Adaptive Practice: Next Generation Evidence-Based Practice in Digital Environments

Evidence-based practice in nursing is considered foundational to safe, competent care. To date, rigid traditional perceptions of what constitutes 'evidence' have constrained the recognition and use of practice-based evidence and the exploitation of novel forms of evidence from data rich environments. Advancements such as the conceptualization of clinical intelligence, the prevalence of increasingly sophisticated digital health information systems, and the advancement of the Big Data phenomenon have converged to generate a new contemporary context. In today's dynamic data-rich environments, clinicians have new sources of valid evidence, and need a new paradigm supporting clinical practice that is adaptive to information generated by diverse electronic sources. This opinion paper presents adaptive practice as the next generation of evidence-based practice in contemporary evidence-rich environments and provides recommendations for the next phase of evolution.

Doctors and Their Patients in the Seventeenth to Nineteenth Centuries

How can these finings be interpreted in conclusion? Analysis has revealed firstly that, depending on the chosen period, the socio-geographical situation and the profile of the individual doctor's practice, the clientele varied widely in terms of gender, age and social rank. The consultation behaviour of men and women changed noticeably. Findings overall suggest that up until t8o the gender distribution varied in the individual practices. There was a trend for women to be overrepresented in urban practices during the earlier period. But in general, from the mid-nineteenth century they predominated - in towns as well as in the country in allopathic as well as homeopathic practices. The absence of children, which was bemoaned by many physicians, did not apply to the practices under investigation. On the contrary: the percentage is consistently high while older patients remained underrepresented right up until the end of the period under investigation, even though their proportion increased in the individual practices during the course of the nineteenth century In each of the nineteenth century practices investigated - and increasingly among the lower and middle classes - the physicians' services were used by several members of the same family. We have found no evidence to support the thesis that up until the nineteenth century academic physicians were mainly consulted by aristocratic or wealthy bourgeois patients. The theory probably applies only to early modern urban doctors. In the practices examined here, from the middle of the eighteenth century, patients from all social strata went to consult physicians. The participation of members of the lower classes or from an artisanal, (proto) industrial or agricultural background clearly increased over time 'despite ubiquitous economic and cultural barriers. That the annual numbers of consultations per physician increased - despite the growing number of physicians available - suggests that for economically disadvantaged social groups also, the consultation of learned physicians became more common: in towns from the first half of the nineteenth century and in the country from the middle of the century. In addition, the individual findings reveal that, prior to the introduction of statutory health insurance for salaried persons, patients of more secure social standing consulted a physician considerably more frequently in the course of the year than lower class patients. While the patient structure clearly changed around 1800, the relationship between physician and patient continued without major changes from the seventeenth to the nineteenth century. The therapeutic encounter up until the end of the investigated period can be summarized as a negotiation process. Patients were discerning in their choice of healer and did not refrain from using rival services. They sought help for unpleasant symptoms such as indigestion, pain or fever, and only rarely in cases of emergency Therapy was decided on after an exchange between a critical and autonomous client and the medical specialist who was generally willing to compromise. While the patient structure clearly changed around 1800, the relationship between physician and patient continued without major changes from the seventeenth to the nineteenth century. The therapeutic encounter up until the end of the investigated period can be summarized as a negotiation process. Patients were discerning in their choice of healer and did not refrain from using rival services. they sought help for unpleasant symptoms such as indigestion, pain or fever, and only rarely in cases of emergency. Therapy was decided on after an exchange between critical and autonomous client and the medical specialist who was generally willing to compromise.

HIV/AIDS pandemic and current practice among Paediatric Surgeons in Nigeria

BACKGROUND

HIV exposed children could require surgical procedures when ill. This study assessed how paediatric HIV/AIDS affected surgical practice among Nigerian paediatric surgeons.

METHODS

Descriptive cross-sectional study among consenting paediatric surgeons completing a self-administered questionnaire on the current practices and perception on HIV/AIDS in relation to their surgical practice. Data were analyzed using descriptive and inferential statistics.

RESULTS

Thirty eight out of forty two copies of questionnaire distributed were completed and included in analysis giving a response rate of 92.5%. Most of the respondents (73.7%) were Consultants and had practised more than 10 years. Mean (SD) age was 42.4 (7.5) years ranging from 31 to 63 years. Nearly all the 35 (92.1%) respondents were males while 3 (7.9%) were females. All of them had operated on known HIV positive children. Over half (57.9%) were in support of pre-operative HIV screening with most (76.3%) worried about getting infected during surgery. Most paediatric surgeons knew their HIV status (81.6%) and would undergo HIV screening preoperatively (84.2%) when requested by their patients or their caregivers. Only 5 (22.7%) out of 22 surgeons were screened previously because of needle stick or sharp instrument injury during surgical procedure. Only 6 (15.8%) surgeons rated their cross infection control practices as excellent.

CONCLUSION

Increasing number of HIV positive children are presenting to pediatric surgeons for surgical treatment in Nigeria in which at present surgical practices are inadequate in terms of cross infection control practices. There is need to optimize cross infection control practices through adequate provision of safe surgical devices.

Geriatric syndromes and geriatric assessment for the generalist

Geriatric assessment is an increasingly important area of outpatient medicine, given the unprecedented aging of the US population. Screening and evaluation for geriatric syndromes, particularly falls, urinary incontinence, frailty, and cognitive impairment, are crucial aspects of outpatient geriatric assessment. Innovative models of care are emerging to improve quality of care and enhance cost savings for the geriatric patient. High-value features of geriatric care systems include providing increased 24/7 access to care, a multidisciplinary team-based approach to care, performing medication reconciliation and comprehensive geriatric assessments, and integrating palliative care into treatment planning.

Establishing an integrated gastroenterology service between a medical center and the community

AIM

To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established.

METHODS

Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators.

RESULTS

An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer.

CONCLUSION

Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Changing physician behavior: what works?

OBJECTIVES

There are various interventions for guideline implementation in clinical practice, but the effects of these interventions are generally unclear. We conducted a systematic review to identify effective methods of implementing clinical research findings and clinical guidelines to change physician practice patterns, in surgical and general practice.

STUDY DESIGN

Systematic review of reviews.

METHODS

We searched electronic databases (MEDLINE, EMBASE, and PubMed) for systematic reviews published in English that evaluated the effectiveness of different implementation methods. Two reviewers independently assessed eligibility for inclusion and methodological quality, and extracted relevant data.

RESULTS

Fourteen reviews covering a wide range of interventions were identified. The intervention methods used include: audit and feedback, computerized decision support systems, continuing medical education, financial incentives, local opinion leaders, marketing, passive dissemination of information, patient-mediated interventions, reminders, and multifaceted interventions. Active approaches, such as academic detailing, led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active educational methods and multifaceted interventions.

CONCLUSIONS

Active forms of continuing medical education and multifaceted interventions were found to be the most effective methods for implementing guidelines into general practice. Additionally, active approaches to changing physician performance were shown to improve practice to a greater extent than traditional passive methods. Further primary research is necessary to evaluate the effectiveness of these methods in a surgical setting.

Characterizing the Structure of a Patient's Care Team through Electronic Encounter Data Analysis

As the field of medicine grows more complicated and doctors become more specialized in a particular field, the number of healthcare providers involved in healing an individual patient increases. This is particularly true of patients with multiple chronic conditions. Establishing effective communications among the care providers becomes critical to facilitate care coordination and more efficient resource use, which will ultimately result in health outcome improvement. The first step for care coordination is to understand who have been involved in a patient's care and their relationships with the patient. The widespread adoption of Electronic Health Records provides us an opportunity to explore solutions to well-coordinated care. This paper presents the concept of a patient's care team and demonstrates the feasibility of identifying relevant healthcare providers for an individual patient by leveraging electronic patient encounter data. Combined with network analysis techniques, we further visualize the care team structure with quantified strength of patient-provider relationships. Our work is foundational to the larger goal of patient-centered, coordinated care in the digital age of healthcare.

[Impact of standing order prescriptions on the joint follow-up of diabetics in primary care: a case study]

The burden of chronic disease requires a new organization of medical care and services. Enhancing collaboration among front-line care givers facilitates access to care and optimizes follow-up. As a result, a new organizational structure has been gradually deployed in Quebec since 2003. Family Medicine Groups (FMGs) use a new type of standing order, prescribing details of care. Among 52 FMGs surveyed, an exemplarygroup was identified that most successfully instituted more and higher-impact standing orders. This single case study explored the impact of standing orders used for diabetes follow-up on professional practices, physician-nurse-patient interactions and patient self-management. The data collected and analyzed were derived from more than 200 documents, 15 hours of observation in the clinic, and individual interviews of ten patients, three nurses and eight doctors. Standing ordersformalizing thejointfollow-up ofdiabetic patients both increased professional collaboration and improved patient-professional interactions. As professionals and patients achieved a better consensus, patient self-management was improved. Ultimately, for professionals, standing orders facilitate a better match between the use of their time and skills, and their aspirationsfor practice. Patients are reassured and empowered by ready access to care and their progress in self-management skills. Concrete measures, such as standing orders, modify care delivery by reinforcing professional collaboration, and facilitate patient self-care, in accordance with the Chronic Care Model (CCM).

[Integrating mental health and addiction services: the encounter of two worlds]

OBJECTIVE

The needfor integrated services to treat co-occurring disorders is now recognized. Specialised clinics have now been created for this purpose. This study analysed the integration process that occurred in a particular clinic in order to identify the strategies and means used and their overall impact.

METHODS

We conducted a longitudinal case study. Data collection was based on three sources: semi-structured interviews, observations and documents. It took place over a period of 3years and covered the first 6 years of the clinic transformation process. We analysed data from a process perspective. The analysis was also validated by informants.

RESULTS

Our analysis shows that the pursuit of integration is associated with important challenges at various levels: patient populations, professional practices, structural framework, inter-organizational relationships. These challenges were encountered right from the creation of the clinic. Various strategies and approaches were used to reduce the tensions raised by these challenges and had a considerable impact on the integration process. However, our analysis reveals that integration is an ongoing process that is never completely achieved. In fact, challenges are never completely resolved, but tend to be transformed, raising new tensions to which members of the organization respond with new strategies and means to ensure a continuing integration process.

CONCLUSIONS

These resultsforce us to reconsider the integration of services, not as a fixed result but rather as an object of change emerging from a complex process with an unknown outcome. Four important implicationsfor practice are derived from these results.