Long-term development of parental knowledge about skin cancer risks in Germany: Has it changed for the better?

Substantial public health efforts have been undertaken throughout the last 25 years to increase awareness about skin cancer risks in the German population. An evaluation of long-term effects of these awareness campaigns and preventive activities on the population level and in specific subgroups is yet lacking. We address the temporal development of knowledge about skin cancer risk factors and agreement to the necessity of sun protection in different outdoor situations among parents of young children. We compiled data from four population-based surveys comprising data from 8184 parents of 3- to 6-year-old children in two regions of Germany performed over a nineteen-year period between 1993 and 2012. These individual cross-sectional studies used an identical methodology to recruit study subjects and to assess the principal outcome measures. Overall, parental knowledge about skin cancer risk factors and agreement to the necessity of sun protection improved significantly over the nineteen-year period. For instance, the recognition of fair skin/hair, sunburns during childhood and a high number of naevi, respectively, being risk factors for skin cancer increased by 20.0%, 19.9% and 19.2% from the first to the most recent survey. Two remaining knowledge gaps became evident: (i) the underrating of intermittent intensive sun exposure as a skin cancer risk factor and (ii) the erroneous belief that clouds provide sufficient sun protection at midday during summertime. The messages of future public health campaigns in Germany addressing skin cancer risks and informing about preventive measures for sun protection should thus be refined regarding these aspects.     

What evidence, whose evidence?: Physical therapy in New York State's clinical practice guideline and in the lives of mothers of disabled children

To provide recommendations based on the best scientific evidence available about "best practices," the New York State Department of Health Early Intervention Program sponsored the development of an evidence-based clinical practice guideline for assessment and intervention for young children with motor disabilities. The author served on the multidisciplinary consensus panel convened to develop the guideline, holding a position as a parent of a child with motor disabilities, and in addition utilizing data from her qualitative anthropological research on mothers of young children newly diagnosed with disabilities. This article describes the state panel's process for developing the guideline, focusing on recommendations about physical therapy interventions for cerebral palsy. Although evidence-based practice privileges randomized clinical trials, few studies of physical therapy techniques for young children with motor disabilities meet such criteria for evidence. The panel's recommendations, in the absence of such scientific evidence, are analyzed in comparison with competing theories of motor development in physical therapy research and practice, and with interpretations of physical therapy held by mothers of young children with disabilities who were interviewed in the study. The article explores questions of what constitutes evidence in three arenas: (1) clinical practice guidelines, (2) physical therapy research, and (3) the lives of families of young children with motor disabilities. It has broader implications for understanding how information, variously derived, is transformed into evidence. While to some extent authority and power affect the range of knowledge that can be transformed into evidence, the more significant constraints may be the rules of evidence we value and the particular paradigm of our science.     

The efficiency of specialist outreach clinics in general practice: is further evaluation needed?

OBJECTIVES: To assess the need for further evaluation of general practice-based outreach clinics in two specialties using data from a UK pilot study to model their cost-effectiveness. METHODS: A pilot study was undertaken comparing one outreach and one outpatient clinic held by three dermatology specialists and three orthopaedic specialists. Information was collected on waiting times, costs to patients, casemix and resource use. RESULTS: Only dermatology outreach clinic patients experienced significantly shorter waiting times for first appointments than their hospital counterparts. Outreach clinic patients incurred lower costs in attending appointments in either specialty but the differences were not statistically significant. Evidence of a difference in casemix between patients attending outreach and outpatient clinics meant that treatment costs incurred in both types of clinic could not be compared. Outreach clinics in both specialties were significantly more costly in terms of staff, staff travel and associated opportunity costs compared with outpatient clinics. Sensitivity analysis showed that outreach and outpatient clinics had the same marginal cost if the number of patients per outreach clinic increased greatly or attendance fell considerably at outpatient clinics. CONCLUSIONS: This study has found no evidence that outreach clinics in these two specialties are cost-effective in terms of costs and benefits. A more definitive conclusion could only be made if studies estimated other costs and benefits not accounted for in this study. Further research is required to see whether outreach clinics in other specialties or clinics with different configurations to those studied are efficient.     

The planning of cervical cancer screening programmes in Eastern Europe: is viral testing a suitable alternative to smear testing?

Cervical cancer screening with human papillomavirus (HPV) DNA testing has potential advantages over conventional smear testing in that it can predict cases in which invasive cancers are more likely to develop, may be cheaper to implement and improve compliance. In areas of the world where little formalised cervical cancer screening takes place, or where health resources are limited, HPV testing has been suggested as a possible alternative for primary screening. In this paper we demonstrate the use of mathematical modelling to evaluate the effects of setting up screening programmes in Eastern Europe with HPV DNA testing as the primary screening tool and compare it with conventional smear testing. The impact of screening is measured in terms of the life years gained and the resulting resource usage and cost. We investigate several screening options with different screening intervals and age ranges for the target population. This revised version was published online in July 2006 with corrections to the Cover Date.     

The pedagogical value of testing: how far does it extend?

Information is generally more memorable after it is studied and tested than when it is only studied. One must be cautious to use this phenomenon strategically, however, due to uncertainty about whether testing improves memorability for only tested material, facilitates learning of related non-tested content, or inhibits memory of non-tested material. 52 second-year Pharmacy students were asked to study therapeutic aspects of gastroesophageal reflux disease and peptic ulcer disease. One group was given 30 min to study. Another was given 20 min to study and 10 min to complete a 10-item test. Two weeks later a 40-item test was delivered to both groups that contained (a) the 10 learning phase questions, (b) 10 new questions drawn from the studied material, (c) 10 new questions about therapeutics in different disease states, and (d) 10 new questions drawn from more general pharmaceutical knowledge (e.g., basic physiology and drug characteristics). Moderate to large retrieval-enhanced learning effects were observed for both questions about material that was tested (22.9% difference in scores, p?<?0.05, d?=?0.60) and questions about material that was studied without being tested (18.9% difference, p?<?0.05, d?=?0.75). Such effects were not observed for questions that were not part of the study material: therapeutic questions that addressed different disease states (1.8% difference, p?>?0.7, d?=?0.08) or generic pharmaceutical questions (7.4% difference, p?>?0.2, d?=?0.32). Being tested made it more likely that students would report reviewing the material after the initial learning session, but such reports were not associated with better test performance. The benefit of mentally retrieving information from studied material appears to facilitate the retrieval of information that was studied without being tested. Such generalization of the benefit of testing can increase the flexibility of test-based pedagogic interventions.     

The proliferation of clinical practice guidelines: professional development or medicine-by-numbers?

In a medical milieu of extensive research, rapidly proliferating information, and a multitude of potential therapies, there has been an escalating trend toward the development and dissemination of clinical practice guidelines outlining investigative and management protocols for clinical problems. There are substantial benefits to providing educational directives and securing widespread adherence to specific clinical practice standards as a means to ensure a consistent acceptable standard-of-care. On the other hand, the increasing tendency to regard authoritative documents as dogma may hinder ongoing medical progress and facilitate the adoption of a "follow-the-recipe" approach to medical practice. A healthy tension between physician autonomy and recommended practice guidelines needs to be cultivated in primary care as well as in specialty clinical practice. In response to increasing concern surrounding issues of impartiality and commercial influence on the development of practice directives, a mechanism designed to assure integrity and credibility of guidelines is required.     

The use of patient reported outcome measures in routine clinical practice: lack of impact or lack of theory?

This paper applies a theory-driven approach to explore why the use of patient-reported outcome (PRO) measures in clinical practice, in particular, health-related quality of life (HRQoL) instruments, has little or no apparent influence on clinical decision making. A theory-driven approach involves combining knowledge of whether and how an intervention works. It is argued that such an approach is currently lacking within the literature evaluating the effectiveness of feeding back HRQoL information to clinicians. The paper identifies a number of mechanisms that might give rise to the expected outcomes that are currently implicit within the design of the intervention and hypotheses specified within the trials evaluating the use of HRQoL measures in clinical practice. It then examines how far current clinical practice matches these mechanisms and in doing so, a number of possible explanations for the lack of impact of HRQoL on clinical decision making are reviewed. The influence of HRQoL information on clinical decision making depends on a large number of factors related to the design of the intervention, patients' and clinicians' desire to discuss HRQoL issues within the consultation and the legitimacy that clinicians give to HRQoL instruments. To date, knowledge of how the feedback of HRQoL information to clinicians might improve doctor-patient communication or clinical decision making has yet to sufficiently inform an assessment of whether these aspects of patient care are improved. The paper concludes by specifying how the feedback of HRQoL information to clinicians might be modified to maximise its impact on clinical decision making.