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PubMed2005

[Patient-oriented healthcare programs. Concepts and practical experience in the field of chronic heart failure].

Disease management programs (DMP) have been recently introduced in the German statutory healthcare sector by federal law. These compulsory programs are aimed at enhancing guideline-based treatment by primary care physicians. Based on a systematic analysis of disease models and deficits in healthcare delivery, patient-oriented DMP offer an alternative approach. Their standardized services include care calls, written educational material, reminder systems, health reports, and optional telemetric monitoring. As an example of this approach, the medical results of 151 patients participating in a comprehensive chronic heart failure (CHF) program were evaluated. Within the observation period of 12 months, the number of patients receiving appropriate prescriptions (ACE inhibitors, diuretics, or beta blockers) rose significantly. In many patients there was a remission of CHF key symptoms (leg edema, shortness of breath, dizziness). The daily weight monitoring was particularly appreciated by the patients. For further development of patient-oriented DMP in the German healthcare system, it will be crucial that financial savings can be convincingly demonstrated besides the clinical benefits. These include quality of life, particularly for those chronic conditions in which patient self-management has a large impact on disease course.

Adrenergic alpha-Antagonists↗
PubMed2005

Educational and organisational interventions used to improve the management of hypertension in primary care: a systematic review.

BACKGROUND: The optimal way in which to organise and deliver care to patients with hypertension has not been clearly identified. AIM: To determine the effectiveness of educational and organisational strategies used to improve control of blood pressure. DESIGN OF STUDY: Systematic review of randomised controlled trials (RCTs). METHOD: Quantitative pooling of RCT data on patients with hypertension that evaluated the following interventions: (1) self monitoring, (2) educational interventions directed to the patient, (3) educational interventions directed to the health professional, (4) health professional (nurse or pharmacist) led care, (5) organizational interventions that aimed to improve the delivery of care, (6) appointment reminder systems. RESULTS: Fifty-six RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2mmHg, -11.7/-6.5mmHg, -10.6/-7.6mmHg for three strata of entry blood pressure) and all-cause mortality at 5 years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT (the Hypertension Detection and Follow-up study). Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure, weighted mean difference (WMD): -2.03 mmHg, 95% confidence interval (CI) = -2.7 to -1.4 mmHg. Educational interventions directed towards physicians were associated with small reductions in systolic blood pressure (WMD) -2.0mmHg, 95% CI = -3.5 to -0.6mmHg and diastolic blood pressure (WMD) -0.4mmHg, 95% CI -1.1 to 0.3mmHg. CONCLUSIONS: General practices and community-based clinics need to have an organised system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. These findings have important implications for recommendations concerning implementation of structured delivery of care in hypertension guidelines.

Adult↗
PubMed1991

Computer-generated physician and patient reminders. Tools to improve population adherence to selected preventive services.

Despite an emerging consensus on appropriate preventive services, a minority of patients receive them. A study was undertaken to assess the impact of computer-generated reminders to adult patients, their physicians, or both patients and physicians on adherence to five recommended preventive services: cholesterol measurements, fecal occult blood testing, mammography, Papanicolaou smears, and tetanus immunization. During the academic year 1988-1989, all 7397 adult patients and their 49 physicians in a university family medicine clinical practice were randomized by practice group into one of four study groups: control, physician reminders, patient reminders, and both physician and patient reminders. Adherence was defined in community-oriented terms: the percentage of patients within each group who had received the preventive service in the recommended interval. During the study period, adherence to four of the five preventive services increased significantly, with the largest increases in the physician and patient reminder group: cholesterol measurements increased from 19.5% to 38.1%, fecal occult blood testing 9.3% to 27.0%, mammography 11.4% to 27.1%, and tetanus immunization 23.4% to 35.4% (for each increase, P less than .0001, McNemar's chi-square test). In general, increases were greater in blacks and in patients with any form of insurance coverage. Computer-based physician and patient reminder systems have great promise of improving adherence to preventive services in primary care settings.

Adult↗
PubMedDate not supplied

Improving mammography recommendation: a nurse-initiated intervention.

We attempted to improve our compliance with recommendations for screening mammography, according to the American Cancer Society (ACS) guidelines, for eligible women patients seen by family practice residents by using a multipart intervention designed to eliminate identified barriers of knowledge and behavior on the part of the residents. Copies of the ACS cancer screening guidelines were posted in all examination and conference rooms and were provided to all residents. The intervention addressing the behavioral barriers had three components: (1) identification by the nursing staff of eligible women who were overdue for a mammogram as they presented for care, (2) completion of a checklist by residents indicating whether a mammogram was or was not recommended and why, and (3) a nurse-initiated backup reminder system for patients who escaped the primary checklist system. An audit of 200 preintervention and 270 postintervention charts showed statistically and clinically significant increases in mammograms recommended or done. Similar statistically significant increases were found in a cohort of 111 charts of patients in both the pre- and the postintervention audits. Results indicate that an intervention designed to eliminate identified resident-dependent barriers to compliance with screening mammography guidelines can be effective in increasing recommended mammography rates.

Appointments and Schedules↗
PubMed1995

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.

OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.

Humans↗
PubMed1994

Use of screening mammography by general internists.

While physician endorsement has been shown to be highly important in motivating women to obtain screening mammograms, there is evidence that doctors do not refer women for the procedure as often as they should. The objective of this study was to help understand why physicians do not routinely utilize screening mammography. Randomly selected Washington State general internists were surveyed by mail, concerning mammography, during 1989. An expanded theory of reasoned action was used as a broad conceptual framework for considering factors potentially associated with use. The survey response rate was 66%, yielding a study sample of 85. Only 38% of the respondents reported they always ordered mammograms for women aged 50 years and over during preventive office visits. Nearly half (43%) had no reminder system for the test. Correlates of use included beliefs concerning the screening behavior of other doctors, the location of mammography facilities in relation to physician offices, and age. Physician-related barriers, such as doubts about effectiveness, were found to affect use more than patient-related barriers, such as cost. The recommendations of professional organizations were shown to have been important in influencing physician use of screening mammography. This study indicates a proportion of general internists are not routinely ordering mammograms for their age-eligible female patients. The findings identify barriers to use of mammography that need to be overcome if national efforts to promote use of the procedure by primary care physicians are to succeed. Implications for intervention are reviewed.

Aged↗
PubMedDate not supplied

Medical community involvement in a breast cancer screening promotional project.

The analysis, mobilization, and involvement of medical communities in two counties targeted for intervention by the Washington State Community Breast Cancer Screening Project is described. Principles of community organization were applied to the health care sectors in the counties, and the PRECEDE-PROCEED model was used as a conceptual framework for considering individual physician behavior. Quantitative and qualitative medical community assessment methods included a demographic study, a survey of primary care physicians, personal interviews with physicians, and medical office staff focus groups. In both intervention areas, physician planning groups selected, developed, and helped implement intervention activities targeting the health care sectors. These activities included informational mailings to physicians, training of medical office staff members and clinical mammographers, and support for a reminder system. The experience demonstrated that physicians practicing in medium-sized cities are willing to be active in community disease prevention programs.

Breast Neoplasms↗
PubMed1994

An evaluation of cervical screening in general practice.

OBJECTIVES: To identify the technical practices of general practitioners (GPs) in relation to Papanicolaou (Pap) smear screening, and the differences in screening practices between male and female practitioners; to determine the cellular content of smears taken; and to correlate screening practices and demographic variables with smear results. DESIGN: During February-May 1992, a sample of Melbourne GPs filled in a questionnaire concerning their screening practices, and the results were correlated retrospectively with results of Pap smears taken in March and October 1991. SETTING: Melbourne metropolitan general practice. PARTICIPANTS: One hundred and seventy-nine GPs (72% participation rate among eligible practitioners) from a sample obtained from the register of the Medical Board of Victoria. RESULTS: Female doctors took significantly more smears than male doctors. An opportunistic approach to cervical screening was most commonly practised, with the patient being asked to ring for her results and the practice staff only contacted her if the result was abnormal. Only 43% of doctors indicated the use of a specific reminder system when rescreening was due. Endocervical cells were present in 79% of smears. The presence of endocervical cells was found to be related to the year of a doctor's graduation (with both very recent and older graduates [pre-1960s] having lower endocervical cell rates), and to be positively correlated with more postgraduate training. CONCLUSIONS: Our study suggests that further education and training in cervical screening is needed for some GPs, in particular, male doctors, graduates of less than four or greater than 20 years, and those without postgraduate training.

Adult↗
PubMed1995

Attitudes of Colorado health professionals toward breast and cervical cancer screening in Hispanic women.

BACKGROUND: A variety of economic, cultural, and communication barriers appear to be involved in breast and cervical cancer screening among Hispanic women. These barriers include culture-based embarrassment both for mammography and for Pap smears and fear and hopelessness concerning a diagnosis of cancer. Cost and access barriers are shared by low-income women from various ethnic and racial groups, as is a purported lack of physician referral. Hispanic women may have the latter problem enhanced by a language barrier between physicians and patients when the physicians do not speak or understand Spanish. PURPOSE: The goal of this project, conducted by the Cancer Education Division of the University of Colorado Cancer Center, has been to determine the attitudes and practices among health care providers in areas of Colorado with relatively large Hispanic populations (concerning screening mammography, clinical breast examination, breast self-examination, and Pap testing) and to design interventions to address any deficiencies or problems recognized. These studies were coordinated with telephone surveys and focus groups involving Hispanic women, directed by E. Flores in the Department of Sociology of the University of Colorado at Boulder and by C. Chrvala at the Colorado Department of Health. METHODS: Data were collected from 520 primary care physicians, nurses, and allied health personnel in 11 Colorado counties through focus groups and mailed questionnaires. Responses were analyzed by considering a variety of demographic characteristics of the respondents and by stratifying the associated practices by percent of Hispanic patients. RESULTS: The physicians involved in the focus groups and responding to the questionnaires, as well as their associated nurses and other health care personnel, are generally familiar with the breast and cervical cancer-screening guidelines as developed and disseminated by several organizations, including the National Cancer Institute and the American Cancer Society. Major barriers to screening Hispanic women, as perceived by these health care providers, appear to be cost; lack of transportation, child care, and release from work; fear of diagnosis of cancer; patients considering the test unnecessary; discomfort; and embarrassment. The prompt use of colposcopy to evaluate patients whose Pap smears indicated dysplasia appeared less than optimal, especially among internists. CONCLUSIONS: Familiarity with guidelines for breast and cervical cancer screening is widespread among Colorado physicians and associated health care personnel, including those with high percentages of Hispanic patients in their practices. Increased continuing education efforts may be indicated concerning the application of colposcopy to the evaluation of women with abnormal Pap smears and concerning the application of computer technology to cancer-screening reminder systems. IMPLICATIONS: Educational approaches to primary care professionals may improve the effectiveness of breast and cervical cancer screening, although a variety of other approaches will also be necessary to decrease barriers to screening of Hispanic women.

Adult↗
PubMed1997

Barriers to cancer prevention in the older person.

Barriers to cancer screening are numerous and include both immutable barriers, such as a patient's low income, as well as more mutable barriers; fortunately, most barriers are potentially mutable ones. These encompass, among others, doctor patient communication patterns, inadequate and inaccurate health information, at attitudinal barriers such as patient anxiety, and community barriers, such as the lack of a provider reminder system to patients that prompts compliance. One of the easiest enablers of patient screening to implement is for clinicians to communicate their enthusiastic belief in screening to their older patients. Numerous studies now have documented the effectiveness of the physician's role in increasing patient compliance with screening guidelines.

Aged↗
PubMed1997

The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review.

OBJECTIVE: To assess the evidence for the effectiveness of clinical practice guidelines (CPGs) in improving patient outcomes in primary care. DATA SOURCES: A search of the MEDLINE, HEALTHPLAN, CINAHL and FAMLI databases was conducted to identify studies published between Jan. 1, 1980, and Dec. 31, 1995, concerning the use of guidelines in primary medical care. The keywords used in the search were "clinical guidelines," "primary care," "clinical care," "intervention," "randomized controlled trial" and "effectiveness." STUDY SELECTION: Studies of the use of CPGs were selected if they involved a randomized experimental or quasi-experimental method, concerned primary care, were related to clinical care and examined patient outcomes. Of 91 trials of CPGs identified through the search, 13 met the criteria for inclusion in the critical appraisal. DATA EXTRACTION: The following data were extracted, when possible, from the 13 trials: country and setting, number of physicians, number of patients (and the proportion followed to completion), length of follow-up, study method (including random assignment method), type of intervention, medical condition treated and effect on patient outcomes (including clinical and statistical significance, with confidence intervals). DATA SYNTHESIS: The most common conditions studied were hypertension (7 studies), asthma (2 studies) and cigarette smoking (2 studies). Four of the studies followed nationally developed guidelines, and 9 used locally developed guidelines. Six studies involved computerized or automated reminder systems, whereas the others relied on small-group workshops and education sessions. Only 5 of the 13 trials (38%) produced statistically significant results. CONCLUSION: There is very little evidence that the use of CPGs improves patient outcomes in primary medical care, but most studies published to date have used older guidelines and methods, which may have been insensitive to small changes in outcomes. Research is needed to determine whether the newer, evidence-based CPGs have an effect on patient outcomes.

Humans↗
PubMedDate not supplied

The effect of patient and provider reminders on mammography and Papanicolaou smear screening in a large health maintenance organization.

BACKGROUND: We evaluated the effectiveness of 2 reminder interventions to increase the use of screening mammograms and Papanicolaou (Pap) smears among female members of a large health maintenance organization. METHODS: Seven thousand seventy-seven female health maintenance organization members (aged 50-74 years with no prior mammogram in the previous 30 months or aged 20-64 years with no prior Pap smear in the previous 36 months) were randomized to receive one of the following: a letter inviting them to make an appointment for a mammogram or a Pap smear; in addition to the letter, a reminder manually placed in the patient's medical chart alerting providers of that member's need for screening; or their usual care. RESULTS: Compared with women who did not receive the reminder letter, women who did receive the letter were more likely to obtain mammograms (16.0% vs 25.5%, respectively; P < .001) or Pap smears (9.1% vs 19.5%, respectively; P < .001) in the 6 months following their entry into the study. Compared with women who received only the reminder letter, women who received a reminder letter and had a reminder placed in their medical chart were more likely to obtain mammograms (26.5% vs 30.9%, respectively; P = .02) and marginally more likely to receive Pap smears (19.5% vs 22.8%, respectively; P = .04). CONCLUSIONS: We recommend the use of patient reminder letters as a first step in a mammography or Pap smear screening outreach program. Further research is needed to evaluate a cost-effective provider reminder system and additional outreach strategies directed to women who do not use health care services.

Adult↗
PubMed1997

Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines.

OBJECTIVE: To recommend effective strategies for implementing clinical practice guidelines (CPGs). DATA SOURCES: The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE from January 1990 to June 1996, inclusive, with the use of the MeSH heading "practice guidelines" and relevant text words. STUDY SELECTION: Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians' performance or health care outcomes were emphasized. DATA EXTRACTION: Articles were reviewed to determine the effect of various factors on the adoption of guidelines. DATA SYNTHESIS: The articles showed that CPG dissemination or implementation processes have mixed results. Variables that affect the adoption of guidelines include qualities of the guidelines, characteristics of the health care professional, characteristics of the practice setting, incentives, regulation and patient factors. Specific strategies fell into 2 categories: primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines. The interventions were shown to be weak (didactic, traditional continuing medical education and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers and delivered by peers or opinion leaders) and relatively strong (reminder systems, academic detailing and multiple interventions). CONCLUSIONS: The evidence shows serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic.

Clinical Trials as Topic↗
PubMed1996

The IPSOC project: integrating prevention strategies into ongoing care.

Each primary care clinical visit can be an opportunity to promote health and provide primary prevention and screening. An innovative prompting and reminder system (IPSOC), using computer technology as an enabler, has been developed to facilitate integration of disease prevention and health promotion into ongoing clinical care for an unemployed and working poor population. In addition, the prompting system is being converted to a database program designed to prompt providers and educate consumers about the value of health promotion, screening, and disease prevention.

Ambulatory Care↗
PubMed1998

The effect of physician characteristics on compliance with adult preventive care guidelines.

BACKGROUND AND OBJECTIVES: This study identified physician characteristics and attitudes related to self-reported compliance with adult prevention guidelines. METHODS: A questionnaire was mailed to family practice and internal medicine residents and faculty at the University of Iowa (n = 209). The questionnaire's 78 items fell into seven categories, including physician demographics, history-taking practices, counseling practices, self-perceived effectiveness in changing patient behavior, beliefs about preventive care, knowledge about preventive care, and perceived barriers to the delivery of preventive care. RESULTS: Compliance with history-taking recommendations was independently associated with high knowledge scores, female physician gender, and high self-perceived effectiveness in changing patient behavior. The only factor that was independently associated with counseling efforts was self-perceived effectiveness in changing patient behavior. CONCLUSIONS: Factors that were independently associated with self-reported preventive care efforts include female physician gender, knowledge about preventive care guidelines, and perceived effectiveness in changing patient behavior. After controlling for these factors, other variables such as lack of time, lack of reminder systems, attitudes about preventive care, and amount of formal preventive care education were not related to self-reported compliance with counseling and history-taking recommendations.

Adult↗
PubMed1998

Immunisation of babies. The mothers' perspective.

OBJECTIVES: It would appear that mothers are the main organisers for their child's immunisation. What do they know about immunisation? What are their reasons for having their child immunised? What are their experiences of the process and the difficulties they encounter? This study focuses on these questions. METHOD: A representative sample (n = 242) of mothers giving birth in southern Tasmania completed two questionnaires post partum, one during the first week and the other at 12 months. RESULTS: Primigravidae women were less well-informed about immunisation than multigravidae women. Almost all the mothers intended to immunise their babies for their child's welfare. However, at 54 weeks only 21% were fully immunised. General practitioners immunised 74% of the babies. Mothers were primarily responsible for arranging and overseeing the baby's immunisation. Problems included: lack of child care and of accompanying adults; post immunisation reactions (80% of babies); and inadequate information about immunisation reactions. Most mothers supported immunisation reminder systems and written records of immunisation. CONCLUSION: The general practitioner, the preferred provider of immunisation, can facilitate the translation of a mother's positive convictions into action important potential strategies include: mother friendly appointment systems; providing more information on immunisation, including possible reactions; general practice based immunisation outreach programs and domiciliary visiting.

Adult↗
PubMed1998

Factors associated with women's adherence to mammography screening guidelines.

OBJECTIVE: To examine individual and environmental factors associated with adherence to mammography screening guidelines. DATA SOURCES: A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File). STUDY DESIGN: The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years. PRINCIPAL FINDINGS: Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges. CONCLUSIONS: A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.

Aged↗