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Signe Flottorp

Publications and source records attributed to Signe Flottorp.

16 recordsLinked to original sources
PubMed2005

Systems for grading the quality of evidence and the strength of recommendations II: pilot study of a new system.

BACKGROUND: Systems that are used by different organisations to grade the quality of evidence and the strength of recommendations vary. They have different strengths and weaknesses. The GRADE Working Group has developed an approach that addresses key shortcomings in these systems. The aim of this study was to pilot test and further develop the GRADE approach to grading evidence and recommendations. METHODS: A GRADE evidence profile consists of two tables: a quality assessment and a summary of findings. Twelve evidence profiles were used in this pilot study. Each evidence profile was made based on information available in a systematic review. Seventeen people were given instructions and independently graded the level of evidence and strength of recommendation for each of the 12 evidence profiles. For each example judgements were collected, summarised and discussed in the group with the aim of improving the proposed grading system. Kappas were calculated as a measure of chance-corrected agreement for the quality of evidence for each outcome for each of the twelve evidence profiles. The seventeen judges were also asked about the ease of understanding and the sensibility of the approach. All of the judgements were recorded and disagreements discussed. RESULTS: There was a varied amount of agreement on the quality of evidence for the outcomes relating to each of the twelve questions (kappa coefficients for agreement beyond chance ranged from 0 to 0.82). However, there was fair agreement about the relative importance of each outcome. There was poor agreement about the balance of benefits and harms and recommendations. Most of the disagreements were easily resolved through discussion. In general we found the GRADE approach to be clear, understandable and sensible. Some modifications were made in the approach and it was agreed that more information was needed in the evidence profiles. CONCLUSION: Judgements about evidence and recommendations are complex. Some subjectivity, especially regarding recommendations, is unavoidable. We believe our system for guiding these complex judgements appropriately balances the need for simplicity with the need for full and transparent consideration of all important issues.

Comprehension↗
PubMed2005

[How to improve continuing education and quality improvement in general practice?].

BACKGROUND: Research has shown that many activities routinely used for continuing education and quality improvement in general practice, such as written information and lectures, have little or no effect on practice. MATERIAL AND METHODS: The Norwegian Institute of Public Health initiated a consensus-building process on how to improve continuing education and quality improvement in Norwegian general practice. RESULTS AND INTERPRETATION: The work of the consensus panel led to a report in which nine initiatives were proposed: development of a national plan, strengthening of the support available for group-based learning, academic outreach visits, practice based activities, personal learning plans, a national centre for quality improvement in general practice, improved use of referral and discharge information, multidisciplinary collaboration, and patient involvement.

Biomedical Research↗
PubMed2005

[Guidelines in general practice--are they read and are they used?].

BACKGROUND: Many guidelines are not developed from systematic models and are not based on high-quality evidence. The existence of a guideline does not in itself lead to changes in practice and many guidelines are not used once they have been issued. MATERIAL AND METHODS: A questionnaire on continuing education and the use of guidelines was sent to 1500 general practitioners (GP) and GP assistants in 1321 general practices in Norway. 857 GPs and 948 GP assistants returned the questionnaire. RESULTS: There was a large variation in the extent to which guidelines were known and used. Many GPs and GP assistants had little knowledge of guidelines published in the Journal of the Norwegian Medical Association or by the Norwegian Medicines Agency, the Norwegian Board of Health or the Norwegian Centre for Health Technology Assessment. There were exceptions: 52% of GPs used the Norwegian College of General Practitioners' treatment programme for diabetes and 77% of GP assistants used the Norwegian quality assurance programme for laboratory services in primary care. INTERPRETATION: Guidelines should be based on the best available evidence but this in itself is not enough to ensure that they are adhered to. Effective strategies for implementation are also important.

Education, Medical, Continuing↗
PubMed2005

[What do general practitioners do to keep themselves up to date?].

BACKGROUND: Continuing education should ensure that a doctor provides effective care based on the best available evidence. But not all continuing education is equally effective. MATERIAL AND METHODS: A questionnaire on continuing education was sent to 1500 general practitioners (GPs) in Norway. The response rate was 58%. RESULTS: GPs spent on average 2.3 hours per week on continuing education. Discharge reports were used daily for continuing education by 75% of GPs and represented 10% of the total time spent on continuing education in a 30-day period. Courses were not used so often but took up a lot of time when attended. Traditional lectures accounted for 80% of course instruction. Learning something new and improving practice were the two most important objectives for participating in continuing education. Around every second GP participated in a small group of colleagues. INTERPRETATION: GPs spend a lot of time on continuing education activities that research has shown to have little or no effect on practice. It is essential that the activities used are evaluated to a much greater extent than what they are now.

Clinical Competence↗
PubMed2005

[How do general practice assistants keep themselves up to date?].

BACKGROUND: The opportunities for continuing education among general practice (GP) assistants vary because of their dependence on their employers' attitudes and interests. Not all available continuing education activities are equally effective. The purpose of this study was to describe GP assistants' use of a range of quality improvement and continuing education activities, especially with regard to how much time was spent on each activity and how often the activities were used. MATERIAL AND METHODS: A questionnaire was sent to GP assistants in 1321 general practices. RESULTS: 948 GP assistants returned the questionnaires. They spent on average one hour per week on continuing education. The primary activities were discussions with colleagues (daily), and meetings with pharmaceutical industry representatives (weekly). The use of courses was relatively modest; more than half of them were organised by pharmaceutical companies. Learning something new, improving practice and personal development were the most important motives for participating in continuing education. INTERPRETATION: The opportunities for continuing education available to GP assistants vary a great deal and are to a large extent left to the pharmaceutical industry. Many if not most of the opportunities available cannot be expected to lead to changes in practice. Those responsible for general practice - GPs as well as the health authorities--should ensure that GP assistants have a wider and better range of options for continuing education.

Clinical Competence↗
PubMed2004

Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group.

BACKGROUND: A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. METHODS: Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. RESULTS: There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. CONCLUSIONS: All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.

Advisory Committees↗
PubMed2004

Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change.

BACKGROUND: We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions. METHODS: We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention. RESULTS: A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention. CONCLUSIONS: A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.

Anticholesteremic Agents↗
PubMed2004

Grading quality of evidence and strength of recommendations.

Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.

Cost-Benefit Analysis↗
PubMed2003

Identifying barriers and tailoring interventions to improve the management of urinary tract infections and sore throat: a pragmatic study using qualitative methods.

BACKGROUND: Theories of behaviour change indicate that an analysis of factors that facilitate or impede change is helpful when trying to influence professional practice. The aim of this study was to identify barriers to implementing evidence-based guidelines for urinary tract infection and sore throat in general practice in Norway, and to tailor interventions to address these barriers. METHODS: We used a checklist to identify barriers and possible interventions to address these in an iterative process that included a review of the literature, brainstorming, focus groups, a pilot study, small group discussions and interviews. RESULTS: We identified at least one barrier for each category. Both guidelines recommended increased use of telephone consultations and reduced use of laboratory tests, and the barriers and the interventions were similar for the two guidelines. The complexity of changing routines involving patients, general practitioners and general practitioner assistants, loss of income with telephone consultations, fear of overlooking serious disease, perceived patient expectations and lack of knowledge about the evidence for the guidelines were the most prominent barriers. The interventions that were tailored to address these barriers included support for change processes in the practices, increasing the fee for telephone consultations, patient information leaflets and computer-based decision support and reminders. CONCLUSION: A systematic approach using qualitative methods helped identify barriers and generate ideas for tailoring interventions to support the implementation of guidelines for the management of urinary tract infections and sore throat. Lack of resources limited our ability to address all of the barriers adequately.

Adolescent↗
PubMed2003

Process evaluation of a cluster randomized trial of tailored interventions to implement guidelines in primary care--why is it so hard to change practice?

BACKGROUND: A cluster randomized trial of tailored interventions to support the implementation of guidelines for sore throat and urinary tract infection found little or no change in the main outcomes, which were antibiotic prescriptions, use of laboratory tests and use of telephone consultations. There was great variation between the practices in the change in these outcomes. OBJECTIVES: Our aim was to evaluate how the interventions were received and to understand why practices did or did not change. METHODS: The trial was conducted in general practices in Norway. Data for this process evaluation were collected from the 120 practices that completed the trial. Multiple methods were used: observations, semi-structured telephone interviews, a postal survey and data extracted from electronic medical records. We investigated factors that might explain a lack of change, including: agreement with the guidelines; communication within each practice; degree of participation in the project; taking time to discuss the guidelines and their implementation; use of the components of the interventions; and routines for telephone consultations. Possible explanatory factors were explored in relation to variation in change and the overall extent of change in rates of use of antibiotics, laboratory tests and telephone consultations. RESULTS: Sixty-three per cent of practices agreed with the guidelines. Only 35% reported having regular meetings, and 33% discussed the project before its start, although 75% reported agreement about participating within the practice. Only 33% reported meeting to discuss the guidelines. Use of the components of the interventions ranged from 11% for the increased fee for telephone consultations to 48% for the computerized decision support. Forty-four per cent reported problems with telephone routines. No single factor explained the observed variation in the extent of change across practices. CONCLUSIONS: Inadequate time, resources and support were the most salient factors that might explain a lack of change. Problems with internal communication and telephone routines were important contributing factors in many practices.

Cluster Analysis↗
PubMed2002

Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat.

OBJECTIVE: To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat. DESIGN: Unblinded, cluster randomised pretest-post-test trial. SETTING: 142 general practices in Norway. PARTICIPANTS: 72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection. INTERVENTIONS: Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants. MAIN OUTCOME MEASURES: Changes in rates of use of antibiotics, laboratory tests, and telephone consultations. RESULTS: Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practices in the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures. CONCLUSIONS: Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice.

Adolescent↗