Differences in belief about likely outcomes account for differences in doctors' treatment preferences: but what accounts for the differences in belief?

Ethical issues after pre-natal diagnosis

Following pre-natal diagnosis of congenital heart defect parents and family face a dramatic psychological crisis because of their state of shock, contradictory information available on potential outcomes, limited availability of time for decisions and for autonomous choices. Counselling the parents can present additional difficulties due to influence of education, cultural and religious background, individual cognitive and emotional processes, and cross-cultural patient care is a challenging issue for the caregivers. Type and quality of messages transmitted by the caregivers determine the counselling process, with the risk of misunderstandings particularly high with reduced available evidence, or with different outcomes accordingly with the various alternatives of treatment. Since the introduction of pre-natal diagnosis for congenital abnormality, interruption of pregnancy became available on these grounds in many Western countries, and the numbers of babies born with congenital heart defects has declined significantly despite concomitant advances in treatment options and outcomes. Detailed and objective information, with all available options, should be provided after pre-natal diagnosis of congenital heart defect. One of the major achievements of pediatric medicine in the last 50 years is the increased understanding of the pathogenetic causal mechanisms of congenital heart defects as well as its treatment. For congenital heart defects the progress of surgical treatments allowed a huge proportion of these children to reach adult life with a decent quality of life and social integration. Therefore, must be a considerable concern that universal pre-natal diagnosis widespread pregnancy interruption may obviate those gains. A reduction in the post-natal population undergoing treatment may have a significantly deleterious effect on the expertise of the caregivers, producing a reduction in outcome quality. With all respect for the parental choices and the obligations to follow the national laws, is necessary to remark that our society is genuinely ambivalent.

"Functionally" univentricular hearts: impact of pre-natal diagnosis

Within the last few decades the pre-natal echocardiographic diagnosis of congenital heart defects has made substantial progresses, particularly for the identification of complex malformation. "Functionally" univentricular hearts categorize a huge variety of heart malformations. Since no one of the patients with these congenital heart defects can ever undergo a bi-ventricular type of repair, early recognition and decision-making from the neonatal period are required in order to allow for appropriate multiple-step diagnostic and treatment procedures, either of interventional cardiology and/or surgery, on the pathway of "univentricular" heart. In the literature strong disagreements exist about the potential impact of the pre-natal diagnosis on the early and late outcomes of complex congenital heart defects. This review of the recent reports has been undertaken to better understand the impact of pre-natal diagnosis in "functionally" univentricular hearts taking into consideration the following topics: pre-natal screening, outcomes and survival, general morbidity, neurologic and developmental consequences, pregnancy management and delivery planning, resources utilization and costs/benefits issues, ethical implications, parents counseling, and interruption of pregnancy versus treatment.

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Background

Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use.

Objectives

Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies.

Selection criteria

Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses.

Outcome measure

Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction.

Data collection and analysis

An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007.

Main results

The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support.

Conclusions

Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.

Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol)

BACKGROUND

Many patients at high risk of cardiovascular diseases are managed and monitored in general practice. Recommendations for cardiovascular risk management, including lifestyle change, are clearly described in the Dutch national guideline. Although lifestyle interventions, such as advice on diet, physical exercise, smoking and alcohol, have moderate, but potentially relevant effects in these patients, adherence to lifestyle advice in general practice is not optimal. The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics. The aim of this paper is to describe the design and methods of a study to evaluate an intervention aimed at involving patients in cardiovascular risk management.

METHODS

A cluster-randomised controlled trial in 20 general practices, 10 practices in the intervention arm and 10 in the control arm, starting on October 2005. A total of 720 patients without existing cardiovascular diseases but eligible for cardiovascular risk assessment will be recruited. In both arms, the general practitioners and nurses will be trained to apply the national guideline for cardiovascular risk management. Nurses in the intervention arm will receive an extended training in risk assessment, risk communication, the use of a decision aid and adapted motivational interviewing. This communication technique will be used to support the shared decision-making process about risk reduction. The intervention comprises 2 consultations and 1 follow-up telephone call. The nurses in the control arm will give usual care after the risk estimation, according to the national guideline. Primary outcome measures are self-reported adherence to lifestyle advice and drug treatment. Secondary outcome measures are the patients' perception of risk and their motivation to change their behaviour. The measurements will take place at baseline and after 12 and 52 weeks. Clinical endpoints will not be measured, but the absolute 10-year risk of cardiovascular events will be estimated for each patient from medical records at baseline and after 1 year.

DISCUSSION

The combined use of risk communication, a decision aid and motivational interviewing to enhance patient involvement in decision making is an innovative aspect of the intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51556722.

When there is too much to do: how practicing physicians prioritize among recommended interventions

BACKGROUND

Recent evidence suggests that patients are receiving only 50% of recommended processes of care. It is important to understand physician priorities among recommended interventions and how these priorities are influenced both intentionally as well as unintentionally.

METHODS

A survey was mailed to all primary care physicians (PCPs) from two VA hospital networks (N= 289), one of which had participated in a broad, evidence-based guideline development effort 8 to 12 months earlier, and all endocrinologists nationwide in the VA (N= 213); response rate, 63% (n= 315). Using the method of paired comparisons, we assessed physician priorities among 11 clinical triggers for interventions in the management of an uncomplicated patient with type 2 diabetes.

RESULTS

Both PCPs and specialists consistently identified several high-impact clinical triggers for treatment as the highest priority interventions (hemoglobin A1c = 9.5%, diastolic blood pressure [DBP]= 95 mm Hg, low-density lipoprotein = 145 mg/dl). Several low-impact interventions that are commonly used as performance measures also received relatively high ratings. Treatments that have recently been found to be highly beneficial were often rated as being of low importance (e.g., treating when DBP = 88 mm Hg). Almost 80% of PCPs rated tight glycemic control as more important than tight DBP control, in direct contrast to clinical trial evidence. Specialists' ratings followed the same general pattern, but were more consistent with the epidemiological evidence. The PCPs at the sites that participated in the guideline intervention rated blood pressure control significantly higher.

CONCLUSION

Although several high-priority aspects of diabetes care were clearly identified, there were also notable examples of ratings that were clearly inconsistent with the epidemiological literature. Recommendations based upon more recent evidence were substantially underrated and some guidelines used as performance measures were relatively overrated. These results support the arguments that a more proactive approach is needed to facilitate rapid dissemination of new high-priority findings, and that intervention priority, and not just ease of measurement, should be considered carefully when disseminating guidelines and when selecting performance measures.