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PubMed2002

Effects of managed care on teaching, research, and clinical practice in academic plastic surgery.

The aim of this study was to determine: 1) if there have been changes in teaching, research, and clinical practice in academic plastic surgery in recent years; and 2) if there have been, are they associated with changes in the managed care environment? Gaining a clearer perspective on how managed care affects academic plastic surgery will enable academicians to define better the problems and opportunities they face mutually and to respond effectively to these issues. This study used a cross-sectional study design. Reference time periods were the premanaged care era (1990-1991) versus the current time (1997-1998). Data were collected by questionnaires sent to 94 academic program directors in plastic surgery. The main independent variable of managed care was measured as the difference in the percent of income from health maintenance organizations generated by each program in 1990 to 1991 versus 1997 to 1998. The dependent variables of teaching, research, and clinical practice were measured by the percentage of time spent in each category, the number of work hours per week, the number of staff personnel, the location of teaching, the number of grants and publications, and the percentage of reconstructive and cosmetic cases in 1990 to 1991 versus 1997 to 1998. Univariate analysis, paired Student's t-test, Fisher's exact test, Pearson's correlation, Spearman's correlation, and linear regression were used to establish significance (alpha = 0.05) of the effects of managed care on dependent variables. Sixty-six questionnaires were completed and returned (70% response rate). There were significant changes in the managed care environment, clinical practice (operating room and clinics), and research in academic plastic surgery from 1990 to 1997. The percentage of income generated from managed care increased from 9.8% (of total revenue) in 1990 to 23.6% in 1997 (an increase of 13.8%; p < 0.0001). Academic plastic surgeons were found to spend significantly more time in clinical practice (3% more of total time spent; 5.3 hours more per week in 1997; p < 0.016). This change correlated significantly with the increase in managed care (p < 0.015). In addition, the percentage of cosmetic cases increased from 18.0% in 1990 to 28.3% in 1997 (p < 0.001), and that of reconstructive surgery was reduced proportionately (p < 0.001). Also, a significant decrease in the time spent for research was observed (mean reduction, 2.8 hours less per week; p < 0.001). Although the trend was to a lower number, there were no significant changes in the amount of time spent in teaching (p > 0.08) and in administrative duty (p > 0.06), or in the number of personnel employed in the teaching programs (p > 0.05). In summary, these findings suggest that: 1) a greater percentage of revenue was generated from managed care in 1997 than in 1990, indicating a growing fiscal influence by managed care on academic plastic surgery; 2) furthermore, this change is associated with academic plastic surgeons devoting more time to clinical practice and less time to research endeavors; and 3) although managed care policies do affect teaching adversely, this effect has not yet reached significance for the period examined during this study.

Academic Medical Centers↗
PubMed2002

Role of JCAHO standards and clinical practice guidelines in promoting appropriate antimicrobial use.

The role of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards and clinical practice guidelines in promoting appropriate antimicrobial use and the development of such standards and guidelines are described. JCAHO is committed to continuously improve the safety and quality of patient care. Reducing antimicrobial resistance in health systems often requires change, something that many health care practitioners are reluctant to embrace. Current JCAHO standards suggest that the use of clinical practice guidelines be considered, but guideline use is not required. JCAHO's standards development process is lengthy and involved. Therefore, it is easier to effect change by modifying the statements of intent that accompany the standards than the standards themselves. Concerns about antimicrobial resistance can be addressed through performance measurement. In July 2002, core measures of patient care processes and outcomes will be implemented for the first time. JCAHO requires hospital laboratories to be accredited, which increases the stature of the laboratory in the eyes of hospital administration. JCAHO laboratory standards directly relate to clinical practice guidelines, antimicrobial resistance, and NCCLS (formerly known as the National Committee for Clinical Laboratory Standards) and support efforts to reduce inappropriate antimicrobial use. Hospital laboratories play a vital role in effecting change in antimicrobial use. JCAHO laboratory standards for clinical practice guidelines and quality control support efforts to reduce inappropriate antimicrobial use. Hospitals have been reluctant to require the use of clinical practice guidelines in JCAHO standards, although guidelines promote appropriate antimicrobial use and reduce antimicrobial resistance. Pharmacists should work with laboratory staff and JCAHO to effect the changes needed to stem antimicrobial resistance.

Anti-Infective Agents↗
PubMed2002

Boundary issues in clinical practice as reported by Army social workers.

Clinical practice in military settings requires the clinician to be acutely aware of boundary issues that may arise. Given the legal significance associated with therapeutic relationships in which one stands in a special relationship of trust, confidence, or responsibility, setting appropriate boundaries in practice is critical. This article specifically addresses various questions faced by mental health practitioners in making boundary-related choices. The code of ethics of the National Association of Social Work as well as those of other disciplines now place increasing emphasis on the obligation to protect the public from known or perceived risks emanating from boundary crossings. This article presents the findings of a study involving active duty and reserve Army clinical social work officers regarding boundary issues. The study addresses the social work officers' perceptions of boundary issues and behavior related to boundary choices in clinical practice. The results provide insight regarding boundary crossings, boundary violations, and dual relationships.

Adult↗
PubMedDate not supplied

Immunonutrition in clinical practice: what is the current evidence?

The clinical trials of immunonutrition that we have undertaken have often been small, single centre studies. They have often been of limited statistical power and have often included patients with a variety of underlying disease states and at different points in the disease process. Three meta-analysis and a consensus statement in conjunction with a systematic review, have been performed in an attempt to overcome many of these limitations and understand further the clinical place for immunonutrition. However, there are still many questions regarding the place of immunonutrition in clinical practice that we still do not understand or have definitive answers to. For example, do we really know what is the optimal combination of nutrients and in what quantities they should be provided? Do we understand any potential interactions that might occur between these nutrients? What is the effect of the patients nutritional state? When and for how long should immunonutrition provided? What is the impact of the patients' underlying disease process and how does this interact with the provision of immunonutrition? At the present time whilst there is some indication and evidence as to which patients might benefit most, and as to those who may not benefit or even suffer detrimental effects from immunonutrition, we still can not answer these questions with any definitive authority. It is essential now that we undertake large well designed, well controlled multicentre studies with adequate statistical power to answer these questions. The indications are that immunonutrition has the potential to help patients but its place must be more clearly defined before its widespread acceptance into clinical practice is based on sound scientific evidence.

Clinical Trials as Topic↗
PubMed2005

From autonomy to accountability: the role of clinical practice guidelines in professional power.

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. Inspired by the theory of countervailing powers, this article explores how clinical practice guidelines have shifted the focus of professional power from autonomy to accountability. Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care.

Evidence-Based Medicine↗
PubMed2004

Implementation of clinical practice guidelines for upper respiratory infection in Thailand.

OBJECTIVE: To determine the effectiveness of implementing clinical practice guidelines (CPG) on antibiotic prescribing for adults with upper respiratory infection (URI) in terms of the changes in diagnosis and prevalence and patterns of antibiotic prescribing. METHODS: The CPG on antibiotic treatments for adults with URI published in the Annals of Internal Medicine 2001; 134: 479-52 were considered to be of high quality and applicable to Thai patients. A one-page clinical practice protocol in Thai was prepared from these guidelines. The dissemination strategy provided CPG and clinical practice protocol to 12 general practitioners in Siriraj Social Security Program in Bangkok during interactive educational meetings in April 2001. The information on 837 URI episodes from January to March (pre-CPG phase) and 774 URI episodes during May to July (post-CPG phase) were extracted from the patients' medical records. Telephone follow up for patients without antibiotics in the post-CPG phase was also attempted. RESULTS: Changes in the post-CPG period included (1) The diagnosis of URI was used less frequently whereas the diagnosis of common cold, pharyngitis and acute bronchitis were used more frequently (p<0.05). (2) Antibiotic use fell from 74.0% to 44.1% (p<0.001). (3) Fewer prescriptions for amoxicillin, roxithromycin, co-trimoxazole and doxycycline, and more for penicillin V (p<0.05). Patients (n=97) not given antibiotics reported recovery in 83.5% and improvement in 16.5%. CONCLUSION: A locally prepared clinical practice protocol based on US CPG for appropriate antibiotic use for URI combined with interactive educational meetings is effective in promoting appropriate diagnosis and antibiotic therapy in an ambulatory setting in a tertiary care hospital in Thailand.

Adult↗
PubMed2006

EBCPG: A visualized evidence-based clinical practice guideline system.

Evidence-based clinical practice guidelines (CPG) have been recognized as an important guide to physicians for decision-making. These guidelines can assist physicians in giving good clinical care to their patients. Based on the overall healthcare improvements, medical care quality can be preserved while practice discrepancies and errors can be eliminated. Clear representation and accessible guideline content at the point care are also critical. One way to make implementation easier is through computerized and visualized guidelines combined with evidence-based literature. Therefore, this paper presents a computerized guideline system, EBCPG, which is composed of three main components: CPGs exploration, EBM exploration and Web-base management to accommodate clinician decision-making and maintainability. Two tasks based on CPGs exploration and visualization technologies are involved in facilitating the presentation of the CPG model. EBCPG provides a comprehensive way to assist clinicians in making decisions according to the visualized clinical practice guidelines while dealing with patients.

Decision Making, Computer-Assisted↗
PubMed2004

Outcomes of evidence-based clinical practice guidelines: a systematic review.

OBJECTIVES: This study aimed to investigate whether evidence-based clinical practice in health care improves outcomes for patients, personnel, and/or organizations. METHODS: A systematic review of studies was conducted with various quantitative and qualitative methods up to the Spring of 2002. Protocols were used in quality assessment. Data synthesis is descriptive in a narrative form. RESULTS: Of 305 assessed articles, eight studies were included. The outcomes in the included studies were related to the experiences of patients and personnel and to organization concerning changed patient care and resource utilization. Because the included studies are heterogeneous in design, focus of research area, and scientific quality, the scientific foundation for the findings is weak. There is some support that evidence-based clinical practice guidelines, when put to use, improve outcomes (i) for patients--less likelihood of showing worsening of skin condition and disruption of skin condition improves more rapidly for infants; (ii) for personnel--support in daily work situation; and (iii) for organizations--decreased admission rates and length of stay, less resource utilization and reduced costs. CONCLUSIONS: There is a need for further research as the findings are based on a rather limited number of studies. There is a tendency toward support for the idea that outcomes improve for patients, personnel, or organizations if clinical practice in health care is evidence-based, that is, if evidence-based clinical practice guidelines are used, although these findings could be specific to the settings and context of the studies reported in this systematic review.

Attitude of Health Personnel↗
PubMed1995

Good clinical practices: past, present, and future.

Clinical quality assurance has its roots in the evolution of the GCPs. Historically, the fundamental elements of GCPs provided a springboard to develop and refine a paradigm of standard measurements to assure the integrity and quality of research. The research community spontaneously responded by voluntarily establishing quality assurance units and implementing auditing functions to ensure the highest standards in an industry that encompasses science, medicine, and ethics. Although clinical quality assurance is still unregulated in the United States, the performance of good clinical practices has become an integral part of the clinical research process and has impacted the research community on worldwide basis. The establishment of the EC guidelines, the WHO guidelines, and the International Conference on Harmonization are testaments to the increasing emphasis on the future of GCP-related activities.

Drug Approval↗
PubMed2005

Health-related quality of life measurement in pediatric clinical practice: an appraisal and precept for future research and application.

Health-related quality of life (HRQOL) measurement has emerged as an important health outcome in clinical trials, clinical practice improvement strategies, and healthcare services research and evaluation. HRQOL measures are also increasingly proposed for use in clinical practice settings to inform treatment decisions. In settings where HRQOL measures have been utilized with adults, physicians report such measures as useful, some physicians alter their treatment based on patient reports on such instruments, and patients themselves generally feel the instruments to be helpful. However, there is a dearth of studies evaluating the clinical utility of HRQOL measurement in pediatric clinical practice. This paper provides an updated review of the literature and proposes a precept governing the application of pediatric HRQOL measurement in pediatric clinical practice. Utilizing HRQOL measurement in pediatric healthcare settings can facilitate patient-physician communication, improve patient/parent satisfaction, identify hidden morbidities, and assist in clinical decision-making. Demonstrating the utility of pediatric HRQOL measurement in identifying children with the greatest needs, while simultaneously demonstrating the cost advantages of providing timely, targeted interventions to address those needs, may ultimately provide the driving force for incorporating HRQOL measurement in pediatric clinical practice.

Child↗
PubMed2005

Blood pressure dipping is reproducible in clinical practice.

OBJECTIVE: Blood pressure dipping pattern has clinical and prognostic consequences. However, reproducibility of night-time blood pressure fall during 24-h ambulatory blood pressure monitoring is considered limited. This limited reproducibility is possibly a result of inadequate day-night definitions. We retrospectively examined the reproducibility of blood pressure dipping in clinical practice, applying a method that accounts for sleep-awake states and does not rely on arbitrary day-night definitions. We also examined dipping repeatability in subjects with changing blood pressure. METHODS: Of 962 consecutive ambulatory measurements performed in our unit during a 3-year period, 100 patients (age 60+/-15) had a prior session, and were the subjects of this study. Based on patients' report we defined 'awake blood pressure' as the average of pressure recordings while the subject was awake, including night-time arousals, and 'sleep blood pressure' as the average of pressure recordings while the subject was sleeping, including afternoon naps. RESULTS: We found systolic blood pressure dipping not less reproducible than 24-h, awake- and sleep systolic blood pressure, as evaluated by both Pearson correlations (r=0.52 versus 0.5, 0.5, 0.49, respectively, P < or =0.0002 in all), and Bland-Altman repeatability. In a subgroup of 35 subjects (age 63+/-15) with at least 10 mmHg change in systolic blood pressure between the two sessions, systolic blood pressure dipping remained reproducible (r=0.45, P<0.007). CONCLUSIONS: When interpreted in a way that accounts for sleep-awake pattern, sleep-induced systolic blood pressure dipping in clinical practice is a very reproducible feature of ambulatory blood pressure monitoring, in accordance with its vital prognostic implications.

Aged↗
PubMed1999

[The costs of treatment with the new antidepressants in clinical practice].

OBJECTIVE: To assess if, in usual clinical practice, the patterns of use of new antidepressant are associated to different health resource utilisation. DESIGN: Naturalistic, retrospective, observational study. SETTING: Urban health center. PATIENTS: DSM-IIIR diagnostic criteria of depressive disorder and treatment with a new antidepressant (n = 328). INTERVENTIONS: Information on resource utilisation was collected in those patients treated with fluoxetine (FLX), fluvoxamine (FLV) sertraline (SER), paroxetine (PAR) and venlafaxine (VLF). Direct, indirect and total costs were compared according to the different patterns of use (stable therapy, upward dose titration, switching or augmentation) and according to the initially prescribed antidepressant. The follow-up period was 6 months. RESULTS: Direct and total daily costs of those patients with unestable therapy (upward dose titration, switching or augmentation) were 55% (p < 0.01) and 87% (p = 0.001) higher than for patients with stable therapy, respectively. Patients who initiated therapy on SER, VLF and PAR had 35% (p < 0.05), 80% (p < 0.05) and 37% (p < 0.05), respectively, higher average total costs per day than patients who initiated therapy with FLX. Regarding direct costs, patients who initiated therapy on SER and VLF had 48% (p < 0.001) and 58% (p < 0.05) higher average costs per day than patients who initiated therapy with FLX. CONCLUSIONS: New antidepressants show different patterns of use in a clinical practice setting, being FLX the agent more associated to a stable pattern of use. The pattern of use is associated to different health resource utilisation. Patients under stable therapy show lower health costs than those who need upward titration, switching or augmentation strategies. It is necessary to conduct randomized naturalistic studies to confirm these results.

Adult↗
PubMed2005

Accuracy of radiographer plain radiograph reporting in clinical practice: a meta-analysis.

AIM: To determine the accuracy of radiographer plain radiograph reporting in clinical practice. MATERIALS AND METHODS: Studies were identified from electronic sources and by hand searching journals, personal communication and checking reference lists. Eligible studies assessed radiographers' plain radiograph reporting in clinical practice compared with a reference standard, and provided accuracy data to construct 2 x 2 contingency tables. Data were extracted on study eligibility and characteristics, quality and accuracy. Summary estimates of sensitivity and specificity and receiver operating characteristic curves were used to pool the accuracy data. RESULTS: Radiographers compared with a reference standard, report plain radiographs in clinical practice at 92.6% (95% CI: 92.0-93.2) and 97.7% (95% CI: 97.5-97.9) sensitivity and specificity, respectively. Studies that compared selectively trained radiographers and radiologists of varying seniority against a reference standard showed no evidence of a difference between radiographer and radiologist reporting accuracy of accident and emergency plain radiographs. Selectively trained radiographers were also found to report such radiographs as accurately as those not solely from accident and emergency, although some variation in reporting accuracy was found for different body areas. Training radiographers improved their accuracy when reporting normal radiographs. CONCLUSION: This study systematically synthesizes the literature to provide an evidence-base showing that radiographers can accurately report plain radiographs in clinical practice.

Clinical Competence↗
PubMed2003

A UML approach to process modelling of clinical practice guidelines for enactment.

Although clinical practice guidelines (CPGs) have been suggested as a means of encapsulating best practice in evidence-based medical treatment, their usage in clinical environments has been disappointing. Criticisms of guideline representations have been that they are predominantly narrative and are difficult to incorporate into clinical information systems. This paper analyses the use of UML process modelling techniques for guideline representation and proposes the automated generation of executable guidelines using XMI. This hybrid UML-XMI approach provides flexible authoring of guideline decision and control structures whilst integrating appropriate data flow. It also uses an open XMI standard interface to allow the use of authoring tools and process control systems from multiple vendors. The paper first surveys CPG modelling formalisms followed by a brief introduction to process modelling in UMI. Furthermore, the modelling of CPGs in UML is presented leading to a case study of encoding a diabetes mellitus CPG using UML.

Decision Support Systems, Clinical↗
PubMed2004

Optic neuritis: diagnostic criteria application in clinical practice.

Optic neuritis (ON) refers to any inflammatory optic neuropathy. In clinical practice ON is mainly diagnosed by ophthalmologists and less frequently by neurologists. ON diagnostic criteria are included in the Classification of International Headache Society (IHS) and in other classification systems, both in neurological and ophthalmologic fields. The aims of this study were to verify the application of IHS ON diagnostic criteria in clinical practice and the role of the ocular pain qualitative aspects. We performed a partially retrospective (140 cases) and prospective (43 cases) study analysing the clinical characteristics of patients with ON. We observed retro orbital pain in a huge percentage of patients; it was provoked or spontaneous and worsened by eye movements. We found that the new IHS classification criteria (IHS 2004) do not fully satisfy the requirements for ON diagnosis. Further study is necessary to validate the diagnostic criteria of ON in clinical practice.

Eye Movements↗
PubMed2006

Assessment of full-time dental hygiene faculty participation in clinical practice.

The purpose of this research project was to determine how many U.S. dental hygiene (DH) programs had full-time (FT) faculty members who provided direct patient care unrelated to the curriculum. Questions in this project also assessed attitudes and opinions of DH directors regarding clinical practice and opportunities for salary supplementation. A questionnaire of twenty open-ended and closed-ended questions was designed on Survey Monkey, an online survey engine. After IRB approval and pilot testing, 278 U.S. DH program directors received two emails with the survey link requesting their participation. A response rate of 69.1 percent (n=192) was achieved. Results revealed that 14.2 percent of the programs required FT DH faculties to participate in clinical practice settings unrelated to the curriculum, while 67 percent of the programs had faculties who also participated in clinical practice. Eighty-three percent of respondents reported faculties who participated in clinical practice were financially compensated. The majority (95.4 percent) of directors indicated maintaining clinical skills was an advantage to clinical practice, while 48 percent of directors indicated participation takes time away from being an educator. Overall, the majority of DH programs did not require FT faculties to participate in clinical practice; however, respondents were generally in favor of allowing faculties the opportunity to practice and thought that it enhanced their competency as clinical instructors.

Attitude of Health Personnel↗
PubMed2006

Generalizing results of randomized trials to clinical practice: reliability and cautions.

BACKGROUND: Well designed randomized controlled trials provide reliable evidence of treatment effects, but there is no consensus on how best to apply these results to clinical practice. The main concerns are that populations enrolled in trials are more selected than those treated in a clinical setting, and whether the treatment effects observed in trials will also be observed in clinical practice. METHODS: An informal literature review was undertaken to find studies analysing the issue of generalizing trial results (external validity) to clinical practice. RESULTS: Most of the studies focused on differences in patients characteristics (age, gender, severity of disease, concomitant treatments and so on) between the clinical trial population and a 'real world' clinical population. None provided good evidence of a reduction in the treatment effect in the trial compared to what might happen in clinical practice for simple pharmacological treatments. However complex treatments like surgery or percutaneous interventional procedures, had a greater potential for variation. Extrapolating treatments to different health care settings from the trial can result in important variations in treatment effects. CONCLUSIONS: Complex therapies need careful consideration before they can be applied routinely from trials into practice, and applying results from one health care environment to a different one should be carried out with caution. Generalizing results from well conducted trials to clinical practice can mostly be carried out with confidence, especially for simple therapies with good evidence of benefit.

Humans↗
PubMed2004

Donepezil for Alzheimer's disease in clinical practice--The DONALD Study. A multicenter 24-week clinical trial in Germany.

This multicenter open-label clinical trial was designed to investigate the safety and efficacy of donepezil, a selective acetylcholinesterase inhibitor, in the treatment of Alzheimer's disease (AD) in routine clinical practice in Germany. A total of 237 patients with mild-to-moderate AD were treated with donepezil for 24 weeks, 186 completed the study according to the protocol. In the completer group, mean MMSE score for efficacy showed an improvement from baseline of +1.6 points at week 12 (95% CI +1.1 to +2.1) and of +1.1 points at week 24 (95% CI +0.5 to +1.7). In more than 80% of the patients, global tolerability was rated to be very good or good. There were only insignificant effects on ECG parameters. This study confirms the results obtained in previous double-blind trials, which showed that donepezil is effective and well tolerated in patients with mild-to-moderately severe AD.

Aged↗