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Biomedical subjects

M Cranney

Publications and source records attributed to M Cranney.

12 recordsLinked to original sources
PubMed2001

Why do GPs not implement evidence-based guidelines? A descriptive study.

BACKGROUND: There is an acknowledged gap between research findings and their implementation in clinical practice despite the existence of effective educational interventions. OBJECTIVES: Our aim was to identify what is impeding GPs from pursuing currently recognized good practice and implementing evidence-based guidelines in their management of hypertension in the elderly. METHOD: We carried out a qualitative study using semi-structured interviews conducted during focus group outreach visits to 34 GPs from nine practices in Merseyside involved in an educational programme designed to improve the management of hypertension in the elderly. RESULTS: Several barriers to the implementation of evidence-based guidelines in the management of hypertension in the elderly were identified. These included: doubts about the applicability of trial data to particular patients; the poor adherence of GPs to practice protocols; ageist attitudes of some GPs; the effect of time pressure and financial considerations making the subject a low priority; the absence of an effective computer system; and the absence of an educational mentor. All participants demonstrated a very positive attitude to practice-based education. They also welcomed external audit data, which compared their performance with that of other practices. Single-handed GPs were particularly enthusiastic about this approach as it provided them with the peer pressure they lacked. CONCLUSIONS: In order to bridge the gap between research and practice, educators need to address the various 'barriers to change' amongst practitioners.

Evidence-Based Medicine↗
PubMed2001

Low grade astrocytomas in the West of Scotland 1987-96: treatment, outcome, and cognitive functioning.

BACKGROUND: Low grade astrocytomas are among the most common central nervous system tumours in children. AIMS: To identify risk factors for the development of persistent intellectual handicap. METHODS: The notes of 30 children with histologically proven low grade astrocytoma who presented during the period 1987-96 were reviewed. Thirteen of these children who were diagnosed with intracranial tumours between 1992 and 1996 underwent cognitive assessment one year after the completion of treatment. RESULTS: Low grade astrocytomas were found in the cerebellum (59%), thalamus (17%), cerebral hemispheres (10%), and the cervical spinal cord (9%). Where possible all patients were treated with gross total resection of the tumour. Symptomatic children with tumours judged to be inoperable underwent biopsy followed by radiotherapy (13%). Three patients developed progressive disease following surgery and underwent repeat surgery and radiotherapy. Survival at a median follow up of 75 months (range 30-131) is 97%. At one year after the completion of treatment persisting cognitive impairment was common. The strongest predictor of IQ scores was the duration of symptoms of increased intracranial pressure preoperatively. CONCLUSIONS: Although the overall survival rate of children with low grade astrocytoma is excellent, significant long term disability occurs. Early diagnosis is essential to reduce postoperative cognitive morbidity.

Adolescent↗
PubMed1999

Addressing barriers to change: an RCT of practice-based education to improve the management of hypertension in the elderly.

BACKGROUND: In the future, primary care groups (PCGs) will have to consider how best to apply audit and education to fulfil their commitment to clinical governance and to facilitate the implementation of research findings. AIM: To establish whether an exploration of 'barriers to change' can enhance the effectiveness of an educational intervention designed to improve the management of hypertension in the elderly. METHOD: A parallel-arm, randomized, single-blind, controlled trial of practice-based educational visits in 18 practices. These practices had previously taken part in a multipractice audit of the management of hypertension in the elderly. Both groups received outreach visits in their own practice, during which they received the results of the previous audit. The nine 'intervention' practices were encouraged to explore barriers that would prevent them from implementing pertinent research findings. The control group was not encouraged to do this. The main outcome measure of the trial was determined in advance as 'the stated management of systolic hypertension in patients aged 70 to 79'. A secondary endpoint was the stated management of a specific patient scenario. The endpoints were tested by questionnaire before and after the educational intervention. RESULTS: For the primary endpoint, there was a statistically significant difference in the stated threshold for treating systolic hypertension between intervention and control groups after the visits (161.8 mmHg versus 167.2 mmHg; P = 0.007). For the secondary endpoint, there was also a statistically significant difference between the two groups, after the visits, in their willingness to treat a 70-year-old male with mild hypertension (89% of doctors would treat in the intervention group versus 57% in the control group; P = 0.047). CONCLUSION: The effectiveness of an educational intervention is significantly improved by addressing the barriers preventing practitioners from implementing the findings of research.

Aged↗
PubMed1998

Hypertension in the elderly: attitudes of British patients and general practitioners.

The perceptions of patients and GPs of the risk of stroke in treated and untreated elderly hypertensives, and their attitudes towards anti-hypertensive therapy were examined. To explore attitudes of patients to the management of hypertension a qualitative approach was used, employing semi-structured interviews, with subsequent thematic analysis of the transcriptions. A questionnaire study of GPs' attitudes to the same subject was also conducted. The elderly (n = 75) greatly overestimate the risks of hypertension and the benefits of treatment. Most would accept anti-hypertensive therapy despite being informed of the true risks, citing confidence in their doctor as the major determinant in their decision. GPs (n = 121) were well informed of the risks and benefits, but less than half adhere to current guidelines. GPs should be aware how much the elderly overestimate the risks of hypertension and the benefits of its treatment. When considering treating hypertension in this group, patient contributions in the treatment decision-making process should be actively encouraged, especially as many elderly hold a deferential attitude towards their doctor. Patients should be informed of the risks of their disease and the benefits of treatment in terms they understand. The use of visual aids helps patients to grasp the difficult concepts of risk and benefit.

Adolescent↗
PubMed1998

The management of hypertension in the elderly by general practitioners in Merseyside: the rule of halves revisited.

BACKGROUND: Treatment of hypertension in the elderly significantly reduces cardiovascular events and confers greater absolute benefit compared with treating younger adults. However, this group has been undertreated in the past. AIM: To perform a reliable and valid multipractice audit of the current management of elderly hypertensive patients. METHOD: An observational study conducted as multiple standardized audits in general practices. The notes of 6139 patients aged 65 years or over from 76 general practices in Merseyside were examined to determine the percentage of elderly patients who had their blood pressure recorded. The percentages of hypertensive patients who were diagnosed, treated, and controlled was also recorded. RESULTS: Eighty-one per cent of the sample had their blood pressure recorded. Fifty-three per cent of patients over the age of 65 were identified as hypertensive; 64% of hypertensive patients are receiving antihypertensive medication and 54% of treated hypertensive patients can be considered controlled. However, very small changes in the criteria used to define blood pressure control have dramatic effects on the results. Digit preference and the number of available blood pressure recordings also significantly affect the results. CONCLUSION: The management of hypertension in the elderly by Merseyside general practitioners (GPs) gives better results than predicted by the 'rule of halves'. Elderly hypertensive patients are more likely to be detected and treated, but only half achieve control to 160/90. The results are particularly sensitive to the degree of digit preference, the number of available recordings, and to the precise definition used for control.

Aged↗
PubMed1998

Auditing the management of hypertension in British general practice: a critical literature review.

Hypertension is a common condition almost exclusively managed by general practitioners (GPs), making it an ideal subject for practice-based audit. However, the conduct and interpretation of such audits is complex. Even minor variations in methodology can produce dramatic differences in results obtained. We used a focus group of seven GPs with a special interest in audit to establish a standardized method for the planning and reporting of audits for the management of hypertension. In order to enhance the reliability and comparability of hypertension audits, 13 key areas of audit methodology were produced by the focus group. Eleven audits were identified in a literature search using pre-determined selection criteria. These were then assessed to compare their methodology with the criteria produced by the focus group. None of the recently published audits in this subject covered all of the key areas (range: 27-65% of the areas covered). One key area, that of digit preference, was not mentioned by any. Other problematic key areas included the selection of patient records without bias, the determination of the prevalence of hypertension, the number of recordings used to determine the diagnosis of hypertension and its subsequent control, the time period examined by the audit, and the approach taken to notes containing an inadequate number of blood pressure recordings. Significant variability in the methods used by different authors in these key areas calls into question the reliability of their results and makes comparisons between them very difficult. We propose a standardized method for hypertension audits comprising 13 key areas, which will enhance the reliability of results and facilitate such comparisons.

Family Practice↗
PubMed1996

Same information, different decisions: the influence of evidence on the management of hypertension in the elderly.

BACKGROUND: Evidence-based medicine requires general practitioners (GPs) to act upon the results of clinical trials. Clinical trial evidence may be difficult to understand and apply in practice. AIM: To investigate whether GPs were unduly influenced in managing hypertension in the elderly by the ways in which benefits of trial results were presented, and to establish whether their current treatment of an elderly hypertensive patient was broadly in line with recent clinical trial evidence. METHOD: Seventy-three GPs attending a refresher course were given a written questionnaire containing data from one clinical trial of treatment of hypertension in the elderly presented in four different ways (absolute risk reduction, relative risk reduction, difference in event-free patients, and number of patients who had to be treated in order to prevent one clinical event), as if from four different trials. The effect of each presentation on treatment preferences was assessed using Likert scales. The results were analysed to determine whether the method of presentation of results influenced decision making. A clinical scenario was presented to investigate their current treatment preferences in an elderly hypertensive. RESULTS: All GPs returned completed questionnaires. Relative risk reduction was the only presentation which was significantly different from the others, and was the most likely to influence prescribing. In free-text comments, 75% of GPs admitted having problems understanding statistics commonly found in medical journals. More than 90% conformed with recent clinical trial evidence for the management of hypertension. CONCLUSION: GPs were most influenced by relative risk reduction, and were unaware of how the presentation of research results could affect treatment decisions. Most GPs freely admitted to difficulty in comprehending medical statistics. Almost all of the GPs expressed treatment decisions which were broadly in line with clinical evidence.

Aged↗