Perceived barriers to and facilitators of the implementation of priority clinical preventive services guidelines.

Am J Manag Care. 2007 Mar;13(3):150-5

Authors: Ayres CG, Griffith HM

OBJECTIVE: To obtain feedback from contracted health plan (HP) clinicians responsible for implementing preventive services regarding an established set of priority guidelines identified by a coalition of medical directors and to identify barriers to and facilitators of the implementation of these priority guidelines in clinician practice. STUDY DESIGN: Qualitative design using a focus group approach. PARTICIPANTS AND METHODS: Three focus group meetings among contracted HP clinicians were conducted in New Jersey in 3 geographic regions (northern, central, and southern New Jersey). Clinicians directly involved in delivering preventive services to pediatric, adult, and geriatric patients participated. RESULTS: Barriers to guideline implementation were identified by the clinicians regarding payment and cost, time, legal issues, inconsistency among HP tools, tracking, a lack of internalization, and the patient-clinician relationship. In addition, facilitators of guideline implementation, including HP support, patient materials, clinician awareness, and tool consistency, were identified. CONCLUSIONS: Clinicians’ perceived barriers to guideline implementation are in themselves a barrier to the delivery of preventive care services. If clinicians perceive barriers to implementing priority recommendations, they may be unlikely to make the conscious effort to deliver preventive care. There needs to be better dialogue between HPs and contracted clinicians to minimize the perceptions of barriers and to increase clinician awareness of and sensitivity to preventive care for priority implementation. To improve the delivery of preventive services in clinician practice, competing HPs must communicate in a single voice with contracted clinicians in the area of preventive care.

PMID: 17335358 [PubMed - in process]

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Role-play for medical students learning about communication: Guidelines for maximising benefits.

BMC Med Educ. 2007 Mar 2;7(1):3

Authors: Nestel D, Tierney T

ABSTRACT: BACKGROUND: Role-play is widely used as an educational method for learning about communication in medical education. Although educational theory provides a sound rationale for using this form of simulation, there is little published evidence for its effectiveness. Students prior experiences of role-play may influence the way in which they engage in this method. This paper explores students experiences with the aim of producing guidelines for maximising the benefits of role-play within this learning context. METHODS: First-year undergraduate medical students participated in a role-play session as part of their communication programme. Before and after the session, students completed questionnaires. In the pre-session questionnaire, students were asked about their experiences of role-play and asked to identify helpful and unhelpful elements. Immediately after the session, students answered similar questions in relation to the role-play activity they had just completed. Descriptive statistics were used to analyse quantitative data and qualitative data was thematically analysed. RESULTS: 284 students completed evaluation forms. Although 63 (22.2%) had prior unhelpful experiences, most students (n=274; 96.5%) found this experience helpful. Summary findings were that students reported the key aspects of helpful role-play were opportunities for observation, rehearsal and discussion, realistic roles and alignment of roles with other aspects of the curriculum. Unhelpful aspects were those that evoked strong negative emotional responses and factors that contributed to a lack of realism. CONCLUSION: Role-play was valued by students in the acquisition of communication skills even though some had prior unhelpful experiences. Guidelines for effective role-play include adequate preparation, alignment of roles and tasks with level of practice, structured feedback guidelines and acknowledgment of the importance of social interactions for learning.

PMID: 17335561 [PubMed - as supplied by publisher]

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Nonfatal acute myocardial infarction in Costa Rica: modifiable risk factors, population-attributable risks, and adherence to dietary guidelines.

Circulation. 2007 Mar 6;115(9):1075-81

Authors: Kabagambe EK, Baylin A, Campos H

BACKGROUND: Cardiovascular disease, including myocardial infarction (MI), is increasing in developing countries. Knowledge of risk factors and their impact on the population could offer insights into primary prevention. METHODS AND RESULTS: We estimated the population-attributable risk (PAR) for major MI risk factors among Costa Ricans without a history of diabetes, hypertension, or regular use of medication (889 MI cases, 1167 population-based controls). Lifestyle and dietary variables were measured with validated questionnaires. In multivariate analyses, abdominal obesity (PAR, 29.3%), smoking (PAR, 25.6%), nonuse of alcohol (PAR, 14.8%), caffeine intake (PAR, 12.8%), physical inactivity (PAR, 9.6%), and poor diet (PAR, 6.0%) were the most important MI risk factors. Subjects in the favorable categories of the above 6 risk factors showed a lower risk of MI (odds ratio, 0.09; 95% CI, 0.03 to 0.33) than those in the unfavorable categories. Compared with women, men were more likely to smoke (31% versus 10%) but less likely to have waist circumferences greater than Adult Treatment Panel III cutoffs (9% versus 35%). Many subjects did not meet the American Heart Association or World Health Organization/Food and Agriculture Organization dietary guidelines. For instance, 95% obtained > or = 7% of energy from saturated fat, 25% had or = 1% energy from trans fat, and 53% had low fiber intake (

PMID: 17339565 [PubMed - in process]

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[Guidelines for the treatment of child spasticity using botulinum toxin.]

Rev Neurol. 2007 Mar 1-15;44(5):303-9

Authors: Pascual-Pascual SI, Herrera-Galante A, Poo P, Garcia-Aymerich V, Aguilar-Barbera M, Bori-Fortuny I, Garcia-Ruiz PJ, Garreta-Figuera R, Lanzas-Melendo G, de Miguel-Leon I, Miquel-Rodriguez F, Vivancos-Matellano F, Español de Espasticidad G

AIMS. The introduction of botulinum toxin has been a significant step forward in the treatment of spasticity in children and is now considered to be the preferred treatment in focal spasticity. With the aim of optimising this therapeutic resource, a group of Spanish neurologists and specialists in rehabilitation have drawn up these therapeutic guidelines based on the currently available evidence on its use and indications, and on their own experience. DEVELOPMENT. Spasticity in childhood is mainly caused by infantile cerebral palsy. Its natural history is not favourable due to the negative effect of growth and it should be treated before permanent deformities in bones and joints appear. Treatment with botulinum toxin diminishes hyperactivity and muscle tone, and allows the muscle to grow longitudinally, which prevents permanent contractions. The advantages of botulinum toxin are obvious (ease of use and dosing, long-lasting effects, reversibility in case of adverse responses, and so forth) and outnumber by far the few drawbacks it offers. Before it can be used patients, treatment goals and the muscle areas to be treated must all be selected correctly and, at the same time, a tailored rehabilitation scheme must also be developed. The growing body of experience suggests that its early administration is effective in preventing or reducing the severe complications of spasticity. CONCLUSIONS. Botulinum toxin type A is very effective in the treatment of spasticity. These guidelines offer the well-documented experience gained from its use and our knowledge about its indications, effects and safety in clinical practice.

PMID: 17342682 [PubMed - in process]

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Developing guidelines in the absence of traditional research evidence: an example from the Lymphoedema Framework Project.

Int J Low Extrem Wounds. 2007 Mar;6(1):6-7

Authors: Franks PJ, Morgan PA

PMID: 17344194 [PubMed - in process]

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A survey of adherence to community-generated safety guidelines in rotor-wing air medical programs.

Air Med J. 2007 Mar-Apr;26(2):100-3

Authors: Frakes MA, Kelly JG

INTRODUCTION: Operational safety, both crash prevention and improved crash survival, is a central concern in the air medical community. Professional organizations have published operational safety guidelines, but the extent to which those guidelines are followed is unclear. We report the results of a survey of adherence with selected safe practice recommendations. METHODS: An anonymous survey of adherence with 8 individual and 11 program safety guidelines was distributed to flight team members at 10 Association of Air Medical Services-member rotor-wing air medical programs selected by stratified random sample to ensure geographic diversity. Descriptive statistics are reported and relationships are evaluated with the chi-square test. The sample size provided 80% power at a .05 significance level for the comparisons. RESULTS: Data were analyzed from 126 of the 200 surveys distributed. Adherence with program-wide safety behaviors ranged from 41.3% (complete a pre-departure checklist) to 99.2% (program has an annual safety review). Adherence to individual behaviors ranged from 15.1% (wear fire-resistant gloves) to 99.2% (wear seatbelts and shoulder harnesses on approach and departure). There was 100% adherence to wearing helmets by the respondents whose program provided a helmet at no cost to the staff member. There were no associations between job description and any individual behavior. Hospital-operated programs were less likely to have a daily briefing (P

PMID: 17346647 [PubMed - in process]

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Systematic review of economic evaluations and cost analyses of guideline implementation strategies.

Eur J Health Econ. 2007 Mar 9;

Authors: Vale L, Thomas R, Maclennan G, Grimshaw J

To appraise the quality of economic studies undertaken as part of evaluations of guideline implementation strategies, we conducted a systematic review of such studies published between 1966 and 1998. Studies were assessed against BMJ economic evaluations guidelines for each stage (guideline development, implementation and treatment). Of 235 studies identified, 63 reported some information on cost. Only 3 studies provided evidence that their guideline was effective and efficient, 38 reported treatment costs only, 12 implementation and treatment costs, 11 implementation costs alone, and 2 guideline development, implementation and treatment costs. No study gave reasonably complete information on costs. Thus, very few satisfactory economic evaluations of guideline implementation strategies have been performed. Current evaluations have numerous methodological defects and rarely consider all relevant costs and benefits. Future evaluations should focus on evaluating the implementation of evidence-based guidelines.

PMID: 17347844 [PubMed - as supplied by publisher]

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