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PubMed1991

Tightrope management.

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Consensus Statements as Topic↗
PubMed1991

What have we learnt about the cultural, social and behavioural determinants of health? From selected readings to the first Health Transition Workshop.

The article explores the issue of whether the holding of an international workshop in Canberra in 1989, and the preparation of papers for it, increased our knowledge of the cultural, social and behavioural determinants of health and whether the publication of the proceedings placed new knowledge in the public domain. The approach adopted is to compare those proceedings with a collection of selected readings on the subject made shortly before as part of the same program and also with certain other publications. The conclusions reached are that, in addition to having stimulated interest in the field, the workshop and its proceedings furthered knowledge in at least five important areas: (1) the existence of mortality-prone households; (2) the impact of differing cultural situations of women in terms of individualism on their children's survival; (3) the mechanisms whereby maternal education is translated into child survival; (4) the impact of culture and ethnicity on mortality; and (5) indirect indices of the impact of care. The workshop failed to contribute to substantial advances (or draw attention to the lack of advance) in the following areas: (1) the measurement of Third World morbidity or health; (2) adult health transition; (3) the impact of radicalism or egalitarianism in communities other than Kerala and Sri Lanka on mortality; (4) the impact of lifestyle diseases on Third World mortality; (5) the identification of economically optimum mixes of social change and the provision of health services in reducing mortality and improving health; and (6) the employment of health transition knowledge in the reduction of mortality and the improvement of health.

Adult↗
PubMed1995

The small group consensus process for changing physician practices: influenza vaccination.

OBJECTIVE: To evaluate the effectiveness of a small group consensus process in enhancing compliance with guidelines for influenza vaccination among older HMO members. DESIGN: A controlled study of the practice of primary care physicians, with pre/post comparisons and a 2-year follow-up. SETTING: An 84,000 member prepaid staff model HMO group practice. PARTICIPANTS: Primary care clinicians (N = 36) practicing in a staff model HMO. INTERVENTION: A small-group process, including opinion leader, feedback, and group decision making. MAIN OUTCOME MEASURE: Percentage of patients in a given physician-panel who received influenza immunization. RESULTS: Improvement in vaccination rate from 60.8% to 72.35% (with further increases over 2 successive years), in the intervention group as compared with improvement in the control from 60.7% to 65.93%. CONCLUSION: In this model, the small group consensus process resulted in an alteration in physician practice pattern, yielding a significant improvement in immunization rates above the already-established level of 60%.

Aged↗
PubMed1997

Treatment of hypertension in patients with diabetes.

Approximately 3 million Americans have the dual diagnosis of hypertension and diabetes. Both conditions are associated with and are risk factors for cardiovascular events, nephropathy, and retinopathy. When these conditions coexist, the prevalence, progression, and severity of these adverse outcomes are dramatically enhanced. For these reasons, hypertension should be treated aggressively and early in the diabetic patient to curtail the morbidity and mortality associated with these disease states. To this end, a number of consensus statements have been formulated and promulgated in an effort to increase the awareness of this condition and to provide guidelines by which optimal care may be afforded to patients. In addition, specific patient and drug-related factors and conditions should be considered so patients can be committed to the optimal therapeutic plan. The outcome to attain optimal blood pressure should be mirrored by efforts to obtain glycemic and lipidemic control. By the implementation and optimization of effective therapeutic measures, which have the least amount of impact on the patient's concomitant disease states and body chemistry, positive differences in outcomes may be realized in this population.

Antihypertensive Agents↗
PubMed1997

Osteoporosis: review of guidelines and consensus statements.

UNLABELLED: This activity is designed for physicians, pharmacists, nurses, health planners, directors of managed care organizations, and payers of health services. GOAL: To understand current guidelines and consensus statements regarding the prevention, diagnosis, and treatment of osteoporosis. OBJECTIVE: List four national or international organizations involved in the development of consensus statements regarding the prevention, diagnosis, and treatment of osteoporosis. 2. Discuss the significant differences among different countries regarding the prevention and treatment of osteoporosis. 3. List the major risk factors for osteoporosis. 4. Describe the differences in the application of bone mineral density scans, biochemical markers, and ultrasound in evaluating patients with suspected osteopenia and osteoporosis. 5. Distinguish between and briefly discuss therapeutic modalities used in primary prevention, secondary prevention, and treatment of osteoporosis. 6. Discuss the advantages and disadvantages of estrogen/hormone replacement therapy. 7. Describe alternatives to estrogen/hormone replacement therapy.

Adolescent↗
PubMed1998

A new method of developing expert consensus practice guidelines.

To improve the quality of medical care while reducing costs, it is necessary to standardize best practice habits at the most crucial clinical decision points. Because many pertinent questions encountered in everyday practice are not well answered by the available research, expert consensus is a valuable bridge between clinical research and clinical practice. Previous methods of developing expert consensus have been limited by their relative lack of quantification, specificity, representativeness, and implementation. This article describes a new method of developing, documenting, and disseminating expert consensus guidelines that meets these concerns. This method has already been applied to four disorders in psychiatry and could be equally useful for other medical conditions. Leading clinical researchers studying a given disorder complete a survey soliciting their opinions on its most important disease management questions that are not covered well by definitive research. The survey response rates among the experts for the four different psychiatric disorders have each exceeded 85%. The views of the clinical researchers are validated by surveying separately a large group of practicing clinicians to ensure that the guideline recommendations are widely generalizable. All of the suggestions made in the guideline are derived from, and referenced to, the experts' survey responses using criteria that were established a priori for defining first-, second-, and third-line choices. Analysis of survey results suggests that this method of quantifying expert responses achieves a high level of reliability and reproducibility. This survey method is probably the best available means for standardizing practice for decisions points not well covered by research.

Bias↗
PubMed1999

[Economic impact of the consensus conference guidelines on postoperative artificial nutrition in the Rhone-Alps region].

OBJECTIVES: To assess the economic impact of the French guidelines produced by the 1994 consensus conference on postoperative artificial nutrition (AN) in elective surgery. STUDY DESIGN: Multicentre before-after study, conducted on a cost-containment model from the hospital perspective. PATIENTS AND METHODS: Ten hospitals were randomly selected in the Rhône-Alpes area, after a stratification of hospital category. Twenty consecutive patients, who underwent upper and lower abdominal surgery in each hospital, were included over each study period. Data were collected on site by investigators from patients' records before (1994) and after (1995) guidelines had been circulated. The calculated costs were direct and partial medical and non medical staff costs of a one-day parenteral nutrition. They included nutrients, disposable devices, staff time and laboratory tests. RESULTS: Between 1994 and 1995, the study showed a 7.4% decrease in the postoperative prescription rate of AN, a 4.7% increase in the duration of AN and a 3.6% (FF 74.07 constant francs per patient) increase in the total cost of AN in surgical patients. Guidelines had mainly a positive impact in patients suffering from denutrition, as the duration of postoperative AN increased by 23.7% in this group, leading to a 65.1% (FF 175.53) increase in cost in 1995. CONCLUSIONS: The cost variable is a valuable indicator of the impact of practice guidelines, as it includes the rate and duration of prescriptions. The consensus conference had a significant impact in patients suffering from denutrition. Conversely, only minor changes in practices concerning patients non suffering from denutrition have been observed, leading to a slight cost increase in AN.

Aged↗
PubMed1987

Nurses come together to face ethical issues.

In today's society, the role of the nurse is complex, challenging, and, at times, conflicting. The realities of limited resources, regulations, technology, and professional and personal integrity often given rise to ethical dilemmas and difficult decisions. To deal with these, forums designed specifically for nurses are needed. At Calvary Hospital, Bronx, NY, a Nursing Ethics Group was established to explore ethical choices nurses make daily and to deal with controversies that arise in the care of advanced cancer patients. The Nursing Ethics Group's goal was to promote responsible and ethical nursing practice by increasing awareness of the ethical dimensions of nursing, facilitating communication among nurses, and familiarizing nurses with ethical principles and components of the decision-making process. The group evolved in three phases: exploration of feelings and issues, consideration of an ethical decision-making model, and values clarification. Although membership is open to all, a core group has been established to plan agendas and provide continuity. Plans call for integrating sessions on values clarification and the ethical decision-making process into the orientation program and continuing education programs for all staff.

Bioethical Issues↗