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PubMed2005

[Pharmacological therapy in Alzheimer's disease. Current clinical practice in The Netherlands].

Pharmacological therapy in Alzheimer's disease. Current clinical practice in The Netherlands. Dementia affects 195,000 patients of 65 years and older in The Netherlands currently. Rivastigmine and galantamine, both cholinesterase inhibitors, and memantine, an NMDA (N-methyl-D-aspartate) antagonist, are licensed for the treatment of AD. In clinical practice, these drugs have limited effects on cognitive and other symptoms of dementia. We describe the practical care of some patients treated with these drugs and discuss the pros and cons of pharmacotherapy in AD. Extensive knowledge of the drugs, other treatment options and of dementia are necessary for good clinical practice in the treatment of these patients and the counselling of their caregivers.

Aged↗
PubMedDate not supplied

Perspectives on faculty clinical practice: views of occupational therapy curriculum chairpersons and faculty members.

OBJECTIVE: This study investigated whether and how faculty clinical practice (FCP) was being implemented in occupational therapy professional education programs. METHOD: Chairpersons and faculty members from all accredited entry-level occupational therapy curricula in the United States were asked to complete questionnaires about their involvement in FCP. The chairperson questionnaire consisted of primarily closed-ended questions that addressed the organization of faculty practice within their programs, whereas the faculty questionnaire was primarily open-ended and addressed faculty members' individual involvement in FCP as well as the perceived benefits and drawbacks. Responses were analyzed for 39 program chairpersons and 136 faculty members were analyzed. RESULTS: Twenty-five chairperson respondents reported that their educational program had FCP, and 44 faculty respondents indicated involvement in FCP during the past year. FCP was more prevalent in public-funded institutions and academic health centers. Faculty members primarily engaged in FCP in order to stay current, enhance teaching, and develop networks. They reported increased credibility with students as an important benefit of clinical practice. The primary reasons faculty members did not engage in clinical practice were insufficient time and institutional policies. CONCLUSION: Although many faculty members in occupational therapy education programs value clinical practice as a part of their educator role, it is necessary to negotiate responsibilities and rewards to prevent role overload and comply with institutional policies.

Attitude of Health Personnel↗
PubMed2003

A generic model of clinical practice.

OBJECTIVES: Many shared-care projects feel the need for electronic patient-record (EPR) systems. In absence of practical experiences from paper record keeping, a theoretical model is the only reference for the design of these systems. In this article, we review existing models of individual clinical practice and integrate their useful elements. We then present a generic model of clinical practice that is applicable to both individual and collaborative clinical practice. METHODS: We followed the principles of the conversation-for-action theory and the DEMO method. According to these principles, information can only be generated by a conversation between two actors. An actor is a role that can be played by one or more human subjects, so the model does not distinguish between inter-individual and intra-individual conversations. RESULTS: Clinical practice has been divided into four actors: service provider, problem solver, coordinator, and worker. Each actor represents a level of clinical responsibility. Any information in the patient record is the result of a conversation between two of these actors. Connecting different conversations to one another can create a process view with meta-information about the rationale of clinical practice. Such process view can be implemented as an extension to the EPR. CONCLUSIONS: The model has the potential to cover all professional activities, but needs to be further validated. The model can serve as a theoretical basis for the design of EPR-systems for shared care, but a successful EPR-system needs more than just a theoretical model.

Communication↗
PubMed2001

Teaching advanced practice nursing students how to use the Internet to support an evidence-based clinical practice.

In the past decade, clinicians have dramatically increased their use of the Internet as an information resource to guide clinical practice. The amount of evidence-based information on the World Wide Web (WWW) is growing at an explosive rate. Although the term "Internet" actually refers to the wires that link computers, and the term "World Wide Web" refers to the linked information, these terms will be used interchangeably in this article. Advanced practice nurses (APNs) need to learn how to locate evidence-based information efficiently on the Internet, how to evaluate the validity and relevance of the information, and how to use the information to support their practice decisions. This article describes a research course that the author teaches to APN students at the University of San Francisco School of Nursing. The course was designed to improve students' skills in using the Internet to support an evidence-based clinical practice (EBCP). The information in this article can assist nurse educators in teaching their APN students how to locate and evaluate evidence-based information on the Internet. It also can assist practicing APNs in using the Internet to facilitate an EBCP.

Evidence-Based Medicine↗
PubMed2001

Are the results of randomized controlled trials on anticoagulation in patients with atrial fibrillation generalizable to clinical practice?

BACKGROUND: Randomized trials demonstrate a clear benefit of anticoagulation in patients with atrial fibrillation at risk of stroke, but the proportion of eligible patients who are treated with anticoagulants remains low. The reluctance to treat all eligible patients with anticoagulants may be due to studies in clinical practice showing variable risk-benefit, raising concerns about application to general medical practice. METHODS: A systematic review of published medical literature was performed to identify studies of patients with atrial fibrillation who were treated with warfarin in actual clinical practice. Data from these studies were compared with pooled data from randomized controlled trials. RESULTS: Three studies met the predefined criteria, each in a different health care setting, totaling 410 patients with 842 patient-years of follow-up. Patients in clinical practice were older and had more comorbid conditions compared with trial participants. However, the ischemic stroke rate was similar between clinical practice and randomized studies (1.8% [95% confidence interval (CI), 0.9%-2.7%] vs 1.4% [95% CI, 0.9%-2.0%]). Intracranial hemorrhage (0.1% [95% CI, 0%-0.3%] vs 0.3% [95% CI, 0.06%-0.5%]) and major bleeding (1.1% [95% CI, 0.4%-1.8%] vs 1.3% [95% CI, 0.8%-1.8%]) rates were also similar. There was a higher rate of minor bleeding in clinical practice than in trials (12.0% [95% CI, 9.7%-14.3%] vs 7.9% [95% CI, 6.6%-9.2%]). CONCLUSIONS: Patients who undergo anticoagulation for atrial fibrillation in actual clinical practice differ from those in randomized trials, but have similar rates of stroke and major bleeding. The risk of minor bleeding is higher and may require more intensive monitoring in practice.

Aged↗
PubMed1994

Clinical practice beyond science: debunking the scientific myth.

The theme of the RANZCP 28th Conference questioned the science of clinical practice. This question is explored in the light of prevailing paradigms of 20th century psychiatry and recent claims by scientism, especially biologism, that assumes an organic causation for all abnormal behaviour. It is argued that a paradigm of objective science is necessary to understanding many aspects of mental illness, but not sufficient to explain certain essential phenomena, such as altered states of consciousness and empathy, encounted daily in clinical practice. Discarding these phenomena in the name of "science" runs the risk of clinical practice becoming "mindless". The "reconquest of the subjective" is offered as a way to extend clinical practice beyond objective science.

Cultural Characteristics↗
PubMed2007

Pediatrician characteristics associated with attention to spirituality and religion in clinical practice.

OBJECTIVE: The literature suggests that a majority of pediatricians believe that spirituality and religion are relevant in clinical practice, but only a minority gives them attention. This project explored this disparity by relating personal/professional characteristics of pediatricians to the frequency with which they give attention to spirituality and religion. METHODS: Pediatricians (N = 737) associated with 3 academic Midwestern pediatric hospitals responded to a survey that requested information concerning the frequency with which they (1) talked with patients/families about their spiritual and religious concerns and (2) participated with them in spiritual or religious practices (eg, prayer). The associations between these data and 10 personal and professional characteristics were examined. RESULTS: The results demonstrated the disparity, and the analysis identified 9 pediatrician characteristics that were significantly associated with more frequently talking with patients/families about their spiritual and religious concerns. The characteristics included increased age; a Christian religious heritage; self-description as religious; self-description as spiritual; the importance of one's own spirituality and religion in clinical practice; the belief that the spirituality and religion of patients/families are relevant in clinical practice; formal instruction concerning the role of spirituality and religion in health care; relative comfort asking about beliefs; and relative comfort asking about practices. All of these characteristics except pediatrician age were also significantly associated with the increased frequency of participation in spiritual and religious practices with patients/families. CONCLUSIONS: Attention to spiritual and religious concerns and practices are associated with a web of personal and professional pediatrician characteristics. Some characteristics pertain to the physician's personal investment in spirituality and religion in their own lives, and others include being uncomfortable with spiritual and religious concerns and practices. These associations shed light on the disparity between acknowledged spirituality and religion relevancy and inattention to it in clinical practice.

Adult↗
PubMed1999

What is recommended for healthy women during pregnancy? A comparison of seven prenatal clinical practice guideline documents.

BACKGROUND: Several countries have developed clinical practice guidelines for the content of prenatal care. This study examines the consistency of recommendations in clinical practice guidelines describing routine prenatal care. METHODS: The recommendations for low-risk women in seven guideline documents were examined: two from Australia, two from the United States, two from Canada, and one from Germany. The recommendations were listed into the four areas of "general health screening and health promotion during pregnancy," "organization of care," "clinical tests and screening," and "education specific for pregnancy." RESULTS: A total of 69 recommendations were identified within the seven documents, most of which fell within the "clinical tests and screening" domain. Notable differences were identified in the number of recommendations made within the same country. Of the 69 recommendations, only four were included in all seven documents. CONCLUSION: Little consistency was demonstrated within or among countries in terms of the content of their prenatal care guidelines, suggesting a need to reexamine their content and the evidence on which such recommendations are based.

Australia↗
PubMed2004

Clinical practice guidelines for treating depression in primary care.

Clinical practice guidelines for depression offer the best available treatment options as evidenced by randomized controlled clinical studies. Although the use of evidence-based guidelines has been shown to improve treatment success, there are few data to suggest the extent to which they are used or their effect on treatment outcomes. Keeping guidelines current and increasing the probability of use in daily clinical practice are critical.

Adult↗
PubMed2001

Aortic valve replacement: current clinical practice and opportunities for quality improvement.

This is a review of the current clinical practice and opportunities for quality improvement in aortic valve replacement surgery. The topics include trends and regional variation in procedure rates, and changes in the use of aortic valve replacement among the elderly. Recent developments guiding the choice of prosthetic valves and trends in in-hospital mortality rates for aortic valve surgery are summarized. Lastly, a discussion of topics relevant to clinical practice improvement including the implementation of clinical practice guidelines, the need for consensus on risk adjustment, better understanding of volume-outcome effects, and the opportunities for comprehensive assessment of aortic valve surgery.

Aortic Valve↗
PubMed1994

Clinical practice guidelines and critical paths--roadmaps to quality, cost-effective care (Part I).

Clinical practice guidelines and critical paths have gained widespread acceptance in recent years. Part I of this article will examine clinical practice guidelines, or practice parameters, and their application to patient care. Part II (in the February issue of JAHIMA) will look at multi-disciplinary care plans known as critical paths and how they can incorporate clinical practice guidelines. Health information management professionals can play an important role in implementation and ongoing evaluation of these clinical tools.

Clinical Protocols↗
PubMed1999

Impact of clinical practice guidelines on clinicians' behaviour: tonsillectomy in children.

OBJECTIVE: This study was conducted to assess the extent to which developing and implementing clinical practice guidelines for listing children for tonsillectomy (with or without adenoidectomy) influenced the behaviour of participating ENT surgeons. METHOD: A before and after study in which the intervention (the development and dissemination of local practice guidelines) was introduced sequentially into different hospitals and surgical practice. The study was conducted in four ear, nose, and throat surgical services in the North of England, with 16 consultant ENT surgeons and their junior staff on 1190 children aged 0 to 14 years who were judged, prior to consultation with an ENT surgeon, to have been referred for throat-related problems for which tonsillectomy was one possible treatment option were included in the study. Decision reached by surgeons and proportion of decisions that complied with new guidelines. RESULTS: Of the clinical decisions to list children for tonsillectomy taken before introduction of locally agreed guidelines, 73% (486/660) conformed to the criteria in the subsequent guidelines, 15% (97/660) did not, and in 12% (77/660), it was impossible to judge. After the intervention, the corresponding figures were 73% (386/530), 14% (73/53), and 13% (71/530), respectively. When decisions were taken to break the guidelines, this was more often to list for tonsillectomy when it was not indicated--83% (141/170)--than to withhold tonsillectomy when it was indicated--17% (29/170). The aspects of guidelines that were breached in decisions to carry out tonsillectomy were: the age of the child was younger than the guidelines recommended--54% (75/141); there had been fever attacks of tonsillitis than the guidelines recommended--22% (32/141); and there were "significant" symptoms not included in the guidelines--20% (29/141). CONCLUSIONS: In spite of strong evidence to the contrary, local guidelines were formulated at a level that the majority of surgeons already attained. Guideline development and implementation, therefore, had very little impact on clinical practice. The process of local formulation of guidelines was not sufficient to achieve change toward evidence-based practice; clinical preference proved to be quite intractable. There is a need to enhance the ability of clinicians in the assessment and interpretation of research evidence. Previous work has emphasized the need to explore factors that influence clinical behaviour toward evidence-based practice. Our study suggests the need for more research into why clinicians continue to follow clinical preference even when invited to base agreed local clinical policies on evidence.

Adolescent↗
PubMed2000

Clinical practice guidelines and the cost of care. A growing alliance.

UNLABELLED: Healthcare policy, medical practice, and cost of care are no longer considered distinct entities. Each is an integral factor in determining not only what, but how, patient care will be delivered. Clinical practice guidelines are the lynchpin that connects them. This paper addresses the various components of the clinical practice guideline--cost alliance. OBJECTIVE: To examine the bidirectional influence of choice of care on costs and of cost of care on decision making. METHODS: The literature was used to identify cost-related factors that influence development of guidelines and change in physician practice behavior. In a MEDLINE search with modifiers to the keywords "clinical practice guidelines," particular attention was paid to identifying surveys of practitioners. An analysis, prompted by a recently published guideline, of treating penetrating intraperitoneal colon injuries by different surgical approaches (primary repair versus diverting colostomy) exemplified how implementation of a guideline can affect the cost of care. Inpatient cost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in 1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases from California and Massachusetts. RESULTS: The results showed that a substantial savings in hospital costs was achieved when a primary repair surgical technique, as advocated by the guideline, was used. The effect of cost influences on the development of clinical practice guidelines was established by demonstrating the cyclical effect between usual and customary practices, guideline implementation, changing practice patterns, and the economic considerations influencing the process. CONCLUSIONS: A growing, albeit uneasy, alliance between costs and clinical practice guidelines is evident.

Colon↗
PubMed1996

Advanced practice nurses: change agents for clinical practice.

The article presents the role of advanced practice nurses as change agents in the clinical setting. Research utilization is needed to shape and form the basis of nursing practice. As change agents, the advanced practice nurses in one institution established a research-based minimal stimulation protocol for the very low-birth weight infant and implemented it using a video presentation. Knowledge of change theory, research utilization, and video production was necessary in making this project a success.

Clinical Nursing Research↗
PubMed2000

Pharmacoeconomics and clinical practice guidelines. A survey of attitudes in Swedish formulary committees.

BACKGROUND: Swedish formulary committees are expected to influence prescribing practice by establishing and issuing drug lists and clinical practice guidelines, particularly now that financial responsibility for prescription drugs has been transferred from the national to the county council level. OBJECTIVE: The purpose of this exploratory study was to identify the information sources and decision criteria that individual committee members perceive as important in establishing clinical practice guidelines. Moreover, obstacles to the increased use of pharmacoeconomic evaluations in decision-making were also identified. DESIGN AND SETTING: Data were gathered through a survey questionnaire administered in 1998 to members of central formulary committees throughout Sweden, as determined by a national register. PARTICIPANTS: 312 members of central formulary committees, of whom 69% responded. RESULTS: Treatment policies/guidelines supplied by government authorities, or found in reviewed journals, are considered the most important sources of information, and criteria associated with costs and effects are considered the most important decision criteria. The members' years of experience and their professions affect their assessments of information sources, whereas education in health economics affects their assessments of decision criteria. Committee members voiced an interest in pharmacoeconomic issues, but warned that there was neither sufficient competence among committee members nor an adequate supply of relevant studies. Furthermore, a majority of the members identified difficulty in translating study results into clinical practice guidelines and limited possibilities in comparing studies as obstacles to the increased use of pharmacoeconomic evaluations. CONCLUSIONS: The results of this survey may be useful in designing future economic evaluations and when presenting and diffusing study results.

Attitude of Health Personnel↗
PubMed2003

Relating UMLS semantic types and task-based ontology to computer-interpretable clinical practice guidelines.

Medical knowledge in clinical practice guideline (GL) texts is the source of task-based computer-interpretable clinical guideline models (CIGMs). We have used Unified Medical Language System (UMLS) semantic types (STs) to understand the percentage of GL text which belongs to a particular ST. We also use UMLS semantic network together with the CIGM-specific ontology to derive a semantic meaning behind the GL text. In order to achieve this objective, we took nine GL texts from the National Guideline Clearinghouse (NGC) and marked up the text dealing with a particular ST. The STs we took into consideration were restricted taking into account the requirements of a task-based CIGM. We used DARPA Agent Markup Language and Ontology Inference Layer (DAML + OIL) to create the UMLS and CIGM specific semantic network. For the latter, as a bench test, we used the 1999 WHO-International Society of Hypertension Guidelines for the Management of Hypertension. We took into consideration the UMLS STs closest to the clinical tasks. The percentage of the GL text dealing with the ST "Health Care Activity" and subtypes "Laboratory Procedure", "Diagnostic Procedure" and "Therapeutic or Preventive Procedure" were measured. The parts of text belonging to other STs or comments were separated. A mapping of terms belonging to other STs was done to the STs under "HCA" for representation in DAML + OIL. As a result, we found that the three STs under "HCA" were the predominant STs present in the GL text. In cases where the terms of related STs existed, they were mapped into one of the three STs. The DAML + OIL representation was able to describe the hierarchy in task-based CIGMs. To conclude, we understood that the three STs could be used to represent the semantic network of the task-bases CIGMs. We identified some mapping operators which could be used for the mapping of other STs into these.

Humans↗
PubMed1990

Tips for nursing faculty entering clinical practice.

Many nurse educators perceive a need to maintain clinical competence but encounter obstacles to pursuing ongoing clinical practice. This article identified five key steps for the educator entering clinical practice; expect culture shock, identify orientation needs, find a resource person, learn the institution's formal routine, and assess and use the institution's informal network. Implementing these strategies will alleviate stress and will help faculty members to update their clinical skills and earn the respect of their practice colleagues.

Adaptation, Psychological↗
PubMed1999

[Development of evidence-based clinical practice guidelines; a model project integrating external evidence and clinical expertise].

BACKGROUND: Internationally, evidence-based clinical practice guidelines have been established for several years. In Germany, they are now gaining increasing importance. OWN STUDIES: The Institute of Health Economics and Clinical Epidemiology at the University of Cologne has developed a mostly standardized process for evidence-based guideline development. This process has been implemented in such a way that reproducibility, validity and practicability of guidelines can be assured: evidence from research (external evidence) has been searched and evaluated according to the criteria of the Agency of Health Care Policy and Research (AHCPR). Through cooperation with clinical experts, this evidence has been transferred into practicable recommendations. In addition, acceptance of guideline users and patients was improved by applying this method. CONCLUSION: Evidence-based guidelines are considered as an appropriate tool to assist medical decision-making of all stakeholders involved. The process will be demonstrated developing an evidence-based guideline for obesity treatment.

Evidence-Based Medicine↗