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PubMed1994

Potential of practice-based research networks: experiences from ASPN. Ambulatory Sentinel Practice Network.

During the past 20 years, the feasibility of practice-based research in networks has been established in the United States. The initial work of these networks has revealed the need for a better understanding of family practice and the rest of primary care in order to address the challenges facing our health care system. This paper explores the nature, potential, and limitations of practice-based research networks based on the results of a dozen studies conducted by the Ambulatory Sentinel Practice Network (ASPN).

Adolescent↗
PubMedDate not supplied

Clinical practice guidelines in complementary and alternative medicine. An analysis of opportunities and obstacles. Practice and Policy Guidelines Panel, National Institutes of Health Office of Alternative Medicine.

An estimated 1 of 3 Americans uses some form of complementary and alternative medicine (CAM), such as acupuncture, homeopathy, or herbal medicine. In 1995, the National Institutes of Health Office of Alternative Medicine convened an expert panel to examine the role of clinical practice guidelines in CAM. The panel concluded that CAM practices currently are unsuitable for the development of evidence-based practice guidelines, in part because of the lack of relevant outcomes data from well-designed clinical trials. Moreover, the notions of standardization and appropriateness, inherent in guideline development, face challenging methodologic problems when applied to CAM, which considers many different treatment practices appropriate and encourages highly individualized care. Due to different belief systems and divergent theories about the nature of health and illness, CAM disciplines have fundamental differences in how they define target conditions, causes of disease, interventions, and outcome measures of effectiveness. These differences are even more striking when compared with those used by Western medicine. The panel made a series of recommendations on strategies to strengthen the evidence base for future guideline development in CAM and to meet better the current information needs of clinicians, patients, and guideline developers who seek information about CAM treatments.

Complementary Therapies↗
PubMed1993

Specimen adequacy evaluation in gynecologic cytopathology: current laboratory practice in the College of American Pathologists Interlaboratory Comparison Program and tentative guidelines for future practice.

Routine specimen adequacy evaluation, as advocated by The Bethesda System (TBS), can play an important role in improving the sensitivity and accuracy of cervical cytopathology screening. The effectiveness of this measure, however, has been limited by the lack of uniform criteria for adequacy. Practice parameters are now emerging, through TBS development of tentative criteria and interlaboratory comparison of adequacy practices. This study reviews 1) nationwide responses to surveys of laboratory practices in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology (CAP PAP); 2) the definitions of adequacy based on TBS; and 3) the results of implementation of these criteria in a private independent laboratory, university hospital laboratory, and private nonprofit hospital laboratory. In the initial CAP PAP survey in 1990, 35% of responding laboratories routinely reported specimen adequacy, increasing to 66% in 1991 and 85% in 1992. Interlaboratory variations in adequacy practices were observed, however, underscoring the need for consensus criteria. The experience in the authors' laboratories indicates that TBS criteria can serve as a sound guideline. Effective implementation of adequacy assessment in the individual laboratory requires careful attention to ensuring the quality of adequacy ratings, correlating clinical and prior laboratory information, issuing clear and concise reports, and giving recommendations judiciously. Through interlaboratory comparison and consistent intralaboratory emphasis on specimen adequacy, greater uniformity of adequacy assessment can be achieved, and adequacy evaluation can achieve its promise of improving the quality of cervical cytopathology.

Clinical Laboratory Techniques↗
PubMed2005

Practical recommendations for the use of ACE inhibitors, beta-blockers, aldosterone antagonists and angiotensin receptor blockers in heart failure: putting guidelines into practice.

Surveys of prescribing patterns in both hospitals and primary care have usually shown delays in translating the evidence from clinical trials of pharmacological agents into clinical practice, thereby denying patients with heart failure (HF) the benefits of drug treatments proven to improve well-being and prolong life. This may be due to unfamiliarity with the evidence-base for these therapies, the clinical guidelines recommending the use of these treatments or both, as well as concerns regarding adverse events. ACE inhibitors have long been the cornerstone of therapy for systolic HF irrespective of aetiology. Recent trials have now shown that treatment with beta-blockers, aldosterone antagonists and angiotensin receptor blockers also leads to substantial improvements in outcome. In order to accelerate the safe uptake of these treatments and to ensure that all eligible patients receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of HF. The objective of these recommendations is to provide practical guidance for non-specialists, in order to increase the use of evidenced based therapy for HF. These practical recommendations are meant to serve as a supplement to, rather than replacement of, existing HF guidelines.

Adrenergic beta-Antagonists↗
PubMed2004

A survey of clinical practices and readiness to adopt evidence-based practices: Dissemination research in an addiction treatment system.

Addiction research is challenged to disseminate evidence-based practices into routine clinical settings. The successful adoption of innovation must consider issues of fit, such as the characteristics, readiness, and attitudes of clinicians in the community. We constructed a survey to assess clinical practices and readiness to adopt certain evidence-based practices in addiction treatment programs. The instrument was administered to directors (n = 21) and clinicians (n = 89) from 24 public addiction treatment programs in New Hampshire (USA). Clinicians are more motivated to adopt some evidence-based practices (twelve-step facilitation, cognitive behavioral therapy, motivational interviewing, relapse prevention therapy) than others (contingency management, behavioral couples therapy, pharmacotherapies). Translational strategies for treatment development and research dissemination are discussed.

Adult↗
PubMed2002

Challenges of advanced practice nursing in pediatric acute and critical care: education to practice.

The APN role of the future is dependent on our ability to document through research that NPs, CNSs, and the consolidated role of the NP/CNS plays a critical role in the delivery of high quality cost-effective care. Further information is needed regarding how the APN contributes to and enhances the care delivered by the healthcare team. Cost effectiveness and quality outcome studies are needed including those that describe morbidity and mortality rates, patient satisfaction, and cost effectiveness of models of care that includes APNs. Brooten and Naylor suggest the inclusion of sensitive nursing outcomes, including functional status, mental status, stress level, satisfaction with care, caregiver burden, cost of care. Defining and clarifying the APN functions and qualities of scope of practice is imperative. Perhaps there are populations best served by APNs. Contributions such as continuity, consistency of care, attention to issues such as immobility, skin integrity, and health promotion may have a value added effect. Time motion studies and process logs may add to the information about APNs in pediatric acute and critical care. Professional certification validating competence is essential for the practice of APNs caring for sick children and their families. A disparity exists between the primary care examination now available and the practice of NPs in pediatric acute and critical care. A certification examination is needed with content consistent with the practice of pediatric acute care NP. APNs must possess sufficient knowledge and skill to meet the needs of patients and families in the changing healthcare environment. According to Strodtbeck and colleagues, flexibility, ability to be a self directed learner, critical thinking, relationship skills, and leadership skills including interpersonal insight, interpersonal competence, and ability to stimulate group discussion will serve APNs well as they move into the century. Transitioning brings exciting opportunities along with challenges. Using a blend of abilities, the pediatric acute care APN can provide optimal care to sick children and families.

Child↗
PubMed2001

Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice.

Surveys of prescribing in both hospitals and primary care have shown delays in translating improved survival data from clinical trials into clinical practice thereby denying patients the benefits of proven treatments, such as the angiotensin converting enzyme inhibitors. This may be due to unfamiliarity with clinical guidelines and concerns about adverse events. Recent trials have shown that substantial improvements in survival are associated with spironolactone and beta-blocker therapy. In order to accelerate the uptake of these treatments, and to ensure that all eligible patients should receive the most appropriate medications, a clear and concise set of clinical recommendations has been prepared by a group of clinicians with practical expertise in the management of heart failure. The objective of these recommendations is to provide practical guidance for non-specialists in order to support the implementation of evidenced-based therapy for heart failure. These practical recommendations are meant to supplement rather than replace existing guidelines.

Adrenergic beta-Antagonists↗
PubMed2004

Medical career choice and practice location: early factors predicting course completion, career choice and practice location.

AIMS: The overall aim of the study was to identify the factors that best predict medical career choice and practice location. METHOD: A longitudinal, cohort study was conducted. This followed 2 cohorts of students, numbering a total of 229 students, who commenced medical studies at the University of Western Australia in 1984 and 1989. Data concerning the students' sociodemographic backgrounds, admission scores and personality characteristics were collected in Year 1. Regression analyses were performed to identify the student characteristics that best predicted course completion, a choice of general practice 4 years after graduation and a rural location of practice. OUTCOMES: We found that students who had lower university admission scores and who were less outgoing were less likely to complete the course. Students who were male, had a father in medicine and were more creative and abstract in their thinking and more conscientious and rule-bound were more likely to choose a specialist career. A rural background was found to be the most important predictor of both rural general and specialist practice.

Adolescent↗
PubMed2001

Practice nursing: an evaluation of a training practice initiative.

Globally, health care is moving towards a primary care approach. In the UK initiatives for nurses wishing to gain experience in primary and community care may be crucial with the advent of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). This paper outlines an initiative in practice nursing, developed as a pilot study by a Health Authority. The training practice initiative was aimed at nurses returning to practice and offered them an experiential and supportive career pathway into primary care. The evaluation (carried out over 1 year), highlighted that those primarily involved in the initiative--the trainees, educators and general practitioners--felt it had been successful, especially in relation to professional development issues. The funding bodies for the initiative, who previously had concerns over the recruitment and retention of practice nurses, were also optimistic that the support networks which developed as a result of the initiative had raised morale. The paper suggests several educational, organizational and professional issues which arose from the evaluation exercise. Further, it suggests how this initiative, in an extended form, could provide an effective basis for the training and development of nursing staff in PCGs/PCTs.

Community Health Nursing↗
PubMed2006

Teaching in practice: a survey of a general practice teaching network.

The need for high-quality teaching practices and general practitioners (GPs) skilled in teaching is ever increasing. The authors determined the quality of teaching in the Göttingen general practice teaching network with regard to equipment, student participation and GPs' motivation for teaching. A questionnaire was mailed to all GPs in the Göttingen teaching network. The response rate was 81% (98/121). GPs considered taking histories (98%), decision-making (98%) and physical examination (94%) to be key elements of teaching in general practice. They felt that somatic topics like upper respiratory tract infections (98%) were easy to teach, while 51% acknowledged difficulties conveying psychosocial topics like caring for dying patients. In only half of the practices did students have the opportunity to take histories and perform physical exams by themselves. Participation in medical education was driven mainly by the satisfaction derived from teaching (66%) and the desire for academic affiliation (39%). GPs in the Göttingen network need support to teach their students more psychosocial-oriented topics and to allow them a more active role in consultations.

Community Networks↗
PubMed1998

Dyspepsia in general practice in Denmark. A 1-year analysis of consulters in general practice.

OBJECTIVE: To estimate the incidence rate of patients with dyspepsia in general practice, related to age, gender and dwelling and to classify the patients into dyspepsia subgroups. DESIGN: In a background population of 123,610 persons under the National Health Insurance System a systematic, prospective registration of dyspepsia patients consulting in general practice was done. Each patient was subject to a structured interview covering 18 dyspepsia symptoms and six alarm symptoms. A diagnostic chart was used to classify the patients into subgroups. SETTING: General practice: 93 general practitioners in 63 centres in Denmark. PATIENTS: Patients consulting the general practitioner with dyspepsia as their main complaint. RESULTS: 4215 dyspepsia patients were registered within 1 year. The annual incidence rate of dyspepsia was 3.4%. Alarm symptoms were present in 11.7% of the patients. The highest incidence rates were related to middle age, female gender and rural dwelling. Of these 34% had dysmotility-like, 30% had reflux-like, 17% ulcer-like and 3% uncharacteristic dyspepsia, while 16% were classified into two or more groups. Dysmotility-like dyspepsia was predominant in women and reflux-like dyspepsia was predominant in men. CONCLUSIONS: Within 1 year 34 patients out of 1000 will seek medical advise in general practice with a new episode of dyspepsia. Based on the registration of symptoms 28 of 34 can be classified into a single subgroup of dyspepsia; 4 of 34 patients will present with one or more alarm symptom.

Adolescent↗
PubMed1996

Prevention in practice: results of a 2-year follow-up of routine health promotion interventions in general practice.

BACKGROUND: The effectiveness of health promotion activity in general practice on risk factor reduction for coronary heart disease remains the subject of active debate. OBJECTIVE: The study aimed to assess the impact of practice-based health check-ups on health behaviours over a 2-year period. METHOD: A general practice cohort of 7123 patients from 18 practices was surveyed. Eight hundred and forty (12%) patients had been offered a health check within a 12-month period from September 1992 and 621 (9%) received one. Two hundred and fifty patients (40%) were asked back for follow-up after their health check. RESULTS: Over a 2-year period there was no difference in smoking cessation, alcohol consumption, weight loss nor the amount of exercise taken between those who attended for a health check and those who did not. The food score chosen to assess dietary change (Oxcheck) showed a statistically significant 1.16-point rise for the whole sample over the survey period. There was a significant difference in mean food score change between health check attenders and non-attenders (Mann-Whitney U test: P < 0.002). Maintenance of dietary improvement over a 2-year period was not affected by health check attendance. CONCLUSIONS: This study confirms the low impact of health checks on the self reported modification of cardiovascular risk factors and shows that maintenance of appropriate health behaviour change is no more likely in those who have received a health check.

Adult↗
PubMed2006

Evidence-based practice in an age of relativism: toward a model for practice.

Evidence-based practice (EBP) is considered a hallmark of excellence in clinical practice. However, many social workers are uncertain about how to implement this approach to practice. EBP involves integrating clinical expertise and values with the best available evidence from systematic research while simultaneously considering the client's values and expectations--all within the parameters of the agency mandate and any legislative or environmental considerations. This article explores the feasibility of EBP and attempts to steer a course between those who advocate an EBP model that may appear unachievable to many clinicians and those who dismiss it outright on philosophical grounds. Five areas that affect the feasibility of EBP are explored: misconceptions about EBP, confusion about philosophical issues, questions about the quality of evidence needed to support EBP, substantive knowledge domains required for practice, and issues related to knowledge transfer and translation. An important theme of this analysis is the central role of clinical judgment in all aspects of EBP.

Evidence-Based Medicine↗
PubMed1997

Standards and practice guidelines as the foundation for clinical practice.

The structure and organization of health care delivery are in the midst of rapid change. Health care providers from a variety of disciplines are being challenged to define their practice and the expected patient outcomes resulting from their processes of care delivery. Standards and clinical practice guidelines are important tools for enhancing the quality of health care delivery and for documenting care. The article describes a process for developing standards and clinical practice guidelines and presents an organizational scheme for them. Based on recommendations from diverse national groups, a format for practice guidelines is presented, and a system for implementation and ongoing evaluation is recommended.

American Nurses' Association↗
PubMed2003

Anxiety and anger among family practice residents: a South Carolina family practice research consortium study.

PURPOSE: To study the dimensions of anxiety and anger experienced by a statewide sample of South Carolina family practice residents. METHOD: A total of 350 family practice residents from seven programs participated. Each resident completed the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Profile of Mood States, the Hassles Scale, the Maslach Burnout Inventory, and the State-Trait Anger Expression Inventory (STAXI) on at least one occasion. We analyzed reported anxiety and anger by gender, year of training, race, marital status, type of program (community hospital versus university), location of program, and season of the year. RESULTS: Residents reported lower levels of anxiety and anger across most dimensions compared with the adult populations on which the tests were standardized and with other resident and practicing physician populations. The residents did not demonstrate excessive levels of anger as a trait or in response to situations, nor did they significantly suppress anger. Although the residents reported a higher frequency of hassles than did normal populations, they did not consider these hassles severe. A higher than normal level of depersonalization was found among male, Caucasian, and third-year residents. CONCLUSIONS: These family medicine residents did not experience excessive levels of anxiety or anger during residency training either as a trait, state or somatic response. Extensive social and emotional "in-house" support, attention to stress-management skills, and the moderate personality characteristics of family practice residents help explain these findings. Initial assessment of psychological functioning and early remediation and program support during training may significantly reduce the potential for residents' impairment.

Adult↗
PubMed1992

The Nursing Practice Personnel Data Set. Implications for professional practice systems.

Existing data about nursing practice personnel has been found to be fragmented, incomplete, and non-uniform. These shortcomings can severely hamper administrative decision making related to professional practice systems in general, and differentiated pay and practice models in particular. The Nursing Personnel Practice Data Set (NPPDS) is designed to remedy these deficiencies by providing available, accessible, reliable, and comparable data about nursing personnel. The authors describe elements of the NPPDS and discuss implementation aims.

Career Mobility↗
PubMed1995

Utilization of advanced practice nurses in healthcare systems and multispecialty group practice.

Cost-effective strategies for delivering primary care require the appropriate mix of healthcare providers. The authors define the scope of practice for the advanced practice nurse. Results of a nationwide survey of 26 large healthcare systems and multispecialty group practices are presented. Findings from these practice settings are contrasted with those previously reported in the literature. Implications for the future are discussed.

Cost-Benefit Analysis↗
PubMed1979

Mental health services: utilization by low income enrollees in a prepaid group practice plan and in an independent practice plan.

Mental health services were included in a comprehensive package of benefits available to low income enrollees in a prepaid group practice plan (PGP) and in an independent practice plan (IPP) under the Seattle Prepaid Health Care Project. There were no out-of-pocket costs for enrollees. Utilization of services was studied for four years under conditions that might simulate universal entitlement. The analyses indicated that females used substantially more mental health services than males and that enrollees aged 20-44 used more services than those in other age groups. The prepaid group practice generally experienced higher utilization than the prepaid independent plan. Significant racial differences were evident with whites using more services than blacks and black males using strikingly few services. The prepaid independent plan was oriented toward physician providers and emphasized individual psychotherapy while the prepaid group practice employed a diversity of practitioners and therapeutic modalities. The data indicated that the per cent of enrollees using any mental health services was twice as great in the PGP as in the IPP. However, once access to the provider system was achieved, the number of services utilized was greater in the PGP. Inpatient services were also examined. A significantly higher proportion of IPP enrollees were admitted for inpatient care as compared to PGP enrollees. Finally, the cost of mental health services was less than ten per cent of total health service costs in both plans.

Adolescent↗