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Mevissen FEF, van Deursen B, Voeten HACM, Watzeels AJCM. 'We are not here to enforce; we are here for the people' Factors influencing performance of contact tracing during the COVID-19 pandemic: A qualitative study. J Public Health Res 2023; 12:22799036231208325. [PMID: 38020218 PMCID: PMC10676064 DOI: 10.1177/22799036231208325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 09/29/2023] [Indexed: 12/01/2023] Open
Abstract
Background Provider-initiated contact tracing (CT) is an important measure to slow down the spread of infectious diseases such as COVID-19. However, carrying out effective CT depends on the collaboration between the patient and the contact tracer. To improve CT, it is important to understand which factors influence contact tracers in being able to carry out CT during large pandemics. Methods We performed individual semi-structured interviews with nine contact tracers working for the COVID-19 unit of the Public Health Service (PHS) Rotterdam-Rijnmond, the Netherlands, to explore their experiences with carrying out CT. Data were collected between July 2020 and December 2020. The interview protocol was structured based on the CT tasks and guided by the literature and the framework explaining adherence to clinical practice guidelines. Results In general, CT seemed to be carried out satisfactorily. Individual factors (interviewing techniques and skills, attitude towards the patient and attitude towards CT), factors related to the patient (cooperativeness and engagement, emotions, language and culture and (mis)information), guideline-related factors (characteristics) and factors related to the organisation (interactions with colleagues, support from management, workload and training) were found to influence the carrying out of CT. Conclusion To be well prepared for future pandemics, it is important to explore strategies that can be effective to support the contact tracer in performing CT, support patients in feeling comfortable to be engaged and ways to reach more consistency in policies and protocols.
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Affiliation(s)
- Fraukje EF Mevissen
- Public Health Service (GGD) Rotterdam-Rijnmond, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Helene ACM Voeten
- Public Health Service (GGD) Rotterdam-Rijnmond, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anita JCM Watzeels
- Public Health Service (GGD) Rotterdam-Rijnmond, Rotterdam, The Netherlands
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Zeng LN, Cai H, Gao F, Guan B, Chen WJ, He W, Peng TM, Li XP, Li Y, Kung SS, Wang XM, Liu W, Zhao D, Yan S. Assessment of mental health status among Chinese nursing staff in the intensive care unit: a network analysis. J Res Nurs 2023; 28:285-298. [PMID: 37534263 PMCID: PMC10392721 DOI: 10.1177/17449871231172408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
Backgrounds Nursing is the key group to provide healthcare services, and it is easy for nursing staff to develop mental health problems. Aims The study aimed to evaluate prevalence of psychological symptoms in nurses working in an intensive care unit (ICU) and the inter-relationship of associations of psychological symptoms using network analysis. Methods This study is a cross-sectional design study. The Chinese version of the Symptom Check List-90 (SCL-90) was used to measure the psychological status of ICU nurses. The network structure of psychological symptoms was characterised, and indices of 'Expected influence' were used to identify symptoms central to the network. Network stability was examined using a case-dropping bootstrap procedure. Results Multiple logistic regression analysis found those who had worked more than 15 years were less likely to experience positive psychological symptoms, whereas nurses working in emergency ICU and other ICUs, nurses working in departments with over 16 beds were more likely to develop psychological symptoms. In addition, 'Anxiety', 'Mental degeneration' and 'Depression' were central symptoms in the network. Conclusions ICU nurses reported a high level of psychological symptoms, which may affect the quality of their work and worsen public health problems.
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Affiliation(s)
- Liang-Nan Zeng
- Nurse, Department of Nursing, Chengdu Fifth People’s Hospital, Sichuan, China
| | - Hong Cai
- Nurse, Unit of Psychiatry, Department of Public Health and Medicinal Administration, & Institute of Translational Medicine, Faculty of Health Sciences, Centre for Cognitive and Brain Sciences, University of Macau, University of Macau, Macao SAR, China
| | - Fei Gao
- Engineer, Hebei General Hospital, Heibei, China
| | - Bi Guan
- Nurse, Department of Nursing, Chengdu Fifth People’s Hospital, Sichuan, China
| | - Wen-Jin Chen
- Doctor, NICU of Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Wei He
- Doctor, Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Tang-Ming Peng
- Doctor, Cerebrovascular Department, Chengdu Fifth People’s Hospital, Sichuan, China
| | - Xiao-Peng Li
- Doctor, Department of Intensive Care Unit, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yan Li
- Nurse, Department of Nursing, Chengdu Fifth People’s Hospital, Sichuan, China
| | - Sui Sum Kung
- Doctor, Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan, China
| | | | - Wei Liu
- Doctor, Hebei Psychological Counselor Association, Heibei, China
| | - Di Zhao
- Doctor, Hebei Province Hospital of Chinese Medicine, Affiliated Hospital of Hebei University of Chinese Medicine, Heibei, China
| | - Shu Yan
- Doctor, Medical Affairs Department, Chengdu Fifth People’s Hospital, Sichuan, China
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3
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Auger LP, Filiatrault J, Allegue DR, Vachon B, Thomas A, Morales E, Rochette A. Sexual Rehabilitation After a Stroke: A Multi-site Qualitative Study About Influencing Factors and Strategies to Improve Services. SEXUALITY AND DISABILITY 2023; 41:1-27. [PMID: 37362801 PMCID: PMC10206562 DOI: 10.1007/s11195-023-09795-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 06/28/2023]
Abstract
This study aimed to better understand the factors influencing the provision of sexuality-related post-stroke rehabilitation services by clinicians on different sites and to explore strategies to improve post-stroke rehabilitation services with stakeholders. A qualitative study with co-design methods was conducted with 20 clinicians from five post-stroke rehabilitation centers in Canada, 1 manager and 1 patient-partner. Participants either took part in a focus group or in sessions of an adapted version of the LEGO Serious Play method to explore influencing factors and strategies of improvement in relation to post-stroke sexual rehabilitation services. Thematic analysis was conducted semi-deductively using the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation and Behaviour (COM-B) system and the Behaviour Change Wheel (BCW). A total of twenty factors pertaining either to the categories of Capability (n = 8; e.g., Sexual rehabilitation procedural knowledge), Motivation (n = 4; e.g., Professional boundaries) or Opportunity (n = 8; e.g., Workload) were perceived as influencing provision of sexual rehabilitation services by participants. A theoretical model was conceptualized. Strategies (n = 10) were categorized in concordance with the BCW as Training (n = 1), Enablement (n = 5) or Environmental restructuring (n = 4). This study showed that factors influencing provision of post-stroke rehabilitation services were numerous and interrelated, and that various strategies aiming either clinicians or the rehabilitation environment would be relevant to improve services. This study will help guide the design and implementation of future interventions studies aiming at improving post-stroke sexual rehabilitation services.
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Affiliation(s)
- Louis-Pierre Auger
- Faculty of Medicine, School of Rehabilitation, Université de Montréal, Montreal, QC Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), 6363 Chem. Hudson, Montreal, QC H3S 1M9 Canada
| | - Johanne Filiatrault
- Faculty of Medicine, School of Rehabilitation, Université de Montréal, Montreal, QC Canada
- Montreal Geriatric University Institute Research Center, Montreal, QC Canada
| | - Dorra Rakia Allegue
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), 6363 Chem. Hudson, Montreal, QC H3S 1M9 Canada
- Faculty of Medicine and Health Sciences, School of Physical and Occupational Therapy, McGill University, Montreal, QC Canada
| | - Brigitte Vachon
- Faculty of Medicine, School of Rehabilitation, Université de Montréal, Montreal, QC Canada
- Montreal University Institute of Mental Health, Montreal, QC Canada
| | - Aliki Thomas
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), 6363 Chem. Hudson, Montreal, QC H3S 1M9 Canada
- Faculty of Medicine and Health Sciences, School of Physical and Occupational Therapy, McGill University, Montreal, QC Canada
| | - Ernesto Morales
- Department of Rehabilitation, Université Laval, Quebec City, QC Canada
- Interdisciplinary Research Centre in Rehabilitation and Social Inclusion (CIRRIS), Quebec City, QC Canada
| | - Annie Rochette
- Faculty of Medicine, School of Rehabilitation, Université de Montréal, Montreal, QC Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), 6363 Chem. Hudson, Montreal, QC H3S 1M9 Canada
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4
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Geng Y, Wang Z, Zhou J, Zhu M, Liu J, James TD. Recent progress in the development of fluorescent probes for imaging pathological oxidative stress. Chem Soc Rev 2023. [PMID: 37190785 DOI: 10.1039/d2cs00172a] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Oxidative stress is closely related to the physiopathology of numerous diseases. Reactive oxygen species (ROS), reactive nitrogen species (RNS), and reactive sulfur species (RSS) are direct participants and important biomarkers of oxidative stress. A comprehensive understanding of their changes can help us evaluate disease pathogenesis and progression and facilitate early diagnosis and drug development. In recent years, fluorescent probes have been developed for real-time monitoring of ROS, RNS and RSS levels in vitro and in vivo. In this review, conventional design strategies of fluorescent probes for ROS, RNS, and RSS detection are discussed from three aspects: fluorophores, linkers, and recognition groups. We introduce representative fluorescent probes for ROS, RNS, and RSS detection in cells, physiological/pathological processes (e.g., Inflammation, Drug Induced Organ Injury and Ischemia/Reperfusion Injury etc.), and specific diseases (e.g., neurodegenerative diseases, epilepsy, depression, diabetes and cancer, etc.). We then highlight the achievements, current challenges, and prospects for fluorescent probes in the pathophysiology of oxidative stress-related diseases.
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Affiliation(s)
- Yujie Geng
- State Key Laboratory of Chemical Resource Engineering, College of Chemistry, Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
| | - Zhuo Wang
- State Key Laboratory of Chemical Resource Engineering, College of Chemistry, Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
| | - Jiaying Zhou
- State Key Laboratory of Chemical Resource Engineering, College of Chemistry, Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
| | - Mingguang Zhu
- State Key Laboratory of Chemical Resource Engineering, College of Chemistry, Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
| | - Jiang Liu
- State Key Laboratory of Chemical Resource Engineering, College of Chemistry, Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
| | - Tony D James
- Department of Chemistry, University of Bath, Bath BA2 7AY, UK.
- School of Chemistry and Chemical Engineering, Henan Normal University, Xinxiang 453007, China
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5
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Normand SLT, Zelevinsky K, Abing HK, Horvitz-Lennon M. Statistical Approaches for Quantifying the Quality of Neurosurgical Care. World Neurosurg 2022; 161:331-342.e1. [PMID: 35505552 PMCID: PMC9074098 DOI: 10.1016/j.wneu.2022.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Quantifying quality of health care can provide valuable information to patients, providers, and policy makers. However, the observational nature of measuring quality complicates assessments. METHODS We describe a conceptual model for defining quality and its implications about the data collected, how to make inferences about quality, and the assumptions required to provide statistically valid estimates. Twenty-one binary or polytomous quality measures collected from 101,051 adult Medicaid beneficiaries aged 18-64 years with schizophrenia from 5 U.S. states show methodology. A categorical principal components analysis establishes dimensionality of quality, and item response theory models characterize the relationship between each quality measure and a unidimensional quality construct. Latent regression models estimate racial/ethnic and geographic quality disparities. RESULTS More than 90% of beneficiaries filled at least 1 antipsychotic prescription and 19% were hospitalized for schizophrenia during a 12-month observational period in our multistate cohort with approximately 2/3 nonwhite beneficiaries. Four quality constructs emerged: inpatient, emergency room, pharmacologic/ambulatory, and ambulatory only. Using a 2-parameter logistic model, pharmacologic/ambulatory care quality varied from -2.35 to 1.26 (higher = better quality). Black and Latinx beneficiaries had lower pharmacologic/ambulatory quality compared with whites. Race/ethnicity modified the association of state and pharmacologic/ambulatory care quality in latent regression modeling. Average quality ranged from -0.28 (95% confidence interval, -2.15 to 1.04) for blacks in New Jersey to 0.46 [95% confidence interval, -0.89 to 1.40] for whites in Michigan. CONCLUSIONS By combining multiple quality measures using item response theory models, a composite measure can be estimated that has more statistical power to detect differences among subjects than the observed mean per subject.
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Affiliation(s)
- Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA; Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts, USA.
| | - Katya Zelevinsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Haley K Abing
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, Boston, Massachusetts, USA; Cambridge Health Alliance, Cambridge, Massachusetts, USA
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6
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Longtin C, Décary S, Cook CE, Tousignant-Laflamme Y. What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination. Pain Pract 2021; 22:107-112. [PMID: 33998767 DOI: 10.1111/papr.13032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 02/06/2023]
Abstract
Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.
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Affiliation(s)
- Christian Longtin
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada
| | - Simon Décary
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada.,Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Chad E Cook
- Department of Orthopedics, Duke University, Durham, North Carolina, USA
| | - Yannick Tousignant-Laflamme
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada.,Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
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7
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Scheinberg-Andrews C, Ganz FD. Israeli Nurses' Palliative Care Knowledge, Attitudes, Behaviors, and Practices. Oncol Nurs Forum 2021; 47:213-221. [PMID: 32078607 DOI: 10.1188/20.onf.213-221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe and compare self-perceived end-of-life (EOL) knowledge, attitudes, behaviors, and practices of intensive care unit (ICU) nurses compared to oncology nurses. SAMPLE & SETTING 126 Israeli nurses (79 oncology nurses and 47 ICU nurses) who were members of the Israel Association of Cardiology and Critical Care Nurses and the Israeli Oncology Nurses Organization. METHODS & VARIABLES This cross-sectional study used an online survey to gather demographic information, clinical setting, and study measures (EOL knowledge, attitudes, behaviors, and practices). RESULTS Oncology nurses and ICU nurses showed moderate levels of self-perceived knowledge and attitudes toward palliative care; however, their self-reported behaviors were low. Oncology nurses scored slightly higher than ICU nurses on knowledge and attitudes but not behaviors, although the difference was not statistically significant. IMPLICATIONS FOR NURSING Contrary to the current authors' expectations, oncology nurses and ICU nurses have similar levels of knowledge, attitudes, and behaviors regarding palliative care. Nurses in both settings need to be better trained and empowered to provide such care.
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Washirasaksiri C, Phisalprapa P, Chaisathaphol T, Auesomwang C, Sitasuwan T, Tinmanee R, Kositamongkol C, Sutee R, Chouriyagune C, Srivanichakorn W. Care maps are an effective tool for optimizing quality of care of infectious diseases in a resource-constrained short-stay ambulatory care setting. Medicine (Baltimore) 2021; 100:e23928. [PMID: 33592846 PMCID: PMC7870257 DOI: 10.1097/md.0000000000023928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 11/22/2020] [Accepted: 11/27/2020] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Care maps (CMs), which are innovative, comprehensive, educational, and simple medical tools, were developed for 6 common diseases, including heart failure, stroke, hyperglycemia, urinary tract infection, dengue infection, and upper gastrointestinal bleeding, were implemented in a short-stay ambulatory ward. This study aimed to investigate the effectiveness of and level of clinician satisfaction with CMs in an ambulatory care setting.A retrospective chart review study comparing the quality of care between before and after CM implementation was conducted. The medical records of patients who were admitted to a short-stay ambulatory ward in a tertiary referral center were reviewed. Demographic data, severity of disease, quality of care, length of stay (LOS), admission cost, and CM user satisfaction were collected and recorded.The medical records of 1116 patients were evaluated. Of those, 589 and 527 patients were from before (non-CM group) and after CM (CM group) implementation, respectively. There were no significant differences between groups for age, gender, or disease-specific severity the median (interquartile range) total and essential quality scores were significantly higher in the CM group than in the non-CM group [total quality score 85.3 (75.0-92.9) vs 61.1 (50.0-75.0); P < .001, and essential quality scores 90.0 (75.0-100.0) vs 60.0 (40.6-80.0); P < .0001, respectively]. All aspects of quality of care were significantly improved between before and after CM implementation. Overall median LOS was significantly decreased from 3.8 (2.5-5.7) to 3.0 (2.0-4.9) days, but there was no significant decrease for admission cost. However, CMs were able to significantly reduce both LOS and admission cost in the infectious disease-related subgroup. Most CM users reported satisfaction with CMs.CMs were shown to be an effective tool for improving the quality of care in patients with ambulatory infectious diseases. In that patient subgroup, LOS and admission cost were both significantly reduced compared to pre-CM implementation.
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Affiliation(s)
| | | | | | | | | | | | | | - Rungsinee Sutee
- Department of Nursing, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Hassan S, Chan V, Stevens J, Stupans I. Factors that influence adherence to surgical antimicrobial prophylaxis (SAP) guidelines: a systematic review. Syst Rev 2021; 10:29. [PMID: 33453730 PMCID: PMC7811740 DOI: 10.1186/s13643-021-01577-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 01/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite the extensive research that has been conducted to date, practice often differs from established guidelines and will vary between individuals and organisations. It has been noted that the global uptake of local and international surgical antimicrobial prophylaxis (SAP) guidelines is poor with limited research investigating factors that affect guideline adherence. The purpose of this systematic review was to determine the reported barriers and enablers to the adherence of SAP guidelines. METHODS A search of the literature was performed using four electronic databases (CINAHL, EMBASE, PubMed and SCOPUS) for articles published in the English language from January 1998 to December 2018. Articles were included if they were solely related to SAP and discussed the barriers or enablers to SAP guideline adherence. Articles that assessed the adherence to a range of infection control measures or discussed adherence to antibiotic treatment guidelines rather than SAP guidelines were excluded from this review. Barriers and enablers were mapped to the Theoretical Domains Framework (TDF). The Mixed Methods Appraisal Tool was used to assess the quality of included studies. RESULTS A total of 1489 papers were originally retrieved, with 48 papers meeting the eligibility criteria. Barriers and enablers were mapped to 11 out of 14 TDF domains: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, reinforcement, memory, attention and decision processes, environmental context and resources, social influences, emotion and behavioural regulation. Barriers were further categorised into personal or organisational barriers, while enablers were arranged under commonly trialled interventions. CONCLUSIONS There are numerous factors that can determine the uptake of SAP guidelines. An identification and understanding of these factors at a local level is required to develop tailored interventions to enhance guideline adherence. Interventions, when used in combination, can be considered as a means of improving guideline use.
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Affiliation(s)
- Sarah Hassan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.
| | - Vincent Chan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Julie Stevens
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ieva Stupans
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
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Cases C, Gallini A, Lafont Rapnouil S, Bougon E, Mathur A, Brismontier A, Taib S, Sporer M, Arbus C, Salles J. Developing and Testing a Local Expert-Based Reading Process for Use to Examine Discrepancies Between Guidelines and Current Clinical Practices. Front Psychiatry 2021; 12:581449. [PMID: 33868036 PMCID: PMC8044516 DOI: 10.3389/fpsyt.2021.581449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
The use of relevant guidelines is critical in psychiatric clinical practice to ensure the homogeneity of the global care provided. Consequently, it is important to identify whether they are utilized successfully and, if not, why. This would enable pragmatic solutions to be agreed to improve the organization of care and the removal of any barriers to the guidelines' implementation. The first step in this process, before any exploration of the limitations of the guidelines themselves, involves a determination of whether they are actually applied in clinical practice. We therefore evaluated discrepancies between the guidelines relating to patients with borderline personality disorder and current practices in the psychiatric Emergency Department at Toulouse University Hospital. This was achieved using a reading process involving a panel of eight local experts who analyzed relevant medical files extracted from a database. They were guided by, and instructed to answer, six standardized questions in relation to each file to determine the method's feasibility. A total of 333 files were analyzed to determine whether, in the local experts' judgment, the care provided reflected current guidance. This reading process revealed substantial agreement (0.85%; Fleiss Kappa -0.69), which is a promising outcome and suggests that such methods could be used in future protocols. Moreover, the process is practical and reliable and requires very few materials.
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Affiliation(s)
- Cécile Cases
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France
| | - Adeline Gallini
- CHU de Toulouse, Service d'épidémiologie, Unité de Soutien Méthodologique à la Recherche (USMR), Toulouse, France.,Inserm, Unité 1027 Epidémiologie et analyses en santé publique, Vieillissement et maladie d'Alzheimer: de l'observation à l'intervention, Toulouse, France
| | | | - Emmanuelle Bougon
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France
| | - Anjali Mathur
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France
| | - Ariane Brismontier
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France
| | - Simon Taib
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France
| | - Marie Sporer
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France
| | - Christophe Arbus
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France.,Institut des Handicaps Neurologiques, Psychiatriques et Sensoriels-CHU de Toulouse, Toulouse, France
| | - Juliette Salles
- CHU Toulouse, Service de psychiatrie et psychologie, psychiatrie Toulouse, Toulouse, France.,Institut des Handicaps Neurologiques, Psychiatriques et Sensoriels-CHU de Toulouse, Toulouse, France.,Infinity (Toulouse Institute for Infectious and Inflammatory Diseases), INSERM UMR1291, CNRS UMR5051, Université Toulouse III, Toulouse, France
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11
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Davies-Tuck M, Ruzic M, Davey MA, Hodges R, Nowotny B, Flenady V, Andrews C, Wallace EM. Understanding staff views and experiences of a clinical practice change to reduce stillbirth in South Asian women: A cross-sectional survey. Women Birth 2020; 34:e390-e395. [PMID: 32828713 DOI: 10.1016/j.wombi.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND In July 2017, Victoria's largest maternity service implemented a new clinical practice guideline to reduce the rates of term stillbirth in women of South Asian background. AIM To capture the views and experiences of clinical staff following the implementation of the new clinical guideline. METHODS Cross sectional survey of clinical staff providing maternity care in August 2018, 12 months post implementation. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Open-ended questions provided opportunities to express concerns and offer suggestions for improvement. The frequency of responses to each question were tabulated. Open ended responses were grouped together to identify themes. FINDINGS A total of 120 staff completed the survey, most (n=89, 74%) of whom were midwives. Most staff thought the rationale (n=95, 79%), the criteria for whom they applied (83%, n=99), and the procedures and instructions within the guideline were clear (74%, n=89). Staff reported an increase in workload (72%, n=86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for both staff and pregnant South Asian women, increased workload and insufficient resources, patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified. DISCUSSION This study has identified key barriers to and opportunities for improving implementation and highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse women.
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Affiliation(s)
- Miranda Davies-Tuck
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia.
| | - Mikayla Ruzic
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Mary-Ann Davey
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria 3168, Australia
| | - Ryan Hodges
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria 3168, Australia; Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Benjamin Nowotny
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria 3168, Australia; Safer Care Victoria, Melbourne, Australia
| | - Vicki Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Christine Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria 3168, Australia; Safer Care Victoria, Melbourne, Australia
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Covelli A, Facey M, Kennedy E, Brezden-Masley C, Gupta AA, Greenblatt E, Baxter NN. Clinicians' Perspectives on Barriers to Discussing Infertility and Fertility Preservation With Young Women With Cancer. JAMA Netw Open 2019; 2:e1914511. [PMID: 31693121 PMCID: PMC6865261 DOI: 10.1001/jamanetworkopen.2019.14511] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/15/2019] [Indexed: 12/26/2022] Open
Abstract
Importance Infertility can be a devastating adverse effect of cancer treatment for young women. Fertility preservation may be an important and influential factor in treatment decisions. Despite American Society of Clinical Oncology guidelines recommending discussion around potential infertility with patients, nearly 50% of young women with cancer remain uninformed. Objective To understand and describe from clinicians' perspectives the barriers to discussing infertility and fertility preservation with young women with cancer. Design, Setting, and Participants This qualitative study used purposeful, maximum variation, and snowball sampling strategies to recruit 22 clinicians from cancer centers and community hospitals in 5 Canadian provinces, 5 practice areas, and 12 practice sites. Eligibility criteria included clinicians who regularly treat young women with cancer who might need fertility preservation. Telephone interviews that lasted between 30 to 75 minutes were conducted between May and November 2014 using a semistructured interview guide. Thematic analysis was used to discern the nature of barriers, and the Cabana framework was used to organize and interpret these findings. Analysis was conducted from May 2014 until May 2015. Main Outcomes and Measures Clinician perspectives on what influences their nonadherence to American Society of Clinical Oncology guidelines, which recommend discussing fertility preservation with patients. Results A total of 22 clinicians were interviewed, including 8 medical oncologists, 4 surgical oncologists, 4 fertility specialists, 3 hematology and oncology specialists, and 3 nurse practitioners or clinician nurse specialists. Seventeen clinicians were women and 5 clinicians were men; the median (range) time in practice was 10 (0.67-37) years. Analysis suggested that clinicians' unfamiliarity with infertility risks, fertility preservation technologies, referral processes, and procedures, as well as environmental factors and their perceptions of fertility preservation, influenced their practices regarding fertility discussions. Conclusions and Relevance The findings of this qualitative study suggest that the individual and environmental challenges that clinicians experience might negatively affect their willingness and ability to raise fertility-related issues with young women with cancer. Multiple strategies are needed to address these challenges to improve overall care of young women with cancer.
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Affiliation(s)
- Andrea Covelli
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marcia Facey
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Abha A Gupta
- Department of Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ellen Greenblatt
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Aragonès E, Rambla C, López-Cortacans G, Tomé-Pires C, Sánchez-Rodríguez E, Caballero A, Miró J. Effectiveness of a collaborative care intervention for managing major depression and chronic musculoskeletal pain in primary care: A cluster-randomised controlled trial. J Affect Disord 2019; 252:221-229. [PMID: 30986737 DOI: 10.1016/j.jad.2019.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/07/2019] [Accepted: 04/06/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Depression and chronic musculoskeletal pain commonly occur as comorbid conditions, which increases their negative effects on health outcomes. The objective of this study was to assess the effectiveness of the DROP (DepRessiOn and Pain) programme designed for the management of major depression and chronic musculoskeletal pain in primary care. METHODS A cluster-randomised controlled trial was carried out between June 2015 and December 2017 with 328 patients with major depression and chronic musculoskeletal pain, randomly allocated to either intervention arm or usual care arm. The intervention included care management, optimised management of depression, and a psychoeducational programme. Outcomes were monitored using blinded interviews over a 12-month period. TRIAL REGISTRATION NCT02605278 (ClinicalTrials.gov). RESULTS After 12 months, 274 patients were evaluated (83.5% participation). The severity of depression (Hopkins Symptom Checklist score) was 0.23 points lower in the intervention arm [1.11 vs. 1.34; CI95% = -0.42 to -0.04]. Intervention arm's response rate to antidepressant treatment was 18.9% higher [39.6% vs. 20.7%; OR = 2.74; CI95% = 1.12-6.67] and its remission rate for depression was 9.0% higher [20.1% vs. 11.1%; OR = 2.13; CI95% = 0.94-4.85] compared to the usual care arm. There were no significant differences between the two arms in terms of pain severity (Brief Pain Inventory severity score) [6.23 vs. 6.66; difference = -0.39; CI95% = -1.13-0.35] or pain response rate [18.7% vs. 18.5%; OR = 1.02; CI95% = 0.46-2.26]. LIMITATIONS This is a pragmatic study, and poor adherence to the programme by patients and physicians was a main limitation. CONCLUSION The programme improves clinical outcomes for depression, although no clinical benefits were seen for pain.
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Affiliation(s)
- Enric Aragonès
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Atenció Primària Camp de Tarragona, Institut Català de la Salut, Tarragona, Spain.
| | - Concepció Rambla
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Atenció Primària Camp de Tarragona, Institut Català de la Salut, Tarragona, Spain
| | - Germán López-Cortacans
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Atenció Primària Camp de Tarragona, Institut Català de la Salut, Tarragona, Spain
| | - Catarina Tomé-Pires
- Atenció Primària Camp de Tarragona, Institut Català de la Salut, Tarragona, Spain; Unit for the Study and Treatment of Pain - ALGOS, and Research Center for Behavior Assessment (CRAMC), Department of Psychology, Universitat Rovira i Virgili, Tarragona, Spain; Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
| | - Elisabet Sánchez-Rodríguez
- Unit for the Study and Treatment of Pain - ALGOS, and Research Center for Behavior Assessment (CRAMC), Department of Psychology, Universitat Rovira i Virgili, Tarragona, Spain; Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
| | - Antonia Caballero
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Atenció Primària Camp de Tarragona, Institut Català de la Salut, Tarragona, Spain
| | - Jordi Miró
- Unit for the Study and Treatment of Pain - ALGOS, and Research Center for Behavior Assessment (CRAMC), Department of Psychology, Universitat Rovira i Virgili, Tarragona, Spain; Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
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Heddaeus D, Steinmann M, Daubmann A, Härter M, Watzke B. Treatment selection and treatment initialization in guideline-based stepped and collaborative care for depression. PLoS One 2018; 13:e0208882. [PMID: 30586371 PMCID: PMC6306173 DOI: 10.1371/journal.pone.0208882] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 11/27/2018] [Indexed: 11/18/2022] Open
Abstract
In order to optimize patient allocation, guidelines recommend stepped and collaborative care models (SCM) including low-intensity treatments. The aim of this study is to investigate the implementation of guideline-adherent treatments in a SCM for depression in routine care. We analyzed care provider documentation data of n = 569 patients treated within a SCM. Rates of guideline-adherent treatment selections and initializations as well as accordance between selected and initialized treatment were evaluated for patients with mild, moderate and severe depression. Guideline-adherent treatment selection and initialization was highest for mild depression (91% resp. 85%). For moderate depression, guideline-adherent treatments were selected in 68% and applied in 54% of cases. Guideline adherence was lowest for severe depression (59% resp. 19%). In a multiple mixed logistic regression model a significant interaction between guideline adherence in treatment selection/initialization and severity degree was found. The differences between treatment selection and initialization were significant for moderate (OR: 1.8 [95% CI: 1.30 to 2.59; p = 0.0006]) and severe depression (OR: 6.9; [95% CI: 4.24 to 11.25; p < .0001] but not for mild depression (OR = 1.8, [95%-CI: 0.68 to 4.56; p = 0.2426]). Accordance between selected and initialized treatment was highest for mild and lowest for severe depression. We conclude that SCMs potentially improve care for mild depression and guideline adherence of treatment selections. Guideline adherence of treatment initialization and accordance between treatment selection and initialization varies with depression severity. Deficits in treating severe depression adequately may be more a problem of failed treatment initializations than of inadequate treatment selections.
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Affiliation(s)
- Daniela Heddaeus
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Maya Steinmann
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Daubmann
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgit Watzke
- Clinical Psychology and Psychotherapy Research, Institute of Psychology, University of Zurich, Zurich, Switzerland
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Rauh S, Arnold D, Braga S, Curca R, Eckert R, Fröbe A, Karamouzis M, Lakatos G, Molitor JL. Challenge of implementing clinical practice guidelines. Getting ESMO's guidelines even closer to the bedside: introducing the ESMO Practising Oncologists' checklists and knowledge and practice questions. ESMO Open 2018; 3:e000385. [PMID: 30094071 PMCID: PMC6069906 DOI: 10.1136/esmoopen-2018-000385] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/05/2022] Open
Affiliation(s)
- Stefan Rauh
- Department of Hemato-Oncology, Hospital Center Emile Mayrisch, Esch/Alzette, Luxembourg.
| | - Dirk Arnold
- Asklepios Tumorzentrum Hamburg, AK Altona, Hamburg, Germany; Oncologia, Instituto CUF de Oncologia, Lisbon, Portugal
| | - Sofia Braga
- Oncologia, Instituto CUF de Oncologia, Lisbon, Portugal
| | - Razvan Curca
- Medical Oncology, Emergency County Hospital, Alba Iulia, Romania
| | - Robert Eckert
- Hämato Onkologie, Onkologische Schwerpunktpraxis, Esslingen, Germany
| | - Ana Fröbe
- Department of Oncology and Nuclear Medicine, University Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Michalis Karamouzis
- Department of Medical Oncology, University Hospital Chaidari-Athens, Athens, Greece
| | - Gabor Lakatos
- Oncology, Magyar Klinikai Onkologiai Tarsasag, Budapest, Hungary
| | - Jean-Luc Molitor
- Oncologie Médicale, Institut Mutualiste Montsouris, Paris, France
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Mosavianpour M, Sarmast HH, Kissoon N, Collet JP. Theoretical domains framework to assess barriers to change for planning health care quality interventions: a systematic literature review. J Multidiscip Healthc 2016; 9:303-10. [PMID: 27499628 PMCID: PMC4959766 DOI: 10.2147/jmdh.s107796] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Theoretical domains framework (TDF) provides an integrative model for assessing barriers to behavioral changes in order to suggest interventions for improvement in behavior and ultimately outcomes. However, there are other tools that are used to assess barriers. OBJECTIVE The objective of this study is to determine the degree of concordance between domains and constructs identified in two versions of the TDF including original (2005) and refined version (2012) and independent studies of other tools. METHODS We searched six databases for articles that studied barriers to health-related behavior changes of health care professionals or the general public. We reviewed quantitative papers published in English which included their questionnaires in the article. A table including the TDF domains of both original and refined versions and related constructs was developed to serve as a reference to describe the barriers assessed in the independent studies; descriptive statistics were used to express the results. RESULTS Out of 552 papers retrieved, 50 were eligible to review. The barrier domains explored in these articles belonged to two to eleven domains of the refined TDF. Eighteen articles (36%) used constructs outside of the refined version. The spectrum of barrier constructs of the original TDF was broader and could meet the domains studied in 48 studies (96%). Barriers in domains of "environmental context and resources", "beliefs about consequences", and "social influences" were the most frequently explored in 42 (84%), 37 (74%), and 33 (66%) of the 50 articles, respectively. CONCLUSION Both refined and original TDFs cataloged barriers measured by the other studies that did not use TDF as their framework. However, the original version of TDF explored a broader spectrum of barriers than the refined version. From this perspective, the original version of the TDF seems to be a more comprehensive tool for assessing barriers in practice.
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Affiliation(s)
- Mirkaber Mosavianpour
- Department of Pediatrics, Faculty of Medicine, University of British Columbia; British Columbia Children's Hospital; Child and Family Research Institute, Vancouver, BC, Canada
| | - Hamideh Helen Sarmast
- British Columbia Children's Hospital; Child and Family Research Institute, Vancouver, BC, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, Faculty of Medicine, University of British Columbia; British Columbia Children's Hospital; Child and Family Research Institute, Vancouver, BC, Canada
| | - Jean-Paul Collet
- Department of Pediatrics, Faculty of Medicine, University of British Columbia; British Columbia Children's Hospital; Child and Family Research Institute, Vancouver, BC, Canada
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Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and Strategies in Guideline Implementation-A Scoping Review. Healthcare (Basel) 2016; 4:healthcare4030036. [PMID: 27417624 PMCID: PMC5041037 DOI: 10.3390/healthcare4030036] [Citation(s) in RCA: 459] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/20/2016] [Accepted: 06/24/2016] [Indexed: 01/11/2023] Open
Abstract
Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed.
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Affiliation(s)
- Florian Fischer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Kerstin Lange
- Department of Public Health Medicine, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Kristina Klose
- Department of Health Care Management, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Wolfgang Greiner
- Department of Health Care Management, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
| | - Alexander Kraemer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, 33615 Bielefeld, Germany.
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Di Capua P, Wu B, Sednew R, Ryan G, Wu S. Complexity in Redesigning Depression Care: Comparing Intention Versus Implementation of an Automated Depression Screening and Monitoring Program. Popul Health Manag 2016; 19:349-56. [PMID: 27028043 DOI: 10.1089/pop.2015.0084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Health care technology promises to improve quality and decrease costs while improving the patient experience. A recent trial tested a novel health technology that sought to reduce barriers to guideline-recommended depression care by coupling automated telephonic patient assessment with provider notification and decision support. This study compares the intended effects and the end users' experience with using this technology. Responses to semi-structured interviews with the leadership and design team (the intention group) were compared with responses from health professionals in clinics using the technology (the implementation group). Qualitative methods were applied to compare perspectives on the role of technology in care delivery and on the technology's impact on barriers to providing guideline-recommended care. Four members of the intention group and 17 members of the implementation group were interviewed. The 2 groups had similar notions of technology's role in care delivery. The technology increased provider awareness, empowered midlevel providers, and facilitated collaboration among care team members. However, the implementation group identified gaps in care processes and in the informatics system that the technology did not address, and for which providers remained responsible. The 2 groups had comparable perspectives on the value and limits of technology in improving adherence to guideline-recommended care. However, the intention group did not discuss many of the shortcomings identified by the implementation group. Also, the interviews suggest that although some barriers persisted and a few new ones arose, the technology succeeded in reducing barriers to guideline-recommended care.
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Affiliation(s)
- Paul Di Capua
- 1 Baptist Health Medical Group , Coral Gables, Florida.,2 Department of Family Medicine, Herbert Wertheim College of Medicine at Florida International University , Miami, Florida.,3 Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Brian Wu
- 4 Keck School of Medicine, University of Southern California , Los Angeles, California
| | - Renee Sednew
- 5 UCLA Fielding School of Public Health , Los Angeles, California
| | - Gery Ryan
- 6 Pardee RAND Graduate School, RAND Corporation , Santa Monica, California
| | - Shinyi Wu
- 7 School of Social Work and Epstein Department of Industrial and Systems Engineering, University of Southern California , RAND Corporation, Los Angeles, California
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The VA augmentation and switching treatments for improving depression outcomes (VAST-D) study: Rationale and design considerations. Psychiatry Res 2015; 229:760-70. [PMID: 26279130 DOI: 10.1016/j.psychres.2015.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/22/2015] [Accepted: 08/04/2015] [Indexed: 11/22/2022]
Abstract
Because two-thirds of patients with Major Depressive Disorder do not achieve remission with their first antidepressant, we designed a trial of three "next-step" strategies: switching to another antidepressant (bupropion-SR) or augmenting the current antidepressant with either another antidepressant (bupropion-SR) or with an atypical antipsychotic (aripiprazole). The study will compare 12-week remission rates and, among those who have at least a partial response, relapse rates for up to 6 months of additional treatment. We review seven key efficacy/effectiveness design decisions in this mixed "efficacy-effectiveness" trial.
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Grigoryan L, Zoorob R, Wang H, Trautner BW. Low Concordance With Guidelines for Treatment of Acute Cystitis in Primary Care. Open Forum Infect Dis 2015; 2:ofv159. [PMID: 26753168 PMCID: PMC4675917 DOI: 10.1093/ofid/ofv159] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/22/2015] [Indexed: 12/24/2022] Open
Abstract
We found low concordance with the updated 2010 IDSA guidelines for both the choice of drug and duration of therapy for acute cystitis. Interventions to decrease overuse of fluoroquinolones are needed to preserve the antimicrobial efficacy of these important antimicrobials. Background. The updated 2010 Infectious Diseases Society of America guidelines recommended 3 first-line therapies for uncomplicated cystitis: nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), and fosfomycin, while fluoroquinolones (FQs) remained as second-line agents. We assessed guideline concordance for antibiotic choice and treatment duration after introduction of the updated guidelines and studied patient characteristics associated with prescribing of specific antibiotics and with treatment duration. Methods. We used the Epic Clarity database (electronic medical record system) to identify all female patients aged ≥18 years with uncomplicated cystitis in 2 private family medicine clinics in the period of 2011–2014. For each eligible visit, we extracted type of antibiotic prescribed, duration of treatment, and patient and visit characteristics. Results. We included 1546 visits. Fluoroquinolones were the most common antibiotic class prescribed (51.6%), followed by nitrofurantoin (33.5%), TMP-SMX (12.0%), and other antibiotics (3.2%). A significant trend occurred toward increasing TMP-SMX and toward decreasing nitrofurantoin use. The duration of most prescriptions for TMP-SMX, nitrofurantoin, and FQs was longer than guidelines recommendations (longer durations were prescribed for these agents in 82%, 73%, and 71% of the prescriptions, respectively). No patient or visit characteristic was associated with use of specific antibiotics. Older age and presence of diabetes were independently associated with longer treatment duration. Conclusions. We found low concordance with the updated guidelines for both the choice of drug and duration of therapy for uncomplicated cystitis in primary care. Identifying barriers to guideline adherence and designing interventions to decrease overuse of FQs may help preserve the antimicrobial efficacy of these important antimicrobials.
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Affiliation(s)
| | | | | | - Barbara W Trautner
- Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine; Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Gabzdyl E, Engstrom JL, McFarlin BL. Health Care Workers' Beliefs and Practices Around Pap Screening for Adolescents Seeking Contraception. Nurs Womens Health 2015; 19:216-223. [PMID: 26058904 DOI: 10.1111/1751-486x.12203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Adolescents often avoid seeing a health care provider to obtain contraception because they do not want to undergo a pelvic exam and Pap screening for fear of stress, pain or embarrassment. The purpose of this quality improvement project was to study health care workers, attitudes and beliefs about Pap screening and to educate them on the latest evidence-based guidelines, with the hope of ultimately decreasing unnecessary screening. Results showed a modest reduction in the frequency of Pap screening; however, many adolescents continued to undergo unnecessary Pap screening. The reluctance of health care workers to change their practice demonstrates the need for better methods of translating evidence-based guidelines into practice.
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Isensee C, Hagmayer Y, Rothenberger A, Rothenberger LG, Becker A. [The AWMF-Guidelines for Hyperkinetic Disorders in therapeutic practice- knowledge, familiarity, utilization, and attitude of psychotherapists and physicians]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2015; 43:91-100. [PMID: 25769762 DOI: 10.1024/1422-4917/a000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The AWMF-Guidelines for Hyperkinetic Disorders (ADHD) provide psychotherapists and physicians with guidance concerning diagnostics and treatment for one of the most common disorders in children and adolescents. To date, however, it is unclear how these guidelines are being applied by practicing therapists (both physicians and psychotherapists) and what they consider to be its pros and cons. This study proposes (1) to analyze the differences between the estimation of ADHD-guidelines by users and nonusers, their corresponding attitudes, experiences, and evaluations of context factors; and (2) to analyze whether users and nonusers differ in their therapeutic practice. METHODS 71 therapists participated in a nonrepresentative online survey. RESULTS The hypothesis was confirmed that, on average, users had a more positive attitude toward and experience with guideline-driven treatment than did nonusers. The results also show a small positive effect of guideline use on treatment quality. However, the methods employed by users and nonusers only moderately corresponded with the recommendations of the guidelines. CONCLUSIONS It was shown that the ADHD guideline is only rarely being used, even under advantageous conditions, and that a practice-oriented form of the guideline does not exist until now.
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Affiliation(s)
- Corinna Isensee
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsmedizin Göttingen
| | - York Hagmayer
- Institut für Psychologie, Georg-August-Universität Göttingen
| | - Aribert Rothenberger
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsmedizin Göttingen
| | | | - Andreas Becker
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsmedizin Göttingen
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Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015; 10:21. [PMID: 25889199 PMCID: PMC4328074 DOI: 10.1186/s13012-015-0209-1] [Citation(s) in RCA: 2094] [Impact Index Per Article: 232.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/22/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Identifying, developing, and testing implementation strategies are important goals of implementation science. However, these efforts have been complicated by the use of inconsistent language and inadequate descriptions of implementation strategies in the literature. The Expert Recommendations for Implementing Change (ERIC) study aimed to refine a published compilation of implementation strategy terms and definitions by systematically gathering input from a wide range of stakeholders with expertise in implementation science and clinical practice. METHODS Purposive sampling was used to recruit a panel of experts in implementation and clinical practice who engaged in three rounds of a modified Delphi process to generate consensus on implementation strategies and definitions. The first and second rounds involved Web-based surveys soliciting comments on implementation strategy terms and definitions. After each round, iterative refinements were made based upon participant feedback. The third round involved a live polling and consensus process via a Web-based platform and conference call. RESULTS Participants identified substantial concerns with 31% of the terms and/or definitions and suggested five additional strategies. Seventy-five percent of definitions from the originally published compilation of strategies were retained after voting. Ultimately, the expert panel reached consensus on a final compilation of 73 implementation strategies. CONCLUSIONS This research advances the field by improving the conceptual clarity, relevance, and comprehensiveness of implementation strategies that can be used in isolation or combination in implementation research and practice. Future phases of ERIC will focus on developing conceptually distinct categories of strategies as well as ratings for each strategy's importance and feasibility. Next, the expert panel will recommend multifaceted strategies for hypothetical yet real-world scenarios that vary by sites' endorsement of evidence-based programs and practices and the strength of contextual supports that surround the effort.
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Affiliation(s)
- Byron J Powell
- Center for Mental Health Policy and Services Research, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA.
| | - Thomas J Waltz
- Department of Psychology, Eastern Michigan University, Ypsilanti, MI, USA.
| | - Matthew J Chinman
- VISN 4 MIRECC, Pittsburgh, PA, USA.
- RAND Corporation, Pittsburgh, PA, USA.
| | - Laura J Damschroder
- HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Jeffrey L Smith
- Central Arkansas Veterans Healthcare System, HSR&D and Mental Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs Medical Center, Little Rock, AR, USA.
| | - Monica M Matthieu
- Central Arkansas Veterans Healthcare System, HSR&D and Mental Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs Medical Center, Little Rock, AR, USA.
- School of Social Work, College for Public Health & Social Justice, Saint Louis University, St. Louis, MO, USA.
| | - Enola K Proctor
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.
| | - JoAnn E Kirchner
- Central Arkansas Veterans Healthcare System, HSR&D and Mental Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs Medical Center, Little Rock, AR, USA.
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Haskins R, Osmotherly PG, Southgate E, Rivett DA. Physiotherapists' knowledge, attitudes and practices regarding clinical prediction rules for low back pain. ACTA ACUST UNITED AC 2014; 19:142-51. [DOI: 10.1016/j.math.2013.09.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 08/23/2013] [Accepted: 09/23/2013] [Indexed: 12/27/2022]
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Schellart AJM, Zwerver F, Anema JR, van der Beek AJ. Relationships between the intention to use guidelines, behaviour of insurance physicians and their determinants. BMC Health Serv Res 2013; 13:400. [PMID: 24103198 PMCID: PMC3851955 DOI: 10.1186/1472-6963-13-400] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 09/25/2013] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND We studied the intention of a group of insurance physicians to use the guidelines for depression, and their behaviour in disability assessments. We considered attitude, social norm and self-efficacy, knowledge/skills and stimuli, based on the Attitude-Social norm-self-Efficacy model (ASE model) as possible determinants of both intention and behaviour.The aim of this study was to understand the determinants of insurance physicians' behaviour when they are expected to use guidelines in daily practice. METHOD A representative sample of 42 insurance physicians participated in this study. Cross-sectional data were collected by means of a questionnaire based on the ASE model. We developed the questionnaire on the basis of literature and ascertained the content validity of it. Behaviour was made to comprise both "use of the guidelines" and "change in disability assessment behaviour" by the insurance physicians. Reliability analyses were performed to form additive scales of the ASE constructs. These scales were analysed with structural equations modelling (LISREL), by modifying a start model into a final model with a good fit, within theoretical constraints. In these analyses special attention was paid to the fact that the sample size was small. RESULTS The most important determinants of the intention and the self-reported use of the guidelines, were: the influence of colleagues, the self-efficacy of the insurance physicians in their use of the guidelines, and the way the guidelines were implemented. The intention to use the guidelines for depression was not associated with the self-reported use of these guidelines, but there proved to be a faint, positive association with the self-reported change in assessment behaviour. CONCLUSIONS Almost all the insurance physicians in this study intended to use at least elements of the guidelines. Their intention, self reported use of the guidelines and self-reported change in assessment behaviour were explored with help of the ASE model. The model suggested relationships between intention, self reported use of the guidelines and self-reported change in assessment behaviour on the on the one hand and various determinants on the other hand. Be that as it may, we see opportunities to improve insurance physicians' guideline adherence by offering them a multifaceted training in which they learn to apply the guidelines for depression.
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Affiliation(s)
- Antonius J M Schellart
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.
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Munce S, Kastner M, Cramm H, Lal S, Deschêne SM, Auais M, Stacey D, Brouwers M. Applying the knowledge to action framework to plan a strategy for implementing breast cancer screening guidelines: an interprofessional perspective. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2013; 28:481-487. [PMID: 23749437 DOI: 10.1007/s13187-013-0490-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Integrated knowledge translation (IKT) interventions may be one solution to improving the uptake of clinical guidelines. IKT research initiatives are particularly relevant for breast cancer research and initiatives targeting the implementation of clinical guidelines and guideline implementation initiatives, where collaboration with an interdisciplinary team of practitioners, patients, caregivers, and policy makers is needed for producing optimum patient outcomes. The objective of this paper was to describe the process of developing an IKT strategy that could be used by guideline developers to improve the uptake of their new clinical practice guidelines on breast cancer screening. An interprofessional group of students as well as two faculty members met six times over three days at the KT Canada Summer Institute in 2011. The team used all of the phases of the action cycle in the Knowledge to Action Framework as an organizing framework. While the entire framework was used, the step involving assessing barriers to knowledge use was judged to be particularly relevant in anticipating implementation problems and being able to inform the specific KT interventions that would be appropriate to mitigate these challenges and to accomplish goals and outcomes. This activity also underscored the importance of group process and teamwork in IKT. We propose that an a priori assessment of barriers to knowledge use (i.e., level and corresponding barriers), along with the other phases of the Knowledge to Action Framework, is a strategic approach for KT strategy development, implementation, and evaluation planning and could be used in the future planning of KT strategies.
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Affiliation(s)
- Sarah Munce
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.
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Krastinova E, Seng R, Yeni P, Viard JP, Vittecoq D, Lascoux-Combe C, Fourn E, Pahlavan G, Delfraissy JF, Goujard C, Meyer L. Is clinical practice concordant with the changes in guidelines for antiretroviral therapy initiation during primary and chronic HIV-1 infection? The ANRS PRIMO and COPANA cohorts. PLoS One 2013; 8:e71473. [PMID: 23936509 PMCID: PMC3731276 DOI: 10.1371/journal.pone.0071473] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 06/29/2013] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Guidelines for initiating HIV treatment are regularly revised. We explored how physicians in France have applied these evolving guidelines for ART initiation over the last decade in two different situations: chronic (CHI) and primary HIV-1 infection (PHI), since specific recommendations for PHI are also provided in France. METHODS Data came from the ANRS PRIMO (1267 patients enrolled during PHI in 1996-2010) and COPANA (800 subjects enrolled at HIV diagnosis in 2004-2008) cohorts. We defined as guidelines-inconsistent during PHI and CHI, patients meeting criteria for ART initiation and not treated in the following month and during the next 6 months, respectively. RESULTS ART initiation during PHI dramatically decreased from 91% of patients in 1996-99 to 22% in 2007 and increased to 60% in 2010, following changes in recommendations. In 2007, however, after the CD4 count threshold was raised to 350 cells/mm(3) in 2006, only 55% of the patients with CD4≤350 were treated and 66% in 2008. During CHI, ART was more frequently initiated in patients who met the criteria at entry (96%) than during follow-up: 83% when recommendation to treat was 200 and 73% when it was 350 cells/mm(3). Independent risk factors for not being treated during CHI despite meeting the criteria were lower viral load, lower educational level, and poorer living conditions. CONCLUSION HIV ART initiation guidelines are largely followed by practitioners in France. What can still be improved, however, is time to treat when CD4 cell counts reach the threshold to treat. Risk factors for lack of timely treatment highlight the need to understand better how patients' living conditions and physicians' perceptions influence the decision to initiate treatment.
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Affiliation(s)
- Evguenia Krastinova
- INSERM, U1018, Epidemiology of HIV and STI; University Paris-Sud 11, Le Kremlin-Bicêtre, France.
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Dearing JW, Smith DK, Larson RS, Estabrooks CA. Designing for diffusion of a biomedical intervention. Am J Prev Med 2013; 44:S70-6. [PMID: 23253765 DOI: 10.1016/j.amepre.2012.09.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 09/04/2012] [Accepted: 09/19/2012] [Indexed: 11/18/2022]
Affiliation(s)
- James W Dearing
- Center for Health Education Dissemination and Implementation Research, Kaiser Permanente, Denver, Colorado 80231-5968, USA.
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Curtis JR, Ciechanowski PS, Downey L, Gold J, Nielsen EL, Shannon SE, Treece PD, Young JP, Engelberg RA. Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU. Contemp Clin Trials 2012; 33:1245-54. [PMID: 22772089 PMCID: PMC3823241 DOI: 10.1016/j.cct.2012.06.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 06/20/2012] [Accepted: 06/25/2012] [Indexed: 12/25/2022]
Abstract
The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.
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Affiliation(s)
- J Randall Curtis
- Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA, USA.
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Becker MA, Martinez-Tyson D, DiGennaro J, Ochshorn E. Do Latino and non-Latino White Medicaid-enrolled adults differ in utilization of evidence-based treatment for major depressive disorder? J Immigr Minor Health 2012; 13:1048-54. [PMID: 21805165 DOI: 10.1007/s10903-011-9508-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Although evidence-based practice guidelines have been developed to achieve greater consistency and quality in mental health care, insufficient research exists on implementing these guidelines among different racial/ethnic groups and the impact of guideline adherence on treatment outcomes. This study compared mental health care received by community dwelling Latino and non-Latino White Medicaid enrollees in Florida with a diagnosis of major depressive disorder (MDD) and examined predictors of adherence to American Psychiatric Association (APA) guidelines for the treatment of MDD. Latinos were more likely than Whites to receive guideline adherent treatment (OR = 1.21, P < .0001). Enrollees receiving combination drug therapy were most likely to receive treatment consistent with APA guidelines (OR = 4.25, P < .0001). Despite research demonstrating the efficacy of evidence-based practices, many study participants did not receive guideline adherent treatment. Policies and practices targeted at increasing adherence to approved guidelines and improving treatment outcomes are recommended.
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Affiliation(s)
- Marion A Becker
- Department of Aging and Mental Health Disparities, University of South Florida, Tampa, FL 33612-3807, USA.
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Powell BJ, McMillen JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, Glass JE, York JL. A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev 2011; 69:123-57. [PMID: 22203646 DOI: 10.1177/1077558711430690] [Citation(s) in RCA: 596] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Efforts to identify, develop, refine, and test strategies to disseminate and implement evidence-based treatments have been prioritized in order to improve the quality of health and mental health care delivery. However, this task is complicated by an implementation science literature characterized by inconsistent language use and inadequate descriptions of implementation strategies. This article brings more depth and clarity to implementation research and practice by presenting a consolidated compilation of discrete implementation strategies, based on a review of 205 sources published between 1995 and 2011. The resulting compilation includes 68 implementation strategies and definitions, which are grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. This consolidated compilation can serve as a reference to stakeholders who wish to implement clinical innovations in health and mental health care and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.
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Affiliation(s)
- Byron J Powell
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO 63130, USA.
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Llorca PM, Charpeaud T, Nourry A, Samalin L. [The contributions of the evidence-based medicine or how to optimize the management of major depressive disorder]. L'ENCEPHALE 2011; 37:457-65. [PMID: 22137218 DOI: 10.1016/j.encep.2011.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 10/06/2011] [Indexed: 11/19/2022]
Abstract
In the early 1980s, Evidence-Based Medicine (EBM) has been developed in the Department of Clinical Epidemiology at McMaster Medical School in Canada to meet the ever-increasing need to integrate publications in clinical practice. In this approach, we cannot ever consider that the evidence will replace clinical experience. The quality of scientific data is prioritized taking into account the methodological characteristics of studies. It takes time to learn and practice the method, which is often difficult in daily practice. The concept of "management recommendations" covers multiple realities. It can rely on the results of clinical trials (randomized, controlled or not…), the trends from the meta-analysis that attempt to "simplify" the field of literature or the Clinical Practice Guidelines. Meta-analysis should be used with caution. They do not preclude the need to use the data "sources", but they help the comparability of results and synthesis work. However it should be aware that this is a work of interpretation. The controversy over the action of antidepressants compared to placebo in depression according to the severity of the episode shows that a result depends on the included studies, the statistical technique used, but also how the results are reported. The international literature produced many recommendations in the management of depression. It is useful to refer to it as the meta-analysis because they provide an overall view of the current state of knowledge. We can regret the lack of recent French recommendations that could articulate the specifics of the French practice and data from the literature. The use of guidelines in clinical practice remains low in all fields of medicine. However improving the consideration of the recommendations is an important issue because it is associated with improved patient care. It remains to develop a collective strategy to implement them. The Evidence-Based Medicine is a major change in the everyday clinical practice. It may be insufficiently known and understood, seems too complex, time-consuming and therefore inapplicable. We have to mobilize our efforts to improve our practices.
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Affiliation(s)
- P-M Llorca
- CMP B, université d'Auvergne, CHU de Clermont-Ferrand, France.
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Trautner BW, Kelly PA, Petersen N, Hysong S, Kell H, Liao KS, Patterson JE, Naik AD. A hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of catheter-associated asymptomatic bacteriuria. Implement Sci 2011; 6:41. [PMID: 21513539 PMCID: PMC3107805 DOI: 10.1186/1748-5908-6-41] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 04/22/2011] [Indexed: 11/28/2022] Open
Abstract
Background Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. However, many cases treated as hospital-acquired CAUTI are actually asymptomatic bacteriuria (ABU). Evidence-based guidelines recommend that providers neither screen for nor treat ABU in most catheterized patients, but there is a significant gap between these guidelines and clinical practice. Our objectives are (1) to evaluate the effectiveness of an audit and feedback intervention for increasing guideline-concordant care concerning catheter-associated ABU and (2) to measure improvements in healthcare providers' knowledge of and attitudes toward the practice guidelines associated with the intervention. Methods/Design The study uses a controlled pre/post design to test an intervention using audit and feedback of healthcare providers to improve their compliance with ABU guidelines. The intervention and the control sites are two VA hospitals. For objective 1 we will review medical records to measure the clinical outcomes of inappropriate screening for and treatment of catheter-associated ABU. For objective 2 we will survey providers' knowledge and attitudes. Three phases of our protocol are proposed: the first 12-month phase will involve observation of the baseline incidence of inappropriate screening for and treatment of ABU at both sites. This surveillance for clinical outcomes will continue at both sites throughout the study. Phase 2 consists of 12 months of individualized audit and feedback at the intervention site and guidelines distribution at both sites. The third phase, also over 12 months, will provide unit-level feedback at the intervention site to assess sustainability. Healthcare providers at the intervention site during phase 2 and at both sites during phase 3 will complete pre/post surveys of awareness and familiarity (knowledge), as well as of acceptance and outcome expectancy (attitudes) regarding the relevant practice guidelines. Discussion Our proposal to bring clinical practice in line with published guidelines has significant potential to decrease overdiagnosis of CAUTI and associated inappropriate antibiotic use. Our study will also provide information about how to maximize effectiveness of audit and feedback to achieve guideline adherence in the inpatient setting. Trial Registration NCT01052545
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Affiliation(s)
- Barbara W Trautner
- Houston Health Services Research and Development Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
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Salinas GD, Williamson JC, Kalhan R, Thomashow B, Scheckermann JL, Walsh J, Abdolrasulnia M, Foster JA. Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians. Int J Chron Obstruct Pulmon Dis 2011; 6:171-9. [PMID: 21468169 PMCID: PMC3064423 DOI: 10.2147/copd.s16396] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Indexed: 11/23/2022] Open
Abstract
Purpose: Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines. Patients and methods: A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage. Results: Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response. Conclusions: Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.
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Feigelman S, Dubowitz H, Lane W, Grube L, Kim J. Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment. Acad Pediatr 2011; 11:474-80. [PMID: 21959095 PMCID: PMC5482713 DOI: 10.1016/j.acap.2011.07.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 07/24/2011] [Accepted: 07/31/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objectives of this study were to determine whether 1) residents trained in the SEEK (A Safe Environment for Every Kid) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) intervention residents would be more likely to screen for and assess those risk factors; and 3) families seen by intervention residents would report improved satisfaction with their child's doctor compared to families receiving standard care from control residents. METHODS Pediatric residents in a university-based pediatrics continuity clinic were enrolled onto a randomized controlled trial of the SEEK model. The model included resident training about psychosocial risk factors, a Parent Screening Questionnaire, and a study social worker. Outcome measures included: 1) residents' baseline, 6-month, and 18-month posttraining surveys, 2) medical record review, and 3) parents' satisfaction regarding doctor-parent interaction. RESULTS Ninety-five residents participated. In 4 of 6 risk areas, intervention residents scored higher on the self-assessment compared to control subjects, with sustained improvement at 18 months. Intervention residents were more likely than control subjects to screen and assess parents for targeted risk factors. Parents seen by intervention residents responded favorably regarding interactions with their doctor. CONCLUSIONS The SEEK model helped residents become more comfortable and competent in screening for and addressing psychosocial risk factors. The benefits were sustained. Parents viewed the intervention doctors favorably. The model shows promise as a way of helping address major psychosocial problems in pediatric primary care.
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Affiliation(s)
- Susan Feigelman
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Howard Dubowitz
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Md
| | - Wendy Lane
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Md,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Md
| | - Lawrie Grube
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Md
| | - Jeongeun Kim
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Md
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Hooper LM, Epstein SA, Qu L, Hannah NJ. Family Medicine and Internal Medicine Physicians’ Attitudes and Beliefs About Depression. J Prim Care Community Health 2010; 2:107-15. [PMID: 23804744 DOI: 10.1177/2150131910387647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Studies have long shown that some patients receive less than optimal care for depression in primary care settings. However, few studies have uncovered factors that predict and explain this deficiency. The authors administered a survey to 408 primary care physicians. They examined how physicians’ attitudes (eg, feeling positively or negatively about treating depression in their patients), physicians’ beliefs (eg, beliefs about what their patients think and prefer in terms of depression care), and demographic characteristics (independent variables) predicted optimal depression care (dependent variable). Using logistical regression analyses, they identified differences in treatment decisions between family and internal medicine physicians. Physicians’ specialty and race (family physicians and white physicians were more likely to prescribe a medication) were unique determinants of whether the physician treated depression by prescribing medication; physicians’ specialty and race (family physicians and nonwhite physicians were more likely to provide office-based counseling) were unique determinants of whether the physician treated depression by providing office-based counseling; physicians’ beliefs about depression care and physician age were unique statistically significant determinants of whether the physician treated depression by providing a referral to a mental health specialist. These findings help clarify how physicians’ specialty and beliefs about depression care influence treatment. In addition, the results in this study suggest that there are differences between family and internal medicine physicians in terms of their practice patterns and beliefs in types of treatment that patients would be willing to receive. Implications for future research on primary care depression treatment are discussed.
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Affiliation(s)
| | | | - Lixin Qu
- University of Alabama, Tuscaloosa, AL, USA
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Walter U, Flick U, Neuber A, Fischer C, Hussein RJ, Schwartz FW. Putting prevention into practice: qualitative study of factors that inhibit and promote preventive care by general practitioners, with a focus on elderly patients. BMC FAMILY PRACTICE 2010; 11:68. [PMID: 20854654 PMCID: PMC2949669 DOI: 10.1186/1471-2296-11-68] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 09/20/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND General practitioners (GPs) have a key role in providing preventive care, particularly for elderly patients. However, various factors can inhibit or promote the implementation of preventive care. In the present study, we identified and examined factors that inhibit and promote preventive care by German GPs, particularly for elderly patients, and assessed changes in physicians' attitudes toward preventive care throughout their careers. METHODS A qualitative, explorative design was used to identify inhibitors and promoters of preventive care in German general medical practice. A total of 32 GPs in Berlin and Hannover were surveyed. Questions about factors that promote or inhibit implementation of preventive care and changes in physicians' perceptions of promoting and inhibiting factors throughout their careers were identified. Episodic interviews, which encouraged the reporting of anecdotes regarding daily knowledge and experiences, were analyzed using ATLAS/ti. Socio-demographic data of GPs and structural information about their offices were collected using short questionnaires. The factors identified as inhibitory or promoting were classified as being related to patients, physicians, or the healthcare system. The changes in GP attitudes toward preventive care throughout their careers were classified as personal transitions or as social and health policy transitions. RESULTS Most of the identified barriers to preventive care were related to patients, such as a lack of motivation for making lifestyle changes and a lack of willingness to pay for preventive interventions. In addition, the healthcare system seemed to inadequately promote preventive care, mainly due to poor reimbursement for preventive care and fragmentation of care. GPs own attitudes and health habits seemed to influence the implementation of preventive care. GPs recognized their own lack of awareness of effective preventive interventions, particularly for elderly patients. GPs were motivated by positive preventive experiences, but often lacked the necessary training to counsel and support their patients. CONCLUSIONS German GPs had positive attitudes towards prevention, but the implementation of preventive care was neither systematic nor continuous. Identification and elimination of barriers to preventive care is crucial. Further research is needed to identify effective practice-based approaches to overcome these barriers.
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Affiliation(s)
- Ulla Walter
- Institute for Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Carl-Neuberg Strasse 1, OE 5410, 30623, Hannover, Germany
| | - Uwe Flick
- Alice Salomon University of Applied Sciences, Alice-Salomon-Platz 5, 12627, Berlin, Germany
| | - Anke Neuber
- University of Kassel, Dekanat des Fachbereiches 04, Arnold-Bode-Strasse 10, D-34109 Kassel, Germany
| | - Claudia Fischer
- Alice Salomon University of Applied Sciences, Alice-Salomon-Platz 5, 12627, Berlin, Germany
| | - Rugzan J Hussein
- Institute for Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Carl-Neuberg Strasse 1, OE 5410, 30623, Hannover, Germany
| | - Friedrich W Schwartz
- Institute for Epidemiology, Social Medicine and Health System Research, Hannover Medical School, Carl-Neuberg Strasse 1, OE 5410, 30623, Hannover, Germany
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Fassaert T, Nielen M, Verheij R, Verhoeff A, Dekker J, Beekman A, de Wit M. Quality of care for anxiety and depression in different ethnic groups by family practitioners in urban areas in the Netherlands. Gen Hosp Psychiatry 2010; 32:368-76. [PMID: 20633740 DOI: 10.1016/j.genhosppsych.2010.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 04/29/2010] [Accepted: 04/30/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE There is widespread concern about access to good quality health care for ethnic minority groups. This study investigates differences between ethnic groups regarding prevalence of anxiety and depression, and adherence to treatment guidelines by family practitioners in urban areas in the Netherlands. METHOD Data from electronic medical records, collected for the Netherlands Information Network of General Practice. Diagnoses were based on the International Classification of Primary Care. Adherence to guidelines included at least five consultations, prescription of psychotropics for 6 weeks at most (indicative of cessation in case of nonresponse) or 5 months at least (suggesting continuation in case of response), and/or a referral to a mental health care specialist. Data were analyzed using multilevel logistic regression analyses. RESULTS A total of 6413 patients (4.4% of practice population) were diagnosed with anxiety and/or depression. Prevalence was highest in Turkish patients (5.2%). Of diagnosed patients, 42.9% received guideline-concordant treatment. Only Surinamese/Antillean patients were less likely than ethnic Dutch to receive treatments according to guidelines. CONCLUSION Prevalence of and quality of care for anxiety and depression were comparable between ethnic minority clients, but some differences suggest that efforts to educate primary care providers in management of anxiety/depression should be continued and tailored to specific ethnic groups.
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Affiliation(s)
- Thijs Fassaert
- Department of Epidemiology, Documentation and Health Promotion, Municipal Health Service, 1000 CE Amsterdam, The Netherlands.
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Blais R, Partlová H, Lachaine J, Sewitch MJ. La conformité aux guides de traitement de la dépression est-elle associée à une réduction des coûts des services de santé ? ACTA ACUST UNITED AC 2010. [DOI: 10.3917/pos.414.0349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Brehaut JC, Graham ID, Wood TJ, Taljaard M, Eagles D, Lott A, Clement C, Kelly AM, Mason S, Kellerman A, Stiell IG. Measuring Acceptability of Clinical Decision Rules: Validation of the Ottawa Acceptability of Decision Rules Instrument (OADRI) in Four Countries. Med Decis Making 2009; 30:398-408. [DOI: 10.1177/0272989x09344747] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background. Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. Methods. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. Results. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ‘‘all of the time’’ v. ‘‘most of the time’’ v. ‘‘some of the time,’’ and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. Conclusions. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ‘‘protorules’’ during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.
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Affiliation(s)
- Jamie C. Brehaut
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa,
ON, Canada, , Clinical
Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian D. Graham
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON,
Canada, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa,
ON, Canada, Department of Epidemiology and Community Medicine, University of
Ottawa, Ottawa, ON, Canada, Knowledge Translation Portfolio, Canadian Institutes
of Health Research, Ottawa, ON, Canada
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,
Canada, Department of Epidemiology and Community Medicine, University of Ottawa,
Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, ON, Canada
| | - Alison Lott
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,
Canada
| | - Catherine Clement
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,
Canada
| | - Anne-Maree Kelly
- School of Health and Related Research, University of Sheffield, Sheffield,
UK
| | - Suzanne Mason
- Joseph Epstein Centre for Emergency Medicine Research at Western Health and the
University of Melbourne, Melbourne, Australia
| | | | - Ian G. Stiell
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,
Canada, Department of Epidemiology and Community Medicine, University of Ottawa,
Ottawa, ON, Canada, Department of Emergency Medicine, Emory University, Atlanta,
GA, Department of Emergency Medicine, University of Ottawa, ON, Canada
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Flanagan ME, Ramanujam R, Doebbeling BN. The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance. Implement Sci 2009; 4:71. [PMID: 19874607 PMCID: PMC2777118 DOI: 10.1186/1748-5908-4-71] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Accepted: 10/29/2009] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs. METHODS Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models. RESULTS For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used. CONCLUSION Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.
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Affiliation(s)
- Mindy E Flanagan
- VA Health Services Research & Development Center on Implementing Evidence-Based Practice, Roudebush VAMC, Indianapolis, Indiana, USA
- IU Center for Health Services & Outcomes Research, Regenstrief Institute, Inc., Indiana University, Indianapolis, Indiana, USA
| | - Rangaraj Ramanujam
- Owen Graduate School of Management, Vanderbilt University Nashville, Tennessee, USA
| | - Bradley N Doebbeling
- VA Health Services Research & Development Center on Implementing Evidence-Based Practice, Roudebush VAMC, Indianapolis, Indiana, USA
- IU Center for Health Services & Outcomes Research, Regenstrief Institute, Inc., Indiana University, Indianapolis, Indiana, USA
- Division of General Medicine & Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Stiles PG, Boothroyd RA, Dhont K, Beiler PF, Green AE. Adherence to practice guidelines, clinical outcomes, and costs among Medicaid enrollees with severe mental illnesses. Eval Health Prof 2009; 32:69-89. [PMID: 19164300 DOI: 10.1177/0163278708328744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The treatment of Medicaid enrollees diagnosed with depression or schizophrenia was examined to determine whether adherence to treatment guideline was associated with health care financing strategy, clinical outcomes, and cost-effectiveness. Individuals in a fee-for-service condition were significantly more likely to receive treatment consistent with guidelines than those in managed care. Mental health costs were higher for individuals diagnosed with schizophrenia, individuals in an acute phase of illness at intake into the study, and those receiving treatment consistent with practice guidelines. Being in an acute phase of illness and having treatment that comported with recommended practice guidelines were associated with higher total social costs. Policy implications of the findings and recommendations for future research are discussed.
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Affiliation(s)
- Paul G Stiles
- Louis de la Parte Florida Mental Health Institute, Tampa, FL 33612, USA.
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Delgado-Guay MO, Parsons HA, Li Z, Palmer LJ, Bruera E. Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer 2008; 115:437-45. [DOI: 10.1002/cncr.24017] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care. Health Care Manage Rev 2008; 33:289-99. [PMID: 18815494 DOI: 10.1097/01.hcm.0000318766.29277.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services. METHODOLOGY/APPROACH We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment. FINDINGS Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers. PRACTICE IMPLICATIONS To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change.
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Wisdom JP, Bielavitz S, McFarland B, Collins JC, Hamer A, Haxby D, Pollack DA. Preparing to implement medication algorithms: staff perspectives and system infrastructure. J Psychiatr Pract 2008; 14:209-15. [PMID: 18664889 PMCID: PMC2695876 DOI: 10.1097/01.pra.0000327310.96528.a5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To assess the readiness of mental health facilities in Oregon to implement medication algorithms using the Medication Management Approaches in Psychiatry toolkit (MedMAP) developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), researchers conducted interviews with 68 clinical and administrative employees of four inpatient and four outpatient mental health facilities in Oregon. Respondents had generally positive opinions about the algorithms, but they also expressed many concerns about logistics and implementation, chiefly related to medication selection and expected restrictions on choices for prescribing providers and patients. In implementing medication algorithms, it may be beneficial to assess staff perspectives as well as the capabilities of the program's infrastructure. The extent to which staff concerns, values, and needs are anticipated and promptly and responsively addressed is likely have a major influence on successful implementation.
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Curtis JR, Treece PD, Nielsen EL, Downey L, Shannon SE, Braungardt T, Owens D, Steinberg KP, Engelberg RA. Integrating palliative and critical care: evaluation of a quality-improvement intervention. Am J Respir Crit Care Med 2008; 178:269-75. [PMID: 18480429 DOI: 10.1164/rccm.200802-272oc] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Palliative care in the intensive care unit (ICU) is an important focus for quality improvement. OBJECTIVES To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU. METHODS We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results. MEASUREMENTS AND MAIN RESULTS There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01). CONCLUSIONS We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.
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Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care, Box 359762, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA.
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Feldstein AC, Glasgow RE. A Practical, Robust Implementation and Sustainability Model (PRISM) for Integrating Research Findings into Practice. Jt Comm J Qual Patient Saf 2008; 34:228-43. [DOI: 10.1016/s1553-7250(08)34030-6] [Citation(s) in RCA: 400] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rosenman S, Christensen H, Griffiths K. What is to become of the College clinical practice guidelines? Australas Psychiatry 2008; 16:1-4. [PMID: 18202927 DOI: 10.1080/10398560701760219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE College guidelines have been published "to assist practitioner and patient decisions" in treatment. There is little evidence that the guidelines have been used despite their apparent importance in the maintenance of treatment that is adequate, competent, safe, honest and up-to-date. This paper discusses the value and non-use of College clinical practice guidelines and examines possible ways that they may be promulgated and used. CONCLUSIONS Guideline research indicates that clinicians will ignore guidelines for reasons that include impracticality, inflexibility, oversimplification and disagreements with evidence interpretation. Their objections cannot be solved by guideline writers. Consumers have a legitimate use for guidelines and this can become the starting point for informed discussion of treatment and necessary deviations from standardized care. Through consumers, the guidelines can make their way into practitioners' awareness and play a role in the maintenance of treatment quality.
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Affiliation(s)
- Stephen Rosenman
- Centre for Mental Health Research, Australian National University, Canberra, ACT, Australia.
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Trivedi MH, Rush AJ, Gaynes BN, Stewart JW, Wisniewski SR, Warden D, Ritz L, Luther JF, Stegman D, Deveaugh-Geiss J, Howland R. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR(*)D measurement-based care. Neuropsychopharmacology 2007; 32:2479-89. [PMID: 17406651 DOI: 10.1038/sj.npp.1301390] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The success of well-developed protocols has been limited in real-world practice, where even effective strategies have not been sufficient to meet patient needs in routine clinical care owing to Axis I and III comorbidities. The Sequenced Treatment Alternatives to Relieve Depression (STAR(*)D) trial required that antidepressant medication treatment be optimal regarding dose and duration, yet accommodate flexibility to ensure safety given the wide range of comorbid general medical and psychiatric disorders allowed in the trial. The objective of this study was to develop a measurement-based care (MBC) approach and an automated feedback system to ensure adequate and safe antidepressant treatment delivery suitable for both clinical research and routine practice. Ratings of depressive symptom severity and side-effect frequency, intensity, and burden were obtained at each treatment visit using the MBC system that (1) guided medication dose adjustments and treatment duration, (2) documented clinician adherence to treatment recommendations, and (3) provided prompt feedback to clinicians to enhance appropriate treatment decisions. Physician adherence to protocol-specific treatment was monitored based on measured symptoms and side-effect burden, and dose and duration of antidepressant at each critical decision point during the acute phase treatment of major depression. Feedback was provided at the point of care by the clinical coordinators, assisted by Web-based reports following each treatment visit. On the basis of the first treatment step with citalopram, over 85% of treatment encounters had appropriate fidelity to recommendations. Most deviations from treatment recommendations occurred late in treatment and were often justifiable. MBC proved to be feasible and effective in busy primary and psychiatric settings. This approach signals a paradigm shift toward the use of measurement-based clinical decisions, both at the point of care and following each visit, to deliver optimal pharmacotherapy for depression.
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Affiliation(s)
- Madhukar H Trivedi
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA.
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Campbell DG, Felker BL, Liu CF, Yano EM, Kirchner JE, Chan D, Rubenstein LV, Chaney EF. Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. J Gen Intern Med 2007; 22:711-8. [PMID: 17503104 PMCID: PMC2219856 DOI: 10.1007/s11606-006-0101-4] [Citation(s) in RCA: 291] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. OBJECTIVE To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). DESIGN Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. PARTICIPANTS Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. MEASUREMENTS The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen > or = 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. RESULTS Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. CONCLUSIONS PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.
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Affiliation(s)
- Duncan G Campbell
- Department of Veterans Affairs, Health Services Research and Development Center of Excellence, VA Puget Sound Health Care System, Seattle, Washington, USA.
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