Evidence-based practice in primary care: past, present and future

Introducing Progressive Strength Training Program in Singapore's Elder Care Settings

The use of progressive strength training among the elderly has become an accepted part of evidence-based practice for preventive and rehabilitative care. Exercise is undoubtedly one of the pillars for resilient aging. While research has shown impressive outcomes from strength training, the challenge remains to get elderly persons to exercise. Here we describe a Finnish-Singaporean cross-national project that provides a unique opportunity to evaluate the implementation of strength training in settings where it had previously not been applied. We report from the first 2 years of implementation using assessment data and surveys directed to frontline therapists responsible for the implementation. The strength training concept was progressively implemented in 24 elder care locations in Singapore including residential homes, day rehab/care centers, and senior activity centers. Each location was provided with training, support, gym equipment and technology solutions. It remained for individual sites to enroll elderly to the program, to perform assessments, and to direct the progressive strength training. Based on data from the first 2 years of implementation, improvements in lower body muscle strength were found in Leg Curl (ave 11.1–48.8%), Leg Extension (ave 10.2–24.0%) and Hip Abduction/Hip Adduction (ave 7.0–15.8%). Of the trained therapists, 95% strongly agreed or agreed to some extent that the implementation had been successful. The practice-based evidence from the project has demonstrated that it is feasible to implement progressive strength training in real life settings, using technology. While the implementation initially required handholding and support, the approach yielded consistent improvement rates in muscle strength comparable to results from randomized clinical trials (meta-analysis studies). Significant improvement rates in muscle strength were found in all three types of sites, demonstrating that gym training can be employed broadly in elder care. The Senior Activity Centers offer an interesting model for reaching seniors with preventive actions at an early stage. The data support a 3-month training as an effective intervention of introducing strength training in elder care settings, promoting healthy aging.

Groups or teams in health care: finding the best fit

RATIONALE

In the evolution of the team concept, clear distinctions between 'groups' and 'teams' were made. In this paper we argue that these distinctions were not made explicit in the translation of team structures to health care. Even though teams are appropriate for many health care settings, this paper explores the notion that when teams may not be working, it is the concept of team that may not be appropriate, not the functioning of the team itself.

METHODS

This paper reviews the differences between teams and groups, and identifies how these differences are expressed in health care settings using urban and rural examples from the UK and Australia.

RESULTS

Some suggestions about matching structures to suit the unique nature of health care provision, particularly in community health settings, are made.

DISCUSSION

Instead of concentrating on improving the process of teams, the focus could be better directed to ensure that whatever structure is utilized best facilitates the necessary outcomes in the most effective way. The team approach may not always be the best approach, and sometimes referring to a number of people working together as a group is sufficient.

External validity of randomised controlled trials: "to whom do the results of this trial apply?"

In making treatment decisions, doctors and patients must take into account relevant randomised controlled trials (RCTs) and systematic reviews. Relevance depends on external validity (or generalisability)--ie, whether the results can be reasonably applied to a definable group of patients in a particular clinical setting in routine practice. There is concern among clinicians that external validity is often poor, particularly for some pharmaceutical industry trials, a perception that has led to underuse of treatments that are effective. Yet researchers, funding agencies, ethics committees, the pharmaceutical industry, medical journals, and governmental regulators alike all neglect external validity, leaving clinicians to make judgments. However, reporting of the determinants of external validity in trial publications and systematic reviews is usually inadequate. This review discusses those determinants, presents a checklist for clinicians, and makes recommendations for greater consideration of external validity in the design and reporting of RCTs.

National Service Frameworks and UK general practitioners: street-level bureaucrats at work?

This paper argues that the past decade has seen significant changes in the nature of medical work in general practice in the UK. Increasing pressure to use normative clinical guidelines and the move towards explicit quantitative measures of performance together have the potential to alter the way in which health care is delivered to patients. Whilst it is possible to view these developments from the well-established sociological perspectives of deprofessionalisation and proletarianisation, this paper takes a view of general practice as work, and uses the ideas of Lipsky to analyse practice-level responses to some of these changes. In addition to evidence-based clinical guidelines, National Service Frameworks, introduced by the UK government in 1997, also specify detailed models of service provision that health care providers are expected to follow. As part of a larger study examining the impact of National Service Frameworks in general practice, the response of three practices to the first four NSFs were explored. The failure of NSFs to make a significant impact is compared to the practices' positive responses to purely clinical guidelines such as those developed by the British Hypertension Society. Lipsky's concept of public service workers as 'street-level bureaucrats' is discussed and used as a framework within which to view these findings.

Barriers to evidence based practice in primary care: a review of the literature

People with health problems deserve a service that is based on best available evidence and is possible within obtainable resources. No credible health professional could deny that sound evidence should be an integral part of clinical decision making. The demand for up to date information to inform care and treatment highlights the crucial role of research and development in the modern health service. However, within primary care, practitioners have not always been able to underpin their actions with robust research findings. In addition, the research activities within primary care are limited to a small number of 'enthusiasts'. This paper aims to analyse the literature surrounding this area, highlighting the significance of United Kingdom (UK) government reports on primary care, primary care research activities and the pursuit of evidence based practice in primary care. It shows that primary care research has been the 'poor relation' in terms of research funding and this has resulted is a dearth of high quality research results to underpin practice.

The anatomy and relations of evidence-based medicine

Current tensions between evidence-based medicine (EBM) and some clinicians are counterproductive and unnecessary. The most contentious issues concern (a) the limitations of efficacy data from randomised trials as evidence; (b) differences in attitudes to medical diagnosis and clinical judgement; and (c) political concerns about the use of the concept of clinical evidence and guidelines to restrict physician autonomy. Health services research has evolved in response to a bureaucratic need to study health care, including clinical practice, in order to improve its effectiveness (defined mainly in terms of technological interventions), and to contain costs. Its perspective is from the top-down representing the interests of bureaucracy and managed care, and articulates with political demands for professional accountability and cost-containment. EBM has established its place as an important contributor to the methodological toolbox for health services research. There is a need for a corresponding coherent programme of clinical practice research which would locate EBM in the clinical environment beside quality assurance, the study of the appropriateness and effectiveness of interventions, and multidisciplinary research related to the art of medicine and supportive aspects of clinical care. EBM would then be seen as one organ in relation to many others making their contribution to the body of knowledge needed for clinical decisions and policy making. A 'centre for the study of clinical practice' would be an appropriate structure to support such a comprehensive programme of clinical practice research in a tertiary hospital. The bottom-up perspective of clinical practice research would complement the current top-down perspective of most health services research, providing information to doctors, patients and administrators concerning local quality of care and health outcomes, information which could also be aggregated for guidance of health policy makers. It would also represent the voice of the clinician in policy debates. Such a programme, located in the practice environment, would also foster mutual understanding, respect and cooperation between workers from different backgrounds.

Evidence based general practice

OBJECTIVES

To estimate the proportion of interventions in general practice that are based on evidence.

DESIGN

A one-year cross-sectional study involving all consultations by patients over age 15 years seen in 34 national primary health care centers.

SETTING

The rural Castellon provincial district within the Valencian Community in eastern Spain, with a total population of 21,155 inhabitants.

SUBJECTS

of 1990 case histories registered in the course of one year, 4800 consultations were identified; of these, 2341 (49%) distinct diagnosis-intervention pairs were identified and coded.

MAIN RESULTS

The evidence basis for the diagnosis-intervention pairs in the study was derived from a computerized search of the scientific literature published in 1992-1996. The quality of the evidence was classified according to the method of Ellis et al. Within the 2341 diagnosis-intervention pairs, there was positive evidence in support of the intervention used in 55%. The evidence basis was sound for 42%, with 38% being based on Type I (clinical trials) evidence and 4% on Type II evidence. The most frequently presenting diseases involved the circulatory (18.7%), respiratory (14.9%), nervous (14.2%), musculo-skeletal (12.5%) and nutrition and metabolism and digestive systems, with 12.1% each.

CONCLUSIONS

Clinical practice was clearly supported by positive evidence of all Types (I-III) in a total of 55% of interventions, and by good positive evidence of Type I or II in 42% of interventions. The percentage of evidence-based interventions in general practice serving a substantial population in rural Spain was lower than had been reported by some authors.

Health policy issues and applications for evidence-based medicine and clinical practice guidelines

Evidence-based medicine and clinical practice guidelines have become increasingly salient to the international health care community in the 1990s. Key issues in health policy in this period can be categorised as costs and access to care, quality of and satisfaction with care, accountability for value in health care, and public health and education. This paper presents a brief overview of evidence-based medicine and clinical practice guidelines and describes how they are likely to influence health policy. Evidence-based medicine focuses on the use of the best available clinical (efficacy) evidence to inform decisions about patient care; guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances. Both fields have developed methods for evaluating and synthesising available evidence about the outcomes of alternative health care interventions. They have clear implications for health policy analysts: greater reliance should be placed on scientific evidence, policy decisions should be derived systematically, and health care decisionmaking must allow for the active participation of health care providers, policy makers, and patients or their advocates. The methods and information generated from evidence-based guidelines efforts are critical inputs into health policy analysis and decision-making.