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Park YS, Kim SY, Park EC, Jang SI. Screening for Diabetes Complications during the COVID-19 Outbreak in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095436. [PMID: 35564832 PMCID: PMC9104609 DOI: 10.3390/ijerph19095436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 02/01/2023]
Abstract
This study aimed to investigate the implementation of diabetes complications screening in South Korea during the coronavirus disease (COVID-19) outbreak. Data from the Korea Community Health Surveys conducted in 2019 and 2020 were used. This study included 51,471 participants. Multiple level analysis was used to investigate the relationships between screening for diabetic retinopathy and diabetic nephropathy and variables of both individual- and community-level factors in 2019 and 2020, before and after the COVID-19 outbreak. Diabetes nephropathy complications screening in 2020 had a lower odds ratio. However, regions heavily affected by COVID-19 showed a negative association with diabetes complications screening after the COVID-19 outbreak. For those being treated with medication for diabetes, there was a significant negative association with diabetic nephropathy screening after the outbreak. The COVID-19 outbreak was associated with a reduction in the use of diabetes nephropathy complications screening. Additionally, only regions heavily affected by COVID-19 spread showed a negative association with diabetes complications screening compared to before the COVID-19 outbreak. In this regard, it appears that many patients were unable to attend outpatient care due to COVID-19. As such, these patients should be encouraged to visit clinics for diabetes complications screening. Furthermore, alternative methods need to be developed to support these patients. Through these efforts, the development of diabetes-related complications should be prevented, and the costs associated with these complications will be reduced.
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Affiliation(s)
- Yu shin Park
- Department of Public Health, Graduate School, Yonsei University, Seoul 03772, Korea; (Y.s.P.); (S.Y.K.)
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
| | - Soo Young Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul 03772, Korea; (Y.s.P.); (S.Y.K.)
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University, Seoul 03772, Korea;
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: ; Tel.: +82-2-222-1862; Fax: +82-2-392-8133
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Young SD. The Adaptive Behavioral Components (ABC) Model for Planning Longitudinal Behavioral Technology-Based Health Interventions: A Theoretical Framework. J Med Internet Res 2020; 22:e15563. [PMID: 32589152 PMCID: PMC7351148 DOI: 10.2196/15563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/28/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022] Open
Abstract
A growing number of interventions incorporate digital and social technologies (eg, social media, mobile phone apps, and wearable devices) into their design for behavior change. However, because of a number of factors, including changing trends in the use of technology over time, results on the efficacy of these interventions have been mixed. An updated framework is needed to help researchers better plan behavioral technology interventions by anticipating the needed resources and potential changes in trends that may affect interventions over time. Focusing on the domain of health interventions as a use case, we present the Adaptive Behavioral Components (ABC) model for technology-based behavioral interventions. ABC is composed of five components: basic behavior change; intervention, or problem-focused characteristics; population, social, and behavioral characteristics; individual-level and personality characteristics; and technology characteristics. ABC was designed with the goals of (1) guiding high-level development for digital technology–based interventions; (2) helping interventionists consider, plan for, and adapt to potential barriers that may arise during longitudinal interventions; and (3) providing a framework to potentially help increase the consistency of findings among digital technology intervention studies. We describe the planning of an HIV prevention intervention as a case study for how to implement ABC into intervention design. Using the ABC model to plan future interventions might help to improve the design of and adherence to longitudinal behavior change intervention protocols; allow these interventions to adapt, anticipate, and prepare for changes that may arise over time; and help to potentially improve intervention behavior change outcomes. Additional research is needed on the influence of each of ABC’s components to help improve intervention design and implementation.
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Affiliation(s)
- Sean D Young
- Institute for Prediction Technology, Department of Informatics, University of California, Irvine, Irvine, CA, United States.,Department of Emergency Medicine, UCI School of Medicine, Irvine, CA, United States
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Rognstad S, Brekke M, Gjelstad S, Straand J, Fetveit A. Potentially Inappropriate Prescribing to Older Patients: Criteria, Prevalence and an Intervention to Reduce It: The Prescription Peer Academic Detailing (Rx-PAD) Study - A Cluster-Randomized, Educational Intervention in Norwegian General Practice. Basic Clin Pharmacol Toxicol 2018; 123:380-391. [PMID: 29753315 DOI: 10.1111/bcpt.13040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/29/2018] [Indexed: 12/25/2022]
Abstract
Potentially inappropriate prescriptions (PIP) is drug treatment, which in general, at the group level for a median/mean patient, can be considered unfavourable meaning that the risks commonly may outweigh the benefits. This MiniReview reports and discusses the main findings in a large cluster-randomized educational intervention in Norwegian general practice, aimed at reducing the prevalence of PIPs to patients ≥70 years (The Rx-PAD study). Targets for the intervention were general practitioners (GPs) in continuing medical education (CME) groups receiving educational outreach visits (i.e. peer academic detailing). A Delphi consensus process, with a panel of medical experts, was undertaken to elaborate a list of explicit criteria defining PIPs for patients ≥70 years in general practice. Agreement was achieved for 36 explicit PIP criteria, the so-called Norwegian General Practice (NorGeP) criteria. Using a selection (n = 24) of these criteria during a 1-year baseline period on the prescribing practice of 454 GPs (i.e. those enrolled to participate in the intervention trial), we found a prevalence rate of 24.7 PIPs per 100 patients ≥70 years per year. In the Rx-PAD study, 449 GPs completed an educational intervention (96.6% of the included GPs), 250 in the intervention group and 199 in the control arm. Following the intervention, PIPs were reduced by 13% (95% CI 8.6-17.3), and the number of patients who were no longer exposed to one or more PIPs was reduced by 1173 (8.1%). The GPs who responded most strongly to the educational intervention were the oldest GPs (57-68 years), and these were the GPs with the highest prevalence of PIPs at baseline before the intervention.
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Affiliation(s)
- Sture Rognstad
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Mette Brekke
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jørund Straand
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Arne Fetveit
- General Practice Research Unit, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Rehabilitation Nurses' Knowledge, Attitudes, and Behaviors for Preventing Urinary Tract Infections From Intermittent Catheterization. Rehabil Nurs 2017; 44:171-180. [PMID: 29244034 DOI: 10.1097/rnj.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to develop and examine the reliability of a survey to assess knowledge, attitudes, and behaviors (KAB) of rehabilitation nurses for preventing urinary tract infections in persons requiring intermittent catheterization. DESIGN Cross-sectional survey with principal component analysis. METHODS Survey development and administration based on national guidelines. FINDINGS Principal component analysis produced three reliable components of KAB explaining 54.5% of response variance. Results indicate that nurses report adequate knowledge and training. Although the facility had an evidence-based online catheterization procedure, staff reported that the procedure was not helpful nor useable. Twenty-eight percent incorrectly identified the root cause of urinary tract infection, and 45% reported that other nurses always washed their hands. Barriers to using standard intermittent catheterization technique were staff, time, and patient variables. CONCLUSION The modified survey is a reliable measure of KAB. CLINICAL RELEVANCE The survey assists with identifying knowledge gaps, customizing education, and changing practice.
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Colquhoun HL, Squires JE, Kolehmainen N, Fraser C, Grimshaw JM. Methods for designing interventions to change healthcare professionals' behaviour: a systematic review. Implement Sci 2017; 12:30. [PMID: 28259168 PMCID: PMC5336662 DOI: 10.1186/s13012-017-0560-5] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 02/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic reviews consistently indicate that interventions to change healthcare professional (HCP) behaviour are haphazardly designed and poorly specified. Clarity about methods for designing and specifying interventions is needed. The objective of this review was to identify published methods for designing interventions to change HCP behaviour. METHODS A search of MEDLINE, Embase, and PsycINFO was conducted from 1996 to April 2015. Using inclusion/exclusion criteria, a broad screen of abstracts by one rater was followed by a strict screen of full text for all potentially relevant papers by three raters. An inductive approach was first applied to the included studies to identify commonalities and differences between the descriptions of methods across the papers. Based on this process and knowledge of related literatures, we developed a data extraction framework that included, e.g. level of change (e.g. individual versus organization); context of development; a brief description of the method; tasks included in the method (e.g. barrier identification, component selection, use of theory). RESULTS 3966 titles and abstracts and 64 full-text papers were screened to yield 15 papers included in the review, each outlining one design method. All of the papers reported methods developed within a specific context. Thirteen papers included barrier identification and 13 included linking barriers to intervention components; although not the same 13 papers. Thirteen papers targeted individual HCPs with only one paper targeting change across individual, organization, and system levels. The use of theory and user engagement were included in 13/15 and 13/15 papers, respectively. CONCLUSIONS There is an agreement across methods of four tasks that need to be completed when designing individual-level interventions: identifying barriers, selecting intervention components, using theory, and engaging end-users. Methods also consist of further additional tasks. Examples of methods for designing the organisation and system-level interventions were limited. Further analysis of design tasks could facilitate the development of detailed guidelines for designing interventions.
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Affiliation(s)
- Heather L Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, 160-500 University Ave, Toronto, Ontario, M5G 1V7, Canada.
| | - Janet E Squires
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Ottawa, Ontario, K1H 8L6, Canada.,School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Niina Kolehmainen
- Institute of Health and Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Health Sciences Building Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Ottawa, Ontario, K1H 8L6, Canada.,Department of Medicine, Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
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Munoz-Plaza CE, Parry C, Hahn EE, Tang T, Nguyen HQ, Gould MK, Kanter MH, Sharp AL. Integrating qualitative research methods into care improvement efforts within a learning health system: addressing antibiotic overuse. Health Res Policy Syst 2016; 14:63. [PMID: 27527079 PMCID: PMC4986245 DOI: 10.1186/s12961-016-0122-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 06/17/2016] [Indexed: 01/21/2023] Open
Abstract
Background Despite reports advocating for integration of research into healthcare delivery, scant literature exists describing how this can be accomplished. Examples highlighting application of qualitative research methods embedded into a healthcare system are particularly needed. This article describes the process and value of embedding qualitative research as the second phase of an explanatory, sequential, mixed methods study to improve antibiotic stewardship for acute sinusitis. Methods Purposive sampling of providers for in-depth interviews improved understanding of unwarranted antibiotic prescribing and elicited stakeholder recommendations for improvement. Qualitative data collection, transcription and constant comparative analyses occurred iteratively. Results Emerging themes and sub-themes identified primary drivers of unwarranted antibiotic prescribing patterns and recommendations for improving practice. These findings informed the design of a health system intervention to improve antibiotic stewardship for acute sinusitis. Core components of the intervention are also described. Conclusion Qualitative research can be effectively applied in learning healthcare systems to elucidate quantitative results and inform improvement efforts. Electronic supplementary material The online version of this article (doi:10.1186/s12961-016-0122-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corrine E Munoz-Plaza
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America.
| | - Carla Parry
- Patient Centered Outcomes Research Institute, Washington, DC, 20036, United States of America
| | - Erin E Hahn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America
| | - Tania Tang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America
| | - Huong Q Nguyen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America
| | - Michael K Gould
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America
| | - Michael H Kanter
- Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America
| | - Adam L Sharp
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, United States of America
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Thomas RE, Vaska M, Naugler C, Chowdhury TT. Interventions to Educate Family Physicians to Change Test Ordering: Systematic Review of Randomized Controlled Trials. Acad Pathol 2016; 3:2374289516633476. [PMID: 28725760 PMCID: PMC5497906 DOI: 10.1177/2374289516633476] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 11/16/2022] Open
Abstract
The purpose is to systematically review randomised controlled trials (RCTs) to change family physicians’ laboratory test-ordering. We searched 15 electronic databases (no language/date limitations). We identified 29 RCTs (4,111 physicians, 175,563 patients). Six studies specifically focused on reducing unnecessary tests, 23 on increasing screening tests. Using Cochrane methodology 48.5% of studies were low risk-of-bias for randomisation, 7% concealment of randomisation, 17% blinding of participants/personnel, 21% blinding outcome assessors, 27.5% attrition, 93% selective reporting. Only six studies were low risk for both randomisation and attrition. Twelve studies performed a power computation, three an intention-to-treat analysis and 13 statistically controlled clustering. Unweighted averages were computed to compare intervention/control groups for tests assessed by >5 studies. The results were that fourteen studies assessed lipids (average 10% more tests than control), 14 diabetes (average 8% > control), 5 cervical smears, 2 INR, one each thyroid, fecal occult-blood, cotinine, throat-swabs, testing after prescribing, and urine-cultures. Six studies aimed to decrease test groups (average decrease 18%), and two to increase test groups. Intervention strategies: one study used education (no change): two feedback (one 5% increase, one 27% desired decrease); eight education + feedback (average increase in desired direction >control 4.9%), ten system change (average increase 14.9%), one system change + feedback (increases 5-44%), three education + system change (average increase 6%), three education + system change + feedback (average 7.7% increase), one delayed testing. The conclusions are that only six RCTs were assessed at low risk of bias from both randomisation and attrition. Nevertheless, despite methodological shortcomings studies that found large changes (e.g. >20%) probably obtained real change.
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Affiliation(s)
- Roger Edmund Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcus Vaska
- Knowledge Resource Service, Holy Cross Centre, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.,Departments of Pathology & Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanvir Turin Chowdhury
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Spoorenberg V, Hulscher MEJL, Geskus RB, de Reijke TM, Opmeer BC, Prins JM, Geerlings SE. A Cluster-Randomized Trial of Two Strategies to Improve Antibiotic Use for Patients with a Complicated Urinary Tract Infection. PLoS One 2015; 10:e0142672. [PMID: 26637169 PMCID: PMC4670093 DOI: 10.1371/journal.pone.0142672] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 10/25/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Up to 50% of hospital antibiotic use is inappropriate and therefore improvement strategies are urgently needed. We compared the effectiveness of two strategies to improve the quality of antibiotic use in patients with a complicated urinary tract infection (UTI). METHODS In a multicentre, cluster-randomized trial 19 Dutch hospitals (departments Internal Medicine and Urology) were allocated to either a multi-faceted strategy including feedback, educational sessions, reminders and additional/optional improvement actions, or a competitive feedback strategy, i.e. providing professionals with non-anonymous comparative feedback on the department's appropriateness of antibiotic use. Retrospective baseline- and post-intervention measurements were performed in 2009 and 2012 in 50 patients per department, resulting in 1,964 and 2,027 patients respectively. Principal outcome measures were nine validated guideline-based quality indicators (QIs) that define appropriate antibiotic use in patients with a complicated UTI, and a QI sumscore that summarizes for each patient the appropriateness of antibiotic use. RESULTS Performance scores on several individual QIs showed improvement from baseline to post-intervention measurements, but no significant differences were found between both strategies. The mean patient's QI sum score improved significantly in both strategy groups (multi-faceted: 61.7% to 65.0%, P = 0.04 and competitive feedback: 62.8% to 66.7%, P = 0.01). Compliance with the strategies was suboptimal, but better compliance was associated with more improvement. CONCLUSION The effectiveness of both strategies was comparable and better compliance with the strategies was associated with more improvement. To increase effectiveness, improvement activities should be rigorously applied, preferably by a locally initiated multidisciplinary team. TRIAL REGISTRATION Nederlands Trial Register 1742.
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Affiliation(s)
- Veroniek Spoorenberg
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
- * E-mail: (VS); (SG)
| | - Marlies E. J. L. Hulscher
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Ronald B. Geskus
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Theo M. de Reijke
- Department of Urology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Brent C. Opmeer
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan M. Prins
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - Suzanne E. Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
- * E-mail: (VS); (SG)
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Baker R, Camosso‐Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki‐Cwirko M, van Lieshout J, Jäger C. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev 2015; 2015:CD005470. [PMID: 25923419 PMCID: PMC7271646 DOI: 10.1002/14651858.cd005470.pub3] [Citation(s) in RCA: 307] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants. OBJECTIVES To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants. SEARCH METHODS We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals. SELECTION CRITERIA Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified. MAIN RESULTS We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression. AUTHORS' CONCLUSIONS Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.
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Affiliation(s)
- Richard Baker
- University of LeicesterDepartment of Health Sciences22‐28 Princess Rd WestLeicesterLeicestershireUKLE1 6TP
| | | | - Clare Gillies
- University of LeicesterUniversity Division of Medicine for the ElderlyThe Glenfield HospitalGroby RoadLeicesterUKLE5 4PW
| | - Elizabeth J Shaw
- National Institute for Health and Care Excellence (NICE)Level 1A, City PlazaPiccadilly PlazaManchesterUKM1 4BD
| | - Francine Cheater
- School of Health Sciences, University of East AngliaEdith Cavell BuildingNorwichNorfolkUK
| | - Signe Flottorp
- Norwegian Knowledge Centre for the Health ServicesBox 7004, St. Olavs plassOsloNorway0130
| | - Noelle Robertson
- Leicester UniversitySchool of Psychology (Clinical Section)104 Regent RoadLeicesterLeicestershireUKLE1 7LT
| | - Michel Wensing
- Radboud University Medical CenterRadboud Institute for Health SciencesPO Box 9101117 KWAZONijmegenNetherlands6500 HB
| | | | - Martin P Eccles
- Newcastle UniversityInstitute of Health and SocietyBadiley Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Maciek Godycki‐Cwirko
- Medical University of LodzCentre for Family and Community MedicineKopcindkiego 20LodzPoland90‐153
| | - Jan van Lieshout
- Radboud University Medical CenterScientific Institute for Quality of HealthcareP.O.Box 9101NijmegenNetherlands6500 HB
| | - Cornelia Jäger
- University Hospital of HeidelbergDepartment of General Practice and Health Services ResearchVoßstr. 2, Geb. 37HeidelbergGermany69115
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Bernhardsson S, Larsson MEH, Eggertsen R, Olsén MF, Johansson K, Nilsen P, Nordeman L, van Tulder M, Öberg B. Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial. BMC Health Serv Res 2014; 14:105. [PMID: 24589291 PMCID: PMC3975873 DOI: 10.1186/1472-6963-14-105] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 02/21/2014] [Indexed: 12/21/2022] Open
Abstract
Background Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden. Methods An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test. Results 168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes. Conclusions A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.
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11
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Lauvergeon S, Burnand B, Peytremann-Bridevaux I. [Implementation of a diabetes disease management program in Switzerland: patients' and healthcare professionals' point of view]. Rev Epidemiol Sante Publique 2013; 61:475-84. [PMID: 24035386 DOI: 10.1016/j.respe.2013.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 09/18/2012] [Accepted: 05/10/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND A reorganization of healthcare systems is required to meet the challenge of the increasing prevalence of chronic diseases, e.g. diabetes. In North-America and Europe, several countries have thus developed national or regional chronic disease management programs. In Switzerland, such initiatives have only emerged recently. In 2010, the canton of Vaud set up the "Diabetes Cantonal Program", within the framework of which we conducted a study designed to ascertain the opinions of both diabetic patients and healthcare professionals on the elements that could be integrated into this program, the barriers and facilitators to its development, and the incentives that could motivate these actors to participate. METHODS We organized eight focus-groups: one with diabetic patients and one with healthcare professionals in the four sanitary areas of the canton of Vaud. The discussions were recorded, transcribed and submitted to a thematic content analysis. RESULTS Patients and healthcare professionals were rather in favour of the implementation of a cantonal program, although patients were more cautious concerning its necessity. All participants envisioned a set of elements that could be integrated to this program. They also considered that the program could be developed more easily if it were adapted to patients' and professionals' needs and if it used existing structures and professionals. The difficulty to motivate both patients and professionals to participate was mentioned as a barrier to the development of this program however. Quality or financial incentives could therefore be created to overcome this potential problem. CONCLUSION The identification of the elements to consider, barriers, facilitators and incentives to participate to a chronic disease management program, obtained by exploring the opinions of patients and healthcare professionals, should favour its further development and implementation.
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Affiliation(s)
- S Lauvergeon
- Institut universitaire de médecine sociale et préventive (IUMSP), centre hospitalier universitaire Vaudois et université de Lausanne, Biopôle 2, route de la Corniche 10, 1010 Lausanne, Suisse
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12
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Santi SM, Hinton S, Berg K, Stolee P. Bridging the information divide: health information sharing in home care. Can J Nurs Res 2013; 45:16-35. [PMID: 23789525 DOI: 10.1177/084456211304500104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
As in many health sectors, in home care there have been significant investments made in electronic health information systems (EHIS) and accompanying standardized assessment instruments. While the potential of these systems to enhance the quality of care has been recognized, it has yet to be fully realized in Canadian home care settings. Data on EHIS barriers and facilitators were collected using a survey (n = 22).The results were discussed at a workshop (n = 30) and a "world café" session was held to consider strategies and interventions for improving health information exchange, with a focus on home care rehabilitation.
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Affiliation(s)
- Selena M Santi
- InfoRehab, School of Public Health and Health Systems, University of Waterloo, Ontario, Canada
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13
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Chou CC, Lin WS, Kao TW, Chang YW, Chen WL. Adherence to Available Clinical Practice Guidelines for Initiation of Antihypertensive Medication in Patients With or Without Diabetes Mellitus and Other Comorbidities in Taiwan. J Clin Pharmacol 2013; 52:576-85. [DOI: 10.1177/0091270011398658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pavese P, Coulouma M, Sellier E, Stahl JP, Wintenberger C, François P. CD-ROM continuous medical education model for the management of urinary tract infections in family practice. Med Mal Infect 2012; 42:321-6. [PMID: 22789777 DOI: 10.1016/j.medmal.2012.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/20/2012] [Accepted: 05/29/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations. METHODS We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included. RESULTS All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P=0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required. CONCLUSION FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.
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Affiliation(s)
- P Pavese
- Service des maladies infectieuses, CHU, BP 217, 38043 Grenoble, France
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15
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Pulcini C, Pauvif L, Paraponaris A, Verger P, Ventelou B. Perceptions and attitudes of French general practitioners towards rapid antigen diagnostic tests in acute pharyngitis using a randomized case vignette study. J Antimicrob Chemother 2012; 67:1540-6. [PMID: 22398648 DOI: 10.1093/jac/dks073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES This study had three objectives: (i) to assess the use of rapid antigen diagnostic tests (RADTs) and their impact on the antibiotic prescribing behaviour of general practitioners (GPs) for acute pharyngitis; (ii) to study the barriers to the use of RADTs; and (iii) to identify GPs' characteristics associated with non-compliance with French guidelines. METHODS We conducted a cross-sectional survey of a representative sample of 369 self-employed GPs in south-eastern France using a randomized case vignette study. RESULTS The availability of an RADT allowed a 44% relative reduction in the rate of antibiotic prescriptions. Of GPs for whom the test was available, 34% did not use an RADT in our acute pharyngitis vignette and 13% of those who used the test prescribed an antibiotic despite a negative RADT result. Non-compliance with French guidelines (i.e. not using an RADT and/or prescribing an antibiotic despite a negative RADT result) was independently associated with the following factors: less reading of medical journals, less benefits/risks discussion with patients about vaccinations and higher perception that clinical examination was sufficient to prescribe antibiotics. The three main declared barriers to RADT use were: time to perform the test, patient expectations regarding antibiotics and the perception that clinical examination was sufficient to decide to prescribe an antibiotic. CONCLUSIONS RADTs are a useful but not sufficient tool to reduce antibiotic prescribing in general practice. The results of this study increase understanding of the factors underlying clinical decision making for acute pharyngitis and may contribute to the development of interventions to improve practice.
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Affiliation(s)
- Céline Pulcini
- Centre Hospitalier Universitaire de Nice, Service d'Infectiologie, Nice, France.
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16
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Hoff G. Quality assurance in gastroenterology: QA in research, and research in QA. Best Pract Res Clin Gastroenterol 2011; 25:427-34. [PMID: 21764010 DOI: 10.1016/j.bpg.2011.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 05/16/2011] [Indexed: 01/31/2023]
Abstract
There is no clear distinction between research and quality assurance (QA). Both entities should be of high quality to serve as trustworthy tools for continuous evidence-based improvements in health care. Both research and QA should be of interest to an audience of readers of medical science - provided that the work is up to standards. Quality in research encompasses issues actually dealt with (are we putting our resources into the right things), validity (are the findings valid for other than the patients tested), ethics (why should patients consent to studies that have no prospect of giving an answer to the questions put in the research protocol) - in addition to quality of design and presentation. Likewise, QA work could gain much on a stronger focus on research methods - as suggested in the upcoming Competetitive Effectiveness Research. In conclusion, quality in research and research in QA should be asked and requested more often.
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Ridge AL, Bero LA, Hill SR. Identifying barriers to the availability and use of Magnesium Sulphate Injection in resource poor countries: a case study in Zambia. BMC Health Serv Res 2010; 10:340. [PMID: 21162717 PMCID: PMC3018452 DOI: 10.1186/1472-6963-10-340] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 12/16/2010] [Indexed: 11/09/2022] Open
Abstract
Background Pre-eclampsia and eclampsia are serious complications of pregnancy and major causes of maternal mortality and morbidity worldwide. According to systematic reviews and WHO guidelines magnesium sulphate injection (MgSO4) should be the first -line treatment for severe pre-eclampsia and eclampsia. Studies have shown that this safe and effective medicine is unavailable and underutilized in many resource poor countries. The objective of this study was to identify barriers to the availability and use of MgSO4 in the Zambian Public Health System. Methods A 'fishbone' (Ishikawa) diagram listing probable facilitators to the availability and use of MgSO4 identified from the literature was used to develop an assessment tool. Barriers to availability and use of MgSO4 were assessed at the regulatory/government, supply, procurement, distribution, health facility and health professional levels. The assessment was completed during August 2008 using archival data, and observations at a pragmatic sample of health facilities providing obstetric services in Lusaka District, Zambia. Results The major barrier to the availability of MgSO4 within the public health system in Zambia was lack of procurement by the Ministry of Health. Other barriers identified included a lack of demand by health professionals at the health centre level and a lack of in-service training in the use of MgSO4. Where there was demand by obstetricians, magnesium sulphate injection was being procured from the private sector by the hospital pharmacy despite not being registered and licensed for use for the treatment of severe pre-eclampsia and eclampsia by the national Pharmaceutical Regulatory Authority. Conclusions The case study in Zambia highlights the complexities that underlie making essential medicines available and used appropriately. The fishbone diagram is a useful theoretical framework for illustrating the complexity of translating research findings into clinical practice. A better understanding of the supply system and of the pattern of demand for MgSO4 in Zambia should enable policy makers and stakeholders to develop and implement appropriate interventions to improve the availability and use of MgSO4.
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Affiliation(s)
- Anna L Ridge
- Medicine Access and Rational Use, Department of Essential Medicines and Pharmaceutical Policies, World Health Organization, Geneva, Switzerland.
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18
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Carlfjord S, Lindberg M, Bendtsen P, Nilsen P, Andersson A. Key factors influencing adoption of an innovation in primary health care: a qualitative study based on implementation theory. BMC FAMILY PRACTICE 2010; 11:60. [PMID: 20731817 PMCID: PMC2933616 DOI: 10.1186/1471-2296-11-60] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 08/23/2010] [Indexed: 11/24/2022]
Abstract
Background Bridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden. Methods A qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption. Results The theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process. Conclusion When implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration.
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Affiliation(s)
- Siw Carlfjord
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Stolee P, Steeves B, Manderson BL, Toscan JL, Glenny C, Berg K. Health Information Use in Home Care: Brainstorming Barriers, Facilitators, and Recommendations. Home Health Care Serv Q 2010; 29:37-53. [DOI: 10.1080/01621424.2010.487040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010:CD005470. [PMID: 20238340 PMCID: PMC4164371 DOI: 10.1002/14651858.cd005470.pub2] [Citation(s) in RCA: 440] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain. OBJECTIVES To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes. SEARCH STRATEGY For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints. MAIN RESULTS We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions. AUTHORS' CONCLUSIONS Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.
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Affiliation(s)
- Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Clare Gillies
- University Division of Medicine for the Elderly, University of Leicester, Leicester, UK
| | - Elizabeth J Shaw
- National Institute for Health and Clinical Excellence, Manchester, UK
| | - Francine Cheater
- Institute of Health and Wellbeing, Glasgow Caledonian University, Glasgow, UK
| | - Signe Flottorp
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Noelle Robertson
- School of Psychology (Clinical Section), Leicester University, Leicester, UK
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Hinchey JA, Shephard T, Tonn ST, Ruthazer R, Hermann RC, Selker HP, Kent DM. The Stroke Practice Improvement Network: a quasiexperimental trial of a multifaceted intervention to improve quality. J Stroke Cerebrovasc Dis 2010; 19:130-7. [PMID: 20189089 PMCID: PMC3307384 DOI: 10.1016/j.jstrokecerebrovasdis.2009.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 03/24/2009] [Accepted: 03/26/2009] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The aim of this project was to determine whether a tailored multifaceted intervention aimed at site-specific barriers is more effective than audit feedback alone for improving adherence to inhospital stroke performance measures (PMs): door to needle time of less than 1 hour for tissue plasminogen activator, dysphagia screening, deep venous thrombosis prophylaxis, and warfarin treatment for atrial fibrillation. METHODS Hospitals were paired on baseline adherence to dysphagia screening and quality improvement infrastructure and randomized to receive audit feedback alone (n=7) versus audit feedback plus site-specific interventions (n=6). Data were collected on all admitted patients with stroke seen in the neurology department before and after a 6-month implementation period. The primary end point was the difference in postintervention adherence rates for each PM, except tissue plasminogen activator because of low sample size. RESULTS Data were collected on 2071 preintervention patients and 1240 postintervention patients. Targeted site-specific interventions, such as standing orders and standardized dysphagia screens, were imperfectly implemented during the 6-month intervention period. For atrial fibrillation, the intervention group had an 11% higher postintervention adherence rate beyond that of the control group (98% v 87%, P < .005). No other statistically significant changes in PM adherence were observed. CONCLUSION Implementation of site-specific interventions for quality improvement of specific measures in stroke was difficult to achieve in a 6-month time frame and led to improved adherence for only one of 3 PMs. Studies with a longer intervention period and more sites are required to determine whether tailored interventions can enhance stroke improvement.
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Affiliation(s)
- Judith A Hinchey
- Institute of Clinical Care Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts 02135, USA.
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Donahue PK, Robinson KA. Advancing evidence in preterm neonatal medicine. DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 2010; 16:289-295. [PMID: 25708071 DOI: 10.1002/ddrr.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 06/23/2011] [Indexed: 06/04/2023]
Abstract
Few interventions and treatments for premature infants have undergone the rigors of a randomized controlled trial (RCT), the cornerstone of evidence-based healthcare. Multiple barriers in establishing a quality evidence base for the care of preterm infants are examined including the systematic exclusion of children from drug trials, vulnerability of the infants, burden to families of the consent process for RCTs, and the lack of standard measurements and subgroup definitions that impede systematic reviews. Delays in getting evidence into practice are highlighted, including clinician knowledge of existing evidence, attitudes about the evidence, and behavior. Landmark trials are used as examples. Finally, a call for the research community to develop guidance on good clinical research practice for preterm infants is offered that will allow the synthesis of the totality of evidence.
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Affiliation(s)
- Pamela K Donahue
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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Carling CLL, Kristoffersen DT, Flottorp S, Fretheim A, Oxman AD, Schünemann HJ, Akl EA, Herrin J, MacKenzie TD, Montori VM. The effect of alternative graphical displays used to present the benefits of antibiotics for sore throat on decisions about whether to seek treatment: a randomized trial. PLoS Med 2009; 6:e1000140. [PMID: 19707579 PMCID: PMC2726763 DOI: 10.1371/journal.pmed.1000140] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 07/17/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We conducted an Internet-based randomized trial comparing four graphical displays of the benefits of antibiotics for people with sore throat who must decide whether to go to the doctor to seek treatment. Our objective was to determine which display resulted in choices most consistent with participants' values. METHODS AND FINDINGS This was the first of a series of televised trials undertaken in cooperation with the Norwegian Broadcasting Company. We recruited adult volunteers in Norway through a nationally televised weekly health program. Participants went to our Web site and rated the relative importance of the consequences of treatment using visual analogue scales (VAS). They viewed the graphical display (or no information) to which they were randomized and were asked to decide whether to go to the doctor for an antibiotic prescription. We compared four presentations: face icons (happy/sad) or a bar graph showing the proportion of people with symptoms on day three with and without treatment, a bar graph of the average duration of symptoms, and a bar graph of proportion with symptoms on both days three and seven. Before completing the study, all participants were shown all the displays and detailed patient information about the treatment of sore throat and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS scores for the undesirable consequences of antibiotics from the VAS score for the benefit of symptom relief. We used logistic regression to determine the association between participants' RIS and their choice. 1,760 participants completed the study. There were statistically significant differences in the likelihood of choosing to go to the doctor in relation to different values (RIS). Of the four presentations, the bar graph of duration of symptoms resulted in decisions that were most consistent with the more fully informed second decision. Most participants also preferred this presentation (38%) and found it easiest to understand (37%). Participants shown the other three presentations were more likely to decide to go to the doctor based on their first decision than everyone based on the second decision. Participants preferred the graph using faces the least (14.4%). CONCLUSIONS For decisions about going to the doctor to get antibiotics for sore throat, treatment effects presented by a bar graph showing the duration of symptoms helped people make decisions more consistent with their values than treatment effects presented as graphical displays of proportions of people with sore throat following treatment. CLINICAL TRIALS REGISTRATION ISRCTN58507086.
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Vedel I, De Stampa M, Bergman H, Ankri J, Cassou B, Blanchard F, Lapointe L. Healthcare professionals and managers' participation in developing an intervention: a pre-intervention study in the elderly care context. Implement Sci 2009; 4:21. [PMID: 19383132 PMCID: PMC2678079 DOI: 10.1186/1748-5908-4-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 04/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In order to increase the chances of success in new interventions in healthcare, it is generally recommended to tailor the intervention to the target setting and the target professionals. Nonetheless, pre-intervention studies are rarely conducted or are very limited in scope. Moreover, little is known about how to integrate the results of a pre-intervention study into an intervention. As part of a project to develop an intervention aimed at improving care for the elderly in France, a pre-intervention study was conducted to systematically gather data on the current practices, issues, and expectations of healthcare professionals and managers in order to determine the defining features of a successful intervention. METHODS A qualitative study was carried out from 2004 to 2006 using a grounded theory approach and involving a purposeful sample of 56 healthcare professionals and managers in Paris, France. Four sources of evidence were used: interviews, focus groups, observation, and documentation. RESULTS The stepwise approach comprised three phases, and each provided specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and expectations of healthcare professionals and managers. The second step involved holding focus groups in order to define the characteristics of a tailor-made intervention. The third step allowed validation of the findings. Using this approach, we were able to design and develop an intervention in elderly care that met the professionals' and managers' expectations. CONCLUSION This article reports on an in-depth pre-intervention study that led to the design and development of an intervention in partnership with local healthcare professionals and managers. The stepwise approach represents an innovative strategy for developing tailored interventions, particularly in complex domains such as chronic care. It highlights the usefulness of seeking out the insight of healthcare professionalnd managers and emphasizes the need to intervene at different levels. Further research will be needed in order to develop a more thorough understanding of the impacts of such strategies on the final outcomes of intervention implementations.
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Affiliation(s)
- Isabelle Vedel
- Université de Versailles St-Quentin, Laboratoire Santé Vieillissement, AP-HP, Hôpital Sainte Perine, 49 rue Mirabeau 75016 Paris, France.
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van Eijken M, Melis R, Wensing M, Rikkert MO, van Achterberg T. Feasibility of a new community-based geriatric intervention programme: an exploration of experiences of GPs, nurses, geriatricians, patients and caregivers. Disabil Rehabil 2008; 30:696-708. [PMID: 17852321 DOI: 10.1080/09638280701400508] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To determine the feasibility of the Dutch Geriatric Intervention Programme (DGIP) in primary care. Within the DGIP, a nurse cooperates with a General Practitioner (GP) and a clinical geriatrician to assess and manage care for community-living older patients. The aim of this study was to describe both views of care receivers and those of professionals in order to identify facilitating factors and barriers for implementation of the DGIP. METHOD Combined quantitative and qualitative data collection methods were used. Pre- and post-questionnaires were taken from GPs (n= 15), nurses (n = 6) and geriatricians (n = 2). These professionals were also interviewed. In addition patients (n = 11 out of total n = 54) and their carers (n = 37) were interviewed. RESULTS GPs appreciated the support by the DGIP for problems in cognition, mood and mobility. Lack of knowledge and time restriction was the cause of their incapability at that point. In the cooperation between professionals, nurses felt that they had to initiate the contact. Personal contact helped the mutual communication. Involving the carer of the patient proved very important. All disciplines found this of crucial importance in order to deliver a tailored intervention and create conditions for optimal care. Barriers, for which the programme was tailored during the implementation, were: resistance in referrals of patients to the programme, nurses' and GPs' knowledge of diagnostic tests, communication problems and insufficient involvement of caregivers. CONCLUSIONS The implementation of the DGIP was feasible, but several barriers need ongoing attention by implementation, like communication between disciplines.
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Affiliation(s)
- Monique van Eijken
- Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Wagg A, Cardozo L, Chapple C, Diaz DC, de Ridder D, Espuna-Pons M, Haab F, Kelleher C, Kolbl H, Milsom I, Van Kerrebroeck P, Vierhout M, Kirby M. Overactive Bladder and Continence Guidelines: implementation, inaction or frustration? Int J Clin Pract 2008; 62:1588-93. [PMID: 18822029 DOI: 10.1111/j.1742-1241.2008.01870.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Guidelines for the management of continence and overactive bladder are generally available across Europe. For a majority of countries, these have been adopted by professional societies in either urology or gynaecology for local use. There has, however, been little monitoring of formal implementation of these guidelines and seldom any attempt to audit their operation. The state of continence care therefore remains largely unknown. This article reviews current guidelines and their status across Europe and examines what might be relevant from other disease areas to promote successful implementation.
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Affiliation(s)
- A Wagg
- Department of Geriatric Medicine, University College Hospital, London, UK.
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Kirsh SR, Lawrence RH, Aron DC. Tailoring an intervention to the context and system redesign related to the intervention: a case study of implementing shared medical appointments for diabetes. Implement Sci 2008; 3:34. [PMID: 18533021 PMCID: PMC2442606 DOI: 10.1186/1748-5908-3-34] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 06/04/2008] [Indexed: 11/24/2022] Open
Abstract
Background Incorporating shared medical appointments (SMAs) or group visits into clinical practice to improve care and increase efficiency has become a popular intervention, but the processes to implement and sustain them have not been well described. The purpose of this study was to describe the process of implementation of SMAs in the local context of a primary care clinic over time. Methods The setting was a primary care clinic of an urban academic medical center of the Veterans Health Administration. We performed an in-depth case analysis utilizing both an innovations framework and a nested systems framework approach. This analysis helped organize and summarize implementation and sustainability issues, specifically: the pre-SMA local context; the processes of tailoring and implementation of the intervention; and the evolution and sustainability of the intervention and its context. Results Both the improvement intervention and the local context co-adapted and evolved during implementation, ensuring sustainability. The most important promoting factors were the formation of a core team committed to quality and improvement, and the clinic leadership that was supported strongly by the team members. Tailoring had to also take into account key innovation-hindering factors, including limited resources (such as space), potential to alter longstanding patient-provider relationships, and organizational silos (disconnected groups) with core team members reporting to different supervisors. Conclusion Although interventions must be designed to meet the needs of the sites in which they are implemented, specific guidance tailored to the practice environment was lacking. SMAs require complex changes that impact on care routines, collaborations, and various organizational levels. Although the SMA was not envisioned originally as a form of system redesign that would alter the context in which it was implemented, it became clear that tailoring the intervention alone would not ensure sustainability, and therefore adjustments to the system were required. The innovation necessitated reconfiguring some aspects of the primary care clinic itself and other services from which the patients and the team were derived. In addition, the relationships among different parts of the system were altered.
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Affiliation(s)
- Susan R Kirsh
- Center for Quality Improvement Research, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA.
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van Bokhoven MA, Koch H, Dinant GJ, Bindels PJ, Grol RP, van der Weijden T. Exploring the black box of change in improving test-ordering routines. Fam Pract 2008; 25:139-45. [PMID: 18535302 DOI: 10.1093/fampra/cmn022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effects of quality improvement strategies are sometimes limited in spite of a systematic development approach. What elements play a role in the change process is not yet fully understood. OBJECTIVE To explore this 'black box' of change, by analysing the barriers and facilitators GPs perceive during the change process. METHODS Qualitative study among GPs who participated in the quality improvement strategy arm of a randomized clinical trial on blood test ordering for unexplained complaints (UCs). The strategy was based on a national guideline that advocates delayed test ordering in patients presenting with UCs. Each GP's change process was assessed by means of a semi-structured interview about barriers to and facilitators of change. RESULTS Twenty-four interviews were analysed. Important themes identified in the interviews were lack of problem awareness, the time and effort it takes to change, influence of patients and the pros and cons of the changed behaviour. CONCLUSION The themes can be summarized into one comprehensive issue: the GPs lack a sense of urgency to change. An important explanation seems to be that two questions from the problem analysis prior to the development of the strategy had not been adequately answered: "Is the GPs' current behaviour a problem and does the problem have consequences for patients?" and if so, "What is the extent of the problem?." As a result, insufficient attention was given to applicability issues, such as time investment, costs and patient and practitioner satisfaction and anxiety.
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Affiliation(s)
- Marloes A van Bokhoven
- Department of General Practice/Centre for Quality of Care Research (WOK), Care and Public Health Research Institute, Maastricht University, PO Box 616, NL-6200 MD, Maastricht.
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Cortoos PJ, De Witte K, Peetermans WE, Simoens S, Laekeman G. Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. J Antimicrob Chemother 2008; 62:189-95. [PMID: 18397925 DOI: 10.1093/jac/dkn143] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES The aim of this study was to determine the opinions and problems concerning the use of a local antibiotic hospital guideline in a 1900-bed tertiary-care, university teaching hospital. METHODS A qualitative study using focus group discussions explored the usability and applicability of local antibiotic guidelines together with possible supportive measures. The sample included 22 physicians, deliberately divided between internal medicine (59.1%) and surgery (40.9%), and levels of experience (59.1% residents; 40.9% supervisors). Focus groups were conducted within one specific subgroup. Analysis was carried out using a framework analysis approach. RESULTS General acceptance of local guidelines was high but clear differences were present between subgroups with different desires and requirements from guideline contents. Opposing views were present towards supportive measures, especially multidisciplinary collaboration. Guideline distribution and accessibility appeared to be confusing, resulting in delayed application. An important supplementary barrier was the need to collect the guideline personally. Supervisors in their role as opinion leaders were mentioned as highly influential towards residents' practice. CONCLUSIONS Locally developed hospital guidelines experience the same barriers as other guidelines. Within one hospital, prescribers have to be seen as a number of different target groups instead of a homogeneous population. For an optimal effect, interventions will have to consider these differences. Also, in order to improve local guideline use and antibiotic consumption, supervisors have to be aware of how their role as opinion leaders can influence residents. Lastly, active guideline distribution and promotion remains critical to ensure efficient guideline use. Future research should focus on how to adapt interventions to these different target groups.
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Affiliation(s)
- Pieter-Jan Cortoos
- Research Centre for Pharmaceutical Care and Pharmaco-Economics, Katholieke Universiteit Leuven, O&N 2, Herestraat 49, PB 521, B-3000 Leuven, Belgium.
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Van Duppen D, Aertgeerts B, Hannes K, Neirinckx J, Seuntjens L, Goossens F, Van Linden A. Online on-the-spot searching increases use of evidence during consultations in family practice. PATIENT EDUCATION AND COUNSELING 2007; 68:61-5. [PMID: 17540531 DOI: 10.1016/j.pec.2007.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Revised: 04/12/2007] [Accepted: 04/16/2007] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The project aimed to search for online evidence in a structured way in consultation with the patient, to investigate whether the evidence discovered changed decisions. METHODS We developed the "Online on-the-spot" method (OOS) as a part of a quality improvement program. Within a general practice consultation three physicians and two trainees searched in a fixed pattern and sequence the national guidelines of general practitioners developed by the Dutch College of General Practitioners, Clinical Evidence, Trip-database and the British Medical Journal. All GPs who performed this quality improvement program were in favor of the project. RESULTS During 3 months five GPs registered 365 searches out of 2920 patient-doctor contacts. For each eight patient-doctor contacts there was one online search. Patients were actively involved in 53% of the searches (95%C.I.: 48-57%). On average, two databases were consulted. An answer to the question was found in 87% of cases and in almost half of cases it was relevant new information for the doctor. The GP changed his decision due to the problem in 26% (95%C.I.: 21-29) of cases. At the end of the OOS project, the number of searches within 5 min were significantly higher than at the start: 51% (95% C.I.: 44-59) to 33% (95% C.I.: 24-43), respectively. CONCLUSIONS The OOS project is a timely answer to the doctors' educational needs in attending to the patient. PRACTICE IMPLICATIONS OOS could connect the patient, the doctor and the evidence.
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Kabir Z, Feely J, Bennett K. Primary care prescribing patterns in Ireland after the publication of large hypertension trials. Br J Clin Pharmacol 2007; 64:381-5. [PMID: 17610535 PMCID: PMC2000662 DOI: 10.1111/j.1365-2125.2007.02896.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS This study assessed prescribing patterns of antihypertensive therapies (AHT) before and after the publication of the LIFE, ALLHAT and VALUE trials between 2000 and 2005. METHODS The Irish HSE-PCRS prescribing database was used to identify those initiated any AHT. Any change 12 months before and after the trial publications was examined using a segmented regression analysis. RESULTS There was little or no effect of any of the trials on new AHT prescribing, except for ALLHAT where there was an increase in new prescriptions for ACE inhibitors, and VALUE with a slight increase in prescriptions for calcium channel blockers. CONCLUSIONS Our findings show that there was little or no effect of any of the three clinical trials studied on new AHT prescribing patterns in Irish general practice. Future studies should assess any underlying barriers to implementing new evidence into clinical practice.
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Affiliation(s)
- Zubair Kabir
- Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St James's Hospital and Trinity College Dublin, Dublin 8, Ireland
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Bosch M, van der Weijden T, Wensing M, Grol R. Tailoring quality improvement interventions to identified barriers: a multiple case analysis. J Eval Clin Pract 2007; 13:161-8. [PMID: 17378860 DOI: 10.1111/j.1365-2753.2006.00660.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The prevailing view on implementation interventions to improve the organization and management of health care is that the interventions should be tailored to potential barriers. Ideally, possible barriers are analysed before the quality improvement interventions are developed to influence both type and content of the implementation intervention. While tailoring educational improvement interventions generally requires the assessment of professional knowledge and skills, less is known about methods to tailor organizational interventions. In the present study, the results of previous studies on the development of educational and organizational interventions to improve the quality of health care are examined. METHOD Qualitative analyses were conducted on a purposeful sample of 20 quality improvement studies reporting barrier analyses and covering both educational and organizational interventions. RESULTS Several methods were used to identify barriers, including focus group discussions, face-to-face interviews and telephone interviews. Attention to barriers prior to the development of the intervention did not always mean that the choice of a specific type of intervention was based on such, although identified barriers were often used to adjust the specific content of the intervention. A few methods to link improvement interventions to identified barriers were described, including theory-based reasoning and iterative design processes. Results suggest there is often a mismatch between the level of identified barriers and the type of interventions selected for use. No differences in the tailoring of educational or organizational interventions could be identified. CONCLUSIONS The design of quality improvement interventions appears to still be in its infancy. The translation of identified barriers into tailor-made implementation interventions is still a black box for both educational and organizational interventions.
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Affiliation(s)
- Marije Bosch
- Centre for Quality of Care Research, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Harris M, Smith BJ, Veale A, Esterman A, Frith PA, Selim P. Providing patients with reviews of evidence about COPD treatments: a controlled trial of outcomes. Chron Respir Dis 2006; 3:133-40. [PMID: 16916007 DOI: 10.1191/1479972306cd112oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Studies in many countries have identified gaps between what is known from research evidence and what is done in clinical practice. Merely making research evidence available to practitioners does not cause much change in their behaviour, and researchers are now looking for more effective ways to improve the implementation of evidence. We report outcomes at three months of a parallel group trial of an evidence based patient manual designed to improve implementation of evidence by the patient's doctors. The patient manual was produced with extensive patient and professional input. It contained summaries of the evidence for treatments used in COPD (chronic obstructive pulmonary disease) and prompted discussion of evidence with doctors. Participants in the intervention arm of the trial (n = 125) were supplied with the manual and participants in the control arm (n = 124) were supplied with a pamphlet about COPD produced by the Australian Lung Foundation. The primary outcome measure (rates of current influenza vaccination and bone density testing) was an indicator of evidence based management of COPD. Secondary outcomes were quality of life (mastery component), satisfaction with information, communication with usual doctor, and anxiety. At three months no pattern of benefit in outcome measures was found for either group. Process measures showed high levels of personal use of the manual but progression to conversations with doctors for fewer than half of participants, and little treatment change. The findings highlight the difficulties of promoting changes in health behaviour and show that even when all stakeholders are consulted success is not guaranteed. Further research is required to identify those patients most likely to use manuals such as the one reported here, and how to make patient mediated interventions more effective for a greater proportion of the target population.
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Affiliation(s)
- M Harris
- Department of Medicine, The University of Adelaide, Australia.
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Fretheim A, Oxman AD, Håvelsrud K, Treweek S, Kristoffersen DT, Bjørndal A. Rational prescribing in primary care (RaPP): a cluster randomized trial of a tailored intervention. PLoS Med 2006; 3:e134. [PMID: 16737346 PMCID: PMC1472695 DOI: 10.1371/journal.pmed.0030134] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 03/02/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease. METHODS AND FINDINGS We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49-2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals. CONCLUSIONS Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.
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Affiliation(s)
- Atle Fretheim
- Norwegian Knowledge Centre for Health Services, Oslo, Norway.
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Shaw B, Cheater F, Baker R, Gillies C, Hearnshaw H, Flottorp S, Robertson N. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2005:CD005470. [PMID: 16034980 DOI: 10.1002/14651858.cd005470] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers. OBJECTIVES To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included. SELECTION CRITERIA Randomised controlled trials (RCTs) that reported objectively measured professional practice or health care outcomes in which at least one group received an intervention designed (or tailored) to address prospectively identified barriers to change. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken. MAIN RESULTS We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant. AUTHORS' CONCLUSIONS Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.
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Affiliation(s)
- B Shaw
- Clinical Governance Research & Development Unit, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, Leicestershire, UK, LE5 4PW.
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ten Asbroek AHA, Delnoij DMJ, Niessen LW, Scherpbier RW, Shrestha N, Bam DS, Gunneberg C, van der Hor CW, Klazinga NS. Implementing global knowledge in local practice: a WHO lung health initiative in Nepal. Health Policy Plan 2005; 20:290-301. [PMID: 16000368 DOI: 10.1093/heapol/czi034] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.
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Affiliation(s)
- A H A ten Asbroek
- Institute of Medical Technology Assessment/Institute of Health Policy and Management, Erasmus Medical Centre, Erasmus University Rotterdam, Netherlands.
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Gagan M, Hewitt-Taylor J. The issues for nurses involved in implementing evidence in practice. ACTA ACUST UNITED AC 2005; 13:1216-20. [PMID: 15580091 DOI: 10.12968/bjon.2004.13.20.17013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Evidence-based practice (EBP) is currently high on political and professional agendas. However, there is a suggestion that despite apparent enthusiasm for EBP, it is not becoming a reality. A variety of reasons for evidence not being implemented in practice exist, including the way in which evidence is communicated, how staff are involved in changes in practice, the availability of resources, patient expectations and the priority afforded to EBP by individuals and organizations. These issues must be addressed if EBP is to succeed.
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Affiliation(s)
- Mark Gagan
- Institute of Health and Community Studies, Bournemouth University, UK
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Øvretveit J. A Framework for Quality Improvement Translation: Understanding the Conditionality of Interventions. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1549-3741(04)30105-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fretheim A, Oxman AD, Flottorp S. Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change. BMC Health Serv Res 2004; 4:23. [PMID: 15347426 PMCID: PMC517506 DOI: 10.1186/1472-6963-4-23] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Accepted: 09/03/2004] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions. METHODS We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention. RESULTS A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention. CONCLUSIONS A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.
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Affiliation(s)
- Atle Fretheim
- Informed Choice Research Department, Norwegian Health Services Research Centre, P.O. Box 7004, St. Olavs plass, Oslo, Norway
| | - Andrew D Oxman
- Informed Choice Research Department, Norwegian Health Services Research Centre, P.O. Box 7004, St. Olavs plass, Oslo, Norway
| | - Signe Flottorp
- Informed Choice Research Department, Norwegian Health Services Research Centre, P.O. Box 7004, St. Olavs plass, Oslo, Norway
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Flottorp S, Håvelsrud K, Oxman AD. Process evaluation of a cluster randomized trial of tailored interventions to implement guidelines in primary care--why is it so hard to change practice? Fam Pract 2003; 20:333-9. [PMID: 12738704 DOI: 10.1093/fampra/cmg316] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A cluster randomized trial of tailored interventions to support the implementation of guidelines for sore throat and urinary tract infection found little or no change in the main outcomes, which were antibiotic prescriptions, use of laboratory tests and use of telephone consultations. There was great variation between the practices in the change in these outcomes. OBJECTIVES Our aim was to evaluate how the interventions were received and to understand why practices did or did not change. METHODS The trial was conducted in general practices in Norway. Data for this process evaluation were collected from the 120 practices that completed the trial. Multiple methods were used: observations, semi-structured telephone interviews, a postal survey and data extracted from electronic medical records. We investigated factors that might explain a lack of change, including: agreement with the guidelines; communication within each practice; degree of participation in the project; taking time to discuss the guidelines and their implementation; use of the components of the interventions; and routines for telephone consultations. Possible explanatory factors were explored in relation to variation in change and the overall extent of change in rates of use of antibiotics, laboratory tests and telephone consultations. RESULTS Sixty-three per cent of practices agreed with the guidelines. Only 35% reported having regular meetings, and 33% discussed the project before its start, although 75% reported agreement about participating within the practice. Only 33% reported meeting to discuss the guidelines. Use of the components of the interventions ranged from 11% for the increased fee for telephone consultations to 48% for the computerized decision support. Forty-four per cent reported problems with telephone routines. No single factor explained the observed variation in the extent of change across practices. CONCLUSIONS Inadequate time, resources and support were the most salient factors that might explain a lack of change. Problems with internal communication and telephone routines were important contributing factors in many practices.
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Affiliation(s)
- Signe Flottorp
- Department of Health Services Research, Norwegian Directorate for Health and Social Affairs, PO Box 8054 Dep, N-0031 Oslo, Norway.
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Espeland A, Baerheim A. Factors affecting general practitioners' decisions about plain radiography for back pain: implications for classification of guideline barriers--a qualitative study. BMC Health Serv Res 2003; 3:8. [PMID: 12659640 PMCID: PMC153534 DOI: 10.1186/1472-6963-3-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2003] [Accepted: 03/24/2003] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND General practitioners often diverge from clinical guidelines regarding spine radiography. This study aimed to identify and describe A) factors general practitioners consider may affect their decisions about ordering plain radiography for back pain and B) barriers to guideline adherence suggested by such factors. METHODS Focus group interviews regarding factors affecting ordering decisions were carried out on a diverse sample of Norwegian general practitioners and were analysed qualitatively. Results of this study and two qualitative studies from the Netherlands and USA on use of spine radiography were interpreted for barriers to guideline adherence. These were compared with an existing barrier classification system described by Dr Cabana's group. RESULTS The factors which Norwegian general practitioners considered might affect their decisions about ordering plain radiography for back pain concerned the following broader issues: clinical ordering criteria, patients' wishes for radiography and the general practitioner's response, uncertainty, professional dignity, access to radiology services, perception of whether the patient really was ill, sense of pressure from other health care providers/social security, and expectations about the consequences of ordering radiography. The three studies suggested several attitude-related and external barriers as classified in a previously reported system described by Dr Cabana in another study. Identified barriers not listed in this system were: lack of expectancy that guideline adherence will lead to desired health care process, emotional difficulty with adherence, improper access to actual/alternative health care services, and pressure from health care providers/organisations. CONCLUSIONS Our findings may help implement spine radiography guidelines. They also indicate that Cabana et al.'s barrier classification system needs extending. A revised system is proposed.
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Affiliation(s)
- Ansgar Espeland
- Section of Radiology, Institute of Surgical Sciences, University of Bergen, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Anders Baerheim
- Division for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Ulriksdal 8c, N-5009 Bergen, Norway
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Fretheim A, Oxman AD, Treweek S, Bjørndal A. Rational Prescribing in Primary Care (RaPP-trial). A randomised trial of a tailored intervention to improve prescribing of antihypertensive and cholesterol-lowering drugs in general practice [ISRCTN48751230]. BMC Health Serv Res 2003; 3:5. [PMID: 12657163 PMCID: PMC152643 DOI: 10.1186/1472-6963-3-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2002] [Accepted: 02/27/2003] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The underlying reasons for differences between clinical practice and systematically developed guidelines vary from one clinical problem to another. It is therefore logical to tailor strategies to support the implementation of guidelines to address identified barriers to change. The objective of this trial is to evaluate the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease. METHODS/DESIGN Unblinded, cluster-randomised trial. 150 general practices will be recruited from two geographical areas in Norway, and randomised to the intervention or control group (passive dissemination of guidelines). Outcomes will be measured for all eligible patients seen in the participating practices during one year after the intervention. A multifaceted intervention has been tailored to address identified barriers to change. Key components are an educational outreach visit with audit and feedback, and computerised reminders. Pharmacists will conduct the visits. During the outreach visit the main recommendations will be presented and software will be installed that links to the electronic medical record systems used in the participating practices. The software will perform an audit that will be fed back during the visit, present pop-up reminders for patients with high blood pressure or cholesterol, and provide a cardiovascular risk calculator and patient education material. The main outcomes are the proportions of 1) first time prescriptions for hypertension where thiazides are not prescribed, 2) patients not assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and 3) patients treated for hypertension or high cholesterol for three months or more who have not achieved recommended treatment goals.
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Affiliation(s)
- Atle Fretheim
- Department of Health Services Research, Norwegian Directorate for Health and Social Affairs, N-0031 Oslo, Norway
| | - Andrew D Oxman
- Department of Health Services Research, Norwegian Directorate for Health and Social Affairs, N-0031 Oslo, Norway
| | - Shaun Treweek
- Department of Health Services Research, Norwegian Directorate for Health and Social Affairs, N-0031 Oslo, Norway
| | - Arild Bjørndal
- Division of Knowledge Management, Norwegian Directorate for Health and Social Affairs, N-0031 Oslo, Norway
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