by Elsevier Inc.

Lost opportunities to identify and treat HIV-positive patients: results from a baseline assessment of provider-initiated HIV testing and counselling (PITC) in Malawi.

PubMed

Ahmed, Saeed; Schwarz, Monica; Flick, Robert J; Rees, Chris A; Harawa, Mwelura; Simon, Katie; Robison, Jeff A; Kazembe, Peter N; Kim, Maria H

2016-04-01

To assess implementation of provider-initiated testing and counselling (PITC) for HIV in Malawi. A review of PITC practices within 118 departments in 12 Ministry of Health (MoH) facilities across Malawi was conducted. Information on PITC practices was collected via a health facility survey. Data describing patient visits and HIV tests were abstracted from routinely collected programme data. Reported PITC practices were highly variable. Most providers practiced symptom-based PITC. Antenatal clinics and maternity wards reported widespread use of routine opt-out PITC. In 2014, there was approximately 1 HIV test for every 15 clinic visits. HIV status was ascertained in 94.3% (5293/5615) of patients at tuberculosis clinics, 92.6% (30,675/33,142) of patients at antenatal clinics and 49.4% (6871/13,914) of patients at sexually transmitted infection clinics. Reported challenges to delivering PITC included test kit shortages (71/71 providers), insufficient physical space (58/71) and inadequate number of HIV counsellors (32/71) while providers from inpatient units cited the inability to test on weekends. Various models of PITC currently exist at MoH facilities in Malawi. Only antenatal and maternity clinics demonstrated high rates of routine opt-out PITC. The low ratio of facility visits to HIV tests suggests missed opportunities for HIV testing. However, the high proportion of patients at TB and antenatal clinics with known HIV status suggests that routine PITC is feasible. These results underscore the need to develop clear, standardised PITC policy and protocols, and to address obstacles of limited health commodities, infrastructure and human resources. © 2016 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.

Pragmatic characteristics of patient-reported outcome measures are important for use in clinical practice.

PubMed

Kroenke, Kurt; Monahan, Patrick O; Kean, Jacob

2015-09-01

Measures for assessing patient-reported outcomes (PROs) that may have initially been developed for research are increasingly being recommended for use in clinical practice as well. Although psychometric rigor is essential, this article focuses on pragmatic characteristics of PROs that may enhance uptake into clinical practice. Three sources were drawn on in identifying pragmatic criteria for PROs: (1) selected literature review including recommendations by other expert groups; (2) key features of several model public domain PROs; and (3) the authors' experience in developing practical PROs. Eight characteristics of a practical PRO include: (1) actionability (i.e., scores guide diagnostic or therapeutic actions/decision making); (2) appropriateness for the relevant clinical setting; (3) universality (i.e., for screening, severity assessment, and monitoring across multiple conditions); (4) self-administration; (5) item features (number of items and bundling issues); (6) response options (option number and dimensions, uniform vs. varying options, time frame, intervals between options); (7) scoring (simplicity and interpretability); and (8) accessibility (nonproprietary, downloadable, available in different languages and for vulnerable groups, and incorporated into electronic health records). Balancing psychometric and pragmatic factors in the development of PROs is important for accelerating the incorporation of PROs into clinical practice. Published by Elsevier Inc.

Peer learning partnerships: exploring the experience of pre-registration nursing students.

PubMed

Christiansen, Angela; Bell, Amelia

2010-03-01

This paper explores the impact of a peer learning initiative developed to facilitate, purposefully, mutually supportive learning relationships between student nurses in the practice setting. Finding effective strategies to support learning in the practice setting has been the focus of professional concern for a considerable time. In the UK clinical mentorship is seen as pivotal to ensuring fitness to practice; however, recent debate on the nature of learning has revealed the clinical workplace as a rich learning environment where learning occurs not only through hierarchical relationships, but also from a network of peer relationships. Formalising peer relationships through peer assisted learning is increasingly suggested as a strategy to support workplace learning and support novice students' transition to the clinical setting. Despite the developing literature in this field there is limited understanding about how students experience facilitated peer relationships. An interpretive qualitative design. Focus group interviews were used to collect interactive and situated discourse from nursing students who had recently participated in peer learning partnerships (n = 54). Narrative data were analysed thematically. Findings suggest that active support from a fellow student reduced the feelings of social isolation experienced by novice students in initial clinical placements, helping them to deal more effectively with the challenges faced and reducing the factors that have an impact on attrition. In addition, the reciprocity of the peer learning partnerships facilitated understanding of mentorship and created a heightened sense of readiness for registration and professional practice. Peer learning partnerships facilitated by mentors in clinical practice can support the transition to nursing for first year students and can help more experienced students gain a confidence and a heightened readiness for mentorship and registered practice. Facilitated peer learning partnerships can enhance the student experience in the practice setting and can help maximise opportunities for learning and support. This suggests that peer assisted learning is a legitimate area for innovation and further research.

Behavioral Medicine Training in Postdoctoral Dental Education.

ERIC Educational Resources Information Center

Lockhart, Peter B.; And Others

1992-01-01

Carolinas Medical Center (North Carolina) initiated a behavioral training program for general practice dental residents to develop skills in handling patient anxiety/stress, obesity, and depression. The program includes monthly seminars, a clinical rotation in behavioral medicine with additional related seminars, and a month-long clinical rotation…

Moving from institutional dependence to entrepreneurialism. Creating and funding a collaborative research and practice development position.

PubMed

Darbyshire, Philip; Downes, Maeve; Collins, Carmel; Dyer, Susan

2005-09-01

The paper describes the creation of, the rationale behind and the external funding of a collaborative research-clinical practice development position. The paper also demonstrates the benefits of nursing's collaboration with external funding bodies and the value of moving from our traditional position of assuming that 'the hospital' will always provide. There is a constant refrain that nursing must become more 'research-based' and develop an active research culture. In harsh financial times however, funding for research development is scarce. Nurses can respond to this by bemoaning the lack of money or by taking an entrepreneurial approach, creating innovative project proposals that develop new partnerships and attract external funding. Institutional support for clinical research is often more verbal than financial as most health care systems are experiencing extreme financial stringencies. Nurses need to reconsider the notion that every initiative must automatically be funded by the institution. In this paper we show how in a busy major hospital, clinicians and researchers collaborated to create and fund the kind of innovative research and practice development position that may be impossible to fund through existing budgets. With creativity and determination, nurses can challenge the orthodoxy that they are solely dependent on institutional funding. If there is a clear project vision, a convincing rationale, a strongly argued 'business case' and a passionate and persistent team, then innovative new projects and positions can be realized. Developing clinical focused, practice based research is now a worldwide policy and practice imperative for nurses. Unfortunately, current levels of institutional funding are unlikely to support research promotion positions and initiatives. This paper outlines an approach to securing funding for research initiatives that can create exciting new positions and develop productive partnerships between researchers, clinicians and external agencies.

Development and participant assessment of a practical quality improvement educational initiative for surgical residents.

PubMed

Sellers, Morgan M; Hanson, Kristi; Schuller, Mary; Sherman, Karen; Kelz, Rachel R; Fryer, Jonathan; DaRosa, Debra; Bilimoria, Karl Y

2013-06-01

As patient-safety and quality efforts spread throughout health care, the need for physician involvement is critical, yet structured training programs during surgical residency are still uncommon. Our objective was to develop an extended quality-improvement curriculum for surgical residents that included formal didactics and structured practical experience. Surgical trainees completed an 8-hour didactic program in quality-improvement methodology at the start of PGY3. Small teams developed practical quality-improvement projects based on needs identified during clinical experience. With the assistance of the hospital's process-improvement team and surgical faculty, residents worked through their selected projects during the following year. Residents were anonymously surveyed after their participation to assess the experience. During the first 3 years of the program, 17 residents participated, with 100% survey completion. Seven quality-improvement projects were developed, with 57% completing all DMAIC (Define, Measure, Analyze, Improve, Control) phases. Initial projects involved issues of clinical efficiency and later projects increasingly focused on clinical care questions. Residents found the experience educationally important (65%) and believed they were well equipped to lead similar initiatives in the future (70%). Based on feedback, the timeline was expanded from 12 to 24 months and changed to start in PGY2. Developing an extended curriculum using both didactic sessions and applied projects to teach residents the theory and implementation of quality improvement is possible and effective. It addresses the ACGME competencies of practice-based improvement and learning and systems-based practice. Our iterative experience during the past 3 years can serve as a guide for other programs. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Integrating research into clinical internship training bridging the science/practice gap in pediatric psychology.

PubMed

McQuaid, Elizabeth L; Spirito, Anthony

2012-03-01

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a "capstone experience"; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the "business of science." Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists.

Medicinal cannabis in oncology.

PubMed

Engels, Frederike K; de Jong, Floris A; Mathijssen, Ron H J; Erkens, Joëlle A; Herings, Ron M; Verweij, Jaap

2007-12-01

In The Netherlands, since September 2003, a legal medicinal cannabis product, constituting the whole range of cannabinoids, is available for clinical research, drug development strategies, and on prescription for patients. To date, this policy, initiated by the Dutch Government, has not yet led to the desired outcome; the amount of initiated clinical research is less than expected and only a minority of patients resorts to the legal product. This review aims to discuss the background for the introduction of legal medicinal cannabis in The Netherlands, the past years of Dutch clinical experience in oncology practice, possible reasons underlying the current outcome, and future perspectives.

The safety net medical home initiative: transforming care for vulnerable populations.

PubMed

Sugarman, Jonathan R; Phillips, Kathryn E; Wagner, Edward H; Coleman, Katie; Abrams, Melinda K

2014-11-01

Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.

The Value of Electronic Medical Record Implementation in Mental Health Care: A Case Study

PubMed Central

Fischler, Ilan; Stuckey, Melanie I; Klassen, Philip E; Chen, John

2017-01-01

Background Electronic medical records (EMR) have been implemented in many organizations to improve the quality of care. Evidence supporting the value added to a recovery-oriented mental health facility is lacking. Objective The goal of this project was to implement and customize a fully integrated EMR system in a specialized, recovery-oriented mental health care facility. This evaluation examined the outcomes of quality improvement initiatives driven by the EMR to determine the value that the EMR brought to the organization. Methods The setting was a tertiary-level mental health facility in Ontario, Canada. Clinical informatics and decision support worked closely with point-of-care staff to develop workflows and documentation tools in the EMR. The primary initiatives were implementation of modules for closed loop medication administration, collaborative plan of care, clinical practice guidelines for schizophrenia, restraint minimization, the infection prevention and control surveillance status board, drug of abuse screening, and business intelligence. Results Medication and patient scan rates have been greater than 95% since April 2014, mitigating the adverse effects of medication errors. Specifically, between April 2014 and March 2015, only 1 moderately severe and 0 severe adverse drug events occurred. The number of restraint incidents decreased 19.7%, which resulted in cost savings of more than Can $1.4 million (US $1.0 million) over 2 years. Implementation of clinical practice guidelines for schizophrenia increased adherence to evidence-based practices, standardizing care across the facility. Improved infection prevention and control surveillance reduced the number of outbreak days from 47 in the year preceding implementation of the status board to 7 days in the year following. Decision support to encourage preferential use of the cost-effective drug of abuse screen when clinically indicated resulted in organizational cost savings. Conclusions EMR implementation allowed Ontario Shores Centre for Mental Health Sciences to use data analytics to identify and select appropriate quality improvement initiatives, supporting patient-centered, recovery-oriented practices and providing value at the clinical, organizational, and societal levels. PMID:28057607

Bench to bedside: integrating advances in basic science into daily clinical practice.

PubMed

McGoldrick, Rory B; Hui, Kenneth; Chang, James

2014-08-01

This article focuses on the initial steps of commercial development of a patentable scientific discovery from an academic center through to marketing a clinical product. The basics of partnering with a technology transfer office (TTO) and the complex process of patenting are addressed, followed by a discussion on marketing and licensing the patent to a company in addition to starting a company. Finally, the authors address the basic principles of obtaining clearance from the Food and Drugs Administration, production in a good manufacturing practice (GMP) facility, and bringing the product to clinical trial. Published by Elsevier Inc.

Key Lessons Learned from Moffitt's Molecular Tumor Board: The Clinical Genomics Action Committee Experience.

PubMed

Knepper, Todd C; Bell, Gillian C; Hicks, J Kevin; Padron, Eric; Teer, Jamie K; Vo, Teresa T; Gillis, Nancy K; Mason, Neil T; McLeod, Howard L; Walko, Christine M

2017-02-01

The increasing practicality of genomic sequencing technology has led to its incorporation into routine clinical practice. Successful identification and targeting of driver genomic alterations that provide proliferative and survival advantages to tumor cells have led to approval and ongoing development of several targeted cancer therapies. Within many major cancer centers, molecular tumor boards are constituted to shepherd precision medicine into clinical practice. In July 2014, the Clinical Genomics Action Committee (CGAC) was established as the molecular tumor board companion to the Personalized Medicine Clinical Service (PMCS) at Moffitt Cancer Center in Tampa, Florida. The processes and outcomes of the program were assessed in order to help others move into the practice of precision medicine. Through the establishment and initial 1,400 patients of the PMCS and its associated molecular tumor board at a major cancer center, five practical lessons of broad applicability have been learned: transdisciplinary engagement, the use of the molecular report as an aid to clinical management, clinical actionability, getting therapeutic options to patients, and financial considerations. Value to patients includes access to cutting-edge practice merged with individualized preferences in treatment and care. Genomic-driven cancer medicine is increasingly becoming a part of routine clinical practice. For successful implementation of precision cancer medicine, strategically organized molecular tumor boards are critical to provide objective evidence-based translation of observed molecular alterations into patient-centered clinical action. Molecular tumor board implementation models along with clinical and economic outcomes will define future treatment standards. The Oncologist 2017;22:144-151 Implications for Practice: It is clear that the increasing practicality of genetic tumor sequencing technology has led to its incorporation as part of routine clinical practice. Subsequently, many cancer centers are seeking to develop a personalized medicine services and/or molecular tumor board to shepherd precision medicine into clinical practice. This article discusses the key lessons learned through the establishment and development of a molecular tumor board and personalized medicine clinical service. This article highlights practical issues and can serve as an important guide to other centers as they conceive and develop their own personalized medicine services and molecular tumor boards. © AlphaMed Press 2017.

Key Lessons Learned from Moffitt's Molecular Tumor Board: The Clinical Genomics Action Committee Experience

PubMed Central

Knepper, Todd C.; Bell, Gillian C.; Hicks, J. Kevin; Padron, Eric; Teer, Jamie K.; Vo, Teresa T.; Gillis, Nancy K.; Mason, Neil T.; Walko, Christine M.

2017-01-01

Abstract Background. The increasing practicality of genomic sequencing technology has led to its incorporation into routine clinical practice. Successful identification and targeting of driver genomic alterations that provide proliferative and survival advantages to tumor cells have led to approval and ongoing development of several targeted cancer therapies. Within many major cancer centers, molecular tumor boards are constituted to shepherd precision medicine into clinical practice. Materials and Methods. In July 2014, the Clinical Genomics Action Committee (CGAC) was established as the molecular tumor board companion to the Personalized Medicine Clinical Service (PMCS) at Moffitt Cancer Center in Tampa, Florida. The processes and outcomes of the program were assessed in order to help others move into the practice of precision medicine. Results. Through the establishment and initial 1,400 patients of the PMCS and its associated molecular tumor board at a major cancer center, five practical lessons of broad applicability have been learned: transdisciplinary engagement, the use of the molecular report as an aid to clinical management, clinical actionability, getting therapeutic options to patients, and financial considerations. Value to patients includes access to cutting‐edge practice merged with individualized preferences in treatment and care. Conclusions. Genomic‐driven cancer medicine is increasingly becoming a part of routine clinical practice. For successful implementation of precision cancer medicine, strategically organized molecular tumor boards are critical to provide objective evidence‐based translation of observed molecular alterations into patient‐centered clinical action. Molecular tumor board implementation models along with clinical and economic outcomes will define future treatment standards. Implications for Practice. It is clear that the increasing practicality of genetic tumor sequencing technology has led to its incorporation as part of routine clinical practice. Subsequently, many cancer centers are seeking to develop a personalized medicine services and/or molecular tumor board to shepherd precision medicine into clinical practice. This article discusses the key lessons learned through the establishment and development of a molecular tumor board and personalized medicine clinical service. This article highlights practical issues and can serve as an important guide to other centers as they conceive and develop their own personalized medicine services and molecular tumor boards. PMID:28179575

Clopidogrel and warfarin pharmacogenetic tests: what is the evidence for use in clinical practice?

PubMed Central

Shahin, Mohamed H.A.; Johnson, Julie A.

2013-01-01

Purpose of review To review the most promising genetic markers associated with the variability in the safety or efficacy of warfarin and clopidogrel and highlight the verification and validation initiatives for translating clopidogrel and warfarin pharmacogenetic tests to clinical practice. Recent findings Rapid advances in pharmacogenetics, continuous decrease in genotyping cost, development of point-of-care devices and the newly established clinical genotyping programs at several institutions hold the promise of individualizing clopidogrel and warfarin based on genotype. Guidelines have been established to assist clinicians in prescribing clopidogrel or warfarin dose based on genotype. However, the clinical utility of clopidogrel and warfarin is still limited. Accordingly, large randomized clinical trials are underway to define the role of clopidogrel and warfarin pharmacogenetics in clinical practice. Summary Pharmacogenetics has offered compelling evidence toward the individualization of clopidogrel and warfarin therapies. The rapid advances in technology make the clinical implementation of clopidogrel and warfarin pharmacogenetics possible. The clinical genotyping programs and the ongoing clinical trials will help in overcoming some of the barriers facing the clinical implementation of clopidogrel and warfarin pharmacogenetics. PMID:23478884

Quality improvement and practice-based research in neurology using the electronic medical record

PubMed Central

Frigerio, Roberta; Kazmi, Nazia; Meyers, Steven L.; Sefa, Meredith; Walters, Shaun A.; Silverstein, Jonathan C.

2015-01-01

Abstract We describe quality improvement and practice-based research using the electronic medical record (EMR) in a community health system–based department of neurology. Our care transformation initiative targets 10 neurologic disorders (brain tumors, epilepsy, migraine, memory disorders, mild traumatic brain injury, multiple sclerosis, neuropathy, Parkinson disease, restless legs syndrome, and stroke) and brain health (risk assessments and interventions to prevent Alzheimer disease and related disorders in targeted populations). Our informatics methods include building and implementing structured clinical documentation support tools in the EMR; electronic data capture; enrollment, data quality, and descriptive reports; quality improvement projects; clinical decision support tools; subgroup-based adaptive assignments and pragmatic trials; and DNA biobanking. We are sharing EMR tools and deidentified data with other departments toward the creation of a Neurology Practice-Based Research Network. We discuss practical points to assist other clinical practices to make quality improvements and practice-based research in neurology using the EMR a reality. PMID:26576324

Dental Hygienists' Perceptions of Preparedness for Clinical Practice: A Phenomenological Study

ERIC Educational Resources Information Center

Cantrell, Lezlie M.

2012-01-01

The purpose of this phenomenological study was to identify, compile, and describe how community college graduate dental hygienists perceived their initial dental hygiene curriculum preparation and how they subsequently adapted their curriculum preparation in order to perform their responsibilities in their first clinical dental hygiene job.…

How Do Clinicians Become Teachers? A Communities of Practice Perspective

ERIC Educational Resources Information Center

Cantillon, P.; D'Eath, M.; De Grave, W.; Dornan, T.

2016-01-01

There is widespread acceptance that clinical educators should be trained to teach, but faculty development for clinicians is undermined by poor attendance and inadequate learning transfer. As a result there has been growing interest in situating teacher development initiatives in clinical workplaces. The relationship between becoming a teacher and…

Patient access in plastic surgery: an operational and financial analysis of service-based interventions to improve ambulatory throughput in an academic surgery practice.

PubMed

Hultman, Charles Scott; Gilland, Wendell G; Weir, Samuel

2015-06-01

Inefficient patient throughput in a surgery practice can result in extended new patient backlogs, excessively long cycle times in the outpatient clinics, poor patient satisfaction, decreased physician productivity, and loss of potential revenue. This project assesses the efficacy of multiple throughput interventions in an academic, plastic surgery practice at a public university. We implemented a Patient Access and Efficiency (PAcE) initiative, funded and sponsored by our health care system, to improve patient throughput in the outpatient surgery clinic. Interventions included: (1) creation of a multidisciplinary team, led by a project redesign manager, that met weekly; (2) definition of goals, metrics, and target outcomes; 3) revision of clinic templates to reflect actual demand; 4) working down patient backlog through group visits; 5) booking new patients across entire practice; 6) assigning a physician's assistant to the preoperative clinic; and 7) designating a central scheduler to coordinate flow of information. Main outcome measures included: patient satisfaction using Press-Ganey surveys; complaints reported to patient relations; time to third available appointment; size of patient backlog; monthly clinic volumes with utilization rates and supply/demand curves; "chaos" rate (cancellations plus reschedules, divided by supply, within 48 hours of booked clinic date); patient cycle times with bottleneck analysis; physician productivity measured by work Relative Value Units (wRVUs); and downstream financial effects on billing, collection, accounts receivable (A/R), and payer mix. We collected, managed, and analyzed the data prospectively, comparing the pre-PAcE period (6 months) with the PAcE period (6 months). The PAcE initiative resulted in multiple improvements across the entire plastic surgery practice. Patient satisfaction increased only slightly from 88.5% to 90.0%, but the quarterly number of complaints notably declined from 17 to 9. Time to third available new patient appointment dropped from 52 to 38 days, whereas the same metric for a preoperative appointment plunged from 46 to 16 days. The size of the new patient backlog fell from 169 to 110 patients, and total monthly clinic volume climbed from 574 to 766 patients. Our "chaos" rate dropped from 12.3% to 1.8%. Mean patient cycle time in the clinic decreased dramatically from 127 to 44 minutes. Mean monthly productivity for the practice increased from 2479 to 2702 RVUs. Although our collection rate did not change, days in A/R dropped from 66 to 57 days. Mean monthly charges increased from U.S. $535,213 to U.S. $583,193, and mean monthly collections improved from U.S. $181,967 to U.S. $210,987. Payer mix remained unchanged. Implementation of a PAcE initiative, focusing on outpatient clinic throughput, yields significant improvements in access to care, patient satisfaction as measured by complaints, physician productivity, and financial performance. An academic, university-based, plastic surgery practice can use throughput interventions to deliver timely care and to enhance financial viability.

Coeliac disease screening is suboptimal in a tertiary gastroenterology setting.

PubMed

Iskandar, Heba; Gray, Darrell M; Vu, Hongha; Mirza, Faiz; Rude, Mary Katherine; Regan, Kara; Abdalla, Adil; Gaddam, Srinivas; Almaskeen, Sami; Mello, Michael; Marquez, Evelyn; Meyer, Claire; Bolkhir, Ahmed; Kanuri, Navya; Sayuk, Gregory; Gyawali, C Prakash

2017-08-01

Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. 616 consecutive patients (49±0.6 years, range 16-87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

An education and motivation intervention to change clinical management of the third stage of labor - the GIRMMAHP Initiative.

PubMed

Figueras, Albert; Narváez, Edgar; Valsecia, Mabel; Vásquez, Susana; Rojas, Germán; Camilo, Angiolina; del Valle, José-María; Aguilera, Cristina

2008-12-01

Hemorrhage and hypertensive disorders are major contributors to death after delivery in developing countries. The GIRMMAHP Initiative was designed to describe the actual delivery care in five Latin American countries and to educate and motivate clinical staff at 17 hospitals with the purpose of implementing their own clinical practice guidelines to prevent postpartum hemorrhage. A multicountry education intervention was developed in four consecutive stages, using two analyses: (a) an observational study of the clinical records in eight teaching and nine nonteaching hospitals and (b) a study of the long-term changes measured 12 months after completion of an education intervention and writing a local clinical guideline. Data from 2,247 pregnant women showed that only 23.3 percent had an active management of the third stage of labor and that 22.7 percent received no prenatal care visit. These data were used to prepare local clinical practice guidelines in each participant hospital. The proportion of active management increased to 72.6 percent of deliveries at 3 months and 58.7 percent 1 year later. Use of oxytocin during the third stage of labor increased to 85.9 percent of included deliveries. The proportion of women who had postpartum hemorrhage decreased from 12.7 percent at baseline to 5 percent at 1 year after the intervention. An education intervention and discussion of actual clinical practice problems with health professionals and their involvement in drafting clinical guidelines helped improve health care quality and practitioners' adherence to these guidelines.

Two-Year Costs and Quality in the Comprehensive Primary Care Initiative.

PubMed

Dale, Stacy B; Ghosh, Arkadipta; Peikes, Deborah N; Day, Timothy J; Yoon, Frank B; Taylor, Erin Fries; Swankoski, Kaylyn; O'Malley, Ann S; Conway, Patrick H; Rajkumar, Rahul; Press, Matthew J; Sessums, Laura; Brown, Randall

2016-06-16

The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support. We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices. During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively). Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

Using the knowledge-to-action framework to guide the timing of dialysis initiation.

PubMed

Sood, Manish M; Manns, Braden; Nesrallah, Gihad

2014-05-01

The optimal time at which to initiate chronic dialysis remains unknown. Using a contemporary knowledge translation approach (the knowledge-to-action framework), a pan-Canadian collaboration (CANN-NET) set out to study the scope of the problem, then develop and disseminate evidence-based guidelines addressing the timing of dialysis initiation. The purpose of this review is to summarize the key findings and describe the planned Canadian knowledge translation strategy for improving knowledge and practices pertaining to the timing dialysis initiation. New research has provided considerable insights regarding the initiation of dialysis. A Canadian cohort study identified significant variation in the estimated glomerular filtration rate level at dialysis initiation, and a survey of providers identified related knowledge gaps that might be amenable to knowledge translation interventions. A recent knowledge synthesis/guideline concluded that early dialysis initiation is costly, and provides no measureable clinical benefits. A systematic knowledge translation intervention including a multifaceted approach may aid in reducing variation in practice and improving the quality of care. Utilizing the knowledge-to-action framework, we identified practice variation and key barriers to the optimal timing for dialysis initiation that may be amenable to knowledge translation strategies.

Using systems thinking to support clinical system transformation.

PubMed

Best, Allan; Berland, Alex; Herbert, Carol; Bitz, Jennifer; van Dijk, Marlies W; Krause, Christina; Cochrane, Douglas; Noel, Kevin; Marsden, Julian; McKeown, Shari; Millar, John

2016-05-16

Purpose - The British Columbia Ministry of Health's Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC's health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings. Design/methodology/approach - Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey. Findings - The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system. Research limitations/implications - The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels - policy, management and practice - about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue. Practical implications - Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues. Originality/value - Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

Physiotherapy clinical educators' perspectives on a fitness to practice initiative.

PubMed

Lo, Kristin; Curtis, Heather; Francis-Cracknell, Alison; Maloney, Stephen; Nickson, Wendy; Bearman, Margaret; Keating, Jennifer L

2018-01-01

Health practitioner registration boards require health professionals to evaluate and maintain "fitness to practice" (FTP). This encompasses the professional behavior, clinical competence, and freedom from impairment required for safe and effective service provision. We developed and implemented policies to promote student self-assessment and support of FTP that were pre-emptive and designed to be helpful and sought clinician feedback on this initiative. An innovative student-centered FTP approach was devised with consideration of defensible ethico-legal practice. A survey explored clinical educators' perceptions of the FTP policy and the associated education and support. Closed and open survey questions were analyzed using descriptive statistics, qualitative evaluation, and thematic analysis. Seventy-nine physiotherapy clinical educators from 34 sites across eight Australian health services returned surveys. Educators had positive perceptions of policy components, particularly incorporating professionalism as a hurdle requirement and the attendance and incident reporting policies. The benefits of a student-centered FTP approach included clarity and consistency in managing FTP issues and facilitation of student awareness through active engagement in maintaining their FTP. To our knowledge, this paper is the first to report a comprehensive approach to the range of FTP issues incorporating student self-declaration of issues that may affect desirable progression through clinical placements. The policy and program of education and support are likely to be generalizable to health professional training programs that utilize workplace training.

Description and evaluation of an initiative to develop advanced practice nurses in mainland China.

PubMed

Wong, Frances Kam Yuet; Peng, Gangyi; Kan, Eva C; Li, Yajie; Lau, Ada T; Zhang, Liying; Leung, Annie F; Liu, Xueqin; Leung, Vilna O; Chen, Weiju; Li, Ming

2010-05-01

This paper describes an initiative to develop Advanced Practice Nurses (APNs) in mainland China and evaluation of the outcomes of the described programme. The pioneer project was an APN postgraduate programme involving 38 students conducted in Guangzhou, China during 2004-2005. Data related to curriculum content and process, student performance, self-reported competence and programme effects were collected. Quantitative data such as demographic data, student performance were analysed using descriptive statistics and the pre and post self-reported practice of competence was compared using chi-square test. Qualitative data such as case reports and interviews were examined using thematic analyses. Reflective journals and case studies revealed the attributes of APNs in managing clinical cases at advanced level, applying theory into practice and exercising evidence-based practice. The relatively modest self-reported practice of competence suggested that the graduates were novice APNs and needed continued development after the completion of the programme. This study reports the experience of an initiative in China and suggests a useful curriculum framework for educating APNs. Copyright 2009 Elsevier Ltd. All rights reserved.

A triadic interplay between academics, practitioners and students in the nursing theory and practice dialectic.

PubMed

Chan, Engle Angela; Chan, Kitty; Liu, Yat Wa Justina

2012-05-01

  This article is a report of a descriptive study of the effectiveness of classroom teaching by clinical nurse specialists on students' transfer of theory into practice.   Ongoing concern about a theory-practice merger in nursing has led to collaborative initiatives between academics and practitioners globally. There are different forms of collaborative efforts, but information on their evaluation is scarce and inconclusive. Integration of theory and practice is important for an outcome-based approach, which emphasizes students' clinical competence as the measure of success. The limited nursing discussion on theory and practice collaboration in education was our impetus for the study.   Between 2007 and 2008, focus group interviews were held, first with 75 and then with 35 from the same group of first-year students, regarding their learning experience from the lectures of the two clinical nurse specialists in diabetes and colostomy care, respectively, prior to and after their clinical placements. Six of their clinical instructors and the two clinical nurse specialists were also interviewed. The audiotaped interviews were transcribed verbatim and analysed using content analysis.   Three themes were identified: impact of students' vicarious learning from clinical nurse specialists' stories of experience; improving the collaboration between clinical nurse specialists and subject lecturers for junior students' learning experience; continuity in the clinical integration of theory-practice as dialectic through an interplay between academics, practitioners and students.   The theory and practice issue is best addressed as a triadic paradigm in a community of practice with the collaboration among academics, practitioners and students. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments.

PubMed

Stern, Robert A; Seichepine, Daniel; Tschoe, Christine; Fritts, Nathan G; Alosco, Michael L; Berkowitz, Oren; Burke, Peter; Howland, Jonathan; Olshaker, Jonathan; Cantu, Robert C; Baugh, Christine M; Holsapple, James W

2017-02-15

Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting.

Prevalence of hip osteoarthritis in chiropractic practice in Denmark: a descriptive cross-sectional and prospective study.

PubMed

Poulsen, Erik; Christensen, Henrik W; Overgaard, Søren; Hartvigsen, Jan

2012-05-01

The purposes of this study were to measure the prevalence of clinical and radiographic hip osteoarthritis (OA) and first-time diagnosis of hip OA in consecutive patients presenting to chiropractic practices in Denmark and to report the components of the initial treatment rendered by the chiropractic practitioner. A total of 2000 patient records and 1000 radiographs were reviewed retrospectively in 20 chiropractic clinics throughout Denmark. Information obtained included patients' primary complaint, physical examination and radiographic findings of hip OA, and treatment. Subsequently, the 20 clinics participated in a prospective survey where they collected equivalent information over a 2-week period. Retrospective review of records revealed that 1.4% of patients in Danish chiropractic practice had signs of clinical hip OA. Of these, 59% demonstrated radiographic signs of hip OA. Prospective data collection revealed that 3.4% of new patients had signs of clinical hip OA. Fifty-four percent of these demonstrated radiographic signs of hip OA, and of these 70% were diagnosed as having OA of the hip for the first time. Initial treatment involved manual treatment and advice on over-the-counter pain medication and/or supplements. Of all 1000 retrospectively reviewed radiographs in patients 40 years or older, 19.2% demonstrated radiographic signs of hip OA. Osteoarthritis of the hip is diagnosed and managed in primary care chiropractic practice in Denmark; however, it is likely underdiagnosed. In those newly presenting to chiropractic practitioners, first-time diagnosis with clinical and radiographic signs of hip OA appears to be common. Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.

Nursing and health-care assistant experience of supervision in a medium secure psychiatric service for women: implications for service development.

PubMed

Long, C G; Harding, S; Payne, K; Collins, L

2014-03-01

In secure psychiatric services where the potential for 'burnout' by nurses is high, clinical supervision is viewed as a key to reflective practice to support staff in stressful working environments. Barriers to the uptake of clinical supervision in such service settings are personal and organizational. The study was prompted by the need to evaluate the effectiveness of supervision for registered nurses and health-care assistants (HCAs) and a desire to use survey findings to improve the quality and uptake of supervision. The study examined the perceived benefits, the best practice elements and the practical aspects of clinical supervision including how to improve practice. An approximate uptake of clinical supervision by 50% of staff confirmed previous findings; that HCAs were significantly less likely to engage in supervision and less likely to perceive benefit from it. Initiatives to address the training and managerial obstacles to the provision of formal supervision are described. © 2013 John Wiley & Sons Ltd.

A retrospective explanatory case study of the implementation of a bleeding management quality initiative, in an Australian cardiac surgery unit.

PubMed

Pearse, Bronwyn Louise; Rickard, Claire M; Keogh, Samantha; Lin Fung, Yoke

2018-03-09

Bleeding management in cardiac surgery is challenging. Many guidelines exist to support bleeding management; however, literature demonstrates wide variation in practice. In 2012, a quality initiative was undertaken at The Prince Charles Hospital, Australia to improve bleeding management for cardiac surgery patients. The implementation of the quality initiative resulted in significant reductions in the incidence of blood transfusion, re-exploration for bleeding; superficial leg and chest wound infections; length of hospital stay, and cost. Given the success of the initiative, we sought to answer the question; "How and why was the process of implementing a bleeding management quality initiative in the cardiac surgery unit successful, and sustainable?" A retrospective explanatory case study design was chosen to explore the quality initiative. Analysis of the evidence was reviewed through phases of the 'Knowledgeto Action' planned change model. Data was derived from: (1) document analysis, (2) direct observation of the local environment, (3) clinical narratives from interviews, and analysed with a triangulation approach. The study period extended from 10/2011 to 6/2013. Results demonstrated the complexity of changing practice, as well as the significant amount of dedicated time and effort required to support individual, department and system wide change. Results suggest that while many clinicians were aware of the potential to apply improved practice, numerous barriers and challenges needed to be overcome to implement change across multiple disciplines and departments. The key successful components of the QI were revealed through the case study analysis as: (1) an appropriately skilled project manager to facilitate the implementation process; (2) tools to support changes in workflow and decision making including a bleeding management treatment algorithm with POCCTs; (3) strong clinical leadership from the multidisciplinary team and; (4) the evolution of the project manager position into a perpetual clinical position to support sustainability. Copyright © 2018 Australian College of Critical Care Nurses Ltd. All rights reserved.

Building clinicians-researchers partnerships: lessons from diverse natural settings and practice-oriented initiatives.

PubMed

Castonguay, Louis G; Youn, Soo Jeong; Xiao, Henry; Muran, J Christopher; Barber, Jacques P

2015-01-01

In this concluding paper, we identify the type of studies conducted by 11 teams of contributors to a special issue on building clinicians-researchers partnerships. Those studies were conducted across a variety of clinical settings. We also integrate the lessons that have emerged from their collaborative initiatives in terms of obstacles faced, strategies adopted to address these challenges, benefits gained, and general recommendations offered to facilitate studies conducted with or by clinicians. The paper ends with the authors' thoughts about the future success of practice-oriented research in general.

Change in Cardiopulmonary Arrest Response in an Anesthesiology Residency: A practice-based learning initiative.

PubMed

Takla, Amgad; Dorotta, Ihab; Staszak, John; Tetzlaff, John E

2007-01-01

Because of increases in the acuity in our patient population, increasing complexity of the care provided and the structure of our residency, we decided to systematically alter our participation in the hospital-wide cardiac arrest system. The need to provide optimum service in an increasingly complex clinical care system was the motivation for change. With substantive input from trainees and practitioners, we created a multi-tier-system of response along with predefined criteria for the anesthesiology response. We report the result of our practice based learning initiative.

Agents for Change: Nonphysician Medical Providers and Health Care Quality

PubMed Central

Boucher, Nathan A; McMillen, Marvin A; Gould, James S

2015-01-01

Quality medical care is a clinical and public health imperative, but defining quality and achieving improved, measureable outcomes are extremely complex challenges. Adherence to best practice invariably improves outcomes. Nonphysician medical providers (NPMPs), such as physician assistants and advanced practice nurses (eg, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, and certified nurse midwives), may be the first caregivers to encounter the patient and can act as agents for change for an organization’s quality-improvement mandate. NPMPs are well positioned to both initiate and ensure optimal adherence to best practices and care processes from the moment of initial contact because they have robust clinical training and are integral to trainee/staff education and the timely delivery of care. The health care quality aspects that the practicing NPMP can affect are objective, appreciative, and perceptive. As bedside practitioners and participants in the administrative and team process, NPMPs can fine-tune care delivery, avoiding the problem areas defined by the Institute of Medicine: misuse, overuse, and underuse of care. This commentary explores how NPMPs can affect quality by 1) supporting best practices through the promotion of guidelines and protocols, and 2) playing active, if not leadership, roles in patient engagement and organizational quality-improvement efforts. PMID:25663213

Improving blood transfusion practice by regular education in the United Arab Emirates.

PubMed

Sajwani, F H

2012-07-01

A cross-match to transfused unit ratio of less than 2.0 is frequently used to assess performance in many hospital blood banks. This brief report was initiated to evaluate the practice at a local hospital and to emphasize the importance of regular educational sessions to improve blood transfusion practice. Retrospective data on cross-match : transfused (C : T) ratio of all departments was collected and educational sessions were given to improve practice. Thereafter, a new set of data was collected and change in practice was assessed. Initial data showed total (C : T) ratio of 1.95. After medical staff education, analysis showed clinically significant improvement in blood utilization practice with a (C : T) ratio of 1.60. This brief report indicates the importance of regular physician education, the potential role of blood transfusion committee, and the need to implement clear guidelines for blood transfusion. © 2012 American Association of Blood Banks.

Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives.

PubMed

Von Korff, Michael; Walker, Rod L; Saunders, Kathleen; Shortreed, Susan M; Thakral, Manu; Parchman, Michael; Hansen, Ryan N; Ludman, Evette; Sherman, Karen J; Dublin, Sascha

2017-08-01

No studies have assessed the comparative effectiveness of guideline-recommended interventions to reduce risk of prescription opioid use disorder among chronic opioid therapy (COT) patients. We compared the prevalence of prescription opioid use disorder among COT patients from intervention clinics that had implemented opioid dose and risk reduction initiatives for more than 4 years relative to control clinics that had not. After a healthcare system in Washington State implemented interventions to reduce opioid dose and risks, we surveyed 1588 adult primary care COT patients to compare the prevalence of prescription opioid use disorder among COT patients from the intervention and control clinics. Intervention clinics managed COT patients at lower COT doses and with more consistent use of risk reduction practices. Control clinics cared for similar COT patients but prescribed higher opioid doses and used COT risk reduction practices inconsistently. Prescription opioid use disorder was assessed with the Psychiatric Research Interview for Substance and Mental Disorders. The prevalence of prescription opioid use disorder was 21.5% (95% CI=18.9% to 24.4%) among COT patients in the intervention clinics and 23.9% (95% CI=20.5% to 27.6%) among COT patients in the control clinics. The adjusted relative risk of prescription opioid use disorder was 1.08 (95% CI=0.89, 1.32) among the control clinic patients relative to the intervention clinic patients. Long-term implementation of opioid dose and risk reduction initiatives was not associated with lower rates of prescription opioid use disorder among prevalent COT patients. Extreme caution should be exercised by clinicians considering COT for patients with chronic non-cancer pain until benefits of this treatment and attendant risks are clarified. Copyright © 2017 Elsevier B.V. All rights reserved.

Leadership by collaboration: Nursing's bold new vision for academic-practice partnerships.

PubMed

Sebastian, Juliann G; Breslin, Eileen T; Trautman, Deborah E; Cary, Ann H; Rosseter, Robert J; Vlahov, David

In 2016 the American Association of Colleges of Nursing issued a report, Advancing Healthcare Transformation: A New Era for Academic Nursing that included recommendations for more fully integrating nursing education, research, and practice. The report calls for a paradigm shift in how nursing leaders in academia and practice work together and with other leaders in higher education and clinical practice. Only by doing so can we realize the full benefits of academic nursing in this new era in which integration and collaboration are essential to success. In this paper we: 1) examine how academic nursing can contribute to healthcare innovation across environments; 2) explore leadership skills for deans of nursing to advance the goals of academic nursing in collaboration with clinical nursing partners, other health professions and clinical service leaders, academic administrators, and community members; and, 3) consider how governance structures and policy initiatives can advance this work. Copyright © 2017 Elsevier Inc. All rights reserved.

Estimating the cost of blood: past, present, and future directions.

PubMed

Shander, Aryeh; Hofmann, Axel; Gombotz, Hans; Theusinger, Oliver M; Spahn, Donat R

2007-06-01

Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare sectors worldwide. To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channeled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. Shrinking donor availability and application of a precautionary principle to minimize transfusion risks are factors that continue to drive the cost of blood products upward. Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-center clinic). These initiatives, their rationale, importance, and future directions are described.

Diffusion of a Nurse-led Healthcare Innovation: Describing Certified Clinical Nurse Leader Integration Into Care Delivery.

PubMed

Bender, Miriam; Williams, Marjory; Su, Wei

2016-01-01

The Clinical Nurse Leader™ (CNL) initiative is in its 2nd decade. Despite a growing theoretical and empirical body of CNL knowledge, little is known about CNLs themselves or where and how their competencies are being integrated into care delivery across the country. The aim of this study was to describe certified CNL characteristics and roles as part of a larger study validating a model for CNL practice. This study used a descriptive analysis of survey data from a national sample of certified CNLs. Survey response rate was 19%. Sixty percent have greater than 10 years of RN experience, and 75% have additional specialty certifications. Fifty-eight percent are practicing in a formal CNL role and report a high degree of accountability for all 9 CNL essential competencies. Findings help understand the extent of CNL adoption and spread across the country and the level to which the initial vision of CNL practice is being achieved.

Implementation of quality management for clinical bacteriology in low-resource settings.

PubMed

Barbé, B; Yansouni, C P; Affolabi, D; Jacobs, J

2017-07-01

The declining trend of malaria and the recent prioritization of containment of antimicrobial resistance have created a momentum to implement clinical bacteriology in low-resource settings. Successful implementation relies on guidance by a quality management system (QMS). Over the past decade international initiatives were launched towards implementation of QMS in HIV/AIDS, tuberculosis and malaria. To describe the progress towards accreditation of medical laboratories and to identify the challenges and best practices for implementation of QMS in clinical bacteriology in low-resource settings. Published literature, online reports and websites related to the implementation of laboratory QMS, accreditation of medical laboratories and initiatives for containment of antimicrobial resistance. Apart from the limitations of infrastructure, equipment, consumables and staff, QMS are challenged with the complexity of clinical bacteriology and the healthcare context in low-resource settings (small-scale laboratories, attitudes and perception of staff, absence of laboratory information systems). Likewise, most international initiatives addressing laboratory health strengthening have focused on public health and outbreak management rather than on hospital based patient care. Best practices to implement quality-assured clinical bacteriology in low-resource settings include alignment with national regulations and public health reference laboratories, participating in external quality assurance programmes, support from the hospital's management, starting with attainable projects, conducting error review and daily bench-side supervision, looking for locally adapted solutions, stimulating ownership and extending existing training programmes to clinical bacteriology. The implementation of QMS in clinical bacteriology in hospital settings will ultimately boost a culture of quality to all sectors of healthcare in low-resource settings. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Use of demographic and pharmacy data to identify patients included within both the Clinical Practice Research Datalink (CPRD) and The Health Improvement Network (THIN).

PubMed

Carbonari, Dena M; Saine, M Elle; Newcomb, Craig W; Blak, Betina; Roy, Jason A; Haynes, Kevin; Wood, Jennifer; Gallagher, Arlene M; Bhullar, Harshvinder; Cardillo, Serena; Hennessy, Sean; Strom, Brian L; Lo Re, Vincent

2015-09-01

Pharmacoepidemiology researchers often utilize data from two UK electronic medical record databases, the Clinical Practice Research Datalink (CPRD) and The Health Improvement Network (THIN), and may choose to combine the two in an effort to increase sample size. To minimize duplication of data, previous studies examined the practice-level overlap between these databases. However, the proportion of overlapping patients remains unknown. We developed a method using demographic and pharmacy variables to identify patients included in both CPRD and THIN, and applied this method to measure the proportion of overlapping patients who initiated the oral anti-diabetic drug saxagliptin. We conducted a cross-sectional study among patients initiating saxagliptin in CPRD and THIN between October 2009 and September 2012. Within both databases, we identified patients: (i) ≥18 years, (ii) newly prescribed saxagliptin, and (iii) with ≥180 days enrollment prior to saxagliptin initiation. Demographic data (birth year, sex, patient registration date, family number, and marital status) and prescriptions (including dates) for the first two oral anti-diabetic drugs prescribed within the study period were used to identify matching patients. Among 4202 CPRD and 3641 THIN patients initiating saxagliptin, 2574 overlapping patients (61% of CPRD saxagliptin initiators; 71% of THIN saxagliptin initiators) were identified. Among these patients, 2474 patients (96%) perfectly matched on all demographic and prescription data. Within each database, over 60% of patients initiating saxagliptin were included within both CPRD and THIN. Combined demographic and prescription data can be used to identify patients included in both CPRD and THIN. Copyright © 2015 John Wiley & Sons, Ltd.

SUPPORTING PHYSICIANS' PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA.

PubMed

Baumgart, Leigh A; Bass, Ellen J; Lyman, Jason A; Springs, Sherry; Voss, John; Hayden, Gregory F; Hellems, Martha A; Hoke, Tracey R; Schlag, Katharine A; Schorling, John B

2010-01-01

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process.

SUPPORTING PHYSICIANS’ PRACTICE-BASED LEARNING AND IMPROVEMENT (PBLI) AND QUALITY IMPROVEMENT THROUGH EXPLORATION OF POPULATION-BASED MEDICAL DATA

PubMed Central

Baumgart, Leigh A.; Bass, Ellen J.; Lyman, Jason A.; Springs, Sherry; Voss, John; Hayden, Gregory F.; Hellems, Martha A.; Hoke, Tracey R.; Schlag, Katharine A.; Schorling, John B.

2011-01-01

Participating in self-assessment activities may stimulate improvement in practice behaviors. However, it is unclear how best to support the development of self-assessment skills, particularly in the health care domain. Exploration of population-based data is one method to enable health care providers to identify deficiencies in overall practice behavior that can motivate quality improvement initiatives. At the University of Virginia, we are developing a decision support tool to integrate and present population-based patient data to health care providers related to both clinical outcomes and non-clinical measures (e.g., demographic information). By enabling users to separate their direct impact on clinical outcomes from other factors out of their control, we may enhance the self-assessment process. PMID:21874123

[Clinical practice guidelines for assessment and treatment of transsexualism. SEEN Identity and Sexual Differentiation Group (GIDSEEN)].

PubMed

Moreno-Pérez, Oscar; Esteva De Antonio, Isabel

2012-01-01

Transsexual patients can only be diagnosed and treated at functional gender identity Units with provision of high quality care, development of clinical practice guidelines, and interdisciplinary working groups. The therapeutic process has three mainstays: initial psychological diagnostic evaluation and psychotherapy, endocrinological evaluation and hormone therapy, and sex reassignment surgery. Cross-sex hormone therapy is essential for the anatomical and psychological transition process in duly selected patients. Hormones help optimize real-life sex identity, improve quality of life, and limit psychiatric co-morbidities often associated to lack of treatment. Development of this clinical practice guideline addresses the need for implementing a coordinated action protocol for comprehensive health care for transgender people in the National Health System. Copyright © 2012 SEEN. Published by Elsevier Espana. All rights reserved.

Introducing Advanced Clinical Reasoning to an Adult Learning Disability Service

ERIC Educational Resources Information Center

Stansfield, Jois; Matthews, Alison

2014-01-01

The advanced clinical reasoning approach is widely adopted in speech and language therapy practice. This article reports on the introduction of the approach across a multidisciplinary adult learning disability service and staff reports on the impact of this initiative. Staff and team managers reported that the training had a positive impact on…

Interprofessional Education in Gross Anatomy: Experience with First-Year Medical and Physical Therapy Students at Mayo Clinic

ERIC Educational Resources Information Center

Hamilton, Steven S.; Yuan, Brandon J.; Lachman, Nirusha; Hellyer, Nathan J.; Krause, David A.; Hollman, John H.; Youdas, James W.; Pawlina, Wojciech

2008-01-01

Interprofessional education (IPE) in clinical practice is believed to improve outcomes in health care delivery. Integrating teaching and learning objectives through cross discipline student interaction in basic sciences has the potential to initiate interprofessional collaboration at the early stages of health care education. Student attitudes and…

Engaging clinical nurses in quality and performance improvement activities.

PubMed

Albanese, Madeline P; Evans, Dietra A; Schantz, Cathy A; Bowen, Margaret; Disbot, Maureen; Moffa, Joseph S; Piesieski, Patricia; Polomano, Rosemary C

2010-01-01

Nursing performance measures are an integral part of quality initiatives in acute care; however, organizations face numerous challenges in developing infrastructures to support quality improvement processes and timely dissemination of outcomes data. At the Hospital of the University of Pennsylvania, a Magnet-designated organization, extensive work has been conducted to incorporate nursing-related outcomes in the organization's quality plan and to integrate roles for clinical nurses into the Department of Nursing and organization's core performance-based programs. Content and strategies that promote active involvement of nurses and prepare them to be competent and confident stakeholders in quality initiatives are presented. Engaging clinical nurses in the work of quality and performance improvement is essential to achieving excellence in clinical care. It is important to have structures and processes in place to bring meaningful data to the bedside; however, it is equally important to incorporate outcomes into practice. When nurses are educated about performance and quality measures, are engaged in identifying outcomes and collecting meaningful data, are active participants in disseminating quality reports, and are able to recognize the value of these activities, data become one with practice.

Resuscitation skills after Helping Babies Breathe training: a comparison of varying practice frequency and impact on retention of skills in different types of providers.

PubMed

Tabangin, M E; Josyula, S; Taylor, K K; Vasquez, J C; Kamath-Rayne, B D

2018-05-01

Helping Babies Breathe (HBB), a basic neonatal resuscitation curriculum, improves early neonatal mortality in low-resource settings. Our goal was to determine retention of resuscitation skills by different cadres of providers using the approved HBB Spanish translation in a rural clinic and community hospital in Honduras. Twelve clinic and 37 hospital providers were trained in 1 d HBB workshops and followed from July 2012 to February 2014. Resuscitation skills were evaluated by objective structured clinical evaluations (OSCEs) at regular intervals. Clinic providers practiced monthly, whereas hospital providers were randomized to monthly practice for 6 months vs three consecutive practices at 3, 5 and 6 months. In the rural clinic, follow-up OSCE assessment showed rapid loss of skills by 1 month after HBB training. For all providers, repeated monthly testing resulted in improvements and maintenance of OSCE performance. In the community hospital, over all time points, the group with monthly OSCEs had 2.9 greater odds of passing compared with the group who practiced less frequently. Physicians were found to have 4.3 times greater odds of passing compared with nurses. Rapid loss of resuscitation skills occurs after an initial training. Repeated practice leads to retention of skills in all types of providers. Further investigation is warranted to determine the clinical correlation of neonatal outcomes after HBB training.

Saving mothers and newborns in communities: strengthening community midwives to provide high quality essential newborn and maternal care in Baluchistan, Pakistan in a financially sustainable manner.

PubMed

Mumtaz, Zubia; Cutherell, Andrea; Bhatti, Afshan

2014-04-06

To address it's persistently high maternal mortality rate of 276/100,000 live births, the government of Pakistan created a new cadre of community based midwives (CMW). One expectation is that CMWs will improve access to maternal health services for underserved women. Recent research shows the CMWs have largely failed to establish midwifery practices, because CMW's lack of skills, both clinical and entrepreneurial and funds necessary to develop their practice infrastructure and logistics. Communities also lack trust in their competence to conduct safe births. To address these issues, the Saving Mothers and Newborn (SMNC) intervention will implement three key elements to support the CMWs to establish their private practices: (1) upgrade CMW clinical skills (2) provide business-skills training and small loans (3) generate demand for CMW services using cellular phone SMS technology and existing women's support groups. This 3-year project aims to investigate whether CMWs enrolled in this initiative are providing the essential maternal and newborn health care to women and children living in districts of Quetta, and Gwadar in a financially self-sustaining manner. Specifically the research will use quasi-experimental impact assessment to document whether the SMNC initiative is having an impact on CMW services uptake, financial analysis to assess if the initiative enabled CMWs to develop financially self-sustainable practices and observation methods to assess the quality of care the CMWs are providing. A key element of the SMNC initiative - the provision of business skills training and loans to establish private practices - is an innovative initiative in Pakistan and little is known about its effectiveness. This research will provide emperic evidence of the effectiveness of the intervention as well as contribute to the body of evidence around potential solutions to improve sustainable coverage of high impact Maternal, Neonatal and Child Health interventions in vulnerable populations living in remote rural areas.

Teaching clinical reasoning to medical students.

PubMed

Gay, Simon; Bartlett, Maggie; McKinley, Robert

2013-10-01

Keele Medical School's new curriculum includes a 5-week course to extend medical students' consultation skills beyond those historically required for competent inductive diagnosis. Clinical reasoning is a core skill for the practice of medicine, and is known to have implications for patient safety, yet historically it has not been explicitly taught. Rather, it has been assumed that these skills will be learned by accumulating a body of knowledge and by observing expert clinicians. This course aims to assist students to develop their own clinical reasoning skills and promote their greater understanding of, and potential to benefit from, the clinical reasoning skills of others. The course takes place in the fourth or penultimate year, and is integrated with students' clinical placements, giving them opportunities to practise and quickly embed their learning. This course emphasises that clinical reasoning extends beyond initial diagnosis into all other aspects of clinical practice, particularly clinical management. It offers students a variety of challenging and interesting opportunities to engage with clinical reasoning across a wide range of clinical practice. It addresses bias through metacognition and increased self-awareness, considers some of the complexities of prescribing and non-pharmacological interventions, and promotes pragmatic evidence-based practice, information management within the consultation and the maximising of patient adherence. This article describes clinical reasoning-based classroom and community teaching. Early evaluation suggests that students value the course and benefit from it. © 2013 John Wiley & Sons Ltd.

Challenges and opportunities in clinical translation of biomedical optical spectroscopy and imaging

NASA Astrophysics Data System (ADS)

Wilson, Brian C.; Jermyn, Michael; Leblond, Frederic

2018-03-01

Medical devices face many hurdles before they enter routine clinical practice to address unmet clinical needs. This is also the case for biomedical optical spectroscopy and imaging systems that are used here to illustrate the opportunities and challenges involved. Following initial concept, stages in clinical translation include instrument development, preclinical testing, clinical prototyping, clinical trials, prototype-to-product conversion, regulatory approval, commercialization, and finally clinical adoption and dissemination, all in the face of potentially competing technologies. Optical technologies face additional challenges from their being extremely diverse, often targeting entirely different diseases and having orders-of-magnitude differences in resolution and tissue penetration. However, these technologies can potentially address a wide variety of unmet clinical needs since they provide rich intrinsic biochemical and structural information, have high sensitivity and specificity for disease detection and localization, and are practical, safe (minimally invasive, nonionizing), and relatively affordable.

Pediatric hospital medicine: a strategic planning roundtable to chart the future.

PubMed

Rauch, Daniel A; Lye, Patricia S; Carlson, Douglas; Daru, Jennifer A; Narang, Steve; Srivastava, Rajendu; Melzer, Sanford; Conway, Patrick H

2012-04-01

Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association sponsored a roundtable to discuss the future of the field. Twenty-one leaders were invited plus a facilitator utilizing established health care strategic planning methods. A "vision statement" was developed. Specific initiatives in 4 domains (clinical practice, quality of care, research, and workforce) were identified that would advance PHM with a plan to complete each initiative. Review of the current issues demonstrated gaps between the current state of affairs and the full vision of the potential impact of PHM. Clinical initiatives were to develop an educational plan supporting the PHM Core Competencies and a clinical practice monitoring dashboard template. Quality initiatives included an environmental assessment of PHM participation on key committees, societies, and agencies to ensure appropriate PHM representation. Three QI collaboratives are underway. A Research Leadership Task Force was created and the Pediatric Research in Inpatient Settings (PRIS) network was refocused, defining a strategic framework for PRIS, and developing a funding strategy. Workforce initiatives were to develop a descriptive statement that can be used by any PHM physician, a communications tool describing "value added" of PHM; and a tool to assess career satisfaction among PHM physicians. We believe the Roundtable was successful in describing the current state of PHM and laying a course for the near future. Copyright © 2011 Society of Hospital Medicine.

When Wait Lists Are Not Feasible, Nothing Is a Thing That Does Not Need to Be Done

ERIC Educational Resources Information Center

Devilly, Grant J.; McFarlane, Alexander C.

2009-01-01

Clinical psychology practices initially grew through the use of case studies, uncontrolled trials, and eventually through randomized controlled trials (RCTs). The use of a wait-list control group is standard practice in such trials of treatment regimens for psychopathological conditions. However, as knowledge advances regarding the successful…

Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change

PubMed Central

Snipes, Shedra Amy; King, Denae W.; Torres-Vigil, Isabel; Goldberg, Daniel S.; Weinberg, Armin D.

2010-01-01

Older adults are vastly underrepresented in clinical trials in spite of shouldering a disproportionate burden of disease and consumption of prescription drugs and therapies, restricting treatments' generalizability, efficacy, and safety. Eliminating Disparities in Clinical Trials, a national initiative comprising a stakeholder network of researchers, community advocates, policymakers, and federal representatives, undertook a critical analysis of older adults' structural barriers to clinical trial participation. We present practice and policy change recommendations emerging from this process and their rationale, which spanned multiple themes: (1) decision making with cognitively impaired patients; (2) pharmacokinetic differences and physiological age; (3) health literacy, communication, and aging; (4) geriatric training; (5) federal monitoring and accountability; (6) clinical trial costs; and (7) cumulative effects of aging and ethnicity. PMID:20147682

[Effects of practical training to increase motivation for learning and related factors].

PubMed

Yamaguchi, Takumi; Akiyama, Shinji; Sagara, Hidenori; Tanaka, Akihiro; Miyauchi, Yoshirou; Araki, Hiroaki; Shibata, Kazuhiko; Izushi, Fumio; Namba, Hiroyuki

2014-01-01

Under the six-year pharmaceutical education system that was initiated in April 2006, students who had completed the course in March 2012 became the first graduates. The six-year system encourages students to develop a well-rounded personality, a deep sense of ethics, knowledge required for health care professionals, abilities to identify and solve problems, and practical skills required in clinical settings, as well as basic knowledge and skills. Under the new education system based on the "pharmaceutical education model core curriculums" and "practical training model core curriculums", general pharmaceutical education is implemented in each college, and five-month practical training is conducted in clinical settings. Clinical tasks experienced by students for the first time are expected to significantly influence their motivation to learn and future prospects. In the present survey research, students who had completed practical training evaluated the training program, and correspondence and logistic regression analyses of the results were conducted to examine the future effects and influences of the training on the students. The results suggest that the students viewed the practical training program positively. In addition, clinical experience during the training sessions not only influenced their decisions on future careers, but also significantly increased their motivation to learn. Furthermore, their motivation for learning was increased most by the enthusiasm of pharmacists who advised them in clinical settings, rather than the training program itself. To improve pharmaceutical clinical learning, it is important to develop teaching and working environments for pharmacists in charge of advising students in clinical training.

Safety and efficacy of pirfenidone in idiopathic pulmonary fibrosis in clinical practice.

PubMed

Okuda, Ryo; Hagiwara, Eri; Baba, Tomohisa; Kitamura, Hideya; Kato, Terufumi; Ogura, Takashi

2013-09-01

Previous pirfenidone trials have only involved patients with mild-to-moderate idiopathic pulmonary fibrosis (IPF). The aim of this study was to investigate the safety and efficacy of pirfenidone in patients with mild-to-severe IPF in clinical practice. The clinical records of 76 patients who were diagnosed with IPF and received pirfenidone were reviewed. The most frequent adverse event was anorexia, although the grade of anorexia in most patients was mild. Dose reduction of pirfenidone improved anorexia in 84% affected patients, which resulted in a high medication compliance rate. The mean forced vital capacity (FVC) at the initiation of pirfenidone therapy in this study was approximately 10% lower than that in previous clinical trials. The mean change in FVC during the 6-month period prior to the therapy initiation was -188 mL, which improved to -19 mL during the 6-month period after therapy. Significant attenuation in percentage predicted diffusion capacity of the lung for carbon monoxide decline was also achieved after pirfenidone therapy initiation. The efficacy of pirfenidone in attenuating the degree of FVC decline was higher in the group with FVC decline of ≥150 mL during the 6-month period prior to therapy initiation. The levels of serum markers, such as KL-6 and SP-D, were also lowered by the therapy. These results showed that pirfenidone was well-tolerated and had beneficial effects in patients with mild-to-severe and/or progressive IPF. The degree of disease progression prior to the initiation of pirfenidone therapy had an impact on the response to the therapy. Copyright © 2013 Elsevier Ltd. All rights reserved.

Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and statewide action.

PubMed

Dusing, Stacey C; Van Drew, Catherine M; Brown, Shaaron E

2012-07-01

Infants born preterm are at high risk of developmental disabilities and benefit from early developmental intervention programs. Physical therapists with neonatal expertise are ideally suited to educate parents about ways to support their infant's development in the first months of life. However, administrative policies are needed to support the therapist in providing adequate parent education in the neonatal intensive care unit (NICU). This administrative case report describes the process used by a team of neonatal therapists to evaluate clinical practice, determine the need for change, and develop and implement a new parent education program in the NICU. Physical therapy parent education practices were evaluated in an academic medical center with a 36-bed, level-3 NICU. Physical therapists with neonatal expertise covered multiple units within the hospital each day. A series of focus groups, a small descriptive study, and staff discussion were used to evaluate parent education practices in this academic medical center. A new parent education program was developed based on data collected and literature to improve clinical care. The new parent education model was implemented over the course of several months using overlapping initiatives. Administrative support for the change was developed through collaboration, open communication, and presentation of clinical data. In addition, this hospital-based program contributed to the development of a statewide initiative to educate parents of preterm infants about the importance of supporting development in the first months of life. A collaborative and data-driven approach to evaluating parent education practices supported the development of a new parent education practice while acknowledging the need to meet staff productivity standards and provide excellent care throughout the hospital.

Instituting Parent Education Practices in the Neonatal Intensive Care Unit: An Administrative Case Report of Practice Evaluation and Statewide Action

PubMed Central

Van Drew, Catherine M.; Brown, Shaaron E.

2012-01-01

Background and Purpose Infants born preterm are at high risk of developmental disabilities and benefit from early developmental intervention programs. Physical therapists with neonatal expertise are ideally suited to educate parents about ways to support their infant's development in the first months of life. However, administrative policies are needed to support the therapist in providing adequate parent education in the neonatal intensive care unit (NICU). This administrative case report describes the process used by a team of neonatal therapists to evaluate clinical practice, determine the need for change, and develop and implement a new parent education program in the NICU. Case Description Physical therapy parent education practices were evaluated in an academic medical center with a 36-bed, level-3 NICU. Physical therapists with neonatal expertise covered multiple units within the hospital each day. A series of focus groups, a small descriptive study, and staff discussion were used to evaluate parent education practices in this academic medical center. A new parent education program was developed based on data collected and literature to improve clinical care. Outcomes The new parent education model was implemented over the course of several months using overlapping initiatives. Administrative support for the change was developed through collaboration, open communication, and presentation of clinical data. In addition, this hospital-based program contributed to the development of a statewide initiative to educate parents of preterm infants about the importance of supporting development in the first months of life. Discussion A collaborative and data-driven approach to evaluating parent education practices supported the development of a new parent education practice while acknowledging the need to meet staff productivity standards and provide excellent care throughout the hospital. PMID:22466024

Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

PubMed Central

Seichepine, Daniel; Tschoe, Christine; Fritts, Nathan G.; Alosco, Michael L.; Berkowitz, Oren; Burke, Peter; Howland, Jonathan; Olshaker, Jonathan; Cantu, Robert C.; Baugh, Christine M.; Holsapple, James W.

2017-01-01

Abstract Evidence-based clinical practice guidelines can facilitate proper evaluation and management of concussions in the emergency department (ED), often the initial and primary point of contact for concussion care. There is no universally adopted set of guidelines for concussion management, and extant evidence suggests that there may be variability in concussion care practices and limited application of clinical practice guidelines in the ED. This study surveyed EDs throughout New England to examine current practices of concussion care and utilization of evidence-based clinical practice guidelines in the evaluation and management of concussions. In 2013, a 32-item online survey was e-mailed to 149/168 EDs throughout New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine). Respondents included senior administrators asked to report on their EDs use of clinical practice guidelines, neuroimaging decision-making, and discharge instructions for concussion management. Of the 72/78 respondents included, 35% reported absence of clinical practice guidelines, and 57% reported inconsistency in the type of guidelines used. Practitioner preference guided neuroimaging decision-making for 57%. Although 94% provided written discharge instructions, there was inconsistency in the recommended time frame for follow-up care (13% provided no specific time frame), the referral specialist to be seen (25% did not recommend any specialist), and return to activity instructions were inconsistent. There is much variability in concussion care practices and application of evidence-based clinical practice guidelines in the evaluation and management of concussions in New England EDs. Knowledge translational efforts will be critical to improve concussion management in the ED setting. PMID:27112592

Biothermal Model of Patient for Brain Hypothermia Treatment

NASA Astrophysics Data System (ADS)

Wakamatsu, Hidetoshi; Gaohua, Lu

A biothermal model of patient is proposed and verified for the brain hypothermia treatment, since the conventionally applied biothermal models are inappropriate for their unprecedented application. The model is constructed on the basis of the clinical practice of the pertinent therapy and characterized by the mathematical relation with variable ambient temperatures, in consideration of the clinical treatments such as the vital cardiopulmonary regulation. It has geometrically clear representation of multi-segmental core-shell structure, database of physiological and physical parameters with a systemic state equation setting the initial temperature of each compartment. Its step response gives the time constant about 3 hours in agreement with clinical knowledge. As for the essential property of the model, the dynamic temperature of its face-core compartment is realized, which corresponds to the tympanic membrane temperature measured under the practical anesthesia. From the various simulations consistent with the phenomena of clinical practice, it is concluded that the proposed model is appropriate for the theoretical analysis and clinical application to the brain hypothermia treatment.

Integrating Research Into Clinical Internship Training Bridging the Science/Practice Gap in Pediatric Psychology

PubMed Central

Spirito, Anthony

2012-01-01

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a “capstone experience”; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the “business of science.” Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists. PMID:22286345

Patient Dashboard: the use of a colour-coded computerised clinical reminder in Whanganui regional general practices.

PubMed

McMenamin, John; Nicholson, Rick; Leech, Ken

2011-12-01

Clinical reminders have been shown to help general practice achieve an increase in some preventive care items, especially if they identify a patient's eligibility for the target item, prompt clinicians at the right time, provide a fast link to management tools and facilitate clinical recording. WRPHO has introduced the Patient Dashboard clinical reminder and monitored its impact on health targets. This paper reports the impact of a computerised colour-coded clinical reminder on achieving agreed health targets in Whanganui regional practices. Patient Dashboard was developed from previous versions in Auckland and Northland and provided to Whanganui regional practices with Primary Health Organisation (PHO) support. The Dashboard was linked with existing and new clinical management tools which automatically updated clinical records. Data from practices was pooled by Whanganui Regional Primary Health Organisation and target achievement rates reported over 15 months. Over the initial 15 months of Patient Dashboard use, recording of smoking status increased from 74% to 82% and of alcohol use from 15% to 47%. Screening for diabetes increased from 62% to 74%, cardiovascular risk assessment from 20% to 43%, cervical screening from 71% to 79%, and breast screening from 60% to 80%. Patient Dashboard was associated with increased performance indicators both for those targets which were part of a PHO programme and for targets without additional support.

A mixed methods approach to adapting health-related quality of life measures for use in routine oncology clinical practice.

PubMed

Harley, Clare; Takeuchi, Elena; Taylor, Sally; Keding, Ada; Absolom, Kate; Brown, Julia; Velikova, Galina

2012-04-01

The current study reviewed and adapted existing health-related quality of life (HRQoL) instruments for use in routine clinical practice delivering outpatient chemotherapy for colorectal, breast and gynaecological cancers. 564 (288 gynaecological, 208 breast and 68 colorectal) outpatient consultations of 141 patients were audio-recorded and analysed to identify discussed issues. Issues were ranked from most to least commonly discussed within each disease group. Existing HRQoL instruments were evaluated against these lists and best fitting items entered into cancer-specific item banks. Item banks were evaluated during semi-structured interviews by twenty-one oncologists (13 consultants and 8 specialist registrars), four clinical nurse specialists and thirty patients, from breast, gynaecological and colorectal cancer practices. Pilot questionnaires were completed by 448 (145 breast, 148 gynaecological and 155 colorectal) patients attending outpatient clinics. Item selection and scale reliability was explored using descriptive data and psychometric methods alongside qualitative patient and clinician ratings. Each questionnaire includes five physical and three psychosocial function scales each with good internal consistency reliability (α > 0.70) plus disease-specific individual-symptom items identified as useful in clinical practice. Three cancer-specific health-related quality of life measures were developed for use in routine clinical practice. Initial analyses suggest good clinical utility and acceptable psychometric properties for the new instruments.

A comprehensive approach in high-grade glioma management: position statement from the Neuro-Oncology Scientific Club (NOSC), Shiraz, Iran

PubMed Central

Ansari, Mansour; Mosalaei, Ahmad; Ahmadloo, Niloufar; Rasekhi, Alireza; Geramizadeh, Bita; Razmkon, Ali; Anvari, Kazem; Afarid, Mohammad; Dadras, Ali; Nafarieh, Leila; Mohammadianpanah, Mohammad; Nasrolahi, Hamid; Hamedi, Seyed Hasan; Omidvari, Shapour; Nami, Mohammad

2017-01-01

Establishing a robust teamwork model in the practice of neuro-oncology requires continued interdisciplinary efforts. The Neuro-Oncology Scientific Club (NOSC) initiative is an interdisciplinary clinical forum promoting the comprehensive approach across involved disciplines in the management of central nervous system (CNS) malignancies. With its provincial founding panels and national steering board, NOSC has been operational in Iran since 2011. This initiative has pursued its mission through interval strategic meetings, tumor boards, case discussions as well as publishing neuro-oncology updates, case study periodicals, and newsletters. A provincial meeting of NOSC in Shiraz put together insights from international practice guidelines, emerging evidence, and expert opinions to draw a position statement on high-grade glioma management in adults. The present report summarizes key highlights from the above clinical forum. PMID:28325997

A comprehensive approach in high-grade glioma management: position statement from the Neuro-Oncology Scientific Club (NOSC), Shiraz, Iran.

PubMed

Ansari, Mansour; Mosalaei, Ahmad; Ahmadloo, Niloufar; Rasekhi, Alireza; Geramizadeh, Bita; Razmkon, Ali; Anvari, Kazem; Afarid, Mohammad; Dadras, Ali; Nafarieh, Leila; Mohammadianpanah, Mohammad; Nasrolahi, Hamid; Hamedi, Seyed Hasan; Omidvari, Shapour; Nami, Mohammad

2017-01-01

Establishing a robust teamwork model in the practice of neuro-oncology requires continued interdisciplinary efforts. The Neuro-Oncology Scientific Club (NOSC) initiative is an interdisciplinary clinical forum promoting the comprehensive approach across involved disciplines in the management of central nervous system (CNS) malignancies. With its provincial founding panels and national steering board, NOSC has been operational in Iran since 2011. This initiative has pursued its mission through interval strategic meetings, tumor boards, case discussions as well as publishing neuro-oncology updates, case study periodicals, and newsletters. A provincial meeting of NOSC in Shiraz put together insights from international practice guidelines, emerging evidence, and expert opinions to draw a position statement on high-grade glioma management in adults. The present report summarizes key highlights from the above clinical forum.

Innovative health systems projects.

PubMed

Green, Michael; Amad, Mansoor; Woodland, Mark

2015-02-01

Residency programmes struggle with the systems-based practice and improvement competency promoted by the Accreditation Council for Graduate Medical Education. The development of Innovative Health Systems Projects (IHelP) was driven by the need for better systems-based initiatives at an institutional level. Our objective was to develop a novel approach that successfully incorporates systems-based practice in our Graduate Medical Education (GME) programmes, while tracking our impact on health care delivery as an academic medical centre. We started the IHelP programme as a 'volunteer initiative' in 2010. A detailed description of the definition, development and implementation of the IHelP programme, along with our experience of the first year, is described. Residents, fellows and faculty mentors all played an important role in establishing the foundation of this initiative. Following the positive response, we have now incorporated IHelP into all curricula as a graduating requirement. IHelP has promoted scholarly activity and faculty mentorship, [and] has improved aspects of patient care and safety A total of 123 residents and fellows, representing 26 specialties, participated. We reviewed 145 projects that addressed topics ranging from administrative and departmental improvements to clinical care algorithms. The projects by area of focus were: patient care - clinical care, 38 per cent; patient care - quality, 27 per cent; resident education, 21 per cent; and a cumulative 16 per cent among pharmacy, department activities, patient education, medical records and clinical facility. We are pleased with the results of our first year of incorporating a systems-based improvement programme into the GME programmes. This initiative has promoted scholarly activity and faculty mentorship, has improved aspects of patient care and safety, and has led to the development of many practical innovations. © 2015 John Wiley & Sons Ltd.

Current status of the joint Mayo Clinic-IBM PACS project

NASA Astrophysics Data System (ADS)

Hangiandreou, Nicholas J.; Williamson, Byrn, Jr.; Gehring, Dale G.; Persons, Kenneth R.; Reardon, Frank J.; Salutz, James R.; Felmlee, Joel P.; Loewen, M. D.; Forbes, Glenn S.

1994-05-01

A multi-phase collaboration between Mayo Clinic and IBM-Rochester was undertaken, with the goal of developing a picture archiving and communication system for routine clinical use in the Radiology Department. The initial phase of this project (phase 0) was started in 1988. The current system has been fully integrated into the clinical practice and, to date, over 6.5 million images from 16 imaging modalities have been archived. Phase 3 of this project has recently concluded.

Social franchising primary healthcare clinics--a model for South African National Health Insurance?

PubMed

Robinson, Andrew Ken Lacey

2015-09-21

This article describes the first government social franchise initiative in the world to deliver a 'brand' of quality primary healthcare (PHC) clinic services. Quality and standards of care are not uniformly and reliably delivered across government PHC clinics in North West Province, South Africa, despite government support, numerous policies, guidelines and in-service training sessions provided to staff. Currently the strongest predictor of good-quality service is the skill and dedication of the facility manager. A project utilising the social franchising business model, harvesting best practices, has been implemented with the aim of developing a system to ensure reliably excellent healthcare service provision in every facility in North West. The services of social franchising consultants have been procured to develop the business model to drive this initiative. Best practices have been benchmarked, and policies, guidelines and clinic support systems have been reviewed, evaluated and assessed, and incorporated into the business plan. A pilot clinic has been selected to refine and develop a working social franchise model. This will then be replicated in one clinic to confirm proof of concept before further scale-up. The social franchise business model can provide solutions to a reliable and recognisable 'brand' of quality universal coverage of healthcare services.

Provincial Comparison of Pharmacist Prescribing in Canada Using Alberta’s Model as the Reference Point

PubMed Central

Bhatia, Surya; Simpson, Scot H; Bungard, Tammy

2017-01-01

Background In the past decade, pharmacist practice has evolved tremendously in Canada, but the scope of practice varies substantially from one province to another. Objective To describe pharmacists’ scopes of practice relevant to prescribing within various jurisdictions of Canada, using the prescribing model in Alberta (authors’ province) as the reference point. Methods This cross-sectional survey consisted of clinical scenarios for emergency prescribing, adapting or renewing a prescription, and initial-access prescribing for a chronic disease. Pharmacists were asked about their ability to administer injections and to order or access the results of laboratory tests, as well as certification and training requirements and reimbursement models. Results Thirteen pharmacists representing Canadian provinces other than Alberta were surveyed in late 2015, for comparison with Alberta. With specific reference to the scenarios presented, pharmacists were able to prescribe in an emergency in 9 of the 10 provinces, renew prescriptions in all provinces, and adapt prescriptions in 6 provinces. Three provinces required that pharmacists have collaborative practice agreements identifying a specific practice area in order to initiate a prescription for a chronic disease (with 6–12 pharmacists per province having such agreements). Alberta required pharmacists to have authorization, based on a detailed application, in order to initiate any provincially regulated drug (with about 1150 pharmacists having this authorization). Pharmacists were allowed to administer vaccines in 9 provinces, and 5 provinces allowed pharmacists to administer drugs by injection. Three provinces had systems in place for pharmacists to access laboratory test results, and 2 allowed pharmacists to order laboratory tests. Five provinces had government-reimbursed programs in place for select prescribing services; however, all 9 provinces with public vaccination programs reimbursed pharmacists for this service. Conclusions Pharmacist prescribing differs among Canadian provinces. Although most provinces allow emergency prescribing and renewal or adaptation of prescriptions by pharmacists, only 4 provinces allow prescription initiation, with variable criteria and scope. Despite some progress to enhance patient flow through the health care system (e.g., by allowing pharmacists to extend prescriptions), further work should be pursued to harmonize clinical practices across Canada and to enable pharmacists to initiate and manage drug therapy. PMID:29109578

First employment characteristics for the 2011 pediatric surgery fellowship graduates.

PubMed

Stolar, Charles J H; Aspelund, Gudrun

2013-01-01

Information regarding initial employment of graduating pediatric surgery fellows is limited. More complete data could yield benchmarks of initial career environment. An anonymous survey was distributed in 2011 to 41 pediatric surgery graduates from all ACGME training programs interrogating details of initial positions and demographics. Thirty-seven of 41 (90%) fellows responded. Male to female ratio was equal. Graduates carried a median debt of $220,000 (range: $0-$850,000). The majority of fellows were married with children. 70% were university/hospital employees, and 68% were unaware of a business plan. Median starting compensation was $354,500 (range: $140,000-$506,000). Starting salary was greatest for >90% clinical obligation appointments (median $427,500 vs. $310,000; p=0.002), independent of geographic location. Compensation had no relationship to private practice vs. hospital/university/military position, coastal vs. inland location, and practice sites number. Median clinical time was 75% and research time 10%. 49% identified a formal mentor. Graduates covered 1-5 different offices (median 1) and 1-5 surgery sites (median 2). 60% were satisfied with their compensation. Recent pediatric surgery graduates are engaged mainly in clinical care. Research is not incentivized. Compensation is driven by clinical obligations. Graduates have limited knowledge of the business plan supporting their compensation, nature of malpractice coverage, and commitments to resources including research. Graduates have important fiscal and parenting obligations. Copyright © 2013 Elsevier Inc. All rights reserved.

Initial Results of a New Clinical Practice Model: Impact on Learners at Risk

ERIC Educational Resources Information Center

Wasburn-Moses, Leah; Noltemeyer, Amity L.; Schmitz, Kristin J.

2015-01-01

The last several years have seen a dramatic increase in interest surrounding the role of clinical experiences in enhancing the learning of teacher candidates. Further, pressure has intensified to demonstrate the impact of teacher candidates on P-12 learners. With these goals in mind, a model alternative school/university partnership was created,…

Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns.

PubMed

Kazis, Lewis E; Sheridan, Robert L; Shapiro, Gabriel D; Lee, Austin F; Liang, Matthew H; Ryan, Colleen M; Schneider, Jeffrey C; Lydon, Martha; Soley-Bori, Marina; Sonis, Lily A; Dore, Emily C; Palmieri, Tina; Herndon, David; Meyer, Walter; Warner, Petra; Kagan, Richard; Stoddard, Frederick J; Murphy, Michael; Tompkins, Ronald G

2018-04-01

There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients. We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010. Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability. The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes. Therapeutic/care management, level IV.

Antenatal Breastfeeding Education and Support: Summary and Analysis of 2 Cochrane Publications.

PubMed

Jacobsen, Noelle

Key breastfeeding outcomes identified by the World Health Organization, the United Nations Children's Fund, the American Academy of Pediatrics, and Healthy People 2020 include early initiation, any such feeding at 6 months of age, and exclusivity. Broader themes in the current literature include infants who ever breastfed and overall duration. Healthcare providers need to know what current practices demonstrate effectiveness. A review of 2 Cochrane articles on which interventions impact these selected outcomes does not reveal any significant implications for clinical practice. Scant evidence exists to support any specific support efforts or educational outreach to improve these outcomes. A discussion of potential strategies to consider for future research and clinical practice is put forth.

Issues and controversies of hepatocellular carcinoma-targeted therapy clinical trials in Asia: experts' opinion.

PubMed

Chen, Pei-Jer; Furuse, Junji; Han, Kwang-Hyub; Hsu, Chiun; Lim, Ho-Yeong; Moon, Hanlim; Qin, Shukui; Ye, Sheng-Long; Yeoh, Ee-Min; Yeo, Winnie

2010-11-01

Asia has a disproportionate share of the world's burden of hepatocellular carcinoma (HCC). However, the highly regarded clinical practice guidelines and recommendations for the design and conduct of clinical trials for HCC largely reflect Western practice. In order to design mutually beneficial international clinical trials of promising targeted therapies, it is imperative to understand how the aetiology, staging and treatment of HCC differ between Asian and Western countries. Our group, comprising experts in oncology and hepatology from countries that constitute the Eastern Asian region, convened to compare and contrast our current practices, evaluate potential compliance with the clinical trial recommendations, and offer suggestions for modifications that would enhance international collaboration. Here, we describe the results of our discussions, including recommendations for appropriate patient stratification based on potentially important differences in HCC aetiology, identification of practices that may confound interpretation of clinical trial outcomes (traditional Chinese medicine; antivirals that target hepatitis B virus; heterogeneous embolization procedures), suggestions for utilizing a common staging system in study protocols, recognition that sorafenib usage is limited by financial constraints and potentially increased toxicity in Asian patients, and expansion of patient populations that should be eligible for initial clinical trials with new agents. © 2010 John Wiley & Sons A/S.

Doing what's right: A grounded theory of ethical decision-making in occupational therapy.

PubMed

VanderKaay, Sandra; Letts, Lori; Jung, Bonny; Moll, Sandra E

2018-04-20

Ethical decision-making is an important aspect of reasoning in occupational therapy practice. However, the process of ethical decision-making within the broader context of reasoning is yet to be clearly explicated. The purpose of this study was to advance a theoretical understanding of the process by which occupational therapists make ethical decisions in day-to-day practice. A constructivist grounded theory approach was adopted, incorporating in-depth semi-structured interviews with 18 occupational therapists from a range of practice settings and years of experience. Initially, participants nominated as key informants who were able to reflect on their decision-making processes were recruited. Theoretical sampling informed subsequent stages of data collection. Participants were asked to describe their process of ethical decision-making using scenarios from clinical practice. Interview transcripts were analyzed using a systematic process of initial then focused coding, and theoretical categorization to construct a theory regarding the process of ethical decision-making. An ethical decision-making prism was developed to capture three main processes: Considering the Fundamental Checklist, Consulting Others, and Doing What's Right. Ethical decision-making appeared to be an inductive and dialectical process with the occupational therapist at its core. Study findings advance our understanding of ethical decision-making in day-to-day clinical practice.

Overcoming Practical Challenges to Conducting Clinical Research in the Inpatient Stroke Rehabilitation Setting

PubMed Central

Campbell, Grace B.; Skidmore, Elizabeth R.; Whyte, Ellen M.; Matthews, Judith T.

2015-01-01

There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work. This paper describes our institution’s experience devising practical solutions to research barriers in this setting. Our efforts facilitated five simultaneous inpatient stroke rehabilitation studies, and led to several benefits, including increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team. PMID:25775955

Advancing working and learning through critical action research: creativity and constraints.

PubMed

Bellman, Loretta; Bywood, Catherine; Dale, Susan

2003-12-01

Continuous professional development is an essential component within many health care 'Learning Organisations'. The paper describes the first phase of an initiative to develop a professional practice development framework for nurses in an NHS general hospital. The project was undertaken within a critical action research methodology. A tripartite arrangement between the hospital, a university and professional nursing organisation enabled clinical, educational and research support for the nurses (co-researchers) engaged in the project. Initial challenges were from some managers, educationalists and the ethics committee who did not appear to understand the action research process. A multi-method approach to data collection was undertaken to capture the change process from different stakeholders' perceptions. Triangulation of the data was undertaken. Despite organisational constraints, transformational leadership and peer support enabled the co-researchers to identify and initiate three patient-focused initiatives. The change process for the co-researchers included: enlightening personal journey, exploring the research-practice gap, enhancing personal and professional knowledge, evolving cultural change and collaborative working, empowering and disempowering messages. A hospital merger and corporate staff changes directly impacted on the project. A more flexible time-scale and longer term funding are required to enable continuity for trust-wide projects undertaken in dynamic clinical settings.

Dose Trends of Aripiprazole from 2004 to 2014 in Psychiatric Inpatients in Korea.

PubMed

Woo, Young Sup; Shim, In Hee; Lee, Sang-Yeol; Lee, Dae-Bo; Kim, Moon-Doo; Jung, Young-Eun; Lee, Jonghun; Won, Seunghee; Jon, Duk-In; Bahk, Won-Myong

2017-05-31

Although aripiprazole has been widely used to treat various psychiatric disorders, little is known about the adequate dosage for Asian patients in clinical practice. Hence, we evaluated the initial and maximum doses of aripiprazole from 2004 to 2014 to estimate the appropriate dosage for Korean psychiatric inpatients in clinical practice. In this retrospective study, we reviewed the medical records of patients who were hospitalized in five university hospitals in Korea from March 2004 to December 2014. The psychiatric diagnosis according to the text revision of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition during index hospitalization and the initial and maximum doses of aripiprazole were evaluated. There were 74 patients in Wave 1 (2004-2006), 201 patients in Wave 2 (2007-2010), and 353 patients in Wave 3 (2011-2014). The initial doses of aripiprazole in all diagnostic groups were significantly lower in Wave 3 than in Wave 2. The maximum doses of aripiprazole in each diagnostic group were not significantly different among Waves 1, 2, and 3. The relatively low initial doses of aripiprazole documented in our study may reflect a strategy by clinicians to minimize the side effects associated with aripiprazole use, such as akathisia.

The Value of Electronic Medical Record Implementation in Mental Health Care: A Case Study.

PubMed

Riahi, Sanaz; Fischler, Ilan; Stuckey, Melanie I; Klassen, Philip E; Chen, John

2017-01-05

Electronic medical records (EMR) have been implemented in many organizations to improve the quality of care. Evidence supporting the value added to a recovery-oriented mental health facility is lacking. The goal of this project was to implement and customize a fully integrated EMR system in a specialized, recovery-oriented mental health care facility. This evaluation examined the outcomes of quality improvement initiatives driven by the EMR to determine the value that the EMR brought to the organization. The setting was a tertiary-level mental health facility in Ontario, Canada. Clinical informatics and decision support worked closely with point-of-care staff to develop workflows and documentation tools in the EMR. The primary initiatives were implementation of modules for closed loop medication administration, collaborative plan of care, clinical practice guidelines for schizophrenia, restraint minimization, the infection prevention and control surveillance status board, drug of abuse screening, and business intelligence. Medication and patient scan rates have been greater than 95% since April 2014, mitigating the adverse effects of medication errors. Specifically, between April 2014 and March 2015, only 1 moderately severe and 0 severe adverse drug events occurred. The number of restraint incidents decreased 19.7%, which resulted in cost savings of more than Can $1.4 million (US $1.0 million) over 2 years. Implementation of clinical practice guidelines for schizophrenia increased adherence to evidence-based practices, standardizing care across the facility. Improved infection prevention and control surveillance reduced the number of outbreak days from 47 in the year preceding implementation of the status board to 7 days in the year following. Decision support to encourage preferential use of the cost-effective drug of abuse screen when clinically indicated resulted in organizational cost savings. EMR implementation allowed Ontario Shores Centre for Mental Health Sciences to use data analytics to identify and select appropriate quality improvement initiatives, supporting patient-centered, recovery-oriented practices and providing value at the clinical, organizational, and societal levels. ©Sanaz Riahi, Ilan Fischler, Melanie I Stuckey, Philip E Klassen, John Chen. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 05.01.2017.

Rotigotine transdermal patch in combination therapy for Parkinson's disease--observations in routine clinical practice.

PubMed

Ceballos-Baumann, Andres; Häck, Hermann-Josef

2011-10-01

The dopamine agonist rotigotine has shown efficacy and safety for the treatment of early and advanced Parkinson's disease (PD) in controlled clinical trials. This observational study evaluated rotigotine administration in combination with other antiparkinsonian medication in routine clinical practice. Data were collected by 688 German practice-based neurologists, initiating rotigotine treatment in patients with idiopathic Parkinson's disease. Assessments included rotigotine maintenance dose, changes in concomitant PD medication, changes in sleep quality, and rotigotine tolerability over an observation period of 12-16 weeks. The median rotigotine maintenance dose was 6 mg/24 h (n = 969, full analysis set). The proportion of all other prescribed PD medications declined over the observation period; combination therapy decreased by 18.7%. Daily levodopa intake was markedly reduced by 87 mg (18.9%) in 47.6% of the patients with levodopa documentation; 7% no longer required levodopa after 12-16 weeks. Mean overall sleep quality (PD Sleep Scale item 1) improved by 21.4 points, the occurrence of nocturias (PDSS item 8) by 13.4 points, and 'turning in bed' (Unified Parkinson's Disease Rating Scale part II) by 0.6 points. Drug-related adverse events were reported for 7.9% of all patients (n = 1152, safety population). Application site reactions were the most common adverse events (2.2%) resulting in early discontinuation in 1.4% of patients. In routine clinical practice, treatment initiation with rotigotine transdermal patch was associated with a reduction of other prescribed PD medications and with an improvement of self-reported sleep quality.

Financial incentives, quality improvement programs, and the adoption of clinical information technology.

PubMed

Robinson, James C; Casalino, Lawrence P; Gillies, Robin R; Rittenhouse, Diane R; Shortell, Stephen S; Fernandes-Taylor, Sara

2009-04-01

Physician use of clinical information technology (CIT) is important for the management of chronic illness, but has lagged behind expectations. We studied the role of health insurers' financial incentives (including pay-for-performance) and quality improvement initiatives in accelerating adoption of CIT in large physician practices. National survey of all medical groups and independent practice association (IPA) physician organizations with 20 or more physicians in the United States in 2006 to 2007. The response rate was 60.3%. Use of 19 CIT capabilities was measured. Multivariate statistical analysis of financial and organizational factors associated with adoption and use of CIT. Use of information technology varied across physician organizations, including electronic access to laboratory test results (medical groups, 49.3%; IPAs, 19.6%), alerts for potential drug interactions (medical groups, 33.9%; IPAs, 9.5%), electronic drug prescribing (medical groups, 41.9%; IPAs, 25.1%), and physician use of e-mail with patients (medical groups, 34.2%; IPAs, 29.1%). Adoption of CIT was stronger for physician organizations evaluated by external entities for pay-for-performance and public reporting purposes (P = 0.042) and for those participating in quality improvement initiatives (P < 0.001). External incentives and participation in quality improvement initiatives are associated with greater use of CIT by large physician practices.

Applying self-determination theory for improved understanding of physiotherapists' rationale for using research in clinical practice: a qualitative study in Sweden.

PubMed

Dannapfel, Petra; Peolsson, Anneli; Ståhl, Christian; Öberg, Birgitta; Nilsen, Per

2014-01-01

Physiotherapists are generally positive to evidence-based practice (EBP) and the use of research in clinical practice, yet many still base clinical decisions on knowledge obtained during their initial education and/or personal experience. Our aim was to explore motivations behind physiotherapists' use of research in clinical practice. Self-Determination Theory was applied to identify the different types of motivation for use of research. This theory posits that all behaviours lie along a continuum of relative autonomy, reflecting the extent to which a person endorses their actions. Eleven focus group interviews were conducted, involving 45 physiotherapists in various settings in Sweden. Data were analysed using qualitative content analysis and the findings compared with Self-Determination Theory using a deductive approach. Motivations underlying physiotherapists use of research in clinical practice were identified. Most physiotherapists expressed autonomous forms of motivation for research use, but some exhibited more controlled motivation. Several implications about how more evidence-based physiotherapy can be achieved are discussed, including the potential to tailor educational programs on EBP to better account for differences in motivation among participants, using autonomously motivated physiotherapists as change agents and creating favourable conditions to encourage autonomous motivation by way of feelings of competence, autonomy and a sense of relatedness.

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under payment-by-results.

PubMed

Nouraei, S A R; O'Hanlon, S; Butler, C R; Hadovsky, A; Donald, E; Benjamin, E; Sandhu, G S

2009-02-01

To audit the accuracy of otolaryngology clinical coding and identify ways of improving it. Prospective multidisciplinary audit, using the 'national standard clinical coding audit' methodology supplemented by 'double-reading and arbitration'. Teaching-hospital otolaryngology and clinical coding departments. Otolaryngology inpatient and day-surgery cases. Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician-coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment. 1250 randomly-selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician-coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially-missed secondary diagnoses and procedures. In 203 cases, patient's initial HRG changed. Incorrect coding caused an average revenue loss of 174.90 pounds per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly-complex head and neck cancer cases. The 'HRG drift' created the appearance of disproportionate resource utilisation when treating 'simple' cases. At our institution the total cost of maintaining a clinician-coder MDT was 4.8 times lower than the income regained through the double-reading process. This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost-effective clinician-coder double-reading multidisciplinary team as part of a data-assurance clinical governance framework which we recommend should be established in hospitals.

CE: Original Research: Creating an Evidence-Based Progression for Clinical Advancement Programs.

PubMed

Burke, Kathleen G; Johnson, Tonya; Sites, Christine; Barnsteiner, Jane

2017-05-01

: Background: The Institute of Medicine (IOM) and the Quality and Safety Education for Nurses (QSEN) project have identified six nursing competencies and supported their integration into undergraduate and graduate nursing curricula nationwide. But integration of those competencies into clinical practice has been limited, and evidence for the progression of competency proficiency within clinical advancement programs is scant. Using an evidence-based approach and building on the competencies identified by the IOM and QSEN, a team of experts at an academic health system developed eight competency domains and 186 related knowledge, skills, and attitudes (KSAs) for professional nursing practice. The aim of our study was to validate the eight identified competencies and 186 related KSAs and determine their developmental progression within a clinical advancement program. Using the Delphi technique, nursing leadership validated the newly identified competency domains and KSAs as essential to practice. Clinical experts from 13 Magnet-designated hospitals with clinical advancement programs then participated in Delphi rounds aimed at reaching consensus on the developmental progression of the 186 KSAs through four levels of clinical advancement. Two Delphi rounds resulted in consensus by the expert participants. All eight competency domains were determined to be essential at all four levels of clinical practice. At the novice level of practice, the experts identified a greater number of KSAs in the domains of safety and patient- and family-centered care. At more advanced practice levels, the experts identified a greater number of KSAs in the domains of professionalism, teamwork, technology and informatics, and continuous quality improvement. Incorporating the eight competency domains and the 186 KSAs into a framework for clinical advancement programs will likely result in more clearly defined role expectations; enhance accountability; and elevate and promote nursing practice, thereby improving clinical outcomes and quality of care. With their emphasis on quality and safety, the eight competency domains also offer a framework for enhancing position descriptions, performance evaluations, clinical recognition, initial and ongoing competency assessment programs, and orientation and residency programs.

Revisiting Antipsychotic-induced Akathisia: Current Issues and Prospective Challenges

PubMed Central

Salem, Haitham; Nagpal, Caesa; Pigott, Teresa; Teixeira, Antonio Lucio

2017-01-01

Background: Akathisia continues to be a significant challenge in current neurological and psychiatric practice. Prompt and accurate detection is often difficult and there is a lack of consensus concerning the neurobiological basis of akathisia. No definitive treatment has been established for akathisia despite numerous preclinical and clinical studies. Method: We reviewed antipsychotic-induced akathisia including its clinical presentation, proposed underlying pathophysiology, current and under investigation therapeutic strategies. Conclusion: Despite the initial promise that second generation antipsychotics would be devoid of akathisia effects, this has not been confirmed. Currently, there are limited therapeutic options for the clinical practice and the evidence supporting the most widely used treatments (beta blockers, anticholinergic drugs) is still absent or inconsistent. PMID:27928948

Patients first! Engaging the hearts and minds of nurses with a patient-centered practice model.

PubMed

Small, Deborah C; Small, Robert M

2011-05-31

Like every healthcare system today, the Cleveland Clinic health system is a combination of medical hospitals, institutes, and services in which the implementation of uniform care methodologies faces significant barriers. The guiding principle of the Cleveland Clinic, 'Patients First,' focuses on the principle of patient- and family-centered care (PFCC) but deliberately lacks details due to the wide scope of care delivered by the organization. The Stanley Shalom Zielony Institute of Nursing Excellence (the Nursing Institute) at the Cleveland Clinic was charged with standardizing nursing practice across a system with 11,000 registered nurses and 800 advanced practice nurses. The challenge involved providing firm direction on delivering PFCC that was appropriate for all clinical disciplines and could be implemented quickly across existing practices and technologies. Successful implementation required full engagement in the concept of PFCC by what the Institute for Healthcare Improvement has termed the 'hearts and minds' of nurses. To achieve these ends, development of a systemwide nursing practice model was initiated. In this article the authors identify the essence of PFCC, consider barriers to PFCC, review their process of developing PFCC, and describe how the Cleveland Clinic health system has implemented a PFCC nursing practice model. In doing so the authors explore how the concept of 'Passion for Nursing' was used to stimulate nurse engagement in PFCC.

Why the Quality Oncology Practice Initiative Matters: It's Not Just About Cost.

PubMed

Chiang, Anne C

2016-01-01

The nature and cost of cancer care is evolving, affecting more patients and often involving expensive treatment options. The upward cost trends also coincide with a national landscape of increasing regulatory mandates that may demand improved outcomes and value, but that often require significant up-front investment in infrastructure to achieve safety and quality. Oncology practices participating in the American Society of Clinical Oncology (ASCO) Institute for Quality's Quality Oncology Practice Initiative (QOPI) and the QOPI Certification Program (QCP) continue to grow in number and reflect changing demographics of the provision of cancer care. QOPI and QCP benchmarking can be used to achieve quality improvement and to build collaborative quality communities. These programs may be useful tools for oncology practices to comply with new legislation such as the Medicare Access and CHIP Reauthorization Act (MACRA).

Continuity of midwifery care for rural women through caseload group practice: Delivering for almost 20 years.

PubMed

Haines, Helen M; Baker, Janet; Marshall, Diana

2015-12-01

To describe the clinical outcomes and sustainability factors of a long-standing midwifery led caseload model of rural maternity care. Retrospective clinical audit from 1998 to 2011 and autoethnographic narrative of the midwifery program told by the longest serving midwives under three key themes relating to sustainable practice. Regional Health Service with annual birth rate of 500. Maternity care is provided by either public antenatal clinic/GP shared care or midwife-led care. Women attending a rural caseload midwifery group practice between the period 1998-2011 and midwives working in the same group practice during that period. Antenatal attendance, maternal mortality, infant morbidity and mortality, mode of birth, known midwife at birth, initiation of breastfeeding. There were 1674 births between 1998 and 2011. Clinical outcomes for women and infants closely reflected national maternity indicator data. The group practice midwives attribute sustainability of the program to the enjoyment of flexibility in their working environment, to establishing trust amongst themselves, the women they care for, and with the obstetricians, GPs and health service executives. The rigorous application of midwifery principles including robust clinical governance have been hallmarks of success. This caseload midwifery group practice is a safe, satisfying and sustainable model of maternity care in a rural setting. Clinical outcomes are similar to standard care. Success can be attributed to strong leadership across all levels of policy, health service management and, most importantly, the rural midwives providing the service. © 2015 National Rural Health Alliance Inc.

Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy.

PubMed

Narayanan, Jaishree; Dobrin, Sofia; Choi, Janet; Rubin, Susan; Pham, Anna; Patel, Vimal; Frigerio, Roberta; Maurer, Darryck; Gupta, Payal; Link, Lourdes; Walters, Shaun; Wang, Chi; Ji, Yuan; Maraganore, Demetrius M

2017-01-01

Using the electronic medical record (EMR) to capture structured clinical data at the point of care would be a practical way to support quality improvement and practice-based research in epilepsy. We describe our stepwise process for building structured clinical documentation support tools in the EMR that define best practices in epilepsy, and we describe how we incorporated these toolkits into our clinical workflow. These tools write notes and capture hundreds of fields of data including several score tests: Generalized Anxiety Disorder-7 items, Neurological Disorders Depression Inventory for Epilepsy, Epworth Sleepiness Scale, Quality of Life in Epilepsy-10 items, Montreal Cognitive Assessment/Short Test of Mental Status, and Medical Research Council Prognostic Index. The tools summarize brain imaging, blood laboratory, and electroencephalography results, and document neuromodulation treatments. The tools provide Best Practices Advisories and other clinical decision support when appropriate. The tools prompt enrollment in a DNA biobanking study. We have thus far enrolled 231 patients for initial visits and are starting our first annual follow-up visits and provide a brief description of our cohort. We are sharing these EMR tools and captured data with other epilepsy clinics as part of a Neurology Practice Based Research Network, and are using the tools to conduct pragmatic trials using subgroup-based adaptive designs. © 2016 The Authors. Epilepsia published by Wiley Periodicals, Inc. on behalf of International League Against Epilepsy.

Insulin therapy for adult patients with type 2 diabetes mellitus: a position statement of the Korean Diabetes Association, 2017.

PubMed

Lee, Byung-Wan; Kim, Jin Hwa; Ko, Seung-Hyun; Hur, Kyu Yeon; Kim, Nan-Hee; Rhee, Sang Youl; Kim, Hyun Jin; Moon, Min Kyong; Park, Seok-O; Choi, Kyung Mook

2017-11-01

The Korean Diabetes Association (KDA) has regularly updated its Clinical Practice Guidelines. In 2017, the KDA published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). Growing evidence from new multinational clinical trials using novel and traditional insulin analogues has also been accumulated. Following global trends, many results of clinical trials, especially concerning the clinical efficacy and safety of insulin therapy, have been published about Korean patients with T2DM. After a systematic search of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the initiation, choice, and intensification of insulin and created an insulin treatment algorithm for the first time to guide physicians caring for adult Korean patients with T2DM.

Using scenario-based training to promote information literacy among on-call consultant pediatricians

PubMed Central

Pettersson, Jonas; Bjorkander, Emil; Bark, Sirpa; Holmgren, Daniel; Wekell, Per

2017-01-01

Background Traditionally, teaching hospital staff to search for medical information relies heavily on educator-defined search methods. In contrast, the authors describe our experiences using real-time scenarios to teach on-call consultant pediatricians information literacy skills as part of a two-year continuing professional development program. Case Presentation Two information-searching workshops were held at Sahlgrenska University Hospital in Gothenburg, Sweden. During the workshops, pediatricians were presented with medical scenarios that were closely related to their clinical practice. Participants were initially encouraged to solve the problems using their own preferred search methods, followed by group discussions led by clinical educators and a medical librarian in which search problems were identified and overcome. The workshops were evaluated using questionnaires to assess participant satisfaction and the extent to which participants intended to implement changes in their clinical practice and reported actual change. Conclusions A scenario-based approach to teaching clinicians how to search for medical information is an attractive alternative to traditional lectures. The relevance of such an approach was supported by a high level of participant engagement during the workshops and high scores for participant satisfaction, intended changes to clinical practice, and reported benefits in actual clinical practice. PMID:28670215

Using scenario-based training to promote information literacy among on-call consultant pediatricians.

PubMed

Pettersson, Jonas; Bjorkander, Emil; Bark, Sirpa; Holmgren, Daniel; Wekell, Per

2017-07-01

Traditionally, teaching hospital staff to search for medical information relies heavily on educator-defined search methods. In contrast, the authors describe our experiences using real-time scenarios to teach on-call consultant pediatricians information literacy skills as part of a two-year continuing professional development program. Two information-searching workshops were held at Sahlgrenska University Hospital in Gothenburg, Sweden. During the workshops, pediatricians were presented with medical scenarios that were closely related to their clinical practice. Participants were initially encouraged to solve the problems using their own preferred search methods, followed by group discussions led by clinical educators and a medical librarian in which search problems were identified and overcome. The workshops were evaluated using questionnaires to assess participant satisfaction and the extent to which participants intended to implement changes in their clinical practice and reported actual change. A scenario-based approach to teaching clinicians how to search for medical information is an attractive alternative to traditional lectures. The relevance of such an approach was supported by a high level of participant engagement during the workshops and high scores for participant satisfaction, intended changes to clinical practice, and reported benefits in actual clinical practice.

Driving out waste: a framework to enhance value in clinical care.

PubMed

Burton, David A

2013-06-01

Many healthcare providers today are seeking to improve the value of the care they deliver by implementing standardized clinical practice guidelines aimed at reducing variations in care, avoiding complications, and lowering costs. To succeed, such an initiative requires the full support and participation of the clinicians who will use the guidelines. Providers also should have a fully developed infrastructure consisting of a clinical content system, an analytics system, and a deployment system.

Exploring Factors Affecting Voluntary Adoption of Electronic Medical Records Among Physicians and Clinical Assistants of Small or Solo Private General Practice Clinics.

PubMed

Or, Calvin; Tong, Ellen; Tan, Joseph; Chan, Summer

2018-05-29

The health care reform initiative led by the Hong Kong government's Food and Health Bureau has started the implementation of an electronic sharing platform to provide an information infrastructure that enables public hospitals and private clinics to share their electronic medical records (EMRs) for improved access to patients' health care information. However, previous attempts to convince the private clinics to adopt EMRs to document health information have faced challenges, as the EMR adoption has been voluntary. The lack of electronic data shared by private clinics carries direct impacts to the efficacy of electronic record sharing between public and private healthcare providers. To increase the likelihood of buy-in, it is essential to proactively identify the users' and organizations' needs and capabilities before large-scale implementation. As part of the reform initiative, this study examined factors affecting the adoption of EMRs in small or solo private general practice clinics, by analyzing the experiences and opinions of the physicians and clinical assistants during the pilot implementation of the technology, with the purpose to learn from it before full-scale rollout. In-depth, semistructured interviews were conducted with 23 physicians and clinical assistants from seven small or solo private general practice clinics to evaluate their experiences, expectations, and opinions regarding the deployment of EMRs. Interview transcripts were content analyzed to identify key factors. Factors affecting the adoption of EMRs to record and manage health care information were identified as follows: system interface design; system functions; stability and reliability of hardware, software, and computing networks; financial and time costs; task and outcome performance, work practice, and clinical workflow; physical space in clinics; trust in technology; users' information technology literacy; training and technical support; and social and organizational influences. The factors are interrelated with the others. The adoption factors identified are multifaceted, ranging from technological characteristics, clinician-technology interactions, skills and knowledge, and the user-workflow-technology fit. Other findings, which have been relatively underrepresented in previous studies, contribute unique insights about the influence of work and social environment on the adoption of EMRs, including limited clinic space and the effects of physicians' decision to use the technology on clinical staffs' adoption decisions. Potential strategies to address the concerns, overcome adoption barriers, and define relevant policies are discussed.

Does short-term virologic failure translate to clinical events in antiretroviral-naïve patients initiating antiretroviral therapy in clinical practice?

PubMed

Mugavero, Michael J; May, Margaret; Harris, Ross; Saag, Michael S; Costagliola, Dominique; Egger, Matthias; Phillips, Andrew; Günthard, Huldrych F; Dabis, Francois; Hogg, Robert; de Wolf, Frank; Fatkenheuer, Gerd; Gill, M John; Justice, Amy; D'Arminio Monforte, Antonella; Lampe, Fiona; Miró, Jose M; Staszewski, Schlomo; Sterne, Jonathan A C

2008-11-30

To determine whether differences in short-term virologic failure among commonly used antiretroviral therapy (ART) regimens translate to differences in clinical events in antiretroviral-naïve patients initiating ART. Observational cohort study of patients initiating ART between January 2000 and December 2005. The Antiretroviral Therapy Cohort Collaboration (ART-CC) is a collaboration of 15 HIV cohort studies from Canada, Europe, and the United States. A total of 13 546 antiretroviral-naïve HIV-positive patients initiating ART with efavirenz, nevirapine, lopinavir/ritonavir, nelfinavir, or abacavir as third drugs in combination with a zidovudine and lamivudine nucleoside reverse transcriptase inhibitor backbone. Short-term (24-week) virologic failure (>500 copies/ml) and clinical events within 2 years of ART initiation (incident AIDS-defining event, death, and a composite measure of these two outcomes). Compared with efavirenz as initial third drug, short-term virologic failure was more common with all other third drugs evaluated; nevirapine (adjusted odds ratio = 1.87, 95% confidence interval (CI) = 1.58-2.22), lopinavir/ritonavir (1.32, 95% CI = 1.12-1.57), nelfinavir (3.20, 95% CI = 2.74-3.74), and abacavir (2.13, 95% CI = 1.82-2.50). However, the rate of clinical events within 2 years of ART initiation appeared higher only with nevirapine (adjusted hazard ratio for composite outcome measure 1.27, 95% CI = 1.04-1.56) and abacavir (1.22, 95% CI = 1.00-1.48). Among antiretroviral-naïve patients initiating therapy, between-ART regimen, differences in short-term virologic failure do not necessarily translate to differences in clinical outcomes. Our results should be interpreted with caution because of the possibility of residual confounding by indication.

Barriers to diagnosing and managing hypertension - a qualitative study in Australian general practice.

PubMed

Howes, Faline; Hansen, Emily; Williams, Danielle; Nelson, Mark

2010-07-01

Elevated blood pressure (BP) is a major modifiable risk factor. However hypertension still remains underdiagnosed, untreated or suboptimally treated. This study aimed to identify and explore barriers to initiating medication and treating elevated BP to target levels in the general practice setting. Six focus groups involving 30 clinicians were audio recorded, transcribed in full and analysed for common emerging themes using an iterative thematic analysis. After making the decision to commence treatment, medication initiation was relatively straightforward. Clinical uncertainty about true underlying BP, distrust of measurement technology, and distrust of the evidence underpinning hypertension management were expressed. Patient age, gender and comorbidity influenced treatment strategy. Related themes included perceived patient attitude, clinical inertia, and patient centred care. Systems issues included lack of resources and lack of time. The management of an asymptomatic chronic disease within a patient centred, encounter based primary care context can be challenging.

Narrative Approaches to Organizational Development: A Case Study of Implementation of Collaborative Helping.

PubMed

Madsen, William C

2016-06-01

Across North America, community agencies and state/provincial jurisdictions are embracing family-centered approaches to service delivery that are grounded in strength-based, culturally responsive, accountable partnerships with families. This article details a collaborative consultation process to initiate and sustain organizational change toward this effort. It draws on innovative ideas from narrative theory, organizational development, and implementation science to highlight a three component approach. This approach includes the use of appreciative inquiry focus groups to elicit existing best practices, the provision of clinical training, and ongoing coaching with practice leaders to build on those better moments and develop concrete practice frameworks, and leadership coaching and organizational consultation to develop organizational structures that institutionalize family-centered practice. While the article uses a principle-based practice framework, Collaborative Helping, to illustrate this process, the approach is applicable with a variety of clinical frameworks grounded in family-centered values and principles. © 2016 Family Process Institute.

Prosthetists' perceptions and use of outcome measures in clinical practice: Long-term effects of focused continuing education.

PubMed

Hafner, Brian J; Spaulding, Susan E; Salem, Rana; Morgan, Sara J; Gaunaurd, Ignacio; Gailey, Robert

2017-06-01

Continuing education is intended to facilitate clinicians' skills and knowledge in areas of practice, such as administration and interpretation of outcome measures. To evaluate the long-term effect of continuing education on prosthetists' confidence in administering outcome measures and their perceptions of outcomes measurement in clinical practice. Pretest-posttest survey methods. A total of 66 prosthetists were surveyed before, immediately after, and 2 years after outcomes measurement education and training. Prosthetists were grouped as routine or non-routine outcome measures users, based on experience reported prior to training. On average, prosthetists were just as confident administering measures 1-2 years after continuing education as they were immediately after continuing education. In all, 20% of prosthetists, initially classified as non-routine users, were subsequently classified as routine users at follow-up. Routine and non-routine users' opinions differed on whether outcome measures contributed to efficient patient evaluations (79.3% and 32.4%, respectively). Both routine and non-routine users reported challenges integrating outcome measures into normal clinical routines (20.7% and 45.9%, respectively). Continuing education had a long-term impact on prosthetists' confidence in administering outcome measures and may influence their clinical practices. However, remaining barriers to using standardized measures need to be addressed to keep practitioners current with evolving practice expectations. Clinical relevance Continuing education (CE) had a significant long-term impact on prosthetists' confidence in administering outcome measures and influenced their clinical practices. In all, approximately 20% of prosthetists, who previously were non-routine outcome measure users, became routine users after CE. There remains a need to develop strategies to integrate outcome measurement into routine clinical practice.

Development of the Champlain primary care cardiovascular disease prevention and management guideline

PubMed Central

Montoya, Lorraine; Liddy, Clare; Hogg, William; Papadakis, Sophia; Dojeiji, Laurie; Russell, Grant; Akbari, Ayub; Pipe, Andrew; Higginson, Lyall

2011-01-01

Abstract Problem addressed A well documented gap remains between evidence and practice for clinical practice guidelines in cardiovascular disease (CVD) care. Objective of program As part of the Champlain CVD Prevention Strategy, practitioners in the Champlain District of Ontario launched a large quality-improvement initiative that focused on increasing the uptake in primary care practice settings of clinical guidelines for heart disease, stroke, diabetes, and CVD risk factors. Program description The Champlain Primary Care CVD Prevention and Management Guideline is a desktop resource for primary care clinicians working in the Champlain District. The guideline was developed by more than 45 local experts to summarize the latest evidence-based strategies for CVD prevention and management, as well as to increase awareness of local community-based programs and services. Conclusion Evidence suggests that tailored strategies are important when implementing specific practice guidelines. This article describes the process of creating an integrated clinical guideline for improvement in the delivery of cardiovascular care. PMID:21673196

Methodological challenges of validating a clinical decision-making tool in the practice environment.

PubMed

Brennan, Caitlin W; Daly, Barbara J

2015-04-01

Validating a measurement tool intended for use in the practice environment poses challenges that may not be present when validating a tool intended solely for research purposes. The aim of this article is to describe the methodological challenges of validating a clinical decision-making tool, the Oncology Acuity Tool, which nurses use to make nurse assignment and staffing decisions prospectively each shift. Data were derived from a larger validation study, during which several methodological challenges arose. Revisions to the tool, including conducting iterative feedback cycles with end users, were necessary before the validation study was initiated. The "true" value of patient acuity is unknown, and thus, two approaches to inter-rater reliability assessment were used. Discordant perspectives existed between experts and end users. Balancing psychometric rigor with clinical relevance may be achieved through establishing research-practice partnerships, seeking active and continuous feedback with end users, and weighing traditional statistical rules of thumb with practical considerations. © The Author(s) 2014.

Initiating a Human Variome Project Country Node.

PubMed

AlAama, Jumana; Smith, Timothy D; Lo, Alan; Howard, Heather; Kline, Alexandria A; Lange, Matthew; Kaput, Jim; Cotton, Richard G H

2011-05-01

Genetic diseases are a pressing global health problem that requires comprehensive access to basic clinical and genetic data to counter. The creation of regional and international databases that can be easily accessed by clinicians and diagnostic labs will greatly improve our ability to accurately diagnose and treat patients with genetic disorders. The Human Variome Project is currently working in conjunction with human genetics societies to achieve this by establishing systems to collect every mutation reported by a diagnostic laboratory, clinic, or research laboratory in a country and store these within a national repository, or HVP Country Node. Nodes have already been initiated in Australia, Belgium, China, Egypt, Malaysia, and Kuwait. Each is examining how to systematically collect and share genetic, clinical, and biochemical information in a country-specific manner that is sensitive to local ethical and cultural issues. This article gathers cases of genetic data collection within countries and takes recommendations from the global community to develop a procedure for countries wishing to establish their own collection system as part of the Human Variome Project. We hope this may lead to standard practices to facilitate global collection of data and allow efficient use in clinical practice, research and therapy. © 2011 Wiley-Liss, Inc.

The impact of psychopharmacology on contemporary clinical psychiatry.

PubMed

Vázquez, Gustavo H

2014-08-01

Clinical psychiatric evaluations of patients have changed dramatically in recent decades. Both initial assessments and follow-up visits have become brief and superficial, focused on searching for categorical diagnostic criteria from checklists, with limited inquiry into patient-reported symptomatic status and tolerability of treatments. The virtually exclusive therapeutic task has become selecting a plausible psychotropic, usually based on expert consensus guidelines. These guidelines and practice patterns rest mainly on published monotherapy trials that may or may not be applicable to particular patients but are having a profound impact, not only on modern psychiatric practice but also on psychiatric education, research, and theory.

Review of proton pump inhibitors for the initial treatment of heartburn: is there a dose ceiling effect?

PubMed

Kushner, Pamela R; Peura, David A

2011-05-01

Proton pump inhibitors (PPIs) are widely used in clinical practice. However, concerns have been expressed about their long-term use, particularly with regard to bone health, Clostridium difficile infections, and drug interactions with platelet aggregation inhibitors. There has been limited guidance for clinicians concerning appropriate dose selection of PPIs for the initial treatment of heartburn. This review explored whether published clinical trials provide evidence of a ceiling above which higher PPI doses do not provide additional clinical benefit over the lowest approved dose. All articles of randomized, controlled clinical trials in nonerosive gastroesophageal reflux disease (GERD) in which the effects of two or more doses of the same PPI on symptomatic relief of heartburn were quantified as a study endpoint were identified and analyzed through PubMed searches up to the end of September 2010. The majority of trials evaluated provided no evidence that higher PPI doses were superior to the lowest approved dose for the initial treatment of heartburn. There were no clinically relevant findings with respect to dose dependence and safety outcomes in these studies. Efficacy outcomes from the trials suggest there may be a dose ceiling effect and highlight the need for further research on the use of the lowest effective PPI doses as an appropriate strategy in the initial treatment of uncomplicated heartburn. Observational studies and some meta-analyses have suggested that long-term PPI pharmacotherapy might be associated with safety concerns, which necessitate the periodic evaluation of therapeutic benefit in terms of symptom resolution and regimen tolerability. However, evidence to date suggests that use of the lowest effective dose for the indication is not associated with significant adverse events, particularly in the short term. Clinical practice suggests that patients requiring long-term treatment should be maintained on the lowest dose necessary to control symptoms, and monitored for potentially confounding factors that may lead to safety concerns.

Did our current initial treatment practice change after EAU/ESPU vesicoureteral reflux risk grouping?

PubMed

Tokat, Eda; Gurocak, Serhat; Ure, Iyimser; Acar, Cenk; Sınık, Zafer; Tan, Mustafa Ozgur

2018-06-02

The "European Association of Urology (EAU) Guidelines on Vesicoureteral Reflux (VUR) in Children (September 2012)" established risk classification by analyzing and defining risk factors for each patient. In this study we aimed to investigate how our initial treatment procedures were affected by EAU/ESPU guideline vesicoureteral reflux risk grouping and to compare the early clinical results of treatments performed before and after the risk classification in our patients with VUR. 334 renal units with regular clinical follow-up who were treated owing to VUR (vesicoureteral reflux) between years 2009 and 2017 were retrospectively reviewed. Preoperative clinical parameters such as grade and laterality of reflux, presence of renal scar, initial and follow-up treatments, findings of medical treatment and surgical procedures were analyzed. The initial medical and surgical methods were compared by categorizing patients according to risk groups before and after 2013. Mean age and follow-up duration were 71.4(6-216) months and 47(4-141) months, respectively. Among the preoperative parameters, only high EAU risk group (p = 0.01) and treating lower urinary tract symptoms (p < 0.001) were determining the postoperative success rates significantly, while age, sex, and presence of renal scar at DMSA were not affecting the success of treatment significantly. While no significant difference in medical and surgical treatment rates is observed after risk grouping system in low risk group, the percentages of patients who are treated with surgical methods initially were significantly decreased in moderate and high risk groups (p = 0.002 and p = 0.012, respectively). We determined that VUR risk grouping did not change clinical success significantly in all risk groups. Despite the fact that EAU/ESPU VUR risk classification changed our current practice in terms of initial treatment method, this different approach did not seem to affect early clinical success positively. There is still an absolute need for studies with larger sample size and long-term follow-up to reach more reliable results. Therapeutic. Level 4. Copyright © 2018 Elsevier Inc. All rights reserved.

Clinical pathways for acute coronary syndromes in China: protocol for a hospital quality improvement initiative.

PubMed

Rong, Ye; Turnbull, Fiona; Patel, Anushka; Du, Xin; Wu, Yangfeng; Gao, Runlin

2010-09-01

Clinical pathways have been shown to be effective in improving quality of care for patients admitted to hospital for acute coronary syndromes (ACS) in high-income countries. However, their utility has not formally been evaluated in low- or middle-income countries. The Clinical Pathways for Acute Coronary Syndromes in China program is a 7-year study with the overall goal of reducing evidence-practice gaps in the management of patients admitted to hospitals in China with suspected ACS. The program comprises 2 phases: a prospective survey of current management of ACS patients to identify the areas that evidence-based patient care can be potentially improved, and a quality care initiative to maximize the use of evidence-based investigations and treatments for ACS patients in China. In this article, we outline the details of the study protocol, including key aspects of the development, implementation, and evaluation of the quality improvement initiative (clinical pathway) for management of patients with suspected ACS.

Practice Facilitator Strategies for Addressing Electronic Health Record Data Challenges for Quality Improvement: EvidenceNOW.

PubMed

Hemler, Jennifer R; Hall, Jennifer D; Cholan, Raja A; Crabtree, Benjamin F; Damschroder, Laura J; Solberg, Leif I; Ono, Sarah S; Cohen, Deborah J

2018-01-01

Practice facilitators ("facilitators") can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices' electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality's initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support. © Copyright 2018 by the American Board of Family Medicine.

Results from the first 4 years of pay for performance.

PubMed

DeVore, Susan D

2010-01-01

Some of the lessons hospitals that have participated in the Hospital Quality Incentive Demonstration project have learned include: the need to tie in quality-of-care initiatives to the organization's strategic plan and to incentive plans for all employees, from executives on down; the value in allowing hospital physicians to "own" quality improvement initiatives; the importance of making results of the initiative available to all staff; the benefit of creating best-practice teams to address improvements in specific clinical areas.

Recruitment of private practices for primary care research: experience in a preventive services clinical trial.

PubMed

McBride, P E; Massoth, K M; Underbakke, G; Solberg, L I; Beasley, J W; Plane, M B

1996-10-01

Recruitment of community primary care practices for studies to improve health service delivery is important to many health care organizations. Prior studies have focused on individual physician recruitment or academic settings. This descriptive study evaluated the efficiency and utility of three different recruitment methods to encourage community practice participation in a preventive services research trial. Primary care practices in four midwestern states were recruited using different sources for initial mailings (physician lists, practice lists, and a managed care organization's primary care network) and different recruiting methods. Outcome measures included response rates, participation rates, and comparative costs of each method. Of the 86 eligible practices contacted, 52 (60%) consented to participate. Mailing to individual physicians was the most cumbersome and expensive method and had the lowest response rate. Initial contacts with practice medical directors increased the participation rate substantially, and practice recruitment meetings improved both study participation and practice-project communication. Experience with these three methods suggests that the most efficient way to recruit practices for participation in a preventive services research trial involves targeted mailings and phone calls to medical directors, followed by on-site practice meetings.

Envisaging the use of evidence-based practice (EBP): how nurse academics facilitate EBP use in theory and practice across Australian undergraduate programmes.

PubMed

Malik, Gulzar; McKenna, Lisa; Griffiths, Debra

2017-09-01

This paper is drawn from a grounded theory study that aimed to investigate processes undertaken by academics when integrating evidence-based practice into undergraduate curricula. This paper focuses on how nurse academics facilitated students to apply evidence-based practice in theory and practice. Facilitating undergraduate nursing students to develop skills within an evidence-based practice framework is vital to achieving evidence-based care. Studies on evidence-based practice conducted globally suggests that there is a need to investigate approaches used by nurse academics in facilitating students' understanding and use of evidence-based practice during their nurse education. Employing constructivist grounded theory approach, 23 nurse academics across Australian universities were interviewed and nine observed during their teaching. Some study participants shared their unit guides to enrich analysis. Data analysis was performed by following Charmaz's approach of coding procedures; as a result, four categories were constructed. This paper focuses on the category conceptualised as Envisaging the use of evidence-based practice. Findings revealed that most academics-assisted students to use evidence in academic-related activities. Recognising the importance of evidence-based practice in practice, some also expected students to apply evidence-based practice during clinical experiences. However, the level of students' appreciation for evidence-based practice during clinical experiences was unknown to participants and was influenced by practice-related barriers. Acknowledging these challenges, academics were engaged in dialogue with students and suggested the need for academia-practice collaboration in combating the cited barriers. Ensuring academics are supported to emphasise clinical application of evidence-based practice requires strategies at school and practice levels. Faculty development, engagement of clinical nurses with evidence-based practice, supportive culture for nurses and students to apply evidence-based practice principles, and collaboration between academia and practice will make facilitation by academics practical and meaningful for students. Findings from this study point to a number of initiatives for clinical leadership to provide infrastructure and support for academics, practising nurses and undergraduate students to adopt evidence-based practice in practice settings, thereby influencing practice outcomes. © 2016 John Wiley & Sons Ltd.

The NCI Community Oncology Research Program: what every clinician needs to know.

PubMed

McCaskill-Stevens, Worta; Lyss, Alan P; Good, Marge; Marsland, Thomas; Lilenbaum, Rogerio

2013-01-01

Research in the community setting is essential for the translation of advances in cancer research into practice and improving cancer care for all populations. The National Cancer Institute is proposing a new community-based program, NCI Community Oncology Research Program (NCORP), which is the alignment of two existing programs, the Community Clinical Oncology Program, Minority-Based Community Clinical Oncology Program, and their Research Bases, and the National Cancer Institute's Community Cancer Centers Program. NCROP will support cancer control, prevention, treatment, and screening clinical trials and expand its research scope to include cancer care delivery research. Cancer disparities research will be integrated into studies across the continuum of NCORP research. Input from current NCI-funded community investigators provides critical insight into the challenges faced by oncology practices within various organizational structures. Furthermore, these investigators identify the resources, both administrative and clinical, that will be required in the community setting to support cancer care delivery research and to meet the requirements for a new generation of clinical research. The American Society for Clinical Oncology (ASCO) has initiated a forum to focus on the conduct of clinical research in the community setting. Resources are being developed to help practices in managing cancer care in community settings.

Overcoming practical challenges to conducting clinical research in the inpatient stroke rehabilitation setting.

PubMed

Campbell, Grace B; Skidmore, Elizabeth R; Whyte, Ellen M; Matthews, Judith T

2015-10-01

There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work. This paper describes our institution's experience devising practical solutions to research barriers in this setting. Through concentrated efforts to overcome research barriers, such as by cultivating collaborative relationships and capitalizing on unanticipated benefits, we successfully facilitated conduct of five simultaneous inpatient stroke studies. Tangible benefits realized include increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team.

Nurses' Perceptions and Practices Toward Clinical Alarms in a Transplant Cardiac Intensive Care Unit: Exploring Key Issues Leading to Alarm Fatigue

PubMed Central

Tarriela, Albert Fajardo; Gomez, Tiffany Michelle; Reed, Charles Calhoun; Rapp, Kami Marie

2015-01-01

Background Intensive care units (ICUs) are complex work environments where false alarms occur more frequently than on non-critical care units. The Joint Commission National Patient Safety Goal .06.01.01 targeted improving the safety of clinical alarm systems and required health care facilities to establish alarm systems safety as a hospital priority by July 2014. An important initial step toward this requirement is identifying ICU nurses’ perceptions and common clinical practices toward clinical alarms, where little information is available. Objective Our aim was to determine perceptions and practices of transplant/cardiac ICU (TCICU) nurses toward clinical alarms and benchmark the results against the 2011 Healthcare Technology Foundation’s (HTF) Clinical Alarms Committee Survey. Methods A quality improvement project was conducted on a 20-bed TCICU with 39 full- and part-time nurses. Nurses were surveyed about their perceptions and attitudes toward and practices on clinical alarms using an adapted HTF clinical alarms survey. Results were compared to the 2011 HTF data. Correlations among variables were examined. Results All TCICU nurses provided usable responses (N=39, 100%). Almost all nurses (95%-98%) believed that false alarms are frequent, disrupt care, and reduce trust in alarm systems, causing nurses to inappropriately disable them. Unlike the 2011 HTF clinical alarms survey results, a significantly higher percentage of our TCICU nurses believed that existing devices are complex, questioned the ability and adequacy of the new monitoring systems to solve alarm management issues, pointed to the lack of prompt response to alarms, and indicated the lack of clinical policy on alarm management (P<.01). Major themes in the narrative data focused on nurses’ frustration related to the excessive number of alarms and poor usability of the cardiac monitors. A lack of standardized approaches exists in changing patients’ electrodes and individualizing parameters. Around 60% of nurses indicated they received insufficient training on bedside and central cardiac monitors. A correlation also showed the need for training on cardiac monitors, specifically for older nurses (P=.01). Conclusions False and non-actionable alarms continue to desensitize TCICU nurses, perhaps resulting in missing fatal alarms. Nurses’ attitudes and practices related to clinical alarms are key elements for designing contextually sensitive quality initiatives to fight alarm fatigue. Alarm management in ICUs is a multidimensional complex process involving usability of monitoring devices, and unit, clinicians, training, and policy-related factors. This indicates the need for a multi-method approach to decrease alarm fatigue and improve alarm systems safety. PMID:27025940

SMILE: Simple, Mental Health, Initiative in Learning and Education.

PubMed

Ward, L J

2011-12-01

SMILE is a Simple, Mental health, Initiative in Learning and Education. SMILE was a pilot project introduced into an undergraduate clinical nursing program, Southern Cross University, Australia 2010. The program aimed to improve the knowledge and skills of third-year nursing students participating in their first clinical placement in mental healthcare. Complementary to the clinical nursing program and the university curriculum, SMILE provided further training and support for student learning in mental healthcare. The SMILE project was a structured 15-day education program that covered the following topics: suicide prevention; psychosis; drugs and alcohol education; mental state exam; families and carers in mental health; and the Mental Health Act. The education sessions were one hour in duration. The educational material and resources were created from current research, literature and health service policy. A problem-based learning approach was used to support this education project. The dynamic factor related to SMILE was that it was based in the field. SMILE enabled the students to bridge a theory-practice gap and expand upon their current knowledge base as well as participate in ward activity. Twenty students attending their first clinical placement in mental healthcare participated in SMILE and were asked to complete a pre- and post- evaluation questionnaire before starting and upon completion of the 15-day project. The students participating in SMILE reported a greater understanding of mental healthcare issues and expressed a developing knowledge base and improved practical skill level. SMILE was a positive initiative that provided valuable feedback and opportunity to improve on clinical education in mental healthcare.

"They're younger… it's harder." Primary providers' perspectives on hypertension management in young adults: a multicenter qualitative study.

PubMed

Johnson, Heather M; Warner, Ryan C; Bartels, Christie M; LaMantia, Jamie N

2017-01-03

Young adults (18-39 year-olds) have the lowest hypertension control rates among adults with hypertension in the United States. Unique barriers to hypertension management in young adults with primary care access compared to older adults have not been evaluated. Understanding these differences will inform the development of hypertension interventions tailored to young adults. The goals of this multicenter study were to explore primary care providers' perspectives on barriers to diagnosing, treating, and controlling hypertension among young adults with regular primary care. Primary care providers (physicians and advanced practice providers) actively managing young adults with uncontrolled hypertension were recruited by the Wisconsin Research & Education Network (WREN), a statewide practice-based research network. Semi-structured qualitative interviews were conducted in three diverse Midwestern clinical practices (academic, rural, and urban clinics) using a semi-structured interview guide, and content analysis was performed. Primary care providers identified unique barriers across standard hypertension healthcare delivery practices for young adults. Altered self-identity, greater blood pressure variability, and unintended consequences of medication initiation were critical hypertension control barriers among young adults. Gender differences among young adults were also noted as barriers to hypertension follow-up and antihypertensive medication initiation. Tailored interventions addressing the unique barriers of young adults are needed to improve population hypertension control. Augmenting traditional clinic structure to support the "health identity" of young adults and self-management skills are promising next steps to improve hypertension healthcare delivery.

Assessing clinicians' management of first episode schizophrenia using clinical case vignettes.

PubMed

Huffman, Jeff C; Freudenreich, Oliver; Romeo, Sarah; Baer, Lee; Sutton-Skinner, Kelly; Petersen, Tim; Fromson, John A; Birnbaum, Robert J

2010-02-01

Patients with first episode schizophrenia may present in a variety of clinical settings to providers who have a range of knowledge and skills. A thoughtful workup of patients with new-onset psychosis is critical, and the treatment of first episode schizophrenia differs from that of chronic psychotic disorders. Clinical case vignettes with free-form responses can be used to carefully assess whether front line practitioners provide guideline-adherent management of first episode psychosis. A clinical case vignette, presenting a patient with first episode schizophrenia, was created and administered to the attendees of a continuing medical education programme. Free-form responses to questions regarding differential diagnosis, workup, treatment and treatment duration were scored based on published practice guidelines. Response frequencies were tabulated and performance was compared among professional disciplines. Sixty-two attendees completed the vignette. Though the attendees typically considered a broad differential diagnosis and appropriately initiated treatment with antipsychotics, the respondents' proposed medical workup was limited, and they prescribed antipsychotics at higher doses and for a shorter duration than recommended in the literature. The prescribers outperformed the non-prescribers on treatment questions (P = 0.006), but the two groups' performance did not significantly differ on the assessment questions (P = 0.08). The front line clinicians who encounter patients with first episode schizophrenia may have significant practice gaps in the initial and follow-up care of these patients. Given the preliminary nature of this study and the debate about the optimal care for first episode psychosis, further study is needed. If such gaps are confirmed, additional educational interventions are required to align clinical management with published practice guidelines.

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model.

PubMed

Basu, Sanjay; Phillips, Russell S; Song, Zirui; Landon, Bruce E; Bitton, Asaf

2016-09-01

We assess the financial implications for primary care practices of participating in patient-centered medical home (PCMH) funding initiatives. We estimated practices' changes in net revenue under 3 PCMH funding initiatives: increased fee-for-service (FFS) payments, traditional FFS with additional per-member-per-month (PMPM) payments, or traditional FFS with PMPM and pay-for-performance (P4P) payments. Net revenue estimates were based on a validated microsimulation model utilizing national practice surveys. Simulated practices reflecting the national range of practice size, location, and patient population were examined under several potential changes in clinical services: investments in patient tracking, communications, and quality improvement; increased support staff; altered visit templates to accommodate longer visits, telephone visits or electronic visits; and extended service delivery hours. Under the status quo of traditional FFS payments, clinics operate near their maximum estimated possible net revenue levels, suggesting they respond strongly to existing financial incentives. Practices gained substantial additional net annual revenue per full-time physician under PMPM or PMPM plus P4P payments ($113,300 per year, 95% CI, $28,500 to $198,200) but not under increased FFS payments (-$53,500, 95% CI, -$69,700 to -$37,200), after accounting for costs of meeting PCMH funding requirements. Expanding services beyond minimum required levels decreased net revenue, because traditional FFS revenues decreased. PCMH funding through PMPM payments could substantially improve practice finances but will not offer sufficient financial incentives to expand services beyond minimum requirements for PCMH funding. © 2016 Annals of Family Medicine, Inc.

What is the impact of a national postgraduate medical specialist education reform on the daily clinical training 3.5 years after implementation? A questionnaire survey.

PubMed

Mortensen, Lene; Malling, Bente; Ringsted, Charlotte; Rubak, Sune

2010-06-18

Many countries have recently reformed their postgraduate medical education (PGME). New pedagogic initiatives and blueprints have been introduced to improve quality and effectiveness of the education. Yet it is unknown whether these changes improved the daily clinical training. The purpose was to examine the impact of a national PGME reform on the daily clinical training practice. The Danish reform included change of content and format of specialist education in line with outcome-based education using the CanMEDS framework. We performed a questionnaire survey among all hospital doctors in the North Denmark Region. The questionnaire included items on educational appraisal meetings, individual learning plans, incorporating training issues into work routines, supervision and feedback, and interpersonal acquaintance. Data were collected before start and 31/2 years later. Mean score values were compared, and response variables were analysed by multiple regression to explore the relation between the ratings and seniority, type of hospital, type of specialty, and effect of attendance to courses in learning and teaching among respondents. Response rates were 2105/2817 (75%) and 1888/3284 (58%), respectively. We found limited impact on clinical training practice and learning environment. Variances in ratings were hardly affected by type of hospital, whereas belonging to the laboratory specialities compared to other specialties was related to higher ratings concerning all aspects. The impact on daily clinical training practice of a national PGME reform was limited after 31/2 years. Future initiatives must focus on changing the pedagogical competences of the doctors participating in daily clinical training and on implementation strategies for changing educational culture.

An educational approach to improve outcomes in acute kidney injury (AKI): report of a quality improvement project.

PubMed

Xu, Gang; Baines, Richard; Westacott, Rachel; Selby, Nick; Carr, Susan

2014-03-20

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). 2 large acute teaching hospitals in England, serving a combined population of over 1.5 million people. All secondary care clinicians working in the clinical areas were targeted, with a specific focus on clinicians working in acute admission areas. A multifaceted educational intervention consisting of traditional didactic lectures, case-based teaching in small groups and an interactive web-based learning resource. 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. 26% of clinicians reported that they were aware of local AKI guidelines in the preintervention questionnaire compared to 64% in the follow-up questionnaire (χ²=60.2, p<0.001). There was an improvement in the number of clinicians reporting satisfactory practice when diagnosing AKI, 50% vs 68% (χ²=12.1, p<0.001) and investigating patients with AKI, 48% vs 64% (χ²=9.5, p=0.002). Clinical audit makers showed a trend towards better clinical practice. 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.

Refining and validating a conceptual model of Clinical Nurse Leader integrated care delivery.

PubMed

Bender, Miriam; Williams, Marjory; Su, Wei; Hites, Lisle

2017-02-01

To empirically validate a conceptual model of Clinical Nurse Leader integrated care delivery. There is limited evidence of frontline care delivery models that consistently achieve quality patient outcomes. Clinical Nurse Leader integrated care delivery is a promising nursing model with a growing record of success. However, theoretical clarity is necessary to generate causal evidence of effectiveness. Sequential mixed methods. A preliminary Clinical Nurse Leader practice model was refined and survey items developed to correspond with model domains, using focus groups and a Delphi process with a multi-professional expert panel. The survey was administered in 2015 to clinicians and administrators involved in Clinical Nurse Leader initiatives. Confirmatory factor analysis and structural equation modelling were used to validate the measurement and model structure. Final sample n = 518. The model incorporates 13 components organized into five conceptual domains: 'Readiness for Clinical Nurse Leader integrated care delivery'; 'Structuring Clinical Nurse Leader integrated care delivery'; 'Clinical Nurse Leader Practice: Continuous Clinical Leadership'; 'Outcomes of Clinical Nurse Leader integrated care delivery'; and 'Value'. Sample data had good fit with specified model and two-level measurement structure. All hypothesized pathways were significant, with strong coefficients suggesting good fit between theorized and observed path relationships. The validated model articulates an explanatory pathway of Clinical Nurse Leader integrated care delivery, including Clinical Nurse Leader practices that result in improved care dynamics and patient outcomes. The validated model provides a basis for testing in practice to generate evidence that can be deployed across the healthcare spectrum. © 2016 John Wiley & Sons Ltd.

Revisioning a clinical nurse specialist curriculum in 3 specialty tracks.

PubMed

Arslanian-Engoren, Cynthia; Sullivan, Barbara-Jean; Struble, Laura

2011-01-01

The objective of the present study was to revise 3 clinical nurse specialist (CNS) educational tracks with current National Association of Clinical Nurse Specialist core competencies and educational expectations. National curricula recommendations include core competencies by the 3 spheres of influence. Advanced practice registered nurses consensus model educational requirements include a minimum of 500 faculty-supervised clinical hours; separate graduate courses in pharmacology, pathophysiology, and advanced physical assessment; and content in differential diagnosis disease management, decision making, and role preparation. This educational initiative was designed to (1) align with core competencies and advanced practice registered nurse consensus model recommendations, (2) create an innovative learning environment, (3) meet the needs of diverse student populations, (4) align with emerging doctor of nursing practice programs, (5) create a high-efficiency and high-quality environment to manage human and fiscal resources, and (6) reduce duplication of efforts. Courses were revised that did not meet current CNS educational preparation expectations. A total of 11 didactic and clinical sequences courses were developed for the 3 tracks to (1) ensure minimum numbers of clinical hours; (2) expand content on health promotion and risk reduction, advanced practice nurse role, and the healthcare delivery system; (3) consolidate clinical courses; and (4) resequence foundational content before beginning clinical courses. Revisioning a CNS curriculum in 3 specialty tracks is challenging but doable using innovative and creative approaches. The innovative process used to revise our CNS curriculum will assist nurse educators faced with similar program delivery challenges to meet future directions for educating CNS students in advanced nursing practice. Copyright © 2011 Lippincott Williams & Wilkins.

A review of the literature regarding stress among nursing students during their clinical education.

PubMed

Alzayyat, A; Al-Gamal, E

2014-09-01

There has been increased attention in the literature about stress among nursing students. It has been evident that clinical education is the most stressful experience for nursing students. The aim of this paper was to critically review studies related to degrees of stress and the type of stressors that can be found among undergraduate nursing students during their clinical education. The search strategy involved the utilization of the following databases: MEDLINE (Medical Literature on-Line), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO (Psychology Information) and PubMed. Keywords were stress, undergraduate nursing students, clinical practice. The review included those studies published between 2002 and 2013, conducted in any country as long as reported in English, and including a focus on the clinical practice experience of nursing students. Thirteen studies met the eligibility criteria. Four themes were identified: initial clinical experience, comparison between different academic years, cross-cultural comparison, and eustress aspects of clinical experience. This review expands current knowledge in the area of stress in clinical settings and calls for further research. Nursing teachers should utilize the findings of this review to direct their students during clinical practice. Moreover, hospital administrators need to promote policies to promote a training environment where students are supported and inspired. © 2014 International Council of Nurses.

The Role of the Clinical Laboratory in the Future of Health Care: Lean Microbiology

PubMed Central

Samuel, Linoj

2014-01-01

This commentary will introduce lean concepts into the clinical microbiology laboratory. The practice of lean in the clinical microbiology laboratory can remove waste, increase efficiency, and reduce costs. Lean, Six Sigma, and other such management initiatives are useful tools and can provide dividends but must be accompanied by organizational leadership commitment to sustaining the lean culture in the laboratory setting and providing resources and time to work through the process. PMID:24574289

Pilot study of pharmacist-assisted delivery of pharmacogenetic testing in a primary care setting.

PubMed

Haga, Susanne B; LaPointe, Nancy M Allen; Cho, Alex; Reed, Shelby D; Mills, Rachel; Moaddeb, Jivan; Ginsburg, Geoffrey S

2014-09-01

To describe the rationale and design of a pilot program to implement and evaluate pharmacogenetic (PGx) testing in a primary care setting. Several factors have impeded the uptake of PGx testing, including lack of provider knowledge and challenges with operationalizing PGx testing in a clinical practice setting. We plan to compare two strategies for the implementation of PGx testing: a pharmacist-initiated testing arm compared with a physician-initiated PGx testing arm. Providers in both groups will be required to attend an introduction to PGx seminar. Anticipated results: We anticipate that providers in the pharmacist-initiated group will be more likely to order PGx testing than providers in the physician-initiated group. Overall, we aim to generate data that will inform an effective delivery model for PGx testing and to facilitate a seamless integration of PGx testing in primary care practices.

Electronic decision support for diagnostic imaging in a primary care setting

PubMed Central

Reed, Martin H

2011-01-01

Methods Clinical guideline adherence for diagnostic imaging (DI) and acceptance of electronic decision support in a rural community family practice clinic was assessed over 36 weeks. Physicians wrote 904 DI orders, 58% of which were addressed by the Canadian Association of Radiologists guidelines. Results Of those orders with guidelines, 76% were ordered correctly; 24% were inappropriate or unnecessary resulting in a prompt from clinical decision support. Physicians followed suggestions from decision support to improve their DI order on 25% of the initially inappropriate orders. The use of decision support was not mandatory, and there were significant variations in use rate. Initially, 40% reported decision support disruptive in their work flow, which dropped to 16% as physicians gained experience with the software. Conclusions Physicians supported the concept of clinical decision support but were reluctant to change clinical habits to incorporate decision support into routine work flow. PMID:21486884

Insulin Therapy for Adult Patients with Type 2 Diabetes Mellitus: A Position Statement of the Korean Diabetes Association, 2017.

PubMed

Lee, Byung Wan; Kim, Jin Hwa; Ko, Seung Hyun; Hur, Kyu Yeon; Kim, Nan Hee; Rhee, Sang Youl; Kim, Hyun Jin; Moon, Min Kyong; Park, Seok O; Choi, Kyung Mook

2017-10-01

The Korean Diabetes Association (KDA) has regularly updated its Clinical Practice Guidelines. In 2017, the KDA published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). Growing evidence from new multinational clinical trials using novel and traditional insulin analogues has also been accumulated. Following global trends, many results of clinical trials, especially concerning the clinical efficacy and safety of insulin therapy, have been published about Korean patients with T2DM. After a systematic search of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the initiation, choice, and intensification of insulin and created an insulin treatment algorithm for the first time to guide physicians caring for adult Korean patients with T2DM. Copyright © 2017 Korean Diabetes Association.

Neuropsychology in Mexico.

PubMed

Ostrosky Shejet, Feggy; Velez Garcia, Alicia

2016-11-01

This invited paper explores the diverse pathways that have led to the development of neuropsychology in Mexico. The authors conducted a review of the literature and their own experiences to describe the seminal events and people relevant to the development of this area of research and practice. The master's degree is the usual level of educational attainment for those who wish to practice clinical neuropsychology. As of now, there is not a board certification process in neuropsychology, although there is one in clinical psychology. Neuropsychology and other mental health disciplines in Mexico and Latin America have historically been poorly funded, and have lacked optimal means of communication as to research findings and clinical initiatives and standards. However, there is reason to think that this will be improved upon in coming years.

Multinational evidence-based recommendations for pain management by pharmacotherapy in inflammatory arthritis: integrating systematic literature research and expert opinion of a broad panel of rheumatologists in the 3e Initiative

PubMed Central

Colebatch, Alexandra N.; Buchbinder, Rachelle; Edwards, Christopher J.; Adams, Karen; Englbrecht, Matthias; Hazlewood, Glen; Marks, Jonathan L.; Radner, Helga; Ramiro, Sofia; Richards, Bethan L.; Tarner, Ingo H.; Aletaha, Daniel; Bombardier, Claire; Landewé, Robert B.; Müller-Ladner, Ulf; Bijlsma, Johannes W. J.; Branco, Jaime C.; Bykerk, Vivian P.; da Rocha Castelar Pinheiro, Geraldo; Catrina, Anca I.; Hannonen, Pekka; Kiely, Patrick; Leeb, Burkhard; Lie, Elisabeth; Martinez-Osuna, Píndaro; Montecucco, Carlomaurizio; Østergaard, Mikkel; Westhovens, Rene; Zochling, Jane; van der Heijde, Désirée

2012-01-01

Objective. To develop evidence-based recommendations for pain management by pharmacotherapy in patients with inflammatory arthritis (IA). Methods. A total of 453 rheumatologists from 17 countries participated in the 2010 3e (Evidence, Expertise, Exchange) Initiative. Using a formal voting process, 89 rheumatologists representing all 17 countries selected 10 clinical questions regarding the use of pain medications in IA. Bibliographic fellows undertook a systematic literature review for each question, using MEDLINE, EMBASE, Cochrane CENTRAL and 2008–09 European League Against Rheumatism (EULAR)/ACR abstracts. Relevant studies were retrieved for data extraction and quality assessment. Rheumatologists from each country used this evidence to develop a set of national recommendations. Multinational recommendations were then formulated and assessed for agreement and the potential impact on clinical practice. Results. A total of 49 242 references were identified, from which 167 studies were included in the systematic reviews. One clinical question regarding different comorbidities was divided into two separate reviews, resulting in 11 recommendations in total. Oxford levels of evidence were applied to each recommendation. The recommendations related to the efficacy and safety of various analgesic medications, pain measurement scales and pain management in the pre-conception period, pregnancy and lactation. Finally, an algorithm for the pharmacological management of pain in IA was developed. Twenty per cent of rheumatologists reported that the algorithm would change their practice, and 75% felt the algorithm was in accordance with their current practice. Conclusions. Eleven evidence-based recommendations on the management of pain by pharmacotherapy in IA were developed. They are supported by a large panel of rheumatologists from 17 countries, thus enhancing their utility in clinical practice. PMID:22447886

Quality measures for nurse practitioner practice evaluation.

PubMed

Kleinpell, Ruth; Kapu, April N

2017-08-01

Evaluating the impact of nurse practitioner (NP) practice has become a priority area of focus for demonstrating outcomes. A number of quality measures are available to enable practice-specific evaluation of NP roles and initiatives. This article reviews sources of quality measures that can be used to facilitate quantifying the outcomes of NP practice as part of an overall evaluation agenda. National resources and published literature on NP quality measures were reviewed. Various resources and toolkits exist to assist NPs in identifying outcomes of practice using quality measures. The need to demonstrate outcomes of NP practice remains an ongoing priority area regardless of the clinical practice setting. A variety of sources of quality measures exist that can be used to showcase the effect of NP care. The use of quality measures can be effectively integrated into evaluation of NP role and NP-directed initiatives to demonstrate impact, and enhance the conduct of an NP outcomes assessment. The use of organizational, NP-specific, and national-related quality measures can help to showcase how NP care improves the quality, safety, and costs of health care. ©2017 American Association of Nurse Practitioners.

The Computer-Based Writing Program: A Clinical Teaching Experience for Education Interns to Develop Professional Knowledge and Skills in Effective Instructional Writing Practices

ERIC Educational Resources Information Center

Painter, Diane D.

2016-01-01

The four-week university-sponsored summer Computer-based Writing (CBW) Program directed by the head of a special education initial teacher licensure program gave teaching interns opportunities to work with young struggling writers in a supervised clinical setting to address keyboarding skills, writing conventions and knowledge and application of…

Hydroxyurea Effectiveness in Children and Adolescents with Sickle Cell Anemia: A Large Retrospective, Population-Based Cohort

PubMed Central

Quarmyne, Maa-Ohui; Dong, Wei; Theodore, Rodney; Anand, Sonia; Barry, Vaughn; Adisa, Olufolake; Buchanan, Iris D.; Bost, James; Brown, Robert C.; Joiner, Clinton H.; Lane, Peter A.

2016-01-01

The clinical efficacy of hydroxyurea in patients with sickle cell anemia (SCA) has been well established. However, data about its clinical effectiveness in practice is limited. We evaluated the clinical effectiveness of hydroxyurea in a large pediatric population using a retrospective cohort, pre-post treatment study design to control for disease severity selection bias. The cohort included children with SCA (SS, S β 0thalassemia) who received care at Children's Healthcare of Atlanta (CHOA) and who initiated hydroxyurea in 2009-2011. Children on chronic transfusions, or children with inadequate follow up data and/or children who had taken hydroxyurea in the 3 years prior were excluded. For each patient, healthcare utilization, laboratory values and clinical outcomes for the 2-year period prior to hydroxyurea initiation were compared to those 2 years after initiation. Of 211 children with SCA who initiated hydroxyurea in 2009-2011, 134 met eligibility criteria. After initiation of hydroxyurea, rates of hospitalizations, pain encounters, and emergency department visits were reduced by 47% (<0.0001), 36% (p=0.0001) and 43% (p<0.0001), respectively. Average hemoglobin levels increased by 0.7g/dl (p<0.0001). Hydroxyurea effectiveness was similar across gender, insurance types and age, although there was a slightly greater reduction in hospitalizations in younger children. PMID:27761932

"Heidelberg standard examination" and "Heidelberg standard procedures" - Development of faculty-wide standards for physical examination techniques and clinical procedures in undergraduate medical education.

PubMed

Nikendei, C; Ganschow, P; Groener, J B; Huwendiek, S; Köchel, A; Köhl-Hackert, N; Pjontek, R; Rodrian, J; Scheibe, F; Stadler, A-K; Steiner, T; Stiepak, J; Tabatabai, J; Utz, A; Kadmon, M

2016-01-01

The competent physical examination of patients and the safe and professional implementation of clinical procedures constitute essential components of medical practice in nearly all areas of medicine. The central objective of the projects "Heidelberg standard examination" and "Heidelberg standard procedures", which were initiated by students, was to establish uniform interdisciplinary standards for physical examination and clinical procedures, and to distribute them in coordination with all clinical disciplines at the Heidelberg University Hospital. The presented project report illuminates the background of the initiative and its methodological implementation. Moreover, it describes the multimedia documentation in the form of pocketbooks and a multimedia internet-based platform, as well as the integration into the curriculum. The project presentation aims to provide orientation and action guidelines to facilitate similar processes in other faculties.

The 5C Concept and 5S Principles in Inflammatory Bowel Disease Management

PubMed Central

Hibi, Toshifumi; Panaccione, Remo; Katafuchi, Miiko; Yokoyama, Kaoru; Watanabe, Kenji; Matsui, Toshiyuki; Matsumoto, Takayuki; Travis, Simon; Suzuki, Yasuo

2017-01-01

Abstract Background and Aims The international Inflammatory Bowel Disease [IBD] Expert Alliance initiative [2012–2015] served as a platform to define and support areas of best practice in IBD management to help improve outcomes for all patients with IBD. Methods During the programme, IBD specialists from around the world established by consensus two best practice charters: the 5S Principles and the 5C Concept. Results The 5S Principles were conceived to provide health care providers with key guidance for improving clinical practice based on best management approaches. They comprise the following categories: Stage the disease; Stratify patients; Set treatment goals; Select appropriate treatment; and Supervise therapy. Optimised management of patients with IBD based on the 5S Principles can be achieved most effectively within an optimised clinical care environment. Guidance on optimising the clinical care setting in IBD management is provided through the 5C Concept, which encompasses: Comprehensive IBD care; Collaboration; Communication; Clinical nurse specialists; and Care pathways. Together, the 5C Concept and 5S Principles provide structured recommendations on organising the clinical care setting and developing best-practice approaches in IBD management. Conclusions Consideration and application of these two dimensions could help health care providers optimise their IBD centres and collaborate more effectively with their multidisciplinary team colleagues and patients, to provide improved IBD care in daily clinical practice. Ultimately, this could lead to improved outcomes for patients with IBD. PMID:28981622

Developing clinical practice guidelines for Chinese herbal treatment of polycystic ovary syndrome: A mixed-methods modified Delphi study.

PubMed

Lai, Lily; Flower, Andrew; Moore, Michael; Lewith, George

2015-06-01

Preliminary evidence suggests Chinese herbal medicine (CHM) could be a viable treatment option for polycystic ovary syndrome (PCOS). Prior to conducting a clinical trial it is important to consider the characteristics of good clinical practice. This study aims to use professional consensus to establish good clinical practice guidelines for the CHM treatment of PCOS. CHM practitioners participated in a mixed-methods modified Delphi study involving three rounds of structured group communication. Round 1 involved qualitative interviews with practitioners to generate statements regarding good clinical practice. In round 2, these statements were distributed online to the same practitioners to rate their agreement using a 7-point Likert scale, where group consensus was defined as a median rating of ≥5. Statements reaching consensus were accepted for consideration onto the guideline whilst those not reaching consensus were re-distributed for consideration in round 3. Statements presented in the guidelines were graded from A (strong consensus) to D (no consensus) determined by median score and interquartile range. 11 CHM practitioners in the UK were recruited. After three Delphi rounds, 91 statement items in total had been considered, of which 89 (97.8%) reached consensus and 2 (2.2%) did not. The concluding set of guidelines consists of 85 items representing key features of CHM prescribing for PCOS. These guidelines can be viewed as an initial framework that captures fundamental principles of good clinical practice for CHM. Copyright © 2015 Elsevier Ltd. All rights reserved.

APPLaUD: access for patients and participants to individual level uninterpreted genomic data.

PubMed

Thorogood, Adrian; Bobe, Jason; Prainsack, Barbara; Middleton, Anna; Scott, Erick; Nelson, Sarah; Corpas, Manuel; Bonhomme, Natasha; Rodriguez, Laura Lyman; Murtagh, Madeleine; Kleiderman, Erika

2018-02-17

There is a growing support for the stance that patients and research participants should have better and easier access to their raw (uninterpreted) genomic sequence data in both clinical and research contexts. We review legal frameworks and literature on the benefits, risks, and practical barriers of providing individuals access to their data. We also survey genomic sequencing initiatives that provide or plan to provide individual access. Many patients and research participants expect to be able to access their health and genomic data. Individuals have a legal right to access their genomic data in some countries and contexts. Moreover, increasing numbers of participatory research projects, direct-to-consumer genetic testing companies, and now major national sequencing initiatives grant individuals access to their genomic sequence data upon request. Drawing on current practice and regulatory analysis, we outline legal, ethical, and practical guidance for genomic sequencing initiatives seeking to offer interested patients and participants access to their raw genomic data.

Creating an evidence-based practice environment: one hospital's journey.

PubMed

Hockenberry, Marilyn; Walden, Marlene; Brown, Terri; Barrera, Patrick

2007-01-01

There is increasing effort in promoting evidence-based practice (EBP) that supports the best possible care to patients and families. This article describes essential concepts for developing an environment of EBP and its implementation at a large pediatric hospital. Essential components for creating an EBP environment include vision, engagement, integration, and evaluation. An institutional initiative to decrease procedure-related pain demonstrates how EBP is used to improve clinical care.

The Morningside Initiative: Collaborative Development of a Knowledge Repository to Accelerate Adoption of Clinical Decision Support

DTIC Science & Technology

2010-01-01

Comparative Effectiveness Research, or other efforts to determine best practices and to develop guidelines based on meta-analysis and evidence - based medicine . An...authoritative reviews or other evidence - based medicine sources, but they have been made unambiguous and computable – a process which sounds...best practice recommendation created through an evidence - based medicine (EBM) development process. The lifecycle envisions four stages of refinement

Adoption of telemedicine in Scottish remote and rural general practices: a qualitative study.

PubMed

King, Gerry; Richards, Helen; Godden, David

2007-01-01

We conducted a qualitative interview study to explore the factors that have facilitated and prevented the adoption of telemedicine in general practice in remote and rural Scotland. Face-to-face interviews were carried out with general practitioners (GPs) and practice nurses in 26 of Scotland's most remote practices and five of the seven most rural health boards. The interview study found that GPs were more positive about the use of computers and telemedicine than nurses. Although electronic access to simple data, such as laboratory results, had become widely accepted, most respondents had very little experience of more sophisticated telemedicine applications, such as videoconferencing. There was widespread scepticism about the potential usefulness of clinical applications of telemedicine, although it was perceived to have potential benefit in facilitating access to educational resources. A number of barriers to the adoption of telemedicine were reported, including concerns that videoconferencing could diminish the quality of communication in educational and clinical settings, and that telemedicine would not fit easily with the organizational routines of the practices. Policy-makers should prioritize strategies to develop educational programmes, as these are more likely to succeed than clinical initiatives. It may then follow that clinicians will see opportunities for use in their clinical work.

[How to write, how to implement and how to evaluate a practice guideline in order to improve quality of care?].

PubMed

Moret, L; Lefort, C; Terrien, N

2012-11-01

Initiatives of clinical practices improvement have been gradually developing in France for 20 years. Nevertheless, effective implementation of change is still difficult for numerous reasons. The use of clinical practices guidelines is one of the different ways of improvement. It is however necessary to adapt these national guidelines to the specificities of the hospital and the team, to ensure implementation and appropriation by the professionals. These recommendations are thus translated into applicable and concrete standard operating procedures. These documents have to be built by and for the concerned professionals. They are also communication and training tools, precise, directive, uniform in terms of presentation and attractive visually. Once drafted, they have to be distributed widely to the professionals to facilitate implementation. The simple distribution of the recommendations is insufficient to modify the clinical practices and require association of several methods of promotion for an optimal appropriation. How then to make sure of their effective use? Practices evaluation is one of the steps of continuous professional development, including continuous training and analysis of clinical practices by using methods promoted by the "Haute Autorité de santé". One of them is the clinical audit; use of method assessing non-pertinent treatment is interesting too. Analysis of the non-conformities and gaps between theory and practice allows identifying various possible causes (professional, institutional, organizational or personal) in order to implement corrective action plans, in a logic of continuous improvement. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Utility of the Electrocardiogram in Drug Overdose and Poisoning: Theoretical Considerations and Clinical Implications

PubMed Central

Yates, Christopher; Manini, Alex F

2012-01-01

The ECG is a rapidly available clinical tool that can help clinicians manage poisoned patients. Specific myocardial effects of cardiotoxic drugs have well-described electrocardiographic manifestations. In the practice of clinical toxicology, classic ECG changes may hint at blockade of ion channels, alterations of adrenergic tone, or dysfunctional metabolic activity of the myocardium. This review will offer a structured approach to ECG interpretation in poisoned patients with a focus on clinical implications and ECG-based management recommendations in the initial evaluation of patients with acute cardiotoxicity. PMID:22708912

Twenty years of human immunodeficiency virus care at the Mayo Clinic: Past, present and future.

PubMed

Cummins, Nathan W; Badley, Andrew D; Kasten, Mary J; Sampath, Rahul; Temesgen, Zelalem; Whitaker, Jennifer A; Wilson, John W; Yao, Joseph D; Zeuli, John; Rizza, Stacey A

2016-05-12

The Mayo human immunodeficiency virus (HIV) Clinic has been providing patient centered care for persons living with HIV in Minnesota and beyond for the past 20 years. Through multidisciplinary engagement, vital clinical outcomes such as retention in care, initiation of antiretroviral therapy and virologic suppression are maximized. In this commentary, we describe the history of the Mayo HIV Clinic and its best practices, providing a "Mayo Model" of HIV care that exceeds national outcomes and may be applicable in other settings.

Twenty years of human immunodeficiency virus care at the Mayo Clinic: Past, present and future

PubMed Central

Cummins, Nathan W; Badley, Andrew D; Kasten, Mary J; Sampath, Rahul; Temesgen, Zelalem; Whitaker, Jennifer A; Wilson, John W; Yao, Joseph D; Zeuli, John; Rizza, Stacey A

2016-01-01

The Mayo human immunodeficiency virus (HIV) Clinic has been providing patient centered care for persons living with HIV in Minnesota and beyond for the past 20 years. Through multidisciplinary engagement, vital clinical outcomes such as retention in care, initiation of antiretroviral therapy and virologic suppression are maximized. In this commentary, we describe the history of the Mayo HIV Clinic and its best practices, providing a “Mayo Model” of HIV care that exceeds national outcomes and may be applicable in other settings. PMID:27175350

Medication monitoring and drug testing ethics project.

PubMed

Payne, Richard; Moe, Jeffrey L; Sevier, Catherine Harvey; Sevier, David; Waitzkin, Michael

2015-01-01

In 2012, Duke University initiated a research project, funded by an unrestricted research grant from Millennium Laboratories, a drug testing company. The project focused on assessing the frequency and nature of questionable, unethical, and illegal business practices in the clinical drug testing industry and assessing the potential for establishing a business code of ethics. Laboratory leaders, clinicians, industry attorneys, ethicists, and consultants participated in the survey, were interviewed, and attended two face-to-face meetings to discuss a way forward. The study demonstrated broad acknowledgment of variations in the legal and regulatory environment, resulting in inconsistent enforcement of industry practices. Study participants expressed agreement that overtly illegal practices sometimes exist, particularly when laboratory representatives and clinicians discuss reimbursement, extent of testing, and potential business incentives with medical practitioners. Most respondents reported directly observing probable violations involving marketing materials, contracts, or, in the case of some individuals, directly soliciting people with offers of clinical supplies and other "freebies." While many study respondents were skeptical that voluntary standards alone would eliminate questionable business practices, most viewed ethics codes and credentialing as an important first step that could potentially mitigate uneven enforcement, while improving quality of care and facilitating preferred payment options for credentialed parties. Many were willing to participate in future discussions and industry-wide initiatives to improve the environment.

PCI Choice: Cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease.

PubMed

Coylewright, Megan; O'Neill, Elizabeth S; Dick, Sara; Grande, Stuart W

2017-06-01

Describe cardiovascular clinicians' perceptions of Shared Decision Making following use of a decision aid (DA) for stable coronary artery disease (CAD) "PCI Choice", in a randomized controlled trial. We conducted a semi-structured qualitative interview study with cardiologists and physician extenders (n=13) after using PCI Choice in practice. Interviews were transcribed then coded. Codes were organized into salient themes. Final themes were determined by consensus with all authors. Most clinicians (70%) had no prior knowledge of SDM or DAs. Mixed views about the role of the DA in the visit were related to misconceptions of how patient education differed from SDM. Qualitative assessment of clinician perceptions generated three themes: 1) Gaps exist in clinician knowledge around SDM; 2) Clinicians are often uncomfortable with modifying baseline practice; and 3) Clinicians express interest in using DAs after initial exposure within a research setting. Use of DAs by clinicians during clinic visits may improve understanding of SDM. Initial use is marked by a reluctance to modify established practice patterns. As clinicians explore new approaches to benefit their patients, there is an opportunity for DAs that provide clinician instruction on core elements of SDM to lead to enhanced SDM in clinical practice. Copyright © 2017 Elsevier B.V. All rights reserved.

Clinical practice on the horizon: personalized medicine.

PubMed

Chadwell, Katherine

2013-01-01

With the advent of the human genome project, we have never known so much about the uniqueness of individuals. Personalized medicine is poised to use this genetic and genomic information along with the impact of environment and clinical presentation to provide healthcare from an individual perspective. This offers the opportunity to improve our ability to diagnose and predict disease, provide earlier intervention, identify new treatment regimens, and address the safety and efficacy of drug use. The impact of personalized medicine to our current model of healthcare delivery is tremendous, and although strides have been made, there are still challenges and barriers to overcome before personalized medicine can be fully implemented. Advanced practice nurses may not be fully aware of the personalized medicine initiative or may not be well versed on genetic and genomic content, which is a key concept of personalized medicine. The role of advanced practice nurses is an integral part of the healthcare system, and as such, they are poised to be key providers and contributors to personalized medicine. The personalized medicine initiative is discussed along with examples of genetic and genomic information that lend to our understanding, diagnosis, and treatment of disease, as well as the role and responsibilities of advanced practice nurses. Resources for personalized medicine and genetic and genomic content are provided.

Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory.

PubMed

Manski-Nankervis, Jo-Anne; Furler, John; Blackberry, Irene; Young, Doris; O'Neal, David; Patterson, Elizabeth

2014-01-31

The majority of care for people with type 2 diabetes occurs in general practice, however when insulin initiation is required it often does not occur in this setting or in a timely manner and this may have implications for the development of complications. Increased insulin initiation in general practice is an important goal given the increasing prevalence of type 2 diabetes and a relative shortage of specialists. Coordination between primary and secondary care, and between medical and nursing personnel, may be important in achieving this. Relational coordination theory identifies key concepts that underpin effective interprofessional work: communication which is problem solving, timely, accurate and frequent and relationships between professional roles which are characterized by shared goals, shared knowledge and mutual respect. This study explores roles and relationships between health professionals involved in insulin initiation in order to gain an understanding of factors which may impact on this task being carried out in the general practice setting. 21 general practitioners, practice nurses, diabetes nurse educators and physicians were purposively sampled to participate in a semi-structured interview. Transcripts of the interviews were analysed using framework analysis. There were four closely interlinked themes identified which impacted on how health professionals worked together to initiate people with type 2 diabetes on insulin: 1. Ambiguous roles; 2. Uncertain competency and capacity; 3. Varying relationships and communication; and 4. Developing trust and respect. This study has shown that insulin initiation is generally recognised as acceptable in general practice. The role of the DNE and practice nurse in this space and improved communication and relationships between health professionals across organisations and levels of care are factors which need to be addressed to support this clinical work. Relational coordination provides a useful framework for exploring these issues.

Initial Clinical Trial of Robot of Endovascular Treatment with Force Feedback and Cooperating of Catheter and Guidewire.

PubMed

Jiang, Yuhua; Liu, Keyun; Li, Youxiang

2018-01-01

To evaluate the feasibility and safety of the robot of endovascular treatment (RobEnt) in clinical practice, we carried out a cerebral angiography using this robot system. We evaluated the performance of application of the robot system to clinical practice through using this robotic system to perform the digital subtraction angiography for a patient who was suspected of suffering intracranial aneurysm. At the same time, through comparing the postoperative head nuclear magnetic and blood routine with the preoperative examination, we evaluated the safety of application of the robot system to clinical practice. We performed the robot system to complete the bilateral carotid artery and bilateral vertebral arteriography. The results indicate that there was no obvious abnormality in the patient's cerebral artery. No obvious abnormality was observed in the examination of patients' check-up, head nuclear magnetism, and blood routine after the digital subtraction angiography. From this clinical trial, it can be observed that the robot system can perform the operation of cerebral angiography. The robot system can basically complete the related observation indexes, and its accuracy, effectiveness, stability, and safety basically meet the requirements of clinical application in neurointerventional surgery.

Use of and satisfaction of pet owners with a clinical behavior service in a companion animal specialty referral practice.

PubMed

Herron, Meghan E; Lord, Linda K

2012-12-01

To determine whether availability of a veterinary behavior service aids in the recruitment of clients to a referral practice who may not have chosen to visit a referral practice otherwise and to assess the priorities and satisfaction of first-time clients. Prospective survey study. 87 questionnaires completed by pet owners. Owners of dogs and cats visiting the Behavior Medicine Clinic, a veterinary behavior service, at The Ohio State University Veterinary Medical Center for the first time were asked to participate in a 10-question survey at the end of their initial appointment. 59 of 87 (68%) new clients had never visited the Veterinary Medical Center for any other specialty service; in addition, 56 of 87 (64%) had never taken a pet to any specialty practice prior to their appointment with the Behavior Medicine Clinic. Seventy-four of 85 (87%) clients reported that they were likely to bring their pet to another specialty service on the basis of their experience with the Behavior Medicine Clinic. On the basis of the survey findings, availability of veterinary behavior services may result in recruitment of first-time clients to a referral center. Clients' experience with a veterinary behavior service may increase their likelihood of visiting other specialty practices within the same hospital, potentially increasing revenue for the entire practice.

Adolescent testicular microlithiasis: A case-based, multinational survey of clinical management practices.

PubMed

Brodie, Katie E; Saltzman, Amanda F; Cost, Nicholas G

2018-04-01

Testicular microlithiasis (TM) is a condition characterized by calcium deposits within the testis, usually detected incidentally during ultrasonography of the scrotum. TM has been associated with the presence of, and possibly the development of, testicular malignancy. Our aim was to document international clinical management practices for TM and to analyze what factors and perception of risk influence conservative versus active management and follow-up. European Society for Paediatric Urology (ESPU) and Society for Pediatric Urology (SPU) members were invited to complete an online case-based survey of clinical management practices of TM. Eight cases had a single variable changed each time (classic versus limited TM, unilateral versus bilateral, prior cryptorchidism versus no cryptorchidism) to ascertain the provider's perception of risk. The respondents completed multiple choice questions on initial management, follow-up plan, length and interval of follow-up. Multivariate logistic regression was performed to determine factors associated with decisions on management and follow-up. There were 265 respondents to the survey from 35 countries (Table). Median time in practice was 13 years. Factors that were significantly associated with more aggressive initial management (more than counseling on self-examination) included: not yet in independent practice, low volume TM cases per year, those practicing pediatric and adult urology, classic appearance of TM and cryptorchidism. Factors that were significantly associated with urologist follow-up and active investigation included: European practitioners, low TM case volume per year, those practicing both pediatric urology and pediatric surgery, classic TM appearance and a case history of cryptorchidism. Interval and length of follow-up was wide-ranging, with most respondents favoring annual follow-up. Management of TM varies and a mix of surgeon and case factors significantly influences management strategies. This baseline understanding of the lack of systematic management suggests the need for the development of consensus guidelines and prospective study. Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Evidence-based emergency medicine. Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.

PubMed

Wright, Stewart W; Trott, Alexander; Lindsell, Christopher J; Smith, Carol; Gibler, W Brian

2008-01-01

The Institute of Medicine, through its landmark report concerning errors in medicine, suggests that standardization of practice through systematic development and implementation of evidence-based clinical pathways is an effective way of reducing errors in emergency systems. The specialty of emergency medicine is well positioned to develop a complete system of innovative quality improvement, incorporating best practice guidelines with performance measures and practitioner feedback mechanisms to reduce errors and therefore improve quality of care. This article reviews the construction, ongoing development, and initial impact of such a system at a large, urban, university teaching hospital and at 2 affiliated community hospitals. The Committee for Procedural Quality and Evidence-Based Practice was formed within the Department of Emergency Medicine to establish evidence-based guidelines for nursing and provider care. The committee measures the effect of such guidelines, along with other quality measures, through pre- and postguideline patient care medical record audits. These measures are fed back to the providers in a provider-specific, peer-matched "scorecard." The Committee for Procedural Quality and Evidence-Based Practice affects practice and performance within our department. Multiple physician and nursing guidelines have been developed and put into use. Using asthma as an example, time to first nebulizer treatment and time to disposition from the emergency department decreased. Initial therapeutic agent changed and documentation improved. A comprehensive, guideline-driven, evidence-based approach to clinical practice is feasible within the structure of a department of emergency medicine. High-level departmental support with dedicated personnel is necessary for the success of such a system. Internet site development (available at http://www.CPQE.com) for product storage has proven valuable. Patient care has been improved in several ways; however, consistent and complete change in provider behavior remains elusive. Physician scorecards may play a role in altering these phenomena. Emergency medicine can play a leadership role in the development of quality improvement, error reduction, and pay-for-performance systems.

Hospital protocols for targeted glycemic control: Development, implementation, and models for cost justification.

PubMed

Magee, Michelle F

2007-05-15

Evolving elements of best practices for providing targeted glycemic control in the hospital setting, clinical performance measurement, basal-bolus plus correction-dose insulin regimens, components of standardized subcutaneous (s.c.) insulin order sets, and strategies for implementation and cost justification of glycemic control initiatives are discussed. Best practices for targeted glycemic control should address accurate documentation of hyperglycemia, initial patient assessment, management plan, target blood glucose range, blood glucose monitoring frequency, maintenance of glycemic control, criteria for glucose management consultations, and standardized insulin order sets and protocols. Establishing clinical performance measures, including desirable processes and outcomes, can help ensure the success of targeted hospital glycemic control initiatives. The basal-bolus plus correction-dose regimen for insulin administration will be used to mimic the normal physiologic pattern of endogenous insulin secretion. Standardized insulin order sets and protocols are being used to minimize the risk of error in insulin therapy. Components of standardized s.c. insulin order sets include specification of the hyperglycemia diagnosis, finger stick blood glucose monitoring frequency and timing, target blood glucose concentration range, cutoff values for excessively high or low blood glucose concentrations that warrant alerting the physician, basal and prandial or nutritional (i.e., bolus) insulin, correction doses, hypoglycemia treatment, and perioperative or procedural dosage adjustments. The endorsement of hospital administrators and key physician and nursing leaders is needed for glycemic control initiatives. Initiatives may be cost justified on the basis of the billings for clinical diabetes management services and/or the return- on-investment accrued to reductions in hospital length of stay, readmissions, and accurate documentation and coding of unrecognized or uncontrolled diabetes, and diabetes complications. Standardized insulin order sets and protocols may minimize risk of insulin errors. The endorsement of these protocols by administrators, physicians, nurses, and pharmacists is also needed for success.

Diagnosis of airway obstruction in primary care in the UK: the CADRE (COPD and Asthma Diagnostic/management REassessment) programme 1997-2001.

PubMed

Pearson, Mike; Ayres, Jon G; Sarno, Maria; Massey, Dan; Price, David

2006-01-01

Asthma and COPD require different management strategies, but differentiation in primary care is difficult. This primary care support initiative observed the impact of spirometry and clinical assessment on the diagnosis of airway disease. Of 61,191 patients aged > or =40 years being treated for respiratory conditions within 1003 UK primary care practices, 43,203 underwent a diagnostic review including standardized spirometric assessment. The proportion of patients in whom the diagnosis was changed by the additional information was determined. The relationship of various patient characteristics was compared with the baseline and review diagnoses and with any change in diagnosis. Asthma was initially diagnosed in 43% of patients, COPD in 35%, mixed disease in 9%, and other respiratory condition in 13%. Patients initially diagnosed with asthma, mixed disease, or another condition were more likely to have their diagnosis changed at review (54%, 46%, and 63%, respectively) than those initially diagnosed with COPD (14%). A change from asthma to COPD was associated with male gender, smoking, older age, and reduced lung function, the opposite being associated with a change from COPD to asthma. In this study, a clinical review supplemented by additional information including spirometry highlights apparent mislabeling of significant numbers of patients with chronic obstructive disease in general practice with significant implications for individual treatment and healthcare provision. This study shows that the addition of more clinical information can have a major effect on diagnostic tendency in patients with airway disease. An initial diagnosis of COPD seems less likely to change following review than an asthma diagnosis. While it is likely that greater information leads to a more accurate diagnosis, the differential effect of new information on diagnostic labeling highlights the insecurity of the diagnostic process in primary care in the UK.

Physicians' opinions and clinical practice patterns for actinic keratosis management in Italy.

PubMed

Peris, K; Neri, L; Calzavara Pinton, P; Catricalà, C; Pellacani, G; Pimpinelli, N; Peserico, A

2014-04-01

We report dermatologists' opinions and clinical practice patterns about clinical factors driving decision making in the management of actinic keratosis (AK) in Italy. We carried out a cross-sectional survey among 33 Italian dermatologists. Physicians were asked to report their management choices in consecutive patients with AK seen at their practice within 2 weeks since study initiation. We collected patients' clinical and socio-demographic characteristics with a standardized data collection form and assessed physicians' opinions on AK management with a self-reported questionnaire. Six hundred fifty-seven patients with new, single AK lesions without evidence of photo-damaged skin in the surrounding areas, were predominantly treated with lesion-directed therapies (primarily cryotherapy). In contrast, physicians preferentially prescribed field-directed therapies to patients with multiple lesions and evidence of photo-damaged skin in AK surrounding areas. However we observed a wide variation in treatment choices and physicians' opinions on AK management. Dermatologists underlined the importance of fostering patients' adherence and minimize therapy side effects. Overall, our results show that current guidelines regarding management of AK are only partially integrated in dermatology practice. The active dissemination of up-to-date national guidelines might help harmonize clinical decision making in this complex and fast growing therapeutic area.

Advantages of the Dental Practice-Based Research Network Initiative and Its Role in Dental Education

PubMed Central

Curro, Frederick A.; Grill, Ashley C.; Thompson, Van P.; Craig, Ronald G.; Vena, Don; Keenan, Analia V.; Naftolin, Frederick

2012-01-01

Practice-based research networks (PBRNs) provide a novel venue in which providers can increase their knowledge base and improve delivery of care through participation in clinical studies. This article describes some aspects of our experience with a National Institute of Dental and Craniofacial Research-supported PBRN and discusses the role it can play in dental education. PBRNs create a structured pathway for providers to advance their professional development by participating in the process of collecting data through clinical research. This process allows practitioners to contribute to the goals of evidence-based dentistry by helping to provide a foundation of evidence on which to base clinical decisions as opposed to relying on anecdotal evidence. PBRNs strengthen the professional knowledge base by applying the principles of good clinical practice, creating a resource for future dental faculty, training practitioners on best practices, and increasing the responsibility, accountability, and scope of care. PBRNs can be the future pivotal instruments of change in dental education, the use of electronic health record systems, diagnostic codes, and the role of comparative effectiveness research, which can create an unprecedented opportunity for the dental profession to advance and be integrated into the health care system. PMID:21828299

Advantages of the dental practice-based research network initiative and its role in dental education.

PubMed

Curro, Frederick A; Grill, Ashley C; Thompson, Van P; Craig, Ronald G; Vena, Don; Keenan, Analia V; Naftolin, Frederick

2011-08-01

Practice-based research networks (PBRNs) provide a novel venue in which providers can increase their knowledge base and improve delivery of care through participation in clinical studies. This article describes some aspects of our experience with a National Institute of Dental and Craniofacial Research-supported PBRN and discusses the role it can play in dental education. PBRNs create a structured pathway for providers to advance their professional development by participating in the process of collecting data through clinical research. This process allows practitioners to contribute to the goals of evidence-based dentistry by helping to provide a foundation of evidence on which to base clinical decisions as opposed to relying on anecdotal evidence. PBRNs strengthen the professional knowledge base by applying the principles of good clinical practice, creating a resource for future dental faculty, training practitioners on best practices, and increasing the responsibility, accountability, and scope of care. PBRNs can be the future pivotal instruments of change in dental education, the use of electronic health record systems, diagnostic codes, and the role of comparative effectiveness research, which can create an unprecedented opportunity for the dental profession to advance and be integrated into the health care system.

Clinical prediction of Gardnerella vaginalis in general practice

PubMed Central

O'Dowd, T.C.; West, R.R.

1987-01-01

In a study of 162 women with vaginal symptoms the clinical features of increased discharge, yellow discharge, 'high cheese' odour and pH greater than 5 were statistically strongly associated with the presence of Gardnerella vaginalis, confirmed by microbiological culture. The sensitivities and specificities of these clinical tests, although not as high as those of previously described sideroom tests using the amine test and microscopy for 'clue cells' nevertheless allow the clinician to predict G. vaginalis reliably and initiate treatment at first consultation. PMID:3499508

Translating research into practice: the role of provider-based research networks in the diffusion of an evidence-based colon cancer treatment innovation.

PubMed

Carpenter, William R; Meyer, Anne-Marie; Wu, Yang; Qaqish, Bahjat; Sanoff, Hanna K; Goldberg, Richard M; Weiner, Bryan J

2012-08-01

Provider-based research networks (PBRNs)--collaborative research partnerships between academic centers and community-based practitioners--are a promising model for accelerating the translation of research into practice; however, empirical evidence of accelerated translation is limited. Oxaliplatin in adjuvant combination chemotherapy is an innovation with clinical trial-proven survival benefit compared with prior therapies. The goal of this study is to examine the diffusion of oxaliplatin into community practice, and whether affiliation with the National Cancer Institute's (NCI's) Community Clinical Oncology Program (CCOP)--a nationwide cancer-focused PBRN--is associated with accelerated innovation adoption. This retrospective observational study used linked Surveillance, Epidemiology, and End Results-Medicare and NCI CCOP data to examine Medicare participants with stage III colon cancer initiating treatment in 2003 through 2006, the years surrounding oxaliplatin's Food and Drug Administration approval. A fixed-effects analysis examined chemotherapy use among patients treated outside academic centers at CCOP-affiliated practices compared with non-CCOP practices. Two-group modeling controlled for multiple levels of clustering, year of chemotherapy initiation, tumor characteristics, patient age, race, comorbidity, Medicaid dual-eligibility status, and education. Of 4055 community patients, 35% received 5-fluoruracil, 20% received oxaliplatin, 7% received another chemotherapy, and 38% received no chemotherapy. Twenty-five percent of CCOP patients received oxaliplatin, compared with 19% of non-CCOP patients. In multivariable analysis, CCOP exposure was associated with higher odds of receiving guideline-concordant treatment in general, and oxaliplatin specifically. These findings contribute to a growing set of evidence linking PBRNs with a greater probability of receiving treatment innovations and high-quality cancer care, with implications for clinical and research policy.

Exploring the Transition to Practice for the Newly Credentialed Athletic Trainer: A Programmatic View.

PubMed

Mazerolle, Stephanie M; Walker, Stacy E; Thrasher, Ashley Brooke

2015-10-01

Some newly credentialed athletic trainers (ATs) pursue a postprofessional degree with a curriculum that specifically advances their athletic training practice. It is unknown how those postprofessional programs assist in their transition to practice. To gain an understanding of initiatives used by postprofessional athletic training programs to facilitate role transition from student to professional during their graduate degree programs. Qualitative study. Semistructured telephone interviews. A total of 19 program directors (10 men, 9 women) from 13 Commission on Accreditation of Athletic Training Education-accredited and 6 unaccredited postprofessional athletic training programs. Telephone interviews were recorded digitally and transcribed verbatim. For data analysis, we used the principles of general inductive approach. Credibility was maintained using peer review, member checks, and researcher triangulation. Three facilitators of transition to practice emerged: orientation sessions, mentoring, and assistantship. Participants used orientation sessions ranging from a few hours to more than 1 week to provide and discuss program polices and expectations and to outline roles and responsibilities. Faculty, preceptors, and mentors were integrated into the orientation for the academic and clinical portions of the program. All participants described a mentoring process in which students were assigned by the program or informally developed. Mentors included the assigned preceptor, a staff AT, or peer students in the program. The clinical assistantship provided exposure to the daily aspects of being an AT. Barriers to transition to practice included previous educational experiences and time management. Participants reported that students with more diverse didactic and clinical education experiences had easier transitions. The ability to manage time also emerged as a challenge. Postprofessional athletic training programs used a formal orientation session as an initial means to help the newly credentialed AT transition into the role. Mentoring provided both more informal and ongoing support during the transition.

Creating structure for continuation of initiatives.

PubMed

McClave, Stephen A; Mechanick, Jeffrey I; Kushner, Robert F; DeLegge, Mark H

2010-01-01

The Summit for Increasing Physician Nutrition Experts brought nutrition leaders from North America together to forge new strategies for promoting greater physician involvement in clinical nutrition. The initiatives derived from the Summit address issues related to education, board certification, research, and clinical practice. To seek consensus from participating societies and to establish a format for the implementation of these initiatives, a council of representatives needs to be formed. The council must be noncompetitive, promote collaboration and facilitation of nutrition activities for participating societies, and ultimately provide service to the healthcare system and individual practitioners. The structure of this council may evolve from a temporary task force to an enduring committee. Participating societies will be asked to fund expenses for their representative and host council meetings on a rotating basis. The council will assume responsibility for pursuing Summit initiatives and providing ongoing communication and collaboration between participant groups.

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model

PubMed Central

Basu, Sanjay; Phillips, Russell S.; Song, Zirui; Landon, Bruce E.; Bitton, Asaf

2016-01-01

PURPOSE We assess the financial implications for primary care practices of participating in patient-centered medical home (PCMH) funding initiatives. METHODS We estimated practices’ changes in net revenue under 3 PCMH funding initiatives: increased fee-for-service (FFS) payments, traditional FFS with additional per-member-per-month (PMPM) payments, or traditional FFS with PMPM and pay-for-performance (P4P) payments. Net revenue estimates were based on a validated microsimulation model utilizing national practice surveys. Simulated practices reflecting the national range of practice size, location, and patient population were examined under several potential changes in clinical services: investments in patient tracking, communications, and quality improvement; increased support staff; altered visit templates to accommodate longer visits, telephone visits or electronic visits; and extended service delivery hours. RESULTS Under the status quo of traditional FFS payments, clinics operate near their maximum estimated possible net revenue levels, suggesting they respond strongly to existing financial incentives. Practices gained substantial additional net annual revenue per full-time physician under PMPM or PMPM plus P4P payments ($113,300 per year, 95% CI, $28,500 to $198,200) but not under increased FFS payments (−$53,500, 95% CI, −$69,700 to −$37,200), after accounting for costs of meeting PCMH funding requirements. Expanding services beyond minimum required levels decreased net revenue, because traditional FFS revenues decreased. CONCLUSIONS PCMH funding through PMPM payments could substantially improve practice finances but will not offer sufficient financial incentives to expand services beyond minimum requirements for PCMH funding. PMID:27621156

Integrating primary and secondary care for children and young people: sharing practice.

PubMed

Woodman, Jenny; Lewis, Hannah; Cheung, Ronny; Gilbert, Ruth; Wijlaars, Linda Pmm

2016-09-01

To share innovative practice with enough detail to be useful for paediatricians involved in planning services. A review of practice, adopting a realist approach. We collected detailed information about five initiatives which were presented at two meetings in July and October 2014 and telephone interviews between July and November 2014 with key informants, updating information again in February 2015. The five case studies involved three clinical commissioning groups (CCGs): Islington CCG and Southwark and Lambeth CCG in London and Taunton CCG in the Southwest. All five initiatives involved acute paediatric units. We heard about four distinct types of services designed to bring paediatric expertise into primary care and/or improve joint working between paediatricians and primary care professionals: telephone multidisciplinary team, hospital at home, general practitioner (GP) outreach clinics, and advice and guidance. We defined four common ways that initiatives might work: promoting shared responsibility; upskilling GPs; establishing relationships between paediatricians and primary healthcare professionals; and by taking specialist care to the patient. We derived common aims and mechanisms and generated programme (mid-level) theory for each integrated care initiative about how they might work. These descriptions of what is being done can inform debate about which interventions should be prioritised for wider implementation. There is an urgent need for evaluation of these interventions and more indepth research into how mechanisms and their effectiveness could be assessed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Translation of ERC resuscitation guidelines into clinical practice by emergency physicians

PubMed Central

2014-01-01

Purpose Austrian out-of-hospital emergency physicians (OOHEP) undergo mandatory biannual emergency physician refresher courses to maintain their licence. The purpose of this study was to compare different reported emergency skills and knowledge, recommended by the European Resuscitation Council (ERC) guidelines, between OOHEP who work regularly at an out-of-hospital emergency service and those who do not currently work as OOHEP but are licenced. Methods We obtained data from 854 participants from 19 refresher courses. Demographics, questions about their practice and multiple-choice questions about ALS-knowledge were answered and analysed. We particularly explored the application of therapeutic hypothermia, intraosseous access, pocket guide use and knowledge about the participants’ defibrillator in use. A multivariate logistic regression analysed differences between both groups of OOHEP. Age, gender, years of clinical experience, ERC-ALS provider course attendance and the self-reported number of resuscitations were control variables. Results Licenced OOHEP who are currently employed in emergency service are significantly more likely to initiate intraosseous access (OR = 4.013, p < 0.01), they initiate mild-therapeutic hypothermia after successful resuscitation (OR = 2.550, p < 0.01) more often, and knowledge about the used defibrillator was higher (OR = 2.292, p < 0.01). No difference was found for the use of pocket guides. OOHEP who have attended an ERC-ALS provider course since 2005 have initiated more mild therapeutic hypothermia after successful resuscitation (OR = 1.670, p <0.05) as well as participants who resuscitated within the last year (OR = 2.324, p < 0.01), while older OOHEP initiated mild therapeutic hypothermia less often, measured per year of age (OR = 0.913, p <0.01). Conclusion Licenced and employed OOHEP implement ERC guidelines better into clinical practice, but more training on life-saving rescue techniques needs to be done to improve knowledge and to raise these rates of application. PMID:24476488

Using risk assessment in periodontics.

PubMed

Woodman, Alan J

2014-08-01

Risk assessment has become a regular feature in both dental practice and society as a whole, and principles used to assess risk in society are similar to those used in a clinical setting. Although the concept of risk assessment as a prognostic indicator for periodontal disease incidence and activity is well established in the management of periodontitis, the use of risk assessment to manage the practical treatment of periodontitis and its sequelae appears to have less foundation. A simple system of initial risk assessment - building on the use of the Basic Periodontal Examination (BPE), clinical, medical and social factors - is described, linked to protocols for delivering care suited to general dental practice and stressing the role of long-term supportive care. The risks of not treating the patient are considered, together with the possible causes of failure, and the problems of successful treatment are illustrated by the practical management of post-treatment recession.

Quality measures for the management of hydrocephalus: concepts, simulations, and preliminary field-testing.

PubMed

Barton, Spencer E; Campbell, Jeffrey W; Piatt, Joseph H

2013-04-01

The authors define and examine the properties of 2 new, practice-based quality measures for the management of hydrocephalus. The Surgical Activity Rate (SAR) is defined as the number of definitive operations for the treatment of hydrocephalus performed in a neurosurgical practice over the course of a year, divided by the number of patients with hydrocephalus seen in follow-up during that year. The Revision Quotient (RQ) is defined as the number of definitive revision operations performed in a neurosurgical practice in the course of a year, divided by the number of definitive initial operations during that year for patients with newly diagnosed hydrocephalus. Using published actuarial shunt survival data, the authors conducted Monte Carlo simulations of a pediatric neurosurgical practice to illustrate the properties and interpretations of the SAR and RQ. They used data from the Kids' Inpatient Database (KID) for 2009 to calculate RQs for hospitals accounting for more than 10 admissions coded for initial CSF shunt insertions. During the initial growth phase of a simulated neurosurgical practice, the SAR approached its steady-state value much earlier than the RQ. Both measures were sensitive to doubling or halving of monthly failure rates. In the 2009 KID, 117 hospitals reported more than 10 initial shunt insertions. The weighted mean (± standard deviation) RQ for these hospitals was 1.79 ± 0.69. Among hospitals performing 50 or more initial shunt insertions, the RQ ranged between 0.71 and 3.65. The SAR and RQ have attractive qualitative features as practice-based quality measures. The RQ, at least, exhibits clinically meaningful interhospital variation as applied to CSF shunt surgery. The SAR and RQ merit prospective field-testing as measures of quality in the management of childhood hydrocephalus.

A national evaluation of a dissemination and implementation initiative to enhance primary care practice capacity and improve cardiovascular disease care: the ESCALATES study protocol.

PubMed

Cohen, Deborah J; Balasubramanian, Bijal A; Gordon, Leah; Marino, Miguel; Ono, Sarah; Solberg, Leif I; Crabtree, Benjamin F; Stange, Kurt C; Davis, Melinda; Miller, William L; Damschroder, Laura J; McConnell, K John; Creswell, John

2016-06-29

The Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW Initiative to rapidly disseminate and implement evidence-based cardiovascular disease (CVD) preventive care in smaller primary care practices. AHRQ funded eight grantees (seven regional Cooperatives and one independent national evaluation) to participate in EvidenceNOW. The national evaluation examines quality improvement efforts and outcomes for more than 1500 small primary care practices (restricted to those with fewer than ten physicians per clinic). Examples of external support include practice facilitation, expert consultation, performance feedback, and educational materials and activities. This paper describes the study protocol for the EvidenceNOW national evaluation, which is called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES). This prospective observational study will examine the portfolio of EvidenceNOW Cooperatives using both qualitative and quantitative data. Qualitative data include: online implementation diaries, observation and interviews at Cooperatives and practices, and systematic assessment of context from the perspective of Cooperative team members. Quantitative data include: practice-level performance on clinical quality measures (aspirin prescribing, blood pressure and cholesterol control, and smoking cessation; ABCS) collected by Cooperatives from electronic health records (EHRs); practice and practice member surveys to assess practice capacity and other organizational and structural characteristics; and systematic tracking of intervention delivery. Quantitative, qualitative, and mixed methods analyses will be conducted to examine how Cooperatives organize to provide external support to practices, to compare effectiveness of the dissemination and implementation approaches they implement, and to examine how regional variations and other organization and contextual factors influence implementation and effectiveness. ESCALATES is a national evaluation of an ambitious large-scale dissemination and implementation effort focused on transforming smaller primary care practices. Insights will help to inform the design of national health care practice extension systems aimed at supporting practice transformation efforts in the USA. NCT02560428 (09/21/15).

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents

DOE Office of Scientific and Technical Information (OSTI.GOV)

Burmeister, Jay, E-mail: burmeist@karmanos.org; Chen, Zhe; Chetty, Indrin J.

Purpose: The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. Methods and Materials: The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. Results: The newmore » curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. Conclusions: The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint.« less

Undergraduate cancer education in Spain: The debate, the opportunities and the initiatives of the University Forum of the Spanish Society of Radiation Oncology (SEOR).

PubMed

Lara, Pedro; Calvo, Felipe A; Guedea, Ferran; Bilbao, Pedro; Biete, Alberto

2013-11-09

Most medical schools in Spain (80%) offer undergraduate training in oncology. This education is highly variable in terms of content (theory and practical training), number of credits, and the medical specialty and departmental affiliation of the professors. Much of this variability is due to university traditions in the configuration of credits and programmes, and also to the structure of the hospital-based practical training. Undergraduate medical students deserve a more coherent and modern approach to education with a strong emphasis on clinical practice. Oncology is an interdisciplinary science that requires the input of professors from multiple specialties to provide the primary body of knowledge and skills needed to obtain both a theoretical and clinical understanding of cancer. Clinical skills should be a key focus due to their importance in the current model of integrated medical management and care. Clinical radiation oncology is a traditional and comprehensive hospital-based platform for undergraduate education in oncology. In Spain, a significant number (n = 80) of radiation oncology specialists have a contractual relationship to teach university courses. Most Spanish universities (80%) have a radiation oncologist on staff, some of whom are department chairs and many others are full professors who have been hired and promoted under competitive conditions of evaluation as established by the National Agency for Quality Evaluation. The Spanish Society of Radiation Oncology (SEOR) has identified new opportunities to improve undergraduate education in oncology. In this article, we discuss proposals related to theoretical (20 items) and practical clinical training (9 items). We also describe the SEOR University Forum, which is an initiative to develop a strategic plan to implement and organize cancer education at the undergraduate level in an interdisciplinary teaching spirit and with a strong contribution from radiation oncologists.

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents.

PubMed

Burmeister, Jay; Chen, Zhe; Chetty, Indrin J; Dieterich, Sonja; Doemer, Anthony; Dominello, Michael M; Howell, Rebecca M; McDermott, Patrick; Nalichowski, Adrian; Prisciandaro, Joann; Ritter, Tim; Smith, Chadd; Schreiber, Eric; Shafman, Timothy; Sutlief, Steven; Xiao, Ying

2016-07-15

The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. The new curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Issues Facing Pharmacy Leaders in 2015: Suggestions for Pharmacy Strategic Planning

PubMed Central

Weber, Robert J.

2015-01-01

Issues facing pharmacy leaders in 2015 include practice model growth and the role of pharmacy students, clinical privileging of health-system pharmacists and provider status, medication error prevention, and specialty pharmacy services. The goal of this article is to provide practical approaches to 4 issues facing pharmacy leaders in 2015 to help them focus their department’s goals. This article will address (1) advances in the pharmacy practice model initiative and the role of pharmacy students, (2) the current thinking of pharmacists being granted clinical privileges in health systems, (3) updates on preventing harmful medication errors, and (4) the growth of specialty pharmacy services. The sample template of a strategic plan may be used by a pharmacy department in 2015 in an effort to continue developing patient-centered pharmacy services. PMID:25717212

Utility of Liquid Biopsy by Improved PNA-LNA PCR Clamp Method for Detecting EGFR Mutation at Initial Diagnosis of Non-Small-Cell Lung Cancer: Observational Study of 190 Consecutive Cases in Clinical Practice.

PubMed

Ito, Kentaro; Suzuki, Yuta; Saiki, Haruko; Sakaguchi, Tadashi; Hayashi, Kosuke; Nishii, Yoichi; Watanabe, Fumiaki; Hataji, Osamu

2018-03-01

The clinical benefit of liquid biopsy for unselected patients at initial diagnosis has thus far been unclear. We aimed to evaluate the utility of liquid biopsy at initial diagnosis, as well as the efficacy of epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) based on liquid biopsy results in clinical practice, using the improved peptide nucleic acid-locked nucleic acid (PNA-LNA) PCR clamp method. We routinely performed liquid biopsy using the improved PNA-LNA PCR clamp method for all patients diagnosed with non-small-cell lung cancer (NSCLC) between June 2015 and October 2016. We retrospectively evaluated the reliability of liquid biopsy based either on clinical stage or between sensitizing EGFR mutation and T790M mutation, and the clinical benefit of EGFR-TKI based on the liquid biopsy results in practice. A total of 244 patients underwent liquid biopsies, with 168 patients tested at diagnosis and 22 tested for T790M after pretreatment of EGFR-TKI. For detecting a sensitizing EGFR mutation, the sensitivity, specificity, positive predictive value, and negative predictive value were 72.7%, 100%, 100%, and 93.7% in the group with advanced-stage NSCLC and 0, 100%, not evaluable, and 70.5% in the group with early-stage NSCLC. The positive predictive value and negative predictive value for T790M were 33.3% and 55.6%, respectively. Fourteen patients in the liquid-positive group and 16 patients in the tissue-positive group received EGFR-TKI. The objective response rates of first- and second-generation EGFR-TKI for the liquid-positive and tissue-positive groups were 90.0% and 90.9%, respectively. There was no significant difference in median progression-free survival between the liquid-positive and tissue-positive groups (P = .839). Patients with early-stage NSCLC should not be candidates for this liquid biopsy method. We recommend tissue biopsy as the preferred initial method of molecular analysis, with the exception of patients who are T790M positive or patients who are unable to tolerate invasive biopsy. Copyright © 2017 Elsevier Inc. All rights reserved.

Predictors of Treatment with Duloxetine or Venlafaxine XR among Adult Patients Treated for Depression in Primary Care Practices in the United Kingdom

PubMed Central

Shi, Nianwen; Durden, Emily; Torres, Amelito; Cao, Zhun; Happich, Michael

2012-01-01

Background. Knowledge about real-world use of duloxetine and venlafaxine XR to treat depression in the UK is limited. Aims. To identify predictors of duloxetine or venlafaxine XR initiation. Method. Adult depressed patients who initiated duloxetine or venlafaxine XR between January 1, 2006 and September 30, 2007 were identified in the UK's General Practice Research Database. Demographic and clinical predictors of treatment initiation with duloxetine and venlafaxine XR were identified using logistic regression. Results. Patients initiating duloxetine (n = 909) were 4 years older than venlafaxine XR recipients (n = 1286). Older age, preexisting unexplained pain, respiratory disease, and pre-period use of anticonvulsants, opioids, and antihyperlipidemics were associated with increased odds of initiating duloxetine compared to venlafaxine XR. Pre-period anxiety disorder was associated with decreased odds of receiving duloxetine. Conclusion. Initial treatment choice with duloxetine versus venlafaxine XR was primarily driven by patient-specific mental and medical health characteristics. General practitioners in the UK favor duloxetine over venlafaxine XR when pain conditions coexist with depression. PMID:22720149

An academic nursing clinic's financial survival.

PubMed

Holman, E J; Branstetter, E

1997-01-01

The authors suggest that academic institutions build business-oriented policies and practices into the development of any nurse-run clinic to set the stage for financial independence when special or development funding ends. One university-affiliated program that provides 4,000 to 5,000 annual visits drastically changed its strategies when threatened with closure after free rent and other subsidies were withdrawn. The growing emphasis on ambulatory care roles for nurses at all levels makes such clinics critical to the success of the broad-based curricula of nursing education programs, as well as the clinic's value to communities they serve. Funding difficulties frequently threaten the existence of such nurse-run clinics once the initial grant funding is no longer available. This has caused a new emphasis on running such clinics in a business-wise manner. Among the strategies initiated were: direct full-pay at the time of service; a realistic business management plan; aggressive planned marketing; contracts and agreements with other agencies; obtaining provider status with selected HMOs.

Patient engagement and attrition in pediatric obesity clinics and programs: results and recommendations.

PubMed

Hampl, Sarah; Paves, Heather; Laubscher, Katie; Eneli, Ihuoma

2011-09-01

Pediatric tertiary care institutions are well positioned to provide multidisciplinary, intensive interventions for pediatric obesity known as stage 3 treatment. One contributor to the difficulty in administering this treatment is the high rate of patient attrition. Little is known about the practices used by pediatric weight-management clinics and group-based programs to minimize attrition. Hospital members and nonmembers of FOCUS on a Fitter Future were surveyed on the methods used to engage and retain obese children in their clinics and programs. Shortly thereafter, a benchmarking activity that centered on rates of patient nonattendance at initial and follow-up clinic visits was initiated among FOCUS-group-participating hospitals. Clinic- and group-based program results were contrasted. Staff from group-based programs reported that the majority of patients did not complete even 50% of program follow-up visits. Multiple patient/family- and clinic/program-level barriers to retention were identified. Attention to successful techniques should be paid during planning for new programs and improvement of established ones.

Integrating on campus problem based learning and practice based learning: issues and challenges in using computer mediated communication.

PubMed

Conway, J; Sharkey, R

2002-10-01

The Faculty of Nursing, University of Newcastle, Australia, has been keen to initiate strategies that enhance student learning and nursing practice. Two strategies are problem based learning (PBL) and clinical practice. The Faculty has maintained a comparatively high proportion of the undergraduate hours in the clinical setting in times when financial constraints suggest that simulations and on campus laboratory experiences may be less expensive.Increasingly, computer based technologies are becoming sufficiently refined to support the exploration of nursing practice in a non-traditional lecture/tutorial environment. In 1998, a group of faculty members proposed that computer mediated instruction would provide an opportunity for partnership between students, academics and clinicians that would promote more positive outcomes for all and maintain the integrity of the PBL approach. This paper discusses the similarities between problem based and practice based learning and presents the findings of an evaluative study of the implementation of a practice based learning model that uses computer mediated communication to promote integration of practice experiences with the broader goals of the undergraduate curriculum.

Clinical solid waste management practices and its impact on human health and environment - A review

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hossain, Md. Sohrab; Santhanam, Amutha; Nik Norulaini, N.A.

2011-04-15

Research highlights: > Appropriate waste management technology for safe handling and disposal of clinical solid waste. > Infectious risk assessment on unsafe handling of clinical solid waste. > Recycling-reuse program of clinical solid waste materials. > Effective sterilization technology to reduce exposure of infectious risk. - Abstract: The management of clinical solid waste (CSW) continues to be a major challenge, particularly, in most healthcare facilities of the developing world. Poor conduct and inappropriate disposal methods exercised during handling and disposal of CSW is increasing significant health hazards and environmental pollution due to the infectious nature of the waste. This articlemore » summarises a literature review into existing CSW management practices in the healthcare centers. The information gathered in this paper has been derived from the desk study of open literature survey. Numerous researches have been conducted on the management of CSW. Although, significant steps have been taken on matters related to safe handling and disposal of the clinical waste, but improper management practice is evident from the point of initial collection to the final disposal. In most cases, the main reasons of the mismanagement of CSW are the lack of appropriate legislation, lack of specialized clinical staffs, lack of awareness and effective control. Furthermore, most of the healthcare centers of the developing world have faced financial difficulties and therefore looking for cost effective disposal methods of clinical waste. This paper emphasizes to continue the recycle-reuse program of CSW materials after sterilization by using supercritical fluid carbon dioxide (SF-CO2) sterilization technology at the point of initial collection. Emphasis is on the priority to inactivate the infectious micro-organisms in CSW. In that case, waste would not pose any threat to healthcare workers. The recycling-reuse program would be carried out successfully with the non-specialized clinical staffs. Therefore, the adoption of SF-CO2 sterilization technology in management of clinical solid waste can reduce exposure to infectious waste, decrease labor, lower costs, and yield better compliance with regulatory. Thus healthcare facilities can both save money and provide a safe environment for patients, healthcare staffs and clinical staffs.« less

[Budget impact analysis of antiretroviral therapy. A reflection based on the GESIDA guidelines].

PubMed

2012-01-01

The latest version of the Spanish clinical practice guidelines on antiretroviral therapy (ART) in HIV-infected adults, developed by the Spanish AIDS Study Group (GESIDA) and the National AIDS Plan, recommends initiating ART early in certain circumstances. The aim of this study was to estimate the budget impact of this recommendation by using the data from the VACH cohort. We considered a scenario in which all naïve asymptomatic patients would initiate ART if they had <500 lymphocytes, or a CD4/μL count >500/μL if they were older than 55 years, or had high viral load, liver disease, chronic kidney disease or high cardiovascular risk. The study was designed as a cost analysis in terms of annual pharmaceutical expenditure. The only costs included were those relating to the ART combinations analyzed. To estimate these costs, we assumed that this guideline had a penetration of 80%, an adherence of 95% and 12% dropouts. A total of 12,500 patients were reviewed. Of these, 1,127 (10%) had not initiated ART; CD4 lymphocyte count was 350-500 in 294 (26.1%) and > 500 in 685 (60.8%). If the new clinical practice guideline were applied, 45.2% of naïve patients (95% CI: 42.4%-48.2%) would be advised to start ART. Carrying out this recommendation in hospitals of the VACH cohort would require an additional annual investment of € 3,270,975 and would increase the overall cost of antiretroviral drugs by 3%. In the framework of health economics, incorporating economic impact estimates - such as those performed in this study - into clinical practice guidelines would be advisable to increase their feasibility. Copyright © 2011 SESPAS. Published by Elsevier Espana. All rights reserved.

Treatment of transfusional iron overload in patients with myelodysplastic syndrome or severe anemia: data from multicenter clinical practices.

PubMed

Raptis, Anastasios; Duh, Mei Sheng; Wang, Si-Tien; Dial, Ellison; Fanourgiakis, Ilias; Fortner, Barry; Paley, Carole; Mody-Patel, Nikita; Corral, Mitra; Scott, Jeffrey

2010-01-01

Patients with myelodysplastic syndrome (MDS) or severe anemia requiring repeated red blood cell (RBC) transfusions risk developing transfusional iron overload, which can reduce survival. Iron chelation therapy (ICT) has been shown to improve survival and quality of life in patients; however, ICT utilization in clinical practices is not well understood. Medical records of patients diagnosed with MDS or severe anemia at least 6 months before data extraction, aged at least 21 years at diagnosis, and who received at least one RBC transfusion were reviewed. ICT eligibility was defined as at least 20 units of RBCs transfused or at least two serum ferritin levels exceeding 1000 microg/L. Study endpoint was ICT treatment rate among ICT-eligible patients with lower-risk MDS (International Prognostic Scoring System [low or intermediate-1]; World Health Organization [refractory anemia {RA}, refractory anemia with ringed sideroblasts {RARS}, refractory cytopenia with multilineage dysplasia {RCMD}, refractory cytopenia with multilineage dysplasia and ringed sideroblasts, or 5q]; French-American-British [RA/RARS]). Among 78 ICT-eligible patients with lower-risk MDS, 32 (41%) received ICT. At ICT initiation, treated patients received on average 13.3 transfusions (27.6 units) and mean first post-ICT initiation serum ferritin was twice the MDS Foundation recommendation at 1949 microg/L. Median overall survival for all ICT-eligible patients was significantly longer for those ICT-treated patients than untreated patients (8.7 years vs. 4.7 years, log-rank p = 0.02; multivariate hazard ratio 0.372, p = 0.03). This study finds only 41% of ICT-eligible patients with lower-risk MDS received ICT in clinical practice, and treatment was initiated later than recommended. Receipt of ICT was associated with significantly longer survival.

Nursing praxis, compassionate caring and interpersonal relations: an observational study.

PubMed

Fry, Margaret; MacGregor, Casimir; Ruperto, Kate; Jarrett, Kate; Wheeler, Janet; Fong, Jacqueline; Fetchet, Wendy

2013-05-01

The Clinical Initiative Nurse (CIN) is a role that requires experienced emergency nurses to assess, initiate diagnostic tests, treat and manage a range of patient conditions. The CIN role is focused on the waiting room and to 'communicate the wait', initiate diagnostics or treatment and follow-up for waiting room patients. We aim to explore what emergency nurses' do in their extended practice role in observable everyday life in the emergency department (ED). The paper argues that compassionate caring is a core nursing skill that supports CIN interpersonal relations, despite the role's highly clinical nature. Sixteen non-participant observations were undertaken in three EDs in New South Wales, Australia. Nurses were eligible for inclusion if they had two years of emergency experience and had worked in the CIN role for more than one year. All CIN's that were observed were highly experienced with a minimum three year ED experience. The CIN observations revealed how compassionate caring was utilised by CIN's to quickly build a therapeutic relationship with patients and colleagues, and helped to facilitate core communication and interpersonal skills. While the CIN role was viewed as extended practice, the role relied heavily on compassionate care to support interpersonal relationships and to actualise extended practice care. The study supports the contribution made by emergency nurses and demonstrates how compassionate caring is central to nursing praxis. This paper also demonstrates that the CIN role utilises a complex mix between advanced clinical skills and compassion that supports interpersonal and therapeutic relationships. Further research is needed to understand how compassionate care can be optimised within nursing praxis and the duty of care between nurses and patients, nurses and other health care professionals so that future healthcare goals can be realised. Copyright © 2013 College of Emergency Nursing Australasia Ltd. All rights reserved.

International models of investigator-initiated trials: implications for Japan

PubMed Central

Trimble, E. L.; Ledermann, J.; Law, K.; Miyata, T.; Imamura, C. K.; Nam, B.-H.; Kim, Y.H.; Bang, Y.-J.; Michaels, M.; Ardron, D.; Amano, S.; Ando, Y.; Tominaga, T.; Kurokawa, K.; Takebe, N.

2012-01-01

Background Academic/institutional investigator-initiated clinical trials benefit individuals and society by supplementing gaps in industry-sponsored clinical trials. Materials In May 2010, experts from Japan, the Republic of Korea, the UK, and the United States, met at a symposium in Tokyo, Japan, to discuss how policies related to the conduct of clinical trials, which have been shown to be effective, may be applied to other regions of the world. Results In order to increase the availability of anticancer drugs world-wide, nations including Japan should examine the benefits of increasing the number of investigator-initiated clinical trials. These trials represent one of the most effective ways to translate basic scientific knowledge into clinical practice. These trials should be conducted under GCP guidelines and include Investigational New Drug application submissions with the ultimate goal of future drug approval. Conclusions To maximize the effectiveness of these trials, a policy to educate health care professionals, cancer patients and their families, and the public in general on the benefits of clinical trials should be strengthened. Finally, policies that expedite the clinical development of novel cancer drugs which have already been shown to be effective in other countries are needed in many nations including Japan to accelerate drug approval. PMID:22843420

Talking with patients about spirituality and worldview: practical interviewing techniques and strategies.

PubMed

Josephson, Allan M; Peteet, John R

2007-06-01

Psychiatrists now recognize that religion and spirituality are important to much of the populace and that attending to them probably will improve clinical psychiatric practice. This article presents a practical guide for addressing some of the key interviewing skills needed to explore a patient's framework for meaning-the patient's religion, spirituality, and worldview. It offers guidelines on the process of the interview, including ways to initiate conversation in this area, with suggestions and specific questions for a more thorough exploration of the patient's religious and spiritual life.

State laws related to billing third parties for healthcare services at public STD clinics in the United States.

PubMed

Cramer, Ryan; Loosier, Penny S; Krasner, Andee; Kawatu, Jennifer

2018-02-07

Health departments (HDs) cite state laws as barriers to billing third parties for sexually transmitted disease (STD) services, but the association between legal/policy barriers and third party HD billing has not been examined. This study investigates the relationship between laws that may limit HDs' ability to bill, clinic perceptions of billing barriers, and billing practices. Two surveys (1) clinic managers [N=246], 2) STD program managers [N=63]) conducted via a multi-regional needs assessment of federally funded HD clinics' capacity to bill for STD services, billing/reimbursement practices, and perceived barriers were combined with an analysis of state laws regarding third party billing for STD services. Statistical analyses examined relationships between laws that may limit HDs' ability to bill, clinic perceptions, and billing practices. Clinic managers reported clinics were less likely to bill Medicaid and other third parties in jurisdictions with a state law limiting their ability to bill compared to respondents who billed neither or one payer (OR=0.31, CI=0.10,0.97) and cited practical concerns as a primary barrier to billing (OR=2.83 CI=1.50,5.37). STD program managers' reports that staff believed STD services should be free (OR=0.34, CI=0.13, 0.90) was associated with not billing (not sure versus no resistance to billing); confidentiality concerns was not a reported barrier to billing among either sample. Practical concerns and clinic staff beliefs that STD services should be free emerged as possible barriers to billing, and laws less so. Attempts to initiate HD billing for STD services may benefit from staff education as well as addressing perceived legal barriers and staff concerns.

Toxicologists in public health--Following the path of Louis Roche (based on the Louis Roche lecture "An accidental toxicologist in public health", Bordeaux, 2010).

PubMed

Dawson, Andrew H; Buckley, Nicholas A

2011-02-01

The global burden of clinical toxicology suggests a natural partnership with public health. This article reflects the content of a Louis Roche lecture given in 2010. HISTORICAL CONTEXT: Our practice and research in clinical toxicology has evolved from clinical cases to toxico-epidemiology to public health. This evolution in practice was initially unplanned but gained momentum and impact as we placed it more formally in a public health framework. This perspective is implicit in Louis Roche's call to "examine all aspects of the poisoning problem" and still provides a valuable starting point for any clinical toxicologist. Clinical toxicology has always had a patient centered focus but its greatest successes have been related to public health interventions. Our early failures and later success in pubic health toxicology correlated with our understanding of the importance of partnerships outside our field. The most rapid dissemination and implementation of information derived from research occur through apriori partnerships with other agencies and international partners. Addressing both local and global need has a number of bilateral synergies. Repositioning clinical toxicology into a public health framework increases access to strategic partnerships, research funds, and policy implementation while still addressing questions that are important to clinical practice.

Induced pluripotent stem cells--alchemist's tale or clinical reality?

PubMed

Rashid, S Tamir; Vallier, Ludovic

2010-08-13

Following Shinya Yamanaka's first report describing the reprogramming of fibroblasts into stem cells over three years ago, some sceptics initially drew analogies between this new field of research and the quasi-mystical practice of 'alchemy'. Unlike the alchemist, however, stem cell researchers have rigorously tested and repeated experiments, proving their very own brand of cellular 'alchemy' to be a reality, with potentially massive implications for the study of human biology and clinical medicine. These investigations have resulted in an explosion of related publications and initiated the field of stem cell research known as 'induced pluripotency'. In this review, we give an account of the historical development, current technologies and potential clinical applications of induced pluripotency and conclude with a perspective on the possible future directions for this dynamic field.

Improving maternal care with a continuous quality improvement strategy: a report from the Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network.

PubMed

Bennett, Ian M; Coco, Andrew; Anderson, Janice; Horst, Michael; Gambler, Angela S; Barr, Wendy Brooks; Ratcliffe, Stephen

2009-01-01

Maternal medical care (prenatal and postpartum) involves a set of clinical interventions addressing risk factors associated with important maternal and infant outcomes. Programs to increase the rate of delivery of these interventions in clinical practice have not been widely implemented. A practice-based research network focused on developing continuous quality improvement (CQI) processes for maternal care among 10 family medicine residency training sites in the northeastern United States (the IMPLICIT Network) from January 2003 through September 2007. Documented delivery of 5 standard maternal care interventions was assessed before and after initiating a program to increase their frequency. Proportion chart analyses were conducted comparing the period before and after implementation of the CQI interventions. Data were available for 3936 pregnancies during the course of the study period. Results varied across the clinical interventions. Significant improvement in care processes was seen for 3 screening activities: (1) prenatal depression symptomatology (by 15 weeks' gestation); (2) screening for smoking at 30 weeks' gestation; (3) and postpartum contraception planning. Screening for smoking by 15 weeks' gestation and testing for asymptomatic bacteriuria were already conducted >90% of the time during the baseline period and did not increase significantly after initiating the CQI program. Screening for postpartum depression symptomatology was recorded in 50% to 60% of women before the CQI program and did not increase significantly. A practice-based research network of family medicine residency practices focused on CQI outcomes was successful in increasing the delivery of some maternal care interventions.

European influence on Russian neurology in the eighteenth and nineteenth centuries.

PubMed

Shterenshis, Michael; Vaiman, Michael

2007-01-01

In this study we consider the development of clinical neurology in the eighteenth and the nineteenth centuries focusing on European influence on Russian medicine. Russian physicians readily accepted newly described clinical signs, theories, and classification of nervous diseases designed in Europe. This influence initiated neurology's separation from general medicine and its transformation into a new clinical discipline. In Russia this happened already in the 1860s, decades before the similar trend in Europe. The Russian example is nearly unknown in the general history of neurology. It illustrates the relationships between physiology and practical neurology at the moment of establishment of the new discipline. It also shows that the Russian physicians of the time readily accepted European medical knowledge putting it immediately into medical practice and education.

Education, employment and practice: Midwifery graduates in Papua New Guinea.

PubMed

Moores, Alison; Puawe, Paula; Buasi, Nancy; West, Florence; Samor, Mary K; Joseph, Nina; Rumsey, Michele; Dawson, Angela; Homer, Caroline S E

2016-10-01

Papua New Guinea has a very high maternal mortality rate (773/100,000), low rates of supervised births and a critical shortage of skilled midwives. A midwifery education initiative commenced in 2012, funded by the Australian Government and led by the National Department of Health. One specific objective of the initiative was to improve the standard of clinical teaching and practice in four schools of midwifery. There were 394 midwives educated over the 4 year period (2012-2015) representing half of all midwives in Papua New Guinea. A study was undertaken to describe the educational programme, employment, practices and experiences of graduates who studied midwifery in 2012 and 2013 as part of the initiative. the aim of this paper is to explore the education, employment and practice of newly graduated midwives in Papua New Guinea. a mixed methods descriptive study design was used. Surveys and focus groups were used to gather data. Ethical approval was granted by the relevant Human Research Ethics Committees. all midwifery graduates in 2012 and 2013 from the four midwifery schools in Papua New Guinea were included in the study and almost 80% were contacted. nearly 90% of graduates were working as midwives, with an additional 3% working as midwifery or nursing educators. This study discovered that graduates exhibited increased skills acquisition and confidence, leadership in maternal and newborn care services and a marked improvement in the provision of respectful care to women. The graduates faced challenges to implement evidence based care with barriers including the lack of appropriate resources and differences of opinion with senior staff. factors affecting the quality of midwifery education will need to be addressed if Papua New Guinea is to continue to improve the status of maternal and newborn health. Specifically, the length of the midwifery education, the quality of clinical practice and the exposure to rural and remote area practice need addressing in many contexts like Papua New Guinea. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Ranibizumab (Lucentis) in neovascular age-related macular degeneration: evidence from clinical trials.

PubMed

Mitchell, P; Korobelnik, J-F; Lanzetta, P; Holz, F G; Prünte, C; Schmidt-Erfurth, U; Tano, Y; Wolf, S

2010-01-01

Neovascular age-related macular degeneration (AMD) has a poor prognosis if left untreated, frequently resulting in legal blindness. Ranibizumab is approved for treating neovascular AMD. However, further guidance is needed to assist ophthalmologists in clinical practice to optimise treatment outcomes. An international retina expert panel assessed evidence available from prospective, multicentre studies evaluating different ranibizumab treatment schedules (ANCHOR, MARINA, PIER, SAILOR, SUSTAIN and EXCITE) and a literature search to generate evidence-based and consensus recommendations for treatment indication and assessment, retreatment and monitoring. Ranibizumab is indicated for choroidal neovascular lesions with active disease, the clinical parameters of which are outlined. Treatment initiation with three consecutive monthly injections, followed by continued monthly injections, has provided the best visual-acuity outcomes in pivotal clinical trials. If continued monthly injections are not feasible after initiation, a flexible strategy appears viable, with monthly monitoring of lesion activity recommended. Initiation regimens of fewer than three injections have not been assessed. Continuous careful monitoring with flexible retreatment may help avoid vision loss recurring. Standardised biomarkers need to be determined. Evidence-based guidelines will help to optimise treatment outcomes with ranibizumab in neovascular AMD.

DianaHealth.com, an On-Line Database Containing Appraisals of the Clinical Value and Appropriateness of Healthcare Interventions: Database Development and Retrospective Analysis.

PubMed

Bonfill, Xavier; Osorio, Dimelza; Solà, Ivan; Pijoan, Jose Ignacio; Balasso, Valentina; Quintana, Maria Jesús; Puig, Teresa; Bolibar, Ignasi; Urrútia, Gerard; Zamora, Javier; Emparanza, José Ignacio; Gómez de la Cámara, Agustín; Ferreira-González, Ignacio

2016-01-01

To describe the development of a novel on-line database aimed to serve as a source of information concerning healthcare interventions appraised for their clinical value and appropriateness by several initiatives worldwide, and to present a retrospective analysis of the appraisals already included in the database. Database development and a retrospective analysis. The database DianaHealth.com is already on-line and it is regularly updated, independent, open access and available in English and Spanish. Initiatives are identified in medical news, in article references, and by contacting experts in the field. We include appraisals in the form of clinical recommendations, expert analyses, conclusions from systematic reviews, and original research that label any health care intervention as low-value or inappropriate. We obtain the information necessary to classify the appraisals according to type of intervention, specialties involved, publication year, authoring initiative, and key words. The database is accessible through a search engine which retrieves a list of appraisals and a link to the website where they were published. DianaHealth.com also provides a brief description of the initiatives and a section where users can report new appraisals or suggest new initiatives. From January 2014 to July 2015, the on-line database included 2940 appraisals from 22 initiatives: eleven campaigns gathering clinical recommendations from scientific societies, five sets of conclusions from literature review, three sets of recommendations from guidelines, two collections of articles on low clinical value in medical journals, and an initiative of our own. We have developed an open access on-line database of appraisals about healthcare interventions considered of low clinical value or inappropriate. DianaHealth.com could help physicians and other stakeholders make better decisions concerning patient care and healthcare systems sustainability. Future efforts should be focused on assessing the impact of these appraisals in the clinical practice.

DianaHealth.com, an On-Line Database Containing Appraisals of the Clinical Value and Appropriateness of Healthcare Interventions: Database Development and Retrospective Analysis

PubMed Central

Bonfill, Xavier; Osorio, Dimelza; Solà, Ivan; Pijoan, Jose Ignacio; Balasso, Valentina; Quintana, Maria Jesús; Puig, Teresa; Bolibar, Ignasi; Urrútia, Gerard; Zamora, Javier; Emparanza, José Ignacio; Gómez de la Cámara, Agustín; Ferreira-González, Ignacio

2016-01-01

Objective To describe the development of a novel on-line database aimed to serve as a source of information concerning healthcare interventions appraised for their clinical value and appropriateness by several initiatives worldwide, and to present a retrospective analysis of the appraisals already included in the database. Methods and Findings Database development and a retrospective analysis. The database DianaHealth.com is already on-line and it is regularly updated, independent, open access and available in English and Spanish. Initiatives are identified in medical news, in article references, and by contacting experts in the field. We include appraisals in the form of clinical recommendations, expert analyses, conclusions from systematic reviews, and original research that label any health care intervention as low-value or inappropriate. We obtain the information necessary to classify the appraisals according to type of intervention, specialties involved, publication year, authoring initiative, and key words. The database is accessible through a search engine which retrieves a list of appraisals and a link to the website where they were published. DianaHealth.com also provides a brief description of the initiatives and a section where users can report new appraisals or suggest new initiatives. From January 2014 to July 2015, the on-line database included 2940 appraisals from 22 initiatives: eleven campaigns gathering clinical recommendations from scientific societies, five sets of conclusions from literature review, three sets of recommendations from guidelines, two collections of articles on low clinical value in medical journals, and an initiative of our own. Conclusions We have developed an open access on-line database of appraisals about healthcare interventions considered of low clinical value or inappropriate. DianaHealth.com could help physicians and other stakeholders make better decisions concerning patient care and healthcare systems sustainability. Future efforts should be focused on assessing the impact of these appraisals in the clinical practice. PMID:26840451

Different usage of the same oncology information system in two hospitals in Sydney--lessons go beyond the initial introduction.

PubMed

Yu, Ping; Gandhidasan, Senthilkumar; Miller, Alexis A

2010-06-01

The experience of clinicians at two public hospitals in Sydney, Australia, with the introduction and use of an oncology information system (OIS) was examined to extract lessons to guide the introduction of clinical information systems in public hospitals. Semi-structured interviews were conducted with 12 of 15 radiation oncologists employed at the two hospitals. The personnel involved in the decision making process for the introduction of the system were contacted and their decision making process revisited. The transcribed data were analyzed using NVIVO software. Themes emerged included implementation strategies and practices, the radiation oncologists' current use and satisfaction with the OIS, project management and the impact of the OIS on clinical practice. The hospitals had contrasting experiences in their introduction and use of the OIS. Hospital A used the OIS in all aspects of clinical documentation. Its implementation was associated with strong advocacy by the Head of Department, input by a designated project manager, and use and development of the system by all staff, with timely training and support. With no vision of developing a paperless information system, Hospital B used the OIS only for booking and patient tracking. A departmental policy that data entry for the OIS was centrally undertaken by administrative staff distanced clinicians from the system. All the clinicians considered that the OIS should continuously evolve to meet changing clinical needs and departmental quality improvement initiatives. This case study indicates that critical factors for the successful introduction of clinical information systems into hospital environment were an initial clear vision to be paperless, strong clinical leadership and management at the departmental level, committed project management, and involvement of all staff, with appropriate training. Clinician engagement is essential for post-adoption evolution of clinical information systems. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

Factors associated with the decision of the rheumatologist to order sacroiliac joints magnetic resonance imaging (SI-MRI) or HLA-B27 testing in the diagnostic work-up of patients with spondyloarthritis in clinical practice.

PubMed

Bautista-Molano, Wilson; Landewé, Robert B M; Serna, Cesar; Valle-Oñate, Rafael; van der Heijde, Désirée

2017-01-01

To evaluate the patients' characteristics associated with the clinical decision to request SI-MRI and/or HLA-B27 in patients with SpA in daily practice. Patients referred to a rheumatology outpatient-clinic in a national referral-centre were selected. Patients with a clinical diagnosis of SpA according to the rheumatologist were included. SI-MRI and HLA-B27 was available for patients in whom the rheumatologists had ordered these tests. Characteristics associated with ordering SI-MRI or HLA-B27 were identified with univariable analyses. Variables with p-value <0.05 and >80% completeness were selected for further analysis. A multivariable logistic regression analysis was used to evaluate the determinants related with the decision to perform SI-MRI and/or HLA-B27 and odds ratios with 95% confidence intervals were calculated. In total, 581 patients with SpA were included in the cohort, 72% were men, mean age 34.6±12.1 and disease duration 7.3±9.7 years. Of these patients, 24% (n=137) had SI-MRI and 77% (n=441) had HLA-B27 tests ordered. Independently predictive factors for ordering a SI-MRI were the presence of IBP (OR=1.81), enthesitis (OR=1.57) and the number of initial-symptoms at presentation (OR=1.27 per additional symptom present). Independently predictive factors of HLA-B27 testing were the number of initial-symptoms (OR=1.45 per symptom) and uveitis (OR=3.19). This study strongly suggests that rheumatologists use certain clinical clues to decide if they order expensive and scarce tests in the diagnostic work-up of SpA patients. These manifestations may increase the efficiency of these tests in clinical practice and suggest that clinical reasoning follows principles of Bayesian theory.

The IGNITE network: a model for genomic medicine implementation and research.

PubMed

Weitzel, Kristin Wiisanen; Alexander, Madeline; Bernhardt, Barbara A; Calman, Neil; Carey, David J; Cavallari, Larisa H; Field, Julie R; Hauser, Diane; Junkins, Heather A; Levin, Phillip A; Levy, Kenneth; Madden, Ebony B; Manolio, Teri A; Odgis, Jacqueline; Orlando, Lori A; Pyeritz, Reed; Wu, R Ryanne; Shuldiner, Alan R; Bottinger, Erwin P; Denny, Joshua C; Dexter, Paul R; Flockhart, David A; Horowitz, Carol R; Johnson, Julie A; Kimmel, Stephen E; Levy, Mia A; Pollin, Toni I; Ginsburg, Geoffrey S

2016-01-05

Patients, clinicians, researchers and payers are seeking to understand the value of using genomic information (as reflected by genotyping, sequencing, family history or other data) to inform clinical decision-making. However, challenges exist to widespread clinical implementation of genomic medicine, a prerequisite for developing evidence of its real-world utility. To address these challenges, the National Institutes of Health-funded IGNITE (Implementing GeNomics In pracTicE; www.ignite-genomics.org ) Network, comprised of six projects and a coordinating center, was established in 2013 to support the development, investigation and dissemination of genomic medicine practice models that seamlessly integrate genomic data into the electronic health record and that deploy tools for point of care decision making. IGNITE site projects are aligned in their purpose of testing these models, but individual projects vary in scope and design, including exploring genetic markers for disease risk prediction and prevention, developing tools for using family history data, incorporating pharmacogenomic data into clinical care, refining disease diagnosis using sequence-based mutation discovery, and creating novel educational approaches. This paper describes the IGNITE Network and member projects, including network structure, collaborative initiatives, clinical decision support strategies, methods for return of genomic test results, and educational initiatives for patients and providers. Clinical and outcomes data from individual sites and network-wide projects are anticipated to begin being published over the next few years. The IGNITE Network is an innovative series of projects and pilot demonstrations aiming to enhance translation of validated actionable genomic information into clinical settings and develop and use measures of outcome in response to genome-based clinical interventions using a pragmatic framework to provide early data and proofs of concept on the utility of these interventions. Through these efforts and collaboration with other stakeholders, IGNITE is poised to have a significant impact on the acceleration of genomic information into medical practice.

“Heidelberg standard examination” and “Heidelberg standard procedures” – Development of faculty-wide standards for physical examination techniques and clinical procedures in undergraduate medical education

PubMed Central

Nikendei, C.; Ganschow, P.; Groener, J. B.; Huwendiek, S.; Köchel, A.; Köhl-Hackert, N.; Pjontek, R.; Rodrian, J.; Scheibe, F.; Stadler, A.-K.; Steiner, T.; Stiepak, J.; Tabatabai, J.; Utz, A.; Kadmon, M.

2016-01-01

The competent physical examination of patients and the safe and professional implementation of clinical procedures constitute essential components of medical practice in nearly all areas of medicine. The central objective of the projects “Heidelberg standard examination” and “Heidelberg standard procedures”, which were initiated by students, was to establish uniform interdisciplinary standards for physical examination and clinical procedures, and to distribute them in coordination with all clinical disciplines at the Heidelberg University Hospital. The presented project report illuminates the background of the initiative and its methodological implementation. Moreover, it describes the multimedia documentation in the form of pocketbooks and a multimedia internet-based platform, as well as the integration into the curriculum. The project presentation aims to provide orientation and action guidelines to facilitate similar processes in other faculties. PMID:27579354

Thinking in clinical nursing practice: a study of critical care nurses' thinking applying the think-aloud, protocol analysis method.

PubMed

Han, Kyung-Ja; Kim, Hesook Suzie; Kim, Mae-Ja; Hong, Kyung-Ja; Park, Sungae; Yun, Soon-Nyoung; Song, Misoon; Jung, Yoenyi; Kim, Haewon; Kim, Dong-Oak Debbie; Choi, Heejung; Kim, Kyungae

2007-06-01

The purpose of the paper is to discover the patterns and processes of decision-making in clinical nursing practice. A set of think-aloud data from five critical care nurses during 40 to 50 minutes of caregiving in intensive care units were obtained and analyzed by applying the procedures recommended by Ericsson and Simon for protocol analysis. Four thinking processes before acting were identified to constitute various sorts of thoughts in which the nurses were engaged during patient care: reviewing, validation, consideration, rationalization, and action. In addition, three patterns of sequential streaming of thinking (short, intermediate, long) were identified to reveal various ways the nurses dealt with clinical situations involving nursing tasks and responsibilities. This study specifies the initial categories of thoughts for each of the processes and various patterns with which these processes are sequentially combined, providing insights into the ways nurses think about problems and address their concerns. The findings suggest that the thinking in clinical practice involves more than focused decision-making and reasoning, and needs to be examined from a broader perspective.

Bridging the gap between the neurocognitive lab and the addiction clinic.

PubMed

Franken, Ingmar H A; van de Wetering, Ben J M

2015-05-01

In the past decennium there has been an enormous increase in new insights in cognitive mechanisms of addiction and their neural substrates. These candidate neurocognitive mechanisms, particularly those associated with "drive" and "control" aspects of addiction, are clearly involved in substance use problems but do not yet provide a full explanation. The neurocognitive mechanisms addressed in the present perspective are attentional bias, reward processing (both drive aspects) and error-processing and cognitive control (both control aspects). The time has come to transfer these recent insights more consistently to clinical practice by studying their relevance for diagnosis and treatment in patient samples. The present perspective echoes the development of recent initiatives such as the RDoC system to integrate developments in neuroscience into clinical practice. The aim of this article is to open new vistas for addiction diagnosis and treatment and to discuss why and how these neurocognitive aspects of addictive behavior can be used in clinical practice. In addition, present problematic issues and a future research agenda are provided. Copyright © 2014 Elsevier Ltd. All rights reserved.

The impact of nurse prescribing on the clinical setting.

PubMed

Creedon, Rena; Byrne, Stephen; Kennedy, Julia; McCarthy, Suzanne

To investigate the impact nurse prescribing has on the organisation, patient and health professional, and to identify factors associated with the growth of nurse prescribing. Systematic search and narrative review. Data obtained through CINAHL, PubMed, Science direct, Online Computer Library Centre (OCLC), databases/websites, and hand searching. English peer-reviewed quantitative, qualitative and mixed-method articles published from September 2009 through to August 2014 exploring nurse prescribing from the perspective of the organisation, health professional and patient were included. Following a systematic selection process, studies identified were also assessed for quality by applying Cardwell's framework. From the initial 443 citations 37 studies were included in the review. Most studies were descriptive in nature. Commonalities addressed were stakeholders' views, prescribing in practice, jurisdiction, education and benefits/barriers. Prescriptive authority for nurses continues to be a positive addition to clinical practice. However, concerns have emerged regarding appropriate support, relationships and jurisdictional issues. A more comprehensive understanding of nurse and midwife prescribing workloads is required to capture the true impact and cost-effectiveness of the initiative.

Ethics in clinical drug trial research in private practice.

PubMed

Beran, R G; Beran, M E

2006-09-01

Private clinics and clinicians have been involved in clinical drug trials for approximately two decades. This paper reviews the ethical consideration inherent in this process. Involvement of a single community based, private, Australian neurological clinic in the conduct of trials was audited. Changes in ethical considerations were analysed. The clinic previously audited its clinical trial involvement, starting with pharmaceutical company orchestrated trials. These were vetted by hospital based ethics committees (ECs) which then refused to review private research. A private EC accommodating NH & MRC standards was formed to assess private research. Indemnity concerns forced return to institutional ECs with government guaranteed indemnification. Trials evolved to investigator initiated, company sponsored studies thence a company asking the clinic to devise, sponsor and manage a trial. The latter relegated trial co-ordination to the clinic which would control publication thereby creating new ethical standards. Private practice trial involvement evolved from reluctant inclusion to a pivotal role in privately sponsored studies. Access to ECs is government endorsed and publication is independent for investigator-sponsored trials. There has been modification of standard operating procedures and enhanced ethical standards.

Quantitative structural MRI for early detection of Alzheimer’s disease

PubMed Central

McEvoy, Linda K; Brewer, James B

2011-01-01

Alzheimer’s disease (AD) is a common progressive neurodegenerative disorder that is not currently diagnosed until a patient reaches the stage of dementia. There is a pressing need to identify AD at an earlier stage, so that treatment, when available, can begin early. Quantitative structural MRI is sensitive to the neurodegeneration that occurs in mild and preclinical AD, and is predictive of decline to dementia in individuals with mild cognitive impairment. Objective evidence of ongoing brain atrophy will be critical for risk/benefit decisions once potentially aggressive, disease-modifying treatments become available. Recent advances have paved the way for the use of quantitative structural MRI in clinical practice, and initial clinical use has been promising. However, further experience with these measures in the relatively unselected patient populations seen in clinical practice is needed to complete translation of the recent enormous advances in scientific knowledge of AD into the clinical realm. PMID:20977326

[Generalization of the results of clinical studies through the analysis of subgroups].

PubMed

Costa, João; Fareleira, Filipa; Ascensão, Raquel; Vaz Carneiro, António

2012-01-01

Subgroup analysis in clinical trials are usually performed to define the potential heterogeneity of treatment effect in relation with the baseline risk, physiopathology, practical application of therapy or the under-utilization in clinical practice of effective interventions due to uncertainties of its benefit/risk ratio. When appropriately planned, subgroup analysis are a valid methodology the define benefits in subgroups of patients, thus providing good quality evidence to support clinical decision making. However, in order to be correct, subgroup analysis should be defined a priori, done in small numbers, should be fully reported and, most important, must endure statistical tests for interaction. In this paper we present an example of the treatment of post-menopausal osteoporosis, in which the benefits of an intervention (the higher the fracture risk is, the better the benefit is) with a specific agent (bazedoxifene) was only disclosed after a post-hoc analysis of the initial global trial sample.

Evolution of Functional Family Therapy as an Evidence-Based Practice for Adolescents with Disruptive Behavior Problems.

PubMed

Robbins, Michael S; Alexander, James F; Turner, Charles W; Hollimon, Amy

2016-09-01

This article summarizes the evolution of functional family therapy (FFT) based upon four decades of clinical practice and scientific scrutiny through research evidence. FFT research has evolved from an initial focus upon clinical process research, which examined sequential exchanges between therapists and family members. A key element of this research has been an examination of the way in which clinicians acquire, consolidate, and maintain the skills needed to implement FFT effectively with youth and families. Many randomized efficacy and effectiveness studies have evaluated the impact of FFT across diverse clinical populations. Subsequent research investigated factors that influence the effectiveness of implementation across more than 300 clinical settings in which more than 2,500 trained clinicians have provided service to nearly 400,000 families. Another important set of investigations concerned the cost-effectiveness of the interventions. © 2016 Family Process Institute.

The dissemination of clinical practice guidelines over an intranet: an evaluation.

PubMed Central

Stolte, J. J.; Ash, J.; Chin, H.

1999-01-01

This study compares two clinical practice guideline dissemination systems. It was hypothesized that placing guidelines on an intranet would make this information easier to retrieve. Retrieval time, retrieval accuracy, and ease of use were empirically evaluated. Sixteen clinicians from Kaiser Permanente volunteered to complete tasks that measured these variables. Time values were significantly longer for tasks completed with intranet guidelines (Intranet = 6.7 minutes, Paper = 5.7 minutes). Tasks completed with paper guidelines had a significantly higher percentage of perfect scores than those completed with the intranet (Paper = 85%, Intranet = 59%). There was no significant difference in reported ease of use. Simply placing clinical information on an electronic system does not guarantee that the information will be easier to retrieve. Such information needs to be fully integrated into the clinical decision making process. Computerizing guidelines may provide a necessary initial step toward this goal, but it does not represent the final solution. PMID:10566503

Development of questionnaires to measure patient preferences for intranasal corticosteroids in patients with allergic rhinitis.

PubMed

Meltzer, Eli O; Hadley, James; Blaiss, Michael; Benninger, Michael; Kimel, Miriam; Kleinman, Leah; Dupclay, Leon; Garcia, Jorge; Leahy, Michael; Georges, George

2005-02-01

To develop a questionnaire to evaluate preferences for attributes of intranasal corticosteroids (INSs) in clinical trials with allergic rhinitis (AR) patients. Established questionnaire development practices were used, including performance of a literature review and use of patient and physician focus groups, cognitive debriefing interviews, and pilot testing before validation. Findings from patient and physician focus groups suggest that sensory attributes are relevant to AR patients when choosing INSs. Physician focus groups identified the need for 2 distinct preference instruments, a clinical trial patient preference questionnaire (CTPPQ) and a clinical practice preference questionnaire (CPPPQ). A pilot study suggests that the CTPPQ is capable of discriminating between 2 INSs in the clinical trial setting. Initial findings suggest that items in the CTPPQ and CPPPQ are easy to understand and relevant to patients. Further validation studies with larger sample sizes are needed to assess the psychometric properties of both questionnaires. B-20.

Long-term prospective teaching effectivity of practical skills training and a first OSCE in cranio maxillofacial surgery for dental students.

PubMed

Landes, Constantin A; Hoefer, Sebastian; Schuebel, Florian; Ballon, Alexander; Teiler, Anna; Tran, Andreas; Weber, Roxane; Walcher, Felix; Sader, Robert

2014-07-01

Basic skills in oral/CMF surgery should be taught effectively to dental students as surgical skills training is traditionally under-represented in the dental curriculum compared to its later need in daily clinical practice. Rigid curricular time frames and prospectively condensed professional education foster new effective teaching and examination formats. Transmitting and assessing clinical competence objectively (independent of subjective bias), reliably (repeatable, inter-rater consistency) and valid (representative, structured task selection) was intended and evaluated in oral/CMF surgery skills acquisition starting in summer 2009. A small-group practical skills training (PST) day initiated a one-week practical training course, covering previously formulated learning objectives. An objective structured clinical evaluation (OSCE) was held at the end of each semester. Theoretical background knowledge and clinical skills should have to be memorized within a representative number of practical tasks (test stations). A first semester (26 students) used classical practical training alone as controls, the following semesters (171 students) had PST, considered as a study group. All 197 students were assessed with OSCE's over a 3-year period. An instructor held PST based on presentations, videos and practical training, including mannequins, with pairs of students. This included history taking, communication and interpretation of laboratory/image diagnostics, structured clinical facial examination, fracture diagnosis, venipuncture, suturing, biopsy and wire loops on pig jaws for manual and clinical skills, which were later incorporated in OSCE stations. OSCE average results increased from 63.3 ± 9.7% before and to 75.5 ± 10% after the inclusion of PST (p < 0.05). Knowledge diffusion between sittings on the same test date and between consecutive semesters was insignificant. Students and faculty rated their learning/teaching experience "very good" to "good". PST was effective in optimizing clinical skills as evaluated by OSCE. Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Scottish Asthma Management Initiative.

PubMed

Hoskins, G; Neville, R G; McCowan, C; Smith, B; Clark, R A; Ricketts, I W

2000-11-01

To describe the development process of a system that links audit, research and patient care and to detail the lessons learned from establishing a Scotland wide asthma management initiative. Health Boards and practices throughout Scotland were invited to participate in an initiative which links review of care, guideline implementation, chronic disease management (CDM) approval and post-graduate education for doctors (PGEA) and nurses (PREP). Participating practices were given the materials to review 30 patients randomly selected from their asthma register. Health service resource use and drugs prescribed over a retrospective 12 month period were recorded for each patient using paper or electronic materials. All patients were invited for clinical assessment. A two-tier management system proved effective. Twelve of the 15 Scottish health authorities agreed to recognise the audit for automatic CDM approval although the negotiation process was prolonged; 566 practices from all parts of Scotland have expressed an interest in the initiative. Provision of distance learning material linked to PGEA accreditation is free to general practitioners (GP's) and is a useful incentive for participation. To date 42 GPs have completed the distance learning element. The Scottish Asthma Management Initiative has provided the opportunity for all sectors of the health service in Scotland to work together to explore innovative ways to improve the management and care of chronic disease. Participation in an initiative linked to guidelines, education and CDM approval is an excellent way to facilitate health professionals to improve care.

Facilitators of transforming primary care: a look under the hood at practice leadership.

PubMed

Donahue, Katrina E; Halladay, Jacqueline R; Wise, Alison; Reiter, Kristin; Lee, Shoou-Yih Daniel; Ward, Kimberly; Mitchell, Madeline; Qaqish, Bahjat

2013-01-01

This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership

PubMed Central

Donahue, Katrina E.; Halladay, Jacqueline R.; Wise, Alison; Reiter, Kristin; Lee, Shoou-Yih Daniel; Ward, Kimberly; Mitchell, Madeline; Qaqish, Bahjat

2013-01-01

PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41–4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08–1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement. PMID:23690383

Clinical Management of ADHD in a Family Medicine Residency Program: Comparison with AAP Guidelines.

PubMed

Skelley, Jessica W; Carpenter, P Chase; Morehead, M Shawn; Murphy, Patrick L

2016-06-01

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder. Research has shown that even with the growing incidence of children diagnosed as having ADHD, physicians may find providing optimal care to these patients challenging. Our objective was to contrast existing clinical management of ADHD in a family medicine setting with published American Academy of Pediatrics guidelines and review the literature pertinent to differences. A report was generated for all visits with "ADHD" or "ADD" (attention-deficit disorder) as a current or past medical problem that had been addressed at the family medicine clinic from July 2012 to June 2014. A total of 60 pediatric patients were identified. A retrospective chart review of clinical practice and management patterns for these patients was completed using a standardized data collection form based on the 2011 ADHD treatment guidelines set by the American Academy of Pediatrics. Fifty-seven (95%) patients had documentation of at least one core symptom of ADHD, and 27 (45%) patients had documentation of these symptoms in more than one setting (clinic/school/home). Only 30 (50%) patients were assessed at the initial ADHD visit for coexisting conditions. Coexisting conditions were found to be present in 20 (33.3%) patients. Of these 20 patients, coexisting conditions were not addressed during the visit in 12 (60%) patients before drug therapy for ADHD was initially prescribed. Behavioral therapy was initiated as first-line monotherapy in one of the nine preschool-age patients (4-5 years old). Fifty-two (86.7%) patients received a preferred initial medication as identified by guidelines, and 41 (78.8%) of those patients received an appropriate initial dose. Fifty-one (85%) patients were assessed for improvement of symptoms, and 39 (65%) were assessed for adverse events. Of 62 documented medication adjustments, 54 (87.1%) adjustments coincided with current practice guidelines. Sixteen (26.7%) patients were referred to mental health specialists. This retrospective review identified areas of strength and weakness for attending physicians and medical residents in the diagnosis, evaluation, and treatment of children with ADHD. A significant need was identified for more physician-focused education on the evaluation of coexisting conditions and long-term management associated with ADHD therapy. Further training in the initiation of behavioral therapy as a first-line treatment above drug therapy and proper medication selection in children aged 4 to 5 years also are recommended.

Analysis of Existing Guidelines for the Systematic Planning Process of Clinical Registries.

PubMed

Löpprich, Martin; Knaup, Petra

2016-01-01

Clinical registries are a powerful method to observe the clinical practice and natural disease history. In contrast to clinical trials, where guidelines and standardized methods exist and are mandatory, only a few initiatives have published methodological guidelines for clinical registries. The objective of this paper was to review these guidelines and systematically assess their completeness, usability and feasibility according to a SWOT analysis. The results show that each guideline has its own strengths and weaknesses. While one supports the systematic planning process, the other discusses clinical registries in great detail. However, the feasibility was mostly limited and the special requirements of clinical registries, their flexible, expandable and adaptable technological structure was not addressed consistently.

Factors associated with clinical inertia: an integrative review

PubMed Central

Aujoulat, Isabelle; Jacquemin, Patricia; Rietzschel, Ernst; Scheen, André; Tréfois, Patrick; Wens, Johan; Darras, Elisabeth; Hermans, Michel P

2014-01-01

Failure to initiate or intensify therapy according to evidence-based guidelines is increasingly being acknowledged as a phenomenon that contributes to inadequate management of chronic conditions, and is referred to as clinical inertia. However, the number and complexity of factors associated with the clinical reasoning that underlies the decision-making processes in medicine calls for a critical examination of the consistency of the concept. Indeed, in the absence of information on and justification of treatment decisions that were made, clinical inertia may be only apparent, and actually reflect good clinical practice. This integrative review seeks to address the factors generally associated with clinical inaction, in order to better delineate the concept of true clinical inertia. PMID:24868181

The 5C Concept and 5S Principles in Inflammatory Bowel Disease Management.

PubMed

Hibi, Toshifumi; Panaccione, Remo; Katafuchi, Miiko; Yokoyama, Kaoru; Watanabe, Kenji; Matsui, Toshiyuki; Matsumoto, Takayuki; Travis, Simon; Suzuki, Yasuo

2017-10-27

The international Inflammatory Bowel Disease [IBD] Expert Alliance initiative [2012-2015] served as a platform to define and support areas of best practice in IBD management to help improve outcomes for all patients with IBD. During the programme, IBD specialists from around the world established by consensus two best practice charters: the 5S Principles and the 5C Concept. The 5S Principles were conceived to provide health care providers with key guidance for improving clinical practice based on best management approaches. They comprise the following categories: Stage the disease; Stratify patients; Set treatment goals; Select appropriate treatment; and Supervise therapy. Optimised management of patients with IBD based on the 5S Principles can be achieved most effectively within an optimised clinical care environment. Guidance on optimising the clinical care setting in IBD management is provided through the 5C Concept, which encompasses: Comprehensive IBD care; Collaboration; Communication; Clinical nurse specialists; and Care pathways. Together, the 5C Concept and 5S Principles provide structured recommendations on organising the clinical care setting and developing best-practice approaches in IBD management. Consideration and application of these two dimensions could help health care providers optimise their IBD centres and collaborate more effectively with their multidisciplinary team colleagues and patients, to provide improved IBD care in daily clinical practice. Ultimately, this could lead to improved outcomes for patients with IBD. Copyright © 2017 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com

A Review of 20 Years of Research on Overdiagnosis and Underdiagnosis in the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project

PubMed Central

2016-01-01

The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project represents an integration of research methodology into a community-based outpatient practice affiliated with an academic medical centre. The MIDAS project is the largest clinical epidemiological study using semi-structured interviews to assess a wide range of psychiatric disorders in a general clinical outpatient practice. In an early report from the MIDAS project, we found that across diagnostic categories clinicians using unstandardized, unstructured clinical interviews underrecognized diagnostic comorbidity, compared with the results of semi-structured interviews. Moreover, we found that the patients often wanted treatment for symptoms of disorders that were diagnosed as comorbid, rather than principal, conditions. This highlighted the importance, from the patient’s perspective, of conducting thorough diagnostic interviews to diagnose disorders that are not related to the patient’s chief complaint because patients often desire treatment for these additional diagnoses. While several of the initial papers from the MIDAS project identified problems with the detection of comorbid disorders in clinical practice, regarding the diagnosis of bipolar disorder we observed the emergence of an opposite phenomenon—clinician overdiagnosis. The results from the MIDAS project, along with other studies of diagnosis in routine clinical practice, have brought to the forefront the problem with diagnosis in routine clinical practice. An important question is what do these findings suggest about the community standard of care in making psychiatric diagnoses, and whether and how the standard of care should be changed? The implications are discussed. PMID:27253697

A Review of 20 Years of Research on Overdiagnosis and Underdiagnosis in the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project.

PubMed

Zimmerman, Mark

2016-02-01

The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project represents an integration of research methodology into a community-based outpatient practice affiliated with an academic medical centre. The MIDAS project is the largest clinical epidemiological study using semi-structured interviews to assess a wide range of psychiatric disorders in a general clinical outpatient practice. In an early report from the MIDAS project, we found that across diagnostic categories clinicians using unstandardized, unstructured clinical interviews underrecognized diagnostic comorbidity, compared with the results of semi-structured interviews. Moreover, we found that the patients often wanted treatment for symptoms of disorders that were diagnosed as comorbid, rather than principal, conditions. This highlighted the importance, from the patient's perspective, of conducting thorough diagnostic interviews to diagnose disorders that are not related to the patient's chief complaint because patients often desire treatment for these additional diagnoses. While several of the initial papers from the MIDAS project identified problems with the detection of comorbid disorders in clinical practice, regarding the diagnosis of bipolar disorder we observed the emergence of an opposite phenomenon-clinician overdiagnosis. The results from the MIDAS project, along with other studies of diagnosis in routine clinical practice, have brought to the forefront the problem with diagnosis in routine clinical practice. An important question is what do these findings suggest about the community standard of care in making psychiatric diagnoses, and whether and how the standard of care should be changed? The implications are discussed. © The Author(s) 2016.

A national survey on the initial management of upper gastrointestinal bleeding.

PubMed

Liang, Peter S; Saltzman, John R

2014-01-01

To evaluate the initial management of upper gastrointestinal (GI) bleeding in the United States. Various guidelines have addressed the initial management of upper GI bleeding, but the extent to which these guidelines are followed in clinical practice is unknown. We conducted a national survey of emergency physicians, internists, and gastroenterologists practicing in hospitals affiliated with an ACGME-accredited gastroenterology fellowship. Participants rated their agreement and adherence to 9 preendoscopic quality indicators for the initial management of upper GI bleeding. Awareness, use, and barriers to the use of early prognostic risk scores were also assessed. A total of 1402 surveys were completed, with an estimated response rate of 11.3%. Gastroenterologists and trainees agreed with the quality indicators more than nongastroenterologists and attending physicians, respectively. There was no difference in the application of the quality indicators by specialty or clinical position. Among all physicians, 53% had ever heard of and 30% had ever used an upper GI bleeding risk score. More gastroenterologists than nongastroenterologists had heard of (82% vs. 44%, P<0.001) and used (51% vs. 23%, P<0.001) a risk score. There was no difference between attending physicians and trainees. Gastroenterologists and attending physicians more often cited lack of utility as a reason to not use risk scores, whereas nongastroenterologists and trainees more often cited lack of knowledge. Among emergency physicians, internists, and gastroenterologists in the United States, agreement with upper GI bleeding initial management guidelines was high but adherence--especially pertaining to the use of risk scores--was low.

Students' learning of clinical sonography: use of computer-assisted instruction and practical class.

PubMed

Wood, A K; Dadd, M J; Lublin, J R

1996-08-01

The application of information technology to teaching radiology will profoundly change the way learning is mediated to students. In this project, the integration of veterinary medical students' knowledge of sonography was promoted by a computer-assisted instruction program and a subsequent practical class. The computer-assisted instruction program emphasized the physical principles of clinical sonography and contained simulations and user-active experiments. In the practical class, the students used an actual sonographic machine for the first time and made images of a tissue-equivalent phantom. Students' responses to questionnaires were analyzed. On completing the overall project, 96% of the students said that they now understood sonographic concepts very or reasonably well, and 98% had become very or moderately interested in clinical sonography. The teaching and learning initiatives enhanced an integrated approach to learning, stimulated student interest and curiosity, improved understanding of sonographic principles, and contributed to an increased confidence and skill in using sonographic equipment.

Practice-based research networks, part II: a descriptive analysis of the athletic training practice-based research network in the secondary school setting.

PubMed

Valovich McLeod, Tamara C; Lam, Kenneth C; Bay, R Curtis; Sauers, Eric L; Snyder Valier, Alison R

2012-01-01

Analysis of health care service models requires the collection and evaluation of basic practice characterization data. Practice-based research networks (PBRNs) provide a framework for gathering data useful in characterizing clinical practice. To describe preliminary secondary school setting practice data from the Athletic Training Practice-Based Research Network (AT-PBRN). Descriptive study. Secondary school athletic training facilities within the AT-PBRN. Clinicians (n = 22) and their patients (n = 2523) from the AT-PBRN. A Web-based survey was used to obtain data on clinical practice site and clinician characteristics. Patient and practice characteristics were obtained via deidentified electronic medical record data collected between September 1, 2009, and April 1, 2011. Descriptive data regarding the clinician and CPS practice characteristics are reported as percentages and frequencies. Descriptive analysis of patient encounters and practice characteristic data was performed, with the percentages and frequencies of the type of injuries recorded at initial evaluation, type of treatment received at initial evaluation, daily treatment, and daily sign-in procedures. The AT-PBRN had secondary school sites in 7 states, and most athletic trainers at those sites (78.2%) had less than 5 years of experience. The secondary school sites within the AT-PBRN documented 2523 patients treated across 3140 encounters. Patients most frequently sought care for a current injury (61.3%), followed by preventive services (24.0%), and new injuries (14.7%). The most common diagnoses were ankle sprain/strain (17.9%), hip sprain/strain (12.5%), concussion (12.0%), and knee pain (2.5%). The most frequent procedures were athletic trainer evaluation (53.9%), hot- or cold-pack application (26.0%), strapping (10.3%), and therapeutic exercise (5.7%). The median number of treatments per injury was 3 (interquartile range = 2, 4; range = 2-19). These preliminary data describe services provided by clinicians within the AT-PBRN and demonstrate the usefulness of the PBRN model for obtaining such data.

Hydroxyurea effectiveness in children and adolescents with sickle cell anemia: A large retrospective, population-based cohort.

PubMed

Quarmyne, Maa-Ohui; Dong, Wei; Theodore, Rodney; Anand, Sonia; Barry, Vaughn; Adisa, Olufolake; Buchanan, Iris D; Bost, James; Brown, Robert C; Joiner, Clinton H; Lane, Peter A

2017-01-01

The clinical efficacy of hydroxyurea in patients with sickle cell anemia (SCA) has been well established. However, data about its clinical effectiveness in practice is limited. We evaluated the clinical effectiveness of hydroxyurea in a large pediatric population using a retrospective cohort, pre-post treatment study design to control for disease severity selection bias. The cohort included children with SCA (SS, Sβ 0 thalassemia) who received care at Children's Healthcare of Atlanta (CHOA) and who initiated hydroxyurea in 2009-2011. Children on chronic transfusions, or children with inadequate follow up data and/or children who had taken hydroxyurea in the 3 years prior were excluded. For each patient healthcare utilization, laboratory values, and clinical outcomes for the 2-year period prior to hydroxyurea initiation were compared to those 2 years after initiation. Of 211 children with SCA who initiated hydroxyurea in 2009-2011, 134 met eligibility criteria. After initiation of hydroxyurea, rates of hospitalizations, pain encounters, and emergency department visits were reduced by 47% (<0.0001), 36% (P = 0.0001) and 43% (P < 0.0001), respectively. Average hemoglobin levels increased by 0.7 g/dl (P < 0.0001). Hydroxyurea effectiveness was similar across gender, insurance types and age, although there was a slightly greater reduction in hospitalizations in younger children. Am. J. Hematol. 92:77-81, 2017. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

An Interdisciplinary Education Initiative to Promote Blood Conservation in Cardiac Surgery.

PubMed

Goda, Tamara S; Sherrod, Brad; Kindell, Linda

Transfusion practices vary extensively for patients undergoing cardiac surgical procedures, leading to high utilization of blood products despite evidence that transfusions negatively impact outcomes. An important factor affecting transfusion practice is recognition of the importance of teams in cardiac surgery care delivery. This article reports an evidenced-based practice (EBP) initiative constructed using the Society of Thoracic Surgery (STS) 2011 Blood Conservation Clinical Practice Guidelines (CPGs) to standardize transfusion practice across the cardiac surgery team at a large academic medical center. Project outcomes included: a) Improvement in clinician knowledge related to the STS Blood Conservation CPGs; and b) Decreased blood product utilization for patients undergoing cardiac surgical procedures. Participants' scores reflected an improvement in the overall knowledge of the STS CPGs noting a 31.1% (p = 0.012) increase in the number of participants whose practice reflected the Blood Conservation CPGs post intervention. Additionally, there was a reduction in overall blood product utilization for all patients undergoing cardiac surgery procedures post intervention (p = 0.005). Interdisciplinary education based on the STS Blood Conservation CPGs is an effective way to reduce transfusion practice variability and decrease utilization of blood products during cardiac surgery.

Transformative learning and research utilization in nursing practice: a missing link?

PubMed

Matthew-Maich, Nancy; Ploeg, Jenny; Jack, Susan; Dobbins, Maureen

2010-03-01

Poor or inconsistent research utilization into clinical practice is a recurrent theme across study contexts, rendering leaders disillusioned with how best to foster the uptake of research into nursing practice. This makes it imperative to look to new approaches. Research utilization involves a learning process engaging attitudes, beliefs, and behaviors; yet, this is often overlooked in approaches and models used to facilitate research use. This oversight may offer some explanation to the limited progress in research utilization to date. Transformation Theory offers an explanatory theory and specific strategies (critical reflection and critical discourse) to explore attitudes, beliefs, and behaviors so that they are understood, validated, and can better guide actions. The purpose of this article was to explore what Transformation Theory can contribute to research utilization initiatives in nursing practice. Transformation Theory and transformative learning strategies are discussed and critically analyzed in consideration of their potential roles in fostering research utilization in clinical nursing practice. (1) Research utilization is a learning process that involves knowledge, skills, feelings, attitudes, and beliefs. (2) Transformative learning strategies of critical reflection and discourse can facilitate insight into experiences, finding shared meanings among groups of people, and understanding/validating beliefs, attitudes, and feelings so they can more consciously guide future actions. This dimension is frequently neglected in research utilization efforts. (3) In combination with research utilization theories, Transformation Theory may be a missing link to make research utilization initiatives more effective in rendering and sustaining nursing practice change, thus enhancing client care and well-being. (4) Research and further consideration are both warranted and needed.

Cancer Screening Practices Among Physicians in the National Breast and Cervical Cancer Early Detection Program

PubMed Central

Saraiya, Mona S.; Soman, Ashwini; Roland, Katherine B.; Yabroff, K. Robin; Miller, Jackie

2011-01-01

Abstract Background The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides low-income, uninsured women with screening and diagnostic services for breast and cervical cancer. Our study was conducted to describe the demographic and practice characteristics of participating and nonparticipating physicians, as well as their beliefs, adoption of new screening technologies, and recommendations for breast and cervical cancer screening. Methods From a 2006–2007 nationally representative survey, we identified 1,111 practicing primary care physicians who provide breast and cervical cancer screenings and assessed their recommendations using clinical vignettes related to screening initiation, frequency, and cessation. Responses of physicians participating in the NBCCEDP were compared with those from nonparticipating physicians. Results Of the physicians surveyed, 15% reported participation in the NBCCEDP, 65% were not participants, and 20% were not sure or did not respond to this question. Program physicians were significantly more likely to practice in multispecialty settings, in a rural location, and in a hospital or clinic setting and had more patients who were female and insured by Medicaid or uninsured compared with nonprogram physicians. Beliefs about the effectiveness of screening tools or procedures in reducing breast or cervical cancer mortality were similar by program participation. Adoption of new technologies, including digital mammography and human papillomavirus (HPV) testing, and making guideline-consistent recommendations for screening initiation, frequency, and cessation did not differ significantly by program participation. Conclusions Although there may be differences in physician characteristics and practice settings, the beliefs and screening practices for both breast and cervical cancer are similar between program and nonprogram providers. PMID:21774673

Successful implementation of clinical practice guidelines for pressure risk management in a home nursing setting.

PubMed

Kapp, Suzanne

2013-10-01

This paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group. © 2012 John Wiley & Sons Ltd.

Nursing and genetic biobanks.

PubMed

Sanner, Jennifer E; Yu, Erica; Udtha, Malini; Williams, Pamela Holtzclaw

2013-12-01

Biobanks function as vital components in genetic research, which often requires large disease-based or population-based biospecimens and clinical data to study complex or rare diseases. Genetic biobanks aim to provide resources for translational research focusing on rapidly moving scientific findings from the laboratory into health care practice. The nursing profession must evolve as genetic biobanking practices advance. Nursing involvement in genetic biobanking practices comes with a distinct set of educational, ethical, and practice competencies. In response to these growing competency standards, nursing science developed a conceptual framework and continues to study ethical considerations to guide genetic biobanking initiatives. Copyright © 2013 Elsevier Inc. All rights reserved.

Microanalytic Assessment of Self-Regulated Learning During Clinical Reasoning Tasks: Recent Developments and Next Steps.

PubMed

Cleary, Timothy J; Durning, Steven J; Artino, Anthony R

2016-11-01

Helping medical educators obtain and use assessment data to assist medical students, residents, and physicians in reducing diagnostic errors and other forms of ineffective clinical practice is of critical importance. Self-Regulated Learning-Microanalytic Assessment and Training is an assessment-to-intervention framework designed to address this need by generating data about trainees' strategic processes (e.g., focusing on clinical task procedures), regulatory processes (e.g., planning how to do a task), and motivational processes (e.g., increasing confidence for performing a task) as they perform clinical activities. In this article, the authors review several studies that have used an innovative assessment approach, called self-regulated learning (SRL) microanalysis, to generate data about how trainees regulate their thinking and actions during clinical reasoning tasks. Across the studies, initial findings revealed that medical students often do not exhibit strategic thinking and action during clinical reasoning practice tasks even though some regulatory processes (e.g., planning) are predictive of important medical education outcomes. Further, trainees' motivation beliefs, strategic thinking, and self-evaluative judgments tend to shift rapidly during clinical skills practice and may also vary across different parts of a patient encounter. Collectively, these findings underscore the value of dynamically assessing trainees' SRL as they complete clinical tasks. The findings also set the stage for exploring how medical educators can best use SRL microanalytic assessment data to guide remedial practices and the provision of feedback to trainees. Implications and future research directions for connecting assessments to intervention in medical education are discussed.

Partners in research: building academic-practice partnerships to educate and mentor advanced practice nurses.

PubMed

Harbman, Patricia; Bryant-Lukosius, Denise; Martin-Misener, Ruth; Carter, Nancy; Covell, Christine L; Donald, Faith; Gibbins, Sharyn; Kilpatrick, Kelley; McKinlay, James; Rawson, Krista; Sherifali, Diana; Tranmer, Joan; Valaitis, Ruta

2017-04-01

Clinical practice is the primary focus of advanced practice nursing (APN) roles. However, with unprecedented needs for health care reform and quality improvement (QI), health care administrators are seeking new ways to utilize all dimensions of APN expertise, especially related to research and evidence-based practice. International studies reveal research as the most underdeveloped and underutilized aspect of these roles. To improve patient care by strengthening the capacity of advanced practice nurses to integrate research and evidence-based practice activities into their day-to-day practice. An academic-practice partnership was created among hospital-based advanced practice nurses, nurse administrators, and APN researchers to create an innovative approach to educate and mentor advanced practice nurses in conducting point-of-care research, QI, or evidence-based practice projects to improve patient, provider, and/or system outcomes. A practice-based research course was delivered to 2 cohorts of advanced practice nurses using a range of teaching strategies including 1-to-1 academic mentorship. All participants completed self-report surveys before and after course delivery. Through participation in this initiative, advanced practice nurses enhanced their knowledge, skills, and confidence in the design, implementation, and/or evaluation of research, QI, and evidence-based practice activities. Evaluation of this initiative provides evidence of the acceptability and feasibility of academic-practice partnerships to educate and mentor point-of-care providers on how to lead, implement, and integrate research, QI and evidence-based activities into their practices. © 2016 John Wiley & Sons, Ltd.

Clinical impact of 8 prospective, randomized, multicenter glaucoma trials.

PubMed

Panarelli, Joseph F; Banitt, Michael R; Sidoti, Paul A; Budenz, Donald L; Singh, Kuldev

2015-01-01

To determine the impact of 8 multicenter randomized clinical trials (RCTs) on glaucoma practice. An electronic survey was distributed to the members of the American Glaucoma Society (AGS). Each participant was asked 2 study-specific questions and 1 standard question common to all 8 RCTs assessing the study's impact on clinical practice. RCTs included in the survey were the Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CIGTS), Collaborative Normal Tension Glaucoma (CNTG) Study, European Glaucoma Prevention Study (EGPS), Early Manifest Glaucoma Trial (EMGT), Glaucoma Laser Trial (GLT), Ocular Hypertension Treatment Study (OHTS), and Tube Versus Trabeculectomy (TVT) Study. A 5-point Likert scale was used for rating all responses. The practice setting and duration of glaucoma practice was determined for all AGS members who responded. A total of 206 (23.0%) of 894 AGS members participated in the survey. Among those who responded, 46.4% were self classified as academic practitioners and 53.6% worked in a private practice setting. Mean Likert scores for the standard question evaluating the overall impact of the RCT were OHTS 4.47, CNTG Study 4.13, AGIS 3.78, TVT Study 3.53, EMGT 3.48, CIGTS 3.44, GLT 3.39, and 2.69 EGPS. Substantial differences were observed in the clinical impact of several RCTs in glaucoma. The reported impact of each study likely reflects several factors including study timing, design, conduct, and interpretation of results.

Doctors' experience with handheld computers in clinical practice: qualitative study.

PubMed

McAlearney, Ann Scheck; Schweikhart, Sharon B; Medow, Mitchell A

2004-05-15

To examine doctors' perspectives about their experiences with handheld computers in clinical practice. Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns. Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists. 54 doctors who did or did not use handheld computers. Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking. Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care.

The Monmouth University Partnership: Redesigning Practice

ERIC Educational Resources Information Center

Henning, John E.; Bragen, Bernard F., Jr.; Mulvaney, Tracy; George, William O., III.; Duffy, Greg; Aldarelli, Edward; Grabowski, Christine; Harriott, Wendy; Riddle, Meredith; Falco, James; Heaney, Patricia; Earle, Corina; Foster, Linda; Borlan, Christine A.

2018-01-01

In this article, the Monmouth University partners describe our efforts to constantly explore new dimensions of learning, teaching, and teacher preparation. We begin by describing two recent initiatives developed by our partnership: the piloting and implementation of a yearlong clinical internship experience to replace traditional student teaching,…

Pharmacoepidemiology of Clinically Relevant Hypothyroidism and Hypertension from Sunitinib and Sorafenib

PubMed Central

Aubert, Ronald E.; La‐Beck, Ninh M.; Clore, Gosia; Herrera, Vivian; Kourlas, Helen; Epstein, Robert S.; McLeod, Howard L.

2017-01-01

Abstract Background. Thyroid dysfunction and hypertension (HTN) have been sporadically reported with sunitinib (SUN) and sorafenib (SOR). Determination of the side effect incidence will enhance monitoring and management recommendations. Methods. An observational cohort study was performed using deidentified pharmacy claims data from a 3‐year period to evaluate patients prescribed SUN, SOR, or capecitabine (CAP; comparison group). The primary outcome was time to first prescription for thyroid replacement or HTN treatment. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox proportional hazards models. Results. A total of 20,061 patients were eligible for evaluation of thyroid replacement therapy, which was initiated in 11.6% of those receiving SUN (HR, 16.77; 95% CI, 13.54–20.76), 2.6% of those receiving SOR (HR, 3.47; 95% CI, 2.46–4.98), and 1% of those receiving CAP, with median time to initiation of 4 months (range, 1–35 months). A total of 14,468 patients were eligible for evaluation of HTN therapy, which was initiated in 21% of SUN recipients (HR, 4.91; 95% CI, 4.19–5.74), 14% of SOR recipients (HR, 3.25; 95% CI, 2.69–3.91), and 5% of CAP recipients, with median time to initiation of 1 month (range, 1–18 months) for SOR and 2 months (range, 1–25 months) for SUN. Conclusion. SUN and SOR significantly increased the risk for clinically relevant hypothyroidism; the risk was at least 4 times greater with SUN than with SOR. Patients receiving SUN and SOR had a similar elevated risk for clinically relevant HTN. These data provide robust measures of the incidence and time to onset of these clinically actionable adverse events. Implications for Practice. The side effect profiles for novel therapies are typically used to create monitoring and management recommendations using clinical trial data from patient populations that may not represent those seen in standard clinical practice. This analysis using a large pharmacy claims database better reflects typical patients treated with sorafenib or sunitinib outside of a clinical trial. The findings of increased need for thyroid replacement in patients receiving sunitinib compared with sorafenib and a similar increase in need for hypertension therapy with both agents can be used to form clinically relevant monitoring recommendations for these agents. PMID:28167571

[Learning during the early clinical years takes more than good study habits: Perceptions of students and teachers].

PubMed

Zúñiga, Denisse; Leiva, Isabel; Calderón, Maribel; Tomicic, Alemka; Padilla, Oslando; Riquelme, Arnoldo; Bitran, Marcela

2015-11-01

Teaching methods of the undergraduate medical curriculum change considerably from the first years to clinical training. Clinical learning occurs in complex and varied scenarios while caring for patients. Students have to adapt their learning approaches and strategies to be able to integrate theory and clinical practice and become experiential learners. To identify the strategies used by medical students to learn during the initial clinical years, as reported by students themselves and by their clinical tutors. We performed eight focus group discussions with 54 students enrolled in years three to six and we interviewed eight clinical tutors. Both focus group discussions and interviews were audio recorded, transcribed and analyzed according to Grounded Theory. Four main themes were identified in the discourse of both students and tutors: Strategies oriented to theoretical learning, strategies oriented to experiential learning, strategies for integrating theory and practice and strategies oriented to evaluation. The mentioning of individual differences was present across the reports of both students and tutors. Students use a rich variety of strategies to face the challenges of clinical learning. Both students and tutors recognize that the learning approaches and strategies vary according the nature of the task and individual differences. The responses of students bring particular knowledge of the approaches used for the theoretical and practical integration and delve into the social dimension of learning.

Clearing the smoke around medical marijuana.

PubMed

Ware, M A

2011-12-01

The hazy world of "medical marijuana" continues to cry out for clear data on which to base medical decision making and rational policy design. In this issue of Clinical Pharmacology & Therapeutics, Abrams and colleagues report that vaporized cannabis does not meaningfully affect opioid plasma levels and may even augment the efficacy of oxycodone and morphine in patients with chronic non-cancer pain. This Commentary considers the implications of this work for clinical practice and further research initiatives.

Risk of emergent bradycardia associated with the use of carvedilol and metoprolol in routine clinical practice.

PubMed

Shin, Jaekyu; Pletcher, Mark J

2013-09-01

Large randomized trials have reported mixed results regarding the risk of bradycardia between metoprolol and carvedilol. We compared the incidence of emergent bradycardia (measured by an emergency department visit or hospitalization due to bradycardia) for patients initiating metoprolol and carvedilol. Adult beneficiaries of Medi-Cal, the State of California Medicaid program, without a diagnosis of bradycardia who initiated metoprolol or carvedilol between May 1, 2004, and November 1, 2009, were included. Cox proportional hazard regression analysis was performed to model the time to first occurrence of emergent bradycardia after initiation of the study drugs as a dependent variable and the study drug (metoprolol vs carvedilol) as the primary predictor with adjustments for total daily metoprolol-equivalent dose, formulations, and use of nonstudy drugs as time-varying covariates, as well as demographics and comorbidities. Among 38,186 subjects, 77.7% initiated metoprolol and 22.3% initiated carvedilol. The incidence of emergent bradycardia was low and comparable between the drugs (18.1 per 1000 person-years using metoprolol vs 17.7 per 100 person-years using carvedilol; unadjusted hazard ratio, 1.07; 95% confidence interval, 0.76-1.49). However, carvedilol users had substantially different population characteristics compared with metoprolol users. After adjustments for demographics, comorbidities, metoprolol-equivalent dose, formulations, and use of nonstudy drugs, initiation of metoprolol was associated with an increased risk of emergent bradycardia compared with that of carvedilol (adjusted hazard ratio, 1.64; 95% confidence interval, 1.14-2.36). Initiation of metoprolol is associated with an increased risk of emergent bradycardia compared with carvedilol, although the overall incidence of emergent bradycardia is low in routine clinical practice. Copyright © 2013 Elsevier Inc. All rights reserved.

Communication strategies for a successful inpatient dermatology consultative service: a narrative review.

PubMed

Afifi, Ladan; Shinkai, Kanade

2017-03-01

Inpatient dermatology consultative services care for hospitalized patients with skin disease in collaboration with the primary inpatient team. Effective, efficient communication is important. A consultation service must develop strong relationships with primary inpatient teams requesting consults in order to provide optimal patient care. Prior studies have identified effective communication practices for inpatient consultative services. This narrative review provides a summary of effective communication practices for an inpatient dermatology consultation service organized into 5 domains: (1) features of the initial consult request; (2) best practices in responding to the initial consult; (3) effective communication of recommendations; (4) interventions to improve consultations; and (5) handling curbside consultations. Recommendations include identifying the specific reason for consult; establishing urgency; secure sharing of sensitive clinical information such as photographs; ensuring timely responses; providing clear yet brief documentation of the differential diagnosis, problem list, final diagnosis and recommendations; and limiting curbside consultations. Future studies are needed to validate effective strategies to enhance communication practices within an inpatient dermatology consultative service. ©2017 Frontline Medical Communications.

Advance directives: survey of primary care patients.

PubMed

O'Sullivan, Rory; Mailo, Kevin; Angeles, Ricardo; Agarwal, Gina

2015-04-01

To establish the prevalence of patients with advance directives in a family practice, and to describe patients' perspectives on a family doctor's role in initiating discussions about advance directives. A self-administered patient questionnaire. A busy urban family medicine teaching clinic in Hamilton, Ont. A convenience sample of adult patients attending the clinic over the course of a typical business week. The prevalence of advance directives in the patient population was determined, and the patients' expectations regarding the role of their family doctors were elucidated. The survey population consisted of 800 participants (a response rate of 72.5%) well distributed across age groups; 19.7% had written advance directives and 43.8% had previously discussed the topic of advance directives, but only 4.3% of these discussions had occurred with family doctors. In 5.7% of cases, a family physician had raised the issue; 72.3% of respondents believed patients should initiate the discussion. Patients who considered advance directives extremely important were significantly more likely to want their family doctors to start the conversation (odds ratio 3.98; P < .05). Advance directives were not routinely addressed in the family practice. Most patients preferred to initiate the discussion of advance directives. However, patients who considered the subject extremely important wanted their family doctors to initiate the discussion. Copyright© the College of Family Physicians of Canada.

Fingolimod hydrochloride for the treatment of relapsing remitting multiple sclerosis.

PubMed

Thomas, Katja; Proschmann, Undine; Ziemssen, Tjalf

2017-10-01

Fingolimod was the first oral and the first in class disease modifying treatment in multiple sclerosis that acts as sphingosine-1-phospathe receptor agonist. Since approval in 2010 there is a growing experience with fingolimod use in clinical practice, but also next-generation sphingosin-1-receptor agonists in ongoing clinical trials. Growing evidence demonstrates additional effects beyond impact on lymphocyte circulation, highlighting further promising targets in multiple sclerosis therapy. Areas covered: Here we present a systematic review using PubMed database searching and expert opinion on fingolimod use in clinical practice. Long-term data of initial clinical trials and post-marketing evaluations including long-term efficacy, safety, tolerability and management especially within growing disease modifying treatment options and pre-treatment constellation in multiple sclerosis patients are critically discussed. Furthermore novel findings in mechanism of actions and prospective on additional use in progressive forms in multiple sclerosis are presented. Expert opinion: There is an extensive long-term experience on fingolimod use in clinical practice demonstrating the favorable benefit-risk of this drug. Using a defined risk management approach experienced MS clinicians should apply fingolimod after critical choice of patients and review of clinical aspects. Further studies are essential to discuss additional benefit in progressive forms in multiple sclerosis.

Using Simulation in a Psychiatric Mental Health Nurse Practitioner Doctoral Program.

PubMed

Calohan, Jess; Pauli, Eric; Combs, Teresa; Creel, Andrea; Convoy, Sean; Owen, Regina

The use and effectiveness of simulation with standardized patients in undergraduate and graduate nursing education programs is well documented. Simulation has been primarily used to develop health assessment skills. Evidence supports using simulation and standardized patients in psychiatric-mental health nurse practitioner (PMHNP) programs is useful in developing psychosocial assessment skills. These interactions provide individualized and instantaneous clinical feedback to the student from faculty, peers, and standardized patients. Incorporating simulation into advanced practice psychiatric-mental health nursing curriculum allows students to develop the necessary requisite skills and principles needed to safely and effectively provide care to patients. There are no documented standardized processes for using simulation throughout a doctor of nursing practice PMHNP curriculum. The purpose of this article is to describe a framework for using simulation with standardized patients in a PMHNP curriculum. Students report high levels of satisfaction with the simulation experience and believe that they are more prepared for clinical rotations. Faculty feedback indicates that simulated clinical scenarios are a method to ensure that each student experiences demonstrate a minimum standard of competency ahead of clinical rotations with live patients. Initial preceptor feedback indicates that students are more prepared for clinical practice and function more independently than students that did not experience this standardized clinical simulation framework. Published by Elsevier Inc.

Multisite Investigation of Strategies for the Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy.

PubMed

Empey, Philip E; Stevenson, James M; Tuteja, Sony; Weitzel, Kristin W; Angiolillo, Dominick J; Beitelshees, Amber L; Coons, James C; Duarte, Julio D; Franchi, Francesco; Jeng, Linda J B; Johnson, Julie A; Kreutz, Rolf P; Limdi, Nita A; Maloney, Kristin A; Owusu Obeng, Aniwaa; Peterson, Josh F; Petry, Natasha; Pratt, Victoria M; Rollini, Fabiana; Scott, Stuart A; Skaar, Todd C; Vesely, Mark R; Stouffer, George A; Wilke, Russell A; Cavallari, Larisa H; Lee, Craig R

2017-12-26

CYP2C19 genotype-guided antiplatelet therapy following percutaneous coronary intervention is increasingly implemented in clinical practice. However, challenges such as selecting a testing platform, communicating test results, building clinical decision support processes, providing patient and provider education, and integrating methods to support the translation of emerging evidence to clinical practice are barriers to broad adoption. In this report, we compare and contrast implementation strategies of 12 early adopters, describing solutions to common problems and initial performance metrics for each program. Key differences between programs included the test result turnaround time and timing of therapy changes, which are both related to the CYP2C19 testing model and platform used. Sites reported the need for new informatics infrastructure, expert clinicians such as pharmacists to interpret results, physician champions, and ongoing education. Consensus lessons learned are presented to provide a path forward for those seeking to implement similar clinical pharmacogenomics programs within their institutions. © 2018, The American Society for Clinical Pharmacology and Therapeutics.

Developing clinically suitable measures of social cognition for children: initial findings from a normative sample.

PubMed

Saltzman-Benaiah, Jennifer; Lalonde, Christopher E

2007-03-01

Our understanding of children's social competence has increased tremendously over the past two decades. There is increasing evidence to suggest that social-cognitive impairments are not restricted to children on the autistic spectrum, but rather may be associated with a host of developmental and acquired neurological conditions including learning disabilities, attention deficit disorder, traumatic brain injury, and stroke. Although many investigators have begun to bridge the gap between clinical practice and research by applying experimental tasks to clinical populations, few tools are available for the clinical evaluation of social competence, particularly in children. This study marks a series of first steps in the development of measures suitable for the assessment of children between 6 and 12 years of age. The results of the study provide data for a number of experimental tasks that have been adapted with clinical practice in mind. A discussion of the developmental progressions and the relationships among the measures is also included.

Quality of cancer family history and referral for genetic counseling and testing among oncology practices: a pilot test of quality measures as part of the American Society of Clinical Oncology Quality Oncology Practice Initiative.

PubMed

Wood, Marie E; Kadlubek, Pamela; Pham, Trang H; Wollins, Dana S; Lu, Karen H; Weitzel, Jeffrey N; Neuss, Michael N; Hughes, Kevin S

2014-03-10

Family history of cancer (CFH) is important for identifying individuals to receive genetic counseling/testing (GC/GT). Prior studies have demonstrated low rates of family history documentation and referral for GC/GT. CFH quality and GC/GT practices for patients with breast (BC) or colon cancer (CRC) were assessed in 271 practices participating in the American Society of Clinical Oncology Quality Oncology Practice Initiative in fall 2011. A total of 212 practices completed measures regarding CFH and GC/GT practices for 10,466 patients; 77.4% of all medical records reviewed documented presence or absence of CFH in first-degree relatives, and 61.5% of medical records documented presence or absence of CFH in second-degree relatives, with significantly higher documentation for patients with BC compared with CRC. Age at diagnosis was documented for all relatives with cancer in 30.7% of medical records (BC, 45.2%; CRC, 35.4%; P ≤ .001). Referall for GC/GT occurred in 22.1% of all patients with BC or CRC. Of patients with increased risk for hereditary cancer, 52.2% of patients with BC and 26.4% of those with CRC were referred for GC/GT. When genetic testing was performed, consent was documented 77.7% of the time, and discussion of results was documented 78.8% of the time. We identified low rates of complete CFH documentation and low rates of referral for those with BC or CRC meeting guidelines for referral among US oncologists. Documentation and referral were greater for patients with BC compared with CRC. Education and support regarding the importance of accurate CFH and the benefits of proactive high-risk patient management are clearly needed.

Reflective practice groups for nurses: a consultation liaison psychiatry nursing initiative: part 1--The model.

PubMed

Dawber, Chris

2013-04-01

In the present study, we outline the evolution of a process-focused reflective practice group (RPG) model for nurses working in clinical settings. The groups were initiated at Redcliffe and Caboolture hospitals by the consultation liaison psychiatry nurse and author. An associated article provides an evaluation of these RPG. The literature review identifies the key themes and theories on which the model is based, and the article outlines the process and practicalities of facilitating RPG in critical care, midwifery, and oncology specialties over a 3-year period. The model proposes that the effectiveness and sustainability of RPG arises from adequate preparation and engagement with prospective participants. Group rules, based on principles of confidentially, supportiveness, and diversity, were collaboratively developed for each group. Facilitation utilized a group-as-a-whole approach to manage process and stimulate reflection. While the purpose of RPG was a reflection on interpersonal aspects of nursing, contextual workplace issues were frequently raised in groups. Acknowledgement and containment of such issues were necessary to maintain clinical focus. The literature highlights facilitator credibility and style as crucial factors in the overall success of RPG, and it is proposed that reflective practice as a process-focused model for groups succeeds when nurse facilitators are trained in group process and receive concurrent supervision. © 2012 The Author; International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

An overview of clinical governance policies, practices and initiatives.

PubMed

Braithwaite, Jeffrey; Travaglia, Joanne F

2008-02-01

To map the emergence of, and define, clinical governance; to discuss current best practices, and to explore the implications of these for boards of directors and executives wishing to promote a clinical governance approach in their health services. Review and analysis of the published and grey literature on clinical governance from 1966 to 2006. Medline and CINAHL databases, key journals and websites were systematically searched. Central issues were identified in the literature as key to effective clinical governance. These include: ensuring that links are made between health services' clinical and corporate governance; the use of clinical governance to promote quality and safety through a focus on quality assurance and continuous improvement; the creation of clinical governance structures to improve safety and quality and manage risk and performance; the development of strategies to ensure the effective exchange of data, knowledge and expertise; and the sponsoring of a patient-centred approach to service delivery. A comprehensive approach to clinical governance necessarily includes the active participation of boards and executives in sponsoring and promoting clinical governance as a quality and safety strategy. Although this is still a relatively recent development, the signs are promising.

Lessons learned: Infrastructure development and financial management for large, publicly funded, international trials.

PubMed

Larson, Gregg S; Carey, Cate; Grarup, Jesper; Hudson, Fleur; Sachi, Karen; Vjecha, Michael J; Gordin, Fred

2016-04-01

Randomized clinical trials are widely recognized as essential to address worldwide clinical and public health research questions. However, their size and duration can overwhelm available public and private resources. To remain competitive in international research settings, advocates and practitioners of clinical trials must implement practices that reduce their cost. We identify approaches and practices for large, publicly funded, international trials that reduce cost without compromising data integrity and recommend an approach to cost reporting that permits comparison of clinical trials. We describe the organizational and financial characteristics of The International Network for Strategic Initiatives in Global HIV Trials, an infectious disease research network that conducts multiple, large, long-term, international trials, and examine challenges associated with simple and streamlined governance and an infrastructure and financial management model that is based on performance, transparency, and accountability. It is possible to reduce costs of participants' follow-up and not compromise clinical trial quality or integrity. The International Network for Strategic Initiatives in Global HIV Trials network has successfully completed three large HIV trials using cost-efficient practices that have not adversely affected investigator enthusiasm, accrual rates, loss-to-follow-up, adherence to the protocol, and completion of data collection. This experience is relevant to the conduct of large, publicly funded trials in other disease areas, particularly trials dependent on international collaborations. New approaches, or creative adaption of traditional clinical trial infrastructure and financial management tools, can render large, international clinical trials more cost-efficient by emphasizing structural simplicity, minimal up-front costs, payments for performance, and uniform algorithms and fees-for-service, irrespective of location. However, challenges remain. They include institutional resistance to financial change, growing trial complexity, and the difficulty of sustaining network infrastructure absent stable research work. There is also a need for more central monitoring, improved and harmonized regulations, and a widely applied metric for measuring and comparing cost efficiency in clinical trials. ClinicalTrials.gov is recommended as a location where standardized trial cost information could be made publicly accessible. © The Author(s) 2016.

Survey of clinical infant lung function testing practices.

PubMed

Peterson-Carmichael, Stacey L; Rosenfeld, Margaret; Ascher, Simon B; Hornik, Christoph P; Arets, H G M; Davis, Stephanie D; Hall, Graham L

2014-02-01

Data supporting the clinical use of infant lung function (ILF) tests are limited making the interpretation of clinical ILF measures difficult. To evaluate current ILF testing practices and to survey users regarding the indications, limitations and perceived clinical benefits of ILF testing. We created a 26-item survey hosted on the European Respiratory Society (ERS) website between January and May 2010. Notifications were sent to members of the ERS, American Thoracic Society and the Asian Pacific Society of Respirology. Responses were sought from ILF laboratory directors and pediatric respirologists. The survey assessed the clinical indications, patient populations, equipment and reference data used, and perceived limitations of ILF testing. We received 148 responses with 98 respondents having ILF equipment and performing testing in a clinical capacity. Centers in North America were less likely to perform ≥50 studies/year than centers in Europe or other continents (13% vs. 41%). Most respondents used ILF data to either "start a new therapy" (78%) or "help decide about initiation of further diagnostic workup such as bronchoscopy, chest CT or serological testing" (69%). Factors reported as limiting clinical ILF testing were need for sedation, uncertainty regarding clinical impact of study results and time intensive nature of the study. Clinical practices associated with ILF testing vary significantly; centers that perform more studies are more likely to use the results for clinical purposes and decision making. The future of ILF testing is uncertain in the face of the limitations perceived by the survey respondents. © 2013 Wiley Periodicals, Inc.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

PubMed Central

Cho, Won-Sang; Park, Sukh Que; Ko, Jun Kyeung; Kim, Dae-Won; Park, Jung Cheol; Yeon, Je Young; Chung, Seung Young; Chung, Joonho; Joo, Sung-Pil; Hwang, Gyojun; Kim, Deog Young; Chang, Won Hyuk; Choi, Kyu-Sun; Lee, Sung Ho; Sheen, Seung Hun; Kang, Hyun-Seung; Kim, Byung Moon; Bae, Hee-Joon; Oh, Chang Wan; Park, Hyeon Seon

2018-01-01

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research. PMID:29526058

Application of best practice approaches for designing decision support tools: The preparatory education about clinical trials (PRE-ACT) study

PubMed Central

Fleisher, Linda; Ruggieri, Dominique G.; Miller, Suzanne M.; Manne, Sharon; Albrecht, Terrance; Buzaglo, Joanne; Collins, Michael A.; Katz, Michael; Kinzy, Tyler G.; Liu, Tasnuva; Manning, Cheri; Charap, Ellen Specker; Millard, Jennifer; Miller, Dawn M.; Poole, David; Raivitch, Stephanie; Roach, Nancy; Ross, Eric A.; Meropol, Neal J.

2014-01-01

Objective This article describes the rigorous development process and initial feedback of the PRE-ACT (Preparatory Education About Clinical Trials) web-based- intervention designed to improve preparation for decision making in cancer clinical trials. Methods The multi-step process included stakeholder input, formative research, user testing and feedback. Diverse teams (researchers, advocates and developers) participated including content refinement, identification of actors, and development of video scripts. Patient feedback was provided in the final production period and through a vanguard group (N = 100) from the randomized trial. Results Patients/advocates confirmed barriers to cancer clinical trial participation, including lack of awareness and knowledge, fear of side effects, logistical concerns, and mistrust. Patients indicated they liked the tool’s user-friendly nature, the organized and comprehensive presentation of the subject matter, and the clarity of the videos. Conclusion The development process serves as an example of operationalizing best practice approaches and highlights the value of a multi-disciplinary team to develop a theory-based, sophisticated tool that patients found useful in their decision making process. Practice implications Best practice approaches can be addressed and are important to ensure evidence-based tools that are of value to patients and supports the usefulness of a process map in the development of e-health tools. PMID:24813474

Development of the Clinical Teaching Effectiveness Questionnaire in the United States.

PubMed

Wormley, Michelle E; Romney, Wendy; Greer, Anna E

2017-01-01

The purpose of this study was to develop a valid measure for assessing clinical teaching effectiveness within the field of physical therapy. The Clinical Teaching Effectiveness Questionnaire (CTEQ) was developed via a 4-stage process, including (1) initial content development, (2) content analysis with 8 clinical instructors with over 5 years of clinical teaching experience, (3) pilot testing with 205 clinical instructors from 2 universities in the Northeast of the United States, and (4) psychometric evaluation, including principal component analysis. The scale development process resulted in a 30-item questionnaire with 4 sections that relate to clinical teaching: learning experiences, learning environment, communication, and evaluation. The CTEQ provides a preliminary valid measure for assessing clinical teaching effectiveness in physical therapy practice.

Exploring the scope of oncology specialist nurses' practice in the UK.

PubMed

Farrell, Carole; Molassiotis, Alexander; Beaver, Kinta; Heaven, Cathy

2011-04-01

Revolutionary changes have taken place to nurses' roles and clinical responsibilities over the past decade, leading to new ways of working and higher levels of nursing practice. However, despite the development of nurse-led clinics and services within oncology there has been little formal evaluation. A survey of 103 UK oncology specialist nurses was undertaken to explore their scope of practice, with emphasis on nurse-led services. The survey highlighted significant developments within nurses' roles and nurse-led services, although there was a distinct lack of clarity between nurses' titles and their roles/responsibilities. Most nurses had extended their role. However there were significant differences in the nature of clinical practice, such as clinical examination and nurse prescribing. Overall, new roles were greatly valued by the multidisciplinary team, reducing waiting times and providing benefits for patients. However other nurses felt frustrated by deficiencies in infrastructure and support, which often overshadowed potential benefits. There is a great diversity in oncology specialist nurses' roles; however lack of clarity in titles, training, competencies and responsibilities is creating confusion. Role developments and nurse-led clinics have been ad hoc and poorly evaluated. The introduction of a competency framework, national standards and a system of clinical appraisals seems key to providing increased transparency and vital safeguards for both nurses and patients. Without further exploration and evaluation of nurse-led initiatives it is difficult to fully appreciate their impact on patients, staff and service delivery. Copyright © 2010 Elsevier Ltd. All rights reserved.

Practical Applications for Maintenance of Certification Products in Child and Adolescent Residency Training.

PubMed

Williams, Laurel L; Sexson, Sandra; Dingle, Arden D; Young-Walker, Laine; John, Nadyah; Hunt, Jeffrey

2016-04-01

The authors evaluated whether Maintenance of Certification (MOC) Performance-in-Practice products in training increases trainee knowledge of MOC processes and is viewed by trainees as a useful activity. Six child and adolescent psychiatry fellowships used MOC products in continuity clinics to assess their usefulness as training tools. Two surveys assessed initial knowledge of MOC and usefulness of the activity. Forty-one fellows completed the initial survey. A majority of first-year fellows indicated lack of awareness of MOC in contrast to a majority of second-year fellows who indicated some awareness. Thirty-five fellows completed the second survey. A majority of first- and second-year fellows found the activity easy to execute and would change something about their practice as a result. Using MOC products in training appears to be a useful activity that may assist training programs in teaching the principles of self- and peer-learning.

Nursing clinical supervision project in a Neonatal Intensive Care and a Special Care Baby Unit: a best practice implementation project.

PubMed

Johansson, Diana

2015-04-17

Clinical supervision is a process of guided reflective practice and is used in the areas of mental health and palliative care. However, within the Neonatal Intensive Care Unit setting, stressful situations may also arise, with no policies for nurses in regards to participation in clinical supervision. With critical incidents, complex family issues and loss of nursing expertise, clinical supervision could be a potential solution to this dilemma. The aims of the project were to investigate if any hospital policies supported clinical supervision. Specifically, the aims were: (i) to conduct an audit of nurses' knowledge on the topic of clinical supervision, (ii) to investigate if nurses were aware of, or had been involved in, any clinical supervision activities conducted in a Neonatal Intensive Care Unit or a Special Care Baby Unit, and (iii) to investigate if records are maintained of any clinical supervision activities held. A three-phase approach was initiated for this project: a baseline audit, implementation of education sessions, and a follow-up audit using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The Neonatal Intensive Care Unit and Special Care Baby Unit have approximately 180 registered nurses working in the units where the project was conducted. The baseline audit included 37 nurses by convenience sampling and the follow-up audit included nine of these nurses. No policy on clinical supervision has been developed to support nurses in the Neonatal Intensive Care Unit and Special Care Baby Unit. The baseline audit found that nurses described clinical supervision as educational and task orientated, and did not equate clinical supervision with a process that could be also described as "guided reflective practice". Following the education sessions, there was a better understanding of what clinical supervision entailed and the benefits that could lead to improved professional practice, but there were no activities in which nurses could engage in this process. Implementation of a pilot project to test the evidence of clinical supervision in the Neonatal Intensive Care and Special Care Baby speciality units should be undertaken with strategies to assess the effectiveness of clinical supervision and the positive aspects that have been reported in the literature. The Joanna Briggs Institute.

EAP viewpoint on unpublished data from paediatric clinical trials.

PubMed

Schrier, L; Illy, K; Valiulis, A; Wyder, C; Stiris, T

2018-02-01

European children and paediatricians rely heavily on the fair, complete and timely publication of data obtained from paediatric randomised controlled trials (RCTs). Selective publication and reporting of paediatric RCTs is common practice. Industry-sponsored trials are more likely to remain unpublished, and take longer to get published compared with trials sponsored by others. However, also academic sponsors contribute to inefficiencies in publishing clinical data. Publication bias violates the ethical obligation that investigators have towards study participants, leads to considerable inefficiencies in research and a waste of financial and human resources, and has the potential to distort evidence for treatment approaches. The European Academy of Paediatrics (EAP) therefore actively supports initiatives that increase the public dissemination of paediatric clinical trial data. The EAP will raise awareness about the guidelines for Good Publication Practice among European paediatricians and subspecialty societies.

A practical guide to designing a poster for presentation.

PubMed

Briggs, D J

Poster presentations are frequently used to disseminate research findings and clinical initiatives at conferences, and present module material for educational courses. However, many nurses lack confidence when it comes to designing posters. This article considers the skills required to design a poster. Aspects of good poster design are also discussed.

Cancer Care Initiative: Creation of a Comprehensive Cancer Center at Naval Medical Center Dan Diego

DTIC Science & Technology

2008-06-24

to know about and practice evidence - based medicine and are more experienced with many of the complexities related to difficult chronic illnesses...frequent requesters of evidence - based medicine . Clinical information systems are important to the model to help ensure productive interactions. An

SU-E-T-23: A Developing Australian Network for Datamining and Modelling Routine Radiotherapy Clinical Data and Radiomics Information for Rapid Learning and Clinical Decision Support

DOE Office of Scientific and Technical Information (OSTI.GOV)

Thwaites, D; Holloway, L; Bailey, M

2015-06-15

Purpose: Large amounts of routine radiotherapy (RT) data are available, which can potentially add clinical evidence to support better decisions. A developing collaborative Australian network, with a leading European partner, aims to validate, implement and extend European predictive models (PMs) for Australian practice and assess their impact on future patient decisions. Wider objectives include: developing multi-institutional rapid learning, using distributed learning approaches; and assessing and incorporating radiomics information into PMs. Methods: Two initial standalone pilots were conducted; one on NSCLC, the other on larynx, patient datasets in two different centres. Open-source rapid learning systems were installed, for data extraction andmore » mining to collect relevant clinical parameters from the centres’ databases. The European DSSs were learned (“training cohort”) and validated against local data sets (“clinical cohort”). Further NSCLC studies are underway in three more centres to pilot a wider distributed learning network. Initial radiomics work is underway. Results: For the NSCLC pilot, 159/419 patient datasets were identified meeting the PM criteria, and hence eligible for inclusion in the curative clinical cohort (for the larynx pilot, 109/125). Some missing data were imputed using Bayesian methods. For both, the European PMs successfully predicted prognosis groups, but with some differences in practice reflected. For example, the PM-predicted good prognosis NSCLC group was differentiated from a combined medium/poor prognosis group (2YOS 69% vs. 27%, p<0.001). Stage was less discriminatory in identifying prognostic groups. In the good prognosis group two-year overall survival was 65% in curatively and 18% in palliatively treated patients. Conclusion: The technical infrastructure and basic European PMs support prognosis prediction for these Australian patient groups, showing promise for supporting future personalized treatment decisions, improved treatment quality and potential practice changes. The early indications from the distributed learning and radiomics pilots strengthen this. Improved routine patient data quality should strengthen such rapid learning systems.« less

Finessing incivility: The professional socialisation experiences of student nurses' first clinical placement, a grounded theory.

PubMed

Thomas, Juliet; Jinks, Annette; Jack, Barbara

2015-12-01

Clinical practice is where student nurses are socialised into a professional role and acquire the distinct behaviour, attitudes and values of the nursing profession. Getting it right at the outset can maximise the development of a professional identity and the transmission of robust value systems. To explore the impact of the first clinical placement on the professional socialisation of adult undergraduate student nurses in the United Kingdom. Data of a longitudinal qualitative nature were collected and analysed using grounded theory. First year student nurses in hospital ward placements comprising a rural District General Hospital and a large inner city Hospital kept daily unstructured diaries for six weeks. A total of 26 undergraduate adult student nurses were purposefully sampled between 2008 and 2010 before undertaking their initial clinical placement. Data collection and analysis used grounded theory and the key question asked of the diarists 'tell me what it is like to be a first year nurse on a first placement' was theoretically adjusted during constant comparison and as the theory emerged. Ethical approval and consent was obtained. The theory of finessing incivility comprises a conceptual framework depicting how student nurses deal with professional incivility during their initial clinical placement and sustain a student identity. Being disillusioned with their role as worker rather than learner yields a sense of 'status dislocation'. Despite needing professional benevolence, they remain altruistic and seek recompense from significant others to negotiate for learning opportunities and relocate their student status. Despite the stressful transition into clinical practice rather than 'fit in', the student nurses want to belong as learners. His or her own resilience to learn nursing and be a professional student maintains their resolve, their altruism and strengthens their existing values to be benevolent towards an indifferent profession. This behaviour ultimately mirrors the social nature of the practice community. Copyright © 2015 Elsevier Ltd. All rights reserved.

Patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: a systematic review of patient reported outcomes and patient and clinician satisfaction

PubMed Central

2013-01-01

Background The cost to the NHS of missed or inappropriate hospital appointments is considerable. Alternative methods of appointment scheduling might be more flexible to patients’ needs without jeopardising health and service quality. The objective was to systematically review evidence of patient initiated clinics in secondary care on patient reported outcomes among patients with chronic/recurrent conditions. Methods Seven databases were searched from inception to June 2013. Hand searching of included studies references was also conducted. Studies comparing the effects of patient initiated clinics with traditional consultant led clinics in secondary care for patients with long term chronic or recurrent diseases on health related quality of life and/or patient satisfaction were included. Data was extracted by one reviewer and checked by a second. Results were synthesised narratively. Results Seven studies were included in the review, these covered a total of 1,655 participants across three conditions: breast cancer, inflammatory bowel disease and rheumatoid arthritis. Quality of reporting was variable. Results showed no significant differences between the intervention and control groups for psychological and health related quality of life outcomes indicating no evidence of harm. Some patients reported significantly more satisfaction using patient-initiated clinics than usual care (p < 0.001). Conclusions The results show potential for patient initiated clinics to result in greater patient and clinician satisfaction. The patient-consultant relationship appeared to play an important part in patient satisfaction and should be considered an important area of future research as should the presence or absence of a guidebook to aid self-management. Patient initiated clinics fit the models of care suggested by policy makers and so further research into long term outcomes for patients and service use in this area of practice is both relevant and timely. PMID:24289832

Interdisciplinary Evidence-based Practice: Moving from Silos to Synergy

PubMed Central

Newhouse, Robin P.; Spring, Bonnie

2010-01-01

Despite the assumption that health care providers work synergistically in practice, professions have tended to be more exclusive than inclusive when it comes to educating students in a collaborative approach to interdisciplinary evidence-based practice (EBP). This article explores the state of academic and clinical training regarding interdisciplinary EBP, describes efforts to foster interdisciplinary EBP, and suggests strategies to accelerate the translation of EBP across disciplines. Moving from silos to synergy in interdisciplinary EBP will require a paradigm shift. Changes can be leveraged professionally and politically using national initiatives currently in place on improving quality and health care reform. PMID:21074648

Significant clinical practice cost savings through downsizing office supply inventory and just in time ordering.

PubMed

Gonzalez, Chris M; Jang, Tom; Raines, Melanie; Lys, Thomas Z; Schaeffer, Anthony J

2006-07-01

Cost containment in the office is becoming more important secondary to increasing overhead costs and lower reimbursement. In an attempt to limit these particular expenditures we analyzed and restructured our methods of ordering, storing and distributing office supply inventory. In a large academic practice with 11 urologists and approximately 20,000 annual patient visits an attempt was made to decrease overhead costs using the principle of just in time inventory popularized by large manufacturing companies. We initially issued a return of excess and/or unused supplies from our office inventory stock room. Our main supply room was then centralized to contain office supplies for up to 4 weeks. The 12 individual clinic rooms were stocked with appropriate supplies to last 1 week. Limited access to the main supply room was established and a supply manager was established to log all input and output. The initial credit for the return of unused/overstocked supplies was $10,107 in January 2004. Annual office supply charges in calendar year 2004 were $87,444 compared to charges in calendar year 2003 of $175,340. No stock outs occurred during year 2004 and all standing delivery orders were terminated. The total number of patient visits in calendar year 2004 was 20,170 compared to 19,455 in calendar year 2003. Decreasing overall inventory through accurate demand forecasting, judicious accounting, office supply centralization and just in time ordering is a potential area for significant overhead cost savings in a clinical practice.

A Qualitative Study of the Communication Process for Medical Acupuncture in Family Medicine.

PubMed

Ledford, Christy J W; Fisher, Carla L; Crawford, Paul

2018-05-01

As evidence establishes the efficacy of medical acupuncture, more family physicians and family medicine residents may receive medical acupuncture training and need to know how to effectively communicate about the treatment option with patients. By identifying how physicians talk about acupuncture treatment with their patients, we aimed to develop a model for physician training that could enhance their ability to integrate and practice medical acupuncture in conventional clinical settings. To capture the communication process that family physicians engage in when integrating acupuncture treatment into a clinical environment, we sought both physicians' and patients' perspectives. We conducted interviews with 17 family physicians and 15 patients in a US family medicine clinic that has integrated medical acupuncture into its practice. Audio recordings were transcribed and analyzed by two members of the study team in ATLAS.ti, using the constant comparative method. Integrating acupuncture into family medicine entailed a three-phase communication process: (1) introduce acupuncture, (2) explain the medical process, and (3) evaluate treatment outcomes. The emerging three-phase process of communicating acupuncture described here provides an initial model for teaching communication in the context of medical acupuncture. Given the exploratory nature of this initial study and the rarity of acupuncture treatment integrated into family medical settings, this is a first step in building knowledge in this realm of practice. Future research is needed to better understand the experience of patients who do not report notable results of acupuncture and to extend this study into other family medicine settings.

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project.

PubMed

McCulloh, Russell J; Fouquet, Sarah D; Herigon, Joshua; Biondi, Eric A; Kennedy, Brandan; Kerns, Ellen; DePorre, Adrienne; Markham, Jessica L; Chan, Y Raymond; Nelson, Krista; Newland, Jason G

2018-06-07

Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project. We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled "Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE)." The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics. Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]. We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects. ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools' impact on medical decision making, clinical practice, and health outcomes.

Outcomes of Australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum.

PubMed

Greenhill, Jennene A; Walker, Judi; Playford, Denese

2015-01-01

The establishment of the rural clinical schools funded through the Commonwealth Department of Health and Ageing (now Department of Health) Rural Clinical Training and Support program over a decade ago has been a significant policy initiative in Australian rural health. This article explores the impacts of this policy initiative and presents the wide range of educational innovations contextualised to each rural community they serve. This article reviews the achievements of the Australian rural clinical and regional medical schools (RCS/RMS) through semi-structured interviews with the program directors or other key informants. The questions and responses were analysed according to the funding parameters to ascertain the numbers of students, types of student placements and range of activities undertaken by each university program. Sixteen university medical schools have established 18 rural programs, creating an extensive national network of RCS and RMS in every state and territory. The findings reveal extensive positive impacts on rural and regional communities, curriculum innovation in medical education programs and community engagement activities. Teaching facilities, information technology, video-conferencing and student accommodation have brought new infrastructure to small rural towns. Rural clinicians are thriving on new opportunities for education and research. Clinicians continue to deliver clinical services and some have taken on formal academic positions, reducing professional isolation, improving the quality of care and their job satisfaction. This strategy has created many new clinical academics in rural areas, which has retained and expanded the clinical workforce. A total of 1224 students are provided with high-quality learning experiences for long-term clinical placements. These placements consist of a year or more in primary care, community and hospital settings across hundreds of rural and remote areas. Many programs offer longitudinal integrated clerkships; others offer block rotations in general practice and specialist clinics. Nine universities established programs prior to 2004, and these well-established programs are finding graduates who are returning to rural practice. Universities are required to have 25% of the students from a rural background. University admission policies have changed to encourage more applications from rural students. This aspect of the policy implements the extensive research evidence that rural-origin students are more likely to become rural practitioners. Additional capacity for research in RCS has influenced the rural health agenda in fields including epidemiology, population health, Aboriginal health, aged care, mental health and suicide prevention, farming families and climate change. There are strong research partnerships with rural workforce agencies, research centres for early career researchers and PhD students. The RCS policy initiative has vastly increased opportunities for medical students to have long-term clinical placements in rural health services. Over a decade since the policy has been implemented, graduates are being attracted to rural practice because they have positive learning experiences, good infrastructure and support within rural areas. The study shows the RCS initiative sets the stage for a sustainable future Australian rural medical workforce now requiring the development of a seamless rural clinical training pipeline linking undergraduate and postgraduate medical education.

Academic investigator-initiated trials and the challenge of sponsor responsibility: the Cologne Sponsor Model.

PubMed

Georgias, Christine; Grunow, Andrea; Olderog, Miriam; May, Alexander; Paulus, Ursula

2012-12-01

With the amendment to the German Drug Law in 2004, the conduct of clinical trials changed by at least two main aspects: (1) The principles of Good Clinical Practice (GCP) were implemented in the national legislation, and (2) for the first time, the function of the sponsor of a clinical trial and the clinical trial itself have become legally binding definitions. By that, legal differences between industrial and academic clinical trials no longer exist. Clinical trials initiated by investigators have to fulfil the same requirements while the entire sponsor responsibility has to be carried out by the Coordinating Investigator or his institution including implementation of a quality management system according to the GCP. The Cologne Sponsor Model is an effective approach with settings, structures, basic features, action, and reporting lines, as well as funding for clinical trials initiated in an academic environment. The University of Cologne assumes the sponsor responsibility for clinical trials organised by the university researchers according to law. Sponsor's duties are delegated to a central operational unit of the sponsor - the Clinical Trials Center Cologne - which further delegates duties to the Coordinating Investigator. Clinical Trials Center Cologne was established in 2002 to support the performance of clinical trials at the university by offering comprehensive advisory and practical services covering all aspects of study planning and conduct. Furthermore, a specialised division of its quality management department acts as an independent sponsor's Quality Assurance Unit. The Clinical Trials Center Cologne has established a quality management system consisting of different components (1) to enable a reasoned decision to subsequent delegation, (2) for risk-based surveillance of trial conduct (audits, monitoring-checks, and reports), and (3) support and training of the Coordinating Investigator. Double functions of persons and departments in the university environment sometimes make it difficult to define roles in such a model. Therefore, it is necessary to establish clear reporting lines and moreover to monitor regularly and carefully the roles and responsibilities. With the combination of central management and support, control and independence of the researchers, our model represents a 'risk-based' system that offers a sensible option that fulfils the requirements of legal regulations and GCP for trials organised within the university environment.

Potential Applications of the National Institute of Mental Health's Research Domain Criteria (RDoC) to Clinical Psychiatric Practice: How RDoC Might Be Used in Assessment, Diagnostic Processes, Case Formulation, Treatment Planning, and Clinical Notes.

PubMed

Yager, Joel; Feinstein, Robert E

2017-04-01

Offering a new framework for understanding and studying basic dimensions of normal and abnormal human functioning and mental disorders, the National Institute of Mental Health (NIMH) has initiated the Research Domain Criteria (RDoC) project in which a series of higher order domains, representing major systems of emotion, cognition, motivation, and social behavior, and their constituent operationally defined constructs serve as organizing templates for further research and inquiry, eg, to discover validated biomarkers and endophenotypes. Cutting across traditional DSM diagnoses, the domains are defined as Negative Valence Systems, Positive Valence Systems, Cognitive Systems, Systems for Social Processes, and Arousal/Regulatory Systems. To inform educators, trainees, and practitioners about RDoC, alert them to potential practical applications, and encourage their broad exploration in clinical settings, this article reviews the RDoC domains and their subsystem constructs with regard to potential current clinical considerations and applications. We describe ways in which the RDoC domains and constructs offer transdiagnostic frameworks for complementing traditional practice; suggest clinical questions to help elucidate salient information; and, translating RDoC domains and constructs headings into clinically friendly language, offer a template for the psychiatric review of systems that can serve in clinical notes. © Copyright 2017 Physicians Postgraduate Press, Inc.

Caring for individual patients and beyond: enhancing care through secondary use of data in a general practice setting.

PubMed

Tolar, Marianne; Balka, Ellen

2012-07-01

It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends. In this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes. This project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC. The case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place. PRECONDITIONS: Specific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation. Changes in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders. The case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Factors associated with HCV risk practices in methadone-maintained patients: the importance of considering the couple in prevention interventions.

PubMed

Roux, Perrine; Lions, Caroline; Michel, Laurent; Mora, Marion; Daulouède, Jean-Pierre; Marcellin, Fabienne; Spire, Bruno; Morel, Alain; Carrieri, Patrizia M

2014-09-10

One important public health issue associated with opioid use today is the risk of hepatitis C (HCV) infection. Although methadone maintenance may help to decrease HCV-related risk practices, HCV risk behaviors persist and are strongly associated with specific substance use patterns, mental status and social context. The ANRS-Methaville study gave us the opportunity to better disentangle the different relationships between these various factors and HCV risk practices. The ANRS-Methaville multisite randomized trial was designed to assess the feasibility of initiating methadone in primary care by comparing it with methadone initiation in specialized centers. This study recruited 195 participants initiating methadone maintenance and followed up for 12 months. Longitudinal data from this trial was used to acquire a greater understanding of HCV risk practices and their pattern of correlates in this population. We selected 176 patients who had data on HCV risk practices at M0 and M12, accounting for 312 visits. HCV risk practices were defined as follows: sharing needles or syringes, sharing drug paraphernalia, getting a tattoo or having a piercing in a non-professional context, sharing toiletry items. To identify factors associated with HCV risk practices, we performed a mixed logistic regression analysis. HCV risk practices were reported by 19% and 15% of participants at baseline and M12, respectively. After adjustment for age, cocaine use and alcohol dependence as well as suicidal risk, living in a couple with a non-drug user and in a couple with a drug user were both independent predictors of HCV risk practices (OR[CI95%] = 4.16 [1.42-12.12]; OR[CI95%] = 9.85 [3.13-31.06], respectively). Identifying individuals at risk of HCV transmission during methadone treatment such as stimulant users, alcohol dependent individuals, and those at suicidal risk is necessary to optimize response to treatment. Innovative prevention approaches tailored to couples are also urgently needed and could decrease HCV-risk in this population. The trial is registered with the French Agency of Pharmaceutical Products (ANSM) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials. Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

Factors associated with HCV risk practices in methadone-maintained patients: the importance of considering the couple in prevention interventions

PubMed Central

2014-01-01

Background One important public health issue associated with opioid use today is the risk of hepatitis C (HCV) infection. Although methadone maintenance may help to decrease HCV-related risk practices, HCV risk behaviors persist and are strongly associated with specific substance use patterns, mental status and social context. The ANRS-Methaville study gave us the opportunity to better disentangle the different relationships between these various factors and HCV risk practices. Methods The ANRS-Methaville multisite randomized trial was designed to assess the feasibility of initiating methadone in primary care by comparing it with methadone initiation in specialized centers. This study recruited 195 participants initiating methadone maintenance and followed up for 12 months. Longitudinal data from this trial was used to acquire a greater understanding of HCV risk practices and their pattern of correlates in this population. We selected 176 patients who had data on HCV risk practices at M0 and M12, accounting for 312 visits. HCV risk practices were defined as follows: sharing needles or syringes, sharing drug paraphernalia, getting a tattoo or having a piercing in a non-professional context, sharing toiletry items. To identify factors associated with HCV risk practices, we performed a mixed logistic regression analysis. Results HCV risk practices were reported by 19% and 15% of participants at baseline and M12, respectively. After adjustment for age, cocaine use and alcohol dependence as well as suicidal risk, living in a couple with a non-drug user and in a couple with a drug user were both independent predictors of HCV risk practices (OR[CI95%] = 4.16 [1.42-12.12]; OR[CI95%] = 9.85 [3.13-31.06], respectively). Conclusions Identifying individuals at risk of HCV transmission during methadone treatment such as stimulant users, alcohol dependent individuals, and those at suicidal risk is necessary to optimize response to treatment. Innovative prevention approaches tailored to couples are also urgently needed and could decrease HCV-risk in this population. The trial is registered with the French Agency of Pharmaceutical Products (ANSM) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials. Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511. PMID:25209306

Early initiation of beta blockade in heart failure: issues and evidence.

PubMed

Williams, Randall E

2005-09-01

Despite clinical trials demonstrating that inhibitors of the renin-angiotensin and sympathetic nervous systems can reduce the mortality and morbidity risk associated with heart failure, these drugs have remained underutilized in general clinical practice. In particular, many patients with heart failure due to left ventricular systolic dysfunction fail to receive beta blockers, although this class of drugs, as well as other antihypertensive agents such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, are recommended as part of routine heart failure therapy by national expert consensus guidelines. In-hospital initiation of beta-blocker therapy may improve long-term utilization by physicians and compliance by patients through obviating many of the misperceived dangers associated with beta blockade. The following review of the clinical trial data from the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) trial, the Metoprolol Controlled-Release Randomized Intervention Trial in Heart Failure (MERIT-HF), the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) trial, and the Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) trial on the efficacy, safety, and tolerability of beta blockers indicates that early initiation can be safely achieved and can improve patient outcomes.

Strategies for improving outcomes in the acute management of ischemic stroke in rural emergency departments: a quality improvement initiative in the Stroke Belt.

PubMed

Jauch, Edward C; Huang, David Y; Gardner, Allison J; Blum, Julie L

2018-01-01

The timely evaluation and initiation of treatment for acute ischemic stroke (AIS) is critical to optimal patient outcomes. However, clinical practice often falls short of guideline-established goals. Hospitals in rural regions of the USA, and notably those in the Stroke Belt, are particularly challenged to meet timing goals since the vast majority of primary stroke centers (PSCs) are concentrated in urban academic institutions. Between May 2015 and May 2017, emergency department (ED) teams from 5 non-PSC hospitals in the Stroke Belt participated in a quality improvement (QI) initiative. The intervention included a baseline practice assessment survey, repeat audit-and-feedback cycles with patient data on AIS treatment timing, personalized Continuing Medical Education/Continuing Education-certified grand rounds sessions at each participating site with expert study faculty, targeted reinforcement of best practices, and follow-up to evaluate the benefits and limitations of the intervention. At the start of the initiative, clinical staff from participating EDs overestimated the proportion of patients with AIS who received alteplase within the guideline-recommended 60-minute door-to-needle window at their facility. At the end of the 6-month intervention period, significantly more patients were treated with alteplase within 60 minutes of ED arrival compared to baseline across the entire sample (1.9% of patients at baseline vs. 5.2% at 6 months; P < 0.01). Similarly, there was a trend toward a decrease in the percentage of patients whose alteplase treatment was initiated more than 60 minutes after their arrival at the ED (67.3% at baseline vs. 22.2% at 6 months). Structured QI interventions that engage ED care teams to reflect on processes related to AIS diagnosis and treatment and deploy repeat audit-and-feedback cycles with real-time patient data have the potential to support an increase in the number of patients who receive alteplase within the guideline-recommended timeframe of 60 minutes from hospital arrival.

Assessing biocomputational modelling in transforming clinical guidelines for osteoporosis management.

PubMed

Thiel, Rainer; Viceconti, Marco; Stroetmann, Karl

2011-01-01

Biocomputational modelling as developed by the European Virtual Physiological Human (VPH) Initiative is the area of ICT most likely to revolutionise in the longer term the practice of medicine. Using the example of osteoporosis management, a socio-economic assessment framework is presented that captures how the transformation of clinical guidelines through VPH models can be evaluated. Applied to the Osteoporotic Virtual Physiological Human Project, a consequent benefit-cost analysis delivers promising results, both methodologically and substantially.

Gender Parity in Critical Care Medicine.

PubMed

Mehta, Sangeeta; Burns, Karen E A; Machado, Flavia R; Fox-Robichaud, Alison E; Cook, Deborah J; Calfee, Carolyn S; Ware, Lorraine B; Burnham, Ellen L; Kissoon, Niranjan; Marshall, John C; Mancebo, Jordi; Finfer, Simon; Hartog, Christiane; Reinhart, Konrad; Maitland, Kathryn; Stapleton, Renee D; Kwizera, Arthur; Amin, Pravin; Abroug, Fekri; Smith, Orla; Laake, Jon H; Shrestha, Gentle S; Herridge, Margaret S

2017-08-15

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These documents inform and shape patient care around the world. In this Perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government. We propose five strategies to ensure gender parity within critical care medicine.

ICMR programme on Antibiotic Stewardship, Prevention of Infection & Control (ASPIC).

PubMed

Chandy, Sujith J; Michael, Joy Sarojini; Veeraraghavan, Balaji; Abraham, O C; Bachhav, Sagar S; Kshirsagar, Nilima A

2014-02-01

Antimicrobial resistance and hospital infections have increased alarmingly in India. Antibiotic stewardship and hospital infection control are two broad strategies which have been employed globally to contain the problems of resistance and infections. For this to succeed, it is important to bring on board the various stakeholders in hospitals, especially the clinical pharmacologists. The discipline of clinical pharmacology needs to be involved in themes such as antimicrobial resistance and hospital infection which truly impact patient care. Clinical pharmacologists need to collaborate with faculty in other disciplines such as microbiology to achieve good outcomes for optimal patient care in the hospital setting. The ASPIC programme was initiated by the Indian Council of Medical Research (ICMR) in response to the above need and was designed to bring together faculty from clinical pharmacology, microbiology and other disciplines to collaborate on initiating and improving antibiotic stewardship and concurrently curbing hospital infections through feasible infection control practices. This programme involves the participation of 20 centres per year throughout the country which come together for a training workshop. Topics pertaining to the above areas are discussed in addition to planning a project which helps to improve antibiotic stewardship and infection control practices in the various centres. It is hoped that this programme would empower hospitals and institutions throughout the country to improve antibiotic stewardship and infection control and ultimately contain antimicrobial resistance.

Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness.

PubMed

Paxton, Elizabeth W; Kiley, Mary-Lou; Love, Rebecca; Barber, Thomas C; Funahashi, Tadashi T; Inacio, Maria C S

2013-06-01

In response to the increased volume, risk, and cost of medical devices, in 2001 Kaiser Permanente (KP) developed implant registries to enhance patient safety and quality, and to evaluate cost-effectiveness. Using an integrated electronic health record system, administrative databases, and other institutional databases, orthopedic, cardiology, and vascular implant registries were developed in 2001, 2006, and 2011, respectively. These registries monitor patients, implants, clinical practices, and surgical outcomes for KP's 9 million members. Critical to registry success is surgeon leadership and engagement; each geographical region has a surgeon champion who provides feedback on registry initiatives and disseminates registry findings. The registries enhance patient safety by providing a variety of clinical decision tools such as risk calculators, quality reports, risk-adjusted medical center reports, summaries of surgeon data, and infection control reports to registry stakeholders. The registries are used to immediately identify patients with recalled devices, evaluate new and established device technology, and identify outlier implants. The registries contribute to cost-effectiveness initiatives through collaboration with sourcing and contracting groups and confirming adherence to device formulary guidelines. Research studies based on registry data have directly influenced clinical best practices. Registries are important tools to evaluate longitudinal device performance and safety, study the clinical indications for and outcomes of device implantation, respond promptly to recalls and advisories, and contribute to the overall high quality of care of our patients.

Periorbital and eyelid edema: the initial manifestation of acute infectious mononucleosis.

PubMed

Decker, G R; Berberian, B J; Sulica, V I

1991-05-01

A case of periorbital and eyelid edema in an eighteen-year-old student is presented as the initial manifestation of acute infectious mononucleosis occurring one week before the typical prodrome. Although periorbital and eyelid edema have been reported in about 50 percent of patients with early infectious mononucleosis, its occurrence is much less frequent in clinical practice. Physicians, particularly those specializing in the treatment of cutaneous and ocular diseases, should now include acute infectious mononucleosis in the differential diagnosis of periorbital and eyelid edema.

STORC safety initiative: a multicentre survey on preparedness & confidence in obstetric emergencies.

PubMed

Guise, Jeanne-Marie; Segel, Sally Y; Larison, Kristine; M Jump, Sarah; Constable, Marion; Li, Hong; Osterweil, Patricia; Dieter Zimmer

2010-12-01

Patient safety is a national and international priority. The purpose of this study was to understand clinicians' perceptions of teamwork during obstetric emergencies in clinical practice, to examine factors associated with confidence in responding to obstetric emergencies and to evaluate perceptions about the value of team training to improve preparedness. An anonymous survey was administered to all clinical staff members who respond to obstetric emergencies in seven Oregon hospitals from June 2006 to August 2006. 614 clinical staff (74.5%) responded. While over 90% felt confident that the appropriate clinical staff would respond to emergencies, more than half reported that other clinical staff members were confused about their role during emergencies. Over 84% were confident that emergency drills or simulation-based team training would improve performance. Clinical staff who respond to obstetric emergencies in their practice reported feeling confident that the qualified personnel would respond to an emergency; however, they were less confident that the responders would perform well as a team. They reported that simulation and team training may improve their preparedness and confidence in responding to emergencies.

Was it easy to use an Asthma Control Test (ACT) in different clinical practice settings in a tertiary hospital in Singapore?

PubMed

Prabhakaran, Lathy; Earnest, Arul; Abisheganaden, John; Chee, Jane

2009-12-01

The Asthma Control Test (ACT) is a 5-item self-administered tool designed to assess asthma control. It is said to be simple, easy and can be administered quickly by patients in the clinical practice setting. This stated benefit has yet to be demonstrated in our local clinical practice setting. The aim was to identify factors associated with difficulty in the administration of the ACT in different clinical practice settings in a tertiary hospital in Singapore. This is a prospective study performed from April to June 2008. All patients diagnosed with asthma and referred to an asthma nurse from the in-patient and out-patient clinical practice setting in Tan Tock Seng Hospital were enrolled. Four hundred and thirty-four patients were asked to complete the ACT tool. In the univariate model, we found that age, clinical setting and medical history to be significantly associated with the completion of the ACT. The odds of completion decreased by a factor of 0.92 (95% CI, 0.89 to 0.94) for every year's increase in age, and this was statistically significant (P <0.001). Similarly, the odds ratio of completion for those with more than 3 medical conditions by history were 0.59 (95% CI, 0.48 to 0.71) as compared to those with less than 3 medical conditions by history, and this was also significant (P <0.001). In the multivariate model, we only found age to be an independent and significant factor. After adjusting for age, none of the other variables initially significant in the univariate model remained significant. The results show that the ACT was simple and easy to be administered in younger-aged patients.

The development of leadership outcome-indicators evaluating the contribution of clinical specialists and advanced practitioners to health care: a secondary analysis.

PubMed

Elliott, Naomi; Begley, Cecily; Kleinpell, Ruth; Higgins, Agnes

2014-05-01

To report a secondary analysis of data collected from the case study phase of a national study of advanced practitioners and to develop leadership outcome-indicators appropriate for advanced practitioners. In many countries, advanced practitioners in nursing and midwifery have responsibility as leaders for health care development, but without having leadership outcome measures available they are unable to demonstrate the results of their activities. In Ireland, a sequential mixed method research study was used to develop a validated tool for the evaluation of clinical specialists and advanced practitioners. Despite strong evidence of leadership activities, few leadership-specific outcomes were generated from the primary analysis. Secondary analysis of a multiple case study data set. Data set comprised 23 case studies of advanced practitioner/clinical specialists from 13 sites across each region in Ireland from all divisions of the Nursing Board Register. Data were collected 2008-2010. Data sources included non-participant observation (n = 92 hours) of advanced practitioners in practice, interviews with clinicians (n = 21), patients (n = 20) and directors of nursing/midwifery (n = 13) and documents. Analysis focused on leadership outcome-indicator development in line with the National Health Service's Good Indicators Guide. The four categories of leadership outcomes for advanced practitioner developed were as follows: (i) capacity and capability building of multidisciplinary team; (ii) measure of esteem; (iii) new initiatives for clinical practice and healthcare delivery; and (iv) clinical practice based on evidence. The proposed set of leadership outcome-indicators derived from a secondary analysis captures the complexity of leadership in practice. They add to existing clinical outcomes measuring advanced practice. © 2013 John Wiley & Sons Ltd.

Utility of repeat testing of critical values: a Q-probes analysis of 86 clinical laboratories.

PubMed

Lehman, Christopher M; Howanitz, Peter J; Souers, Rhona; Karcher, Donald S

2014-06-01

A common laboratory practice is to repeat critical values before reporting the test results to the clinical care provider. This may be an unnecessary step that delays the reporting of critical test results without adding value to the accuracy of the test result. To determine the proportions of repeated chemistry and hematology critical values that differ significantly from the original value as defined by the participating laboratory, to determine the threshold differences defined by the laboratory as clinically significant, and to determine the additional time required to analyze the repeat test. Participants prospectively reviewed critical test results for 4 laboratory tests: glucose, potassium, white blood cell count, and platelet count. Participants reported the following information: initial and repeated test result; time initial and repeat results were first known to laboratory staff; critical result notification time; if the repeat result was still a critical result; if the repeat result was significantly different from the initial result, as judged by the laboratory professional or policy; significant difference threshold, as defined by the laboratory; the make and model of the instrument used for primary and repeat testing. Routine, repeat analysis of critical values is a common practice. Most laboratories did not formally define a significant difference between repeat results. Repeated results were rarely considered significantly different. Median repeated times were at least 17 to 21 minutes for 10% of laboratories. Twenty percent of laboratories reported at least 1 incident in the last calendar year of delayed result reporting that clinicians indicated had adversely affected patient care. Routine repeat analysis of automated chemistry and hematology critical values is unlikely to be clinically useful and may adversely affect patient care.

Can data extraction from general practitioners' electronic records be used to predict clinical outcomes for patients with type 2 diabetes?

PubMed

Staff, Michael

2012-01-01

The review of clinical data extraction from electronic records is increasingly being used as a tool to assist general practitioners (GPs) manage their patients in Australia. Type 2 diabetes (T2DM) is a chronic condition cared for primarily in the general practice setting that lends itself to the application of tools in this area. To assess the feasibility of extracting data from a general practice medical record software package to predict clinically significant outcomes for patients with T2DM. A pilot study was conducted involving two large practices where routinely collected clinical data were extracted and inputted into the United Kingdom Prospective Diabetes Study Outcomes Model to predict life expectancy. An initial assessment of the completeness of data available was performed and then for those patients aged between 45 and 64 years with adequate data life expectancies estimated. A total of 1019 patients were identified as current patients with T2DM. There were sufficient data available on 40% of patients from one practice and 49% from the other to provide inputs into the UKPDS Outcomes Model. Predicted life expectancy was similar across the practices with women having longer life expectancies than men. Improved compliance with current management guidelines for glycaemic, lipid and blood pressure control was demonstrated to increase life expectancy between 1.0 and 2.4 years dependent on gender and age group. This pilot demonstrated that clinical data extraction from electronic records is feasible although there are several limitations chiefly caused by the incompleteness of data for patients with T2DM.

The Ohio Gestational Diabetes Postpartum Care Learning Collaborative: Development of a Quality Improvement Initiative to Improve Systems of Care for Women.

PubMed

Shellhaas, Cynthia; Conrey, Elizabeth; Crane, Dushka; Lorenz, Allison; Wapner, Andrew; Oza-Frank, Reena; Bouchard, Jo

2016-11-01

Objectives To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). Methods We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. Results Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. Conclusions for Practice QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.

A framework to develop a clinical learning culture in health facilities: ideas from the literature.

PubMed

Henderson, A; Briggs, J; Schoonbeek, S; Paterson, K

2011-06-01

Internationally, there is an increase in demand to educate nurses within the clinical practice environment. Clinical practice settings that encourage teaching and learning during episodes of care delivery can be powerful in educating both the existing nursing workforce and nursing students. This paper presents a framework, informed by the literature, that identifies the key factors that are needed to encourage the interactions fundamental to learning in clinical practice. Learning occurs when nurses demonstrate good practice, share their knowledge through conversations and discussions, and also provide feedback to learners, such as students and novices. These types of interactions occur when positive leadership practices encourage trust and openness between staff; when the management team provides sessions for staff to learn how to interact with learners, and also when partnerships provide support and guidance around learning in the workplace. APPLICATION OF CONCEPTS: This framework presents how the concepts of leadership, management and partnership interact to create and sustain learning environments. The feedback from proposed measurement tools can provide valuable information about the positive and negative aspects of these concepts in the clinical learning environment. Analysis of the subscales can assist in identifying appropriate recommended strategies outlined in the framework to guide nurses in improving the recognized deficits in the relationship between the concepts. Leadership, management and partnerships are pivotal for the creation and maintenance of positive learning environments. Diagnostic measurement tools can provide specific information about weaknesses across these areas. This knowledge can guide future initiatives. © 2011 The Authors. International Nursing Review © 2011 International Council of Nurses.

Using Interactive Patient Engagement Technology in Clinical Practice: A Qualitative Assessment of Nurses' Perceptions.

PubMed

Patmon, Frances L; Gee, Perry M; Rylee, Tina L; Readdy, Noriann L

2016-11-11

Research has shown patients who are more engaged in their care are likely to have better health outcomes and reduced health care costs. Health care organizations are now focusing their efforts in finding ways to improve patient engagement. At the forefront of this movement are patient engagement technology systems. In this paper, these emerging systems are described as interactive patient engagement technologies (iPET). The objective of this descriptive study was to gain an understanding of the perceptions of nurses who are integrating these iPET systems into their daily clinical practice. The research team interviewed 38 nurses from 2 California-based hospitals using a focused rapid ethnographic evaluation methodology to gather data. The study participants reported that using iPET systems may enhance clinical nursing practice. The 4 key findings of iPET were that it (1) is effective for distraction therapy, (2) has functionality that affects both patients and nurses, (3) has implications for clinical practice, and (4) may require additional training to improve usage. With sufficient training on the iPET system, nurses believed they could use these technologies as an enhancement to their clinical practice. Additionally, nurses perceived these systems served as distraction therapy for patients. Initial findings suggest that iPET is beneficial, but more research is required to examine the usefulness of iPET systems in the inpatient settings. ©Frances L Patmon, Perry M Gee, Tina L Rylee, Noriann L Readdy. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.11.2016.

Implementation of a pharmacist-managed heart failure medication titration clinic.

PubMed

Martinez, Amanda S; Saef, Jerold; Paszczuk, Anna; Bhatt-Chugani, Hetal

2013-06-15

The development, implementation, and initial results of a pharmacist-managed heart failure (HF) medication titration clinic are described. In a quality-improvement initiative at a Veterans Affairs health care system, clinical pharmacists were incorporated into the hospital system's interprofessional outpatient HF clinic. In addition, a separate pharmacist-managed HF medication titration clinic was established, in which pharmacists were granted an advanced scope of practice and prescribing privileges, enabling them to initiate and adjust medication dosages under specific protocols jointly established by cardiology and pharmacy staff. Pharmacists involved in the titration clinic tracked patients' daily body weight, vital signs, and volume status using telephone-monitoring technology and via patient interviews. A retrospective chart review comparing achievement of target doses of angiotensin-converting enzyme inhibitor (ACEI), angiotensin-receptor blocker (ARB), and β-blocker therapies in a group of patients (n = 28) whose dosage titrations were carried out by nurses or physicians prior to implementation of the pharmacist-managed HF medication titration clinic and a group of patients (n = 27) enrolled in the medication titration clinic during its first six months of operation indicated that target ACEI and ARB doses were achieved in a significantly higher percentage of pharmacist-managed titration clinic enrollees (52.9% versus 31%, p = 0.007). Patients enrolled in the pharmacist-managed HF medication titration clinic also had a significantly higher rate of attainment of optimal β-blocker doses (49% versus 24.7%, p = 0.012). Implementation of a pharmacist-managed HF medication titration clinic increased the percentage of patients achieving optimal ACEI, ARB, and β-blocker dosages.

[Survey of nurses about compression therapy of acute deep venous thrombosis. Field study in Saxony-Anhalt].

PubMed

Thieme, Dorothea; Langer, Gero; Behrens, Johann

2010-03-01

In clinical practice, the compression therapy is an established method for the treatment of acute deep vein thrombosis (DVT). The aim of this study was to clarify the extent to which current guidelines and results of studies done in the field for the treatment of acute DVT--particularly compression therapy--are implemented in clinical practice. All hospitals in Saxony-Anhalt using primary diagnosis and therapy for DVT (n = 34) were informed about a survey in 2007 and the nursing staff of angiology and internistical wards in these hospitals was asked to take part. The collection of data was done with the help of a questionnaire that had been designed and tested for its validity in a specialised hospital. 510 questionnaires were distributed. The response rate of questionnaires was 69 percent. 79 percent of the nursing staff of internistical wards in Saxony-Anhalt and 94 percent of the nursing staff of angiology wards said that patients with acute DVT have initially received a compression bandage. Significant deficits were visible in transferring the knowledge of evidence-based medicine and nursing regarding techniques of compression bandage. The recommended Fischer-Bandage was only put on in exceptional cases in internistical wards (3 percent) and Angiology (2 percent). Compression stockings were not a suitable method into the treatment of acute deep vein thrombosis of Angiology. 21 percent of the nursing staff of internistical wards said that they have initially applied compression stockings. The treatment of acute DVT is important in clinical practice. The compression bandage should be effectively put on the leg. The quality of care and long-term compliance of the patients could be increased this way, leading to prevention of post thrombotic syndrome (PTS) and reduction the duration of patients stay in the clinics.

Using a patient decision aid for insulin initiation in patients with type 2 diabetes: a qualitative analysis of doctor–patient conversations in primary care consultations in Malaysia

PubMed Central

Syed, Ayeshah; Mohd Don, Zuraidah; Ng, Chirk Jenn; Lee, Yew Kong; Khoo, Ee Ming; Lee, Ping Yein; Lim Abdullah, Khatijah; Zainal, Azlin

2017-01-01

Objective To investigate whether the use of apatient decision aid (PDA) for insulin initiation fulfils its purpose of facilitating patient-centred decision-making through identifying how doctors and patients interact when using the PDA during primary care consultations. Design Conversation analysis of seven single cases of audio-recorded/video-recorded consultations between doctors and patients with type 2 diabetes, using a PDA on starting insulin. Setting Primary care in three healthcare settings: (1) one private clinic; (2) two public community clinics and (3) one primary care clinic in a public university hospital, in Negeri Sembilan and the Klang Valley in Malaysia. Participants Clinicians and seven patients with type 2 diabetes to whom insulin had been recommended. Purposive sampling was used to select a sample high in variance across healthcare settings, participant demographics and perspectives on insulin. Primary outcome measures Interaction between doctors and patients in a clinical consultation involving the use of a PDA about starting insulin. Results Doctors brought the PDA into the conversation mainly by asking information-focused ‘yes/no’ questions, and used the PDA for information exchange only if patients said they had not read it. While their contributions were limited by doctors’ questions, some patients disclosed issues or concerns. Although doctors’ PDA-related questions acted as a presequence to deliberation on starting insulin, their interactional practices raised questions on whether patients were informed and their preferences prioritised. Conclusions Interactional practices can hinder effective PDA implementation, with habits from ordinary conversation potentially influencing doctors’ practices and complicating their implementation of patient-centred decision-making. Effective interaction should therefore be emphasised in the design and delivery of PDAs and in training clinicians to use them. PMID:28490553

Implementation of a drug-use and disease-state management program.

PubMed

Skledar, S J; Hess, M M

2000-12-15

A drug-use and disease-state management (DUDSM) program was instituted in 1996 at a teaching hospital associated with a large nonprofit health care system. The program's goals are to optimize pharmacotherapeutic regimens, evaluate health outcomes of identified disease states, and evaluate the economic impact of pharmacotherapeutic options for given disease states by developing practice guidelines. Through a re-engineering process, resources within the pharmacy department were identified that could be devoted to the DUDSM program, including the use of clinical pharmacy specialists, promotion of staff pharmacists into the DUDSM program, a pharmacy technician, and information systems support. A strength of the program is its systematic approach for developing and implementing new initiatives, as well as monitoring compliance with all initiatives on an ongoing basis. The initiative-design process incorporates continuous quality improvement principles, outcome design and evaluation, competency assessment for all pharmacists, multidisciplinary collaboration, and sophisticated information systems. Seventy-five initiatives have been implemented, ranging from simple dose-optimization strategies for specific drugs to complicated practice guidelines for managing specific disease states. Improved patient outcomes have been documented, including reduced length of stay, postsurgical wound infection, adverse drug reactions, and medication errors. Documented cost savings exceeded $4 million annually for fiscal years 1996-97 through 1999-2000. Overall compliance with DUDSM initiatives exceeds 80%, and physician service profiling has been initiated to monitor variant prescribing. The DUDSM program has successfully integrated practice guidelines into therapeutic decision-making, resulting in improved patient-care outcomes and cost savings.

Series: Clinical Epidemiology in South Africa. Paper 1: Evidence-based health care and policy in Africa: past, present, and future.

PubMed

Young, Taryn; Garner, Paul; Clarke, Mike; Volmink, Jimmy

2017-03-01

Africa has high disease burden and health system challenges but is making progress in recognizing, accepting, and adopting evidence-based health care (EBHC). In this article, we reflect on the developments of the past 2 decades and consider further steps that will help with the translation of reliable research results into the decision making process. There has been a rapid growth in various initiatives to promote EBHC in the African region. These include the conduct and reporting of primary and secondary research, research capacity development and supportive initiatives, access to information, and work with decision makers in getting research into clinical guidelines and health policies. Much, however, still needs to be done to improve the impact on health in the region. A multipronged approach consisting of regionally relevant well-conducted research addressing priority health problems, increased uptake of research in health care policy and practice, dedicated capacity development initiatives to support the conduct as well as use of research, facilitated by wider collaboration, and equitable partnerships will be important. Working together in mutually supporting partnerships is key to advancing both evidence-informed health care practices and better health. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Translating Health Care–Associated Urinary Tract Infection Prevention Research into Practice via the Bladder Bundle

PubMed Central

Saint, Sanjay; Olmsted, Russell N.; Fakih, Mohamad G.; Kowalski, Christine P.; Watson, Sam R.; Sales, Anne E.; Krein, Sarah L.

2009-01-01

Article-at-a-Glance Background: Catheter-associated urinary tract infection (CAUTI), a frequent health care–associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for the extra cost of caring for patients who develop CAUTI. The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality has initiated a statewide initiative, MHA Keystone HAI, to help ameliorate the burden of disease associated with indwelling catheterization. In addition, a long-term research project is being conducted to evaluate the current initiative and to identify practical strategies to ensure the effective use of proven infection prevention and patient safety practices. Overview of the Bladder Bundle Initiative in Michigan: The bladder bundle as conceived by MHA Keystone HAI focuses on preventing CAUTI by optimizing the use of urinary catheters with a specific emphasis on continual assessment and catheter removal as soon as possible, especially for patients without a clear indication. Collaboration Between Researchers and State wide Patient Safety Organizations: A synergistic collaboration between patient safety researchers and a statewide patient safety organization is aimed at identifying effective strategies to move evidence from peer-reviewed literature to the bedside. Practical strategies that facilitate implementation of the bundle will be developed and tested using mixed quantitative and qualitative methods. Discussion: Simply disseminating scientific evidence is often ineffective in changing clinical practice. Therefore, learning how to implement these findings is critically important to promoting high-quality care and a safe health care environment. PMID:19769204

The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care.

PubMed

Norvoll, Reidun; Hem, Marit Helene; Pedersen, Reidar

2017-03-01

Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics (i.e., ethical theory, moral deliberation and clinical ethics support) in such initiatives. This study adds to this subject by exploring health professionals' descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were carried out in 2012 with key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed.

Towards Building a Bridge between Community Engagement in Research (CEnR) and Comparative Effectiveness Research (CER).

PubMed

Ahmed, Syed M; Nelson, David; Kissack, Anne; Franco, Zeno; Whittle, Jeff; Kotchen, Theodore; Meurer, John R; Morzinski, Jeffrey; Brandenburg, Terry

2015-04-01

A major national priority is establishing an effective infrastructure for translation of scientific discoveries into the community. Knowledge and practice continue to accelerate in health research yet healthcare recommendation adoption remains slow for practitioners, patients, and communities. Two areas of research placed in the later stages of the translational research spectrum, Community Engagement in Research and Comparative Effectiveness Research, are ideal for approaching this challenge collaboratively. The Clinical and Translational Science Institute of Southeastern Wisconsin convened academics and community-based organizations familiar with these fields of research in a 1-day workshop to establish an initial dialogue on similarities and differences with a goal of exploring ways to operationalize a collective effort. Participants represented four academic institutions and twelve other healthcare and community-based service organizations. Primary fields of study included community engaged research, comparative effectiveness research, psychology, clinical research, administration, nursing, public health, education, and other professionals. This initial report outlines the results of this diverse discussion and provides insights into the priorities, diverging issues, and areas for future examination and practice. Key discoveries reveal clear crosscutting issues, value in philosophical and provocative discussions among investigators, a need for practice and lessons learned, and bidirectional exchange with community representation. © 2014 Wiley Periodicals, Inc.

The role of emotions in clinical reasoning and decision making.

PubMed

Marcum, James A

2013-10-01

What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care.

Postauthorization safety study of the DPP-4 inhibitor saxagliptin: a large-scale multinational family of cohort studies of five outcomes.

PubMed

Lo Re, Vincent; Carbonari, Dena M; Saine, M Elle; Newcomb, Craig W; Roy, Jason A; Liu, Qing; Wu, Qufei; Cardillo, Serena; Haynes, Kevin; Kimmel, Stephen E; Reese, Peter P; Margolis, David J; Apter, Andrea J; Reddy, K Rajender; Hennessy, Sean; Bhullar, Harshvinder; Gallagher, Arlene M; Esposito, Daina B; Strom, Brian L

2017-01-01

To evaluate the risk of serious adverse events among patients with type 2 diabetes mellitus initiating saxagliptin compared with oral antidiabetic drugs (OADs) in classes other than dipeptidyl peptidase-4 (DPP-4) inhibitors. Cohort studies using 2009-2014 data from two UK medical record data sources (Clinical Practice Research Datalink, The Health Improvement Network) and two USA claims-based data sources (HealthCore Integrated Research Database, Medicare). All eligible adult patients newly prescribed saxagliptin (n=110 740) and random samples of up to 10 matched initiators of non-DPP-4 inhibitor OADs within each data source were selected (n=913 384). Outcomes were hospitalized major adverse cardiovascular events (MACE), acute kidney injury (AKI), acute liver failure (ALF), infections, and severe hypersensitivity events, evaluated using diagnostic coding algorithms and medical records. Cox regression was used to determine HRs with 95% CIs for each outcome. Meta-analyses across data sources were performed for each outcome as feasible. There were no increased incidence rates or risk of MACE, AKI, ALF, infection, or severe hypersensitivity reactions among saxagliptin initiators compared with other OAD initiators within any data source. Meta-analyses demonstrated a reduced risk of hospitalization/death from MACE (HR 0.91, 95% CI 0.85 to 0.97) and no increased risk of hospitalization for infection (HR 0.97, 95% CI 0.93 to 1.02) or AKI (HR 0.99, 95% CI 0.88 to 1.11) associated with saxagliptin initiation. ALF and hypersensitivity events were too rare to permit meta-analysis. Saxagliptin initiation was not associated with increased risk of MACE, infection, AKI, ALF, or severe hypersensitivity reactions in clinical practice settings. NCT01086280, NCT01086293, NCT01086319, NCT01086306, and NCT01377935; Results.

Practice management based on risk assessment.

PubMed

Sandberg, Hans

2004-01-01

The management of a dental practice is most often focused on what clinicians do (production of items), and not so much on what is achieved in terms of oral health. The main reason for this is probably that it is easier to measure production and more difficult to measure health outcome. This paper presents a model based on individual risk assessment that aims to achieve a financially sound economy and good oral health. The close-to-the-clinic management tool, the HIDEP Model (Health Improvement in a DEntal Practice) was pioneered initially in Sweden at the end of 1980s. The experience over a 15-year period with different elements of the model is presented, including: the basis of examination and risk assessment; motivation; task delegation and leadership issues; health-finance evaluations; and quality development within a dental clinic. DentiGroupXL, a software program designed to support the work based on the model, is also described.

The Evolution of Gero-Oncology Nursing

PubMed Central

Bond, Stewart M.; Bryant, Ashley Leak; Puts, Martine

2016-01-01

Objectives This article summarizes the evolution of gero-oncology nursing and highlights key educational initiatives, clinical practice issues, and research areas to enhance care of older adults with cancer. Data Sources Peer-reviewed literature, position statements, clinical practice guidelines, web-based materials, and professional organizations’ resources. Conclusion Globally, the older adult cancer population is rapidly growing. The care of older adults with cancer requires an understanding of their diverse needs and the intersection of cancer and aging. Despite efforts to enhance competence in gerooncology and to develop a body of evidence, nurses and healthcare systems remain under-prepared to provide high quality care for older adults with cancer. Implications for Nursing Practice Nurses need to take a leadership role in integrating gerontological principles into oncology settings. Working closely with interdisciplinary team members, nurses should utilize available resources and continue to build evidence through gero-oncology nursing research. PMID:26830263

Role of laser myringotomy in a pediatric otolaryngology practice: initial experience

NASA Astrophysics Data System (ADS)

Shah, Udayan K.

2001-05-01

A new technology (OtoLAM) to fenestrate the tympanic membrane with the carbon dioxide laser (CO2), in the office or the operating room, has been introduced over the last three years. While not new conceptually, this product offers the ability to easily create a precise window into the middle ear using a portable system. Controversy regarding the indications and benefits of this technique, amplified by the costs of the system and the marketing of the technology prior to extensive clinical testing, has plagued the clinical application of this technology. We report our experience over the past year with this system in a busy pediatric otolaryngology practice. Laser fenestration of the tympanic membrane has been useful for the insertion of tympanostomy tubes, and for the minimally invasive evaluation of the middle ear. Our small experience to date reveals that there is a limited role for laser tympanic membrane fenestration in a busy pediatric otolaryngology practice.

Building capacity in Clinical Epidemiology in Africa: experiences from Masters programmes.

PubMed

Young, Taryn; Naude, Celeste; Brodovcky, Tania; Esterhuizen, Tonya

2017-02-27

To describe and contrast programmatic offering of Clinical Epidemiology Masters programmes in Africa, to evaluate experiences of graduates and faculty, and assess if graduates are playing roles in research, practice and teaching of Clinical Epidemiology. We searched and identified relevant programmes, reviewed programmatic documentation, interviewed convenors and surveyed graduates. Participants provided informed consent, interviews with faculty were recorded and transcribed for analysis purposes, and graduates participated in an online survey. Five structured Masters programmes requiring health science professionals to complete modules and research projects were assessed. Demand for programmes was high. Graduates enjoyed the variety of modules, preferred blended teaching, and regarded assessments as fair. Graduates felt that career paths were not obvious after graduating. Despite this, some have gone on to promote and teach evidence-based health care, and conduct and disseminate research. Areas of concern raised by faculty were quality assurance; research project initiation, implementation and supervisory capacity; staff availability; funding to support implementation and lack of experiential learning. Although faced with challenges, these programmes build capacity of health professionals to practice in an evidence-informed way, and conduct rigorous research, which are central to advancing the practice of Clinical Epidemiology in Africa.

Contemporary roles of registries in clinical cardiology: when do we need randomized trials?

PubMed

Ieva, Francesca; Gale, Chris P; Sharples, Linda D

2014-12-01

Clinical registries are established as tools for auditing clinical standards and benchmarking quality improvement initiatives. They also have an emerging role (as electronic health records) in cardiovascular research and, in particular, the conduct of RCTs. While the RCT is accepted as the most robust experimental design, observational data from clinical registries has become increasingly valuable for RCTs. Data from clinical registries may be used to augment results from RCTs, identify patients for recruitment and as an alternative when randomization is not practically possible or ethically desirable. Here the authors appraise the advantages and disadvantages of both methodologies, with the aim of clarifying when their joint use may be successful.

Developing a clinical academic career pathway for nursing.

PubMed

Coombs, Maureen; Latter, Sue; Richardson, Alison

Since the publication of the UK Clinical Research Collaboration's (UKRC, 2007) recommendations on careers in clinical research, interest has grown in the concept of clinical academic nursing careers, with increased debate on how such roles might be developed and sustained (Department of Health, 2012). To embed clinical academic nursing roles in the NHS and universities, a clear understanding and appreciation of the contribution that such posts might make to organisational objectives and outcomes must be developed. This paper outlines an initiative to define the potential practice and research contribution of clinical academic roles through setting out role descriptors. This exercise was based on our experience of a clinical academic career initiative at the University of Southampton run in partnership with NHS organisations. Role descriptors were developed by a group of service providers, academics and two clinical academic award-holders from the local programme. This paper outlines clinical academic roles from novice to professor and describes examples of role descriptors at the different levels of a career pathway. These descriptors are informed by clinical academic posts in place at Southampton as well as others at the planning stage. Understanding the nature of clinical academic posts and the contribution that these roles can make to healthcare will enable them to become embedded into organisational structures and career pathways.

Complexity theory and the "puzzling" competencies: Systems-based Practice And Practice-based Learning explored.

PubMed

Gonnering, Russell S

2010-01-01

Of all the clinical competencies, the least understood are Systems-Based Practice and Practice-Based Learning and Improvement. With a shift to competency-based education and evaluation across the spectrum of surgical education and practice, a clear understanding of the power and utility of each competency is paramount. Health care operates as a complex adaptive system, with dynamics foreign to many health care professionals and educators. The adaptation and evolution of such a system is related directly to both the individual and the organizational learning of the agents within the system and knowledge management strategies. Far from being "difficult," Systems-Based Practice and Practice-Based Learning form the heart of quality improvement initiatives and future productivity advances in health care. Copyright 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Predicting the onset of psychosis in patients at clinical high risk: practical guide to probabilistic prognostic reasoning.

PubMed

Fusar-Poli, P; Schultze-Lutter, F

2016-02-01

Prediction of psychosis in patients at clinical high risk (CHR) has become a mainstream focus of clinical and research interest worldwide. When using CHR instruments for clinical purposes, the predicted outcome is but only a probability; and, consequently, any therapeutic action following the assessment is based on probabilistic prognostic reasoning. Yet, probabilistic reasoning makes considerable demands on the clinicians. We provide here a scholarly practical guide summarising the key concepts to support clinicians with probabilistic prognostic reasoning in the CHR state. We review risk or cumulative incidence of psychosis in, person-time rate of psychosis, Kaplan-Meier estimates of psychosis risk, measures of prognostic accuracy, sensitivity and specificity in receiver operator characteristic curves, positive and negative predictive values, Bayes' theorem, likelihood ratios, potentials and limits of real-life applications of prognostic probabilistic reasoning in the CHR state. Understanding basic measures used for prognostic probabilistic reasoning is a prerequisite for successfully implementing the early detection and prevention of psychosis in clinical practice. Future refinement of these measures for CHR patients may actually influence risk management, especially as regards initiating or withholding treatment. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Reflective practice groups for nurses: a consultation liaison psychiatry nursing initiative: part 2--the evaluation.

PubMed

Dawber, Chris

2013-06-01

This paper outlines an evaluation of reflective practice groups (RPG) involving nurses and midwives from three clinical nursing specialties at Redcliffe and Caboolture Hospitals, Queensland, Australia. The groups were facilitated by the consultation liaison psychiatry nurse and author using a process-focused, whole-of-group approach to explore clinical narrative in a supportive group setting. This was a preliminary evaluation utilizing a recently-developed tool, the Clinical Supervision Evaluation Questionnaire, along with externally-facilitated focus groups. Nurses and midwives responded favourably to RPG, reporting a positive impact on clinical practice, self-awareness, and resilience. The majority of participants considered RPG had positive implications for team functioning. The focus groups identified the importance of facilitation style and the need to address aspects of workplace culture to enable group development and enhance the capacity for reflection. Evaluation of the data indicates this style of RPG can improve reflective thinking, promote team cohesion, and provide support for nurses and midwives working in clinical settings. Following on from this study, a second phase of research has commenced, providing more detailed, longitudinal evaluation across a larger, more diverse group of nurses. © 2012 The Author; International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

Real-World Use and Outcomes of ALK-Positive Crizotinib-Treated Metastatic NSCLC in US Community Oncology Practices: A Retrospective Observational Study.

PubMed

Reynolds, Craig; Masters, Elizabeth T; Black-Shinn, Jenny; Boyd, Marley; Mardekian, Jack; Espirito, Janet L; Chioda, Marc

2018-05-29

Around 3⁻5% of non-small cell lung cancers (NSCLC) are ALK-positive. Crizotinib was the first approved ALK inhibitor from clinical trials. However, there are less data on the utilization and patient outcomes associated with crizotinib in real-world clinical practice. This was a retrospective, observational study of adult crizotinib-treated ALK-positive metastatic NSCLC patients who received treatment between 1 September 2011 and 31 October 2014, with follow up through 31 December 2015. Data were obtained via programmatic queries of the US Oncology Network/McKesson Specialty Health electronic health record database, supplemented with chart abstraction. Overall survival (OS) and time to treatment failure (TTF) were estimated from crizotinib initiation using the Kaplan⁻Meier (KM) method. Of the n = 199 ALK-positive crizotinib-treated patients meeting eligibility criteria, crizotinib was prescribed as first line (1 L) in n = 123 (61.8%). The majority (88.9%) had confirmed adenocarcinoma histology and 32.2% had brain metastases at initial diagnosis. Median age at crizotinib initiation was 60.2 years (range 27.1⁻88.2); 54.8% were never smokers, 33.7% were former smokers. Treatment of 250 mg, twice daily, was most commonly prescribed (89.5%) with the dose unchanged from an initial dose in 79.4% of patients. The primary discontinuation reason was progression ( n = 91, 58.7%). Patients (3.2%) were identified as discontinuing crizotinib as a result of treatment-related toxicity. With median follow-up time of 13.0 months (min⁻max = 0.03⁻46.6), median OS from crizotinib initiation was 33.8 months (95% CI = 24.3⁻38.8). Median TTF was 10.4 months. Crizotinib usage evaluated within the real-world setting is consistent with prior phase III clinical trial data, and illustrates the real-world effectiveness of crizotinib.

Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU).

PubMed

Nelson, Judith E; Bassett, Rick; Boss, Renee D; Brasel, Karen J; Campbell, Margaret L; Cortez, Therese B; Curtis, J Randall; Lustbader, Dana R; Mulkerin, Colleen; Puntillo, Kathleen A; Ray, Daniel E; Weissman, David E

2010-09-01

To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.

Adherence with bisphosphonate therapy and change in bone mineral density among women with osteoporosis or osteopenia in clinical practice.

PubMed

Weycker, D; Lamerato, L; Schooley, S; Macarios, D; Siu Woodworth, T; Yurgin, N; Oster, G

2013-04-01

In clinical practice, adherence with bisphosphonate therapy varies greatly among women with osteoporosis or osteopenia. Our study suggests that better adherence with bisphosphonates confers tangible benefits in terms of graded increases in bone mineral density. Interventions to improve drug adherence should be an important component of disease management. In clinical trials, bisphosphonates have been found to increase bone mineral density (BMD) in women with osteoporosis or osteopenia. In clinical practice, where drug adherence is more variable, change in BMD with bisphosphonate therapy-overall and by level of adherence-is largely unknown. A retrospective cohort study was conducted at Henry Ford Health System (Detroit, MI, USA). Study subjects were women who had low BMD at the left total hip (T-score<-1.0), began oral bisphosphonate therapy, and had ≥1 BMD measurements at the left total hip≥6 months following treatment initiation. Change in BMD was calculated between the most recent pretreatment scan and the first follow-up scan. Adherence (i.e., medication possession ratio (MPR)) was measured from therapy initiation to the first follow-up scan. Among 644 subjects, mean age was 66 years, pretreatment BMD was 0.73 g/cm2, and pretreatment T-score was -1.8. Over a mean follow-up of 27.1 months, mean MPR was 0.57 (95% CI, 0.54 and 0.59), and mean percentage change in BMD was 1.5% (1.1 and 1.9%). Within the MPR strata (five consecutive equi-intervals, from low (0-0.19) to high (0.80-1.0)), mean change in BMD was -0.8% (-1.6 and 0.1%), 0.7% (-0.3 and 1.7%), 2.1% (1.1 and 3.0%), 2.1% (1.4 and 2.9%), and 2.9% (2.3 and 3.5%), respectively. In adjusted analyses, percentage change in BMD was higher (by 1.4-3.4%, p<0.05 for all) in the highest four MPR intervals, respectively, versus MPR 0-0.19. Among women with osteoporosis or osteopenia in clinical practice, better adherence with bisphosphonates appears to confer tangible benefits in terms of increases in BMD.

Exploring the Transition to Practice for the Newly Credentialed Athletic Trainer: A Programmatic View

PubMed Central

Mazerolle, Stephanie M.; Walker, Stacy E.; Thrasher, Ashley Brooke

2015-01-01

Context  Some newly credentialed athletic trainers (ATs) pursue a postprofessional degree with a curriculum that specifically advances their athletic training practice. It is unknown how those postprofessional programs assist in their transition to practice. Objective  To gain an understanding of initiatives used by postprofessional athletic training programs to facilitate role transition from student to professional during their graduate degree programs. Design  Qualitative study. Setting  Semistructured telephone interviews. Patients or Other Participants  A total of 19 program directors (10 men, 9 women) from 13 Commission on Accreditation of Athletic Training Education-accredited and 6 unaccredited postprofessional athletic training programs. Data Collection and Analysis  Telephone interviews were recorded digitally and transcribed verbatim. For data analysis, we used the principles of general inductive approach. Credibility was maintained using peer review, member checks, and researcher triangulation. Results  Three facilitators of transition to practice emerged: orientation sessions, mentoring, and assistantship. Participants used orientation sessions ranging from a few hours to more than 1 week to provide and discuss program polices and expectations and to outline roles and responsibilities. Faculty, preceptors, and mentors were integrated into the orientation for the academic and clinical portions of the program. All participants described a mentoring process in which students were assigned by the program or informally developed. Mentors included the assigned preceptor, a staff AT, or peer students in the program. The clinical assistantship provided exposure to the daily aspects of being an AT. Barriers to transition to practice included previous educational experiences and time management. Participants reported that students with more diverse didactic and clinical education experiences had easier transitions. The ability to manage time also emerged as a challenge. Conclusions  Postprofessional athletic training programs used a formal orientation session as an initial means to help the newly credentialed AT transition into the role. Mentoring provided both more informal and ongoing support during the transition. PMID:26332029

Doctors' experience with handheld computers in clinical practice: qualitative study

PubMed Central

McAlearney, Ann Scheck; Schweikhart, Sharon B; Medow, Mitchell A

2004-01-01

Objective To examine doctors' perspectives about their experiences with handheld computers in clinical practice. Design Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns. Setting Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists. Participants 54 doctors who did or did not use handheld computers. Results Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking. Conclusions Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care. PMID:15142920

Normal tension glaucoma management: a survey of contemporary practice.

PubMed

Symes, Richard J; Mikelberg, Frederick S

2017-08-01

The aim of this study was to investigate contemporary practice patterns with respect to normal tension glaucoma (NTG) management and to determine whether the 2 largest NTG trials have influenced ophthalmologists' clinical practice. A survey questionnaire was sent to ophthalmologists via the American Glaucoma Society, the Canadian Glaucoma Society, and the Canadian Ophthalmological Society. The questionnaire was designed to investigate ophthalmologists' usual practice with respect to NTG and the extent to which practice has been influenced by the Collaborative Normal Tension Glaucoma Study (CNTGS) and the Low pressure Glaucoma Treatment Study (LoGTS). In total, 419 ophthalmologists completed the survey. Of these, 264 respondents were glaucoma subspecialists. The survey showed that 95% and 64% of ophthalmologists were familiar with the CNTGS and the LoGTS, respectively. Of the respondents, 70% indicated that they would initiate treatment in mild-to-moderate NTG without waiting for documented disease progression. Of the respondents, 61% of the total surveyed and 50% of the glaucoma subspecialists felt that the LoGTS results had no impact on their usual clinical practice. The first-choice topical drug for NTG was a prostaglandin analogue (88% of respondents) or brimonidine (10% of respondents). Most ophthalmologists treat NTG more aggressively than recommended by the CTNGS protocol. Most ophthalmologists felt that the LoGTS results had no impact on their normal clinical practice. The prostaglandin analogues are, by far, the most popular choice of drug for contemporary management of NTG. Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.

Hospitalization for community-acquired febrile urinary tract infection: validation and impact assessment of a clinical prediction rule.

PubMed

Stalenhoef, Janneke E; van der Starre, Willize E; Vollaard, Albert M; Steyerberg, Ewout W; Delfos, Nathalie M; Leyten, Eliane M S; Koster, Ted; Ablij, Hans C; Van't Wout, Jan W; van Dissel, Jaap T; van Nieuwkoop, Cees

2017-06-06

There is a lack of severity assessment tools to identify adults presenting with febrile urinary tract infection (FUTI) at risk for complicated outcome and guide admission policy. We aimed to validate the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE), a modified form of the pneumonia severity index, and to subsequentially assess its use in clinical practice. A prospective observational multicenter study for model validation (2004-2009), followed by a multicenter controlled clinical trial with stepped wedge cluster-randomization for impact assessment (2010-2014), with a follow up of 3 months. Paricipants were 1157 consecutive patients with a presumptive diagnosis of acute febrile UTI (787 in validation cohort and 370 in the randomized trial), enrolled at emergency departments of 7 hospitals and 35 primary care centers in the Netherlands. The clinical prediction rule contained 12 predictors of complicated course. In the randomized trial the PRACTICE included guidance on hospitalization for high risk (>100 points) and home discharge for low risk patients (<75 points), in the control period the standard policy regarding hospital admission was applied. Main outcomes were effectiveness of the clinical prediction rule, as measured by primary hospital admission rate, and its safety, as measured by the rate of low-risk patients who needed to be hospitalized for FUTI after initial home-based treatment, and 30-day mortality. A total of 370 patients were included in the randomized trial, 237 in the control period and 133 in the intervention period. Use of PRACTICE significantly reduced the primary hospitalization rate (from 219/237, 92%, in the control group to 96/133, 72%, in the intervention group, p < 0.01). The secondary hospital admission rate after initial outpatient treatment was 6% in control patients and 27% in intervention patients (1/17 and 10/37; p < 0.001). Although the proposed PRACTICE prediction rule is associated with a lower number of hospital admissions of patients presenting to the ED with presumptive febrile urinary tract infection, futher improvement is necessary to reduce the occurrence of secondary hospital admissions. NTR4480 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4480 , registered retrospectively 25 mrt 2014 (during enrollment of subjects).

"Diesel siphoner's lung": Exogenous lipoid pneumonia following hydrocarbon aspiration.

PubMed

Venkatnarayan, Kavitha; Madan, Karan; Walia, Ritika; Kumar, Jaya; Jain, Deepali; Guleria, Randeep

2014-01-01

Lipoid pneumonia is an unusual and uncommon form of pneumonia caused by aspiration of fatty substances. Hydrocarbon pneumonitis following aspiration of diesel is a form of exogenous lipoid pneumonia wherein, aspirated diesel reaches the alveoli rapidly without evoking any significant cough, but initiates an intense inflammatory reaction in the pulmonary parenchyma. This is a rarely described clinical scenario, although the practice of diesel siphonage from automobiles is a common practice in developing countries. We herein describe a 40-year-old male patient, in whom the diagnosis of lipoid pneumonia was delayed for a long duration and highlight the importance of taking a detailed occupational exposure history in patients with non-resolving pneumonia to rule out the underlying possibility of this rare clinical entity.

Coaching and feedback: enhancing communication teaching and learning in veterinary practice settings.

PubMed

Adams, Cindy L; Kurtz, Suzanne

2012-01-01

Communication is a critical clinical skill closely linked to clinical reasoning, medical problem solving, and significant outcomes of care such as accuracy, efficiency, supportiveness, adherence to treatment plans, and client and veterinarian satisfaction. More than 40 years of research on communication and communication education in human medicine and, more recently, in veterinary medicine provide a substantive rationale for formal communication teaching in veterinary education. As a result, veterinary schools are beginning to invest in communication training. However, if communication training is to result in development of veterinary communication skills to a professional level of competence, there must be follow-through with effective communication modeling and coaching in practice settings. The purpose of this article is to move the communication modeling and coaching done in the "real world" of clinical practice to the next level. The development of skills for communication coaching and feedback is demanding. We begin by comparing communication coaching with what is required for teaching other clinical skills in practice settings. Examining both, what it takes to teach others (whether DVM students or veterinarians in practice for several years) and what it takes to enhance one's own communication skills and capacities, we consider the why, what, and how of communication coaching. We describe the use of teaching instruments to structure this work and give particular attention to how to engage in feedback sessions, since these elements are so critical in communication teaching and learning. We consider the preconditions necessary to initiate and sustain communication skills training in practice, including the need for a safe and supportive environment within which to implement communication coaching and feedback. Finally we discuss the challenges and opportunities unique to coaching and to building and delivering communication skills training in practice settings.

Initiating Self-Assessment Strategies in Novice Physiotherapy Students: A Method Case Study

ERIC Educational Resources Information Center

Young, Catherine

2013-01-01

Student self- and peer-assessment strategies ideally are instigated early in programmes for health professionals. This study presents an innovative method of stimulating critical evaluation of clinical skills learned in the practical class setting for first year physiotherapy students. Twice in the semester (beginning and end) students assessed…

An Examination of the EeTPA Portfolio Assessment and Other Measures of Teacher Preparation and Readiness

ERIC Educational Resources Information Center

Russell, Victoria; Davidson Devall, Kelly F.

2016-01-01

The authors examined the outcomes on several measures of world language teacher preparedness, including university- and state-mandated summative evaluations and the edTPA portfolio assessment, for seven world language teacher candidates during their final semester of clinical practice. The candidates were enrolled in an initial certification…

Indications for Vitamin B12 Therapy

PubMed Central

Delva, M. Dianne; Anderson, J.E.

1992-01-01

A retrospective chart audit was undertaken to determine the clinical reasons for vitamin B12 therapy in family practice. Abnormal laboratory tests and symptoms were the most common reasons for initiating therapy. The high proportion of cases with little supporting evidence of B12 deficiency suggests that other factors influence treatment decisions. PMID:20469527

The business case as a strategic tool for change.

PubMed

Weaver, Diana J; Sorrells-Jones, Jean

2007-09-01

The authors discuss the clinically focused business case, when it is and is not needed, and the knowledge and skills the nurse executive must master to use the business case effectively as a strategic tool. Necessary skills include translating nursing practice proposals into cost-effective change initiatives and marketing those changes to colleagues.

Salvage microbiology: opportunities and challenges in the detection of bacterial pathogens following initiation of antimicrobial treatment

PubMed Central

Farrell, John J.; Hujer, Andrea M.; Sampath, Rangarajan; Bonomo, Robert A.

2015-01-01

Broad-range 16S ribosomal RNA gene PCR coupled with Sanger sequencing was originally employed by soil scientists and was subsequently adapted for clinical applications. PCR coupled with electrospray ionization mass spectrometry has also progressed from initial applications in the detection of organisms from environmental samples into the clinical realm and has demonstrated promise in detection of pathogens in clinical specimens obtained from patients with suspected infection but negative cultures. We review studies of multiplex PCR, 16S ribosomal RNA gene PCR and sequencing and PCR coupled with electrospray ionization mass spectrometry for detection of bacteria in specimens that were obtained from patients during or after administration of antibiotic treatment, and examine the role of each for assisting in antimicrobial treatment and stewardship efforts. Following an exploration of the available data in this field we discuss the opportunities that the preliminary investigations reveal, as well as the challenges faced with implementation of these strategies in clinical practice. PMID:25523281

REDUCING AMBIGUITY IN THE FUNCTIONAL ASSESSMENT OF PROBLEM BEHAVIOR

PubMed Central

Rooker, Griffin W.; DeLeon, Iser G.; Borrero, Carrie S. W.; Frank-Crawford, Michelle A.; Roscoe, Eileen M.

2015-01-01

Severe problem behavior (e.g., self-injury and aggression) remains among the most serious challenges for the habilitation of persons with intellectual disabilities and is a significant obstacle to community integration. The current standard of behavior analytic treatment for problem behavior in this population consists of a functional assessment and treatment model. Within that model, the first step is to assess the behavior–environment relations that give rise to and maintain problem behavior, a functional behavioral assessment. Conventional methods of assessing behavioral function include indirect, descriptive, and experimental assessments of problem behavior. Clinical investigators have produced a rich literature demonstrating the relative effectiveness for each method, but in clinical practice, each can produce ambiguous or difficult-to-interpret outcomes that may impede treatment development. This paper outlines potential sources of variability in assessment outcomes and then reviews the evidence on strategies for avoiding ambiguous outcomes and/or clarifying initially ambiguous results. The end result for each assessment method is a set of best practice guidelines, given the available evidence, for conducting the initial assessment. PMID:26236145

The metoclopramide black box warning for tardive dyskinesia: effect on clinical practice, adverse event reporting, and prescription drug lawsuits.

PubMed

Ehrenpreis, Eli D; Deepak, Parakkal; Sifuentes, Humberto; Devi, Radha; Du, Hongyan; Leikin, Jerrold B

2013-06-01

We examined the effects of the black box warning about the risk of tardive dyskinesia (TD) with chronic use of metoclopramide on management of gastroparesis within a single clinical practice, and on reporting of adverse events. Medical records of gastroparesis patients were evaluated for physician management choices. The FDA Adverse Event Reporting System (FAERS) was analyzed for event reports, and for lawyer-initiated reports, with metoclopramide from 2004 to 2010. Google Scholar was searched for court opinions against metoclopramide manufacturers. Before the black box warning, 69.8% of patients received metoclopramide for gastroparesis, compared with 23.7% after the warning. Gastroenterologists prescribed domperidone more often after than before the warning. Metoclopramide prescriptions decreased after 2008. Adverse event reporting increased after the warning. Only 3.6% of all FAERS reports but 70% of TD reports were filed by lawyers, suggesting a distortion in signal. Forty-seven legal opinions were identified, 33 from 2009-2010. The black box warning for metoclopramide has decreased its usage and increased its rate of adverse event reporting. Lawyer-initiated reports of TD hinder pharmacovigilance.

Assessing the community clinic replacement effect on private Medicaid practices in oral health care within rural environments.

PubMed

Squillace, Joe

2013-01-01

Children in Medicaid/CHIP public coverage programs who reside in rural counties have limited access to dental care services. Shortages of dental professionals in rural areas impede utilization of dental care. Public and private initiatives are attempting to address this crisis. Missourians instituted deregulatory policies and invested in community-based initiatives. Using a Medicaid/CHIP claims administrative dataset from 2004 to 2007, this research explored patterns of utilization to assess the impact of these efforts. The number of participating private dental office providers declined over the study period, and the number of children utilizing clinics increased. Trends are being observed within the public health dental care market demonstrating clinics are replacing private dentists as providers of Medicaid/CHIP dental services. Allowing greater market entry through deregulation could provide states with greater improvements to their public dental health infrastructure. © 2012 American Association of Public Health Dentistry.

Organizational Cost of Quality Improvement for Depression Care

PubMed Central

Liu, Chuan-Fen; Rubenstein, Lisa V; Kirchner, JoAnn E; Fortney, John C; Perkins, Mark W; Ober, Scott K; Pyne, Jeffrey M; Chaney, Edmund F

2009-01-01

Objective We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA. Data Sources and Study Setting Project records and surveys from three multistate VA administrative regions and seven of their primary care practices. Study Design Descriptive analysis. Data Collection We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan–Do–Study–Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities. Principle Findings Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of $84,438. Technical experts spent 2,147 hours costing $197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design. Conclusions Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care. PMID:19146566

Progress in evidence-based medicine: a quarter century on.

PubMed

Djulbegovic, Benjamin; Guyatt, Gordon H

2017-07-22

In response to limitations in the understanding and use of published evidence, evidence-based medicine (EBM) began as a movement in the early 1990s. EBM's initial focus was on educating clinicians in the understanding and use of published literature to optimise clinical care, including the science of systematic reviews. EBM progressed to recognise limitations of evidence alone, and has increasingly stressed the need to combine critical appraisal of the evidence with patient's values and preferences through shared decision making. In another progress, EBM incorporated and further developed the science of producing trustworthy clinical practice guidelines pioneered by investigators in the 1980s. EBM's enduring contributions to clinical medicine include placing the practice of medicine on a solid scientific basis, the development of more sophisticated hierarchies of evidence, the recognition of the crucial role of patient values and preferences in clinical decision making, and the development of the methodology for generating trustworthy recommendations. Copyright © 2017 Elsevier Ltd. All rights reserved.

Evaluating Industry Payments Among Dermatology Clinical Practice Guidelines Authors.

PubMed

Checketts, Jake X; Sims, Matthew Thomas; Vassar, Matt

2017-12-01

It is well documented that financial conflicts of interest influence medical research and clinical practice. Prior to the Open Payments provisions of the Affordable Care Act, financial ties became apparent only through self-disclosure. The nature of financial interests has not been studied among physicians who develop dermatology clinical practice guidelines. To evaluate payments received by physicians who author dermatology clinical practice guidelines, compare disclosure statements for accuracy, determine whether pharmaceutical companies from which the authors received payments manufactured products related to the guidelines, and examine the extent to which the American Academy of Dermatology enforced their Administrative Regulations for guideline development. Three American Academy of Dermatology guidelines published from 2013 to 2016 were retrieved. Double data extraction was used to record financial payments received by 49 guideline authors using the Open Payments database. Payments received by the authors from the date of the initial literature search to the date of publication were used to evaluate disclosure statement accuracy, detail the companies providing payments, and evaluate Administrative Regulations enforcement. This study is applicable to clinical practice guideline panels drafting recommendations, physicians using clinical practice guidelines to inform patient care, and those establishing policies for guideline development. Our main outcomes are the monetary values and types of payments received by physicians who author dermatology guidelines and the accuracy of disclosure statements. Data were collected from the Open Payments database and analyzed descriptively. Of the 49 authors evaluated, 40 received at least 1 reported industry payment, 31 accepted more than $1000, 25 accepted more than $10 000, and 18 accepted more than $50 000. Financial payments amounted to a mean of $157 177 per author. The total reimbursement among the 49 authors from 2013 to 2015 was $7 701 681. Of the 40 authors receiving payments, 22 did not accurately disclose industry relationships. Authors received payments from companies with products directly related to the guideline topic. Violations to the Administrative Regulations were found. Dermatology clinical practice guideline authors received sizable industry payments and did not completely disclose these payments. The American Academy of Dermatology policies may benefit from stricter enforcement or the adoption of new standards.

Ethical erosion in newly qualified doctors: perceptions of empathy decline.

PubMed

Stratta, Emily C; Riding, David M; Baker, Paul

2016-09-06

This study sought to understand whether UK Foundation doctors perceived the phenomena of ethical erosion and empathy decline during their initial period of clinical practice, and if so, why this occurred. This qualitative study used semi-structured interviews with nine doctors in their first year of clinical practice at Royal Bolton Hospital, UK. Participants were invited to discuss the definition of empathy, how individuals acquire and maintain empathic ability, perceptions of ethical erosion in the self and others, and how clinical experiences have influenced their empathic ability. The interviews were transcribed, and analysed to identify emergent themes. Each participant reported a conscious acknowledgement of empathy decline in their own and their colleagues' early clinical experiences as doctors. Stressful working environments, the prioritisation of patients' physical rather than psychological well-being, and the attitudes of senior colleagues were all suggested as possible causes. Some doctors believed that specialties with reduced patient contact had a culture which precluded empathy, and influenced their own practice. In addition, some described how their value judgements of patients had affected their ability to empathise. However, all doctors perceived that empathy skills were desirable in senior clinicians, and some believed that educational interventions may be useful in arresting ethical erosion. Newly qualified doctors are aware of ethical erosion in themselves and their colleagues as they begin clinical practice. This has serious implications for patient care. Improving working conditions may reverse this trend. Empathy skills training within undergraduate and postgraduate curricula may be a useful intervention.

COPD management: role of symptom assessment in routine clinical practice

PubMed Central

van der Molen, Thys; Miravitlles, Marc; Kocks, Janwillem WH

2013-01-01

Patients with chronic obstructive pulmonary disease (COPD) present with a variety of symptoms that significantly impair health-related quality of life. Despite this, COPD treatment and its management are mainly based on lung function assessments. There is increasing evidence that conventional lung function measures alone do not correlate well with COPD symptoms and their associated impact on patients’ everyday lives. Instead, symptoms should be assessed routinely, preferably by using patient-centered questionnaires that provide a more accurate guide to the actual burden of COPD. Numerous questionnaires have been developed in an attempt to find a simple and reliable tool to use in everyday clinical practice. In this paper, we review three such patient-reported questionnaires recommended by the latest Global Initiative for Chronic Obstructive Lung Disease guidelines, ie, the modified Medical Research Council questionnaire, the clinical COPD questionnaire, and the COPD Assessment Test, as well as other symptom-specific questionnaires that are currently being developed. PMID:24143085

Use of minimal invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies international Society (MiECTiS)

PubMed Central

Anastasiadis, Kyriakos; Murkin, John; Antonitsis, Polychronis; Bauer, Adrian; Ranucci, Marco; Gygax, Erich; Schaarschmidt, Jan; Fromes, Yves; Philipp, Alois; Eberle, Balthasar; Punjabi, Prakash; Argiriadou, Helena; Kadner, Alexander; Jenni, Hansjoerg; Albrecht, Guenter; van Boven, Wim; Liebold, Andreas; de Somer, Fillip; Hausmann, Harald; Deliopoulos, Apostolos; El-Essawi, Aschraf; Mazzei, Valerio; Biancari, Fausto; Fernandez, Adam; Weerwind, Patrick; Puehler, Thomas; Serrick, Cyril; Waanders, Frans; Gunaydin, Serdar; Ohri, Sunil; Gummert, Jan; Angelini, Gianni; Falk, Volkmar; Carrel, Thierry

2016-01-01

Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists. PMID:26819269

Management of diabetes insipidus and adipsia in the child.

PubMed

Di Iorgi, Natascia; Morana, Giovanni; Napoli, Flavia; Allegri, Anna Elsa Maria; Rossi, Andrea; Maghnie, Mohamad

2015-06-01

Central diabetes insipidus (CDI) is a complex and heterogeneous clinical syndrome affecting the hypothalamic-neurohypophyseal network and water balance. A recent national surveillance in Denmark showed a prevalence rate of twenty-three CDI patients per 100,000 inhabitants in five years. The differential diagnosis between several presenting conditions with polyuria and polydipsia is puzzling, and the etiological diagnosis of CDI remains a challenge before the identification of an underlying cause. For clinical practice, a timely diagnosis for initiating specific treatment in order to avoid central nervous system damage, additional pituitary defects and the risk of dissemination of germ cell tumor is advisable. Proper etiological diagnosis can be achieved via a series of steps that start with careful clinical observation of several signs and endocrine symptoms and then progress to more sophisticated imaging tools. This review summarizes the best practice and approach for the diagnosis and treatment of patients with CDI. Copyright © 2015 Elsevier Ltd. All rights reserved.

Growing a Best Babies Zone: Lessons Learned from the Pilot Phase of a Multi-Sector, Place-Based Initiative to Reduce Infant Mortality.

PubMed

Pies, Cheri; Barr, Monica; Strouse, Carly; Kotelchuck, Milton

2016-05-01

Infant mortality reduction in the U.S. has been addressed predominantly through clinical approaches. While these efforts have reduced the infant mortality rate overall, they have not reduced disparities between different racial/socioeconomic groups. To address the interrelated social, economic and environmental factors contributing to infant mortality, a place-based approach is needed to complement existing initiatives and clinical practices. Best Babies Zone (BBZ) is an early attempt to put life course theory into practice, taking a place-based approach to reducing infant mortality by aligning resources, building community leadership, and transforming educational opportunities, economic development, and community systems in concentrated neighborhoods. BBZ is currently in three neighborhoods: Price Hill (Cincinnati, OH), Hollygrove (New Orleans, LA), and Castlemont (Oakland, CA). Assessment In its first 4 years, each BBZ crafted resident-driven strategies for decreasing the root causes of toxic stress and poor birth outcomes. To address resident priorities, BBZ sites experimented with tools from other fields (like design thinking and health impact assessment), and emphasized existing MCH strategies like leadership development. Early challenges, including shifting from traditional MCH interventions and addressing health equity, point to areas of growth in implementing this approach in the maternal and child health field. BBZ aims to elevate local voice and mobilize multiple sectors in order to address the social determinants of infant mortality, and other initiatives working to improve MCH outcomes can learn from the successes and challenges of the first 4 years of BBZ in order to bring life course theory into practice.

Initiation of traditional birth attendants and their traditional and spiritual practices during pregnancy and childbirth in Ghana.

PubMed

Aziato, Lydia; Omenyo, Cephas N

2018-03-07

Prior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana. The design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings. The findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood. Although, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.

ALLHAT in perspective: implications to clinical practice and clinical trials.

PubMed

Yusoff, K

2005-06-01

ALLHAT study is the biggest randomized clinical trial in hypertension ever conducted. Its objective was to ompare the efficacy of newer (calcium channel blocker amlodipine and angiotensin-converting enzyme inhibitor inopril) to the older (diuretic chlorthalidone) antihypertensive agents in the treatment of patients with hypertension. After enrolling 42,000 patients who were followed for an average of 4.9 years, ALLHAT did not find significant differences in the primary end-points between these antihypertenive agents. ALLHAT however found significant differences in the secondary end-points such as heart failure and strokes between chlorthalidone and amlodipine or lisinopril. Based on these and on economic reasons, the investigators unequivocally recommended diuretics as the first line therapy for hypertension. Since its publication, ALLHAT has been much discussed, debated A and opined. The choice of drugs for study, the study design, the conduct of the study and the conclusions drawn by the investigators had all been criticised or controversial. Yet ALLHAT has been widely quoted, commented upon or referred to and it has been instrumental in initiating the JNC VII Guidelines. Thus a thorough understanding of ALLHAT is necessary for clinical practice and in designing and evaluating clinical trials in the future. Moving Points: in Medicine will capture the essence of ALLHAT, discusses its implications to clinical trials and explores its possible impact on the practice of medicine in this country.

Fostering interprofessional learning in a rehabilitation setting: development of an interprofessional clinical learning unit.

PubMed

Vanderzalm, Jeanne; Hall, Mark D; McFarlane, Lu-Anne; Rutherford, Laurie; Patterson, Steven K

2013-01-01

The development and implementation of interprofessional (IP) clinical learning units as a method to enhance IP clinical education and improve patient care in a rehabilitation setting are described. Using a community-based participatory research approach, academia and healthcare delivery agencies formed a partnership to create an IP clinical learning unit in a rehabilitation setting. Preimplementation data from surveys and focus group data identified areas for improvement to enhance IP understanding and collaboration. A working group developed and implemented initiatives to enhance IP practice. Preimplementation, eight themes emerged from which the working group identified goals and implemented strategies to strengthen IP learning. Goals included Creation of an IP Learning Environment, Increased Awareness of IP Practice, Role Clarification, Enhanced IP Communication, and Reflection and Evaluation. Postimplementation data revealed six themes: Communication, Informal IP Learning, Role Awareness, Positive Learning Environment, Logistics, and Challenges. The development of the IP clinical learning unit was successful and rewarding, but not without its challenges. Formal IP education was necessary to enhance collaborative practice, even in a multidisciplinary environment. Commitment and support from all participants, particularly managers and administrators from the healthcare agency, were critical to success. The focus of this unit was on a stroke rehabilitation unit; however, the development and implementation principles identified may be applicable to any team-based clinical setting. © 2013 Association of Rehabilitation Nurses.

HbA1c Outcomes in Patients Treated With Canagliflozin Versus Sitagliptin in US Health Plans.

PubMed

Thayer, Sarah; Aguilar, Richard; Korrer, Stephanie; Chow, Wing

2017-10-01

Clinical trial evidence supports greater glycemic control with canagliflozin than with sitagliptin. The objective of this study was to provide real-world evidence comparing outcomes in routine clinical practice among patients initiating each medication. With the use of a health care administrative database, patients initiating canagliflozin were compared with patients initiating sitagliptin (first prescription fill as index date). Baseline (6 months before index date) demographic and clinical (eg, comorbidities and diabetes-related complications) characteristics were compared, and propensity score matching was used to control for baseline differences between cohorts. Outcomes included change in glycosylated hemoglobin (HbA 1c ) and persistence with medication over a 9-month period after index date. Before matching, the canagliflozin cohort (N = 3993) was younger than the sitagliptin cohort (N = 12,153) and was composed of fewer women and Medicare Advantage enrollees, with lower mean baseline comorbidity scores (all p < 0.001). Before matching, the canagliflozin cohort (valid n = 1482) had a significantly (p < 0.001) higher baseline HbA 1c (8.60) than the sitagliptin cohort (valid n = 3697; HbA 1c , 8.32). After matching (n = 1472 per cohort), patients were well balanced on baseline characteristics, and HbA 1c values were not significantly different (p = 0.634) between the cohorts. Patients initiating canagliflozin had greater reductions in HbA 1c than patients in the sitagliptin cohort (-0.93% versus -0.57%, respectively; p = 0.004), with similar mean (median) time from index date to follow-up HbA 1c of 185.4 (199.0) and 184.3 (190.5) days, respectively (p = 0.802). Only 29.8% of canagliflozin patients discontinued during follow-up compared with 41.5% of sitagliptin patients (p < 0.001); the average days of persistence on index therapy was longer for canagliflozin patients (152 days) than for sitagliptin patients (139 days; p < 0.001). In this observational study, patients initiating canagliflozin had greater reduction in HbA 1c and longer persistence with medication than did patients who initiated sitagliptin, over a 9-month period. Better understanding of antihyperglycemic treatment, HbA 1c results, and differences among patients in demographic/clinical characteristics as well as persistence with treatment will inform optimal diabetes treatment choice in routine practice. Copyright © 2017 Elsevier HS Journals, Inc. All rights reserved.

Scholarship of Practice in the Care of People with Dementia: Creating the Future Through Collaborative Efforts.

PubMed

Forsyth, Kirsty; Melton, Jane; Raber, Christine; Burke, Janice P; Piersol, Catherine Verrier

2015-01-01

A scholarship of practice approach sets the stage for collaborative partnerships across academic and clinical practice settings that result in positive gains for all stakeholders. These gains include an enhanced ability to generate and apply relevant evidence in practice, disseminate knowledge and innovation, and ensure best practice is relevant to and effective for, people receiving services and their caregivers. This paper discusses national and international examples of collaborative, research-based practice initiatives that have implemented a scholarship of practice approach. The exemplars described here are framed within the Model of Human Occupation, which addresses the importance of volition, habits, roles, environment, and performance capacities in facilitating engagement in occupation for people with dementia. Research that focuses on how therapists adopt and use evidence in practice, as well as the opportunities and challenges for supporting therapists and their use of theory and evidence are discussed.

StaR Child Health: developing evidence-based guidance for the design, conduct, and reporting of pediatric trials.

PubMed

Hartling, L; Wittmeier, K D M; Caldwell, P H; van der Lee, J H; Klassen, T P; Craig, J C; Offringa, M

2011-11-01

Standards for Research in (StaR) Child Health was founded in 2009 to address the paucity and shortcomings of pediatric clinical trials. This initiative involves international experts who are dedicated to developing practical, evidence-based standards to enhance the reliability and relevance of pediatric clinical research. Through a systematic "knowledge to action" plan, StaR Child Health will make efforts to improve and expand the evidence base for child health across the world.

History of solid organ transplantation and organ donation.

PubMed

Linden, Peter K

2009-01-01

Solid organ transplantation is one of the most remarkable and dramatic therapeutic advances in medicine during the past 60 years. This field has progressed initially from what can accurately be termed a "clinical experiment" to routine and reliable practice, which has proven to be clinically effective, life-saving and cost-effective. This remarkable evolution stems from a serial confluence of: cultural acceptance; legal and political evolution to facilitate organ donation, procurement and allocation; technical and cognitive advances in organ preservation, surgery, immunology, immunosuppression; and management of infectious diseases. Some of the major milestones of this multidisciplinary clinical science are reviewed in this article.

Recommendations for data monitoring committees from the Clinical Trials Transformation Initiative.

PubMed

Calis, Karim A; Archdeacon, Patrick; Bain, Raymond; DeMets, David; Donohue, Miriam; Elzarrad, M Khair; Forrest, Annemarie; McEachern, John; Pencina, Michael J; Perlmutter, Jane; Lewis, Roger J

2017-08-01

Background/aims Use of data monitoring committees to oversee clinical trials was first proposed nearly 50 years ago. Since then, data monitoring committee use in clinical trials has increased and evolved. Nonetheless, there are no well-defined criteria for determining the need for a data monitoring committee, and considerable variability exists in data monitoring committee composition and conduct. To understand and describe the role and function of data monitoring committees, and establish best practices for data monitoring committee trial oversight, the Clinical Trials Transformation Initiative-a public-private partnership to improve clinical trials-launched a multi-stakeholder project. Methods The data monitoring committee project team included 16 individuals charged with (1) clarifying the purpose of data monitoring committees, (2) identifying best practices for independent data monitoring committee conduct, (3) describing effective communication practices, and (4) developing strategies for training data monitoring committee members. Evidence gathering included a survey, a series of focus group discussions, and a 2-day expert meeting aimed at achieving consensus opinions that form the foundation of our data monitoring committee recommendations. Results We define the role of the data monitoring committee as an advisor to the research sponsor on whether to continue, modify, or terminate a trial based on periodic assessment of trial data. Data monitoring committees should remain independent from the sponsor and be composed of members with no relevant conflicts of interest. Representation on a data monitoring committee generally should include at least one clinician with expertise in the therapeutic area being studied, a biostatistician, and a designated chairperson who has experience with clinical trials and data monitoring. Data monitoring committee meetings are held periodically to evaluate the unmasked data from ongoing trials, but the content and conduct of meetings may vary depending on specific goals or topics for deliberation. To guide data monitoring committee conduct and communication plans, a charter consistent with the protocol's research design and statistical analysis plan should be developed and agreed upon by the sponsor and the data monitoring committee prior to patient enrollment. We recommend concise and flexible charters that explain roles, responsibilities, operational issues, and how data monitoring committee recommendations are generated and communicated. The demand for data monitoring committee members appears to exceed the current pool of qualified individuals. To prepare a new generation of trained data monitoring committee members, we encourage a combination of didactic educational programs, practical experience, and skill development through apprenticeships and mentoring by experienced data monitoring committee members. Conclusion Our recommendations address data monitoring committee use, conduct, communication practices, and member preparation and training. Furthermore recommendations form the foundation for ongoing efforts to improve clinical trial oversight and enhance the safety and integrity of clinical research. These recommendations serve as a call to action for implementation of best practices that benefit study participants, study sponsors, and society.

Effects of limited midwifery clinical education and practice standardisation of student preparedness.

PubMed

Vuso, Zanyiwe; James, Sindiwe

2017-08-01

To explore the perceptions of midwifery educators regarding effects of limited standardisation of midwifery clinical education and practice on clinical preparedness of midwifery students. Investigation of levels of clinical competency of students is a critical need in the current era. Such competency levels are especially important in midwifery practice in South Africa as there is a significant increase of maternal deaths and litigations in the country. Most of the deaths are in the primary healthcare level maternity units where the newly qualified midwives practise. These areas are mainly run by midwives only. The current article seeks to report the findings of the study that was conducted to investigate how midwifery educators prepare students adequately for clinical readiness. The study was conducted amongst midwifery nurse educators on three campuses of the Nursing College in the Eastern Cape. A qualitative, explorative, descriptive and contextual research design was used for the study. Seventeen purposively selected midwifery educators, with the researcher using set criteria, from a Nursing college in the Eastern Cape, were the participants in the study. Data was collected using focus-group interviews that were captured by means of an audio-voice recorder. Tesch's data-analysis method was used to develop themes and sub-themes. Trustworthiness of the study was ensured using the criteria of credibility, transferability, dependability and confirmability. Inconsistent clinical practice amongst midwifery educators in their clinical teaching and assessment were found to be the major factors resulting from limited standardisation. The inconsistent clinical practice and assessments of midwifery educators was found to lead to loss of the necessary skills required by the students which led them to perform poorly in their final clinical assessments. There are some barriers in the current clinical teaching and education strategy used in this college that prohibit the production of confident, independent, and safe practitioners as planned. Midwifery educators need to be assisted in reviewing the current teaching strategy. Furthermore management should be involved if not the initiators of that reviewing and should put in-place new measures to support the teaching of the clinical module. Copyright © 2017 Elsevier Ltd. All rights reserved.

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders.

PubMed

Kredo, Tamara; Abrams, Amber; Young, Taryn; Louw, Quinette; Volmink, Jimmy; Daniels, Karen

2017-08-29

Clinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa's health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level. We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data. We conducted 37 in-depth interviews from June 2014-July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process. Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Interprofessional education workshops in the workplace for pre-registration learners: Aligning to National Standards.

PubMed

Kent, Fiona; Courtney, Jade; Thorpe, Jo

2018-03-01

The inclusion of formal interprofessional education activities within clinical placements aligns with the national agenda in Australia to increase the focus on collaborative practice. However, the challenge remains for health services to determine how to achieve this goal. The education team at one health service elected to align new interprofessional education initiatives to the National Standards for Quality in Healthcare, to increase student focus on the complex domains of practice that require collaborative practice. An interprofessional falls prevention workshop was created for students on clinical placement. In the pilot phase, the 2h workshops ran four times across three months. Simultaneously, a second group of students were invited to complete an online falls prevention module. Knowledge gains from the two interventions were compared using a Mann Whitney test and qualitative data was thematically coded. There was no significant difference in fall prevention knowledge between the two interventions. Thematic analysis illustrated workshops promoted an increased understanding of others roles, person-centred care, interprofessional communication and collaboration. This pilot study has demonstrated that 2h interprofessional educational workshops are a feasible, replicable and useful addition to profession-specific clinical placements. The interprofessional workshop offered the opportunity for students of different professions to come together, practice interprofessional communication, explore the roles and responsibilities of others and collaborate in the theoretical management of a clinical case. Copyright © 2017 Elsevier Ltd. All rights reserved.

Optimal Pain Assessment in Pediatric Rehabilitation: Implementation of a Nursing Guideline.

PubMed

Kingsnorth, Shauna; Joachimides, Nick; Krog, Kim; Davies, Barbara; Higuchi, Kathryn Smith

2015-12-01

In Ontario, Canada, the Registered Nurses' Association promotes a Best Practice Spotlight Organization initiative to enhance evidence-based practice. Qualifying organizations are required to implement strategies, evaluate outcomes, and sustain practices aligned with nursing clinical practice guidelines. This study reports on the development and evaluation of a multifaceted implementation strategy to support adoption of a nursing clinical practice guideline on the assessment and management of acute pain in a pediatric rehabilitation and complex continuing care hospital. Multiple approaches were employed to influence behavior, attitudes, and awareness around optimal pain practice (e.g., instructional resources, electronic reminders, audits, and feedback). Four measures were introduced to assess pain in communicating and noncommunicating children as part of a campaign to treat pain as the fifth vital sign. A prospective repeated measures design examined survey and audit data to assess practice aligned with the guideline. The Knowledge and Attitudes Survey (KNAS) was adapted to ensure relevance to the local practice setting and was assessed before and after nurses' participation in three education modules. Audit data included client demographics and pain scores assessed annually over a 3-year window. A final sample of 69 nurses (78% response rate) provided pre-/post-survey data. A total of 108 pediatric surgical clients (younger than 19 years) contributed audit data across the three collection cycles. Significant improvements in nurses' knowledge, attitudes, and behaviors related to optimal pain care for children with disabilities were noted following adoption of the pain clinical practice guideline. Targeted guideline implementation strategies are central to supporting optimal pain practice. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Cardiac peptide stability, aprotinin and room temperature: importance for assessing cardiac function in clinical practice.

PubMed

Buckley, M G; Marcus, N J; Yacoub, M H

1999-12-01

Brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP) and N-terminal ANP are good research indices of the severity of heart failure. The stability of these peptides at room temperature has become an important factor in assessing their use as indicators of cardiac function in routine clinical practice. Inhibitors such as aprotinin are routinely added in the blood collection process, but may provide no benefit in sample collection and routine clinical practice. We assessed the stability of BNP, ANP and N-terminal ANP in blood samples collected in either the presence or the absence of the protease inhibitor aprotinin. Blood, either with or without aprotinin, was processed immediately (initial; 0 h) and after blood samples had been left for 3 h, 2 days or 3 days at room temperature. These times were chosen to reflect processing in a hospital outpatient clinic (2-3 h), or when posted from general practice (2-3 days). Initial plasma BNP, ANP and N-terminal ANP levels in the absence of aprotinin were 28.2+/-5.4, 44.2+/-7.9 and 1997+/-608 pg/ml respectively, and were not significantly different from initial values in the presence of aprotinin (29.0+/-5.9, 45.2+/-8.0 and 2009+/-579 pg/ml respectively). After 3 h at room temperature, there was a significant fall in ANP in the absence of aprotinin (36. 7+/-7.9 pg/ml; P<0.005), but not in the presence of aprotinin (41. 2+/-7.6 pg/ml). Both BNP and N-terminal ANP were unchanged in either the absence (BNP, 27.6+/-5.5 pg/ml; N-terminal ANP, 2099+/-613 pg/ml) or the presence (BNP, 29.4+/-5.6 pg/ml; N-terminal ANP, 1988+/-600 pg/ml) of aprotinin. After 2 days at room temperature, ANP had fallen significantly in both the absence (16.9+/-3.4 pg/ml) and the presence (24.0+/-5.0 pg/ml) of aprotinin compared with initial values, and there was a significant difference in ANP levels in the absence and presence of aprotinin (P<0.001). ANP levels had decreased further after 3 days at room temperature, to 11.9+/-3.4 pg/ml (no aprotinin) and 20.3+/-5.0 pg/ml (aprotinin added); these values were significantly different (P=0.002). In contrast, there was no change in the levels of BNP or N-terminal ANP after 2 or 3 days at room temperature, in either the absence or the presence of aprotinin. These studies indicate that aprotinin adds little benefit to the stability of cardiac peptides at room temperature. Blood samples for BNP and N-terminal ANP measurement used as a test of heart function in hospital clinics and by general practitioners in the community could be taken into blood tubes containing only EDTA as anticoagulant and without the additional step of adding the routinely used inhibitor aprotinin.

Antiretroviral Simplification with Darunavir/Ritonavir Monotherapy in Routine Clinical Practice: Safety, Effectiveness, and Impact on Lipid Profile

PubMed Central

Santos, José R.; Moltó, José; Llibre, Josep M.; Negredo, Eugenia; Bravo, Isabel; Ornelas, Arelly; Clotet, Bonaventura; Paredes, Roger

2012-01-01

Background Simplification of antiretroviral treatment (ART) with darunavir/ritonavir (DRV/r) monotherapy has achieved sustained suppression of plasma viral load (pVL) in clinical trials; however, its effectiveness and safety profile has not been evaluated in routine clinical practice. Methodology/Principal Findings We performed a retrospective cohort analysis of HIV-1-infected patients who initiated DRV/r monotherapy once daily with a pVL <50 copies/mL under ART and at least 1 subsequent follow-up visit in our clinic. The primary study endpoints were the percentage of patients with virological failure (VF, defined as 2 consecutive pVL>50 copies/mL) at week 48, and time to VF. Other causes of treatment discontinuation and changes in lipid profile were evaluated up to week 48. Ninety-two patients were followed for a median (IQR) of 73 (57–92) weeks. The median baseline and nadir CD4+ T-cell counts were 604 (433–837) and 238 (150–376) cells/mm3, respectively. Patients had previously received a median of 5 (3–9) ART lines and maintained a pVL<50 copies/mL for a median of 76 (32–176) weeks before initiating DRV/r monotherapy. Nine (9.8%) patients developed VF at week 48; time to VF was 47.1 (IQR: 36.1–47.8) weeks among patients with VF. Other reasons for changing ART were gastrointestinal disturbances (n = 3), rash (n = 1), and impaired CD4 recovery (n = 2). Median low-density lipoprotein cholesterol levels increased from 116.1 mg/dL at baseline to 137.3 mg/dL at 48 weeks (p = 0.001). Conclusions/Significance Treatment simplification with DRV/r monotherapy seems safe and effective in routine clinical practice. Further research is needed to elucidate the effect of DRV/r monotherapy on cholesterol levels. PMID:22666357

Safety and efficacy of long-term use of sodium oxybate for narcolepsy with cataplexy in routine clinical practice.

PubMed

Drakatos, Panagis; Lykouras, Dimosthenis; D'Ancona, Grainne; Higgins, Sean; Gildeh, Nadia; Macavei, Raluca; Rosenzweig, Ivana; Steier, Joerg; Williams, Adrian J; Muza, Rexford; Kent, Brian D; Leschziner, Guy

2017-07-01

Sodium oxybate is licensed in Europe for the treatment of narcolepsy with cataplexy in adults. The aim of this study was to assess the efficacy and safety of sodium oxybate in clinical practice in patients with narcolepsy and cataplexy refractory to other treatments. This was a retrospective single centre study including patients with severe narcolepsy with cataplexy refractory to other treatments, who were initiated on sodium oxybate between 2009 and 2015. Patients were allowed to be on other stimulants or/and anti-cataplectic agents. Epworth sleepiness scale (ESS) and weekly cataplexy events were recorded. Side effects (SEs) were recorded at every follow-up visit. 90 patients were prescribed sodium oxybate, with a total of 3116 patient-months of drug exposure. ESS and weekly cataplexy events were significantly reduced by sodium oxybate for all patients (ΔESS = 4.3 ± 4.4 and Δcataplexy = 21.8 ± 18.5 events/week; p < 0.0001, respectively). The required maintenance dose could not be predicted based upon gender, body mass index, or clinical factors. 60% of patients were able to reduce or come off other medications. Half of the patients experienced at least one SE, and 26.6% had to stop treatment due to limiting SEs. Nausea, mood swings and enuresis were the most commonly reported SEs. SEs that led to drug discontinuation, particularly psychosis, were associated with increasing age and were observed early after the initiation of the drug. Sodium oxybate provides a good clinical efficacy and acceptable safety profile in routine clinical practice for the treatment of patients suffering from narcolepsy with cataplexy. A quarter of patients experience SEs requiring withdrawal of the drug with older patients being more vulnerable to the more serious SEs. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Oncology Nurse Generalist Competencies: Oncology Nursing Society's Initiative to Establish Best Practice.

PubMed

Gaguski, Michele E; George, Kim; Bruce, Susan D; Brucker, Edie; Leija, Carol; LeFebvre, Kristine B; Mackey, Heather

2017-12-01

A project team was formulated to create evidence-based oncology nurse generalist competencies (ONGCs) to establish best practices in competency development, including high-risk tasks, critical thinking criteria, and measurement of key areas for oncology nurses.
. This article aims to describe the process and the development of ONGCs. 
. This article explains how the ONGCs were accomplished, and includes outcomes and suggestions for use in clinical practice. 
. Institutions can use the ONGCs to assess and develop competency programs, offer educational strategies to measure proficiency, and establish processes to foster a workplace committed to mentoring and teaching future oncology nurses.

Effectiveness of a Psychoeducational Parenting Group on Child, Parent and Family Behavior: A Pilot Study in a Family Practice Clinic with an Underserved Population

PubMed Central

Berge, Jerica M.; Law, David D.; Johnson, Jennifer; Wells, M. Gawain

2013-01-01

Background Although integrated care for adults in primary care has steadily increased over the last several decades, there remains a paucity of research regarding integrated care for children in primary care. Purpose To report results of a pilot study testing initial feasibility of a parenting psychoeducational group targeting child behavioral problems within a primary care clinic. Method The participants (n = 35) were parents representing an underserved population from an inner-city primary care clinic. Participants attended a 12-week psychoeducational parenting group and reported pre- and post-measures of family functioning, child misbehavior and dyadic functioning. Paired t-tests and effects sizes are reported. Results Participants reported statistically significant improvement in family functioning, child misbehavior and couple functioning after participating in the parenting psychoeducational group. Conclusions Results suggest initial feasibility of a parenting psychoeducational group within a primary care clinic with an underserved population. This intervention may be useful for other primary care clinics seeking to offer more integrative care options for children and their families. PMID:20939627

Opportunities for social workers in the patient centered medical home.

PubMed

Hawk, Mary; Ricci, Edmund; Huber, George; Myers, Marcella

2015-01-01

The Patient Centered Medical Home (PCMH) has been hailed as one method of improving chronic care outcomes in the United States. A number of studies have underscored the importance of the social work role within the PCMH, yet little existing research explores the social worker as a driver of improved patient care. The Pennsylvania Chronic Care Initiative was created with a primary goal of increasing the number of practices that were recognized as PCMH by the National Committee for Quality Assurance. This article describes findings from in-depth qualitative interviews with representatives from seven primary care practices, in which the authors examined barriers and facilitators to implementation of the initiative. Barriers to implementation included small practice size, payer-driven care, not having a strong physician champion, variability within patient populations, and high implementation costs. Facilitators included having a social worker coordinate behavioral health services, clinical nurse case managers, preexisting models of outcomes-driven care, and being part of an integrated health delivery and financing system. Recommendations strengthening the role of medical social workers in primary care practices are discussed.

A review of the organization, regulation, and financing practices of postgraduate education in clinical nursing in 12 European countries.

PubMed

Rautiainen, Elina; Vallimies-Patomäki, Marjukka

2016-01-01

The aim of this study was to generate information of postgraduate education in clinical nursing in the EU member states. Data were collected via a structured electronic questionnaire and the questionnaire was sent to the government chief nurses in 26 EU countries in May 2013. Response rate was 46% (n=12). In total, 42 domains of specialization were identified. The most common domains were intensive care, mental health, operating room, emergency care, and pediatrics. Specialization programs were organized by university in two of the respondent countries, as residency program in one country, and as a mix of them in four countries. Regulation practices varied remarkably between the countries: scope of practice, subjects, entry requirements, length of education, description of the minimum competence requirements, and education standards related to the specialization programs were most often regulated by act, decree or other regulation. In some of the countries, no registration was required beyond the initial registration, whereas in some others, registration practices varied depending on the specialization program. New information was gathered on the regulation practices of postgraduate education in clinical nursing in the European Region concerning title provision, entry requirements, and financing practices. The awarded title on specialization programs depended on the level of postgraduate education, and the title might vary between the domains. General clinical experience was included in the entry requirements in seven countries. The government was mainly responsible for financing the postgraduate education in four countries, employer in three countries, and in the rest of the countries, there was a combination of different financiers. The importance of knowledge exchange on postgraduate education across the European countries needs to be acknowledged. Information provided by this study on international regulation practices provides useful information for the policy-makers regarding the organization of the postgraduate education in clinical nursing. Copyright © 2015 Elsevier Ltd. All rights reserved.

A Review of the Efficacy, Safety, and Clinical Implications of Naturally Derived Dietary Supplements for Dyslipidemia.

PubMed

Thaipitakwong, Thanchanit; Aramwit, Pornanong

2017-02-01

Dyslipidemia is recognized as a major cause of cardiovascular disease. A number of evidence-based guidelines recommend conventional synthetic drugs as standard therapy for dyslipidemia in clinical practice. However, antihyperlipidemic drugs have some serious side effects. Naturally derived dietary supplements are becoming attractive as an alternative strategy because of their high efficacy and safety, as supported by numerous data. Moreover, they could be considered an initial treatment for dyslipidemia. The aims of this literature review were to demonstrate the efficacy, safety, and clinical implications of dietary supplements for treating dyslipidemia. We reviewed the literature, including data from in vitro, in vivo, and human studies, and clinical guideline recommendations. We classified dietary supplements by their proposed mechanisms of action on lipid metabolism and also collected daily dosage recommendations, interactions with concurrent drugs and/or foods, dosage forms, and examples of commercially available products. Various types of naturally derived dietary supplements exhibit lipid-improving properties. Efficacy and safety are acceptable; however, their use in clinical practice will require further well-designed investigations and the support of scientific data.

Addressing Low Literacy and Health Literacy in Clinical Oncology Practice

PubMed Central

Garcia, Sofia F.; Hahn, Elizabeth A.; Jacobs, Elizabeth A.

2011-01-01

Low functional literacy and low health literacy continue to be under-recognized and are associated with poorer patient health outcomes. Health literacy is a dynamic state influenced by how well a healthcare system delivers information and services that match patients’ abilities, needs and preferences. Oncology care poses considerable health literacy demands on patients who are expected to process high stakes information about complex multidisciplinary treatment over lengths of time. Much of the information provided to patients in clinical care and research is beyond their literacy levels. In this paper, we provide an overview of currently available guidelines and resources to improve how the needs of patients with diverse literacy skills are met by cancer care providers and clinics. We present recommendations for health literacy assessment in clinical practice and ways to enhance the usability of health information and services by improving written materials and verbal communication, incorporating multimedia and culturally appropriate approaches, and promoting health literacy in cancer care settings. The paper also includes a list of additional resources that can be used to develop and implement health literacy initiatives in cancer care clinics. PMID:20464884

Clinical education and clinical evaluation of respiratory therapy students.

PubMed

Cullen, Deborah L

2005-09-01

Different blends of knowledge, decision making, problem solving,professional behaviors, values, and technical skills are necessary in the changing health care environments in which respiratory therapists practice. Frequently, novice students are expected to perform quickly and efficiently,and it may be forgotten that students are still learning and mastering the foundation pieces of practice. Clinical educators take on the responsibility of student development in addition to overseeing patient care. Normally,these volunteer instructors are role models for respiratory therapy students. The characteristic of initiative when demonstrated by a beginning student is attractive to the clinical instructor, promotes sharing of experiences, and may evolve into a mentor-protege relationship. Some clinical instructors may be underprepared to teach and are uncomfortable with student evaluation. Respiratory therapy facilities in conjunction with academic institutions may consider sponsoring ongoing programs for clinical teachers. Teaching and learning in the clinical environment is more than demonstration of skills and knowledge. Furthermore, it can be debated whether the memorization of facts or of the steps of a skill is more valuable than competency in problem solving, clinical reasoning, or information retrieval. New knowledge is built within a context and is further integrated when grounded by experience. Development of "prediction in practice" or the anticipation of the next necessary actions may be worth integrating into the instructional toolbox. Intuition has been defined as an "understanding without a rationale". This definition separates intuition from rational decision making and presents intuition as a type of innate ability. Reflection when guided by clinical instructors can help deepen critical thinking, as will Socratic questioning on a regular basis. Most clinical staff can agree on the performance of an incompetent student, but discrimination of the levels of competence is more challenging. Observations allow the assessor to obtain the data necessary to evaluate performance, followed by assessment, which denotes a judgment made on the basis of an observation of events. Performance assessment should have stability and consistency, measure what is intended to be measured, and truly determine competence. In contrast, reflective analysis has been shown to be successful for clinical evaluation, thus departing from strict competency and product-based assessment. Students yearn to become clinically knowledgeable, and their enthusiasm should be fostered. An interest in clinical practice is the primary reason individuals enroll in respiratory therapy education programs. Educators,managers, and staff should assure that students experience an appropriate, rich, and diverse clinical curriculum that with practice develops clinical judgment, reasoning, and reflection on practice.

Practice-Based Research Networks, Part II: A Descriptive Analysis of the Athletic Training Practice-Based Research Network in the Secondary School Setting

PubMed Central

McLeod, Tamara C. Valovich; Lam, Kenneth C.; Bay, R. Curtis; Sauers, Eric L.; Valier, Alison R. Snyder

2012-01-01

Context Analysis of health care service models requires the collection and evaluation of basic practice characterization data. Practice-based research networks (PBRNs) provide a framework for gathering data useful in characterizing clinical practice. Objective To describe preliminary secondary school setting practice data from the Athletic Training Practice-Based Research Network (AT-PBRN). Design Descriptive study. Setting Secondary school athletic training facilities within the AT-PBRN. Patients or Other Participants Clinicians (n = 22) and their patients (n = 2523) from the AT-PBRN. Main Outcome Measure(s) A Web-based survey was used to obtain data on clinical practice site and clinician characteristics. Patient and practice characteristics were obtained via deidentified electronic medical record data collected between September 1, 2009, and April 1, 2011. Descriptive data regarding the clinician and CPS practice characteristics are reported as percentages and frequencies. Descriptive analysis of patient encounters and practice characteristic data was performed, with the percentages and frequencies of the type of injuries recorded at initial evaluation, type of treatment received at initial evaluation, daily treatment, and daily sign-in procedures. Results The AT-PBRN had secondary school sites in 7 states, and most athletic trainers at those sites (78.2%) had less than 5 years of experience. The secondary school sites within the AT-PBRN documented 2523 patients treated across 3140 encounters. Patients most frequently sought care for a current injury (61.3%), followed by preventive services (24.0%), and new injuries (14.7%). The most common diagnoses were ankle sprain/strain (17.9%), hip sprain/strain (12.5%), concussion (12.0%), and knee pain (2.5%). The most frequent procedures were athletic trainer evaluation (53.9%), hot- or cold-pack application (26.0%), strapping (10.3%), and therapeutic exercise (5.7%). The median number of treatments per injury was 3 (interquartile range = 2, 4; range = 2–19). Conclusions These preliminary data describe services provided by clinicians within the AT-PBRN and demonstrate the usefulness of the PBRN model for obtaining such data. PMID:23068594

Pressure ulcer risk assessment and prevention: what difference does a risk scale make? A comparison between Norway and Ireland.

PubMed

Johansen, E; Moore, Z; van Etten, M; Strapp, H

2014-07-01

To explore similarities and differences in nurses' views on risk assessment practices and preventive care activities in a context where patients' risk of developing pressure ulcers is assessed using clinical judgment (Norway) and a context where patients' risk of developing pressure ulcers is assessed using a formal structured risk assessment combined with clinical judgement (Ireland). A descriptive, qualitative design was employed across two different care settings with a total of 14 health care workers, nine from Norway and five from Ireland. Regardless of whether risk assessment was undertaken using clinical judgment or formal structured risk assessment, identified risk factors, at risk patients and appropriate preventive initiatives discussed by participant were similar across care settings. Furthermore, risk assessment did not necessarily result in the planning and implementation of appropriate pressure ulcer prevention initiatives. Thus, in this instance, use of a formal risk assessment tool does not seem to make any difference to the planning, initiation and evaluation of pressure ulcer prevention strategies. Regardless of the method of risk assessment, patients at risk of developing pressure ulcers are detected, suggesting that the practice of risk assessment should be re-evaluated. Moreover, appropriate preventive interventions were described. However, the missing link between risk assessment and documented care planning is of concern and barriers to appropriate pressure ulcer documentation should be explored further. This work is partly funded by a research grant from the Norwegian Nurses Organisation (NNO) (Norsk Sykepleierforbund NSF) in 2012. The authors have no conflict of interest to declare.

Comparison of usual podiatric care and early physical therapy intervention for plantar heel pain: study protocol for a parallel-group randomized clinical trial

PubMed Central

2013-01-01

Background A significant number of individuals suffer from plantar heel pain (PHP) and many go on to have chronic symptoms and continued disability. Persistence of symptoms adds to the economic burden of PHP and cost-effective solutions are needed. Currently, there is a wide variation in treatment, cost, and outcomes of care for PHP with limited information on the cost-effectiveness and comparisons of common treatment approaches. Two practice guidelines and recent evidence of effective physical therapy intervention are available to direct treatment but the timing and influence of physical therapy intervention in the multidisciplinary management of PHP is unclear. The purpose of this investigation is to compare the outcomes and costs associated with early physical therapy intervention (ePT) following initial presentation to podiatry versus usual podiatric care (uPOD) in individuals with PHP. Methods A parallel-group, block-randomized clinical trial will compare ePT and uPOD. Both groups will be seen initially by a podiatrist before allocation to a group that will receive physical therapy intervention consisting primarily of manual therapy, exercise, and modalities, or podiatric care consisting primarily of a stretching handout, medication, injections, and orthotics. Treatment in each group will be directed by practice guidelines and a procedural manual, yet the specific intervention for each participant will be selected by the treating provider. Between-group differences in the Foot and Ankle Ability Measure 6 months following the initial visit will be the primary outcome collected by an independent investigator. In addition, differences in the European Quality of Life – Five Dimensions, Numeric Pain Rating Scale, Global Rating of Change (GROC), health-related costs, and cost-effectiveness at 6 weeks, 6 months, and 1 year will be compared between groups. The association between successful outcomes based on GROC score and participant expectations of recovery generally, and specific to physical therapy and podiatry treatment, will also be analyzed. Discussion This study will be the first pragmatic trial to investigate the clinical outcomes and cost-effectiveness of ePT and uPOD in individuals with PHP. The results will serve to inform clinical practice decisions and management guidelines of multiple disciplines. Trial registration ClinicalTrials.gov: NCT01865734 PMID:24299257

Multipayer patient-centered medical home implementation guided by the chronic care model.

PubMed

Gabbay, Robert A; Bailit, Michael H; Mauger, David T; Wagner, Edward H; Siminerio, Linda

2011-06-01

A unique statewide multipayer ini Pennsylvania was undertaken to implement the Patient-Centered Medical Home (PCMH) guided by the Chronic Care Model (CCM) with diabetes as an initial target disease. This project represents the first broad-scale CCM implementation with payment reform across a diverse range of practice organizations and one of the largest PCMH multipayer initiatives. Practices implemented the CCM and PCMH through regional Breakthrough Series learning collaboratives, supported by Improving Performance in Practice (IPIP) practice coaches, with required monthly quality reporting enhanced by multipayer infrastructure payments. Some 105 practices, representing 382 primary care providers, were engaged in the four regional collaboratives. The practices from the Southeast region of Pennsylvania focused on diabetes patients (n = 10,016). During the first intervention year (May 2008-May 2009), all practices achieved at least Level 1 National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) recognition. There was significant improvement in the percentage of patients who had evidence-based complications screening and who were on therapies to reduce morbidity and mortality (statins, angiotensin-converting enzyme inhibitors). In addition, there were small but statistically significant improvements in key clinical parameters for blood pressure and cholesterol levels, with the greatest absolute improvement in the highest-risk patients. Transforming primary care delivery through implementation of the PCMH and CCM supported by multipayer infrastructure payments holds significant promise to improve diabetes care.

Multinational evidence-based recommendations on how to investigate and follow-up undifferentiated peripheral inflammatory arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative.

PubMed

Machado, P; Castrejon, I; Katchamart, W; Koevoets, R; Kuriya, B; Schoels, M; Silva-Fernández, L; Thevissen, K; Vercoutere, W; Villeneuve, E; Aletaha, D; Carmona, L; Landewé, R; van der Heijde, D; Bijlsma, J W J; Bykerk, V; Canhão, H; Catrina, A I; Durez, P; Edwards, C J; Mjaavatten, M D; Leeb, B F; Losada, B; Martín-Mola, E M; Martinez-Osuna, P; Montecucco, C; Müller-Ladner, U; Østergaard, M; Sheane, B; Xavier, R M; Zochling, J; Bombardier, C

2011-01-01

To develop evidence-based recommendations on how to investigate and follow-up undifferentiated peripheral inflammatory arthritis (UPIA). 697 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2008-9 consisting of three separate rounds of discussions and modified Delphi votes. In the first round 10 clinical questions were selected. A bibliographic team systematically searched Medline, Embase, the Cochrane Library and ACR/EULAR 2007-2008 meeting abstracts. Relevant articles were reviewed for quality assessment, data extraction and synthesis. In the second round each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed. A total of 39,756 references were identified, of which 250 were systematically reviewed. Ten multinational key recommendations about the investigation and follow-up of UPIA were formulated. One recommendation addressed differential diagnosis and investigations prior to establishing the operational diagnosis of UPIA, seven recommendations related to the diagnostic and prognostic value of clinical and laboratory assessments in established UPIA (history and physical examination, acute phase reactants, autoantibodies, radiographs, MRI and ultrasound, genetic markers and synovial biopsy), one recommendation highlighted predictors of persistence (chronicity) and the final recommendation addressed monitoring of clinical disease activity in UPIA. Ten recommendations on how to investigate and follow-up UPIA in the clinical setting were developed. They are evidence-based and supported by a large panel of rheumatologists, thus enhancing their validity and practical use.

Evidence-based decision-making as a practice-based learning skill: a pilot study.

PubMed

Falzer, Paul R; Garman, D Melissa

2012-03-01

As physicians are being trained to adapt their practices to the needs and experience of patients, initiatives to standardize care have been gaining momentum. The resulting conflict can be addressed through a practice-based learning and improvement (PBL) program that develops competency in using treatment guidelines as decision aids and incorporating patient-specific information into treatment recommendations. This article describes and tests a program that is consistent with the ACGME's multilevel competency-based approach, targets students at four levels of training, and features progressive learning objectives and assessments. The program was pilot-tested with 22 paid volunteer psychiatric residents and fellows. They were introduced to a schizophrenia treatment guideline and reviewed six case vignettes of varying complexity. PBL assessments were based on how treatment recommendations were influenced by clinical and patient-specific factors. The task permitted separate assessments of learning objectives all four training levels. Among the key findings at each level, most participants found the treatment guideline helpful in making treatment decisions. Recommendations were influenced by guideline-based assessment criteria and other clinical features. They were also influenced by patients' perceptions of their illness, patient-based progress assessments, and complications such as stressors and coping patterns. Recommendations were strongly influenced by incongruence between clinical facts and patient experience. Practical understanding of how patient experience joins with clinical knowledge can enhance the use of treatment guidelines as decision tools and enable clinicians to appreciate more fully how and why patients' perceptions of their illness should influence treatment recommendations. This PBL program can assist training facilities in preparing students to cope with contradictory demands to both standardize and adapt their practice. The program can be modified to accommodate various disorders and a range of clinical factors and patient-specific complications.

Cancer education and effective dissemination: information access is not enough.

PubMed

Ousley, Anita L; Swarz, Jeffrey A; Milliken, Erin L; Ellis, Steven

2010-06-01

Education is the main avenue for disseminating new research findings into clinical practice. Understanding factors that affect translation of research into practice may help cancer educators design programs that facilitate the time it takes for research-indicated practices to become standard care. To understand various factors, the National Cancer Institute (NCI) Office of Education and Special Initiatives (OESI)(1) with individual cooperation from Oncology Nursing Society (ONS), American Society of Clinical Oncology (ASCO), and Association of Oncology Social Work (AOSW) administered a Practitioner Information Needs survey to five different types of practitioners involved in cancer care. While most of the 2,864 practitioners (83%) agreed they had access to current practice information, practitioners in large practice settings were more likely to report having access to research than those small practice settings. However, only 33% indicated that they had adequate time to access the information. Colleagues or experts within the organization were cited as the most frequently relied on information resource (60%), and peer-reviewed journals were cited as second (57%). Overall, 66% strongly or somewhat agreed that their organizations exhibit effective change management practices. A majority (69%) agreed that implementation of new practices is hindered by the lack of available staff time. Financial factors and the characteristics of the information presented were also believed to be factors contributing to research implementation. Group differences were observed among practitioner groups and practice settings for some factors.

‘Toning’ up hypotonia assessment: A proposal and critique

PubMed Central

Joubert, Robin W.E.

2016-01-01

Background Clinical assessment of hypotonia is challenging due to the subjective nature of the initial clinical evaluation. This poses dilemmas for practitioners in gaining accuracy, given that the presentation of hypotonia can be either a non-threatening or malevolent sign. The research question posed was how clinical assessment can be improved, given the current contentions expressed in the scientific literature. Objectives This paper describes the development and critique of a clinical algorithm to aid the assessment of hypotonia. Methods An initial exploratory sequential phase, consisting of a systematic review, a survey amongst clinicians and a Delphi process, assisted in the development of the algorithm, which is presented within the framework of the International Classification of Functioning, Disability and Health. The ensuing critique followed a qualitative emergent–systematic focus group design with a purposive sample of 59 clinicians. Data were analysed using semantical content analysis and are presented thematically with analytical considerations. Results This study culminated in the development of an evidence-based clinical algorithm for practice. The qualitative critique of the algorithm considered aspects such as inadequacies, misconceptions and omissions; strengths; clinical use; resource implications; and recommendations. Conclusions The first prototype and critique of a clinical algorithm to assist the clinical assessment of hypotonia in children has been described. Barriers highlighted include aspects related to knowledge gaps of clinicians, issues around user-friendliness and formatting concerns. Strengths identified by the critique included aspects related to the evidence-based nature of the criteria within the algorithm, the suitability of the algorithm in being merged or extending current practice, the potential of the algorithm in aiding more accurate decision-making, the suitability of the algorithm across age groups and the logical flow. These findings provide a starting point towards ascertaining the clinical utility of the algorithm as an essential step towards evidence-based praxis. PMID:28730054

The first two years of practice: a longitudinal perspective on the learning and professional development of promising novice physical therapists.

PubMed

Hayward, Lorna M; Black, Lisa L; Mostrom, Elizabeth; Jensen, Gail M; Ritzline, Pamela D; Perkins, Jan

2013-03-01

Physical therapists work in complex health care systems requiring professional competence in clinical reasoning and confidence in decision-making skills. For novice physical therapists, the initial practice years are a time for developing professional identity and practical knowledge. The study purpose was to extend previous research describing the experiences, learning, and professional development of 11 promising novice therapists during their first year of practice. The present study examined the continued development of the same therapists during their second year of clinical practice. Seven researchers from 4 physical therapist educational programs in the eastern and midwestern United States used a longitudinal, qualitative, multiple case study approach. Eleven physical therapist graduates identified as "promising novices" were recruited using purposive sampling. Participants ranged in age from 24 to 29 years and entered varied practice settings. Data were collected for 2 years using semistructured interviews, reflective journals, and participant observation. A conceptual model describing the participants' ongoing development during the second year of practice emerged. The 3 themes were formal and informal learning, increasing confidence and expansion of skills, and engagement in an environment characterized by collaborative exchange and opportunities for teaching. The second year represented consolidation and elaboration of practice-based learning and skills. The expansion of confidence, skills, and responsibilities and the externalization of learning the participants experienced promoted professional role formation. Learning previously directed inward and self-focused turned outward, fueled by growing self-confidence. Research illuminating the professional role formation experienced during early clinical practice is not widely available. The current study and further research into the learning and development of novice practitioners may assist educators in the design of pedagogical strategies and learning environments that enhance the professional development of physical therapists.

Discordant American College of Physicians and international rheumatology guidelines for gout management: consensus statement of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN).

PubMed

Dalbeth, Nicola; Bardin, Thomas; Doherty, Michael; Lioté, Frédéric; Richette, Pascal; Saag, Kenneth G; So, Alexander K; Stamp, Lisa K; Choi, Hyon K; Terkeltaub, Robert

2017-09-01

In November 2016, the American College of Physicians (ACP) published a clinical practice guideline on the management of acute and recurrent gout. This guideline differs substantially from the latest guidelines generated by the American College of Rheumatology (ACR), European League Against Rheumatism (EULAR) and 3e (Evidence, Expertise, Exchange) Initiative, despite reviewing largely the same body of evidence. The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) convened an expert panel to review the methodology and conclusions of these four sets of guidelines and examine possible reasons for discordance between them. The G-CAN position, presented here, is that the fundamental pathophysiological knowledge underlying gout care, and evidence from clinical experience and clinical trials, supports a treat-to-target approach for gout aimed at lowering serum urate levels to below the saturation threshold at which monosodium urate crystals form. This practice, which is truly evidence-based and promotes the steady reduction in tissue urate crystal deposits, is promoted by the ACR, EULAR and 3e Initiative recommendations. By contrast, the ACP does not provide a clear recommendation for urate-lowering therapy (ULT) for patients with frequent, recurrent flares or those with tophi, nor does it recommend monitoring serum urate levels of patients prescribed ULT. Results from emerging clinical trials that have gout symptoms as the primary end point are expected to resolve this debate for all clinicians in the near term future.

Interoperability Assets for Patient Summary Components: A Gap Analysis.

PubMed

Heitmann, Kai U; Cangioli, Giorgio; Melgara, Marcello; Chronaki, Catherine

2018-01-01

The International Patient Summary (IPS) standards aim to define the specifications for a minimal and non-exhaustive Patient Summary, which is specialty-agnostic and condition-independent, but still clinically relevant. Meanwhile, health systems are developing and implementing their own variation of a patient summary while, the eHealth Digital Services Infrastructure (eHDSI) initiative is deploying patient summary services across countries in the Europe. In the spirit of co-creation, flexible governance, and continuous alignment advocated by eStandards, the Trillum-II initiative promotes adoption of the patient summary by engaging standards organizations, and interoperability practitioners in a community of practice for digital health to share best practices, tools, data, specifications, and experiences. This paper compares operational aspects of patient summaries in 14 case studies in Europe, the United States, and across the world, focusing on how patient summary components are used in practice, to promote alignment and joint understanding that will improve quality of standards and lower costs of interoperability.

Regional process redesign of lung cancer care: a learning health system pilot project.

PubMed

Fung-Kee-Fung, M; Maziak, D E; Pantarotto, J R; Smylie, J; Taylor, L; Timlin, T; Cacciotti, T; Villeneuve, P J; Dennie, C; Bornais, C; Madore, S; Aquino, J; Wheatley-Price, P; Ozer, R S; Stewart, D J

2018-02-01

The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions. To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation. The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days. The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.

Using a spreadsheet/table template for economic value added analysis.

PubMed

Cassey, Margaret

2008-01-01

Translating clinical research into practical applications that are cost effective has received significant attention as staff nurses attempt to expand new knowledge into an already complex daily workflow. spreadsheet/table template created in a word processing format can assist with setting up and carrying out the analysis of costs for comparing different approaches to routine activities. By encouraging nurses to take the initiative to examine parts of everyday nursing practice with an eye to cost analysis, significant contributions can be made to maximizing the bottom line.

Shared decision making as part of value based care: New U.S. policies challenge our readiness.

PubMed

Spatz, Erica S; Elwyn, Glyn; Moulton, Benjamin W; Volk, Robert J; Frosch, Dominick L

2017-06-01

Shared decision making in the United States is increasingly being recognized as part of value-based care. During the last decade, several state and federal initiatives have linked shared decision making with reimbursement and increased protection from litigation. Additionally, private and public foundations are increasingly funding studies to identify best practices for moving shared decision making from the research world into clinical practice. These shifts offer opportunities and challenges for ensuring effective implementation. Copyright © 2017. Published by Elsevier GmbH.

Effect of the Procalcitonin Assay on Antibiotic Use in Critically Ill Children.

PubMed

Ross, Rachael K; Keele, Luke; Kubis, Sherri; Lautz, Andrew J; Dziorny, Adam C; Denson, Adam R; O'Connor, Kathleen A; Chilutti, Marianne R; Weiss, Scott L; Gerber, Jeffrey S

2018-05-15

We retrospectively studied the effect of introducing procalcitonin into clinical practice on antibiotic use within a large academic pediatric intensive care unit. In the absence of a standardized algorithm, availability of the procalcitonin assay did not reduce the frequency of antibiotic initiations or the continuation of antibiotics for greater than 72 hours.

The Prediction of Disruptive Behaviour Disorders in an Urban Community Sample: The Contribution of Person-Centred Analyses

ERIC Educational Resources Information Center

Burt, Keith B.; Hay, Dale F.; Pawlby, Susan; Harold, Gordon; Sharp, Deborah

2004-01-01

Background: Variable- and person-centred analyses were used to examine prediction of middle childhood behaviour problems from earlier child and family measures. Method: A community sample of 164 families, initially recruited at antenatal clinics at two South London practices, was assessed for children's behaviour problems and cognitive ability,…

Pharmacy benefit managers, pharmacies, and pharmacogenomic testing: prescription for progress?

PubMed

Topol, Eric J

2010-08-11

Few would argue that the ability to match individual patients with the safest and most effective drugs and doses would be a major advance for clinical medicine. But while clinicians have been reluctant to routinely use pharmacogenomic analyses to guide their prescribing practices, pharmacy benefit managers and drugstores are proceeding with major pharmacogenetic initiatives.

Concepts and clinical use of ultra-long basal insulin.

PubMed

Eliaschewitz, Freddy Goldberg; Barreto, Tânia

2016-01-01

Diabetes mellitus (DM) is a public health issue, affecting around 382 million people worldwide. In order to achieve glycemic goals, insulin therapy is the frontline therapy for type 1 DM patients; for patients with type 2 DM, use of insulin therapy is an option as initial or add-on therapy for those not achieving glycemic control. Despite insulin therapy developments seen in the last decades, several barriers remain for insulin initiation and optimal maintenance in clinical practice. Fear of hypoglycemia, weight gain, pain associated with blood testing and injection-related pain are the most cited reasons for not starting insulin therapy. However, new generation of basal insulin formulations, with longer length of action, have shown the capability of providing adequate glycemic control with lower risk of hypoglycemia.

A critical analysis and discussion of clinical research ethics in the Russian Federation and their implications for Western sponsored trials.

PubMed

Leintz, Christopher

2014-06-01

Globalization, political upheavals, and Western economic struggles have caused a geographical reprioritization in the realm of drug development and human clinical research. Regulatory and cost hurdles as well as a saturation of research sites and subjects in Western countries have forced the pharmaceutical industry to place an unprecedented level of importance on emerging markets, injecting Western corporate initiatives into cultures historically and socially isolated from Western-centric value systems. One of the greatest recipients of this onslaught of Western business and research practices is the Russian Federation. Namely, market forces are dictating a focused research initiative in the traditional emerging markets, but this focus may be at the expense of individual and societal dignity. © 2012 John Wiley & Sons Ltd.

Novel challenges of multi-society investigator-initiated studies: a paradigm shift for technique and technology evaluation.

PubMed

Schwaitzberg, Steven D; Hawes, Robert H; Rattner, David W; Kochman, Michael L

2013-08-01

The introduction of innovative techniques and novel technologies into clinical practice is a challenge that confronts all aspects of healthcare delivery. Upheaval from shrinking research funding and declining healthcare reimbursements now forces patients, doctors, hospitals, payers, regulators, and even health systems into conflict as new therapies struggle to find a place in the therapeutic armamentarium. The escalating costs of healthcare force all parties to consider both the medical risks/benefits as well as the economic efficiency of proposed tools and therapies. We highlight these challenges by examining the process of initiating and conducting a "society-as-investigator" clinical trial to assess the safety of the natural orifice translumenal endoscopic surgery (NOTES) approach to cholecystectomy in the context of the issues that confront technology diffusion today.

Just-in-Time Evidence-Based E-mail “Reminders” in Home Health Care: Impact on Nurse Practices

PubMed Central

Murtaugh, Christopher M; Pezzin, Liliana E; McDonald, Margaret V; Feldman, Penny H; Peng, Timothy R

2005-01-01

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. PMID:15960694

Graduate nurses' experiences of mental health services in their first year of practice: An integrative review.

PubMed

Hooper, Mary-Ellen; Browne, Graeme; O'Brien, Anthony Paul

2016-08-01

New graduate nurses have reported negative experiences in mental health settings, particularly during the transitional period of practice. Previous research has focused on addressing the undergraduate preparation of nurses for practice instead of the experiences and outcomes of the transitional period. Recently, there has been growing interest in exploring the experiences of graduate nurses in transition and the implementation of promising interventions to facilitate new graduates' assimilation to practice. Despite these initiatives, the overall shortage of mental health nurses continues to rise, and graduates still report negative experiences in the mental health setting. The purpose of this study was to identify and explore the experiences of new graduate nurses in mental health services in their first year of clinical practice. An integrative review was conducted with 22 studies sourced from the CINAHL, PubMed, Scopus, and PsychINFO electronic databases, as well as through hand-searching the literature. Literature review findings have highlighted negative clinical experiences and increased attrition from mental health services for graduate nurses. These experiences were closely linked with the changes in the training of mental health nurses, role ambiguity, inadequate clinical preceptorship, encountering the reality of mental health services, and the role of health services in transitioning graduate nurses into clinical practice. Established research into organizational cultures demonstrates that negative organizational outcomes result from negative workplace experiences. Therefore, further research into new graduate nurses' experiences of mental health nursing and its culture might clarify the reasons why they might not be attracted to the discipline and/or are leaving early in their career. © 2016 Australian College of Mental Health Nurses Inc.

Integrative Mental Health (IMH): paradigm, research, and clinical practice.

PubMed

Lake, James; Helgason, Chanel; Sarris, Jerome

2012-01-01

This paper provides an overview of the rapidly evolving paradigm of "Integrative Mental Health (IMH)." The paradigm of contemporary biomedical psychiatry and its contrast to non-allopathic systems of medicine is initially reviewed, followed by an exploration of the emerging paradigm of IMH, which aims to reconcile the bio-psycho-socio-spiritual model with evidence-based methods from traditional healing practices. IMH is rapidly transforming conventional understandings of mental illness and has significant positive implications for the day-to-day practice of mental health care. IMH incorporates mainstream interventions such as pharmacologic treatments, psychotherapy, and psychosocial interventions, as well as alternative therapies such as acupuncture, herbal and nutritional medicine, dietary modification, meditation, etc. Two recent international conferences in Europe and the United States show that interest in integrative mental health care is growing rapidly. In response, the International Network of Integrative Mental Health (INIMH: www.INIMH.org) was established in 2010 with the objective of creating an international network of clinicians, researchers, and public health advocates to advance a global agenda for research, education, and clinical practice of evidence-based integrative mental health care. The paper concludes with a discussion of emerging opportunities for research in IMH, and an exploration of potential clinical applications of integrative mental health care. Copyright © 2012 Elsevier Inc. All rights reserved.

Fulbright project focuses on rehabilitation technician education and physiotherapy practice at the Kachere Rehabilitation Centre in Malawi.

PubMed

Glickman, Leslie B

2017-09-01

The aim of this project was to strengthen rehabilitation technician education and physiotherapy practice at the Kachere Rehabilitation Centre in the less-resourced country of Malawi by enlarging and reinforcing the skills of faculty, administrators, and adjunct clinicians, and fostering their continuing professional development. The project was developed through a partnership with the Kachere Rehabilitation Centre (KRC), the Medical Rehabilitation College (MRC), and a US-trained physical therapist (a Fulbright Program Scholar - FPS). The elements were education of staff, faculty, and students, and administrative consultation for rehabilitation managers, educational administrators, and faculty clinicians. Formal and informal participant feedback on the project was positive. It indicated a receptive audience who expanded their knowledge and willingly considered ideas to modify teaching, clinical, and management approaches for optimal patient care, enhanced clinician/student learning, meeting curricular accreditation standards, and solving day-to-day challenges. The project made a positive impact on the participants, fostering their goal to parallel clinical practice and educational initiatives used by recognized international standard bearers. Lessons learned emphasized the power of partnerships, networking, flexibility, and creative thinking. For international physiotherapists, it is an underutilized opportunity to extend global outreach, scholarship, clinical practice, and academic knowledge in a less-resourced country eager to upgrade the background and skills of rehabilitation providers.

Assessment of safety and efficacy of lamotrigine over the course of 1-year observation in Japanese patients with bipolar disorder: post-marketing surveillance study report

PubMed Central

Terao, Takeshi; Ishida, Atsuko; Kimura, Toshifumi; Yoshida, Mitsuhiro; Hara, Terufumi

2017-01-01

Background A post-marketing surveillance (PMS) study was conducted with a 1-year observation period to assess the safety and efficacy of lamotrigine in routine clinical practice in patients with bipolar disorder (BD). Patients and methods Central enrollment method was used to recruit patients diagnosed with BD who were being treated for the first time with lamotrigine to prevent the recurrence/relapse of BD mood episodes. Adverse drug reactions (ADRs) and recurrence/relapse were assessed. Improvement of mania and depression was also assessed using the Hamilton’s Rating Scale for Depression (HAM-D) and the Young Mania Rating Scale (YMRS) at treatment initiation, 4–6 months post treatment initiation, and 10–12 months post treatment initiation. Results A total of 237/989 patients (24.0%) reported ADRs, most commonly rash (9.1%), and the incidence of serious ADRs was 3.3% (33/989 patients). Skin disorders occurred in 130 patients (13.1%), mostly within 8 weeks post treatment. A total of 237/703 patients (33.7%) experienced recurrence/relapse of mood episodes. The 25th percentile of the time to recurrence/relapse of mood episodes was 105 days. Remission of depression symptoms (HAM-D ≤7) occurred in 147/697 patients (21.1%) at treatment initiation, rising to 361 patients (67.4%) at 10–12 months post treatment. Remission of manic symptoms (YMRS ≤13) occurred in 615/676 patients (91.0%) at treatment initiation, rising to 500 patients (97.3%) at 10–12 months post treatment. Conclusion The results of this PMS study suggest that lamotrigine is a well-tolerated and effective drug for preventing recurrence/relapse of BD in clinical practice. PMID:28652744

Thirty-Year (1975–2005) Trends in the Incidence Rates, Clinical Features, Treatment Practices, and Short-term Outcomes of Patients < 55 Years of Age Hospitalized with an Initial Acute Myocardial Infarction

PubMed Central

McManus, David D.; Piacentine, Stephen M; Lessard, Darleen; Gore, Joel M.; Yarzebski, Jorge; Spencer, Frederick A.; Goldberg, Robert J.

2011-01-01

Sparse data are available describing recent trends in the magnitude, clinical features, treatment practices, and outcomes of comparatively young adults hospitalized with acute myocardial infarction (AMI). The objectives of this population-based study were to describe 3 decade-long trends (1975–2005) in these endpoints among adults less than 55 years old who were hospitalized with an initial AMI. The study population consisted of 1,703 residents of the Worcester (MA) metropolitan area between the ages of 25–54 years who were hospitalized with an initial AMI at all central Massachusetts medical centers during 15 annual periods between 1975 and 2005. The overall hospital incidence rate (per 100,000 persons) of initial AMI in our study population was 66 (95% confidence interval 63–69) and the incidence rates of AMI declined inconsistently over time. Patients hospitalized during the most recent study years were more likely to have important cardiovascular risk factors and comorbidities present but were less likely to have developed heart failure during their index hospitalization. In-hospital and 30-day death rates declined by approximately 50% (p = 0.04) during the years under study concomitant with increasing use of effective cardiac therapies. In conclusion, the results of this community-wide investigation provide insights into the magnitude, changing characteristics, and short-term outcomes of comparatively young patients hospitalized with a first AMI. Declining odds of developing, or dying from, an initial AMI during the 30 years under study likely reflect enhanced primary and secondary prevention and treatment efforts. PMID:21624538

Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

PubMed Central

Kapur, Ajay; Goode, Gina; Riehl, Catherine; Zuvic, Petrina; Joseph, Sherin; Adair, Nilda; Interrante, Michael; Bloom, Beatrice; Lee, Lucille; Sharma, Rajiv; Sharma, Anurag; Antone, Jeffrey; Riegel, Adam; Vijeh, Lili; Zhang, Honglai; Cao, Yijian; Morgenstern, Carol; Montchal, Elaine; Cox, Brett; Potters, Louis

2013-01-01

By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice. PMID:24380074

[ISO 9001certification of a quality management system in a clinical investigation center].

PubMed

Chesnais, Jimmy; Fougerou-Leurent, Claire; Laforest, Claire; Renault, Alain; Bellissant, Eric; Laviolle, Bruno

2018-05-03

Beyond the application of legal requirements, clinical trials must have a permanent approach of quality control. The clinical investigation centers (CICs) are academic structures of clinical research certified by the French National institute of health and medical research (Inserm) and whose functioning relies on recommendations of good practice. It is important to accompany this standardization of practices by the implementation of a quality management system. This article presents the process that enabled the CIC of Rennes to become certified ISO 9001 by French standards association (Afnor) certification in May, 2016. The application of the fundamental principles of the standard ISO 9001 in the domain of clinical research is approached. The problem of the perimeter for the certification and the related process mapping are exposed. The activities of methodology, management and analysis of clinical studies were chosen for the initial certification of the CIC of Rennes. The perspectives for the extension of the perimeter of certification are also approached at the end of article. Copyright © 2018 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.

Big Data in Designing Clinical Trials: Opportunities and Challenges

PubMed Central

Mayo, Charles S.; Matuszak, Martha M.; Schipper, Matthew J.; Jolly, Shruti; Hayman, James A.; Ten Haken, Randall K.

2017-01-01

Emergence of big data analytics resource systems (BDARSs) as a part of routine practice in Radiation Oncology is on the horizon. Gradually, individual researchers, vendors, and professional societies are leading initiatives to create and demonstrate use of automated systems. What are the implications for design of clinical trials, as these systems emerge? Gold standard, randomized controlled trials (RCTs) have high internal validity for the patients and settings fitting constraints of the trial, but also have limitations including: reproducibility, generalizability to routine practice, infrequent external validation, selection bias, characterization of confounding factors, ethics, and use for rare events. BDARS present opportunities to augment and extend RCTs. Preliminary modeling using single- and muti-institutional BDARS may lead to better design and less cost. Standardizations in data elements, clinical processes, and nomenclatures used to decrease variability and increase veracity needed for automation and multi-institutional data pooling in BDARS also support ability to add clinical validation phases to clinical trial design and increase participation. However, volume and variety in BDARS present other technical, policy, and conceptual challenges including applicable statistical concepts, cloud-based technologies. In this summary, we will examine both the opportunities and the challenges for use of big data in design of clinical trials. PMID:28913177

Big Data in Designing Clinical Trials: Opportunities and Challenges.

PubMed

Mayo, Charles S; Matuszak, Martha M; Schipper, Matthew J; Jolly, Shruti; Hayman, James A; Ten Haken, Randall K

2017-01-01

Emergence of big data analytics resource systems (BDARSs) as a part of routine practice in Radiation Oncology is on the horizon. Gradually, individual researchers, vendors, and professional societies are leading initiatives to create and demonstrate use of automated systems. What are the implications for design of clinical trials, as these systems emerge? Gold standard, randomized controlled trials (RCTs) have high internal validity for the patients and settings fitting constraints of the trial, but also have limitations including: reproducibility, generalizability to routine practice, infrequent external validation, selection bias, characterization of confounding factors, ethics, and use for rare events. BDARS present opportunities to augment and extend RCTs. Preliminary modeling using single- and muti-institutional BDARS may lead to better design and less cost. Standardizations in data elements, clinical processes, and nomenclatures used to decrease variability and increase veracity needed for automation and multi-institutional data pooling in BDARS also support ability to add clinical validation phases to clinical trial design and increase participation. However, volume and variety in BDARS present other technical, policy, and conceptual challenges including applicable statistical concepts, cloud-based technologies. In this summary, we will examine both the opportunities and the challenges for use of big data in design of clinical trials.

The role of dialyzer membrane flux in bio-incompatibility.

PubMed

Davenport, Andrew

2008-10-01

Dialyzer membrane flux is currently defined according to beta(2)-microglobulin (a middle molecule) clearance. Traditionally, high flux membranes were synthetic, and caused less inflammatory reaction in the extracorporeal circuit, compared with standard low-flux cuprophan bio-incompatible dialyzers. Initial reports suggested improved patient outcomes in acute renal failure when noncuprophan dialyzer membranes were used. However, over time these positive observations have not been substantiated. As the price differential between these dialyzer membrane types has become marginal, more high-flux dialyzers are now used in routine clinical practice. Two multicenter trials have recently reported a survival advantage for high-flux dialyzers. Whether this is directly consequent upon the choice of dialyzer membrane, or related to improvements in dialysate water quality, or changes in other clinical practices remains to be determined.

Advanced Practice Nursing Committee on Process Improvement in Trauma: An Innovative Application of the Strong Model.

PubMed

West, Sarah Katherine

2016-01-01

This article aims to summarize the successes and future implications for a nurse practitioner-driven committee on process improvement in trauma. The trauma nurse practitioner is uniquely positioned to recognize the need for clinical process improvement and enact change within the clinical setting. Application of the Strong Model of Advanced Practice proves to actively engage the trauma nurse practitioner in process improvement initiatives. Through enhancing nurse practitioner professional engagement, the committee aims to improve health care delivery to the traumatically injured patient. A retrospective review of the committee's first year reveals trauma nurse practitioner success in the domains of direct comprehensive care, support of systems, education, and leadership. The need for increased trauma nurse practitioner involvement has been identified for the domains of research and publication.

American Society of Clinical Oncology National Census of Oncology Practices: Preliminary Report

PubMed Central

Forte, Gaetano J.; Hanley, Amy; Hagerty, Karen; Kurup, Anupama; Neuss, Michael N.; Mulvey, Therese M.

2013-01-01

In response to reports of increasing financial and administrative burdens on oncology practices and a lack of systematic information related to these issues, American Society of Clinical Oncology (ASCO) leadership started an effort to collect key practice-level data from all oncology practices in the United States. The result of the effort is the ASCO National Census of Oncology Practices (Census) launched in June 2012. The initial Census work involved compiling an inventory of oncology practices from existing lists of oncology physicians in the United States. A comprehensive, online data collection instrument was developed, which covered a number of areas, including practice characteristics (staffing configuration, organizational structure, patient mix and volume, types of services offered); organizational, staffing, and service changes over the past 12 months; and an assessment of the likelihood that the practice would experience organizational, staffing, and service changes in the next 12 months. More than 600 practices participated in the Census by providing information. In this article, we present preliminary highlights from the data gathered to date. We found that practice size was related to having experienced practice mergers, hiring additional staff, and increasing staff pay in the past 12 months, that geographic location was related to having experienced hiring additional staff, and that practices in metropolitan areas were more likely to have experienced practice mergers in the past 12 months than those in nonmetropolitan areas. We also found that practice size and geographic location were related to higher likelihoods of anticipating practice mergers, sales, and purchases in the future. PMID:23633966

A Spanish language and culture initiative for a doctor of pharmacy curriculum.

PubMed

VanTyle, W Kent; Kennedy, Gala; Vance, Michael A; Hancock, Bruce

2011-02-10

To implement a Spanish language and culture initiative in a doctor of pharmacy (PharmD) curriculum that would improve students' Spanish language skills and cultural competence so that graduates could provide competent pharmaceutical care to Spanish-speaking patients. Five elective courses were created and introduced to the curriculum including 2 medical Spanish courses; a medical Spanish service-learning course; a 2-week Spanish language and cultural immersion trip to Mexico; and an advanced practice pharmacy experience (APPE) at a medical care clinic serving a high percentage of Spanish-speaking patients. Advisors placed increased emphasis on encouraging pharmacy students to complete a major or minor in Spanish. Enrollment in the Spanish language courses and the cultural immersion trip has been strong. Twenty-three students have completed the APPE at a Spanish-speaking clinic. Eleven percent of 2010 Butler University pharmacy graduates completed a major or minor in Spanish compared to approximately 1% in 2004 when the initiative began. A Spanish language and culture initiative started in 2004 has resulted in increased Spanish language and cultural competence among pharmacy students and recent graduates.

Fatigue as a Driver of Overall Quality of Life in Cancer Patients.

PubMed

McCabe, Ryan M; Grutsch, James F; Braun, Donald P; Nutakki, Swetha B

2015-01-01

This manuscript describes an approach for analyzing large amounts of disparate clinical data to elucidate the most impactful factor(s) that relate to a meaningful clinical outcome, in this case, the quality of life of cancer patients. The relationships between clinical and quality of life variables were evaluated using the EORTC QLQ-C30 global health domain--a validated surrogate variable for overall cancer patient well-being. A cross-sectional study design was used to evaluate the determinants of global health in cancer patients who initiated treatment at two regional medical centers between January 2001 and December 2009. Variables analyzed included 15 EORTC QLQ-C30 scales, age at diagnosis, gender, newly diagnosed/ recurrent disease status, and stage. The decision tree algorithm, perhaps unfamiliar to practicing clinicians, evaluates the relative contribution of individual parameters in classifying a clinically meaningful functional endpoint, such as the global health of a patient. Multiple patient characteristics were identified as important contributors. Fatigue, in particular, emerged as the most prevalent indicator of cancer patients' quality of life in 16/23 clinically relevant subsets. This analysis allowed results to be stated in a clinically-intuitive, rule set format using the language and quantities of the Quality of Life (QoL) tool itself. By applying the classification algorithms to a large data set, identification of fatigue as a root factor in driving global health and overall QoL was revealed. The ability to practice mining of clinical data sets to uncover critical clinical insights that are immediately applicable to patient care practices is illustrated.

Fatigue as a Driver of Overall Quality of Life in Cancer Patients

PubMed Central

McCabe, Ryan M.; Grutsch, James F.; Braun, Donald P.; Nutakki, Swetha B.

2015-01-01

Background This manuscript describes an approach for analyzing large amounts of disparate clinical data to elucidate the most impactful factor(s) that relate to a meaningful clinical outcome, in this case, the quality of life of cancer patients. The relationships between clinical and quality of life variables were evaluated using the EORTC QLQ-C30 global health domain—a validated surrogate variable for overall cancer patient well-being. Methods A cross-sectional study design was used to evaluate the determinants of global health in cancer patients who initiated treatment at two regional medical centers between January 2001 and December 2009. Variables analyzed included 15 EORTC QLQ-C30 scales, age at diagnosis, gender, newly diagnosed/ recurrent disease status, and stage. The decision tree algorithm, perhaps unfamiliar to practicing clinicians, evaluates the relative contribution of individual parameters in classifying a clinically meaningful functional endpoint, such as the global health of a patient. Findings Multiple patient characteristics were identified as important contributors. Fatigue, in particular, emerged as the most prevalent indicator of cancer patients’ quality of life in 16/23 clinically relevant subsets. This analysis allowed results to be stated in a clinically-intuitive, rule set format using the language and quantities of the Quality of Life (QoL) tool itself. Interpretation By applying the classification algorithms to a large data set, identification of fatigue as a root factor in driving global health and overall QoL was revealed. The ability to practice mining of clinical data sets to uncover critical clinical insights that are immediately applicable to patient care practices is illustrated. PMID:26070133

The journey of primary care practices to meaningful use: a Colorado Beacon Consortium study.

PubMed

Fernald, Douglas H; Wearner, Robyn; Dickinson, W Perry

2013-01-01

The Health Information Technology for Economic and Clinical Health Act of 2009 provides for incentive payments through Medicare and Medicaid for clinicians who implement electronic health records (EHRs) and use this technology meaningfully to improve patient care. There are few comprehensive descriptions of how primary care practices achieve the meaningful use of clinical data, including the formal stage 1 meaningful use requirements. Evaluation of the Colorado Beacon Consortium project included iterative qualitative analysis of practice narratives, provider and staff interviews, and separate focus groups with quality improvement (QI) advisors and staff from the regional health information exchange (HIE). Most practices described significant realignment of practice priorities and aims, which often required substantial education and training of physicians and staff. Re-engineering office processes, data collection protocols, EHRs, staff roles, and practice culture comprised the primary effort and commitment to attest to stage 1 meaningful use and subsequent meaningful use of clinical data. While realizing important benefits, practices bore a significant burden in learning the true capabilities of their EHRs with little effective support from vendors. Attestation was an important initial milestone in the process, but practices faced substantial ongoing work to use their data meaningfully for patient care and QI. Key resources were instrumental to these practices: local technical EHR expertise; collaborative learning mechanisms; and regular contact and support from QI advisors. Meeting the stage 1 requirements for incentives under Medicare and Medicaid meaningful use criteria is the first waypoint in a longer journey by primary care practices to the meaningful use of electronic data to continuously improve the care and health of their patients. The intensive re-engineering effort for stage 1 yielded practice changes consistent with larger practice aims and goals. While many of these practices are now poised to use data meaningfully, faster progress will likely come with continued local QI and technical support and planned community-wide learning.

Educational priorities and current involvement in genetic practice: a survey of midwives in the Netherlands, UK and Sweden.

PubMed

Benjamin, Caroline M; Anionwu, Elizabeth N; Kristoffersson, Ulf; ten Kate, Leo P; Plass, Anne Marie C; Nippert, Irmgard; Julian-Reynier, Claire; Harris, Hilary J; Schmidtke, Joerg; Challen, Kirsty; Calefato, Jean Marc; Waterman, Christine; Powell, Eileen; Harris, Rodney

2009-10-01

to investigate whether practising midwives are adequately prepared to integrate genetic information into their practice. a cross-sectional, postal, structured questionnaire survey was sent to practising midwives. practising midwives from the Netherlands (NL), Sweden (SE) and the United Kingdom (UK). 1021 replies were received, achieving a response rate of 62%. 79% (799/1015) of midwives reported attending courses with some 'genetic content' during their initial training. Sixty-eight per cent (533/784) judged this to have been useful for clinical practice. Variation was seen between countries in the amount of genetic content in post-registration training (SE 87%, NL 44%, UK 17%) and most was considered useful. Questions assessing clinical activity identified a current need for genetic knowledge. Midwives described low levels of self-reported confidence both in overtly genetic procedures and in everyday tasks that were underpinned by genetic knowledge. For eight of the 12 procedures, fewer than 20% of midwives considered themselves to be confident. Differences were apparent between countries. Midwives identified psychosocial, screening and risk assessment aspects of genetic education as being important to them, rather than technical aspects or genetic science. given the low reported confidence with genetic issues in clinical practice, it is essential that this is addressed in terms of the amount, content and targeting of genetic education. This is especially important to ensure the success of national antenatal and baby screening programmes. The results of this study suggest that midwives would welcome further training in genetics, addressing genetic topics most relevant to their clinical practice.

Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.

PubMed

Peter, W F; Jansen, M J; Hurkmans, E J; Bloo, H; Dekker, J; Dilling, R G; Hilberdink, W; Kersten-Smit, C; de Rooij, M; Veenhof, C; Vermeulen, H M; de Vos, R J; Schoones, J W; Vliet Vlieland, T P

2011-01-01

An update of a Dutch physiotherapy practice guideline in Hip and Knee Osteoarthritis (HKOA) was made, based on current evidence and best practice. A guideline steering committee, comprising 10 expert physiotherapists, selected topics concerning the guideline chapters: initial assessment, treatment and evaluation. With respect to treatment a systematic literature search was performed using various databases, and the evidence was graded (1-4). For the initial assessment and evaluation mainly review papers and textbooks were used. Based on evidence and expert opinion, recommendations were formulated. A first draft of the guideline was reviewed by 17 experts from different professional backgrounds. A second draft was field-tested by 45 physiotherapists. In total 11 topics were selected. For the initial assessment, three recommendations were formulated, pertaining to history taking, red flags, and formulating treatment goals. Concerning treatment, 7 recommendations were formulated; (supervised) exercise therapy, education and self management interventions, a combination of exercise and manual therapy, postoperative exercise therapy and taping of the patella were recommended. Balneotherapy and hydrotherapy in HKOA, and thermotherapy, TENS, and Continuous Passive Motion in knee OA were neither recommended nor discouraged. Massage therapy, ultrasound, electrotherapy, electromagnetic field, Low Level Laser Therapy, preoperative physiotherapy and education could not be recommended. For the evaluation of treatment goals the following measurement instruments were recommended: Lequesne index, Western Ontario and McMaster Universities osteoarthritis index, Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score, 6-minute walktest, Timed Up and Go test, Patient Specific Complaint list, Visual Analoge Scale for pain, Intermittent and Constant OsteoArthritis Pain Questionnaire, goniometry, Medical Research Council for strength, handheld dynamometer. This update of a Dutch physiotherapy practice guideline on HKOA included 11 recommendations on the initial assessment, treatment and evaluation. The implementation of the guideline in clinical practice needs further evaluation.

Evidence in Practice - A Pilot Study Leveraging Companion Animal and Equine Health Data from Primary Care Veterinary Clinics in New Zealand.

PubMed

Muellner, Petra; Muellner, Ulrich; Gates, M Carolyn; Pearce, Trish; Ahlstrom, Christina; O'Neill, Dan; Brodbelt, Dave; Cave, Nick John

2016-01-01

Veterinary practitioners have extensive knowledge of animal health from their day-to-day observations of clinical patients. There have been several recent initiatives to capture these data from electronic medical records for use in national surveillance systems and clinical research. In response, an approach to surveillance has been evolving that leverages existing computerized veterinary practice management systems to capture animal health data recorded by veterinarians. Work in the United Kingdom within the VetCompass program utilizes routinely recorded clinical data with the addition of further standardized fields. The current study describes a prototype system that was developed based on this approach. In a 4-week pilot study in New Zealand, clinical data on presentation reasons and diagnoses from a total of 344 patient consults were extracted from two veterinary clinics into a dedicated database and analyzed at the population level. New Zealand companion animal and equine veterinary practitioners were engaged to test the feasibility of this national practice-based health information and data system. Strategies to ensure continued engagement and submission of quality data by participating veterinarians were identified, as were important considerations for transitioning the pilot program to a sustainable large-scale and multi-species surveillance system that has the capacity to securely manage big data. The results further emphasized the need for a high degree of usability and smart interface design to make such a system work effectively in practice. The geospatial integration of data from multiple clinical practices into a common operating picture can be used to establish the baseline incidence of disease in New Zealand companion animal and equine populations, detect unusual trends that may indicate an emerging disease threat or welfare issue, improve the management of endemic and exotic infectious diseases, and support research activities. This pilot project is an important step toward developing a national surveillance system for companion animals and equines that moves beyond emerging infectious disease detection to provide important animal health information that can be used by a wide range of stakeholder groups, including participating veterinary practices.

[Post launch studies].

PubMed

Akaza, Hideyuki; Ohashi, Yasuo; Shimada, Yasuhiro; Ikeda, Tadashi; Saijo, Nagahiro; Isonishi, Seiji; Hirao, Yoshihiko; Tsuruo, Takashi; Tsukagoshi, Shigeru; Sone, Saburo; Nakamura, Seigo; Kato, Masuhiro; Mikami, Osamu; von Euler, Mikael; Blackledge, George; Milsted, Bob; Vose, Brent

2002-11-01

Evidence Based Medicine (EBM) is a growing concept in Japan as it is elsewhere. Central to improving the use of EBM is generation of data through well conducted controlled clinical studies. There are many problems associated with conduct of clinical studies after launch in Japan, and many initiatives are ongoing to improve the situation. Development of Clinical Research Coordinators (CRO) and central Data Management centers are key to improving the quality of clinical research in Japan. Currently Japan has an undeveloped legal system with regard to post-launch trials and off-label use of registered drugs. There is no reimbursement for off-label and various restrictions imposed on the recipients of the Ministry of Health, Labour and Welfare's (MHLW) funds. Maybe the biggest problem is the high cost of post-marketing studies sponsored by pharmaceutical manufacturers. A high quality system to support post launch clinical studies need a solid financial base. There is a need for a suitable review system for investigator initiated multi-centre studies, as the current IRB system is not sufficient. There are also challenges regarding the differences, perceived or real, in treatment practice and available registrations in Japan and in the West, causing problems in choosing suitable comparators and study designs. At the present time it is not clear whether investigator initiated trials will be acceptable for registration purposes in Japan. The agreed first priority is to build a suitable and strong infrastructure within the academic community to support researchers to investigate important questions with or without pharmaceutical company support. Despite all these issues, several groundbreaking projects are under way throughout Japan, in many different areas and by different collaborative groups, some with government support. In fact, researcher-initiated clinical trials achieved a rapid growth in Japan in the past year.

Measures of rheumatoid arthritis disease activity in Australian clinical practice.

PubMed

Taylor, Andrew; Bagga, Hanish

2011-01-01

Objectives. To investigate which rheumatoid arthritis (RA) disease activity measures are being collected in patients receiving glucocorticoids, non-biologic or biologic disease-modifying antirheumatic drugs (DMARDs) in Australian rheumatology practice. Methods. A retrospective audit of medical records was conducted from eight rheumatology practices around Australia. Each rheumatologist recruited 30 consecutive eligible patients into the review, 10 of whom must have been receiving a biological agent for rheumatoid arthritis. Disease activity measures and radiographic assessments were collected from each patient's last consultation. For biologic patients, disease activity measures were also collected from when the patient was first initiated on the biological agent. Results. At last consultation, the disease measures that were recorded most often were ESR (89.2%), haemoglobin (87.5%), and CRP (84.2%). DAS28 was infrequently recorded (16.3%). The rate of recording disease activity measures for patients receiving biologic DMARDs decreased over time (mean 27 months). Conclusion. This review has shown inconsistency of RA activity measures being recorded in Australian rheumatology clinical practice. An accurate assessment of the disease process is necessary to effectively target rheumatoid arthritis patients to treat in order to achieve optimal outcomes.