Physician knowledge, attitudes and practices regarding a widely implemented guideline

Individual and community-level factors associated with khat (Catha edulis) use among women of reproductive age in Halaba zone, South Ethiopia: a multilevel mixed effect analysis

Introduction

There is a paucity of data on factors associated with khat chewing among women of reproductive age using multilevel analysis. Furthermore, the effects of some potential factors like stressful life events, knowledge about and attitude toward the effects of khat have been given little attention and are not well understood. Therefore, this study aimed to examine the prevalence and multilevel factors associated with khat use among women of reproductive age in Halaba zone, South Ethiopia.

Methods

A community-based cross sectional study was conducted in Halaba zone from February to July, 2023. Systematic random sampling technique was used to include 1573 study participants. The dependent variable was current khat use, which is operationalized as using khat within 30 days preceding the study. An interviewer administered questionnaire was used for the data collection.

Results

The prevalence of current khat use among women of reproductive age was 65.9% [95%CI (63.5-68.2%)]. Factors significantly associated with khat use were; ages of women 35 and above years [Adjusted Odds Ratio (AOR) = 6.35, 95% CI: (3.62, 11.13)], ever married [AOR = 2.41, 95% CI: (1.10, 5.31)], secondary and above education [AOR = 0.28, 95% CI: (0.15, 0.49)], belong to richer household [AOR = 1.75, 95% CI: (1.12, 2.75)], mass media use [AOR = 3.12, 95% CI: (1.85, 4.81)], low knowledge about khat effects [AOR = 3.12, 95% CI: (1.85, 5.24)], positive attitude towards khat use [AOR = 11.55, 95% CI: (6.76, 19.71)], and strong social support [AOR = 0.43, 95% CI: (0.28, 0.64)] and non-user friend [AOR = 0.31, 95% CI: (0.20, 0.48)]. From the community level variables: rural residence [AOR = 5.06, 95% CI: (1.82, 14.09)] was significantly associated with khat use.

Conclusion

Khat use among women of reproductive age was found to be very high. From individual-level factors: advanced ages of women, secondary and above education, live in the richer wealth quintile, mass media exposure, low knowledge on khat effects, positive attitude towards khat use, strong social support, and from community-level variables: residing in rural area were significantly associated with khat use. Khat use screening for all women of childbearing age, as well as referral to substance use disorder centers for those women identified as having khat use disorder, should become a standard of care in all health facilities.

Sexual and reproductive health knowledge, sexual attitudes, and sexual behaviour of university students: Findings of a Beijing-Based Survey in 2010-2011

BACKGROUND

Although several studies have attempted investigating sex-related knowledge, attitudes, and practices among young people in China, deeper insights were still needed to further understand how this population could be supported to make healthy and safe sexual choices. Against this background, this study used a large set of secondary data to examine associations among sexual and reproductive health (SRH) knowledge, sexual attitudes, and sexual behaviour.

METHODS

A cross-sectional study was employed to explore the associations among SRH knowledge, sexual attitudes, and sexual behaviour with a publicly available survey data among the 1196 university students from freshmen to Ph.D. candidates. Descriptive analysis was used to describe the sociodemographic characteristics of the university students by gender. Associations of sociodemographic factors with sources and categories of SRH knowledge, categories of contraceptive knowledge, sexual attitudes, and sexual behavior were explored with Poisson regressions and logistic regressions, respectively. The mediating effects of sociodemographic factors on the associations between SRH knowledge and sexual behavior, observed sexual attitudes on the associations of SRH knowledge with sexual behavior, and latent sexual attitudes on the relationship between SRH knowledge and sexual behavior were analyzed in order.

RESULTS

Descriptive analysis showed that the sample was dominated by age group (18 to 24 years), undergraduates, females, limited contraceptive knowledge, unfavorable sexual attitudes, and insufficient knowledge sources. Regression analyses showed that sociodemographic factors had significant associations with SRH knowledge, sexual attitudes, and sexual behavior. Subsequently, the mediating effects of sociodemographic factors on the associations of SRH knowledge and sexual attitudes with sexual behavior were confirmed. Controlling for sociodemographic factors, the effects of sexual attitudes on the associations between SRH knowledge and sexual behaviour could be verified. Structural equation modeling indicated that the linear sequence of sources and categories of SRH knowledge → sexual attitudes → sexual behaviour model and the triangle mediating effects of sexual behaviour → sexual attitudes → SRH knowledge model existed.

CONCLUSIONS

Sociodemographic factors and observed sexual attitudes mediated the associations between SRH knowledge and sexual behaviour. The sequence relationship: sources and categories of SRH knowledge → sexual attitudes → sexual behavior and the mediating relationship: sexual behavior → sexual attitude → sources and categories of SRH knowledge & sexual behavior → sources and categories of SRH knowledge and sexual behavior → sexual attitude → categories of contraceptive knowledge & sexual behavior → categories of contraceptive knowledge were confirmed in the sample. This study also identified an urgent need for the university students to access to SRH comprehensive knowledge.

Provider attitudes towards a brief behavioral intervention for sexual health in Moldova

Background

Brief behavioral interventions are seen as an efficient way to improve knowledge, change behavior, and reduce provider stigma regarding sexual health. When grounded in evidence-based behavioral change techniques and delivered using Brief Sexuality-related Communication (BSC) tools, brief behavioral interventions can address client-driven sexual health goals in a single session with their provider. Evidence for the efficacy of brief interventions for creating gains in sexual health comes largely from resource rich settings, and there is a lack of knowledge of how brief interventions can be implemented in the more resource constrained environments of low- and middle-income countries. As a first step in developing a brief intervention to address sexual health issues in Moldova, this paper reports on qualitative data collected from Moldovan providers to understand their attitudes, willingness and perceived barriers to the brief intervention and its implementation.

Methods

Thirty-nine in-depth interviews (IDI) were conducted between February and March 2020, with health providers recruited from three primary health care institutions, two Youth Friendly Health Centers and counselors from three NGOs who work with key populations in Moldova, including health centers selected from two cites - the capital city, Chisinau and from the Comrat Region. The IDI addressed four domains of provider attitudes: 1) attitudes towards the intervention; 2) willingness and motivation to implement the intervention; 3) logistics of providing the intervention and 4) ability to implement the intervention. A coding analysis approach was applied to all interview transcripts.

Results

Providers largely reported being willing to be trained in and implement the brief intervention. Willingness to implement the intervention stemmed from two perceptions: that it would improve the ability of providers to talk with their clients about sex, and that vulnerable groups would benefit from these conversations. However, while there were generally positive attitudes towards the intervention, providers consistently reported structural barriers to their perceived ability to implement the intervention.

Conclusions

While providers reported high levels of initial acceptance of a brief behavioral intervention, care is needed to ensure that brief interventions, and the training of providers on brief interventions, incorporate cultural attitudes and norms around sex, particularly in highly patriarchal settings, and provide opportunities for providers to practice the intervention in ways that address their assumptions and implicit biases.

Barriers to reporting guideline adherence in point-of-care ultrasound research: a cross-sectional survey of authors and journal editors

OBJECTIVE

Although the literature supporting the use of point-of-care ultrasound (POCUS) continues to grow, incomplete reporting of primary diagnostic accuracy studies has previously been identified as a barrier to translating research into practice and to performing unbiased systematic reviews. This study assesses POCUS investigator and journal editor attitudes towards barriers to adhering to the Standards for Reporting of Diagnostic Accuracy Studies (STARD) 2015 guidelines.

DESIGN, SETTING, PARTICIPANTS

Two separate surveys using a 5-point Likert scale were sent to POCUS study investigators and journal editors to assess for knowledge, attitude and behavioural barriers to the complete reporting of POCUS research. Respondents were identified based on a previous study assessing STARD 2015 adherence for POCUS studies published in emergency medicine, anaesthesia and critical care journals. Responses were anonymously linked to STARD 2015 adherence data from the previous study. Written responses were thematically grouped into the following categories: knowledge, attitude and behavioural barriers to quality reporting, or other. Likert response items are reported as median with IQRs.

MAIN OUTCOME MEASURES

The primary outcome was the median Likert score for the investigator and editor surveys assessing knowledge, attitude and behavioural beliefs about barriers to adhering to the STARD 2015 guidelines.

RESULTS

The investigator survey response rate was 18/69 (26%) and the editor response rate was 5/21 (24%). Most investigator respondents were emergency medicine practitioners (13/21, 62%). Two-thirds of investigators were aware of the STARD 2015 guidelines (12/18, 67%) and overall agreed that incomplete reporting limits generalisability and the ability to detect risk of bias (median 4 (4, 5)). Investigators felt that the STARD 2015 guidelines were useful, easy to find and easy to use (median 4 (4, 4.25); median 4 (4, 4.25) and median 4 (3, 4), respectively). There was a shared opinion held by investigators and editors that the peer review process be primarily responsible for ensuring complete research reporting (median 4 (3, 4) and median 4 (3.75, 4), respectively). Three of 18 authors (17%) felt that the English publication language of STARD 2015 was a barrier to adherence.

CONCLUSIONS

Although investigators and editors recognise the importance of completely reported research, reporting quality is still a core issue for POCUS research. The shared opinion held by investigators and editors that the peer review process be primarily responsible for reporting quality is potentially problematic; we view completely reported research as an integral part of the research process that investigators are responsible for, with the peer review process serving as another additional layer of quality control. Endorsement of reporting guidelines by journals, auditing reporting guideline adherence during the peer review process and translation of STARD 2015 guidelines into additional languages may improve reporting completeness for the acute POCUS literature.

TRIAL REGISTRATION NUMBER

Open Science Framework Registry (https://osf.io/5pzxs/).

Exploring general practitioners' perceptions about the primary care gatekeeper role in Indonesia

Background

In the current healthcare delivery system funded by National Health Insurance (NHI) in Indonesia, the gatekeeper role of primary care services is critical to ensuring equal healthcare access for the population. To be effective, gatekeeping relies on the performance of general practitioners (GPs). However, the perceptions held by Indonesian GPs about their gatekeeper role are not yet well documented. This study describes the self-perceived knowledge, attitudes and performance of Indonesian GPs with respect to the gatekeeper role and explores associated factors.

Methods

We conducted a cross-sectional study of all primary care facilities (N = 75) contracted by the regional NHI office in the Banyumas district. The 73 participating GPs completed a written questionnaire that assessed their knowledge, attitudes and performance in relation to the gatekeeper role. Personal and facility characteristics were analysed in a generalised linear model as possible associating factors, as well as for the association between GPs’ knowledge and attitude with performance as gatekeepers.

Results

GPs scored relatively high in the domains of knowledge and performance but scored lower in their attitudes towards the gatekeeper role of primary care. In the full-adjusted model, no factors were significantly associated with the knowledge score. Work experience as GPs, private or civil service employment status and rural or urban location of the primary care facility were linked to attitude scores. Full- or part-time employment and type of facility were factors associated with the performance score. Attitude scores were positively associated with performance score.

Conclusion

GPs in Indonesia are knowledgeable and report that they adequately perform their function as gatekeepers in primary care. However, their attitudes towards the gatekeeper function are less positive. Attitudes and performance with respect to the primary care gatekeeper role are likely influenced more by contextual factors such as location and type of facility than by personal factors. Efforts to address contextual issues could include improvements in practice standards for privately practising physicians and public information campaigns about gatekeeping regulations. Such efforts will be crucial to improving the gatekeeper role of primary care in Indonesia and assuring efficient access to high-quality care for all.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01365-w.

Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients-A qualitative study

BACKGROUND AND OBJECTIVE

Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decision-making in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients.

METHODS

Qualitative methodologies were used that paired ethnographic field observations with semistructured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data.

RESULTS

Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors. Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, microcultures, and indirect observation and second-hand knowledge.

CONCLUSION

Surgeon's personal experiences has a significant impact on the decision-making processes during preoperative assessments. However, non-patient factors such as institutional microcultures passively and actively influence decision-making process during preoperative assessment.

Cluster randomised trial on the effectiveness of a computerised prompt to refer (back) patients with type 2 diabetes

Aims

Information and communications technology (ICT) could support care organisations to cope with the increasing number of patients with diabetes mellitus. We aimed to aid diabetes care providers in allocating patients to the preferred treatment setting (hospital outpatient clinic or primary care practice), by using the Electronic Medical Record (EMR).

Methods

A cluster randomised controlled trial. Physicians in primary and secondary care practices of the intervention group received an advisory message in the EMR during diabetes consultations if patients were treated in the ‘incorrect’ setting according to national management guidelines. Primary outcome: the proportion of patients that shifted to the correct treatment setting at one year follow-up.

Results

47 (38 primary care and 9 internist) practices and 2778 patients were included. At baseline, 1197 (43.1%) patients were in the correct treatment setting (intervention 599; control 598). Advice most often (68.4%) regarded a consultation with the internist. After one year 12.4% of the patients in the intervention and 10.6% in the control group (p = 0.30) had shifted to the correct setting. Main reasons for not following advice were: 1. physician’s preference to consider other treatment options; 2. patients’ preferences.

Conclusions

We could not find evidence that using the EMR to send consultation-linked advice to physicians resulted in a shift in patients. Physicians will not follow the advice, at least partly due to patients’ preferences.

School workers' knowledge, attitude and behaviour related to use of Toombak: a cross sectional study from Khartoum state, Sudan

BACKGROUND

Toombak is a form of smokeless tobacco (SLT) that is locally made and consumed in Sudan and contains several carcinogenic elements. Use of Toombak has been etiologically linked to various oral diseases including oral cancer. This study aimed to obtain baseline information about the Toombak use among Sudanese school workers, as well as their knowledge about Toombak related health hazards and attitude towards their role in Toombak control. In addition, this study assessed the availability and effectiveness of control policies and preventive practices in the schools.

METHODS

A cross-sectional school-based study using one-stage stratified random sampling procedure; four schools were selected randomly from each of seven localities. A total of 239 school workers' were recruited (census) from the selected schools in Khartoum State, Sudan.

RESULTS

Of the school workers, 63% (147) were ≤40 years, half were females and 79.2% (187) were teachers. A total of 9.6% (22) school workers confirmed ever use of Toombak and the percentage of daily users amounted to 64.7% (11). Moreover, 76.2% (16) of ever Toombak users were ≥40 years and all of them were males (p < 0.001). Most of the school workers reported good knowledge, positive attitude towards their role in Toombak control and good preventive practice. Female school workers were more likely to report positive attitude towards their role in Toombak control (p < 05), and to report good knowledge. Those reporting good preventive practice in schools reported good knowledge more than two times than their counterpart (p < 0.001). Age was the strongest predictor of ever Toombak use among school workers (p < .001).

CONCLUSIONS

The use of Toombak among school workers was associated with poor knowledge, negative attitude towards their role in Toombak control and poor preventive practice, Therefore, school workers use of Toombak may reduce their motivation and use of their potential in the prevention of a major health problem caused by Toombak use and affects their role model behaviour. On the other hand, school workers engagement with preventive practices in schools' was associated with good knowledge which in turn empowers their positive attitude towards their role in Toombak control.

Awareness of knowledge and practice regarding physical activity: A population-based prospective, observational study among students in Nanjing, China

Background

Physical activity (PA) promotion has proven effectiveness in preventing childhood obesity. Increasing children’s health knowledge is the most frequently used approach in PA intervention programs targeting childhood obesity prevention. However, little is known about the specific association between the change in a child’s knowledge awareness and their PA practice.

Methods

A one-year follow-up study was conducted among primary and junior high school students in Nanjing, China. At baseline students’ knowledge of healthy behavior, and their PA levels, were assessed. Students who were unaware of the association between PA and obesity were followed for one academic year. After nine-months their knowledge and PA levels were re-measured using the same validated questionnaire. Mixed effects regression models were used to estimate the relationship between awareness of knowledge about the link between PA and obesity and PA changes.

Results

Of the 1899 students who were unaware of the association between PA and obesity at baseline, 1859 (follow-up rate = 97.9%) were successfully followed-up. After nine months 1318 (70.9%) participants had become aware of PA-obesity association. Compared to their counterparts who remained unaware, students who became aware of the PA-obesity association were more likely to increase both the frequency (odds ratio (OR) = 1.34, 95%CI = 1.09, 1.64) and duration (OR = 1.34, 95%CI = 1.09, 1.65) of PA, after adjusting for potentially confounding variables.

Conclusion

Becoming aware of the known link between PA and obesity led to positive behavior modification regarding PA in this cohort of Chinese students. This is of particular importance that knowledge disimination and health education may be a useful approach for population-based physical activity promotion aiming at childhood obesity prevention in China.

Antimicrobial Use Control Measures to Prevent and Control Antimicrobial Resistance in US Hospitals

Objective.

Clinical practice guidelines and recommended practices to control use of antibiotics have been published, but the effect of these practices on antimicrobial resistance (AMR) rates in hospitals is unknown. The objective of this study was to examine relationships between antimicrobial use control strategies and AMR rates in a national sample of US hospitals.

Design.

Cross-sectional, stratified study of a nationally representative sample of US hospitals.

Methods.

A survey instrument was sent to the person responsible for infection control at a sample of 670 US hospitals. The outcome was current prevalences of 4 epidemiologically important, drug-resistant pathogens, considered concurrently: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, ceftazidime-resistant Klebsiella species, and quinolone (ciprofloxacin)-resistant Escherichia coli Five independent variables regarding hospital practices were selected from the survey: the extent to which hospitals (1) implement practices recommended in clinical practice guidelines and ensure best practices for antimicrobial use, (2) disseminate information on clinical practice guidelines for antimicrobial use, (3) use antimicrobial-related information technology, (4) use decision support tools, and (5) communicate to prescribers about antimicrobial use. Control variables included the hospitals' number of beds, teaching status, Veterans Affairs status, geographic region, and number of long-term care beds; and the presence of an intensive care unit, a burn unit, or transplant services. A generalized estimating equation modeled all resistance rates simultaneously to identify overall predictors of AMR levels at the facility.

Results.

Completed survey instruments were returned by 448 hospitals (67%). Four antimicrobial control measures were associated with higher prevalence of AMR. Implementation of recommended practices for antimicrobial use (P< .01) and optimization of the duration of empirical antibiotic prophylaxis (P<.01) were associated with a lower prevalence of AMR. Use of restrictive formularies (P = .05) and dissemination of clinical practice guideline information (P<.01) were associated with higher prevalence of AMR. Number of beds and Veterans Affairs status were also associated with higher AMR rates overall.

Conclusions.

Implementation of guideline-recommended practices to control antimicrobial use and optimize the duration of empirical therapy appears to help control AMR rates in US hospitals. A longitudinal study would confirm the results of this cross-sectional study. These results highlight the need for systems interventions and reengineering to ensure more-consistent application of guideline-recommended measures for antimicrobial use.

Identification of hepatitis B and C screening and patient management guidelines and availability of training for chronic viral hepatitis among health professionals in six European countries: results of a semi-quantitative survey

BACKGROUND

As part of the EU funded project "HEPscreen", the aim of this study is to identify hepatitis B and C screening and patient management guidelines, to assess the awareness of these among health professionals (HPs) and to explore the availability of hepatitis B/C training programmes for HPs in Germany, Italy, the Netherlands, the UK, Spain and Hungary.

METHODS

A comprehensive literature search through the main scientific databases was performed to retrieve guidelines, following which an online survey was developed and sent to HPs in six areas of health care, including public health, to verify whether HPs are aware of these guidelines, to retrieve additional guidelines and to find out whether specific professional training is available.

RESULTS

Twelve national guidelines were identified through the literature search. Of the 268 respondents, 80 % were aware of hepatitis B guidelines and 73 % were aware of hepatitis C guidelines in their country. The national guidelines identified through the literature search were mentioned by 1/3 of HPs in the UK and Germany, 13 % of HPs in the Netherlands, 14 % in Italy and 4 % in Spain. An additional 41 hepatitis B/C related guidance documents were retrieved through the online survey: 15 in the UK, seven in Hungary, six in Italy, five in the Netherlands, four in Germany and four in Spain. Availability of training programmes to improve skills and knowledge in viral hepatitis was most often reported in the Netherlands, with 82 % indicating availability and just 10 % indicating no availability, and least commonly in Italy, with 42 % indicating yes but 40 % indicating no. Availability was also reported by the majority in the UK, Hungary and Spain, while in Germany the majority selected unsure.

CONCLUSIONS

Results suggest that the scientific databases are not the most important information source of best clinical practice for many HPs. Implementation of best practices requires that guidelines are specifically designed and actively promoted among those who are to follow them. Training can disseminate these best practice recommendations and raise awareness of guidelines. It is therefore encouraging that diverse training about hepatitis B/C is available to the different professional groups.

Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines

Background:

Procedural sedation guidelines were established for a tertiary care pediatric emergency department (ED). We developed a pediatric procedural sedation course to disseminate these guidelines.

Objective:

Our objective was to evaluate the effectiveness of a sedation course in improving physicians' knowledge of pediatric procedural sedation practices and guidelines, relative to individual self-directed learning.

Methods:

We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a randomized, controlled, educational intervention. All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment. Participants were randomly assigned to one of 2 groups. The self-directed learning group (n= 24) completed a multiple-choice examination without receiving any formal teaching. The study group (n= 24) participated in a 4-hour formal multi-faceted sedation course before writing the multiple-choice examination.

Results:

The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation. The formal teaching group's median examination score (83.3%; range 75.8%–96.5%) was significantly higher (p&lt; 0.0001) than the median examination score of participants in the self-directed study group (73.3%, range 43.5%–86.6%).

Conclusion:

The multifaceted sedation course was more effective in improving physician knowledge and understanding of sedation guidelines and practices than unstructured, self-directed learning.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students

OBJECTIVE

Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students.

METHODS

Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models.

RESULTS

Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors.

CONCLUSIONS

Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

A qualitative assessment of provider perspectives on smoking cessation counselling

RATIONALE, AIMS AND OBJECTIVES

Few studies have examined doctors' views about counselling unmotivated smokers. This study explored doctors' perceptions of useful strategies to motivate patients to quit, how receptive they felt patients were to these strategies, and the benefits and drawbacks of discussing smoking cessation with patients.

METHODS

Fourteen semi-structured qualitative interviews were conducted with doctors and resident doctors.

RESULTS

Strategies reported by providers included: educating about the health risks of smoking, using 'scare tactics' to highlight the harmful effects and providing advice about how to quit. Providers believed that most patients were receptive to their strategies, but noted that they lacked feedback to know for sure. Providers saw the possibility of improving patients' health and decreasing overall health care costs as potential benefits, but cited the potential to damage rapport, competing priorities during already rushed visits and uncertainty about the effectiveness of their efforts as drawbacks that reduced their motivation to raise the issue with patients.

CONCLUSIONS

Doctors believe in the potential benefits of smoking cessation counselling but predominantly report focusing on enhancing patient's risk perceptions. They did not report attempting to use the wider array of recommended and empirically supported methods to counsel their patients. Providing doctors with increased training in motivational counselling and feedback about the efficacy their efforts or supplementing doctor care with behaviour change specialists would likely increase the benefits of counselling to patients.

Dissemination and implementation of the ARIA guidelines for allergic rhinitis in general practice

BACKGROUND

Allergic rhinitis (AR) is a prevalent problem in general practice. The first evidence-based guidelines for AR, the ARIA guidelines, were published and have been updated repeatedly since 2001 in order to improve the care of AR patients. Very limited information, however, is available on the impact of these guidelines on everyday clinical practice. The aim of this study was to evaluate the dissemination and implementation of the ARIA guidelines in general practice.

METHODS

Three hundred and fifty Flemish general practitioners (GPs) were recruited to complete a questionnaire covering their demographic and professional characteristics, awareness, perception and implementation of the ARIA guidelines. To assess compliance with the ARIA treatment recommendations, 4 fictitious case scenarios of AR were presented, in which the respondents were asked to select the treatment of choice.

RESULTS

Of the 350 GPs included, only 31% were aware of the ARIA guidelines and 10% stated that they implement them. For the diagnosis of AR, 71% of the GPs ask specific IgE tests or perform skin prick tests, whereas only 29% perform an anterior rhinoscopy. ARIA users are more likely to screen for concomitant asthma. In the clinical-case section, there was a large variability in proposed therapeutic strategies. Adherence to the evidence-based ARIA treatment guidelines was low, but recent graduation was a significant predictor of compliance with these recommendations.

CONCLUSIONS

The ARIA guidelines remain relatively unknown among Flemish GPs and even those who are aware of them still tend to treat AR independently of the guideline recommendations.

The impact of computed tomography screening for lung cancer on smoking behaviors: a teachable moment?

BACKGROUND

Helical computed tomography (CT) has emerged as a potential screening test for lung cancer. An important component of care surrounding the use of this technology is the impact of screening on decisions surrounding smoking cessation.

OBJECTIVE

The aim of this article was to conduct an integrative review of literature on the impact of lung cancer screening with CT on smoking behaviors of current smokers.

METHODS

Ganong's [Res Nurs Health. 1987;10(1):1-11] guidelines were used to conduct this integrative review. Computerized databases were used to identify relevant articles. Data were extracted from the studies, and then content analysis was used to synthesize the findings.

RESULTS

Nine studies were identified and reviewed. The quit rate among participants ranged from 6.6% to 42% after screening. Among current smokers, smoking abstinence was associated with older age, worse pulmonary function, and having multiple abnormal CT findings. Motivation to quit smoking, within the next 30 days, ranged from 14% to 35% among smokers. Factors associated with increased motivation were older age, lower nicotine addiction, fewer lung cancer symptoms, higher self-efficacy, and acknowledgment of the advantages of quitting smoking.

CONCLUSIONS

Participants undergoing lung cancer screening had increased motivation to quit smoking. Computed tomographic screening for lung cancer appears to be a teachable moment to address smoking cessation.

IMPLICATIONS FOR PRACTICE

Screening for lung cancer is only one step to fight lung cancer. Incorporating smoking cessation interventions along with the use of technology is necessary to fight this deadly disease.

Relationship between knowledge about the harms of smoking and smoking status in the 2010 Global Adult Tobacco China Survey

BACKGROUND

This analysis estimates the association between smoking-related knowledge and smoking behaviour in a Chinese context. To identify the specific knowledge most directly related to smoking status, we used a novel latent variable analysis approach to adjust for the high correlations between different measures of knowledge about tobacco smoking.

METHOD

Data are from the Global Adult Tobacco China Survey, a nationally representative sample of 13 354 household-dwelling individuals 15 years of age or older. Multinomial logistic regressions estimated the association between smoking status (ie, never smoked, current smoker or past smoker) and four smoking-related beliefs: whether or not smoking causes lung cancer, heart attack and stroke, and whether or not low-tar cigarettes are less harmful. A latent variable approach reassessed these associations while taking into account the general level of knowledge about smoking.

RESULTS

After demographic variables and general knowledge about smoking had been controlled for, the belief that low-tar cigarettes are not less harmful was more prevalent in persons who had never smoked than in current smokers (OR=1.3 (95% CI 1.0 to 1.7) in men and OR=2.8 (95% CI 1.3 to 5.9) in women); this association was even stronger when past smokers and current smokers were compared (OR=2.1 (95% CI 1.5 to 3.0) in men and OR=5.0 (95% CI 1.3 to 20.1) in women).

CONCLUSIONS

Compared with those who have never smoked and those who have ceased smoking, current smokers in China are more likely to believe that low-tar cigarettes are less harmful than regular cigarettes.

Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework

BACKGROUND

Clinical practice guidelines (CPGs) have been hailed as a useful method of translating evidence into practice. Several CPGs have been published that provide recommendations for feeding patients in the intensive care unit (ICU). Despite a rigorous development process and active dissemination of these guidelines, their impact on nutrition practice has been modest. The purpose of this study was to develop a comprehensive framework for understanding adherence to nutrition CPGs in the critical care setting.

METHODS

Multiple case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each ICU site who were asked about their perceptions and attitudes toward guidelines in general and the Canadian Critical Care Nutrition CPGs specifically. Interview transcripts and related documents were analyzed qualitatively using a framework approach.

RESULTS

The 5 key components of the developed framework were characteristics of the CPGs, the implementation process, institutional factors, provider intent, and the clinical condition of the patient. These key themes encapsulate numerous itemized factors that contribute to guideline adherence either as barriers or enablers.

CONCLUSIONS

Adherence to nutrition CPGs is determined by a complex interaction of multiple factors that act as barriers or enablers. The comprehensive framework for adherence to CPGs in the ICU attempts to elucidate this process and provides a useful template for future research. Future quality improvement initiatives should assess local barriers to change and design interventions to overcome these barriers.

Perceptions and attitudes of clinicians in Spain toward clinical practice guidelines and grading systems: a protocol for a qualitative study and a national survey

BACKGROUND

Clinical practice guidelines (CPGs) have become a very popular tool for decision making in healthcare. While there is some evidence that CPGs improve outcomes, there are numerous factors that influence their acceptability and use by healthcare providers. While evidence of clinicians' knowledge, perceptions and attitudes toward CPGs is extensive, results are still disperse and not conclusive. Our study will evaluate these issues in a large and representative sample of clinicians in Spain.

METHODS/DESIGN

A mixed-method design combining qualitative and quantitative research techniques will evaluate general practitioners (GPs) and hospital-based specialists in Spain with the objective of exploring attitudes and perceptions about CPGs and evidence grading systems. The project will consist of two phases: during the first phase, group discussions will be carried out to gain insight into perceptions and attitudes of the participants, and during the second phase, this information will be completed by means of a survey, reaching a greater number of clinicians. We will explore these issues in GPs and hospital-based practitioners, with or without previous experience in guideline development.

DISCUSSION

Our study will identify and gain insight into the perceived problems and barriers of Spanish practitioners in relation to guideline knowledge and use. The study will also explore beliefs and attitudes of clinicians towards CPGs and evidence grading systems used to rate the quality of the evidence and the strength of recommendations. Our results will provide guidance to healthcare researchers and healthcare decision makers to improve the use of guidelines in Spain and elsewhere.

Self-reported familiarity with acute respiratory infection guidelines and antibiotic prescribing in primary care

OBJECTIVE

Familiarity with guidelines is generally thought to be associated with guideline implementation, adherence and improved quality of care. We sought to determine if self-reported familiarity with acute respiratory infection (ARI) antibiotic treatment guidelines was associated with reduced or more appropriate antibiotic prescribing for ARIs in primary care.

DESIGN

SETTING

PARTICIPANTS

and

MAIN OUTCOME MEASURES

We surveyed primary care clinicians about their familiarity with ARI antibiotic treatment guidelines and linked responses to administrative diagnostic and prescribing data for non-pneumonia ARI visits.

RESULTS

Sixty-five percent of clinicians responded to the survey question about guideline familiarity. There were 208 survey respondents who had ARI patient visits during the study period. Respondents reported being 'not at all' (7%), 'somewhat' (30%), 'moderately' (45%) or 'extremely' (18%) familiar with the guidelines. After dichotomizing responses, compared with clinicians who reported being less familiar with the guidelines, clinicians who reported being more familiar with the guidelines had higher rates of antibiotic prescribing for all ARIs combined (46% versus 38%; n = 11 164; P < 0.0001), for antibiotic-appropriate diagnoses (69% versus 59%; n = 3213; P < 0.0001) and for non-antibiotic appropriate diagnoses (38% versus 28%; n = 7951; P < 0.0001). After adjusting for potential confounders, self-reported guideline familiarity was an independent predictor of increased antibiotic prescribing (odds ratio, 1.36; 95% confidence interval, 1.25-1.48).

CONCLUSIONS

Self-reported familiarity with an ARI antibiotic treatment guideline was, seemingly paradoxically, associated with increased antibiotic prescribing. Self-reported familiarity with guidelines should not be assumed to be associated with consistent guideline adherence or higher quality of care.

Training nurses in the treatment of tobacco use and dependence: pre- and post-training results

AIM

This paper is a report of a study conducted to examine the effects of a brief training in the treatment of tobacco use and dependence on the tobacco use intervention-related knowledge and attitudes of nurses.

BACKGROUND

  Nurses are the largest group of healthcare providers and they have an extended reach into the population of tobacco users. Thus, increasing the number of nurses who deliver brief evidence-based interventions for tobacco use and dependence, such as that prescribed by the Public Health Service Clinical Practice Guideline in the United States of America, is likely to expose more tobacco users to evidence-based treatments and lead to more successful quit attempts. Effective training is key to improving provider proficiency in delivering evidence-based interventions for tobacco use and dependence.

METHOD

  A 1-hour didactic training was delivered to 359 nurses from 2006 to 2007, including 54 Advanced Practice Nurses, 250 Registered Nurses and 55 Licensed Practical Nurses. Pre- and post-training tests assessed attitudes, knowledge and behaviours. Paired samples t-tests were used to compare pre- and post-test results.

RESULTS

  Statistically significant increases on nearly all measures were achieved, with Registered Nurses and Licensed Practical Nurses realizing the largest gains.

CONCLUSION

  Given the overwhelming impact of tobacco use on patients, all nurses should be provided with training in the delivery of brief, evidence-based interventions for tobacco use. As the most trusted healthcare provider group with an extended reach into the tobacco using population, nurses have a large potential impact on the prevalence of tobacco use.

Beyond grand rounds: a comprehensive and sequential intervention to improve identification of delirium

PURPOSE OF THE STUDY

Delirium is a widespread concern for hospitalized seniors, yet is often unrecognized. A comprehensive and sequential intervention (CSI) aiming to effect change in clinician behavior by improving knowledge about delirium was tested.

DESIGN AND METHODS

A 2-day CSI program that consisted of progressive 4-part didactic series, including evidence-based reviews of delirium recognition, prevention, and management, interspersed with interactive small group sessions and practical case conferences was conceptualized in consultation with a leading expert on delirium. Pretest and posttest instruments were designed to test the attendees on their knowledge and confidence around delirium identification.

RESULTS

An average of 71 people attended each didactic session. Among all responses, 50 pretests and posttests were matched based on numeric coding (6 MD/DOs, 34 RNs, and 10 others). Mean pretest and posttest scores were 7.9 and 10.8 points, respectively (maximum: 17), showing a positive change in knowledge scores after the intervention (2.9 points, p < .001). Improvement in knowledge scores was higher in the cohort attending 2 or more lectures (3.8 points, p < .001) compared with those attending only 1 lecture (1.3 points, p < .12). Confidence in identifying patients with delirium increased by 28% (p < .001), and self-assessed capacity to correctly administer the Confusion Assessment Method increased by 36% (p < .001).

IMPLICATIONS

A novel CSI increased clinician knowledge about delirium identification and management and improved confidence and self-assessed capacity to identify delirium in the hospitalized elderly patients. This strategy, which incorporates multiple reinforcing modes of education, may ultimately be more effective in influencing clinician behavior when compared with traditional grand rounds.

Community pharmacists' involvement in smoking cessation: familiarity and implementation of the National smoking cessation guideline in Finland

BACKGROUND

Guidelines on smoking cessation (SC) emphasize healthcare cooperation and community pharmacists' involvement. This study explored the familiarity and implementation of the National SC Guideline in Finnish community pharmacies, factors relating to Guideline familiarity, implementation and provision of SC services.

METHODS

A nationwide mail survey was sent to a systematic, sample of community pharmacy owners and staff pharmacists (total n = 2291). Response rate was 54% (n = 1190). Factors related to the SC Guideline familiarity were assessed by bivariate and multivariate analysis.

RESULTS

Almost half (47%) of the respondents (n = 1190) were familiar with the SC Guideline and familiarity enhanced Guideline implementation. The familiarity was associated with the respondents' perceptions of their personal SC skills and knowledge (OR 3.8); of customers' value of counseling on nicotine replacement therapy (NRT) (OR 3.3); and regular use of a pocket card supporting SC counseling (OR 3.0). Pharmacists' workplaces' characteristics, such as size and geographical location were not associated with familiarity. In addition to recommending NRT, the pharmacists familiar with the Guideline used more frequently other Guideline-based SC methods, such as recommended non-pharmacological SC aids, compared to unfamiliar respondents.

CONCLUSIONS

SC Guideline familiarity and implementation is crucial for community pharmacists' involvement in SC actions in addition to selling NRT products. Pharmacists can constitute a potential public health resource in SC easily accessible throughout the country.

Which physician and practice characteristics are associated with adherence to evidence-based guidelines for depressive and anxiety disorders?

BACKGROUND

Research on quality of care for depressive and anxiety disorders has reported low rates of adherence to evidence-based depression and anxiety guidelines. To improve this care, we need a better understanding of the factors determining guideline adherence.

OBJECTIVE

To investigate how practice- and professional-related factors are associated with adherence to these guidelines.

DESIGN

Cross-sectional cohort study.

PARTICIPANTS

A total of 665 patients with a composite interview diagnostic instrument diagnosis of depressive or anxiety disorders, and 62 general practitioners from 21 practices participated.

MEASURES

Actual care data were derived from electronic medical record data. The measurement of guideline adherence was based on performance indicators derived from evidence-based guidelines. Practice-, professional-, and patient-related characteristics were measured with questionnaires. The characteristics associated with guideline adherence were assessed by multivariate multilevel regression analysis.

RESULTS

A number of practice and professional characteristics showed a significant univariate association with guideline adherence. The multivariate multilevel analyses revealed that, after controlling for patient characteristics, higher rates of guideline adherence were associated with stronger confidence in depression identification, less perceived time limitations, and less perceived barriers for guideline implementation. These professional-related determinants differed among the overall concept of guideline adherence and the various treatment options.

CONCLUSIONS

This study showed that rates of adherence to guidelines on depressive and anxiety disorders were not associated with practice characteristics, but to some extent with physician characteristics. Although most of the identified professional-related determinants are very difficult to change, our results give some directions for improving depression and anxiety care.

Health care workers in the Dominican Republic: self-perceived role in smoking cessation

A Dominican Republic (DR)-based multi-community trial of smoking cessation viewed health care workers (HCWs) as potential interventionists. Effectively engaging them requires a clear understanding of their attitudes and practices regarding smoking. A Rapid Assessment Procedure, conducted among HCWs in six economically disadvantaged communities, included physicians, nurses, other health professionals, paraprofessionals, and lay workers. Attitudes and practices about smoking were consistent across the 82 HCWs and mostly reflected community views. HCWs lacked proactiveness related to smoking cessation and had a limited view of their role, attributing clients' quitting successes to personal will. Prior cessation training was limited, although interest was generally high. Material resources about smoking cessation were virtually absent. DR HCWs' views represented features both distinct from and common to HCWs elsewhere. Any intervention with HCWs must first raise awareness before addressing their role in smoking cessation, discussing implementation barriers, and include training and materials about risks and effective interventions.

Training health care providers in the treatment of tobacco use and dependence: pre- and post-training results

RATIONALE

Health care providers have an extended reach into the population of tobacco users. Increasing the number and variety of health care providers that deliver the evidence-based, brief interventions for tobacco use prescribed by the Public Health Service Clinical Practice Guideline is likely to result in more tobacco users exposed to evidence-based treatments and more successful quit attempts. Effective training is key to increasing provider performance and proficiency in this regard.

METHOD

A 1-hour didactic training was delivered to 1286 health care providers (185 physicians, 359 nurses, 75 dental providers and 667 other health-related professions). Pre- and post-training tests assessed provider attitudes, knowledge and behaviours. Paired samples t-tests were used to compare pre- and post-test results. Analysis of variance was used to test for significant differences among professional groups.

RESULTS

Prior to training, physicians engaged in more interventions and reported more knowledge and more positive attitudes towards treating tobacco use than the other professions. Post-training, differences among physicians, nurses and dental providers were minimal. All professions reported significantly more knowledge and more positive attitudes on nearly all measures.

CONCLUSIONS

A large potential benefit can be garnered from a brief, targeted, 1-hour training in the brief, evidence-based interventions for treating tobacco use and dependence. Increases in perceived knowledge and positive attitudes towards treatment among the professional groups suggest that trainees will perform interventions at higher frequency post-training. Overall gains were highest for dental providers and nurses.

Access to mammography screening in a large urban population: a multi-level analysis

Objective

To understand area-based sociodemographics, physician and medical practice characteristics, and community indicators associated with mammography use in Los Angeles County. An earlier multi-level analysis by Gumpertz et al. found that distance to the nearest mammography facility helped explain the higher proportion of Latinas diagnosed with late stage breast cancer compared with non-Latina Whites in Los Angeles County. Our study examined whether Latinas also have lower rates of mammography use.

Methods

We used a multi-level spatial modeling approach to examine individual and community level associations with mammography use among a diverse group of women aged 40–84 years in Los Angeles County. To build our multi-level spatial data set, we integrated five data sources: (1) 2001 California Health Interview Survey (CHIS) data, (2) 2001 Food and Drug Administration (FDA) certified mammography facility data, (3) 2003 LA Transit Authority data, (4) 2000 US Decennial Census data, and (5) 2001 Community Tracking Study (CTS) Physician’s Survey data.

Results

Our study confirmed for Los Angeles County many associations for mammography use found in other locations. An unexpected finding was that women with limited English proficiency (predominantly Latina) were significantly more likely to have had a recent mammogram than English-proficient women. We also found that, after controlling for other factors, mammography use was higher in neighborhoods with a greater density of mammography facilities.

Conclusion

Women with limited English proficiency were especially likely to report recent mammography in Los Angeles. This unexpected finding suggests that the intensive Spanish-language outreach program conducted by the Every Woman Counts (EWC) Program in low-income Latina communities in Los Angeles has been effective. Our study highlights the success of this targeted community-based outreach conducted between 1999 and 2001. These are the same populations that Gumpertz et al. identified as needing intervention. It would be useful to conduct another study of late-stage diagnosis in Los Angeles County to ascertain whether increased rates of mammography have also led to less late-stage diagnosis among Latinas in the neighborhoods where they are concentrated in Los Angeles.

Self-reported smoking cessation activities among Swiss primary care physicians

Background

Individual counselling, pharmacotherapy, and group therapy are evidence-based interventions that help patients stop smoking. Acupuncture, hypnosis, and relaxation have no demonstrated efficacy on smoking cessation, whereas self-help material may only have a small benefit. The purpose of this study is to assess physicians' current clinical practice regarding smokers motivated to stop smoking.

Methods

The survey included 3385 Swiss primary care physicians. Self-reported use of nine smoking cessation interventions was scored. One point was given for each positive answer about practicing interventions with demonstrated efficacy, i.e. nicotine replacement therapy, bupropion, counselling, group therapy, and smoking cessation specialist. No points were given for the recommendation of acupuncture, hypnosis, relaxation, and self-help material. Multivariable logistic analysis was performed to identify factors associated with a good practice score, defined as ≥ 2.

Results

The response rate was 55%. Respondents were predominately over the age of 40 years (88%), male (79%), and resided in urban areas (74%). Seventeen percent reported being smokers. Most of the physicians prescribed nicotine replacement therapy (84%), bupropion (65%), or provided counselling (70%). A minority of physicians recommended acupuncture (26%), hypnosis (8%), relaxation (7%), or self-help material (24%). A good practice score was obtained by 85% of respondents. Having attended a smoking cessation-training program was the only significant predictor of a good practice score (odds ratio: 6.24, 95% CI 1.95–20.04).

Conclusion

The majority of respondents practice recommended smoking cessation interventions. However, there is room for improvement and implementing an evidence-based smoking cessation-training program could provide additional benefit.

Barriers to physician adherence to nonsteroidal anti-inflammatory drug guidelines: a qualitative study

BACKGROUND

Despite wide availability of physician guidelines for safer use of nonsteroidal anti-inflammatory drugs (NSAIDs) and widespread use of these drugs in the US, NSAID prescribing guidelines have been only modestly effective.

AIM

To identify and describe comprehensively barriers to provider adherence to NSAID prescribing guidelines.

METHODS

We conducted interviews with 25 physicians, seeking to identify the major influences explaining physician non-adherence to guidelines. Interviews were standardized and structured probes were used for clarification and detail. All interviews were audio-taped and transcribed. Three independent investigators analysed the transcripts, using the constant-comparative method of qualitative analysis.

RESULTS

Our analysis identified six dominant physician barriers explaining non-adherence to established NSAID prescribing guidelines. These included (i) lack of familiarity with guidelines, (ii) perceived limited validity of guidelines, (iii) limited applicability of guidelines among specific patients, (iv) clinical inertia, (v) influences of prior anecdotal experiences and (vi) medical heuristics.

CONCLUSIONS

A heterogeneous set of influences are barriers to physician adherence to NSAID prescribing guidelines. Suggested measures for improving guideline-concordant prescribing should focus on measures to improve physician education and confidence in guidelines, implementation of physician/pharmacist co-management strategies and expansion of guideline scope.

A survey of tobacco-related knowledge, attitudes and behaviours of primary care providers in Mississippi

RATIONALE

Relative to other regions in the USA, Mississippi has a high prevalence of tobacco use and tobacco-related disease. This study assessed the tobacco-related knowledge, attitudes and intervention behaviours of family doctors, dentists and nurse practitioners in the state of Mississippi.

METHODS

The Provider Attitude Survey, an 85-item measure of tobacco-related knowledge, attitudes and intervention behaviours was mailed to all members of Mississippi's Family Medicine, Dentistry and Nurse Practitioner professional organizations (N=2043).

RESULTS

Over one-third (n=802, 39.2%) of eligible providers responded. Just 24.3% had received training in tobacco cessation and 33.7% were aware of the Public Health Service clinical practice guideline. Over 90% indicated that it was their role to prevent tobacco use; felt rewarded when they helped patients quit; and were bothered and upset by the health effects of tobacco. Doctors assisted more patients than nurses or dentists. Doctors and nurses reported more self-efficacy, motivation and preparedness for treating tobacco use than dentists. Providers with training performed more interventions and reported more self-efficacy, preparedness and fewer barriers than those without training. Training was associated with greater increases in self-efficacy, preparedness and intervention behaviours for dentists than for the other groups.

CONCLUSIONS

Despite a high prevalence of tobacco use and tobacco-related disease in Mississippi, primary care providers in Mississippi provide tobacco cessation interventions at an unacceptably low frequency relative to other regions. Training is likely to increase the frequency of intervention behaviours.

Physician characteristics and the reported effect of evidence-based practice guidelines

OBJECTIVE

To explore characteristics that may contribute to the effect practice guidelines have on the practice of medicine.

DATA SOURCES

From the third round of the Community Tracking Study, Physician Survey, 2000-2001.

STUDY DESIGN

An ordinal logistic regression model was estimated to capture the full range of responses.

PRINCIPAL FINDINGS

Recent medical school graduates, women, minorities, ob-gyn specialists, physicians who use computers for information in their practices, and physicians in nonsolo practice types were significantly more likely to state practice guidelines had an effect on their practice.

CONCLUSIONS

Many barriers have prevented wide acceptance of practice guidelines among the medical community. Our findings suggest there will be positive results on guideline effects as recent graduates, women, and minorities enter the physician workforce.

Variation in interpretation and counselling of blood exposure incidents by different medical practitioners

BACKGROUND

Blood exposure incidents pose a risk for transmission of bloodborne pathogens for both health care workers and public health. Despite several national and international guidelines, counsellors have often different opinions about the risks caused by these incidents. Little is known about the consequences of these variations in risk assessment on the effectiveness of the treatment and the costs for the health care system.

METHODS

The aim of this study was to reveal differences among diverse groups of counsellors in assessing the same blood exposure incidents. Subjects included 4 different kinds of counsellors: public health physicians from infectious disease departments and medical microbiologists, occupational health practitioners, and HIV/AIDS specialists from hospital settings. Surveys with cases of blood exposure incidents were sent to the counsellors in The Netherlands asking questions about their risk assessment and consequent treatment. Questions were categorized for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV risks.

RESULTS

Of the 449 surveys sent, 178 were returned, of which 158 were eligible for the study. In general, occupational health practitioners and medical microbiologists showed a more rigorous approach especially with regard to prophylactic treatment when counselling HBV risk situations, whereas public health physicians and HIV/AIDS specialists were more thorough in the handling of HCV risk accidents. In HIV counselling, HIV/AIDS specialists were far more rigorous in their treatment than the other groups. For 7 of the total of 12 cases, the risk assessment with regard to HBV, HCV, and HIV differed significantly.

CONCLUSION

The assessment of blood exposures significantly differs depending on the medical background of the counsellor handling the incident, leading to remarkable inconsistencies in the response to prevent the transmission of bloodborne pathogens and/or to increased costs for unnecessary diagnostic tests and preventive measures. Although national guidelines for the counselling and treatment of blood exposure incidents are essential, the assessment of blood exposure incidents should be limited to as few as possible, well-trained professionals, operating in regional or national call centers, to ensure comparable assessment and corresponding application of preventive measures for all victims.

Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers

BACKGROUND

Rigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines' acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability.

OBJECTIVE

To examine the clinical acceptability of guidelines having excellent technical quality.

DESIGN AND MEASUREMENTS

We selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including "perceived comprehensiveness" (perceived relevance to common clinical situations) and "perceived validity" (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders.

RESULTS

Five guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as "comprehensive" and 6% to 50% as "valid".

CONCLUSION

Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.

Predictors of self-reported discussion of cessation medications by physicians in New Jersey

Physicians play an important role in smoking cessation, especially discussing medications. This study evaluates physician characteristics associated with higher rates of discussion of smoking cessation medications. 336 primary-care physicians in New Jersey completed a cross-sectional, self-administered, mail survey including physician demographics, practice type, previous training and confidence in treating tobacco dependence, awareness of guidelines, and perceived effectiveness of treatments. Two-thirds of respondents felt confident in using cessation medications despite only 24% having previous training and only 13% having read or implemented practice guidelines. After controlling for other variables, female physicians were more likely to discuss medications compared with males (adjusted odds ratio(AOR) 2.2; 95% confidence interval(CI) 1.0-4.6); physicians who were confident were more likely to discuss (AOR 3.0;95% CI 1.7-5.3); and physicians in private practices (solo, group, or multispecialty) were more likely to discuss than those employed by an agency (hospital, state, or federal) (AOR 3.1;95% CI 1.4-6.8). Most physicians in this sample reported routinely discussing cessation medications, with female physicians, those feeling confident, and those in private practices doing so more frequently. Considering limited resources and opportunities to access physicians, interventions to increase discussion of effective cessation treatments could be targeted to specific physician groups.

Attitudes toward practice guidelines among intensive care unit personnel: a cross-sectional anonymous survey

OBJECTIVES

The study assessed attitudes of intensive care unit (ICU) staff members toward practice guidelines in general and toward a specific guideline, The Centers for Disease Control and Prevention's Guideline for Hand Hygiene in Healthcare Settings; correlated these attitudes with staff and hospital characteristics; and examined the impact of staff attitudes toward the Hand Hygiene Guideline on self-reported implementation of the Guideline.

METHODS

We performed a cross-sectional survey of staff in 70 ICUs in 39 U.S. hospitals, members of The National Nosocomial Infection Surveillance System. A survey, "Attitudes Regarding Practice Guidelines," was administered anonymously to all willing staff during a site visit at each hospital. A total of 1359 ICU personnel responded: 1003 nurses (74%), 228 physicians (17%), and 128 others (10%).

RESULTS

Significantly more positive attitudes toward practice guidelines were found among staff in pediatric compared with adult ICUs (P < .001). Nurses and other staff when compared with physicians had more positive attitudes toward guidelines in general but not toward the specific Hand Hygiene Guideline. Those with more positive attitudes were significantly more likely to report that they had implemented recommendations of the Guideline (P < .001) and used an alcohol product for hand hygiene (P = .002).

CONCLUSIONS

The majority of staff members were familiar with the Centers for Disease Control and Prevention Hand Hygiene Guideline. Staff attitudes toward practice guidelines varied by type of ICU and by profession, and more positive attitudes were associated with significantly better self-reported guideline implementation. Because differences in staff attitudes might hinder or facilitate their acceptance and adoption of evidence-based practice guidelines, these results may have important implications for the education and/or socialization of ICU staff.

Clinicians' perceptions about use of computerized protocols: a multicenter study

PURPOSE

Implementation of evidence-based techniques, such as explicit computerized protocols, has achieved limited success among clinicians. In this study, we describe the development and validation of an instrument for assessing clinicians' perceptions about use of explicit computerized protocols.

METHODS

Qualitative assessment of semi-structured interviews with clinicians gave rise to a cognitive model evaluating the factors that motivate clinicians to use explicit computerized protocols. Using these constructs we developed a 35-item instrument which was administered to 240 clinicians (132 nurses, 53 physicians and 55 respiratory therapists), in three health-care institutions.

RESULTS

Factor analysis identified nine factors that accounted for 66% of the total variance cumulatively. Factors identified were: Beliefs regarding Self-Efficacy, Environmental Support, Role Relevance, Work Importance, Beliefs regarding Control, Attitude towards Information Quality, Social Pressure, Culture, and Behavioral Intention. The strongest predictor was Beliefs regarding Self-Efficacy, which accounted for 26% of the total variance of intention to use explicit computerized protocols. Results supported the reliability and construct validity of the instrument.

CONCLUSIONS

Clinicians' perceptions play a critical role in determining their intention to use explicit computerized protocols in routine clinical practice. Behavioral theories will help us understand factors predicting clinicians' intention to use explicit computerized protocols and recognize the implications of these factors in the design and implementation of these protocols.

Facility-level factors influencing chronic heart failure care process performance in a national integrated health delivery system

BACKGROUND

Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood.

OBJECTIVES

The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facility-level factors influencing adherence.

DESIGN

In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines.

SAMPLE

The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics.

RESULTS

The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process.

CONCLUSIONS

Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.

Clinical practice guideline implementation strategy patterns in Veterans Affairs primary care clinics

BACKGROUND

The Department of Veterans Affairs (VA) mandated the system-wide implementation of clinical practice guidelines (CPGs) in the mid-1990s, arming all facilities with basic resources to facilitate implementation; despite this resource allocation, significant variability still exists across VA facilities in implementation success.

OBJECTIVE

This study compares CPG implementation strategy patterns used by high and low performing primary care clinics in the VA.

RESEARCH DESIGN

Descriptive, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low performance on six CPGs.

SUBJECTS

One hundred and two employees (management, quality improvement, clinic personnel) involved with guideline implementation at each VAMC primary care clinic. MEASURES; Participants reported specific strategies used by their facility to implement guidelines in 1-hour semi-structured interviews. Facilities were classified as high or low performers based on their guideline adherence scores calculated through independently conducted chart reviews.

FINDINGS

High performing facilities (HPFs) (a) invested significantly in the implementation of the electronic medical record and locally adapting it to provider needs, (b) invested dedicated resources to guideline-related initiatives, and (c) exhibited a clear direction in their strategy choices. Low performing facilities exhibited (a) earlier stages of development for their electronic medical record, (b) reliance on preexisting resources for guideline implementation, with little local adaptation, and (c) no clear direction in their strategy choices.

CONCLUSION

A multifaceted, yet targeted, strategic approach to guideline implementation emphasizing dedicated resources and local adaptation may result in more successful implementation and higher guideline adherence than relying on standardized resources and taxing preexisting channels.

Review article: colorectal cancer surveillance in ulcerative colitis - what should we be doing?

Different societies have published guidelines for colorectal cancer (CRC) surveillance in ulcerative colitis (UC). While it would seem that most gastroenterologists and endoscopists agree with these guidelines, different studies have shown that in clinical practice, the concept of dysplasia is not fully understood, and therefore, the guidelines are not always followed. According to some studies, the reason why gastroenterologists do not follow the recommendations is inadequate education. The main advance in recent years in this subject is in endoscopic diagnosis of dysplasia. The magnification and chromoendoscopy allow targeted biopsies to be taken. Some studies indicate that nontargeted biopsies are not useful in ruling out dysplasia. It is also important to realize that most dysplasia is visible in conventional colonoscopy. In colonoscopy, it is not only significant to detect dysplasia-associated lesions or masses; the endoscopist should also be trained to detect, in the course of conventional exploration, subtle changes in colour or in mucosal surfaces that imply dysplasia. Adherence to guidelines had been extensively assessed in other disease conditions (asthma, hypertension, etc.). According to our knowledge there are no such data regarding CRC surveillance in UC. Some barriers that may affect physicians include: (i) knowledge (lack of awareness or lack of familiarity); (ii) attitudes (lack of agreement, lack of self-efficacy, lack of outcome expectancy, or the inertia of previous practice) and (iii) behaviour (external barriers). In conclusion, we need new guidelines for CRC surveillance in UC, which must take into account the advances in risk factors of dysplasia and new technologies to study colon dysplasia.

Gender and age disparities for smoking-cessation treatment

BACKGROUND

Physicians play a critical role in tobacco-dependence treatment, especially prescribing cessation medications. However, it is unclear whether efforts are meeting recommended standards. This study evaluates the frequency and predictors of tobacco-use identification, counseling for tobacco dependence, and the prescription of cessation medications in a nationally representative sample of physician-patient encounters.

METHODS

More than 58,000 physician-patient ambulatory encounters from the National Ambulatory Medical Care Survey 2001 and 2002 were analyzed in 2004-2005, including patient demographics, diagnoses, tobacco counseling, and prescriptions.

RESULTS

Tobacco-use status was identified in 69% of patient encounters, with 16% of those encounters indicating current use. Tobacco counseling occurred in 22.5% of visits by tobacco users, and 2.4% of tobacco users were prescribed cessation medications. These rates are similar to previous analyses in 1991. Patient characteristics associated with being more likely to receive counseling include being a new patient (adjusted odds ratio [OR]=1.34, 95% confidence interval [CI]=1.00-1.77) and having a tobacco-caused diagnosis (OR=2.71, CI=1.95-3.78). Characteristics associated with a lower likelihood of receiving medication include female gender (OR=0.45, CI=0.22-0.90) and age 65 and above (OR=0.14, CI=0.03-0.63), while a tobacco-caused diagnosis (OR=3.91, CI=1.64-9.29) and patient prompting (OR=15.31, CI=3.36-69.8) were associated with higher likelihood of receiving medications.

CONCLUSIONS

Despite increasing national attention, the identification of tobacco status, counseling rates, and the use of cessation medications by physicians are low and unchanged from 1991. Women and elderly tobacco users were much less likely to receive prescriptions for cessation medications, while patients requesting treatment and those with tobacco-caused diagnoses were more likely. Further educational and public health campaigns are needed to encourage the use of these effective medications, especially in women and the elderly.

Performance of methicillin-resistant Staphylococcus aureus protocols in Dutch hospitals

BACKGROUND

Although numerous studies have stressed the importance of compliance with methicillin-resistant Staphylococcus aureus (MRSA) protocols with regard to cost reduction and a safer environment for health care workers and patients, an evaluation of the usability of the protocols themselves is lacking. In this study, we evaluated the usability and performance of those protocols.

METHODS

The performance of MRSA protocols was examined in 5 Dutch hospitals by means of a questionnaire (n = 63), followed by a practical test (n = 50), in a stratified random sample of 3 types of health care workers (physicians, nursing staff, and cleaning personnel). The questionnaire consisted of constructs related to exposure to risk, risk perception, knowledge of and attitude toward the protocols and safety preventive measures, self-reported behavior, and social and organizational support. The practical test consisted of "what if" scenarios that simulate the actual use of the protocol as a guideline for solving infection problems. The health care workers were asked to verbalize their thoughts and actions while using the protocol.

RESULTS

The questionnaire demonstrated adequate knowledge of and attitude toward the MRSA protocols. However, the practical test revealed that the majority of respondents had problems with the accessibility, comprehensibility, applicability, and acceptability of the protocols. Problems not only occurred because of unclear information about the preventive measures and a poor infrastructure but also because of preventive measures that conflict with principles in providing care.

CONCLUSION

The protocols do not reflect the practical needs of the health care workers. In view of the different decisions that health care workers have to take in various circumstances, it would be impracticable to use the same MRSA protocol for all hospital staff. Finally, the practical test provided more reliable results than the questionnaire.

Ethical issues in intensive care--a survey among Scandinavian intensivists

BACKGROUND

The general principles of medical ethics are universally accepted. In practice, however, there is variation on how these principles are interpreted by people with different cultural backgrounds. The aim of this study was to document the views of Scandinavian intensive care physicians on intensive care unit (ICU) admission, triage, withholding and withdrawal of intensive care, and communication between the patient, the family and the ICU team.

METHODS

A questionnaire was developed and sent to 84 intensive care physicians working in Denmark, Finland, Sweden and Norway.

RESULTS

The response rate was 61%. In general, the responses were in agreement with published guidelines. Nevertheless, there was considerable variation on what factors are taken into account when priority decisions are made. In addition, the views on the content of information provided to the family varied. A majority of 80% reported priority decisions being made on a regular basis. Less than one-half of the respondents had correct knowledge regarding the existence or lack of national guidelines on intensive care ethics. Only 8% of the respondents were aware of guidelines published by the Society of Critical Care Medicine.

CONCLUSION

Variation in priority determinants between individual physicians may compromise justice in health care. An effort should be made to discuss and adopt mutual principles. In addition, the quality of information available to the patients' representatives deserves our attention. The results of this study could be used as a basis for discussion when guidelines on the ethical aspects of intensive care are developed and reviewed.

Provider adherence to COPD guidelines: relationship to organizational factors

RATIONALE, AIMS AND OBJECTIVES

A clinical practice guideline for chronic obstructive pulmonary disease (COPD) was implemented in all Veterans Health Administration (VHA) hospitals in the US. The aim of the current analyses is to describe current adherence rates and the organizational factors related to provider adherence to the COPD guideline.

METHODS

We administered a survey to key informants that assessed adherence to the COPD guideline, approaches to disseminating and implementing the COPD guideline, providers' views of the COPD guideline and guidelines in general, and attitudes about the organizational climate.

RESULTS

Surveys were returned by 242 key informants (58%) at 130 of the 143 VHA hospitals (91%). Adherence to the COPD clinical practice guideline is perceived by quality managers within the VHA to be good. The final multivariable predictor model identified five measures that were related to provider adherence with the COPD guideline (R(2) = 0.43): responsibilities were changed to support adherence to the COPD guideline, physicians believe that guidelines implemented in the past year were applicable to their practice, patient care providers consistently participate in activities to improve the quality of care, the regional network office monitors the pace at which guidelines are implemented, and there is a system to provide feedback on routinely collected guideline adherence data collected in addition to External Peer Review Program data.

CONCLUSIONS

Organizations can play an important role in providing a supportive climate to facilitate their providers' adherence to guidelines by implementing processes and culture changes that involve these five measures.

Do peer guidelines or editorial policies affect the reporting and discussion of race and ethnicity in pediatric research?

OBJECTIVES

Two policy statements published in pediatric journals encouraged researchers not to use race and ethnicity [R/E] to explain cohort differences without collecting and analyzing data that examine the potential underlying social mechanisms. We sought to determine if these statements had any impact on the reporting and discussion of R/E and sociodemographic markers [SM].

METHODS

Articles in three general pediatric journals between July 2002 and June 2003 were reviewed, and were compared with previously collected data from July 1999-June 2000. We recorded whether the articles documented R/E or SM, or both, in the results, and whether they discussed their significance. Researchers were surveyed to determine whether and why they collected R/E data.

RESULTS

Race was reported in 156 of 228 articles (68%), but discussed in only one-third (75). Although there is wide interjournal variability, there was little change between the two periods. Seventy-two percent of respondents thought that R/E was or might be relevant to their research, and this influenced their decision to report and discuss R/E.

CONCLUSIONS

Most researchers report R/E and believe it is relevant to their research. Despite policies that reject R/E as explanatory variables, most researchers do not report or discuss the underlying social mechanisms that may explain R/E differences.

Toward a system of cancer screening in the United States: trends and opportunities

The hard work of public health officials, physicians, and disease advocacy groups to educate Americans about the importance of early detection has resulted in uptake of screening tests at levels equivalent to or higher than in countries with organized cancer screening programs. However, the societal costs of high screening rates are larger in the United States than in other countries, including higher prices for screening, more unnecessary testing, and inefficiencies in delivery, especially in small practices. Further, screening rates are not evenly distributed across population groups, and the national expenditure on clinical and community research to promote cancer screening among individuals has not been matched by research efforts that focus on policy or clinical systems to increase screening widely throughout the population. We identify opportunities for organizational change that improve access to use, improve quality, and promote cost effectiveness in cancer screening delivery.

Understanding and resolving adherence problems

The expert panel report version 2 (EPR-2) is a comprehensive set of recommendations for the evaluation and treatment of asthma. However, physicians demonstrate scant adoption of many of the key evaluation and treatment components of the EPR-2, with primary care physicians being less likely to adopt EPR-2 recommendations than specialist physicians. Patients also demonstrate very limited adoption of physician recommendations, such as the use of medications as prescribed. Predictors of physician and patient nonadherence are reviewed, as modifiable predictors may be targets for interventions to enhance adherence. Finally, areas for future efforts are identified.