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At least 73 records · Page 4Linked to original sources
PubMed2000

Economic impact of harmonizing medical practices: compliance with clinical practice guidelines in the follow-up of breast cancer in a French Comprehensive Cancer Center.

PURPOSE: The introduction of clinical practice guidelines (CPGs) and the increasing desire to harmonize clinical practices draw attention to the economic impact of these trends. In 1994, CPGs were introduced in a French Comprehensive Cancer Center (Centre Régional Léon Bérard, Lyon). We evaluated the application of these CPGs in addition to the consequences of harmonizing clinical practices with respect to the distribution of resources by specifically analyzing the posttherapeutic follow-up of patients with localized breast cancer. METHODS: A before-and-after analysis of the records of patients who received posttherapeutic follow-up for localized breast cancer as of either 1993 or 1995 was performed. Two hundred records were chosen at random, 100 from 1993 and 100 from 1995. Follow-up was continued for as long as possible and CPG compliance was studied for each year of the follow-up periods. RESULTS: Follow-up that was not CPG-compliant required a significantly greater amount of resources. This difference was due to neither consultations nor mammographies, but was due to other examinations that were systematically performed without any warning signs to justify them. Depending on the follow-up year, noncompliant follow-up cost the Social Security from 2.2 to 3.6 times more than compliant follow-up. A noticeable change in medical practices was observed after the introduction of CPGs in 1994. This was confirmed by a sharp decrease in mean Social Security expenditure per patient of more than one third between 1993 and 1995, regardless of the follow-up year considered. CONCLUSION: In the follow-up of patients with localized breast cancer, a large decrease in costs has been observed along with the evolution of medical practices toward CPG compliance. This finding is probably generalizable to other settings, but there is nothing that proves that it is applicable to other treatment strategies.

Aged↗
PubMed2006

Exploring the continuum: medical information to effective clinical practice. Paper II. Towards aetiology-centred clinical practice.

Contemporary clinical practice increasingly functions within a disease management paradigm aimed at finding and implementing therapeutic interventions that demonstrate efficacy in clinical trials. Disease prevention, elucidation of illness aetiology and proactive health promotion have taken a back seat. Current clinical care often includes a 'fast-food' type of medical encounter, which frequently neglects disease causality. The medical community is presently challenged by unique administrative and professional adversities as well as undue commercial influence; these factors contribute to a lethargic response to escalating rates of chronic illness and to mainstream medicine's relative inattention to emerging research about disease aetiology. Individual medical practitioners and the medical establishment must strategically seek to advance patient health and maintain professional relevancy by a renewed emphasis on the following principles: patient-based clinical care, aetiology-centred medicine, and proactive health promotion.

Chronic Disease↗
PubMedDate not supplied

Making a difference to practice: clinical benchmarking. Part 1.

In the first of two articles, the authors describe how an internal clinical practice benchmarking group was established in Preston to compare and share examples of best practice. The aim was to ensure consistent high standards of care practice across the trust. Activity related to discharge planning and visiting is used here to illustrate the effectiveness of clinical practice benchmarking as a continuous quality improvement tool. The second article will appear in Nursing Standard on May 3.

Benchmarking↗
PubMed2000

Clinical practice guidelines vs actual clinical practice : the asthma paradigm.

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.

Adult↗
PubMedDate not supplied

Making a difference to practice: clinical benchmarking. Part 2.

In the second of two articles, the authors explore further the use of clinical practice benchmarking. In particular, practice related to improving nutritional care for patients, caring for patients with mental health needs and safely transferring critically ill patients is examined. The authors conclude by summarising the value of clinical practice benchmarking and how it made a difference to practice in their trust. The first article appeared in Nursing Standard last week.

Acute Disease↗
PubMedDate not supplied

Enhancing clinical practice and education with high-fidelity human patient simulators.

Research shows that students exhibit increased autonomy and self-confidence when delivering patient care after practicing first with high-fidelity human patient simulators (HPS). Practicing clinical skills on a high-fidelity HPS allows students to learn in a highly adaptable, safe educational environment that fosters autonomy, independence, and the development of sound analytical skills. The author discusses the use of patient simulators in nursing education, a definition of a high-fidelity HPS, and their value to clinical practice and education. A cost-effective example of how to acquire a high-fidelity HPS without going over budget is provided.

Budgets↗
PubMed1998

Cost effectiveness of treatment for gastro-oesophageal reflux disease in clinical practice: a clinical database analysis.

BACKGROUND: Previous evaluation of the cost effectiveness of antireflux medication used in gastro-oesophageal reflux disease (GORD) have been based on results obtained in controlled clinical trials. Unfortunately such an approach does not necessarily identify the therapeutic option which provides the greatest benefit from available resources in real life situations. To make an informed choice requires a recognition that the costs and benefits of therapy in practice may differ from those identified in trials. AIMS: To evaluate, based on a retrospective prescription database analysis, the cost effectiveness of alternative treatment options for patients with uncomplicated GORD. The analysis assesses health service resource use during the first six months of treatment in three groups of patients initially prescribed cisapride (CIS), ranitidine (RAN), or omeprazole (OME). METHODS: The MediPlus UK database was used to identify all health care resources consumed by patients in the three treatment groups during their first six months of treatment. Patients with more complicated GORD, as indicated by initial referral to a specialist or outpatient hospital visit (< 13%), were excluded from the analysis. RESULTS: The average cost per patient for the initial six months of treatment for CIS, RAN, and OME based therapies was 136 Pounds, 177 Pounds, 189 Pounds per patient, respectively. A major element underlying this cost variation was the acquisition cost and quantity of antireflux medication required by patients. The average number of one month equivalent prescriptions consumed during this six month period was 1.85 (CIS), 2.57 (RAN), and 2.96 (OME) with associated costs of 49 Pounds (CIS), 67 Pounds (RAN), and 105 Pounds (OME). Antacid and alginate/antacid use was higher in the CIS and RAN groups (about 1.0 antacid prescription per patient versus 0.4 for OME), but their contribution to the total cost per patient was less than 2%. The number of general practitioner consultations over the six month period for each treatment group was 2.4 (CIS), 2.9 (RAN), and 2.6 (OME) with associated costs of 60.31 Pounds (CIS), 73.06 Pounds (RAN), and 65.52 Pounds (OME). The average number of non-drug interventions (referrals, outpatient visits, endoscopies, barium meals, or x rays) was 0.34 in the RAN group compared with less than 0.2 in the CIS and OME groups. The costs associated with such interventions were 23.80 Pounds (RAN), 9.60 Pounds (CIS), and 11.10 Pounds (OME) per patient. CONCLUSION: The data indicate that the "step up" approach, starting with a prokinetic or H2 receptor antagonist, represents the most cost effective initial therapeutic strategy for a primary care physician to adopt when faced with a patient with first diagnosis of uncomplicated GORD.

Anti-Ulcer Agents↗
PubMed2004

Breast cancer in Western Australia: clinical practice and clinical guidelines.

OBJECTIVES: To review changes in patterns of care for women with early invasive breast cancer in Western Australia from 1989 to 1999, and compare management with recommendations in the 1995 National Health and Medical Research Council guidelines. DESIGN AND SETTING: Population-based surveys of all cases listed in the Western Australian Cancer Registry and Western Australian Hospital Morbidity Data System. MAIN OUTCOME MEASURES: Congruence of care with guidelines. RESULTS: Data were available for 1649 women with early invasive breast cancer (categories pT1or pT2; pN0 or pN1; and M0). In 1999, 96% had a preoperative diagnosis by fine-needle aspiration or core biopsy (compared with 66% in 1989), with a synoptic pathology report on 95%. Breast-conserving surgery was used for 66% of women with mammographically detected tumours (v 35% in 1989) and 46% of those with clinically detected tumours (v 28% in 1989), with radiotherapy to the conserved breast in 90% of these cases (83% in 1989). Adjuvant chemotherapy was given to 92% of premenopausal women with node-positive disease and 63% with poor-prognosis node-negative tumours (v 78% and 14%, respectively, in 1989). Among postmenopausal women with receptor-positive tumours, tamoxifen was prescribed for 91% of those with positive nodes (85% in 1989) and 79% of those with negative nodes (30% in 1989). Among postmenopausal women with receptor-negative tumours, chemotherapy was prescribed for 70% with positive nodes (v 33%) and 58% with negative nodes (v none). CONCLUSIONS: Patterns of management of women with early invasive breast cancer in Western Australia during the 1990s changed significantly in all respects toward those recommended in the 1995 guidelines.

Adult↗
PubMed1999

A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines.

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.

Diffusion of Innovation↗
PubMed1996

Non-Alzheimer forms of cortical degeneration: frequency in clinical practice and clinical report of six cases.

Recent clinical and neuropathological studies suggest the possibility of distinguishing some forms of cortical degeneration from Alzheimer's disease. We report data on the frequency of non-Alzheimer forms of cerebral atrophy that were diagnosed on the basis of clinical criteria. Six examples of these neurological disorders are described: two patients with Lewy body disease; two patients with frontal lobe type dementia, one of whom had associated features of motor neuron disease; a patient with primary progressive aphasia; and a patient with a familial dementia that was probably an atypical form of Pick's disease.

Aged↗
PubMed2005

Enoxaparin in clinical practice and clinical trials of non-ST-elevation Acute Coronary Syndrome (NSTE-ACS).

Non-ST elevation Acute Coronary Syndrome (NSTE-ACS) is a myocardial ischemic disorder frequently caused by coronary artery plaque rupture and partial or transient vessel occlusion. Platelets and thrombin play pivotal roles in formation and propagation of thrombus at the site of plaque disruption and embolization into the vascular bed. With the outgoing development of antithrombotic, antiplatelet, and mechanical therapies, the management of NSTE-ACS is constantly evolving. Heparins are the cornerstone of antithrombotic therapy in the current management of NSTE-ACS. Unfractionated heparin and fractionated heparins like enoxaparin have been studied in several large clinical trials and found to be effective in reducing death and myocardial infarction rates. For medical management alone or primarily (conservative strategy), enoxaparin has been shown to be superior to unfractionated heparin. With an early invasive strategy providing better clinical outcome compared to a conservative strategy, the paradigm of ACS management has shifted in favor of early (within 48 hours of admission) cardiac catheterization. The effectiveness of enoxaparin compared to unfractionated heparin is now being re-considered in the era of poly-pharmacotherapy and an early invasive strategy for ACS management. We review the role of enoxaparin in the contemporary treatment of NSTE-ACS utilizing recent clinical trial data.

Acute Disease↗
PubMed2004

High-sensitivity C-reactive protein, inflammation, and cardiovascular risk: from concept to clinical practice to clinical benefit.

Advances in vascular biology have shown that inflammation plays an integral role in the development of cardiovascular disease. Extensive study of high-sensitivity C-reactive protein (hs-CRP) has demonstrated that this measure of inflammation predicts cardiovascular risk not reflected by traditional risk factors, adds prognostic information to traditional risk assessment, and predicts long-term cardiovascular risk in individuals with no prior evidence of cardiovascular disease. Patients with elevated hs-CRP levels in the absence of elevated cholesterol appear to derive preventive benefit from statin therapy that is similar in magnitude to that in patients with elevated cholesterol. The large-scale Justification for the Use of statins in Primary prevention: an Intervention Trial Evaluating Rosvastatin (JUPITER) trial represents a critical study to determine the utility of a strategy for targeting statin therapy to prevent incident cardiovascular disease in patients at increased cardiovascular risk on the basis of elevated hs-CRP who would not be considered candidates for therapy on the basis of hypercholesterolemia or traditional risk assessment. Inclusion of hs-CRP measurement in risk screening and use of this information to guide preventive therapy could result in a marked improvement in prevention of cardiovascular morbidity and mortality.

Anticholesteremic Agents↗