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Trautner BW, Prasad P, Grigoryan L, Hysong SJ, Kramer JR, Rajan S, Petersen NJ, Rosen T, Drekonja DM, Graber C, Patel P, Lichtenberger P, Gauthier TP, Wiseman S, Jones M, Sales A, Krein S, Naik AD. Protocol to disseminate a hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of asymptomatic bacteriuria. Implement Sci 2018; 13:16. [PMID: 29351769 PMCID: PMC5775527 DOI: 10.1186/s13012-018-0709-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship to combat the spread of antibiotic-resistant bacteria has become a national priority. This project focuses on reducing inappropriate use of antimicrobials for asymptomatic bacteriuria (ASB), a very common condition that leads to antimicrobial overuse in acute and long-term care. We previously conducted a successful intervention, entitled "Kicking Catheter Associated Urinary Tract Infection (CAUTI): the No Knee-Jerk Antibiotics Campaign," to decrease guideline-discordant ordering of urine cultures and antibiotics for ASB. The current objective is to facilitate implementation of a scalable version of the Kicking CAUTI campaign across four geographically diverse Veterans Health Administration facilities while assessing what aspects of an antimicrobial stewardship intervention are essential to success and sustainability. METHODS This project uses an interrupted time series design with four control sites. The two main intervention tools are (1) an evidence-based algorithm that distills the guidelines into a streamlined clinical pathway and (2) case-based audit and feedback to train clinicians to use the algorithm. Our conceptual framework for the development and implementation of this intervention draws on May's General Theory of Implementation. The intervention is directed at providers in acute and long-term care, and the goal is to reduce inappropriate screening for and treatment of ASB in all patients and residents, not just those with urinary catheters. The start-up for each facility consists of centrally-led phone calls with local site champions and baseline surveys. Case-based audit and feedback will begin at a given site after the start-up period and continue for 12 months, followed by a sustainability assessment. In addition to the clinical outcomes, we will explore the relationship between the dose of the intervention and clinical outcomes. DISCUSSION This project moves from a proof-of-concept effectiveness study to implementation involving significantly more sites, and uses the General Theory of Implementation to embed the intervention into normal processes of care with usual care providers. Aspects of implementation that will be explored include dissemination, internal and external facilitation, and organizational partnerships. "Less is More" is the natural next step from our prior successful Kicking CAUTI intervention, and has the potential to improve patient care while advancing the science of implementation.
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Affiliation(s)
- Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA. .,Baylor College of Medicine in Houston, Houston, TX, USA.
| | | | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX, 77098, USA
| | - Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Suja Rajan
- Department of Management, Policy and Community Heath, University of Texas (UT) - School of Public Health (SPH), E-319, 1200 Pressler Street, Houston, TX, 77030, USA
| | - Nancy J Petersen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Tracey Rosen
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
| | - Dimitri M Drekonja
- Infectious Diseases (111F), Minneapolis VA Medical Center, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Christopher Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, 11301 Wilshire Blvd, 111-F, Los Angeles, CA, 90073, USA
| | - Payal Patel
- Division of Infectious Diseases, III-i, University of Michigan, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | | | | | - Steve Wiseman
- Division of Infectious Diseases, III-i, University of Michigan, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Makoto Jones
- George E. Wahlen Veterans Affairs Medical Center, Mailstop 182, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
| | - Anne Sales
- Department of Learning Health Sciences, University of Michigan Medical School, 209 Victor Vaughan Building, 2054, 1111 E. Catherine St, Ann Arbor, MI, 48109-2054, USA
| | - Sarah Krein
- VA Ann Arbor Center for Clinical Management Research, North Campus Research Complex, Building 16-333W, 2800 Plymouth Rd, Ann Arbor, MI, 48109-2800, USA
| | - Aanand Dinkar Naik
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX, 77030, USA.,Baylor College of Medicine in Houston, Houston, TX, USA
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Nicholls SG, Brehaut JC, Arim RG, Carroll K, Perez R, Shojania KG, Grimshaw JM, Poses RM. Impact of stated barriers on proposed warfarin prescription for atrial fibrillation: a survey of Canadian physicians. Thromb J 2014; 12:13. [PMID: 25161388 PMCID: PMC4144316 DOI: 10.1186/1477-9560-12-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 06/13/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions. METHODS Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants. RESULTS Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ (2) (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ (2) (3) =10.7, p = 0.013). CONCLUSIONS Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin, even in the presence of falls risk.
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Affiliation(s)
- Stuart G Nicholls
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie C Brehaut
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada ; Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Rubab G Arim
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Kelly Carroll
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada
| | - Richard Perez
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kaveh G Shojania
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, General Campus, Clinical Epidemiology Program, Centre for Practice-Changing Research (CPCR), 501 Smyth Road, Ottawa, Ontario, Canada ; Department of Medicine, University of Ottawa, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, Canada
| | - Roy M Poses
- Foundation for Integrity and Responsibility in Medicine, Warren, Rhode Island, USA ; Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Msaouel P, Kappos T, Tasoulis A, Apostolopoulos AP, Lekkas I, Tripodaki ES, Keramaris NC. Assessment of cognitive biases and biostatistics knowledge of medical residents: a multicenter, cross-sectional questionnaire study. MEDICAL EDUCATION ONLINE 2014; 19:23646. [PMID: 24646439 PMCID: PMC3955772 DOI: 10.3402/meo.v19.23646] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 02/16/2014] [Accepted: 02/17/2014] [Indexed: 06/03/2023]
Abstract
PURPOSE The aim of this study is to determine the perceived familiarity of medical residents with statistical concepts, assess their ability to integrate these concepts in clinical scenarios, and investigate their susceptibility to the gambler's fallacy and the conjunction fallacy. METHODS A multi-institutional, cross-sectional survey of Greek medical residents was performed. Participants were asked to indicate their familiarity with basic statistical concepts and answer clinically oriented questions designed to assess their biostatistics knowledge and cognitive biases. Univariate, bivariate, and multivariate statistical models were used for the evaluation of data. RESULTS Out of 153 respondents (76.5% response rate), only two participants (1.3%) were able to answer all seven biostatistics knowledge questions correctly while 29 residents (19%) gave incorrect answers to all questions. The proportion of correct answers to each biostatistics knowledge question ranged from 15 to 51.6%. Residents with greater self-reported familiarity were more likely to perform better on the respective knowledge question (all p<0.01). Multivariate analysis of the effect of individual resident characteristics on questionnaire performance showed that previous education outside Greece, primarily during medical school, was associated with lower biostatistics knowledge scores (p<0.001). A little more than half of the respondents (54.2%) answered the gambler's fallacy quiz correctly. Residents with higher performance on the biostatistics knowledge questions were less prone to the gambler's fallacy (odds ratio 1.38, 95% confidence intervals 1.12-1.70, p=0.003). Only 48 residents (31.4%) did not violate the conjunction rule. CONCLUSIONS A large number of medical residents are unable to correctly interpret crucial statistical concepts that are commonly found in the medical literature. They are also especially prone to the gambler's fallacy bias, which may undermine clinical judgment and medical decision making. Formalized systematic teaching of biostatistics during residency will be required to de-bias residents and ensure that they are proficient in understanding and communicating statistical information.
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Affiliation(s)
- Pavlos Msaouel
- Greek Junior Doctors and Health Scientists Society, Athens, Greece;
| | - Theocharis Kappos
- 2nd Department of Surgery, Metaxa Cancer Memorial Hospital, Pireaus, Greece
| | | | | | - Ioannis Lekkas
- Otorhinolaryngology Clinic, 251 G.N.A. Hospital, Athens, Greece
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Gattellari M, Leung DY, Ukoumunne OC, Zwar N, Grimshaw J, Worthington JM. Study protocol: the DESPATCH study: delivering stroke prevention for patients with atrial fibrillation - a cluster randomised controlled trial in primary healthcare. Implement Sci 2011; 6:48. [PMID: 21599901 PMCID: PMC3121604 DOI: 10.1186/1748-5908-6-48] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/20/2011] [Indexed: 12/21/2022] Open
Abstract
Background Compelling evidence shows that appropriate use of anticoagulation in patients with nonvalvular atrial fibrillation reduces the risk of ischaemic stroke by 67% and all-cause mortality by 26%. Despite this evidence, anticoagulation is substantially underused, resulting in avoidable fatal and disabling strokes. Methods DESPATCH is a cluster randomised controlled trial with concealed allocation and blinded outcome assessment designed to evaluate a multifaceted and tailored implementation strategy for improving the uptake of anticoagulation in primary care. We have recruited general practices in South Western Sydney, Australia, and randomly allocated practices to receive the DESPATCH intervention or evidence-based guidelines (control). The intervention comprises specialist decisional support via written feedback about patient-specific cases, three academic detailing sessions (delivered via telephone), practice resources, and evidence-based information. Data for outcome assessment will be obtained from a blinded, independent medical record audit. Our primary endpoint is the proportion of nonvalvular atrial fibrillation patients, over 65 years of age, receiving oral anticoagulation at any time during the 12-month posttest period. Discussion Successful translation of evidence into clinical practice can reduce avoidable stroke, death, and disability due to nonvalvular atrial fibrillation. If successful, DESPATCH will inform public policy, providing quality evidence for an effective implementation strategy to improve management of nonvalvular atrial fibrillation, to close an important evidence-practice gap. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000074392
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
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Falzer PR, Garman DM. Contextual decision making and the implementation of clinical guidelines: an example from mental health. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2010; 85:548-555. [PMID: 20182137 DOI: 10.1097/acm.0b013e3181ccd83c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE Clinical decision making plays a crucial role in the transformation of science to service. Treatment decisions typically are evaluated by comparing them against norms, such as practice guidelines. An adherence standard has been criticized as inappropriate, but no measurable alternative has been proposed to date. This study develops a new standard of incorporation and a companion matching test, and addresses two questions: (1) Do clinicians incorporate a treatment guideline even when they do not endorse it? (2) If so, do they incorporate the guideline consistently? METHOD The study uses the clinical paradigm of treatment-resistant schizophrenia and a published guideline developed at the Yale University Department of Psychiatry that has been soundly rejected in clinical practice. A vignette study was developed, using a four-factor, fully crossed and within-subject design, then administered to 21 volunteer paid psychiatry residents. RESULTS The endorsement pattern showed a low concurrence rate and significant apparent inconsistency within subjects. However, the matching test showed a clear relationship between endorsement of the guideline and features of individual vignettes. The matching test demonstrated significant within-subject consistency and accounted for 65% of the endorsement variance. CONCLUSIONS Implications are preliminary, given limitations that pertain to the subject population and use of vignettes, the clinical paradigm, and treatment guideline. However, the study's concepts, procedures, and findings may play a valuable role in future transformative initiatives, including training clinicians in the use of clinical guidelines and evaluating the appropriateness of guidelines before their implementation.
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Affiliation(s)
- Paul R Falzer
- Veterans Administration Connecticut Healthcare System, Clinical Epidemiology Research Center, West Haven, Connecticut 06516, USA.
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Abstract
RATIONALE, AIMS AND OBJECTIVES Efforts to describe how individual treatment decisions are informed by systematic knowledge have been hindered by a standard that gauges the quality of clinical decisions by their adherence to guidelines and evidence-based practices. This paper tests a new contextual standard that gauges the incorporation of knowledge into practice and develops a model of evidence-based decision making. Previous work found that the forecasted outcome of a treatment guideline exerts a highly significant influence on how it is used in making decisions. This study proposed that forecasted outcomes affect the recognition of a treatment scenario, and this recognition triggers distinct contextual decision strategies. METHODS Twenty-one volunteers from a psychiatric residency programme responded to 64 case vignettes, 16 in each of the four treatment scenarios. The vignettes represented a fully balanced within-subjects design that included guideline switching criteria and patient-specific factors. For each vignette, participants indicated whether they endorsed the guideline's recommendation. RESULTS Clinicians used consistent contextual decision strategies in responding to clearly positive or negative forecasts. When forecasts were more ambiguous or risky, their strategies became complex and relatively inconsistent. CONCLUSION The results support a three-step model of evidence-based decision making, in which clinicians recognize a decision scenario, apply a simple contextual strategy, then if necessary engage a more complex strategy to resolve discrepancies between general guidelines and specific cases. The paper concludes by noting study limitations and discussing implications of the model for future research in clinical and shared decision making, training and guideline development.
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Affiliation(s)
- Paul R Falzer
- VA Connecticut Healthcare System, West Haven, CT 06516, USA.
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Shibuya A, Nakayama M, Inoue R, Imai Y, Kondo Y. Decision making and physician prescribing characteristics: a pilot study of Japanese physicians. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2009; 2009:604-608. [PMID: 20351926 PMCID: PMC2815422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The factors that affect physicians' prescribing remain unclear. Although previous reports suggest that prescription decisions are associated with various clinical situation, most of these studies analyzed simulated patient models rather than actual clinical practice. Here, we retrospectively analyzed actual cases of statin prescription for hyperlipidemia at Tohoku University Hospital between Apr 1, 2004 and Mar 31, 2008. Twelve physicians (6 cardiologists, 3 nephrologist, and 3 diabetologist) made decisions on whether to prescribe statins to 187 patients in 788 visits. As expected, cardiologists started prescribing statins at significantly lower serum total cholesterol levels than other specialists (221.7mg/dL vs. 244.7mg/dL, P<0.05). Interestingly, the total cholesterol levels that triggered prescribing differed significantly among cardiologists (p<0.05). These results suggested that prescription decisions differed not only among specialties but also among individuals.
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Affiliation(s)
- Akiko Shibuya
- Department of Medical Informatics, Tohoku University Graduate School of Medicine, Sendai, Japan
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Management of traumatic liver injuries without a valid trauma system. Prehosp Disaster Med 2009; 24:349-55. [PMID: 19806560 DOI: 10.1017/s1049023x00007081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Despite a global increase in conservative treatment of blunt liver injuries, the number of surgically treated traumas in one major trauma center in Iran has increased. The aim of this study was to unveil the reasons behind this increase in operative management by studying 228 consecutive patients at this regional center. HYPOTHESIS The increased number of liver injuries operated upon is due to the lack of a solid, well-defined trauma system. METHODS A retrospective review of all patients admitted for liver trauma at Bahonar Hospital, Kerman, Iran, from March 2001 until March 2006 was conducted. Patient data were collected, studied and statistically processed with regard to demographics, clinical and laboratory findings, surgical procedures, complications, and mortality. RESULTS All patients who were admitted between 30-360 minutes after injury were included. Twelve hemodynamically stable patients were treated conservatively in an ordinary surgical ward. The remaining 216 patients, 153 of whom had blunt injuries, were hemodynamically unstable. A total of 70 patients were in hemorrhagic shock at the time of arrival. Hemodynamically unstable patients with either the suspicion of associated injuries and/or who displayed clinical deterioration and could not be observed in an ordinary surgical ward were treated surgically. The majority of patients who were operated upon in this series had a grade-II liver injury. The total mortality rate in surgically treated patients was 18.1%. None of the patients treated conservatively died. CONCLUSIONS Despite the low grade of their liver injuries, the high number of surgically treated patients in this series was due to the absence of a valid trauma system. This result should encourage the authorities to review current trauma systems and trauma surgical guidelines.
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Measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM). BMC Med Inform Decis Mak 2008; 8:20. [PMID: 18507864 PMCID: PMC2432053 DOI: 10.1186/1472-6947-8-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 05/28/2008] [Indexed: 11/13/2022] Open
Abstract
Background Understanding how doctors think may inform both undergraduate and postgraduate medical education. Developing such an understanding requires valid and reliable measurement tools. We examined the measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM), designed to tap this domain with specific reference to medicine, but with previously questionable measurement properties. Methods First year postgraduate entry medical students at Flinders University, and trainees (postgraduate doctors in any specialty) and consultants (N = 348) based at two teaching hospitals in Adelaide, Australia, completed the ICBM and a questionnaire measuring thinking styles (Rational Experiential Inventory). Results Questions with the lowest item-total correlation were deleted from the original 22 item ICBM, although the resultant 17 item scale only marginally improved internal consistency (Cronbach's α = 0.61 compared with 0.57). A factor analysis identified two scales, both achieving only α = 0.58. Construct validity was assessed by correlating Rational Experiential Inventory scores with the ICBM, with some positive correlations noted for students only, suggesting that those who are naïve to the knowledge base required to "successfully" respond to the ICBM may profit by a thinking style in tune with logical reasoning. Conclusion The ICBM failed to demonstrate adequate content validity, internal consistency and construct validity. It is unlikely that improvements can be achieved without considered attention to both the audience for which it is designed and its item content. The latter may need to involve both removal of some items deemed to measure multiple biases and the addition of new items in the attempt to survey the range of biases that may compromise medical decision making.
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Falzer PR, Moore BA, Garman DM. Incorporating clinical guidelines through clinician decision-making. Implement Sci 2008; 3:13. [PMID: 18312671 PMCID: PMC2291071 DOI: 10.1186/1748-5908-3-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 02/29/2008] [Indexed: 12/04/2022] Open
Abstract
Background It is generally acknowledged that a disparity between knowledge and its implementation is adversely affecting quality of care. An example commonly cited is the failure of clinicians to follow clinical guidelines. A guiding assumption of this view is that adherence should be gauged by a standard of conformance. At least some guideline developers dispute this assumption and claim that their efforts are intended to inform and assist clinical practice, not to function as standards of performance. However, their ability to assist and inform will remain limited until an alternative to the conformance criterion is proposed that gauges how evidence-based guidelines are incorporated into clinical decisions. Methods The proposed investigation has two specific aims to identify the processes that affect decisions about incorporating clinical guidelines, and then to develop ad test a strategy that promotes the utilization of evidence-based practices. This paper focuses on the first aim. It presents the rationale, introduces the clinical paradigm of treatment-resistant schizophrenia, and discusses an exemplar of clinician non-conformance to a clinical guideline. A modification of the original study is proposed that targets psychiatric trainees and draws on a cognitively rich theory of decision-making to formulate hypotheses about how the guideline is incorporated into treatment decisions. Twenty volunteer subjects recruited from an accredited psychiatry training program will respond to sixty-four vignettes that represent a fully crossed 2 × 2 × 2 × 4 within-subjects design. The variables consist of criteria contained in the clinical guideline and other relevant factors. Subjects will also respond to a subset of eight vignettes that assesses their overall impression of the guideline. Generalization estimating equation models will be used to test the study's principal hypothesis and perform secondary analyses. Implications The original design of phase two of the proposed investigation will be changed in recognition of newly published literature on the relative effectiveness of treatments for schizophrenia. It is suggested that this literature supports the notion that guidelines serve a valuable function as decision tools, and substantiates the importance of decision-making as the means by which general principles are incorporated into clinical practice.
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Affiliation(s)
- Paul R Falzer
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT, USA.
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