Are nonspecific practice guidelines potentially harmful? A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making.
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OBJECTIVE: To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain. DATA SOURCES/STUDY DESIGN: Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes. Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians, and general internists. INTERVENTION: Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel. The two guidelines were similar in content but varied in the specificity of their recommendations. DATA COLLECTION: The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline, or vignettes plus the specific version of the guideline. PRINCIPAL FINDINGS: The response rate to the survey was 71 percent. The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group, and 79 percent for the specific guideline group (p = .002). The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent, and 26 percent, respectively (p = .08). Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02). Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04). CONCLUSIONS: The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines. (+info)
Domains of research, development and strategic planning in rehabilitation medicine.
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Rehabilitation systems are almost universally struggling to maintain or improve their standings. In this sense it is very useful to draw strategic plans for research and development taking into consideration the characteristics of the profession and, at the same time, the environment where they perform. Five domains of activities can be identified in this sense: measurement of clinical outcomes (including cost/effectiveness and quality assurance), services delivery: the continuum of care, technologies/procedures, pharmacological treatments and opportunities (''niches''). Each domain is described and the different possibilities analyzed. Each system--regional, national--or even a facility should make a selection of what fits their strategic plan best and which modality can be easily incorporated and where human and material resources exist or can be acquired. The need for the justification of the rehabilitation services looks by now as a must, universally. (+info)
Rehabilitation Medicine Summit: Building Research Capacity--executive summary.
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The general objective of the Rehabilitation Medicine Summit: Building Research Capacity was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The 5 elements of research capacity that guided the discussions were: (1) researchers, (2) research environment, infrastructure, and culture, (3) funding, (4) partnerships, and (5) metrics. The [approximately] 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small-group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multi-organizational initiative is called to pursue the agendas outlined in this report. (+info)
Rehabilitation Medicine Summit: Building Research Capacity-Executive Summary.
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The general objective of the "Rehabilitation Medicine Summit: Building Research Capacity" was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The five elements of research capacity that guided the discussions were (1) researchers; (2) research culture, environment, and infrastructure; (3) funding; (4) partnerships; and (5) metrics. The 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multiorganizational initiative is called to pursue the agendas outlined in this report. (+info)
Rehabilitation medicine summit: building research capacity.
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The general objective of the "Rehabilitation Medicine Summit: Building Research Capacity" was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The five elements of research capacity that guided the discussions were 1) researchers; 2) research culture, environment, and infrastructure; 3) funding; 4) partnerships; and 5) metrics. The 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multi-organizational initiative is called to pursue the agendas outlined in this report. (+info)
The state of physical medicine and rehabilitation in Iowa: 2000-2005.
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BACKGROUND: The purpose of this study was to to describe the practice of physical medicine and rehabilitation within Iowa from 2000-2005 by conducting a survey of the 30 practicing physical medicine and rehabilitation physicians in Iowa. RESULTS: Nine of 15 respondents completed medical school or residency training in midwest states. Physiatrists expressed numerous concerns including poor reimbursement, increasing malpractice costs, and difficulty recruiting physiatrists to Iowa. Iowa is ranked 49th in physical medicine and rehabilitation physicians per capita population. It also ranks 50th in Medicare payments per enrollee, yet is ranked fourth in the nation for percentage of citizens over the age of 65. CONCLUSIONS: Recruitment of physical medicine and rehabilitation physicians should be tailored toward resident physicians completing training programs from midwest states. Retention of Iowa physiatrists, due to Iowa's lack of a physical medicine and rehabilitation residency training program, low Medicare reimbursement, and high percentage of patients over the age of 65, may lead to a "perfect storm" public health crisis for Iowans regarding the availability of future physical medicine and rehabilitation services. (+info)
Rehabilitation medicine in Croatia -- sources and practice.
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Sources of rehabilitation medicine, the need for rehabilitation and its practice in Croatia were studied, based on available data. The study revealed that current practice has advanced since the country's independence, but that there are many shortcomings; adequate care is not provided to all who could benefit from it, and there is wastage of resources. (+info)
The learned nonuse phenomenon: implications for rehabilitation.
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Research on monkeys with a single forelimb from which sensation is surgically abolished demonstrates that such animals do not use their deafferented limb even though they possess sufficient motor innervation to do so, a phenomenon labeled learned nonuse. This dissociation also occurs after neurological injury in humans. Instruments that measure these two aspects of motor function are discussed. The effects of a neurological injury may differ widely in regard to motor ability assessed on a laboratory performance test in which movements are requested and actual spontaneous use of an extremity in real-world settings, indicating that these parameters need to be evaluated separately. The methods used in Constraint-Induced Movement therapy (CI therapy) research to independently assess these two domains are reliable and valid. We suggest that these tests have applicability beyond studies involving CI therapy for stroke and may be of value for determining motor status in other types of motor disorders and with other types of treatment. The learned nonuse formulation also predicts that a rehabilitation treatment may have differential effects on motor performance made on request and actual spontaneous amount of use of a more affected upper extremity in the life situation. CI therapy produces improvements in the former, but focuses attention on the latter and, in fact, spontaneous use of the limb is where this intervention has by far its greatest effect. The evidence suggests that this result is driven by use of a ''transfer package'' of techniques, which can be used with other therapies to increase the transfer of improvements made in the clinic to the life situation. The use of CI therapy in humans began with the upper extremity after stroke and was then extended for the upper extremity to cerebral palsy in young children (8 months to 8 years old) and traumatic brain injury. A form of CI therapy was developed for the lower extremities and was used effectively after stroke, spinal cord injury, and fractured hip. Adaptations of CI therapy have also been developed for aphasia (CI aphasia therapy), focal hand dystonia in musicians and phantom limb pain. The range of these applications suggests that CI therapy is not only a treatment for stroke, for which it is most commonly used, but for learned nonuse in general, which manifests as excess motor disability in a number of conditions which until now have been refractory to treatment. (+info)