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BACKGROUND: Minority women in Canada are less likely to be screened for cervical cancer than their counterparts in the general population, despite the fact that the proportion of these women who consult a general practitioner about their health each year is similar to minority women. This study examined the physician and practice characteristics associated with Pap testing and perceived barriers to Pap testing of family physicians serving the Caribbean community of Toronto. METHODS: A mail-back questionnaire was sent to Toronto family physicians practicing in neighborhoods with a high proportion of Caribbean Canadians. RESULTS: Although 79.7% of the 64 participating physicians reported that they were 'very likely" to include Pap testing during an annual check-up, nearly half did not believe that the majority of Caribbean patients were actually screened. The amount of time a physician spent on patient education was significantly associated with his/her likelihood of screening. Male physicians who reported a high proportion of Caribbean female patients in their practices were significantly less likely to screen for cervical cancer than those who saw fewer Caribbean patients. CONCLUSION: These findings suggest that an increased emphasis on patient education is important to increase screening practice and that physician gender may be of major importance to the Caribbean community.
The purpose of this article is to introduce evidence-based concepts and demonstrate how to find valid evidence to answer clinical questions. Evidence-based decision making (EBDM) requires understanding new concepts and developing new skills including how to: ask good clinical questions, conduct a computerized search, critically appraise the evidence, apply the results in clinical practice, and evaluate the process. This approach recognizes that clinicians can never be completely current with all conditions, medications, materials, or available products. Thus EBDM provides a mechanism for addressing these gaps in knowledge in order to provide the best care possible. In Part 1, a case scenario demonstrates the application of the skills involved in structuring a clinical question and conducting an online search using PubMed. Practice tips are provided along with online resources related to the evidence-based process.
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BACKGROUND: Context - the combined effect of factors such as physician type, clinical setting, and guideline characteristics - influences the ability of automated decision support (ADS) to improve physician compliance with clinical practice guidelines (CPGs). Our goal was to determine whether research about the utility of ADS for promoting CPG compliance is contextually applicable to United States physicians. METHODS: We extracted information about physicians, settings, and guidelines from all articles published in the last 10 years that describe original research about the use of ADS to promote CPG compliance. The extracted information was compared to the range of practice contexts seen in the United States. RESULTS: Nearly two-thirds (65.3%) of papers described studies conducted in an academic setting, but only 11% of physicians report academic affiliations (p<0.0001). Physician reimbursement structure is often not reported. Salaried physicians were explicitly included as subjects in 14% of articles, but make up 45% of US physicians (p<0.0001). There are little data about the generalizability of ADS research to emergency care settings (6% of articles), and nursing home or skilled nursing facilities (10% of articles). Finally, ADS has not been studied at all in several epidemiologically important disease categories. CONCLUSION: The literature does not adequately address some physician, setting, and guideline contexts. Before making policy or spending decisions based on the effectiveness of ADS, additional research is needed to determine whether ADS research can be generalized to under-represented contexts.
The French medical profession and health insurance organizations have jointly committed themselves to a concept termed the 'medical regulation' of care. They decided to promote the quality of health care, judging that an approach based on quality was the best option for reducing the increase in health costs. The Clinical Guidelines and Medical References programme was entrusted to ANDEM (Agence Nationale pour le Développement de L'Evaluation Médicale). Fifty working groups (669 experts) and 50 reading groups (1643 experts) met from June 1994 to November 1995 to produce guidelines. Learned societies were involved to propose experts. Hospital practitioners, doctors who specialized in the topic in question and those who did not had equal representation in the groups. The method consisted of a review of the literature to determine the level of scientific evidence. ANDEM's Scientific Council suggested modifications to the groups and agreed to disseminate 48 of the 50 texts. Careful observation of the operation of the groups identified factors that can positively influence the nature of the discussions and help avoid conflict: an abundance of high-quality literature, an understanding of clinical research methodology, the existence of guidelines from different institutions or different countries tending towards the same conclusions, good initial work carried out by the chairperson and the project manager, a limit to the number of questions asked of the group, the chairperson having good people skills and meeting-management skills, and an absence of professional and financial consequences for the participants. Good management of working groups is an additional factor in ensuring success. The regulatory medical references programme has led to changes of behaviour within the medical profession.
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Review articles are an important source of clinical information for family physicians. However, the volume of available reviews is vast and their scientific quality varies enormously. Family physicians must be able to identify trustworthy reviews quickly. This article outlines practical and flexible guidelines for critical appraisal and discusses the respective roles of review articles and original research reports in guiding clinical practice.
In recent years, a multitude of practice guidelines, statements, position papers, and "best practices" have been promulgated for a number of disease entities by a variety of medical societies and managed care organizations. In the case of asthma, for example, the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) initially published guidelines for the diagnosis and management of asthma in 1991; these recommendations were updated in 1997. However, health-care providers have not widely and consistently adhered to these guidelines. Several recent publications suggest that this underutilization of the NIH asthma guidelines may in part be related to a lack of understanding. This lack of understanding appears to span the spectrum of physicians in private practice, physicians working in health maintenance organizations, as well as university-affiliated physicians. Moreover, both primary-care physicians and "asthma specialists" share deficits in their knowledge base. To compound the problem, patients with asthma also demonstrate poor adherence to the guidelines. This poor adherence is evident irrespective of the patient's socioeconomic status. These types of data clearly indicate a need for further educational programs directed to both physicians and patients. However, as with the development and promulgation of any practice guideline, physicians need to be convinced that there exists compelling evidence from well-controlled clinical trials, for example, or from evidence-based medicine, to substantiate implementation of these guidelines.
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BACKGROUND: A U.S. Public Health Service-sponsored clinical practice guideline urges all health care providers to make tobacco-use cessation counseling a routine part of clinical practice. This study assessed practices of dentists in east Texas, their adherence to the guideline and barriers to adherence. METHODS: A cross-sectional survey mailed September 2003 through January 2004 assessed demographic characteristics and knowledge, attitudes and activities of 783 dentists. The survey focused on familiarity with the guideline, adherence to the recommended steps (including the "5 A's" for tobacco users willing to quit and the "5 R's" for tobacco users unwilling to quit), perceived barriers and time spent counseling. RESULTS: Most dentists were unfamiliar with the guideline and usually did not follow its recommended steps. Less than 20 percent of dentists spent three or more minutes per patient on counseling. Knowledge of and training in using the guideline were significantly associated with adherence and time spent counseling. Lack of training was cited as the greatest barrier. CONCLUSIONS: Most dentists in east Texas are unaware of the clinical practice guideline. Lack of training is a major barrier to adherence. Practice Implications. Opportunities for improving patients' health through brief counseling interventions are missed. Measures are needed to increase dentists' familiarity with and adherence to the guideline.
Cardiovascular disease (CVD) is the leading cause of death worldwide, and its prevention and treatment are important healthcare aims. Hypercholesterolemia is among the most important modifiable risk factors for CVD, and numerous guidelines exist for the treatment of this condition. Nevertheless, despite the existence of well-established and safe pharmacologic therapy for lowering cholesterol and preventing CVD, surveys in the United States and Europe have revealed that many patients have elevated cholesterol levels. There is a clear gap between what is known about treating CVD and the implementation of that knowledge. A survey assessing patients' knowledge about CVD observed that many patients are unaware of the disease prevalence and have little knowledge about the main risk factors, including the importance of cholesterol. Another survey demonstrated that many physicians overestimate patients' awareness of CVD and that physicians also overestimate the extent to which guidelines are implemented in clinical practice. Guideline implementation may be improved by narrowing the discrepancies between what patients and physicians believe and the reality. Many physicians claim that lack of time hinders guideline implementation and improvement of patient education. Physicians also appear to lack the motivation to implement lipid-lowering interventions. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment and prevention of CVD.