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PubMed2002

Understanding usage patterns of handheld computers in clinical practice.

Handheld computers are commonly used in clinical practice and often considered invaluable by physicians. Though full of promise, the technology is still costly and literature assessing its real use in clinical practice remains scarce. In an effort to better understand how Personal Digital Assistants (PDA) can be utilized as clinical tools, we designed a study that closely monitored the use of a selection of handheld applications by a cohort of interns in a service of Internal Medicine. Information gathered about actual use of the mobile applications offer valuable insights on usage patterns of tools that promise to be become an important part of our clinical practice in the years to come, and will hopefully help guide future developments.

Computers, Handheld↗
PubMed2003

Evidence-based practice: justifying changes in clinical practice based upon the appraisal of evidence.

Patients with diabetes are known to be at higher risk of foot ulceration that can often lead to limb amputation. Anecdotal evidence suggested that the provision of a multidisciplinary foot clinic for patients with diabetes could improve outcomes. Although this approach appears common sense the author required evidence to support a bid for a change in practice. This paper begins by describing some of the origins and principles of evidence based practice and how they can be applied in practice. The search for evidence and critical appraisal of two papers is explained. The tools used to assist implementation of the change in practice are included. The paper concludes with recommendation for changes in practice based upon the evidence found.

Amputation, Surgical↗
PubMed2001

Using clinical practice analysis to improve care.

BACKGROUND: Improving clinical outcomes requires that physicians examine and change their clinical practice. Sustaining outcome improvements requires a dedicated and dynamic program of analyzing and improving patient care. In 1992 North Mississippi Health Services (NMHS) implemented a program to improve physicians' clinical efficiency. CLINICAL PRACTICE ANALYSIS ( CPA): CPA uses evidenced-based guidelines and examines each physician's resource utilization, processes, and outcomes for a diagnosis or procedure. Clinical practice profiles are developed, and individual performance is compared to local and national benchmarks and presented to physicians. The CPA process is used on its own or as a component of more comprehensive performance improvements projects. Physicians have been engaged in outcome improvement by more than 55 CPA projects. RESULTS: NHMS has progressively reduced its Medicare loss and its length of stay (LOS) to 4.9 days. Mortality and readmission rates have been reduced in specific diagnoses. The community-acquired pneumonia project reduced the LOS from 7.7 to 5.1 days, decreaesed the mortality rate from 8.9% to 5.0%, and decreased the cost of care from $4,269 to $3,834. The ischemic stroke project reduced the aspiration pneumonia rate from 6.4% to 0% and mortality from 11.0% to 4.6%. Patients' average LOS decreased from 10.7 days to 6.5 days, and their cost of care was reduced by $1,100 per patient. DISCUSSION: Providing individualized data has engaged physicians in improving outcomes. The program has evolved from improving efficiency to managing outcomes and from simple CPA projects to integrated performance improvement projects; however, the CPA process remains the cornerstone of the current process.

Anti-Bacterial Agents↗
PubMed1994

Nurse teachers' feelings about participating in clinical practice: an exploratory study.

The aim of this small study was to explore nurse teachers' feelings about participating in clinical practice. An exploratory design was used entailing focused interviews with 10 nurse teachers which explored their current participation in clinical practice and their feelings about this. Other areas addressed were the perceived benefits and negative effects of participating in practice, as well as the factors which may inhibit or enable teachers participating in practice. It was found that while half the teachers had some participation in practice, only one participated on a regular basis. The teachers were generally dissatisfied with their current level of clinical practice. The teachers identified a number of potential benefits of practising, including keeping in touch with clinical practice, maintenance of clinical skills, improved relationships with trained staff and the opportunity to use knowledge and skills in practice. Perceived negative effects were that their clinical participation may be misinterpreted, or may impinge on other aspects of the role. Some also felt that the limited time which they would have available, would lead to their clinical practice being ineffective. The two major factors which affected whether nurse teachers were able to participate in practice were time and the college philosophy/culture. Other important factors were support from clinical staff, clinical confidence, and the teacher's role perception and attitude towards practice. As recent publications have inferred the need for nurse teachers to remain involved in clinical practice, teachers need to identify how clinical practice may best be achieved, and clarify their aims for practising. Different models of practice may be appropriate for individual teachers. It seems that a supportive environment and a college culture which values nurse teachers practising would be beneficial if clinical practice is to become part of the teacher's role.

Attitude of Health Personnel↗
PubMed2003

Good clinical practice: a nuisance, a help or a necessity for clinical pharmacology?

This article reviews the impact of good clinical practice (GCP) on clinical pharmacology with particular reference to the new European Union Clinical Trial Directive. The Directive will be applied to both commercial and noncommercial studies on medicinal products for human use. The Directive requires that GCP should be used in all clinical trials except noninterventional studies. GCP is likely to follow the International Conference on Harmonization GCP guidelines in many aspects. GCP will enforce tighter guidelines on ethical aspects of a clinical study. Higher standards will be required in terms of comprehensive documentation for the clinical protocol, record keeping, training, and facilities including computers. Quality assurance and inspections will ensure that these standards are achieved. The additional requirements of GCP are discussed and any advantage to the study subject. The impact of the new Directive within the Research Governance Framework of the UK Department of Health is reviewed.

Clinical Protocols↗
PubMed2006

The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices.

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Biomedical Research↗
PubMedDate not supplied

Clinical practice: an emphasis strategy for promotion and tenure.

TOPIC: Emphasizing clinical practice in promotion and tenure materials. PURPOSE: To share a successful strategy centered on clinical practice with members of the tenure track, advanced practice nurse faculty. SOURCE: Published literature, author's experience. CONCLUSION: Creativity and planning can assist tenure track faculty members in emphasizing their clinical practice for promotion and tenure. Recognition and rewards for clinical practice beyond the school of nursing continue to be challenges in the larger univerisity.

Career Mobility↗
PubMed1999

Making clinical practice guidelines work: the experience of one home healthcare agency.

Almost 20 years have passed since clinical practice guidelines were introduced into the healthcare system and they have permeated into every area of clinical practice. Originally clinical practice guidelines were regarded, by healthcare chief executive officers, as "the answer" to the need to reduce inappropriate or unnecessary variation in clinical practice. Between 1990 and 1996, the U.S. Agency for Health Care Policy and Research introduced 19 practice guidelines in an effort to support evidence-based methods to assess medical treatments and to set high standards for the development of guidelines. This article will explore the development and/or adoption and clinical application of guidelines into practice.

Chronic Disease↗
PubMed2004

Variations in evidence-based clinical practices in nine United States Veterans Administration opioid agonist therapy clinics.

BACKGROUND: Opioid agonist therapy (OAT) for opioid dependence has a strong evidence base, but clinical practice often does not conform to evidence-based practices. The goal of the OpiATE Initiative is to improve patient outcomes by implementing four evidence-based practices in United States Veterans Administration OAT clinics: (1) long-term maintenance orientation, (2) adequate dosing, (3) adequate counseling, and (4) use of contingency management. METHODS: The OpiATE monitoring system (OMS) was developed to help clinics assess concordance with evidence-based practices. For each patient, counselors record current agonist dose, recent counseling frequency, length of treatment, and urine toxicology results. For patients with sub-standard agonist doses, an algorithm was used to determine if the current dose was clinically appropriate. Maintenance orientation was assessed using the abstinence orientation scale. RESULTS: Concordance with counseling recommendations was uniformly high, concordance with maintenance orientation and dosing recommendations varied widely across clinics, and concordance with contingency management principles was low. Abstinence orientation scores were negatively correlated with dose and patient retention. Dose was negatively correlated with percent of urine screens positive for non-medical opioids and other illicit substances. CONCLUSIONS: The OMS was well accepted by clinic staff. Wide variability in clinical practices and outcomes across clinics supports the importance of individualizing quality improvement strategies to address specific performance gaps.

Analgesics, Opioid↗
PubMed2006

[Patient satisfaction with outpatient/short stay operations in a practice clinic].

BACKGROUND: In a pilot scheme for outpatient/short-stay surgery in a practice clinic in Magdeburg, Germany, as well as medical indicators patient satisfaction was evaluated as part of its research programme. Typically, the recovery phase is transferred to the home environment. For this reason the practice clinic has little opportunity to observe the patient's post-operative course. Patient satisfaction, therefore, is a particularly important indicator in evaluating the quality of patient care in outpatient, generally elective, surgery. This study assessed patient satisfaction with the services offered by the practice clinic. The analysis also identified which determinants had significant impact on patient satisfaction in order to obtain information about reasonable measures for improvement. METHODS: A questionnaire developed by Blum to evaluate patient satisfaction with outpatient surgery in a hospital setting was slightly modified. The questionnaire contained 77 items, which included overall satisfaction as well as the following attributes: information, participation in decision-making, care, health care processes and organisation, post-operative recovery and follow-up care at home. All 420 patients treated were surveyed during two data collection periods in autumn 2001 and summer 2002. RESULTS: Response rate was 55.7% (234/420). Overall satisfaction was very high. Only 3.6% of patients were dissatisfied. Of the individual attributes patients were most satisfied with care, follow-up care at home, and participation in decision-making. 19% of the patients had criticisms relating to "post-operative recovery". Three out of six items could be identified as determinants of overall satisfaction (R(2) = 0.4 in a forward stepwise multiple linear regression analysis): participation in decision-making, follow-up care at home and health care processes and organisation in the practice clinic. Patients expectations and needs explained 79% of variance in satisfaction with participation in decision-making. DISCUSSION: The very high satisfaction scores, however, include criticism of detail and indicate scope for improvement. Negative reaction to the particularly relevant attribute "participation in decision-making" can markedly impair overall satisfaction. Patients' participation in their care has a special place with regard to patient satisfaction. The practice clinic intends to repeat the study as a part of its quality assurance programme.

Adolescent↗
PubMedDate not supplied

Clinical practice guidelines: loss of clinical freedom or a coming of age?

When a woman presents to us with gynecological cancer our duty is to offer the most effective means of treatment; that which maximizes the potential for cure at the same maintaining or improving quality of life. For the majority of our patients we are able to contemplate cure but for many, particularly those with advanced ovarian cancer, this will not be possible although we can provide the prospect of several years of survival. In an international context our ability to provide optimal care depends largely on the healthcare resources which are affordable, and although in many parts of the world these are very limited, the same principles apply. This series of articles will put the spotlight on effective care in gynaecological oncology following an evidence based theme. The articles will be informative, punchy and provocative. The first of these contributions looks at clinical guidelines: what are they for, how do we produce them and is there any evidence that they do any good?

Evidence-Based Medicine↗
PubMed2003

Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.

BACKGROUND: International interest in clinical practice guidelines has never been greater but many published guidelines do not meet the basic quality requirements. There have been renewed calls for validated criteria to assess the quality of guidelines. OBJECTIVE: To develop and validate an international instrument for assessing the quality of the process and reporting of clinical practice guideline development. METHODS: The instrument was developed through a multi-staged process of item generation, selection and scaling, field testing, and refinement procedures. 100 guidelines selected from 11 participating countries were evaluated independently by 194 appraisers with the instrument. Following refinement the instrument was further field tested on three guidelines per country by a new set of 70 appraisers. RESULTS: The final version of the instrument contained 23 items grouped into six quality domains with a 4 point Likert scale to score each item (scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, editorial independence). 95% of appraisers found the instrument useful for assessing guidelines. Reliability was acceptable for most domains (Cronbach's alpha 0.64-0.88). Guidelines produced as part of an established guideline programme had significantly higher scores on editorial independence and, after the publication of a national policy, had significantly higher quality scores on rigour of development (p<0.005). Guidelines with technical documentation had higher scores on that domain (p<0.0001). CONCLUSIONS: This is the first time an appraisal instrument for clinical practice guidelines has been developed and tested internationally. The instrument is sensitive to differences in important aspects of guidelines and can be used consistently and easily by a wide range of professionals from different backgrounds. The adoption of common standards should improve the consistency and quality of the reporting of guideline development worldwide and provide a framework to encourage international comparison of clinical practice guidelines.

Europe↗
PubMedDate not supplied

Skin cancer prevention counseling and clinical practices of pediatricians.

Little is known about pediatricians' counseling and clinical practices to reduce skin cancer risk among their patients. Thus our objectives were to characterize skin cancer preventive counseling and clinical practices in a sample of pediatricians and identify correlates of these practices. Physicians practicing general pediatrics in Harris County, Texas, received a mail survey that assessed their sun protection recommendations and skin cancer preventive counseling and clinical practices. Pediatrician, patient, and medical practice variables were assessed as correlates. Most (76%) pediatricians routinely recommended sunscreen; however, relatively few (24%) suggested reapplying it after prolonged periods outside. About half routinely recommended protective clothing (53%), shade (47%), or limiting midday sun exposure (46%). Even fewer pediatricians routinely discussed skin cancer risk factors, passed out sunscreen samples, made educational materials available, took a family history of skin cancer, or documented risk factors in a patient's chart. More than half reported that they routinely performed full-body skin examinations during a first visit (65%) and annually (56%). Perceived barriers, perceived relevance of skin cancer prevention, and personal sun protection practices were important factors associated with professional practices in this sample. Interventions are needed to increase pediatricians' counseling and clinical practices to reduce skin cancer risk among patients.

Adolescent↗
PubMed2004

Finding the best scientific evidence to support clinical practice.

The role of science in clinical practice is nowadays fundamental. The constant publication of studies and clinical trials provides evidence of good quality that can be used by the clinician as a basis for medical decision-making, even in a context of uncertainty and risk. Valid and relevant information can help solve the problems of clinical knowledge in practice. The main question is then how practicing clinicians can learn about the innovations and acquire the recent information that can help them to change their practice for the better. The volume of medical literature is enormous and constantly growing, and it is difficult to manage. The increasing availability of secondary data sources for daily patient care provides practical and rapid access to all this information, enabling improvements in the quality of care. In this paper we present and discuss a set of modern and high-quality instruments to obtain useful information for clinical practice.

Clinical Medicine↗
PubMed2004

CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease: Application to Clinical and Public Health Practice: clinical use of inflammatory markers in patients with cardiovascular diseases: a background paper.

Inflammation is a recognized key component of acute coronary syndromes. Such pathogenetic achievement has led to the use of inflammatory cells and proteins as prognostic markers in these syndromes. A number of markers have been proposed, including proinflammatory cytokines such as interleukin-6, interleukin-1RA, and tumor necrosis factor-alpha, adhesion molecules such as intracellular adhesion molecule-1 and vascular adhesion molecule-1 and markers of cell activation. Although all are of scientific interest, the clinical use of these markers is limited by their high cost, low availability, and unfavorable biological profile. Conversely, common markers of inflammation such as C-reactive protein (CRP), the prototypic acute phase protein, and to a lesser extent fibrinogen, have been proven to be reliable and important markers of risk in ischemic heart disease. CRP, in particular, has been found to be associated with short- and long-term prognosis in acute coronary syndromes, including ST-elevation myocardial infarction, and in stable angina, and to predict the risk of restenosis and major events, including death, after revascularization procedures. CRP has been consistently found to be independent from other risk factors and to have an incremental value beyond the common risk factors and biochemical markers of risk, including troponin. Whether CRP also should be used as a guide to therapy is still a matter of discussion that deserves further, properly designed studies.

Angioplasty, Balloon, Coronary↗