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PubMed2006

Use of pharmacotherapies for the management of addictive behaviours in Australian clinical practice.

AIMS: To collect data on the behaviours associated with the prescription of pharmacotherapies (bupropion, acamprosate and naltrexone) for nicotine and alcohol dependence in Australian clinical practice. DESIGN: Self-administered questionnaire. SETTING: Australian clinical practice. PARTICIPANTS: Three specialties, psychiatrists, gastroenterologists and general practitioners (GPs) were defined by the Health Insurance Commission's derived major specialty classification codes and stratified by state (and territory) as well as rural and remote metropolitan area classification. A total of 2680 surveys were sent (670 psychiatrists, 82 gastroenterologists and 1928 GPs) with 1291 surveys used in the final analysis (329 psychiatrists, 37 gastroenterologists and 925 GPs). INTERVENTIONS: A 10-page, 46-item survey was distributed by the HIC. The initial survey was sent in March 2003 and sent a subsequent two times to non-responding physicians. MEASUREMENTS: Characteristics of physicians and their therapeutic preferences in managing patients with nicotine or alcohol dependence. FINDINGS: The majority of physicians identified and provided advice to patients who smoked and consumed alcohol at levels harmful to health. Fourteen percent used a formal alcohol-screening instrument, 4% were familiar with the 5 As' of a smoking cessation strategy and less than a third had undertaken any formal training in providing brief advice. The majority of physicians perceived pharmacotherapies to be an effective treatment strategy and indicated adjuncts improved likelihood of behaviour modification. Predictors of pharmacotherapy prescribing included working in a large clinical practice, having an additional mental health qualification and training in provision of brief advice. CONCLUSIONS: Physicians are in a strong position, and are encouraged to, manage additive disorders. Scope exists to improve prescribing of pharmacotherapies for nicotine and alcohol dependence by enhancing appropriate counselling skills and making explicit the nature of a comprehensive treatment regime as an adjunct to medicines.

Acamprosate↗
PubMed2000

The effect of continuous quality improvement on compliance with clinical practice guidelines in an optometric clinic: a retrospective review.

BACKGROUND: Quantitative documentation of quality is becoming increasingly more important. The SUNY State College of Optometry established clinical protocols outlining clinical standards for patient care. We compared documentation of actual clinical performance to these standards. METHODS: The Primary Care Service's Quality Management Team retrospectively reviews a random 10% sample of charts of patients seen in the teaching clinic of the SUNY State College of Optometry on an ongoing basis. They compare the care documented in the medical record to internally distributed clinical protocols. We reviewed the resultant data from January 1995 through June 1997 by analyzing the number of indicators that were out of compliance for each month. Then we graphed these data to ascertain trends and variability to determine what effect this continuous quality improvement process had on clinical care as measured by compliance with clinical protocols. RESULTS: A least-squares regression analysis demonstrated a correlation (0.717) between the decreasing number of items out of compliance and the time during which feedback was provided (r2 = 0.5143, p = 0.0001). These data show a distinct downward trend, indicating better compliance with the clinical protocols over time. We also found that the variability of the data decreased during the time period studied. CONCLUSIONS: A properly designed continuous quality improvement program that gives appropriate feedback to faculty optometrists and student interns measurably increased their compliance with--and decreased their variability from--this clinic's internally distributed clinical protocols over a 30-month time period.

Clinical Competence↗
PubMed2000

[Depression and clinical practice guidelines: evidence or confusion. Study group on the prescription and psychotropic in primary care].

BACKGROUND: The need of designing clinical practice guidelines in the context of the evidence based medicine relates to different aspects concerning the characteristics of the clinical condition, the health care context, the utilization of health services, and the existing knowledge about the topic of study. The objective of this study was to review the guideline development method for managing depression in care and its implications in clinical practice. MATERIAL AND METHODS: Review and classification of scientific articles published between 1990 and 1997 about depression guidelines according to its method of development. RESULTS: Between 1990 and 1997, 2 clinical practice guidelines on the management of depression were published using systematic review, 3 guidelines were developed through unsystematic review, 4 guidelines were developed from experts' consensus, and 19 published articles reviewed the applicability of the existing guidelines in the primary health care sector. Different points of view about the use of these guidelines had been detected. CONCLUSIONS: In the context of the evidence-based medicine, one should take into account that the overall goal of guidelines development is to ensure its validity in different health care levels, as well as to gather professionals' acceptance of its use and applicability.

Depression↗
PubMed2005

Accurate dosimetry: an essential step towards good clinical practice in nuclear medicine.

In nuclear medicine, an increasing number of radiolabelled agents are under investigation for future use in diagnostic imaging and for applications in radionuclide therapy. All these studies require large amounts of human data to allow for statistical comparisons with existing and well established diagnostic or therapeutic methodologies. In the framework of a good clinical practice environment, clinical trials should be carried out according to international guidelines and regulations as described in the Declaration of Helsinki. Studies involving ionizing radiation, as is the case in nuclear medicine, require special consideration to comply with the ALARA (as low as reasonably achievable) principle. Special publications of the International Commission of Radiological Protection and the World Health Organization deal with this topic in medical research. From the legislation point of view, the 97/43/EURATOM Directive represents the reference to clinical research using ionizing radiation within the European Union. In order to keep the radiation dose of (healthy) volunteers as low as possible, predictive dosimetry studies based on in-vivo animal biokinetics are essential. On the other hand, patients included in dose-escalation radionuclide therapy trials should be monitored individually with respect to dosimetry of the tumour and the critical organs. In this paper the importance and methodology of contemporary patient dosimetry in diagnostic and therapeutic nuclear medicine research are reviewed. It is concluded that reliable dosimetry is essential in performing scientific clinical studies according to the principle of good clinical practice.

Biomedical Research↗
PubMed2002

Chiropractors' attitudes to, and perceptions of, the impact of continuing professional education on clinical practice.

OBJECTIVES: As with other health care professions, there is a need for chiropractors to maintain their clinical competencies through continuing professional education (CPE) and development (CPD). This study set out to evaluate chiropractors' attitudes to, and opinions of, current CPE provision, and their perceived needs for the future. In particular, their perceptions of the impact of CPE on clinical practice were assessed. DESIGN: A survey in which primary quantitative and secondary qualitative data were collected using a self-administered questionnaire. The questionnaire concentrated on four areas: (i) attitudes to CPE; (ii) impact of current CPE on practice; (iii) modes of delivery most likely to change practice; and (iv) future learning needs from continuing education programmes. RESPONDENTS: A random sample of chiropractors registered with the British Chiropractic Association. RESULTS: Overall, chiropractors were positive to CPE and cognisant of the need to keep up to date. However, in spite of several benefits, chiropractors did not perceive current CPE to be instrumental in changing practice. As might be expected, chiropractors perceived clinical updates and hands-on practical workshops to be most effective in changing clinical practice. DISCUSSION: There is currently considerable debate surrounding the ability of CPE and CPD to actually make a difference to the way clinicians practice. This study describes a method of evaluating the impact of CPE/D in changing clinical practice from the viewpoint of the practitioners themselves.

Adult↗
PubMed1999

Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit.

OBJECTIVE: In this study, clinical practice guidelines were developed by a multidisciplinary team for patients with infections admitted to a surgical intensive care unit (ICU). DESIGN: A 51-day baseline audit period (Phase I) in a 20-bed (private rooms) surgical ICU was compared with a 34-day period in the same unit after implementation of the guidelines (Phase II). PATIENTS: Phase I included 182 patients (670 patient days), and Phase II included 139 patients (427 patient days). RESULTS: There was no significant difference between patients in the Phase I and Phase II groups regarding age (65.4/19-95 vs. 64.8/18-90 yrs), gender (56% male vs. 55% male), severity of illness (mean Acute Physiology and Chronic Health Evaluation III, 38 vs. 39.1), total infections (respiratory, 8% vs. 4%; urinary tract, 15% vs. 4%; wound, 4% vs. 3%; skin/soft tissue, 3% vs. 7%; sepsis, 5% vs. 3%; intra-abdominal, 9% vs. 17%), and no infection (64% vs. 67%). Clinical outcomes of patients with infections in the Phase I group compared with those in the Phase II group were as follows: clinical improvement or cure, 64% vs. 76%; persistent infection, 17% vs. 11%; clinical failure, 0 vs. 2%; and death, 18% vs. 7% (p = NS). When patients with infections were compared, death rates were 20% in the Phase I group and 5.6% in the Phase II group (p = .02). After implementation of the clinical pathways, antibiotic costs were reduced from $676.54 per patient to $157.88 per patient (p = .001). Length of stay in the ICU was 3.7 days in the Phase I trial and a mean of 3 days in the Phase II trial (p = NS). Specimens of Escherichia coli demonstrated a trend toward a decreased resistance to all antibiotics and Pseudomonas aeruginosa to ciprofloxacin and aminoglycosides (p = NS). CONCLUSIONS: In this study, the use of clinical practice guidelines for patients who were admitted to the surgical ICU was shown to reduce costs, without adversely affecting patients' outcomes. This study has important implications for the use of clinical practice guidelines for the management of patients with infections who are admitted to surgical ICUs.

Aged↗
PubMedDate not supplied

Good clinical laboratory practice (GCLP): the need for a hybrid of good laboratory practice and good clinical practice guidelines/standards for medical testing laboratories conducting clinical trials in developing countries.

There has been a significant increase in the number of clinical drug trials (particularly phase III) being conducted in developing countries for infectious diseases such as HIV, malaria, and tuberculosis. Laboratory results provided by medical testing laboratories in the region are critical to ensuring the safety of patients and the generation of good quality data. A number of well accepted Good Clinical Practice (GCP) and Good Laboratory Practice (GLP) guidelines govern the conduct of clinical trials internationally. Good Clinical Practice guidelines remain too vague with respect to sample analysis to ensure practical implementation in these laboratories. In their strictest sense, Good Laboratory Practice guidelines refer to the analysis of samples from non-clinical studies. A specific set of minimum standards or requirements for practical implementation of clinical trial requirements in medical testing laboratories in the developing world is urgently required.

Benchmarking↗
PubMed2003

The effect of small peer group continuous quality improvement on the clinical practice of midwives in The Netherlands.

OBJECTIVE: To study the effects of small group continuous quality improvement (CQI) on the clinical practice of midwives in the Netherlands. DESIGN: Randomised pre-/post-test (balanced block). INTERVENTION: The CQI groups were assigned to either the set of peer review topics including 'perineal repair' and 'artificial rupture of the membranes (ARM)', or to the set of topics including 'airway aspiration' and 'measuring blood pressure'. The two research groups acted as each other's control group. SETTING: The Netherlands. PARTICIPANTS: Two hundred and fifty-five individual midwives practising in primary and secondary care who made up 28 peer groups. MEASUREMENT AND KEY FINDINGS: Questionnaires were used to collect data on clinical practice prior to the start of the intervention and one year later. Pre- and post-test data were received from 156 respondents. The intervention had a positive effect on adherence to the recommendations with respect to airway aspiration of the baby and measuring blood pressure. For ARM, no difference was found between pre- and post-test adherence to recommendations in the intervention group, while in the control group, the percentage of midwives that adhered to the recommendations decreased in the period between pre- and post-test. No significant effect was found for perineal repair. IMPLICATIONS FOR PRACTICE: Small group CQI had a positive effect on changing clinical practice when the learning of new skills (e.g. learning a new suturing technique) was not necessary. Additional interventions are needed when implementing guidelines that recommend the learning of new skills.

Adult↗
PubMed1999

The experiences of one divisional group of GPs in introducing computers into clinical practice.

OBJECTIVES: To explore the experiences of GPs who have introduced computers into their practices, particularly for clinical use. METHODS: GPs who have introduced computers into their practice for clinical use were identified by a telephone survey of the membership of the Monash Division, Melbourne, Victoria. Eleven 'clinical users' participated in semi-structured interviews to elucidate their experiences of installing computers in their consulting rooms, including their beliefs on how this process could have been given more support. RESULTS: Sixty-two of 67 practices participated in the initial telephone survey. Sixteen percent of responding practices were using computers for clinical purposes, with 11% issuing computerised prescriptions. Interviews with clinical users revealed that most had learned about computer hardware and software through their own independent enquiries. However, the GPs believed that divisions have an increasing role in providing training, education, and offering independent advice about the purchase of appropriate computer systems. DISCUSSION: This group of GPs adopted computers for clinical purposes without much assistance from the medical profession. Their experience of the process of computerisation illustrated that lack of training posed problems as did lack of support. Half of the sample felt that divisions may be able to provide training and education, independent advice and act as a forum to discuss and develop ideas, and thus ease some of the problems associated with adopting new technologies. CONCLUSION: Several suggestions are made for GPs and divisions to assist in the process of computerisation.

Australia↗
PubMed2002

Immunization in rheumatic diseases of childhood: an audit of the clinical practice of British Paediatric Rheumatology Group members and a review of the evidence.

OBJECTIVES: To establish opinion and clinical practice of senior clinicians working with children with rheumatic diseases with regard to immunization and to determine whether or not this is in accordance with current recommendations. To review published guidelines on the subject and examine the evidence base supporting them. METHODS: A questionnaire was sent to all consultant members of the British Paediatric Rheumatology Group. Information on a variety of issues relating to immunization practice in children with rheumatic diseases was collected. A review of published guidelines and the medical literature on the subject was undertaken to assess current recommendations for immunization in patients on immunosuppressive agents and the evidence supporting these. RESULTS: A number of different sources of information are being used to decide whether or not to immunize patients with rheumatic diseases. Clinical practice varies between individuals. Areas of discordance include the doses of corticosteroids and disease-modifying drugs at which significant immunosuppression is felt likely to occur, the level of immunosuppression conferred by rheumatological diseases themselves and whether or not vaccination should be deferred in the presence of active disease. There was also variation in policy with regard to immunizations not part of the routine recommended schedule. CONCLUSIONS: There is variation in both opinion and clinical practice regarding immunization in children with rheumatic diseases amongst senior clinicians working in the field of paediatric rheumatology. This reflects the lack of consistency between various sets of published guidelines and their non-specificity for rheumatic diseases and their treatment, and the lack of published evidence on the safety and efficacy of different vaccines in these situations. Further research is indicated in the hope that more specific guidelines may be developed for this not uncommonly encountered area of uncertainty.

Arthritis, Juvenile↗
PubMed2004

Diagnosis of acute appendicitis in children using a clinical practice guideline.

PURPOSE: In October 2000, our institution implemented a clinical practice guideline (CPG) utilizing selective computed tomography (CT) and ultrasound scan (US) for the evaluation of children with suspected appendicitis. The authors sought to determine surgical outcomes and diagnostic accuracy in the CPG period. METHODS: The authors retrospectively analyzed the medical records of patients evaluated under the CPG at their institution between January 1 and December 31, 2001. Depending on a patient's clinical presentation, the CPG recommends immediate surgery or further evaluation with CT or US. CPG patients were identified if they received an appendectomy or a CT or US for suspected appendicitis. Negative appendectomy and perforation rates, as well as admissions for inpatient observation were compared with control patients treated for suspected appendicitis at our hospital in 1997, before frequent utilization of imaging studies. RESULTS: In the CPG period, 571 patients were evaluated for acute appendicitis, with 272 undergoing an appendectomy. Whereas 513 patients (90%) received a CT or US, only 34 patients (6%) were admitted to the surgical service for serial examinations. Patients with a histologically normal appendix decreased from 27 of 255 (10.6%) in 1997 to 15 of 272 (5.5%) in 2001 (P =.03). Fifty-seven patients (22.2%) in 2001 had a perforated appendix compared with 65 (28.5%) in 1997 (P =.11). The CPG, incorporating clinical judgment and selected imaging, had a sensitivity of 98.8%, a specificity of 95.2%, and positive and negative predictive values of 94.4% and 99.0%, respectively. CONCLUSIONS: A clinical practice guideline selectively utilizing CT and US is highly accurate in the diagnosis of acute appendicitis, minimizing the need for inpatient admission for serial examinations.

Acute Disease↗
PubMed1996

[Motivations and expectations of physicians ordering an echocardiogram and the contribution of transthoracic echocardiography to the clinical practice. The Ligurian Group of the Italian Society of Cardiovascular Echography].

BACKGROUND: Echocardiography is the cardiological diagnostic test the use of which has increased most in recent years. However, despite the popularity and the massive use of the technique, there is little information regarding the usefulness and management impact of echocardiography as routinely ordered in current medical practice. Furthermore, clinical indications and expectations of physicians who ordered an echocardiogram (echo) have never been systematically evaluated in our country. METHODS: During the last two weeks of September 1994, a prospective, observational study was carried out at echocardiographic laboratories in 9 hospitals. By means of a questionnaire completed by the physician who ordered the test prior to its performance, we surveyed: characteristics of the ordering physician, reasons for ordering the test, physicians' expectations regarding the test, and pre-echo clinical diagnosis as well as clinical evaluation of presence or absence and severity of specific cardiac abnormalities. In addition, pre-echo clinical and instrumental assessment of specific cardiac abnormalities was compared with echocardiographic findings. RESULTS: Three hundred and forty-eight questionnaires were successfully completed: 42% by cardiologists (C), 30% by general practitioners (GP), 18% by internists (I), and 10% by other specialists (Sp). Forty percent of the echoes were ordered to "Reevaluate a known cardiac disease" (62% C, 19% GP, 14% I and 5% Sp; p = 0.0001), 39% to "Confirm or exclude a clinical suspicion" (40% C, 24% GP, 24% I, and 12% Sp; p = 0.03), and 21% because of "Screening" purposes (40% GP; 32% C, 15% Sp, and 13% I; p = 0.0017). In the patients who had had a previous echo, the expectation of a significant change with respect to the previous one was "Low" for 48% (57% C, 28% GP, 12% I, and 3% Sp; p = NS), "Moderate" for 42% (44% C, 38% GP, 12% I, and 6% Sp; p = NS), and "High" for only 10% of physicians (58% C, 17% GP; 17% I, and 8% Sp; p = NS). Physicians reported that their expectations from the result of the test on patients' management were: "Modifying therapy or clinical management of the patients" for 66% (45% C, 24% GP, 20% I, and 11% Sp; p < 0.0001), "Objective documentations of presence/absence of cardiac disease" for 21% (40% GP, 35% C, 15% I, and 10% Sp; p = NS), and "Patient's reassurement" for 13% (62% GP, 30% C, 6% I, and 2% Sp; p < 0.0001). The expectation that the result of the echo would influence therapeutic and/or clinical management of the patient was "Moderate" for 44% (42% C, 29% GP, 20% I, and 9% Sp; p = NS), "Low" for 36% (43% C, 34% GP, 15% I, and 8% Sp; p = NS), and "High" for only 20% of the physicians (50% C, 23% GP, 17% I and 10% Sp; p = NS). The echo report was judged in agreement with pre-echo clinical assessment in 40% of cases, in disagreement in 32% and compatible in 28%. At the echo examination, clinical left ventricular (LV) enlargement was not confirmed in 45% of cases and was clinically unsuspected in 13%; clinical LV systolic dysfunction was not confirmed in 53% of cases and was clinically unsuspected in 6%; clinical LV hypertrophy was not confirmed in 43% of cases and was clinically unsuspected in 14%; clinical moderate or severe mitral regurgitation was not confirmed in 32% of cases and was clinically unsuspected in 9%; clinical left atrial enlargement was not confirmed in 27% of cases and was clinically unsuspected in 12%. CONCLUSIONS: GPs ordered echoes mainly for screening or to evaluate suspected cardiac abnormalities for the purpose of reassuring their patients or documenting the presence or absence of a cardiac disease. C ordered echoes to evaluate clinically suspected cardiac abnormalities or to reassess known cardiac diseases with the purpose of modifying patients' therapy or clinical management. One echo out of 3 gave clinically unsuspected results. In 1 echo out of 2 clinical assessment of the severity of the most common morpho-functional cardiac abnormalities was cha

Cardiology↗
PubMed1987

Research trials in general practice: towards a focus on clinical practice.

With current moves towards an emphasis on the 'whole' patient rather than fragmenting the person into organ systems research methods need to be developed which reflect that emphasis and direct us in our endeavour as clinicians. It is possible to have a descriptive science of human behaviour which can be based upon clinical consultations. In this way the clinician is required to act as a clinical anthropologist as well as a clinical epidemiologist.

Clinical Competence↗
PubMed1996

Reflecting on clinical practice: hectoring talk or reality?

Reflection can be seen as a useful tool to enable the practitioner to explore the everyday world of clinical practice. This paper reviews the background to reflection and its relevance to nursing in reducing the theory--practice gap and its role in generating theory from practice. Exemplars from clinical practice are reflected upon and Carper's (1978) 'Patterns of Knowing' are used as a framework to identify nursing knowledge embedded in practice. The process of reflection is critically discussed in the light of the author's experience.

Humans↗
PubMed1998

[Experience as a model hospital for new good clinical practice (GCP) regulations].

The new good clinical practice (GCP) regulations established by the Ministry of Health and welfare aim to promote clinical trials of new drugs that are ethical, reliable, and scientifically sound. According to these regulations, utmost importance should be placed on considerations of trial participant safety, welfare and the protection of his or her human rights. To this end, the responsibilities of the sponsor, the institution at which the trials are conducted, and the physician in charge have been clarified. These regulations stipulate that a system must be established which makes it possible for a third party to verify the course and conduct of a clinical trial. The new GCP regulations not only set standards for the development of new drugs, they also mark the beginning of a new era in medical science and treatment in Japan.

Clinical Competence↗
PubMed2006

Swedish Registered Nurses' incentives to use nursing diagnoses in clinical practice.

AIMS AND OBJECTIVES: The purpose of this study was to describe Registered Nurses' incentives to use nursing diagnoses in clinical practice. BACKGROUND: The use of nursing diagnoses is scarce in Swedish patient records. However, there are hospital wards were all nurses formulate and use nursing diagnoses in their daily work. This leads to the question of what motivates these nurses who do use nursing diagnoses in clinical practice. DESIGN: A qualitative descriptive design. METHODS: A purposeful sampling of 12 Registered Nurses was used. Qualitative interviews to collect data and a content analysis were performed. RESULTS: Five categories were identified: identification of the patient as an individual and as a whole, a working tool for facilitating nursing care, increasing awareness within nursing, support from the management and influence on the professional role. The principle findings of this study were: (i) that the Registered Nurses perceived that nursing diagnoses clarified the patient's individual needs and thereby enabled them to decide on more specific nursing interventions, (ii) that nursing diagnoses were found to facilitate communication between colleagues concerning patient care and thus promoted continuity of care and saved time and (iii) that nursing diagnoses were perceived to increase the Registered Nurses' reflective thinking leading to a continuous development of professional knowledge. CONCLUSIONS: The present findings suggest that the incentives to use nursing diagnoses originate from effects generated from performing a deeper analysis of the patient's nursing needs. Further research is needed to test and validate the usability and consequences of using nursing diagnoses in clinical practice. Motivating factors found in this study may be valuable to Registered Nurses for the use and development of nursing diagnoses in clinical care. Moreover, these factors may be of relevance in other countries that are in a similar situation as Sweden concerning application of nursing diagnoses.

Attitude of Health Personnel↗