Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey

BACKGROUND

Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries.

METHODS

Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results.

RESULTS

Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries.

CONCLUSIONS

More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

The Finnish current care guideline for open-angle glaucoma

This article is an English translation of the 4th Finnish Current Care Guideline for diagnostics, treatment and follow-up of primary open-angle glaucoma, normal-tension glaucoma and pseudoexfoliative glaucoma. This guideline is based on systematic literature reviews and expert opinions with Finland's geographical and operational healthcare environment in mind.

Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review

BACKGROUND

De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research.

METHODS

We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool.

RESULTS

We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%).

CONCLUSION

De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers.

TRIAL REGISTRATION

OSF (Open Science Framework): https://osf.io/ueq32 .

Randomized controlled trials in de-implementation research: a systematic scoping review

BACKGROUND

Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research.

METHODS

MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias.

RESULTS

Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%).

CONCLUSIONS

De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design.

REGISTRATION

OSF Open Science Framework hk4b2.

Incorporating evidence-based rehabilitation into clinical practice guidelines

OBJECTIVE

Rehabilitation is often neglected in clinical practice guidelines, even when there is evidence for its effectiveness. The Current Rehabilitation development project, documented in this article, aimed to develop processes and structures to incorporate evidence and good practice on rehabilitation and functional capacity into the Finnish national Current Care Guidelines.

DESIGN

Descriptive assessment.

METHODS

The 3-year Current Rehabilitation development project was launched in 2012. It began with an assessment of existing rehabilitation evidence on the Current Care Guideline database and a query to Finnish rehabilitation experts. The project group developed and compiled tools for Current Care editors and guideline panels. The editorial team continued to monitor changes in rehabilitation evidence in the guidelines.

RESULTS

During the years 2012-2014, a total of 54 guidelines were published, and rehabilitation was incorporated into 31 of them. The number of rehabilitation-related evidence summaries increased from 49 to 164. During the next 3 years an additional 41 guidelines were published. Rehabilitation was incorporated to 24 of them, and the number of rehabilitation-related evidence summaries increased from 78 to 136.

CONCLUSION

The level of evidence criteria used for rehabilitative interventions were the same as for symptomatic or curative interventions. Evidence showing the effectiveness of rehabilitation increased substantially during the project.

Development and application of implementation tools for rehabilitation guidelines

OBJECTIVE

To describe a project to develop guideline implementation tools (GItools) for rehabilitation guidelines, and a collaboration between a guideline producer and a healthcare organization to implement guidelines into care pathways.

DESIGN

Descriptive case study.

METHODS

A national guideline organization in Finland launched a 3-year project in 2015 to implement rehabilitation recommendations. Usability of the GItools was evaluated and improved, based on literature, workshops and surveys. An implementation plan guided the production of the GItools. An implementation plan was developed to integrate the shoulder disorders guideline into a care pathway at Päijät-Häme district rehabilitation unit. The implementation plan was produced in 3 facilitated workshops, which included brainstorming, snowballing, prioritizing and short lectures.

RESULTS

Twenty implementation plans and 119 different GItools for 22 guidelines were developed. The GItools, in particular patient material, were perceived as useful for the facilitation of guideline implementation. Four seminars and 14 sessions of continuous medical education were arranged. A plan was developed and executed for the implementation of the shoulder disorders guideline.

CONCLUSION

It is feasible for a guideline producer to systematically include GItools into rehabilitation guidelines. This implementation project was an example of a successful collaboration between a guideline producer and a healthcare organization.

Highlighting the need for de-implementation - Choosing Wisely recommendations based on clinical practice guidelines

Background

The Choosing Wisely campaign has spread to many countries. Methods for developing recommendations are inconsistent. We describe our process of developing such recommendations from a comprehensive national set of clinical practice guidelines (Current Care, CC) and the results of a one-year Choosing Wisely Finland project.

Methods

Two of the authors drafted the quality and process criteria for all the Choosing Wisely Finland recommendations. The quality criteria were relevance, feasibility, evidence-based and strength. These were discussed in editors’ meetings and subsequently revised. Two different processes for developing recommendations within national clinical practice guidelines were designed and piloted (processes A and B). Process A was based on a published guideline. The recommendations are drafted by an editor and revised and approved by the guideline development group. In process B the development of the recommendations is integrated with guideline production or update. Choosing Wisely recommendations were then drafted for half of the published CC Guidelines. An additional process (process C) was designed for producing independent recommendations outside a guideline.

Results

At least one Choosing Wisely recommendation could be identified from 39 out of 52 reviewed guidelines. Of the 106 recommendations drafted, 62 (58%) were accepted for publication. The main reasons for rejection were inability to give a strong recommendation (n = 18, 41%) and insufficient relevance (n = 14, 32%). Two thirds (n = 41, 66%) of the published recommendations were based on high to moderate level of evidence, and 18% (n = 11) on low or very low level of evidence, whereas for the rest, the quality of evidence was not critically appraised.

Conclusions

Choosing Wisely recommendations can be produced systematically from existing clinical practice guidelines. The rigorous methods of evidence-based medicine ensure high-quality recommendations. We welcome the use of our processes and methods describes in this article by other guideline-producing organizations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4460-z) contains supplementary material, which is available to authorized users.

Avoidance of Cow's Milk-Based Formula for At-Risk Infants Does Not Reduce Development of Celiac Disease: A Randomized Controlled Trial

BACKGROUND & AIMS

Feeding during the first months of life might affect risk for celiac disease. Individuals with celiac disease or type 1 diabetes have been reported to have high titers of antibodies against cow's milk proteins. Avoidance of cow's milk-based formula for infants with genetic susceptibility for type 1 diabetes reduced the cumulative incidence of diabetes-associated autoantibodies. We performed a randomized controlled trial in the same population to study whether weaning to an extensively hydrolyzed formula reduced the risk of celiac disease autoimmunity or celiac disease.

METHODS

We performed a double-blind controlled trial of 230 infants with HLA-defined predisposition to type 1 diabetes and at least 1 family member with type 1 diabetes. The infants were randomly assigned to groups fed a casein hydrolysate formula (n = 113) or a conventional formula (control, n = 117) whenever breast milk was not available during the first 6-8 months of life. Serum samples were collected over a median time period of 10 years and analyzed for antibodies to tissue transglutaminase (anti-TG2A) using a radiobinding assay, to endomysium using an immunofluorescence assay, and antibodies to a deamidated gliadine peptide using an immunofluorometry assay. Duodenal biopsies were collected if levels of anti-TG2A exceeded 20 relative units. Cow's milk antibodies were measured during the first 2 years of life.

RESULTS

Of the 189 participants analyzed for anti-TG2A, 25 (13.2%) tested positive. Of the 230 study participants observed, 10 (4.3%) were diagnosed with celiac disease. We did not find any significant differences at the cumulative incidence of anti-TG2A positivity (hazard ratio, 1.14; 95% confidence interval, 0.51-2.54) or celiac disease (hazard ratio, 4.13; 95% confidence interval, 0.81-21.02) between the casein hydrolysate and cow's milk groups. Children who developed celiac disease had increased titers of cow's milk antibodies before the appearance of anti-TG2A or celiac disease.

CONCLUSIONS

In a randomized controlled trial of 230 infants with genetic risk factors for celiac disease, we did not find evidence that weaning to a diet of extensively hydrolyzed formula compared with cow's milk-based formula would decrease the risk for celiac disease later in life. Increased titers of cow's milk antibody before anti-TG2A and celiac disease indicates that subjects with celiac disease might have increased intestinal permeability in early life. ClinicalTrials.gov Number: NCT00570102.

The Finnish national guideline for diagnosis, treatment and follow-up of patients with wet age-related macular degeneration

Age-related macular degeneration (AMD) is the main cause of visual impairment in developed countries. Several improvements in the visualization of posterior segment of the eye together with the introduction of intravitreal anti-VEGF treatment have revolutionized the prognosis of the wet form of AMD (wAMD). Increasing incidence of wAMD together with the limited resources of society and of the healthcare system poses challenges for the provision and development of care. In context of these current aspects, we aimed to set evidence-based medical guidelines for diagnosis, treatment and follow-up of patients with wAMD.

[Implementation in Finnish]

Implementation research examines and promotes the uptake of research findings in various operational environments. The concepts of implementation research in Finnish are not yet established. In support of the research field we describe the Finnish equivalents of the central terms related to knowledge translation in healthcare and the frame of reference of Implementation research, with the national Current Care Guidelines as the starting point. The frame of reference is based on literature, experiences of the authors, iterative modification of the frame of reference on the basis of discussions, and results of expert inquiry. The frame of reference describes seven objects of evaluation, examples of research set-ups and methods as well as tools.

[Update on current care guidelines. Pain]

Management of patients suffering from chronic pain is based on long-term therapeutic relationship. The main objectives of the treatment are pain relief, restoration of function and improvement of quality of life. Interventions for treatment and rehabilitation need to be planned in agreement with the patient. Non-pharmaceutical interventions form the basics of the treatment. If medication is needed, it should be tailored to meet the individual needs of the patient according to the etiology and intensity of pain, comorbidities and psychosocial situation.

Psychological distress of children with early-onset type 1 diabetes and their mothers' well-being

AIM

Few studies have focused on the psychological adjustment of pre-adolescent children with type 1 diabetes. This study examined psychosocial functioning in nine- and 10-year-old children with early-onset type 1 diabetes, and their mothers, and associations between psychosocial functioning and diabetes management.

METHODS

The mothers of 63 children with early-onset diabetes and 86 healthy children evaluated their own psychosocial functioning, and their child's, with standardised rating scales. We used general linear models to analyse the children's behaviour problems and the mothers' well-being. Associations between the children's behaviour problems, diabetes-related measures and the mothers' well-being were studied with partial correlations.

RESULTS

Children with diabetes had more internalising problems than the controls (p = 0.001), and these were associated with poor glycaemic control at the early stage of the illness (p = 0.033) and the use of insulin pumps in girls (p = 0.004). Mothers in the diabetes group had more child-related stress than the controls (p < 0.001), and poorer well-being was associated with the children's behavioural problems (p < 0.024).

CONCLUSION

Children with early-onset diabetes faced an increased risk of internalising problems in middle childhood. The mothers' psychological distress was associated with children's behaviour problems rather than their diabetes.

Guidelines International Network: Principles for Disclosure of Interests and Management of Conflicts in Guidelines

Conflicts of interest (COIs) have been defined by the American Thoracic Society as "a divergence between an individual's private interests and his or her professional obligations such that an independent observer might reasonably question whether the individual's professional actions or decisions are motivated by personal gain, such as direct financial, academic advancement, clinical revenue streams, or community standing." In the context of guideline development, the concerns are not simply about identifying and disclosing direct financial or indirect COIs. Despite this recognition, the management of COIs in guidelines is often unsatisfactory. In response to requests from its international membership and informed by existing syntheses of the evidence and policies of international organizations, the Guidelines International Network Board of Trustees developed guidance on the disclosure of interests and management of COIs. Current approaches are relatively similar throughout the guideline development community, with an increasing recognition of the importance of disclosing and managing indirect COIs. Although there are differences in detail among the approaches, the similarities allow for the formulation of 9 core principles for managing COIs. In formulating these principles, the Guidelines International Network Board of Trustees recognizes that COIs cannot be totally avoided when panel members are being chosen for certain guidelines or in certain settings; thus, the important issue is the management of COIs in a fair, judicious, transparent manner.

[Update on Current Care Guideline: Glaucoma]

The up-date of the Finnish Current Care Guideline for glaucoma is based primarily on systematic reviews searched up by March 2014. The recommendations are presented in nine tables, which are based on 95 graded statements with evidence summaries. The online availability (www.kaypahoito.fi) of the English translation of guideline and evidence summaries enables the verification of the evidence and recommendations. Ten external stakeholders gave a mean value of 1.8 (range of 1 = completely agree to 4 = completely disagree) for the structured questions (e.g. definitions, goals, questions, target users) and judged the evidence and the recommendations.

[Update on Current Care Guideline: Diabetic retinopathy]

Good treatment of diabetes decreases the risk of diabetic retinopathy. The goals of the treatment are adequate glucose balance, blood pressure and prevention of metabolic syndrome. Every patient with diabetes should regularly be screened for diabetic retinopathy. Timely and efficient treatment of retinopathy significantly decreases the risk of visual impairment.

Patient-specific computer-based decision support in primary healthcare--a randomized trial

BACKGROUND

Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice. However, evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems. In Finland, we designed a trial where a set of evidence-based, patient-specific reminders was introduced into the local Electronic Patient Record (EPR) system. The aim was to measure the effects of such reminders on patient care. The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group, indicating an improvement in patient care.

METHODS

From July 2009 to October 2010 all the patients of one health center were randomized to an intervention or a control group. The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional (HCP) opened and used the EPR. In the intervention group, the triggered reminders were shown to the HCP; in the control group, the triggered reminders were not shown. The primary outcome measure was the change in the number of reminders triggered over 12 months. We developed a unique data gathering method, the Repeated Study Virtual Health Check (RSVHC), and used Generalized Estimation Equations (GEE) for analysing the incidence rate ratio, which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group.

RESULTS

In total, 13,588 participants were randomized and included. Contrary to our expectation, the total number of reminders triggered increased in both the intervention and the control groups. The primary outcome measure did not show a significant difference between the groups. However, with the inclusion of patients followed up over only six months, the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors (age, gender, number of diagnoses and medications) were controlled for.

CONCLUSIONS

Computerized, tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system.

TRIAL REGISTRATION

ClinicalTrial.gov NCT00915304.

[Systematic reviews]

Systematic reviews aim to systematically identify, critically assess and summarise all relevant studies on a specific topic. The present article gives advice on how to find, assess and exploit systematic review on effectiveness. Systematic reviews on effectiveness constitute a source of knowledge for professionals within health care and welfare, researchers, developers and decision makers.

[How do I evaluate and utilize information provided by observational study]

The strength of observational study is the utilization of large materials in order to evaluate the risk factors and prognosis of disease, rare adverse effects of treatments and their everyday effectiveness. Observational studies are, however, associated with a higher risk of bias as compared with randomized controlled studies. Whereas the effectiveness of individual interventions under ideal conditions must be resolved in randomized studies, the effectiveness of treatment chains under routine healthcare conditions can be assessed only through observational studies.

[Principles and pitfalls of randomized controlled study]

Randomized controlled study is a central tool in the study of the prevention and treatment of diseases and effect of rehabilitation. Whereas prevention of bias resulting from potential differencies in study groups is a great advantage of the randomized study design, pitfalls are also involved in these studies. The task of the reader of the study is to evaluate the validity of the results, their clinical significance and possible applicability to one's own treatment decisions.

Removal of Bovine Insulin From Cow's Milk Formula and Early Initiation of Beta-Cell Autoimmunity in the FINDIA Pilot Study

OBJECTIVE To test whether weaning to a bovine insulin-free cow's milk formula (CMF) reduces type 1 diabetes mellitus-associated autoantibodies in children at genetic risk. DESIGN Randomized, double-blind pilot trial (Finnish Dietary Intervention Trial for the Prevention of Type 1 Diabetes [FINDIA]). SETTING Three pediatric hospitals in Finland from May 15, 2002, to November 22, 2005. PARTICIPANTS A total of 1113 infants with HLA-conferred susceptibility to type 1 diabetes were randomly assigned to receive study infant formulas; 908 children provided at least 1 follow-up blood sample (last follow-up, June 2009). INTERVENTION The CMF (n = 389), whey-based hydrolyzed formula (WHF) (n = 350), or whey-based FINDIA formula essentially free of bovine insulin (n = 365) during the first 6 months of life whenever breast milk was not available. MAIN OUTCOME MEASURES Primary outcome was beta-cell autoimmunity monitored at ages 3, 6, and 12 months and then annually until age 3 years. Autoantibodies to insulin, the 65-kDa isoform of glutamic acid decarboxylase, and the tyrosine phosphatase-related IA-2 molecule were screened, and islet cell autoantibodies and autoantibodies to zinc transporter 8 were analyzed in infants whose primary screening test results were positive. RESULTS In the intention-to-treat analysis, 6.3% of children in the CMF group, 4.9% of those in the WHF group, and 2.6% of children in the FINDIA group were positive for at least 1 autoantibody by age 3 years. The odds ratios were 0.75 (95% CI, 0.37-1.54) in the WHF group and 0.39 (0.17-0.91) in the FINDIA group when compared with the CMF group. In the treatment-received analysis, the corresponding odds ratios were 0.81 (95% CI, 0.37-1.76) and 0.23 (0.08-0.69). CONCLUSION In comparison with ordinary CMF, weaning to an insulin-free CMF reduced the cumulative incidence of autoantibodies by age 3 years in children at genetic risk of type 1 diabetes mellitus. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01055080.

[Update in Current Care guidelines. Evaluation of a suspected child sexual abuse]

According to Finnish Child Welfare Law, the authorities are obligated to report suspicions of child sexual abuse immediately to the police and to social services to ensure the well being of the child. The investigating police may request assistance for forensic interviews and medical assessments from specialized units. The child's disclosure is often the most important part of the evaluation. The timing of medical examination is crucial to obtain biological trace of evidence and to document evidence of acute injury or infection. The need for crisis support must be evaluated.

Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care

Background

Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals.

Methods

The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics.

Results

The content of the guidance is a significant feature of the primary care professional’s intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use.

Conclusions

Primary care professionals have to perceive eCDS guidance useful for their work before they use it.

Academic skills in children with early-onset type 1 diabetes: the effects of diabetes-related risk factors

AIM

The study aimed to assess the effects of diabetes-related risk factors, especially severe hypoglycaemia,on the academic skills of children with early-onset type 1 diabetes mellitus (T1DM).

METHOD

The study comprised 63 children with T1DM (31 females, 32 males; mean age 9 y 11 mo,SD 4 mo) and 92 comparison children without diabetes (40 females, 52 males;mean age 9 y 9 mo,SD 3 mo). Children were included if T1DM had been diagnosed before the age of 5 years and if they were aged between 9 and 10 years at the time of study. Children were not included if their native language was not Finnish and if they had a diagnosed neurological disorder that affected their cognitive development. Among the T1DM group, 37 had and 26 had not experienced severe hypoglycaemia and 26 had avoided severe hypoglycaemia. Severe hypoglycaemia, diabetic ketoacidosis(DKA), and glycaemic control were used as T1DM-related factors. Task performance in reading, spelling, and mathematics was compared among the three groups, and the effects of the T1DM-related factors were analysed with general linear models.

RESULTS

The groups with (p<0.001) and without (p=0.001) severe hypoglycaemia demonstrated a poorer performance than the comparison group in spelling, and the group without severe hypoglycaemia showed a poorer performance than the comparison group in mathematics (p=0.003).Severe hypoglycaemia, DKA, and recent glycaemic control were not associated with poorer skills,but poorer first-year glycaemic control was associated with poorer spelling (p=0.013).

INTERPRETATION

An early onset of T1DM can increase the risk of learning problems, independently of the history of severe hypoglycaemia or DKA. Poorer glycaemic control after the first year of T1DM is associated with a poorer acquisition of academic skills indicating the effect of the timing of metabolic aberrations on cognitive development.

[Update on Current Care guidelines: obesity (children)]

Childhood obesity is an increasing health problem. There may be possibilities to prevent obesity in childhood, and efficient interventions to treat obese children have been published. Local and regional strategies to prevent and to treat childhood obesity are needed.

[Update on current care guidelines: appropriate treatment of medical problems associated with Down's syndrome]

The lifetime prognosis of people with Down's syndrome has improved. Development of the services that health care and society can offer to such people is ongoing. These guidelines are targeted at defining what is required to further increase the lifespan and quality-of-life of people with Down's syndrome.

Verbal and academic skills in children with early-onset type 1 diabetes

AIM

Basic verbal and academic skills can be adversely affected by early-onset diabetes, although these skills have been studied less than other cognitive functions. This study aimed to explore the mechanism of learning deficits in children with diabetes by assessing basic verbal and academic skills in children with early-onset diabetes and in comparison children. In addition, the incidence of dyslexia (< or =10th centile in reading speed or reading-spelling accuracy) was studied.

METHOD

The performance of 51 children with early-onset diabetes (25 females, 26 males; mean age 9y 11mo, SD 4mo; range 9-10y) was compared with that of 92 children without diabetes (40 females, 52 males; mean age 9y 10mo, SD 3mo; range 9-10y) in the tasks of phonological processing, short-term memory, rapid automatized naming, reading, spelling, and mathematics.

RESULTS

The performance of children with diabetes was poorer than that of the comparison children in phonological processing (p=0.001), spelling accuracy (p<0.001), and mathematics (p=0.024). They learned to read later (p=0.013), but reading performance and the incidence of dyslexia in the third grade (aged 9-10y) were similar in the two groups.

INTERPRETATION

Children with early-onset diabetes are prone to minor learning difficulties in their early school years as a result of deficits in phonological processing.

Healthcare professionals' intentions to use clinical guidelines: a survey using the theory of planned behaviour

Background

Finnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour.

Methods

A cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions.

Results

The results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals.

Conclusions

The results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.

Towards a National Health Information System evaluation

Most EU Member States have a documented policy on eHealth. Documented follow-up and evaluation strategies for assessing whether national level systems have reached their set aims and outcomes are, however, rare. Methodologies for large scale information system assessment and evaluation are poorly established. This article describes the approach used to generate the Finnish National Health Information System (NHIS) evaluation plan. The core elements of the plan are illustrated, discussing also challenges and solutions in implementation. The article is based on NHIS evaluation planning project [15] and its presentation in the MIE workshop in Sarajevo in 2009 [16], where core issues and challenges of large-scale evaluations were discussed using the Finnish NHIS evaluation plan as a frame of reference.The Finnish plan offers other countries tools with which to assess their own plans and generate national methodologies for NHIS evaluation.

[Judgment of the level of evidence and strength of recommendations in healthcare according to the GRADE working group]

Finnish doctors are pioneers in the production and utilization of evidence-based recommendations in healthcare. Doctor's databases were established by the end of the 1980s and Current Care guidelines have been devised since 1994. In evidence-based recommendations it is essential to provide the user with a description of the quality of research data used as the basis for the recommendation. Consistent, applicable and transparent methods are helpful in the judgment of the quality of studies and strength of evidence. In this article we describe the judgment of the level of evidence and the strength of recommendations according to the international GRADE working group.

Breastfeeding stimulates total and cow's milk-specific salivary IgA in infants

Breastfeeding may increase the rate of mucosal maturation and IgA production. We sought to determine the effect of breastfeeding vs. formula-feeding on the maturation of oral mucosa by measuring the salivary total antibodies and cow's milk protein-specific IgA. Fifty-eight saliva samples were collected from 39 healthy, full term infants. At the age of 3 months (n = 25) eight infants received only breast milk and seventeen formula (cow's milk based n = 10, hydrolysed n = 7) and breast milk; and at the age of 6 months (n = 33) eleven received breast milk, seventeen formula and breast milk and five were not breastfed any more (cow's milk based n = 14, hydrolysed n = 8). Total IgA, IgG, IgM and protein, and beta-lactoglobulin specific IgA were measured from saliva with enzyme-linked immunoassay (ELISA). The antibody results were proportioned to total protein. No differences in antibody levels between the feeding groups were found at 3 months of age. At 6 months, total IgA, total IgM and beta-lactoglobulin-specific IgA were higher among the breastfed infants compared to those receiving formula as supplement to breast milk or not breastfed any more (breast milk vs. any formula p = 0.029, p = 0.015, p = 0.058; breast milk vs. cow's milk formula p = 0.025, p = 0.044, p = 0.038). To conclude, breastfeeding stimulated the mucosal immune system to produce IgA to saliva, which is a marker for immunological maturation and likely provides protection against environmental antigens.

Planning for national health information system evaluation

Most EU member states have a documented policy on eHealth. Documented follow-up and evaluation policies to assess reaching of the set aims, as well as evaluating outcomes of implemented systems at a national level are, however, rare. Methodologies for large scale information system assessment and evaluation are poorly established. In the workshop, the Finnish evaluation plans for the National Health Information System (NHIS) are used as a case in the workshop to reflect on core issues and challenges in large-scale evaluation for supporting system development, implementation and positive impacts. The results of the discussions are documented to be used in further refinement of the Finnish evaluation methodology and for enhancing networking of respective parties in different countries. The results will also benefit participants including policy makers, developers and researchers of national eHealth systems in pursuit of national evaluation activities.

[Update on current care guidelines. Eating disorders in children and adolescents]

Eating disorders in childhood and adolescence are considered to involve both somatic and psychological problems. Treatment soon after diagnosis is aimed at correcting the nutritional and somatic status, including psychoeducative guidance and support for the patients and their family. Multi-professional cooperation is needed in the diagnosis and treatment of eating disorders. Once serious undernutrition is corrected, psychotherapy is indicated. Early and active treatment is associated with favourable prognosis.

Probe based manipulation and assembly of nanowires into organized mesostructures

A convenient approach to patterning inorganic and organic nanowires using a novel probe manipulator is presented. The system utilizes an electrochemically etched tungsten wire probe mounted onto a 3D actuator that is directed by a 3D controller. When it is engaged by the user, the movement of the probe and the forces experienced by the tip are simultaneously reported in real time. Platinum nanowires are manipulated into organized mesostructures on silicon chip substrates. In particular, individual nanowires are systematically removed from aggregates, transferred to a chosen location, and manipulated into complex structures in which selected wires occupy specific positions with defined orientations. Rapid prototyping of complex mesostructures, by pushing, rotating and bending conjugated polymer, i.e., polyfluorene, nanowires into various configurations, is also achieved. By exploiting the strong internal axial alignment of polymer chains within the polyfluorene nanowires, mesostructures tailored to exhibit distinctly anisotropic optical properties, such as birefringence and photoluminescence dichroism, are successfully assembled on fused silica substrates.

Lumbar bone mineral density in normal subjects aged 3-6 years: a prospective study

Longitudinal studies on bone mineral density (BMD) accrual in young children are scarce. The purpose of the present study was to evaluate prospectively the development of spinal BMD in healthy Finnish children aged 3-6 y by dual-energy x-ray absorptiometry (DXA). Lumbar spine (L2-L4) areal BMD (g/cm2) was measured by DXA (Lunar DPX) in 20 children (10M, 10F) aged 3.3-6.9 y (median 4.8 y) at baseline and after a median follow-up of 1.0y (range 0.8-1.1 y). Apparent volumetric BMD (BMDvol, g/cm3) was calculated to minimize the effect of bone size on BMD in growing spine. At baseline, lumbar areal and volumetric BMDs (mean +/- SD) for males were 0.623+/-0.087 g/cm2 and 0.270+/-0.034 g/cm3, respectively, and for females 0.620+/-0.082 g/cm2 and 0.254+/-0.035 g/cm3, respectively. During the median follow-up of 1 y, lumbar areal and volumetric BMDs (mean +/- SD) increased in males by 4.7+/-2.7% (p < 0.01) and 3.5+/-3.5% (p <0.05), respectively, and in females by 7.2+/-5.3% (p <0.01) and 3.1+/-3.1% (p <0.05), respectively. No statistically significant difference in the BMD values was observed between the sexes.

CONCLUSION

A significant increase in both areal and apparent volumetric BMD was observed in children aged 3-6 y during a follow-up of I y. The increase in volumetric BMD indicated that there was a real accrual of BMD in growing spine measured by DXA. The present study provides prospective data on BMD accrual in young children for the evaluation of bone mass development in early childhood.

A theoretical study of the77Se NMR and vibrational spectroscopic properties of SenS8–nring molecules

The structures and spectroscopic properties of SenS8–nring molecules have been studied by the use of ab initio molecular orbital techniques and density functional techniques involving Stuttgart relativistic large core effective core potential approximation with double zeta basis sets for valence orbitals augmented by two polarization functions for both sulfur and selenium. Full geometry optimizations have been carried out for all 30 isomers at the Hartree-Fock level of theory. The optimized geometries and the calculated fundamental vibrations and Raman intensities of the SenS8–nmolecules agree closely with experimental information where available. The nuclear magnetic shielding tensor calculations have been carried out by the Gauge-independent atomic orbital method at the DFT level using Becke's three-parameter hybrid functional with Perdew/Wang 91 correlation. The isotropic shielding tensors correlate well with the observed chemical shift data. The calculated chemical shifts provide a definite assignment of the observed77Se NMR spectroscopic data and can be used in the prediction of the chemical shifts of unknown SenS8–nring molecules.Key words: selenium sulfides, ab initio, DFT, effective core potentials, geometry optimization, energetics, fundamental vibrations,77Se chemical shifts.