Changes in attitudes and practices in primary health care with regard to early intervention for problem drinkers.
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During an intervention period of 1 to 2 months, a project team supported general practitioners (GPs) and nurses in four primary health care centres in Sweden in introducing new routines for detection and treatment of problem drinkers. After the implementation of the new methods, the GPs reported increased involvement in early detection and intervention significantly more often than the nurses did. A majority in both groups reported perceived improvement in skills. There was a significant positive change of the attitudes concerning working with alcohol-related problems in the nurses reaching the same level as the GPs. In the nurses, attitudes and self-perceived intervention skills were improved, but to a lesser extent than their practice. The results indicate that future efforts concerning improvement of primary health care staff involvement in alcohol interventions should focus on training, supervision, and giving positive examples, rather than on changing an already positive attitude towards alcohol intervention. The potential role of nurses is still uncertain and not utilized sufficiently. (+info)
Project LEAP of New Jersey: lower extremity amputation prevention in persons with type 2 diabetes.
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OBJECTIVE: To reduce type 2 diabetes-related lower extremity amputations (LEAs) in New Jersey through a statewide training program for primary care providers at healthcare agencies in high-risk areas. STUDY DESIGN: Project LEAP provided 27 1-day training workshops to 560 healthcare professionals representing 85 organizations. The effect of training was evaluated based on a multiple-choice knowledge test, self-reported practice behaviors, and a medical records audit of practice behaviors, and pre- and postprogram LEA rates. PATIENTS AND METHODS: We evaluated statistically significant differences in pre- and postprogram knowledge scores using Student's t-tests. We also evaluated providers' intentions to change clinical foot-care practices and compared them with actual practices documented in medical records. We used analysis of variance to determine any statistically significant differences in pre- and postprogram LEA rates at various types of institutions. In addition, we assisted facilities in the development of self-education programs containing specific foot-care modules. RESULTS: Participating providers were: 70.6% nurses, 7.8% physicians, 4.5% podiatrists, 4.2% dietitians, and 12.9% all others. Pre- and postprogram knowledge scores increased by 12% (T = 13.29; P < 0.0001) and were maintained for 9 months (T = 7.58; P < 0.05). Provider intentions to change clinical practice behaviors correlated with self-reported practice changes 9 months postprogram (r = .51; P < 0.001). Medical record audits 1 year before and 9 months after training demonstrated marked improvement in foot-care practices in the following areas: (1) foot-care education given to patients by primary care providers; 2) documentation of peripheral vascular disease; 3) documentation of patient preventive care practices; and 4) referrals to diabetes educators, orthopedists, podiatrists, and diabetologists. Education programs with specific foot-care components increased 10%. The overall incidence of pre- and posttraining LEAs did not change significantly but differed depending on institution type. Hospitals and community healthcare centers were more likely to show postprogram reductions in LEAs than nursing homes and rehabilitation centers. CONCLUSION: Institutionalization of a LEAP program resulted in improved provider knowledge and certain clinical practice behaviors. There was a trend toward an overall reduction in the number of LEAs at participating institutions. (+info)
Thriving in a busy practice: physician-patient communication training.
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BACKGROUND: Despite growing concern about the potential impact of managed care on the physician-patient relationship, efforts to enhance the quality of communication between practicing clinicians and their patients have been limited. OBJECTIVE: To determine the effectiveness of a 1-day educational workshop. DESIGN: Clinician self-assessment of interviewing skills measured immediately before and 3 months after the workshop. SETTING: The Kaiser Permanente Medical Care Program. PARTICIPANTS: Practicing clinicians (n = 1384) in 22 workshops during a 5-year period. Nine hundred eleven participants (66% response rate) completed self-assessment questionnaires 3 months after the workshop. RESULTS: Self-assessed interviewing skills improved in all items 3 months after the workshop (P < 0.05). Clinicians also reported a decline in the proportion of visits that they characterized as frustrating. CONCLUSION: A 1-day educational intervention for large groups of practicing clinicians can improve confidence in medical interviewing skills and the ability to handle difficult encounters. (+info)
Intervention research in rational use of drugs: a review.
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Many studies have been done to document drug use patterns, and indicate that overprescribing, multi-drug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems of irrational drug use by prescribers as well as consumers. Improving drug use would have important financial and public health benefits. Many efforts have been undertaken to improve drug use, but few evaluations have been done in this field. This article provides an overview of 50 intervention studies to improve drug use in developing countries. It highlights what type of interventions exist and what is known about their impact. It reveals that commonly used interventions, such as an essential drug list and standard treatment guidelines, have rarely been systematically evaluated so far. The majority of intervention studies are focused on prescribers in a public health setting, while irrational use of drugs is also widespread in the private sector. Furthermore, the magnitude of inappropriate drug use at community level is often overlooked and few interventions address drug use from a consumer's perspective. More research on different types of intervention strategies in various health care settings is needed to draw conclusions on the effectiveness of a specific intervention strategy. Also more research is needed on socio-cultural factors influencing the impact of drug use interventions, particularly from a user perspective. To enhance evaluative research, more technical support will be needed for researchers in developing countries. The design of available studies from developing countries is generally weak, only six of the 50 studies included in this overview were randomized controlled studies. In order to provide technical support and coordination of future intervention research the establishment of an international resource centre for drug use intervention research is recommended. (+info)
The economics and challenges of breast cancer in a managed care environment. Based on a presentation by Alan H. Heaton, PharmD.
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Breast cancer and its population effect are inseparable. One of the challenges managed care organizations (MCOs) face is instilling the idea that patients are part of a population, and in turn, that population is composed of patients. Therefore, there is a need to treat both patients individually and populations as a whole. Because breast cancer, like other major illnesses, involves large-scale expenditures for drugs, pharmaceutical benefit management companies are working with MCOs to look not only at drug costs but at global healthcare expenditures. Whereas treatment of breast cancer has direct costs to a healthcare plan, it is associated with a great deal of comorbidity as well. In dealing with such potential financial exposure, the challenge to health plans is to find individuals at risk, enable them to access the healthcare system, and see that they get proper care. A proactive communications effort involving such media as patient newsletters and a website can educate healthplan members, thereby facilitating the self-assessment of risk factors. (+info)
The emerging role of psychiatric pharmacists.
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The concept of pharmaceutical care has greatly expanded the role of the pharmacist, from that of strictly a drug dispenser to a more integrated member of a patient's healthcare team. In order for pharmaceutical care practice to succeed, the pharmacist must assume a more proactive role, using his or her knowledge of drug therapy and behavioral medicine to assume more responsibility in achieving improvement in patient health outcomes. The pharmacist must also develop open, professional relationships with patients, their families/caregivers, and other members of the healthcare team. Pharmaceutical care comprises 4 components: education, medical-legal issues, drug therapy knowledge, and communication. Through these efforts, and because pharmacists offer greater access to patients and a broader view of patient outcomes, pharmaceutical care affords the opportunity for these professionals to become patient advocates and prevent line-item decision making. Special considerations exist for psychiatric pharmacists practicing pharmaceutical care, especially in documentation and formulary decisions. Psychiatric pharmacists can ensure that patients have access to the safest, most efficacious (and cost-effective) drugs by considering more than just acquisition costs. (+info)
Librarians, clinicians, evidence-based medicine, and the division of labor.
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Have librarians promoted end user searching to the detriment of the profession and promoted clinical inefficiency from causally trained health practitioners? Issues related to the complexity of bibliographic retrieval in the networked environment are explored within the context of evidence-based medicine and the division of labor. (+info)
Evaluating the effectiveness of 2 educational interventions in family practice.
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BACKGROUND: Structured feedback of information can produce change in physician behaviour. The objective of this study was to assess the effectiveness of 2 educational interventions for improving the quality of care provided by family physicians in Ontario: the Practice Assessment Report (PAR) and the Continuing Medical Education Plan (CMEP) with a follow-up visit by a mentor. METHODS: The study was a randomized controlled trial. Physicians in the control group received only the PAR, whereas those in the experimental group received the PAR, CMEP and mentor interventions. The participants were 56 family physicians and general practitioners (27 in the PAR group and 29 in the CMEP group) in southern Ontario who agreed to participate in the interventions and provide data. A total of 2395 patients randomly sampled from the practices returned questionnaires and consented to have their medical records abstracted. The outcome measures were global scores in 4 areas--quality of care, charting, prevention and overall use of medications--and patient ratings of satisfaction with care and preventive practices. The measures were applied at the beginning (phase 1) and end (phase 2) of the study. RESULTS: The mean global scores at the end of the study for the PAR group were 70.1% for quality of care, 84.7% for prevention, 77.7% for charting and 82.2% for overall use of medications. The corresponding scores for the CMEP group were 68.3%, 82.1%, 76.4% and 83.2%. In the patient satisfaction component, the personal care scores at phase 2 were 93.6% for the PAR group and 94.6% for the CMEP group. Examples of the scores for prevention for the PAR group were 98.3% for children's current immunization, 96.6% for blood pressure measured within the previous 5 years, 79.4% for referral of women of the appropriate age for mammography within the previous 2 years, and 58.4% for discussion about alcohol use. The corresponding scores for the CMEP group were 95.8%, 97.6%, 77.6% and 64.6%. The changes in mean scores between phase 1 and phase 2 ranged from -1.9 to 2.3 points. There were no significant differences between the 2 groups in phase 1 or phase 2 scores or in change in scores. A total of 64.3% of the physicians rated the PAR as useful, 26.5% found the CMEP to be useful, and 41.0% considered the mentor strategy to be a useful form of continuing medical education. Although changes in practice related to the PAR, CMEP or mentor were reported by some physicians, they were not related to chart audit or patient scores. INTERPRETATION: Educational interventions based on quality-of-care assessments and directed to global improvements in quality of care did not result in improvements in the outcome measures. Educational interventions may have to be targeted to specific areas of the practice, with physicians being monitored and receiving ongoing feedback on their performance. (+info)