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Upstream or downstream. Determinants of consumer willingness to recommend an HMO.

Understanding the attributes that explain an HMO members' willingness to recommend a health plan is considered by many to be critical in a competitive managed care market. The study reported in this article examines the relationship between provider panel composition on overall willingness to recommend a health plan. Our results indicate that a strong association exists between an HMO member's available choice of primary care physician and recommendation of their primary care physician with overall HMO members' recommendation of the health plan. Interestingly, a member's recommendations of hospitals and specialists did not influence HMO member's willingness to recommend a health plan.

Female↗

Management of acute gastroenteritis in Europe and the impact of the new recommendations: a multicenter study. The Working Group on acute Diarrhoea of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition.

BACKGROUND: The European Society for Paediatric Gasteroenterology, Hepatology and Nutrition (ESPGHAN) issued two sets of recommendations for the treatment of infants with acute gastroenteritis (1992, 1997). The purpose of this multicentre study performed in 29 European countries was to determine how closely current treatment compares with the ESPGHAN recommendations. METHODS: The outline of the study was based on a questionnaire that addressed the management of a 6-month-old infant with acute gastroenteritis complicated by mild to moderate dehydration. National coordinators circulated the questionnaire to randomly selected primary care physicians and to hospital-based paediatricians. RESULTS: A total of 2997 questionnaires were returned, of which 1768 were from Western Europe (WE) and 1229 from Central and Eastern Europe (CEE). Eighty-four percent of responding physicians said they would follow the ESPGHAN recommendation to use oral rehydration solution (ORS) for rehydration, with 66% using an ORS containing 60 mmol/l sodium ORS. Only 16% (WE 15%, CEE 19%) would follow the guidelines and use rapid oral rehydration over 3 to 4 hours. Forty-five percent would rehydrate infants in a 3- to 6-hour period (WE 35%, CEE 60%), and 17% (WE 23%, CEE 9%) would extend the rehydration period to 12 to 24 hours. ESPGHAN recommendation of rapid reintroduction of normal feeding after 3 to 4 hours of oral rehydration would be followed by only 21% of responding physicians, and only 43% (WE 46%, CEE 38%) would start feeding with full-strength formula. However, the guideline about continuation of breast-feeding is widely followed (total 77%; WE 78%, CEE 75%). Thirty-six percent (WE 45%, CEE 23%) use a lactose-containing formula after successful oral rehydration. Contrary to the ESPGHAN guideline 35% (WE 30%, CEE 42%) would use a lactose-free formula and 19% (WE 12%, CEE 28%) a lactose and cow's milk protein-free formula. Only 37% (WE 30%, CEE 46%) of responding physicians would follow the recommendation to use ORS to replace ongoing losses from watery diarrhoea. CONCLUSIONS: The results of the survey suggest that with the exception of recommending ORS for rehydration and continuation of breast-feeding during diarrhoea, a minority of responding European physicians follow the ESPGHAN guidelines for optimal management of children with acute gastroenteritis.

Acute Disease↗

The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations.

OBJECTIVES: This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times. METHODS: Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states. RESULTS: The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations. CONCLUSIONS: These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.

Awareness↗

A review of the secretion of radioactivity in human breast milk: data, quantitative analysis and recommendations.

A general method is given to quantify the radioactivity ingested by a breast-fed infant following maternal radiopharmaceutical administration, and to derive the period to interrupt feeding which reduces the corresponding effective dose equivalent to below 1 mSv. Results are presented from applying the method to all available measurements of radioactivity secreted in breast milk. This review includes some hitherto unpublished data, takes more account of the scarcity of the available data, and has resulted in modifications to the guidance for interrupting breast feeding. Recommendations for interrupting feeding with mature milk have been expanded into four categories: (1) interruption not essential; (2) interruption for a fixed period of time; (3) interruption until measurements indicate feeding can be resumed; and (4) cease breast feeding. Changes to the earlier guidance are that 99Tcm-pertechnetate, (99Tcm) erythrocytes, 125I-OIH and 131I-OIH have been moved to the third category, and that recommendations have been included for 99Tcm-DMSA, 99Tcm-glucoheptonate, 99Tcm-HDP, 99Tcm-HMDP, 123I-iodide and 123I-OIH. Before recommendations (1) and (2) can be issued to a mother, quality control measurements must be made of the radiopharmaceutical administered. Recommendations (3) or (4) only should be issued to mothers secreting colostrum. If there are changes in the recommended dosimetry in the future, the calculated fractional ingested activities can be used as a basis to refine the recommendations.

Breast Feeding↗

Variation in recommendations for breast and cervical cancer screening among primary care physicians in North Carolina, 1991.

Physicians play an important role in recommending and doing cancer screening for their patients. In 1991, the North Carolina Department of Environment, Health and Natural Resources and the Centers for Disease Control and Prevention conducted a survey to determine the counseling and referral practices of primary care physicians practicing in North Carolina. Physicians were asked to report the percentage of patients in various age groups that they recommended receive a clinical breast examination, referral for mammography screening, or a Pap test and at what intervals they recommended each study. They were also asked their perceived barriers to cervical cancer screening. Obstetrician-gynecologists recommended annual Pap smear screening more frequently than did physicians in other specialties for patients of all ages. For mammography, variation existed for recommended screening intervals for all specialties by patient age (35 to 39 years, 40 to 49 years, 50 to 64 years, and over age 65). Recommendations for mammography also differed significantly according to physicians' age and sex. The medical community and the public need a consistent and clear message to promote effective screening maneuvers.

Adult↗

Effect of discharge recommendations on outcome.

STUDY DESIGN: The incidence of two common discharge recommendations, return to work unrestricted (RTWU) and restricted (RTWR) suggested that most restrictions were applied on the basis of patients' subjective reports of pain or therapists' unfounded fears that return to full duty would result in physical harm. OBJECTIVES: This prospective study compares the therapist's return to work recommendation to the patient's actual work status and analyzes the effect of that recommendation on outcome. METHODS: There were 1438 consecutive patients reviewed by structured telephone interviews during the two halves of the study: the control group when pain was accepted as a reason for restriction and the study group when it was not. SUMMARY OF BACKGROUND DATA: In the control group, 44% of the patients were recommended to RTWU; for the study group, 81% received this recommendation. Compliance was 84% for the control subjects and 78% for the study group. RESULTS: The absolute number of patients who returned to unrestricted work doubled in the study group. CONCLUSIONS: The probability of a successful return to normal duty increased with a recommendation of RTWU (P = 0.0001), whereas the probability of failure increased when restrictions were imposed (P = 0.0001).

Adult↗

Are the recommendations of the French consensus conference on the management of colon cancer followed up?

The aim of this study was to determine how the guidelines published after this conference have spread. Pretherapeutic evaluation and treatment were assessed for all colon cancers diagnosed in a well-defined French population in 2000. Patients were classified either as managed according to the recommendations, or as undermanaged or overmanaged. Outside the emergency context, pretherapeutic work-up was classified as in conformity with the consensus in 48.0% of the cases, as undervalued in 21.9% and as overvalued in 30.1%. The resection rate at 90% was not far from the optimum. Pathological data allowed us to classify nearly all cases according to the tumour node metastasis classification; however, the number of examined nodes was below the recommendations in 30.8% of cases. Chemotherapy was performed according to the recommendations in 71.4% of cases, 23.1% were undertreated and 5.5% were overtreated. The multivariate analysis indicates that patients aged 75 years or more were less likely to receive chemotherapy than was recommended (P<0.001). This study suggested that the main reasons for not following guideline recommendations were inertia due to previous practices, difficulty to perform a recommended behaviour and lack of familiarity.

Aged↗

The relationship among physicians' specialty, perceptions of the risks and benefits of adjuvant tamoxifen therapy, and its recommendation in older patients with breast cancer.

OBJECTIVES: The objectives of this study were to determine whether tamoxifen recommendation differs by physician specialty, to determine whether perception affects tamoxifen recommendation, and to investigate the association between the physician's specialty and the perception of risks and benefits of tamoxifen. METHODS: We enrolled a cohort of geographically diverse women aged 65 and older with stage I through IIIa breast cancer in a prospective cohort study. We recruited their surgeons and, when applicable, their medical oncologists to provide patient-specific information about their perceptions of the risks and benefits of tamoxifen and whether they recommended tamoxifen. Each physician also completed a questionnaire regarding his or her demographic and practice characteristics. Patient data were collected through medical record review and a patient interview 3 months after definitive breast cancer surgery. RESULTS: We collected physician treatment recommendation forms for 585 women. Oncologists were 2.5 times more likely to recommend tamoxifen, compared with surgeons, after adjusting for patient and tumor characteristics (95% confidence interval, 1.5-4.2). For both specialties, their perceptions of the risks and benefits of tamoxifen were strong predictors of tamoxifen recommendation. However, there were differences in perception by physician specialty. Distant metastases and tolerance of tamoxifen side effects were more important to oncologists, whereas local recurrence and risk of cataracts were more important to surgeons. CONCLUSION: Physicians' perceptions of the risks and benefits of tamoxifen therapy for older women are important in their decision-making process.

Age Factors↗

Herbal medicines: predictors of recommendation by physicians.

BACKGROUND: We hypothesized that as the use of herbal medicines increases in the general population, so do patients' requests to physicians for recommendations. However, why some physicians recommend herbal medicines while others do not is not well understood. OBJECTIVE: To identify factors, which predict recommendation of herbal medicines by physicians. DESIGN, LOCATION, SUBJECTS: Face-to-face interview using a structured questionnaire of 206 physicians working at the University of Malaya Medical Centre, Malaysia. RESULTS: About a third (206 of 626) of the physicians in the Centre participated. Only nine of the 215 approached refused to participate. Forty physicians (19%) recommended herbal medicines to patients. Logistic regression modelling identified personal use, general interest, interest in receiving training, race and higher level of medical training as significant predictors of physicians recommending herbal medicines. CONCLUSIONS: Physicians' personal attributes and training influence their likelihood of recommending herbal medicines.

Education, Medical↗

Food-based recommendations to reduce fat intake: an evidence-based approach to the development of a family-focused child weight management programme.

OBJECTIVES: To develop food-based recommendations to lower fat and energy intake for use in a family-focussed weight management programme for 6-9 year old children. METHODS: Secondary analysis of the 1995 National Nutrition Survey (NNS95) informed the development of food-based recommendations aiming to reduce fat and energy intake. Each recommendation was used to progressively modify a model 3-day high fat dietary intake with the accumulative effect on energy and nutrient intake of each recommendation assessed. RESULTS: Six to nine-year-olds in the NNS95 consuming 35-45% energy as fat (n= 280) consumed more total energy (mean +/- SD, 8671 +/- 2741 vs. 7571 +/- 2328 kJ/day) than children consuming a 'low fat' (23-27% energy as fat, n= 85) diet (P < 0.002). Food-based recommendations found to be most effective for reducing energy and fat intake included; changing to reduced fat milk, reducing intake of cereal-based and snack foods and replacing juice or soft drink with water. These changes, together with avoiding adding fat to vegetables and using sources of lean meat, reduced energy intake by approximately 10%, total fat intake by approximately 30% and saturated fat intake by 53%. CONCLUSIONS: Modifying six areas of food choices results in a moderate reduction in fat and energy intake. An eating pattern that is consistent with Australian dietary guidelines and uses foods commonly eaten by children is achievable for children aged 6-9 years. These food-based recommendations provide an evidence-based dietary framework for prevention and management of overweight in children.

Child↗

Are the nutritional recommendations for insulin-dependent diabetic patients being achieved?

Dietary intake was assessed, using a 3-day recorded food diary, in 122 patients with insulin-dependent diabetes. Subjects were selected randomly from patients attending a diabetic clinic and stratified for age, sex, and duration of diabetes. The findings were compared to the dietary recommendations of the European Association for the Study of Diabetes (EASD) and to the findings in a recent Irish National Nutrition Survey. The average daily protein intake among diabetic patients was 18% of the total calories, significantly higher than recommended by EASD and significantly higher than in the age-matched general population. Dietary fat intake was on average 37% of total calorie intake, again significantly higher than recommended and greater than in the general population among older patients. Saturated fat intake was higher than recommended and polyunsaturated fat intake was low. The average carbohydrate intake was 42% of total calories, significantly lower than recommended and similar to that in the general population. Sugar intake was lower and starch intake was higher among patients than in the general population, however. Fibre intake was also lower than recommended, but was higher than in the general population. We conclude that the present dietary targets for diabetic patients are not being fully achieved.

Adolescent↗

Eliciting stated preferences for health-technology adoption criteria using paired comparisons and recommendation judgments.

OBJECTIVES: The principal aim of this study was to illustrate applying discrete-choice methods for eliciting preferences for technology adoption criteria, including threshold values for cost-effectiveness ratios. A secondary objective was to compare the criteria weights of a sample of industry stakeholders with the results obtained from a study of National Institute for Health and Clinical Excellence (NICE) recommendations. METHODS: We administered a two-stage stated-preference (SP) question format to a sample of respondents who have expertise in applying economic analysis to technology adoption decisions. We elicited paired comparisons and recommendation judgments for similar criteria from a sample of International Society for Pharmacoeconomics and Outcomes Research members. Respondents evaluated nine pairs of hypothetical drugs, first indicating which drug was "better," then indicating what they would recommend to a reimbursement authority such as the National Health Service. Stated-choice studies often obtain only paired-comparison judgments. RESULTS: Parameter estimates from the initial paired-comparison question indicate only incremental cost-effectiveness ratio and number of affected patients influence evaluations. These two factors have identical weights in the second recommendation question, but all four factors were considered in determining the recommendation threshold. Our sample was more willing than NICE to accept trade-offs between cost-effectiveness and other drug features and was less concerned about cost-effectiveness ratios and information uncertainty. Nevertheless, our sample was in agreement with NICE about the importance of the number of patients who would benefit as a criterion for influencing adoption recommendations. CONCLUSION: This study demonstrates that including a question allowing respondents the opportunity to reject both alternatives in a forced-choice paired comparison can be important for obtaining accurate preference estimates. Our results demonstrate that SP methods offer a feasible means of quantifying a broad set of valuations that incorporate the preferences of patient, citizen, payer, and other stakeholder groups.

Academies and Institutes↗

Patients' perceptions of physicians' recommendations for comfort care differ by patient age and gender.

OBJECTIVE: To determine patient characteristics associated with patient and proxy perceptions of physicians' recommendations for life-prolonging care versus comfort care, and with acceptance of such recommendations. DESIGN: Cross-sectional. SETTING: Five teaching hospitals in Denver, Colo. PATIENTS: We studied 239 hospitalized adults believed by physicians to have a high likelihood of dying within 6 months. MEASUREMENTS AND MAIN RESULTS: Interviews with patients or proxies were conducted to determine perceptions of physicians' recommended goal of care and roles in decision making. RESULTS: Patients' mean age was 66.6 years; 44% were women. In adjusted analysis, age greater than 70 years and female gender were associated with a higher likelihood of believing that comfort care had been recommended by the physician (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.89 to 7.24; OR, 1.99; 95% CI, 1.04 to 3. 84, respectively). Patients and proxies gave substantial decision-making authority to physicians: 29% responded that physicians dominate decision making, 55% that decision making is equally shared by physicians and patients, and only 16% that patients make decisions. Increasing age was associated with an increased likelihood of believing that physicians should dominate decision making (P <.005). CONCLUSIONS: Among patients with advanced illness, perceived comfort care recommendations were related to patient age and gender, raising concern about possible gender and age bias in physicians' recommendations. Although all patients and proxies gave significant decision-making authority to physicians, older individuals were more likely to give physicians decision-making authority, making them more vulnerable to possible physician bias.

Age Factors↗

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies.

OBJECTIVE: To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations. DESIGN: Validation study. SETTING: A health maintenance organization and a geriatrics academic program. PARTICIPANTS: A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms. MEASUREMENTS: Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker. RESULTS: On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83. CONCLUSION: A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.

Aged↗

Dietary guidelines and food recommendations in Denmark. Nordic Committee of Foods, Nordic Council of Ministers, National Research Council, Denmark.

In Denmark the official dietary guidelines and food recommendations are expressed in the Five Dietary advices and the Danish food circle. Such guidelines are entirely different from recommendations on nutrient intakes, which are expressed in terms of exact values and established through a more formal procedure. Some of the most fundamental principles for food recommendations given to the public are that they are perceived as consistent and based on a firm consensus, and that their relevance and translation into practical action is obvious to the public. When the situation in Denmark is compared to these principles the main issue turns out to be neither lack of consistency in recommendations issued by government agencies and voluntary health organisations, nor is it lack of consensus among the experts about the fundamental messages of the guidelines. A more important problem is that the public does not distinguish between formal recommendations from authorized sources, and a variety of advices from other sources as well as non-formal comments from individual scientists. A cause of serious concern is the fact that the Danish public seems to lack a realistic picture of what the dietary guidelines imply in terms of foods. A number of contradictions is built into the process of communicating dietary recommendations effectively to the public. These can only be solved if the process is planned on a long-term basis.

Animals↗

Evaluation of nutrition knowledge and dietary recommendations by coaches of adolescent Brazilian athletes.

The objectives of this study were to describe the dietary practices recommended by coaches working with adolescent athletes and to assess their nutritional knowledge. During a regional competition in the state of Sao Paulo, Brazil, 55 coaches were interviewed. These coaches represented 22 cities with athletes enrolled in Olympic gymnastics, tennis, swimming, and judo events. A 3-section questionnaire was used to obtain data on demographic characteristics, dietary recommendations, and nutrition knowledge. Results showed that all coaches recommended general dietary practices during training, with no specific strategies for pre-, during-, and post-training periods. The main objectives of the recommendations for the training period were weight control and muscle mass gain. Deleterious weight control practices were recommended by 27% of the coaches. Specific dietary practices pre and post competition were recommended by 93% and 46% of the coaches, respectively. Participants responded correctly to 70% (SD = 3.2) of the nutrition knowledge questions, with no significant differences (p =.61) between sports. The knowledge test identified a tendency to over-value proteins, excessively low-fat diets, and food myths. These findings indicate the importance of developing strategies that will enhance the nutritional training of coaches.

Adolescent↗

EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).

OBJECTIVES: To develop evidence based recommendations for the management of hand osteoarthritis (OA). METHODS: The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference. RESULTS: Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise. CONCLUSION: Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

Anti-Inflammatory Agents, Non-Steroidal↗

EULAR recommendations for conducting clinical studies and/or clinical trials in systemic vasculitis: focus on anti-neutrophil cytoplasm antibody-associated vasculitis.

OBJECTIVES: To develop the European League Against Rheumatism (EULAR) recommendations for conducting clinical studies and/or clinical trials in systemic vasculitis. METHODS: An expert consensus group was formed consisting of rheumatologists, nephrologists and specialists in internal medicine representing five European countries and the USA, a clinical epidemiologist and representatives from regulatory agencies. Using an evidence-based and expert opinion-based approach in accordance with the standardised EULAR operating procedures, the group identified nine topics for a systematic literature search through a modified Delphi technique. On the basis of research questions posed by the group, recommendations were derived for conducting clinical studies and/or clinical trials in systemic vasculitis. RESULTS: Based on the results of the literature research, the expert committee concluded that sufficient evidence to formulate guidelines on conducting clinical trials was available only for anti-neutrophil cytoplasm antibody-associated vasculitides (AAV). It was therefore decided to focus the recommendations on these diseases. Recommendations for conducting clinical trials in AAV were elaborated and are presented in this summary document. It was decided to consider vasculitis-specific issues rather than general issues of trial methodology. The recommendations deal with the following areas related to clinical studies of vasculitis: definitions of disease, activity states, outcome measures, eligibility criteria, trial design including relevant end points, and biomarkers. A number of aspects of trial methodology were deemed important for future research. CONCLUSIONS: On the basis of expert opinion, recommendations for conducting clinical trials in AAV were formulated. Furthermore, the expert committee identified a strong need for well-designed research in non-AAV systemic vasculitides.

Antibodies↗