Influences on clinical practice: the case of glue ear

The use of practice guidelines in the management of pediatric cases of Acute Otitis Media in Amman, Jordan

OBJECTIVES

The widespread emergence of antimicrobial resistance has led many healthcare institutions to adopt more conservative antibiotic prescription practice guidelines for the treatment of acute otitis media (AOM). Little is known about the awareness and use of such guidelines by physicians in Jordan. Our aim was to pilot an anonymous survey instrument that would assess AOM treatment trends as well as awareness of and adherence to practice guidelines in Amman. By qualitatively assessing the management of AOM we could illuminate possible disparities in treatment trends, evaluate variability in practice guideline adherence, and help focus efforts of future educational programs that pertain to pediatric AOM management.

METHODS

A total of 71 practicing physicians were anonymously surveyed in Amman, Jordan. The survey assessed awareness of and adherence to practice guidelines by prompting responses to hypothetical AOM cases. Differences in performance between various physician groups were noted.

RESULTS

In total, participants answered 61.2% of the questions correctly. It was found that trainees would prescribe more appropriate antibiotics relative to attending physicians (p = 0.008). It was found that medical physicians followed guidelines more appropriately relative to ENT surgeons (64.2% of questions answered correctly vs. 58.1% of questions answered correctly; p = 0.015) and that physicians who report adhering to guidelines all/most of the time followed guidelines more appropriately relative to those who report adhering only sometimes or never (64.0% of questions answered correctly vs. 58.0% of questions answered correctly; p = 0.011). Also, cases that dealt with children were the most difficult for participants to diagnose as compared with cases that dealt with adults.

CONCLUSION

We conducted the first known qualitative analysis of otitis media practices in Amman and found numerous shortcomings in AOM guideline familiarity. Awareness of practice guidelines can lead to more appropriate AOM management, but there is variability between groups in guideline familiarity and utilization. Interventions that promote more conservative antibiotic prescriptions could be targeted towards groups that prescribe antibiotics less appropriately relative to their colleagues e.g. attending physicians and ENT surgeons. Interventions could also target physicians who manage pediatric AOM cases as participants had the most difficulty in properly diagnosing cases that involved children and infants.

The Diffusion of Medical Innovations: Can Figurational Sociology Contribute?

This article seeks to present and explore the relevance of a figurational, or process sociological approach, as developed by Norbert Elias, to the investigation of innovation and change. It is argued that Elias’s work offers a theoretically robust framework for exploring such issues. Applications of the principles of his work, in particular the emphasis on an understanding of longer-term unplanned processes, are a potential help to those charged with planning and managing complex change, such as the introduction of innovation. The example of health policy-makers’ attempts to use the principles of evidence-based medicine (EBM) to change clinical practice is used to explore these claims.

Distributed Leadership in Policy Formulation: A Sociomaterial Perspective

Leadership in public policy making is challenging. There is tension in gaining commitment from competing stakeholder groups, in sustaining public engagement in technically complex areas and securing broad-based support. Our paper illuminates these challenges through a case study of health policy development in the UK. We go beyond individual roles and leader–follower exchange relationships to develop the concept of distributed leadership using a sociomaterial approach to reveal how and why leadership is distributed across sociomaterial practices which together (re)configure policy coalitions and context. In so doing we also show how legitimacy and trust are sociomaterially enacted and shape leadership in public policy.

Have guidelines affected ear, nose, and throat specialists' diagnoses and the prescription of antibiotics for acute otitis media?

INTRODUCTION

The Ministry of Health and Medical Education of Iran, and similar institutions in many other countries, advises physicians to use current guidelines for the diagnosis and treatment of acute otitis media (AOM). However, there has been no evaluation of the effectiveness of such guidelines or whether physicians in Iran adhere to them. Thus, as laryngologists are the most important group of people who interact with patients with AOM, the aim of this study was to evaluate the attitude of laryngologists to the established guidelines.

MATERIALS AND METHODS

A total of 120 anonymous surveys were mailed to 120 otolaryngologists in Tehran, Iran, to evaluate the patterns of diagnosis and treatment of AOM used by these physicians. The survey included questions regarding the otolaryngologists' age, gender, place of work, and attitude towards diagnosis and treatment of AOM.

RESULTS

Sixty-two completed surveys were received, for a response rate of 51%. There was no significant difference between respondents to these surveys according to sex, age, practice setting, graduation year, or the number of patients with AOM seen each month.

CONCLUSION

Our study adds new insights to the previous literature on the use of guidelines in the management of AOM. We can now assess the impact of guidelines on the usual practice of physicians in evidenced-based management of AOM.

The contribution of case study research to knowledge of how to improve quality of care

Background

Efforts to improve the implementation of effective practice and to speed up improvements in quality and patient safety continue to pose challenges for researchers and policy makers. Organisational research, and, in particular, case studies of quality improvement, offer methods to improve understanding of the role of organisational and microsystem contexts for improving care and the development of theories which might guide improvement strategies.

Methods

This paper reviews examples of such research and details the methodological issues in constructing and analysing case studies. Case study research typically collects a wide array of data from interviews, documents and other sources.

Conclusion

Advances in methods for coding and analysing these data are improving the quality of reports from these studies.

Developing the protocol for the evaluation of the health foundation's 'engaging with quality initiative' - an emergent approach

In 2004 a UK charity, The Health Foundation, established the 'Engaging with Quality Initiative' to explore and evaluate the benefits of engaging clinicians in quality improvement in healthcare. Eight projects run by professional bodies or specialist societies were commissioned in various areas of acute care. A developmental approach to the initiative was adopted, accompanied by a two level evaluation: eight project self-evaluations and a related external evaluation. This paper describes how the protocol for the external evaluation was developed. The challenges faced included large variation between and within the projects (in approach, scope and context, and in understanding of quality improvement), the need to support the project teams in their self-evaluations while retaining a necessary objectivity, and the difficulty of evaluating the moving target created by the developmental approach adopted in the initiative. An initial period to develop the evaluation protocol proved invaluable in helping us to explore these issues.

Bayes’ theorem: A negative example of a RCT on grommets in children with glue ear

Bayesian inference presupposes that practitioners' belief in the effectiveness of medical intervention is the product of prior belief and recent evidence from studies. Although increasingly used, up to now the posterior belief calculated according to the theorem has not been compared with an empirically measured posterior belief. We conducted a RCT, which was preceded by elicitation of prior beliefs among ENT-surgeons, and which was followed by elicitation of posterior beliefs among ENT-surgeons, 1 year after completion of the trial. We compared the posterior beliefs of ENT-surgeons about the effect of grommets in children with glue ears, as predicted by Bayes' theorem with actual measured posterior beliefs. The distribution of the measured posterior beliefs was not in line with the calculated posterior, but almost identical to the distribution of the measured prior beliefs. The results showed that our trial had little or no impact on the beliefs of the ENT-surgeons, i.e. they did not adjust their belief to the extent that was expected according to Bayes' theorem.

Does a trial on the effects of ventilation tubes influence clinical practice?

A survey was performed to study the implementation of the results of a clinical trial on the effect of ventilation tubes on daily clinical practice. Two random samples of 75 Dutch otorhinolaryngologists each were drawn: one before the conduction of the trial and another after the results were disseminated. In both surveys participants were asked to give their personal estimate of the probability of complete recovery without treatment and after the insertion of ventilation tubes in an infant with bilateral otitis media with effusion. The trial showed no long lasting effects of ventilation tubes on hearing, language development and quality of life, yet, the overall expectation with respect to the effect of ventilation tubes remained high. The study suggests that the adoption of research results require more than simple dissemination of the results. (Inter)national debate is recommended to value the results of clinical trials for daily practice.

Methods for evaluation of small scale quality improvement projects

Evaluation is an integral component of quality improvement and there is much to be learned from the evaluation of small scale quality improvement initiatives at a local level. This type of evaluation is useful for a number of different reasons including monitoring the impact of local projects, identifying and dealing with issues as they arise within a project, comparing local projects to draw lessons, and collecting more detailed information as part of a bigger evaluation project. Focused audits and developmental studies can be used for evaluation within projects, while methods such as multiple case studies and process evaluations can be used to draw generalised lessons from local experiences and to provide examples of successful projects. Evaluations of small scale quality improvement projects help those involved in improvement initiatives to optimise their choice of interventions and use of resources. Important information to add to the knowledge base of quality improvement in health care can be derived by undertaking formal evaluation of local projects, particularly in relation to building theory around the processes of implementation and increasing understanding of the complex change processes involved.

Innovation in healthcare: how does credible evidence influence professionals?

The objectives of the present paper are to describe selected findings from a research project on the diffusion and adoption of innovations in primary-care settings. The project design was a comparative case study design exploring four innovations in different settings. The findings are used to explore the influence of evidence on clinical behaviour, particularly how clinical professionals judge credible evidence and take decisions. The article goes on to explore other influences on behaviour and the role of context in shaping processes and behaviour. Finally, the concluding section draws out the relevance of these data for the current changes being implemented in primary care, and raises questions about the implementation of clinical governance and quality improvements.

No magic targets! Changing clinical practice to become more evidence based

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part?

Reduction in the use of surgery for glue ear: did national guidelines have an impact?

BACKGROUND

It is widely accepted that the passive dissemination of national clinical guidance has little or no impact on practice.

OBJECTIVE

To assess the impact in England of an Effective Health Care bulletin on childhood surgery for glue ear issued in 1992 and to understand the reasons for any change (or lack of change) in practice that ensued.

METHOD

Time series analysis of the rate of use of surgery by children under 10 years of age from 1975 to 1997/8 in 13 English health districts.

RESULTS

Following a rise in the rate of surgery in public (National Health Service) hospitals from 1975 to 1985, the rate declined by 1.6% a year from 1986 to 1992/3. Following publication of the guidelines in November 1992, the rate of decline increased to 10.1% a year. Even after allowing for a slight increase in the use of independent (private) hospitals between 1992/3 and 1997/8, the overall rate of decline was at least 7.9%. It appears that the rate of referral of cases by primary care physicians (general practitioners) halved during this period. Several contextual factors are thought to have contributed to the effect of the guidelines, including pre-existing professional concern about the value of surgery, the introduction of an internal market into the NHS, and growing apprehension among parents fuelled by scepticism in the mass media. During this unprecedented period of rapid change in usage, staff delivering the service remained unaware of the alterations in their own practice.

CONCLUSIONS

Passive dissemination of national guidelines can accelerate an existing trend in clinical practice if the context is hospitable. Policy makers should identify and target such situations.

Practice patterns versus practice guidelines in pediatric otitis media

OBJECTIVE

To study the practice patterns of physicians and their adherence to an evidence-based practice guideline (PG) on pediatric otitis media with effusion. We hypothesized that overall knowledge of the recommendations from the guidelines would be less than 75%, and that specialist physicians would have better knowledge of the recommendations than generalist physicians.

METHODS

We performed a survey study of 1167 otolaryngologists, pediatricians, and pediatric otolaryngologists. Each physician was sent a 6-item survey asking about their practice patterns and treatment preferences for young children with otitis media with effusion. We compared responses between different specialties.

RESULTS

The overall response rate was 48%. Only 8 (1.4%) of the 558 responding physicians answered all 6 items congruent with the PG. Overall, pediatricians, otolaryngologists, and pediatric otolaryngologists had similar total scores, but different scores on individual items.

CONCLUSIONS

These results indicate that the practice patterns of pediatricians, otolaryngologists, and pediatric otolaryngologists differ from the recommendations of an evidence-based PG. In particular, 2 items covering key treatment recommendations were answered in agreement with the PG by fewer than half of the physicians. It is not clear from this study whether these discrepancies were due to poor dissemination or knowledge concerning the PG, or disagreement with its recommendations.