Registry-driven, community-based immunization outreach: a randomized controlled trial

OBJECTIVES: This study evaluated the effectiveness of registry-driven, community-based outreach directed toward children with immunization delays. METHODS: A sample of 1,856 children aged 6 to 10 months was randomly assigned to receive either outreach or no intervention. RESULTS: Children in the outreach group were more likely to receive an immunization during the observation period than children in the control group (61% vs 43%). Outreach was most effective for children with multiple risks, as measured by their immunization record; it was not effective for children whose mothers had received inadequate prenatal care. CONCLUSIONS: Registry-driven outreach can effectively identify high-risk children and bring them to care.     

Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial

In a randomized controlled trial, an intensive promotional campaign failed to increase the uptake of vaccination against influenza among health care workers. The uptake of vaccination was low.     

Evaluation of a community-based randomized controlled prenatal care trial in rural China

Background  

A community-based randomized control prenatal care trial was performed in a rural county of China during 2000-2003. The purpose of this paper is to describe the trial implementation and the impact of the trial on the utilization of prenatal care and perinatal outcomes.     

Improving quality of organizing cardiovascular preventive care in general practice by outreach visitors: a randomized controlled trial

BACKGROUND: Adequate care for patients with cardiovascular risks requires an adequate practice organization. Educational outreach visits are a promising approach to modifying professional behavior. We aimed to assess whether the quality of cardiovascular preventive care in general practice can be improved through a comprehensive intervention implemented by an educational outreach visitor. METHODS: After baseline measurements, general practices (n = 124) in the southern half of The Netherlands were randomly allocated to either intervention or control group. The intervention, based on the educational outreach model, comprised 15 practice visits over a period of 21 months and addressed a large number of issues around task delegation, availability of instruments and patient leaflets, record-keeping, and follow-up routines. Twenty-one months after the start of the intervention, postintervention measurements were performed. The difference between ideal and actual practice in each aspect of organizing preventive care was defined as a deficiency score. Primary outcome measure was the difference in deficiency scores before and after the intervention. RESULTS: All practices completed both baseline and postintervention measurements. The difference in change between intervention and control group adjusted for baseline was statistically significant (P < 0.001) for each aspect of organizing preventive care. The largest absolute improvement was found for the number of preventive tasks performed by the practice assistant. CONCLUSIONS: This study showed that a comprehensive intervention implemented by outreach visitors was effective in improving organization of cardiovascular preventive care in general practice.     

Coffee, blood pressure and plasma lipids: a randomized controlled trial

A randomized controlled trial was conducted to examine the effects of coffee (as commonly drunk in Britain) on blood pressure and plasma lipids in healthy subjects. Fifty-four subjects followed three regimens successively, the order being randomized according to a Latin square design: five or more cups of coffee daily for 4 weeks; five or more cups of decaffeinated coffee daily for 4 weeks but no ordinary coffee; no coffee for 4 weeks. Coffee appeared to cause a small rise (of 3 mm Hg) in recumbent systolic blood pressure; this effect was less than, and obscured by, changes induced by posture and mild stress. No consistent changes attributable to coffee were found in diastolic blood pressure or pulse rate. Small changes in the expected directions occurred in plasma high density lipoprotein (HDL) cholesterol and apolipoprotein AI (decrease), and in total cholesterol, non-HDL cholesterol and apolipoprotein B (increase), but none of these were statistically significant. The effect of coffee on risk of heart disease in Britain is probably small.     

Is untargeted outreach visiting in primary care effective? A pragmatic randomized controlled trial.

BACKGROUND: There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. Outreach visits may improve prescribing behaviour. METHODS: Within a before-and-after pragmatic randomized controlled trial, involving all general practices in one health district, routine methods were used to distribute guidelines for management of Helicobacter pylori eradication. Intervention practices were offered a visit and the conduct of an audit by a pharmacist trained in the techniques of outreach visiting. The intervention was evaluated using level three Prescribing Analysis and Cost (PACT) data for metronidazole and omeprazole for the two 12 month periods around the introduction of the guidelines. RESULTS: Of the 38 intervention practices 19 accepted an outreach visit and three accepted the offer of an audit. There was a significant increase in omeprazole use during the study of 0.24 [95 per cent confidence interval (CI) +0.19 to +0.29] dose units per year but no effect from the offer [-0.02 (95 per cent CI -0.12 to +0.08) dose units] or acceptance of a visit [-0.03 (95 per cent CI -0.15 to +0.08) dose units]. The results for metronidazole were similar, with an increase in use of 0.028 (95 per cent CI +0.018 to +0.038) dose units per year. The effect of the intervention was a non-significant change in prescribing of -0.005 (95 per cent CI -0.025 to +0.015) dose units. Accepting a visit had little effect on prescribing: a change of 0.003 (95 per cent CI -0.021 to +0.027) dose units. CONCLUSIONS: The routine use of untargeted outreach visiting is probably not a worthwhile strategy.     

Managing depression in home health care: a randomized clinical trial

A prospective randomized trial was conducted to examine the effectiveness, feasibility, and degree of implementation of home health care quality improvement interventions when implemented under usual conditions by usual care providers. A total of 311 older adults were randomized to enhanced usual care (EUC) that included routine depression screening and staff training in depression care management for older adults or to the intervention group (INT) that included antidepressants and/or psychotherapy treatment plus EUC. Implementing a routine screening protocol using the PHQ-9 and depression care management quality improvements is feasible in diverse home health care organizations and results in consistently better (but not statistically significant) depression outcomes in the INT group.     

Contraceptive injections by community health workers in Uganda: a nonrandomized community trial

OBJECTIVE: To compare the safety and quality of contraceptive injections by community-based health workers with those of clinic-based nurses in a rural African setting. METHODS: A nonrandomized community trial tested provision of injectable Depo Provera (DMPA) by community reproductive health workers and compared it with routine DPMA provision at health units in Nakasongola District, Uganda. The primary outcome measures were safety, acceptability and continuation rates. FINDINGS: A total of 945 new DMPA users were recruited by community workers, clinic-based nurses and midwives. Researchers successfully followed 777 (82% follow-up): 449 community worker clients and 328 clinic-based clients. Ninety-five percent of community-worker clients were "satisfied" or "highly satisfied" with services, and 85% reported receiving information on side-effects. There were no serious injection site problems in either group. Similarly, there was no significant difference between continuation to second injection (88% among clients of community-based workers, 85% among clinic-going clients), nor were there significant differences in other measures of safety, acceptability and quality. CONCLUSION: Community-based distribution (CBD) of injectable contraceptives is now routine in some countries in Asia and Latin America, but is practically unknown in Africa, where arguably the need for this practice is greatest. This research reinforces experience from other regions suggesting that well-trained community health workers can safely provide contraceptive injections.     

An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]

Background

The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting.

Methods

Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis.

Results

Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69–14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up.

Conclusions

While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a pauCity of well controlled trial evidence but where significant health outcomes can be attained.     

宿迁市医改后居民就医满意度及影响因素调查

目的通过对体检人员进行满意度调查,为改善服务质量提供依据。方法2018年5—6月份随机抽取复旦大学附属华山医院健康管理中心200名受检者作为调查对象,采用面对面问卷的方式进行调查。结果有效回收问卷199份,问卷回收率99.5%;男性51.8%,女性48.2%,平均年龄43.54岁;自费体检占66.7%,单位出资占33.3%。对中心的检查项目、医生服务水平、医生服务态度、护士服务态度、硬件环境、体检收费、后续服务、预约服务的满意度均达到95%以上。对体检后的后续服务需求：需要体检报告解读占89.45%、异常指标就医指导占73.37%、长期的健康咨询占43.72%、健康危险因素评估占25.63%、特需门诊服务占16.08%、健康危险因素干预占12.56%、多学科会诊占6.53%。结论受检者对复旦大学附属华山医院健康管理中心的满意度较高,体检后的健康管理需求较大。     

Hospital outreach community-based health care: the case of Chogoria, Kenya

This article presents an analysis of the community health activities of Chogoria Hospital, Kenya, as they evolved from a typical 'outreach' programme to a heavily community-based one, and the factors that contributed to this conversion. Factors considered include family planning, being the central theme of the programme since its inception, financing, and the impact of the programme is illustrated with data from an extensive evaluation carried out in 1985. The question of long-term financial viability is addressed, contrasting the desired self-sufficiency with the need and extent of donor contributions and finally a number of key factors are listed that may have been important to the success of the programme.     

Public health in managed care: a randomized controlled trial of the effectiveness of postcard reminders.

OBJECTIVES: This study evaluated the effectiveness of an annual public health intervention in a managed care setting. METHODS: Managed care organization members 65 years and older who received influenza immunization in 1996 were randomized to an intervention group (mailed a postcard reminder to receive an influenza vaccination in 1997) or a control group (no postcard). Vaccination rates for both groups were assessed monthly. RESULTS: Members receiving the intervention were no more likely to be immunized (78.6%) than members of the control group (77.2%, P = .222). Members were vaccinated at the same pace regardless of vaccination history and postcard intervention status. CONCLUSIONS: Postcard reminders were not an effective intervention among seniors who had been vaccinated the previous year.     

Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed. RESULTS: No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions. CONCLUSIONS: Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour.     

Infant health effects of a nurse–community health worker home visitation programme: a randomized controlled trial

Background Home visiting is supported as a way to improve child health and development. Home visiting has been usually provided by nurses or community health workers (CHWs). Few studies compared the child health advantages of a nurse–CHW team approach over nurse prenatal and postnatal home visiting. Methods A randomized trial was conducted with Medicaid‐insured pregnant women in Kent County, Michigan. Pregnant women were assigned to a team intervention including nurse–CHW home visitation, or standard community care (CC) including nurse home visitation. Morbidity was assessed in 530 infants over their first 12 months of life from medical claims and reported by the mother. Results There were no differences in overall child health between the nurse–CHW intervention and the CC arm over the first year of life. There were fewer mother‐reported asthma/wheezing/croup diagnostics in the team intervention group among infants whose mothers have low psychosocial resources (13% vs. 27%, P = 0.01; adjusted OR = 0.4, P = 0.01). There were no differences in diagnosed asthma/wheezing/croup documented by medical claims. There were no differences in immunizations, hospitalizations and ear infections. Conclusions There was no strong evidence that infant health was improved by the addition of CHWs to a programme of CC that included nurse home visitation. Targeting such interventions at common health problems of infancy and childhood or at diagnosed chronic conditions may prove more successful.     

Training primary health care workers to foster community participation.

A low level of community participation was identified as one of the weaknesses of the health sector in the United Republic of Tanzania. In order to remedy this situation, a systematic process of training trainers and students was established with full involvement of village people. Twenty-five themes were put forward as starting points for discussions between students and villagers. The students were encouraged to learn from the villagers by listening to them and asking them questions. They also participated in community activities and lived with villagers so as to obtain a good understanding of rural living conditions. In this way, problems were identified and solutions were jointly formulated. A workbook was developed during a series of workshops with students, trainers, village communities, and planners. At least two teachers were trained from each health training school; all schools were supplied with workbooks. The approach has been adopted by most health training schools in Tanzania, and the Ministry of Health is now committed to it. Both students and trainers find this to be a valuable learning experience.     

A randomized controlled trial to increase cancer screening among attendees of community health centers

BACKGROUND: We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations. METHODS: Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT). RESULTS: In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096). CONCLUSIONS: The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.     

武汉市社区医务人员对社区高血压管理参与及满意度调查

目的了解湖北省武汉市社区医务人员对高血压管理的参与及满意度现状及其满意度影响因素,为进一步完善国内社区高血压管理提供可行性建议。方法于2015年1月在武汉市随机抽取14个行政区249名社区医务人员进行问卷调查。结果武汉市249名社区医务人员中,有71.9%的人认为高血压管理质量基本达标,有40.2%的人对高血压管理工作整体表示满意;有60.6%的社区医务人员将高血压临床诊疗视为本职工作,但社区医务人员在护理服务、健康档案管理和信息系统维护方面的参与度较低,分别占17.3%、28.1%、21.3%;在社区高血压管理工作改进评价方面,要求改进医疗保险对慢性病支持、患者参与配合度、员工工作激励和经费支持的比例较高,分别占67.1%、69.5%、71.9%、73.9%;多因素非条件logistic回归分析结果显示,对培训工作、药品品种、对象配合和随访质量满意的武汉市社区医务人员对高血压管理的满意度越高。结论武汉市社区医务人员对社区高血压管理工作满意度一般,参与度有待提高;对高血压管理培训工作、药品品种、对象配合和随访质量的满意情况是社区医务人员对高血压管理满意度的主要影响因素。     

Effect of preventive health screening on long-term primary health care utilization. A randomized controlled trial

BACKGROUND: Regular preventive health screenings are a feature of primary health care in several countries. Studies of the effect of regular preventive health checks have reported different results regarding primary health care utilization. OBJECTIVE: To analyse the effect of preventive health screening and health discussions on contacts to general practice. METHODS: A randomized controlled trial with all GPs in the district of Ebeltoft, Denmark. All middle-aged residents registered with a GP in the district of Ebeltoft were included (n = 3464). A random sample of 2030 subjects was selected for invitation to participate in health screening or health screening and discussions. The remaining 1434 subjects were never contacted and served as an external control group. Main outcome measure was number of daytime consultations in general practice. RESULTS: The annual rate ratios for daytime consultations showed a very clear time trend (P < 0.0001) with a high rate of contacts among invited compared with non-invited subjects during the first year (P = 0.001) followed by a gradual decrease to a lower level after eight years (P = 0.037). The total rate ratio for daytime consultations was 1.01 (95% CI 0.93 to 1.10). CONCLUSION: We observed no differences between the invited group and the non-invited group in any type of contact to general practice when the entire follow-up period was considered. There was a significant trend in rate ratios for daytime consultations with an initial rise followed by a gradual decrease in rate ratios. More investigations are needed to confirm and explore reasons for this trend.