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

Effectiveness of four deconstructive meditative practices on well-being and self-deconstruction: study protocol for an exploratory randomized controlled trial

INTRODUCTION

The efficacy of interventions based on mindfulness and compassion has been demonstrated in both clinical and general population, and in different social contexts. These interventions include so-called attentional and constructive meditation practices, respectively. However, there is a third group, known as deconstructive meditation practices, which has not been scientifically studied. Deconstructive practices aim to undo maladaptive cognitive patterns and generate knowledge about internal models of oneself, others and the world. Although there are theoretical and philosophical studies on the origin of addiction to the self or on the mechanisms of action associated with the deconstruction of the self, there are no randomized controlled trials evaluating these techniques in either a healthy population or clinical samples. This study aims to evaluate the effect of three deconstructive techniques by comparing them to mindfulness in the general population.

METHODS AND ANALYSIS

A randomized controlled clinical trial will be conducted with about 240 participants allocated to four groups: (a) mindful breathing, (b) prostrations, according to Tibetan Buddhist tradition; (c) the Koan Mu, according to Zen Buddhist tradition; and (d) the mirror exercise, according to Toltec tradition. The primary outcome will be the qualities of the non-dual experience and spiritual awakening, measured by the Nondual Embodiment Thematic Inventory, assessed at pre- and post-treatment and at 3- and 6-month follow-ups. Other outcomes will be mindfulness, happiness, compassion, affectivity and altered state of consciousness. Quantitative data will be compared using mixed-effects linear regression models, and qualitative data will be analysed through thematic analysis and using the constant comparative method from grounded theory.

ETHICS AND DISSEMINATION

Approval was obtained from the Research Ethics Committee of Aragon, Spain. The results will be submitted to peer-reviewed specialized journals, and brief reports will be sent to participants on request.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05317754. Registered on August 2,2022.

Physicians’ Attitudes Against Clinical Practice Guidelines on the Use of Guidelines: A Scale Development Study

This study aims at developing scale measuring attitudes of physicians against clinical practice guidelines (CPGs) and investigate whether the attitude of physicians against CPGs has an effect on the use of CPGs. ‘The Physicians’ Attitudes Against CPGs and The Use of CPGs’ was developed and used to collect data from the physicians working in a public education and research hospital. Physicians’ attitudes that were constructed as an upper latent variable were significant, positive and highly effective on the use of CPGs. Furthermore, the attitude upper latent variable explained 30% of the variance in the observed variable for the use of CPGs. The attitude upper latent variable was affected significantly, positively and at a remarkably high level by positive attitude latent variable while it was affected significantly, negatively and at a remarkably high level by negative attitude latent variable. Physicians’ attitudes against CPGs were found to be a highly important factor in the use of CPGs. And it was also observed that physicians’ positive attitudes against CPGs affected the use of CPGs in a positive way while negative attitudes had negative effect on use of CPGs.

Clinician Engagement in Quality: A Literature Review

BACKGROUND AND OBJECTIVES

Defining quality in the health care context has proven difficult, with many organizations not able to clearly articulate their use of this term in a manner that is easily understood by their clinical staff. This review seeks to investigate the literature to explore clinician engagement in quality including where engagement has been problematic, and if the reasons for this have been identified.

METHODS

An integrative review of the literature was undertaken to determine whether evidence within the literature supports a hypothesis that there is a lack of understanding of and engagement in quality at an organizational level by health professionals. A search of the literature was conducted using EBSCO Academic Complete, CINAHL, and MEDLINE databases.

RESULTS

This article identified 18 studies where the understanding of quality by clinicians and their level of engagement with the process are investigated. We found that there has been no comprehensive study that explores the development of an agreed-upon definition and measurement of quality or clinician understanding and engagement in quality. The studies conducted have been small and discipline-specific.

CONCLUSION

There is a growing body of evidence indicating that clinical and nonclinical staff interpret the meaning of quality and quality improvement differently. Quality and quality improvement are interpreted in relation to the clinician's individual work, professional, and learning and development experience. The literature suggests that clinician interpretation is influenced in part by their own personal beliefs and values, in addition to their interpretation of their individual work/professional responsibilities.

Effectiveness and cost-effectiveness of a multicomponent intervention to implement a clinical practice guideline for systemic lupus erythematosus: protocol for a cluster-randomized controlled trial

Background

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with significant potential morbidity and mortality. Substantial gaps have been documented between the development and dissemination of clinical practice guidelines (CPG) and their implementation in practice. The aim of this study is to assess the effectiveness and cost-effectiveness of a multi-component knowledge transfer intervention to implement a CPG for the management of SLE (CPG-SLE).

Methods

The study is an open, multicentre, controlled trial with random allocation by clusters to intervention or control. Clusters are four public university hospitals of the Canary Islands Health Service where rheumatologists are invited to participate. Patients diagnosed with SLE at least one year prior to recruitment are selected. Rheumatologists in intervention group receive a short educational group programme to both update their knowledge about SLE management according to CPG-SLE recommendations and to acquire knowledge and training on use of the patient-centred approach, a decision support tool embedded in the electronic clinical record and a quarterly feedback report containing information on management of SLE patients. Primary endpoint is change in self-perceived disease activity. Secondary endpoints are adherence of professionals to CPG-SLE recommendations, health-related quality of life, patient perception of their participation in decision making, attitudes of professionals towards shared decision making, knowledge of professionals about SLE and use of healthcare resources. Calculated sample size is 412 patients. Data will be collected from questionnaires and clinical records. Length of follow-up will be 18 months. Multilevel mixed models with repeated time measurements will be used to analyze changes in outcomes over time. Cost-effectiveness, from both social and healthcare services perspectives, will be analyzed by measuring effectiveness in terms of quality-adjusted life years gained. Deterministic and probabilistic sensitivity analyses are planned.

Discussion

Impact of CPGs in clinical practice could be improved by applying proven value interventions to implement them. The results of this ongoing trial are expected to generate important scientifically valid and reproducible information not only on clinical effectiveness but also on cost-effectiveness of a multi-component intervention for implementation of a CPG based on communication technologies for chronic patients in the hospital setting.

Trial registration

ClinicalTrial.gov NCT03537638. Registered on 25 May 2018.

Use of clinical practice guidelines and factors related to their uptake: a survey of health professionals in Spain

RATIONALE, AIMS AND OBJECTIVE

This study aims to assess the use of clinical practice guidelines (CPGs) among health professionals and factors related to their uptake in clinical practice.

METHODS

Cross-sectional study based on an online survey conducted among primary care (PC) and hospital-based care (HC) doctors in Spain in 2011. Questionnaire development included adaptation of similar surveys and contextualization through a qualitative study. After a pilot study and review, the final survey contained five domains: demographics, involvement in CPGs, consultation of CPGs, perceptions and attitudes regarding CPGs and Spanish NHS CPGs Programme. Professionals from selected health care centres in seven regions were contacted by email with an invitation and link to the Web-based questionnaire. We analysed between-group differences and explored potential predictors of CPGs use by means of a logistic regression.

RESULTS

Six hundred seventy-six doctors responded to the survey (27.7% response rate). 47.1% were PC and 49.5% were HC doctors. 32.5% stated previous involvement in CPGs and 56.5% stated training in research methodology. 67.5% of the surveyed professionals reported using CPGs more than one time per week. The use of a system for classifying the quality of evidence (62.3%) and for grading the strength of the recommendations (58.6%), as well as the use of a rigorous methodology (49.6%), were the most frequently reported aspects related to CPG credibility. The lack of time (56.4%), especially in PC (65.3% versus 49.5% in HC; P < 0.001), and the absence of brief and easily accessible format (42.2%) were the main reported barriers to using CPGs. None of the studied factors showed statistically significant association in the logistic regression model.

CONCLUSIONS

Study results suggest that, in general, Spanish doctors trust and use CPGs frequently. To improve uptake by health professionals and to overcome existing barriers, CPGs should be rigorously developed and made accessible at the point-of-care in user-friendly electronic formats. Due to the low response rate, findings should be extrapolated with caution.

Attitudes and perceptions about clinical guidelines: a qualitative study with Spanish physicians

BACKGROUND

Clinical guidelines (CGs) are popular for healthcare decision making but their acceptability and use by healthcare providers is influenced by numerous factors. Some of these factors are professional-related, such as knowledge and perceptions of and attitudes toward CGs in general. The aim of our study was to evaluate attitudes and perceptions of Spanish physicians towards CGs.

METHODS

We coordinated six discussion groups with a total of 46 physicians. The participants were drawn from 12 medical specialties from both specialized and primary care. We recorded the sessions and transcribed the content verbatim. We analyzed the data using an approach based on the grounded theory.

RESULTS

We identified two main constructs that defined the physicians' perceptions towards guidelines: knowledge and usefulness. "Knowledge" defined the theoretical meanings of guidelines, while "Usefulness" referred to the pragmatic approach to guidelines. These constructs were interrelated through a series of categories such as confidence, usability, accessibility, dissemination and formats.

CONCLUSIONS

In our study, the constructs that impacted most on physician's attitudes to clinical guidelines were knowledge and usefulness. The tension between the theoretical and the pragmatic constructs determined the attitudes and how physicians use guidelines. Groups developing guidelines should ask relevant clinical questions and develop implementable and context specific recommendations. Developers should be explicit and consistent in the development and presentation of recommendations.

Expectations, experiences and attitudes of patients and primary care health professionals regarding online psychotherapeutic interventions for depression: protocol for a qualitative study

BACKGROUND

In the year 2020, depression will cause the second highest amount of disability worldwide. One quarter of the population will suffer from depression symptoms at some point in their lives. Mental health services in Western countries are overburdened. Therefore, cost-effective interventions that do not involve mental health services, such as online psychotherapy programs, have been proposed. These programs demonstrate satisfactory outcomes, but the completion rate for patients is low. Health professionals' attitudes towards this type of psychotherapy are more negative than the attitudes of depressed patients themselves. The aim of this study is to describe the profile of depressed patients who would benefit most from online psychotherapy and to identify expectations, experiences, and attitudes about online psychotherapy among both patients and health professionals that can facilitate or hinder its effects.

METHODS

A parallel qualitative design will be used in a randomised controlled trial on the efficiency of online psychotherapeutic treatment for depression. Through interviews and focus groups, the experiences of treated patients, their reasons for abandoning the program, the expectations of untreated patients, and the attitudes of health professionals will be examined. Questions will be asked about training in new technologies, opinions of online psychotherapy, adjustment to therapy within the daily routine, the virtual and anonymous relationship with the therapist, the process of online communication, information necessary to make progress in therapy, process of working with the program, motivations and attitudes about treatment, expected consequences, normalisation of this type of therapy in primary care, changes in the physician-patient relationship, and resources and risks. A thematic content analysis from the grounded theory for interviews and an analysis of the discursive positions of participants based on the sociological model for focus groups will be performed.

DISCUSSION

Knowledge of the expectations, experiences, and attitudes of both patients and medical personnel regarding online interventions for depression can facilitate the implementation of this new psychotherapeutic tool. This qualitative investigation will provide thorough knowledge of the perceptions, beliefs, and values of patients and clinicians, which will be very useful for understanding how to implement this intervention method for depression.

Survey of preferred guideline attributes: what helps to make guidelines more useful for emergency health practitioners?

BACKGROUND

Enhancing CPG acceptance and implementation can play a major role in the development and establishment of emergency medicine as a specialty in many parts of the world. A Guideline International Network special interest group established to support collaboration to improve uptake of clinical practice guidelines (CPGs) across the emergency care sector conducted an international survey to identify attributes of guideline likely to enhance their use.

METHODS

A Web-based survey was undertaken to determine how CPGs were accessed, the preferred formats and attributes of guidelines, and familiarity with GRADE. The criteria used to identify preferred attributes of guidelines were adapted from the AGREE II Tool.

RESULTS

Two hundred six responses were received from 31 countries, 74/206 (36%) from the US, 28/206 (16%) from Canada, 17/206 (8%) from Australia and 15/206 (7%) from the UK. The majority of responses were from physicians (176/206, 85%) with 15/206 (7%) of responses from nurses and 9/206 (4%) from pre-hospital emergency services personnel. The preferred format for guidelines was clinical protocols that incorporated recommendations into workflow, and the most preferred attribute of guidelines was the clear identification of key recommendations. The results also identified that within the group that responded to the question related to GRADE, 66% were unfamiliar with this system for summarizing evidence in relationship to recommendations.

CONCLUSIONS

The findings provide the basis for further research to explore the most appropriate formats for guidelines or guidelines resources tailored to the needs of the emergency care providers.

[Clinical practice guidelines and primary care. SESPAS report 2012]

Clinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.