Effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface: A quantitative systematic review

BACKGROUND

Globally, chronic disease is a leading cause of illness, disability and death and an important driver of health system utilization and spending. Continuity of care is a significant component of quality healthcare. However, an association between nurse-led services, interventions, patient outcomes and continuity of care at the primary and secondary interface as an outcome, has not been established for people with chronic disease.

OBJECTIVE

To identify the effectiveness of nurse-led services for people with chronic disease in achieving an outcome of continuity of care at the primary-secondary healthcare interface.

DESIGN

Quantitative systematic review.

DATA SOURCES

Systematic searches of Medline, Cochrane, Embase, Emcare, JBI and Scopus databases were conducted of studies published between 1946 and May 2019 using the search terms "nurse", "continuity of care" and "chronic disease".

REVIEW METHODS

Quality of the included studies was assessed using the Cochrane risk of bias tool for randomized controlled trials and Joanna Briggs Institute quality appraisal checklists. A second reviewer screened 10% of full text articles and all articles in critical appraisal. Studies were excluded from the review if they were of poor methodological quality or the description of the effect of the nurse-led service was inadequately reported.

RESULTS

Fourteen studies were included in the review (n=4,090 participants). All studies incorporated recognized continuity of care interventions. The nurse-led services were associated with fewer hospitalizations, reduced by 2-8.9% and re-admissions reduced by 14.8-51% (n=886). Reporting of positive patient experiences and improvement in symptoms and lifestyle was also evident. An association of nurse-led services with improved continuity of care between primary and secondary health services as an outcome per se could not be concluded.

CONCLUSION

Nurse-led services for adults provide coordinated interventions that support continuity of care for people with chronic disease in both the primary and secondary healthcare settings that are associated with reduced hospitalizations or readmissions and patient satisfaction. However, the limited use of validated continuity of care outcome measurement tools precluded establishing correlations between interventions, patient outcomes and continuity of care as a specific outcome.

The optical characters of Antimonite

In a paper communicated to this Society in March, 1903, it was shown that antimonite is fairly transparent to radiations of long wave-length and that its behaviour between crossed nicols is consistent with orthorhombic symmetry. At the same time it was pointed out that it would be of interest to determine the wave-lengths of the radiations transmitted and the principal indices of refraction of antimonlte for these radiations. On undertaking this investigation it was soon found that antimonite was quite sufficiently transparent to the rays at the extreme red end of the visible spectrum to enable visual observations to, be made, and in a verbal communication to the Society on March 22, 1904, it was stated that the indices of refraction for red light were 4.129 for rays vibrating parallel to the axis Z and 3.873 for rays vibrating parallel to the axis X.

Participatory action research: moving beyond the mental health 'service user' identity

Contemporary models of involvement within statutory services pay little regard to the identity of individuals beyond the 'service user' label and in doing so unwittingly perpetuate and sustain the negative impact of mental illness. The aim of this paper is to discuss the process of a 3-year participatory action research study facilitated by a mental health nurse. It highlights the perspective of those involved as co-researchers, all having experience of accessing statutory mental health services. It identifies both the process and the impact of this type of involvement on them illustrating their move beyond an illness identity. The study involved them undertaking a series of interviews with other service users in relation to their life stories. They subsequently mapped and analysed the transcripts. In order that the people were enabled to undertake these roles the study included a process of interviewing and appointing service user researchers followed by a programme of training workshops, supervision and discussion group/peer support. The accounts provided reflect the six researchers' attempts to make sense of their experience and reveal the path of transformation through collaboration.

Abstract LB-337: Synergistic effects of twelve common genetic polymorphisms and smoking habits on absolute risk of bladder cancer

Smoking is the strongest established risk factor for bladder cancer and recent studies have identified multiple common susceptibility loci for this disease. Evaluation of gene-smoking interactions on absolute risk of bladder cancer could be important for understanding both the public health and biological significance of the combined effect of these factors. However, previous studies of gene-environment interactions focused on relative rather than absolute risk measures and thus did not address this important question. The aim of our analyses was to estimate absolute risk of bladder cancer in relation to smoking habits and 12 known susceptibility variants for this disease, and to evaluate if smoking risk differences (RD) vary by levels of a polygenic risk score derived from these variants, using additive tests for interaction. Analyses were based on data from 4,098 cases and 5,995 controls of European background in eight studies participating in the NCI bladder cancer genome-wide association study (GWAS). Absolute risks were estimated based on US incidence and mortality data. The main outcome measures were 30-year cumulative absolute risk of bladder cancer and RDs for males aged 50 years in relation to smoking habits and the polygenic risk score. RDs for ever compared to never smokers were significantly larger (P-additive interaction < 0.05) for subjects carrying risk alleles for seven out of 12 known susceptibility variants. Polymorphisms in two detoxification enzymes, NAT2 and UGT1A6, provided the strongest evidence of additive interactions (P-additive interaction of 0.0002 and 0.0003, respectively), supporting the presence of biological interactions between smoking and these variants. The 30-year risk of bladder cancer in never, former and current smokers was 0.7%, 1.6% and 3.7%, respectively, for subjects in the bottom quartile of the polygenic risk score, compared to 2.0%, 5.1% and 8.0% for subjects in the top quartile. This translates into a significantly larger number of projected cases, which could be avoided by smoking prevention in subjects at higher compared to lower genetic risk (P-additive (2df)=4.6x10-9 for top to bottom quartile of the polygenic risk score). In conclusion, our analyses provide strong evidence for synergistic effects of smoking and known susceptibility loci for bladder cancer on the absolute risk of the disease. This indicates that targeting intense smoking prevention efforts to individuals at elevated genetic risk for bladder cancer could improve the public health impact of such efforts. However, genetic susceptibility for other smoking-related diseases, as well as practical and ethical considerations, would need to be taken into account before any recommendations could be made. (MGC, NR are Co-first authors; N.C. and DTS are Co-last authors)

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-337. doi:1538-7445.AM2012-LB-337

Worldwide genetic structure in 37 genes important in telomere biology

Telomeres form the ends of eukaryotic chromosomes and are vital in maintaining genetic integrity. Telomere dysfunction is associated with cancer and several chronic diseases. Patterns of genetic variation across individuals can provide keys to further understanding the evolutionary history of genes. We investigated patterns of differentiation and population structure of 37 telomere maintenance genes among 53 worldwide populations. Data from 898 unrelated individuals were obtained from the genome-wide scan of the Human Genome Diversity Panel (HGDP) and from 270 unrelated individuals from the International HapMap Project at 716 single-nucleotide polymorphism (SNP) loci. We additionally compared this gene set to HGDP data at 1396 SNPs in 174 innate immunity genes. The majority of the telomere biology genes had low to moderate haplotype diversity (45-85%), high ancestral allele frequencies (>60%) and low differentiation (FST<0.10). Heterozygosity and differentiation were significantly lower in telomere biology genes compared with the innate immunity genes. There was evidence of evolutionary selection in ACD, TERF2IP, NOLA2, POT1 and TNKS in this data set, which was consistent in HapMap 3. TERT had higher than expected levels of haplotype diversity, likely attributable to a lack of linkage disequilibrium, and a potential cancer-associated SNP in this gene, rs2736100, varied substantially in genotype frequency across major continental regions. It is possible that the genes under selection could influence telomere biology diseases. As a group, there appears to be less diversity and differentiation in telomere biology genes than in genes with different functions, possibly due to their critical role in telomere maintenance and chromosomal stability.

Assessing quality of care from hospital case notes: comparison of reliability of two methods

OBJECTIVES

To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care.

DESIGN

Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale.

SETTING

Nine randomly selected acute hospitals in England.

PARTICIPANTS

Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. ANALYSIS METHODS: Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison.

RESULTS

A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods.

CONCLUSIONS

Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.

Assessing the feasibility of distributing child poison safety messages through three existing parent information pathways

The objective of this exploratory study was to assess the feasibility of increasing parents' poison safety awareness and behaviours using existing pathways. The aim was to compare the release of true stories of child unintentional poisoning via three modes: (a) parent "networker"; (b) maternal and child health nurse; (c) the media. The stories spread by the parent networker were readily recalled by the parents, with examples of changed behaviour and spreading of the stories. Parents who were part of the maternal and child health nurse strategy were not able to recall the stories without prompts. The media strategy could not be implemented because of difficulties finding parents ready to publicise their story. Given that it is an exploratory study, it is not possible to draw conclusions about the effectiveness of each of the intervention strategies. However, it appears that a low-resource intervention using stories shared via parent networkers may have exciting potential as a health promotion tool. A stronger study design to examine its effectiveness is proposed.

Antibiotic prophylaxis for wound infections in total joint arthroplasty

We reviewed systematically the published evidence on the effectiveness of antibiotic prophylaxis for the reduction of wound infection in patients undergoing total hip and total knee replacement. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases. We also contacted authors to identify unpublished trials. We included randomised controlled trials which compared any prophylaxis with none, the administration of systemic antibiotics with that of those in cement, cephalosporins with glycopeptides, cephalosporins with penicillin-derivatives, and second-generation with first-generation cephalosporins.

A total of 26 studies (11 343 participants) met the inclusion criteria. Methodological quality was variable. In a meta-analysis of seven studies (3065 participants) antibiotic prophylaxis reduced the absolute risk of wound infection by 8% and the relative risk by 81% compared with no prophylaxis (p < 0.00001). No other comparison showed a significant difference in clinical effect.

Antibiotic prophylaxis should be routine in joint replacement but the choice of agent should be made on the basis of cost and local availability.

Polymorphisms in chemokine receptor genes and susceptibility to Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis occurring in young children. Its aetiology is unknown, but an infectious agent is assumed. Increased levels of proinflammatory cytokines and chemokines have been reported in KD. Genetic variation in these genes and the receptors for these genes could influence the regulation of cytokines and chemokines. In a case-control study of 170 Dutch Caucasian KD patients and 300 healthy Dutch Caucasian controls, common genetic variants in chemokine receptor genes CCR3, CCR2, CCR5, CX3CR1, CXCR1 and CXCR2 were analysed. Of the eight studied single nucleotide polymorphisms (SNPs) in the CCR3-CCR2-CCR5 gene cluster, four showed a significant association with susceptibility to KD. Moreover the CCR5-Delta32 was observed with an allele frequency of 10.7% in the control population compared to 6.5% in the KD patients (P = 0.04). Two haplotypes of the CCR3-CCR2-CCR5 gene-cluster appear to be at risk haplotypes for KD and one a protective haplotype. No association was observed with the studied SNPs in CX3CR1, CXCR1 and CXCR2. In conclusion, in a Dutch cohort of KD patients an association of KD occurrence with common genetic variants in the chemokine receptor gene-cluster CCR3-CCR2-CCR5 was observed.

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability

AIM

To explore the factor structure, reliability, and potential usefulness of a patient safety climate questionnaire in UK health care.

SETTING

Four acute hospital trusts and nine primary care trusts in England.

METHODS

The questionnaire used was the 27 item Teamwork and Safety Climate Survey. Thirty three healthcare staff commented on the wording and relevance. The questionnaire was then sent to 3650 staff within the 13 NHS trusts, seeking to achieve at least 600 responses as the basis for the factor analysis. 1307 questionnaires were returned (36% response). Factor analyses and reliability analyses were carried out on 897 responses from staff involved in direct patient care, to explore how consistently the questions measured the underlying constructs of safety climate and teamwork.

RESULTS

Some questionnaire items related to multiple factors or did not relate strongly to any factor. Five items were discarded. Two teamwork factors were derived from the remaining 11 teamwork items and three safety climate factors were derived from the remaining 11 safety items. Internal consistency reliabilities were satisfactory to good (Cronbach's alpha > or =0.69 for all five factors).

CONCLUSIONS

This is one of the few studies to undertake a detailed evaluation of a patient safety climate questionnaire in UK health care and possibly the first to do so in primary as well as secondary care. The results indicate that a 22 item version of this safety climate questionnaire is useable as a research instrument in both settings, but also demonstrates a more general need for thorough validation of safety climate questionnaires before widespread usage.

266 nm photolysis of CF3I and C2F5I studied by diode laser gain FM spectroscopy

Frequency modulated diode laser based absorption at 1.315 microm has been used to measure the Doppler lineshapes of the I((2)P(1/2)-(2)P(3/2)) transition in atomic iodine produced from the 266 nm photolysis of both CF(3)I and C(2)F(5)I. Wavelength resolved laser gain is seen following photolysis as excited iodine atoms ((2)P(1/2)) are produced with a quantum yield close to unity from photolysis of both parent molecules. Time resolved measurements were made and the nascent speed distribution and translational anisotropy parameter, beta were determined. Mean atomic speeds of 800 and 850 ms(-1), which correspond to 83 and 68% of the maximum possible kinetic energy release into the iodine photofragment, were determined for photolysis of CF(3)I and C(2)F(5)I, respectively. The nascent translational anisotropy parameter was found to be beta = 1.77 +/- 0.05 for CF(3)I and beta = 1.69 +/- 0.05 for C(2)F(5)I. These values are explicable in terms of parent rotational motion and non-adiabatic processes in the exit channel.

People with learning disabilities in 'out-of-area' residential placements: 1. Policy context

BACKGROUND

A growing shortage of residential care for people with learning disabilities leads to placement funded by one authority in another authority's area. Such out-of-area placements are governed by guidance from different government departments in respect of different funding streams.

METHOD

This paper presents an analysis of this guidance and shows that it is inconsistent and incomplete.

RESULTS AND CONCLUSION

The guidance creates a framework of incentives for health and social services authorities that could lead to people being placed out-of-area against their own best interests, with negative consequences for them and for the 'receiving' authorities. A companion paper uses interview data to examine the reasons for and effects of out-of-area placement.

People with learning disabilities in 'out-of-area' residential placements: 2. Reasons for and effects of placement

BACKGROUND

Official guidance on out-of-area placements creates incentives that could lead to people being placed against their own best interests, with negative consequences for them and for the 'receiving' authorities.

METHOD

Information was collected for 30 people through interviews with them, their families, home managers and care managers. Interviews concerned resident needs, reasons for placement, the homes, care management arrangements, resident quality of life and social inclusion. Information on care standards was abstracted from official records.

RESULTS

The main reasons for out-of-area placement were insufficient local services of acceptable quality, financial incentives and loss of family contact through prior institutionalization. The effects varied, with the most disabled people experiencing worst outcomes. Some aspects were worse than comparison studies (choice, community involvement, number of homes meeting all the national minimum standards), some were the same (participation, family visiting and other contact), and one was better (visits to families). Variation was also evident in the involvement of social services staff from the placing authority and in ease of access to local healthcare resources.

CONCLUSIONS

Social services and health authorities should develop services locally that can support people with the full range of individual needs. Perverse incentives should be removed, perhaps by increasing the application of direct payments and personalized budgets.

Vascular endothelial growth factor gene haplotypes in Kawasaki disease

OBJECTIVE

To investigate whether common genetic variants in the vascular endothelial growth factor (VEGF) gene are associated with Kawasaki disease (KD) and the subsequent development of coronary artery lesions.

METHODS

Common genetic variants in the VEGF gene were analyzed in an association study in a Dutch cohort of 170 KD patients and 300 healthy Dutch Caucasian controls. Genotyping was done with 5'-nuclease TaqMan assays and 3'-hybridization-triggered fluorescence minor groove binder Eclipse assays.

RESULTS

An association with susceptibility to KD was observed with 2 of the 6 single-nucleotide polymorphisms analyzed in VEGF: -2594 A>C (rs699947) and the 236 bp 3' of STP C>T (rs3025039). Also for an 18-bp deletion in the promoter of VEGF a significant difference in the genotype and allele frequencies was observed between the KD patients and the controls. The haplotype CGCC (based on rs699947, rs2010963, rs25648, and rs3025039) was significantly associated with the development of KD (hap score 3.8; P = 0.0002). VEGF plasma levels were significantly higher in patients with the early phase of KD than in the healthy controls, and there was a trend toward higher VEGF plasma levels in KD patients with the -2594 CC and 236 bp 3' of STP CC genotypes.

CONCLUSION

Our results suggest that polymorphisms of the VEGF gene may play a role in the pathogenesis of KD.

Understanding parental motivators and barriers to uptake of child poison safety strategies: a qualitative study

OBJECTIVES

To develop an understanding of factors acting as barriers and motivators to parental uptake of child poison safety strategies.

DESIGN

A qualitative study involving semistructured interviews and focus groups. A grounded theory approach was used for the collection and analysis of data.

PARTICIPANTS

Sixty five parents of children under 5 years of age, some of whom had experienced an unintentional child poisoning incident.

RESULTS

A range of knowledge based, environmental, and behavioral barriers to comprehensive parental uptake of poison safety practices were identified. As a result there tended to be only partial implementation of safety initiatives in the home. Selection of safety practices was often guided by the interests and behaviors of the child. This made the child vulnerable to changes in the home environment, inadequate supervision, and/or shifts in their own behavior and developmental ability. Personal or vicarious exposure of a parent to a child poisoning incident was a significant motivator for parental review of safety practices.

CONCLUSION

Environmental measures targeting child resistant containers, warning labels, and lockable poisons cupboards will support parents' efforts to maintain poison safety. Additional education campaigns using stories of actual poisoning incidents may help to increase awareness of risk and encourage increased uptake.

Clinical practice guidelines: barriers to durability after effective early implementation

BACKGROUND

Clinical practice guidelines in general (General-CPG) may reduce variation in clinician performance and improve patient outcomes. Short-term evaluation is now routine, but demonstration of early successful implementation does not necessarily ensure longer-term effectiveness.

AIM

To assess adherence to chronic obstructive pulmonary disease (COPD)-CPG recommendations at the Royal Melbourne Hospital (RMH), 2 years after successful implementation. To identify barriers to sustained success of General-CPG.

METHODS

A multi-faceted evaluation was performed to document: (i) current adherence to COPD management recommendations (medical record audit); (ii) awareness of attitudes towards and barriers for the use of COPD-CPG and General-CPG (staff survey, focus groups and key informant interviews) and (iii) access to and quality of available General-CPG (internet review and random sample General-CPG evaluation.

RESULTS

Adherence to COPD-CPG recommendations was highly variable. Adherence was higher in the Emergency Department than the general wards and for specific therapeutic recommendations. It was lower for non-pharmacological therapy and for recommendations relating to processes of care. Most health professionals were in favour of General-CPG. Barriers to use of General-CPG were in keeping with previous literature reports. Organizational issues including high levels of staff turnover and lack of integration of General-CPG into hospital quality frameworks were highlighted as major barriers. Hospital intranet access and presentation of General-CPG identified lack of consistency in terminology and presentation.

CONCLUSION

Short-term effectiveness of COPD-CPG implementation did not ensure sustained success. Departmental organizational behaviours and organizational system barriers are major factors influencing durability.

Readmission patterns in patients with chronic obstructive pulmonary disease, chronic heart failure and diabetes mellitus: an administrative dataset analysis

Comprehensive disease management programmes for chronic disease aim to improve patient outcomes and reduce health-care utilization. Readmission rates are often used as an outcome measure of effectiveness. This study aimed to document readmission rates, and risk for early and late readmission, for patients discharged from the Royal Melbourne Hospital with a disease diagnosis of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or diabetes mellitus compared to those with other general medical conditions. Eighty five (8.6%) of patients were readmitted within 28 days and 183 (20.8%) were readmitted between 29 and 180 days. No risk factors for early readmission were identified. Patients with a primary disease diagnosis of CHF and COPD are at increased risk of late readmissions (29-180 days).

Genotyping microarray (gene chip) for the ABCR (ABCA4) gene

Genetic variation in the ABCR (ABCA4) gene has been associated with five distinct retinal phenotypes, including Stargardt disease/fundus flavimaculatus (STGD/FFM), cone-rod dystrophy (CRD), and age-related macular degeneration (AMD). Comparative genetic analyses of ABCR variation and diagnostics have been complicated by substantial allelic heterogeneity and by differences in screening methods. To overcome these limitations, we designed a genotyping microarray (gene chip) for ABCR that includes all approximately 400 disease-associated and other variants currently described, enabling simultaneous detection of all known ABCR variants. The ABCR genotyping microarray (the ABCR400 chip) was constructed by the arrayed primer extension (APEX) technology. Each sequence change in ABCR was included on the chip by synthesis and application of sequence-specific oligonucleotides. We validated the chip by screening 136 confirmed STGD patients and 96 healthy controls, each of whom we had analyzed previously by single strand conformation polymorphism (SSCP) technology and/or heteroduplex analysis. The microarray was >98% effective in determining the existing genetic variation and was comparable to direct sequencing in that it yielded many sequence changes undetected by SSCP. In STGD patient cohorts, the efficiency of the array to detect disease-associated alleles was between 54% and 78%, depending on the ethnic composition and degree of clinical and molecular characterization of a cohort. In addition, chip analysis suggested a high carrier frequency (up to 1:10) of ABCR variants in the general population. The ABCR genotyping microarray is a robust, cost-effective, and comprehensive screening tool for variation in one gene in which mutations are responsible for a substantial fraction of retinal disease. The ABCR chip is a prototype for the next generation of screening and diagnostic tools in ophthalmic genetics, bridging clinical and scientific research.

Phenotype and genotype correlations in two best families

OBJECTIVE

To evaluate mutations in the Best mascular dystrophy (VMD2) gene in two families with Best disease and to describe the phenotype-genotype correlations of genetically determined affected and unaffected individuals.

DESIGN

Family genetic study.

PARTICIPANTS

Two families with Best disease were identified, and family members were evaluated by ophthalmologic examination or fundus photography to assess their phenotype. All affected patients and some of the unaffected family members had a blood sample drawn, and the DNA was analyzed for mutations in the VMD2 gene.

MAIN OUTCOME MEASURES

Twenty-one subjects in the two pedigrees with Best disease were studied. One amino acid-changing mutation in the VMD2 gene was found to segregate independently in each family (P297S or E300D, respectively).

RESULTS

Eleven individuals had some evidence of maculopathy, including retinal pigment epithelial changes, drusen, pigment epithelial irregularities, or cicatricial changes. Ten of these 11 patients (91%) with maculopathy had a mutation in the VMD2 gene, of whom 8 were clinically diagnosed as having Best disease and 2 were diagnosed as having possible Best maculopathy. The one patient without a mutation in the VMD2 gene had age-related macular degeneration (AMD). Ten family members did not have evidence of maculopathy, of whom 6 had no mutation in the VMD2 gene. Four family members (2 in each pedigree) had mutations in the VMD2 gene, abnormal electro-oculogram (EOG) results, but normal maculae at age 40 or older. Of the 7 individuals with no mutation in the VMD2 gene, 6 were phenotypically normal and the other had late-onset visual loss resulting from AMD.

CONCLUSIONS

All family members with maculopathy consistent with Best disease (n = 10) had an amino acid-changing mutation in the VMD2 gene. Four individuals who did not have maculopathy, but did have an abnormal EOG, also had mutations in the VMD2 gene. The presence of a VMD2 mutation is associated with abnormal retinal function, which can occur in the absence of phenotypic manifestation of macular disease.

Towards efficient guidelines: how to monitor guideline use in primary care

OBJECTIVES

To develop a model for using routine data monitoring in the evaluation of clinical guideline usage in primary healthcare settings.

DESIGN

A monitoring framework was developed following a number of semistructured interviews with potential users. These data informed a postal survey among a random sample of primary healthcare professionals. Then to test out the framework, a further semistructured interview study was used to explore the practical issues relating to monitoring guideline use. Case studies were then undertaken to investigate the use of evidence-based review criteria and patient-centred outcome measures as methods for providing monitoring information. A case study in one general practice used interviews to examine the possible costs associated with guideline-use monitoring.

SETTING AND PARTICIPANTS

Interviews were undertaken with primary care professionals from one local health community. The postal survey was undertaken among staff from a purposive sample of Health Authorities in England and a random sample of general practitioners and practice nurses from the selected Health Authority areas. The second phase involved interviews with Health Authority, Primary Care Group and general practice staff from three Health Authority areas. Case studies were undertaken in volunteer general practices and among patients who consented to provide confidential health outcome information.

RESULTS

Interviewees recognised some value in guideline-use monitoring, however they were concerned about the practicalities from two perspectives. First, although primary care computing systems were to be found in most general practices, the technology for monitoring was absent in many practices. Training in these skills would be required before monitoring of guideline use could be a practical reality. Second, there were clear signals of a more general lack of interest or awareness in the subject of continuous review of care. This, together with a feeling of being overloaded with new initiatives, meant that implementation of a monitoring framework could be problematic and might need considerable support in order to make progress.

CONCLUSIONS

Effective methods can be developed for monitoring guideline use in primary care. However there is a need to address the degree of understanding that many primary healthcare professionals have of the concepts and practical issues in the area of guideline-use monitoring, and of expectations of this within the NHS. In addition there are a number of technical issues concerned with efficient capture of clinical information and its evaluation. Further research is recommended in the following areas: the extent to which patient concordance with the guideline recommendations be taken into account in the assessment of clinician conformance with guideline recommendations; the costs and benefits to patient care of guideline-use monitoring; the most efficient methods of developing valid and reliable review criteria which are policy and evidence (guidelines) based; whether review criteria are more useful than guidelines in improving quality of care; what additional benefits to patient care can offered by monitoring patient-centred health outcomes in addition to process of care, and at what cost?