[Promoting the improvement of clinical practice: guidelines].
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Clinical Competence↗
Biomedical subjects
R Grilli
Publications and source records attributed to R Grilli.
[Geographic variability in the appropriateness of surgical treatment of breast carcinoma].
To assess appropriateness of surgical care delivered to breast cancer patients in Italy and quantify the use of unnecessary radical procedures, a retrospective charts review of patients treated in 1988-1989 was conducted. Information about hospital characteristics was collected directly from administrative departments as a part of a national survey. A series of 1724 consecutive patients (median age 61 years; range 17-89) treated in 63 hospitals selected from within 8 regions, with newly diagnosed operable breast carcinoma was evaluated. Overall, 541 (38%) patients had inappropriate surgery with more than two thirds of it being accounted for by the use of unnecessary mutilating Halsted mastectomy. About one-fourth of patients with stage I-II disease undergone mastectomy according Halsted technique and conservative surgery in patients with small tumors (i.e. tumor size < = 2 cm) was under utilized. Substantial geographic variations emerged in the overall rates of inappropriateness (range 12-48%) which were not substantially affected by allowance for imbalances in patient- and hospital-related variables. Despite the important contribution given by Italian clinical researchers to the demonstration that less radical surgery can be as good as more radical procedures, still a substantial proportion of breast cancer patients are treated too aggressively. Besides pointing to the urgent need of interventions aimed at promoting more appropriate surgical care these results suggest that efforts to increase patients' participation into treatment decision and awareness about alternative treatment options are warranted.
Adolescent↗
Developing recommendations to promote the uptake of research information in clinical practice.
This paper is aimed at highlighting some often overlooked aspects of the development of recommendations for clinical practice, and at addressing some of the key factors that can play a role as determinants of the acceptability of recommendations in clinical practice by the targeted health care providers. It is contended that, even in areas of clinical practice where clearcut recommendations could easily be drawn from the available evidence and apparently the issue at stake is just to transfer the appropriate message to the targeted audience, it is important to acknowledge--from the development stage of the recommendations--the complexity and the role of non-scientific key determinants (i.e. beliefs, values, vested interests) of clinical behaviour.
Clinical Nursing Research↗
[The systematic review of studies on the efficacy of interventions for the primary prevention of alcohol abuse among adolescents].
UNLABELLED: Italy finds itself one of the world's leading countries for alcohol consumption. This problem is particularly relevant amongst adolescents. In the past 20 years many preventive interventions of alcohol abuse, addressed to adolescents, have been realized mainly in the United States. PURPOSE OF THE STUDY: To evaluate the effect of educational preventive interventions addressed to youths from 10 to 18 years old on alcohol use. MATERIALS AND METHODS: We have done a systematic review of articles indexed on Medline between 1983 and July 1995. We also consulted the bibliography of the articles retrieved for further references. Randomized controlled trials using alcohol consumption as outcome measure have been included. RESULTS: Of the 100 articles found only 21 were included, in which 27 preventive programs, using 5 different types of intervention, were evaluated. Only 3 resulted effective on all the outcome measures utilized and 6 were partially effective. Overall the methodological quality was low. CONCLUSIONS: The low methodological quality and the great variability of outcome measures utilized made it difficult to compare the results of different studies and impossible to reach definitive conclusions. All the studies were done in the United States and therefore their results cannot be presently generalized to Italy. Consequently, prior to implementing expensive prevention programs in the Italian schools, it would be opportune to perform further well-designed effectiveness trials.
Adolescent↗
[Guidelines as shared auxiliary policies].
Practice guidelines can be thought as a "dynamic technology", whose characteristics vary according to the specific context of application, the type of social relationships they assume, their implicit or explicit goals. In this light, guidelines can be seen as an operational interpretation of the relationships among social components both within and outside the medical profession. The currently dominant models in terms of development of recommendations for clinical practice, using guidelines respectively as assistance to and administrative control over clinical decision making, seem to be both inadequate because of the social models they implicitly assume: the medical-technical dominance and an external political control over the medical profession, respectively. These models fall short in dealing with the complexity of the health care issues we are facing. As an alternative, the notion of guidelines as development of shared clinical policies is put forward. Development of shared clinical policies relies on: a) use of available empirical evidence, whose qualitative and quantitative limitations are fully acknowledged, as the frame of reference for an open conformation among the different stakeholders; b) the acknowledgement that conflicts among different views and vested interests are an organic component of health care.
Decision Making↗
[Impact of mass media on the use of health services. A systematic review of the literature].
BACKGROUND: Mass media may influence the use of health services either through campaigns promoting the use of specific procedures or through the coverage of health related issues outside the context of a planned intervention. To assess their effect on the utilization of health services a systematic overview of primary research was undertaken. METHODS: Experimental and quasi experimental studies meeting pre defined entry criteria and providing information on the impact of mass media on objective measures on health services utilization were searched through Medline, Embase, Psychlit, Eric, as well as handsearching key journals. Data on the detail and content of interventions were abstracted and raw data describing health services utilization obtained. Effect sizes were calculated for each study and then pooled across studies on the same topic using a random effects model. RESULTS: Out of 69 papers providing information on the impact of mass media on aspects of health services utilization, 17 interrupted time series met our quality criteria. Fourteen evaluated the impact of formal mass media campaigns, 3 of media coverage of health related issues. The overall methodological quality was rather variable, with 6 studies not performing any statistical analysis, and 7 using inadequate statistical tests (i.e. not taking into account the effect of time trend). All the studies but the concluded positively on the effect of mass media. These positive findings were confirmed by our re-analysis in 7, while in the remaining the effect of mass media was not statistically significant. The direction of effect was consistent across individual studies and the pooled effect sizes revealed an effect upon the utilization of health services that could not be explained by chance alone, ranging from -1.96 (95% CI: -1.19, -2.73) for campaigns promoting immunization programs, to -1.12 (95% CI: -0.49, -2.46) for those concerning cancer screening. CONCLUSIONS: Despite the overall limited quality of primary research, this review supports the view that these channels of communication may have an important role in influencing the use of health care interventions. Mass media should be considered as one of the tools that may encourage the use of effective services and discourage those of unproved effectiveness.
Data Interpretation, Statistical↗