Would evidence-based regulation improve the practice and management of patient care?

The use of evidence to achieve sound medical diagnoses and optimal treatment plans is considered a standard of practice for healthcare providers. Indeed, failure to do so is prima facie evidence of malpractice. Health and medical care managers have begun espousing a similar philosophy: to make decisions that are data-driven rather than based on logic, intuition, personal preference, or last experience. Unfortunately, regulatory policies and practices in patient care are not always founded upon strong evidence. As a result, unintended consequences often surface after the passage of legislation or the adoption of policies by nongovernmental entities. These dysfunctions might be avoided if policymakers embraced evidence-based protocols commonly found throughout medicine and its management. This paper reviews the dilemmas that unfold when policy is formed without giving sufficient attention, in advance, to "hard" evidence.     

Home,school partnerships in family child care: providers’ relationships within their communities

Professional family child care providers’ work with children from birth through age five can be exemplary, particularly with regard to building stable and substantive relational ties. Such long‐term engagements with client children and their families offer potential for strong partnership with families and local contexts over time. This paper explores providers’ stories that illustrate such a favourable connection: how continuity between providers, parents and neighbourhood schools becomes a mutually beneficial relationship.     

Health care providers’ perspectives on the provision of prenatal care to immigrants

In addition to facing barriers to health care and experiencing poor health status, immigrants to Canada and Sweden tend to have more negative birth outcomes than the native-born population, including low birth weight and perinatal mortality rates. Explored through interviews with health care professionals, including midwives, nurse practitioners, social workers and obstetrician gynaecologists, this paper evaluates their experiences in providing prenatal care to immigrants in Hamilton, Ontario, Canada. Results reveal the complexity of delivering care to immigrants, particularly with respect to expectations surrounding language, culture and type and professionalism of care. The paper concludes by discussing future research options and implications for the delivery of prenatal care to this population.     

Supporting trust in home healthcare providers: insights into the care recipients’ perspective

Successful care in home health for older adults is heavily dependent on the relationships between care recipients and care providers. A key component of that relationship is trust. To investigate trust in this context, we explored what older care recipients perceive as supporting trust in home care providers. Participants discussed three main categories that support trust in a care provider: professional skills (e.g., safety), personal traits (e.g., honesty), and communication (e.g., content). Insights from the care recipients’ perspective are utilized to provide training recommendations for developing trust. For example, care providers should complete tasks in the care recipients’ preferred manner.     

Patients’ experience with cancer care: A qualitative study in family practice

Abstract

Background: Continuity is an important aspect of cancer care that is often a challenge owing to the movement of patients between family practice, cancer clinics, and hospitals.

Objectives: To investigate the experiences of cancer patients in relation to continuity of care.

Methods: A qualitative study was conducted in a family practice setting. Semi-structured interviews were used for data collection. 10 cancer patients with a wide variation in their disease duration and experiences with medical care were interviewed. Open questions were used to encourage patients to express their personal experiences with cancer care. The interviews were recorded, transcribed and analysed by three researchers using thematic analysis.

Results: Cancer patients experienced a lack of information concerning cancer and its treatment. They also perceived that the cancer treatment made them suffer. In the patients’ opinion, the family doctor has a limited role in cancer care. However, the patients felt that the family doctor should be aware of their health. The patients’ satisfaction with the oncologist's care was high. They considered that their role in cancer care was to mediate an exchange of information between the oncologist and the family doctor.

Conclusion: Cancer patients experience continuity of care in several ways: continuity in cancer care should be implemented by co-ordinating activities, such as regular check-ups, a clear timeframe and provision of adequate information. In addition, communication between the primary and secondary sector could be improved.     

Ngāti and healthy: translating diabetes prevention evidence into community action

Introduction: Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Māori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested.

Objective: To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Māori community.

Approach: Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design.

Discussion: Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages.

Conclusion: Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential.     

Enhancing prevention in primary care: are interventions targeted towards consumers’ and providers’ perceived needs?

Objective

To explore perceived barriers to the implementation of prevention guidelines, with a particular interest to perceived information needs from the point of view of health professionals and consumers.

Study Design

Focus group.

Setting and Participants

Eight focus groups were held in three Canadian cities: three with consumer, three with family physician, and two with primary care nurses.

Analysis

Inductive analysis based on transcribed interviews. The material was analysed by two of the investigators. Agreement on interpretation was checked independently by three other researchers on 10% of the material.

Results

Lack of motivation, discontinuity of care and lack of adequate remuneration were perceived as the strongest barriers to prevention implementation. Computerized information management systems were not perceived by physicians and nurses as strong facilitating factors. Consumers expressed strongly a need for information on non‐traditional preventive interventions. Physicians and nurses expressed a need for patient education material more than for practice guidelines. Research evidence was not considered as the first criteria to judge the value of preventive information.

Conclusions

Evidence‐based medicine has triggered a massive effort to develop technologies to support the dissemination of evidence‐based information on the assumption that poor access to such information is an important barrier to implementation of effective practices. Our results suggest that such an assumption may not be correct. Providing only evidence‐based information from the realm of traditional medicine will appear restrictive to most users, particularly to consumers, and may not be as valued as anticipated considering the expressed scepticism toward research evidence.

     

Is the practice of psychological therapists evidence-based?

An interview-based survey of evidence-based practice (EBP) and the research, continuing professional development (CPD) and audit activity that support it was conducted in the North East of England amongst a representative sample of NHS clinical psychologists and counsellors (n = 30). It profiled their participation in EBP activities over the past year and their intentions for the next year. The findings suggest that the sample had used guidelines and protocols on 56 per cent of occasions, had on average drawn on research, CPD and audit approximately half of the time, but had been only minimally influenced by research, CPD or audit. It is concluded that EBP has occurred in all defined areas and that the conditions for an increased degree of EBP are promising.     

Home care: the experience of a private hospital in the state of São Paulo

Home care is defined as a group of hospital procedures that can be developed at home, encompassing health actions developed by a multiprofessional team. This study aims at disseminating the experience of a home care service offered by S?o Francisco Hospital, located in the city of Ribeir?o Preto, presenting the results of a 12-month period (from September 2001 to August 2002). During the analyzed period, the service provided care mainly to women (57%), with age between 70 and 80 years (30%), with diagnosis of neurological diseases (27%) and tumors (17%). The sector is coordinated by nurses, who are also responsible for bringing in clients. The work is performed by an interprofessional team that performs procedures of collecting material for lab examinations, dressing, deliver care with catheters and ostomies, as well as home hospitalization.     

Parents’ child care experience: effects of sex and parity

A sample of 94 couples was surveyed to determine effects on child care experience associated with sex, parity, and various other demographic variables; experience was measured by scores on the Experience with Young Children Scale. As expected, women had higher scores than men; experience was a linear function of parity for men, but not for women, and was unrelated to scores on the Attitudes Toward Women Scale. Couples tended to resemble each other in experience, even when parity was statistically controlled. Discussion emphasized implications for sex differences in child care responsibility, and the need for additional attention to socialization for the child caregiver role.     

Recruitment into diabetes prevention programs: what is the impact of errors in self-reported measures of obesity?

ABSTRACT: BACKGROUND: Error in self-reported measures of obesity has been frequently described, but the effect of self-reported error on recruitment into diabetes prevention programs is not well established. The aim of this study was to examine the effect of using self-reported obesity data from the Finnish diabetes risk score (FINDRISC) on recruitment into the Greater Green Triangle Diabetes Prevention Project (GGT DPP). METHODS: The GGT DPP was a structured group-based lifestyle modification program delivered in primary health care settings in South-Eastern Australia. Between 2004-05, 850 FINDRISC forms were collected during recruitment for the GGT DPP. Eligible individuals, at moderate to high risk of developing diabetes, were invited to undertake baseline tests, including anthropometric measurements performed by specially trained nurses. In addition to errors in calculating total risk scores, accuracy of self-reported data (height, weight, waist circumference (WC) and Body Mass Index (BMI)) from FINDRISCs was compared with baseline data, with impact on participation eligibility presented. RESULTS: Overall, calculation errors impacted on eligibility in 18 cases (2.1%). Of n=279 GGT DPP participants with measured data, errors (total score calculation, BMI or WC) in self-report were found in n=90 (32.3%). These errors were equally likely to result in under- or over-reported risk. Under-reporting was more common in those reporting lower risk scores (Spearman-rho = -0.226, p-value < 0.001). However, underestimation resulted in only 6% of individuals at high risk of diabetes being incorrectly categorised as moderate or low risk of diabetes. CONCLUSIONS: Overall FINDRISC was found to be an effective tool to screen and recruit participants at moderate to high risk of diabetes, accurately categorising levels of overweight and obesity using self-report data. The results could be generalisable to other diabetes prevention programs using screening tools which include self-reported levels of obesity.     

Do words matter? health care providers’ use of the term prediabetes

Communication of risk is not solely the transfer of information; it is an interaction and exchange of ideas between concerned individuals. Health care provider communication about type 2 diabetes risk status may influence individual participation in behaviours that prevent or delay the disease, which is concerning from a public health perspective. The term prediabetes is used to convey risk status and little is known about how health care providers view or use the term. In this article, we describe health care provider use and perceptions of the term prediabetes drawing on data from interviews conducted between August and November 2011 of 15 health care providers practicing in Southeast Wyoming and Northern Colorado USA. We used a grounded theory research design to guide data collection and analysis and in the interviews invited providers to describe their use and perception of the term prediabetes. We found that providers’ use of the term ‘prediabetes’ depended on their view of the term’s meaning (e.g. whether patients were likely to understand or be confused by it) and impact (in terms of motivating patients to mitigate risk). We found there were differences in providers’ perceptions of the negative and positive associations of the term and this influenced whether or not they used it. These findings are not surprising given the lack of consensus over definitions and diagnosis criteria for prediabetes. Given this lack of agreement, there are difficulties about the use of the term prediabetes and its use should take place within effective risk communication. Health care providers must consider essential aspects of risk communication in order to enable individuals at risk of type 2 diabetes to mitigate the risk and by doing so reduce incidence and prevalence rates of the disease.     

Use of hormone replacement therapy in Washington State: is prevention being put into practice?

BACKGROUND: American women are using hormone replacement therapy (HRT) for long-term disease prevention, as well as symptom control, in increasing numbers. Our study examined the role of prevention in women's decisions to initiate HRT and their intended duration of therapy. METHODS: We analyzed the mailed survey responses of 2023 women aged 50 to 70 years from the practices of 46 physicians in the Puget Sound region for knowledge and attitudes about HRT, current use, and intended duration of therapy. Multiple logistic regression was used to model current HRT use and intended treatment length. RESULTS: A total of 71% of our respondents were using HRT. Women with osteoporosis, coronary heart disease (CHD), or risk factors for CHD were not more likely to be using HRT, and women with CHD or risk factors for CHD were not targeted by their physicians for discussion of HRT. Of women using HRT, 77% expected lifelong use, and this was not more common among women initiating HRT for disease prevention. CONCLUSIONS: Despite the high rates of HRT use and expected lifelong duration, use of HRT for prevention was neither higher among women most likely to benefit nor a major determinant of expected lifetime use.     

Disability-competence training influences health care providers’ conceptualizations of disability: An evaluation study

BackgroundOften, health care providers’ approach to people with disabilities is grounded in a medical model perspective. This view highlights individual deficits and does not foster patient-centeredness. Learning about and adopting a more social model, focused on creating accessible and inclusive approaches and environments, could help providers to reshape their attitudes about disability, dismantling barriers to care.ObjectiveThis study used innovative methods to evaluate a recorded, online disability-competence training for health care providers. It was hypothesized that the training would 1) shift providers’ conceptualizations of disability away from a medical model view toward a social model view of disability and 2) equip providers with actionable strategies to improve access to care for people with disabilities.MethodsQuantitative and qualitative evaluation data were analyzed for n = 192 training participants. Measures included participants’ pre- and post-training conceptualizations of disability, proposed actions steps to facilitate patient-centered care, and measures of satisfaction and self-assessed knowledge gain.ResultsBoth hypotheses were supported. After the training, participants’ conceptualizations of disability were more reflective of the social model, and participants were better able to articulate specific action steps they could take to promote accessible, responsive care.ConclusionsThis study demonstrates that health care provider training can positively affect providers’ knowledge, outlook, and approach to caring for people with disabilities. Its findings can inform broader efforts aimed at systematically changing the way health professionals are educated and trained to provide care in disability-competent ways.     

Integration of comprehensive women’s health programmes into health systems: cervical cancer prevention,care and control in Rwanda

Problem

Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda.

Approach

By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment.

Local setting

Rwanda – a small, landlocked nation in East Africa with a population of 10.4 million – is well positioned to tackle a number of “high-burden” noncommunicable diseases. The country’s integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade.

Relevant changes

In 2011–2012, Rwanda vaccinated 227 246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options.

Lessons learnt

Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women’s health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years.     

Are women and providers satisfied with antenatal care? Views on a standard and a simplified,evidence-based model of care in four developing countries

BACKGROUND: This study assessed women and providers' satisfaction with a new evidence-based antenatal care (ANC) model within the WHO randomized trial conducted in four developing countries. The WHO study was a randomized controlled trial that compared a new ANC model with the standard type offered in each country. The new model of ANC emphasized actions known to be effective in improving maternal or neonatal health, excluded other interventions that have not proved to be beneficial, and improved the information component, especially alerting pregnant women to potential health problems and instructing them on appropriate responses. These activities were distributed within four antenatal care visits for women that did not need any further assessment. METHODS: Satisfaction was measured through a standardized questionnaire administered to a random sample of 1,600 pregnant women and another to all antenatal care providers. RESULTS: Most women in both arms expressed satisfaction with ANC. More women in the intervention arm were satisfied with information on labor, delivery, family planning, pregnancy complications and emergency procedures. More providers in the experimental clinics were worried about visit spacing, but more satisfied with the time spent and information provided. CONCLUSIONS: Women and providers accepted the new ANC model generally. The safety of fewer visits for women without complications with longer spacing would have to be reinforced, if such a model is to be introduced into routine practice.     

Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting

BackgroundWhile Video Remote Interpreting services provides prompt services for emergency care and is cheaper than in-person interpreting services, there have been several issues, such as poor connection and limited flexibility to maneuver.ObjectivesThis study proposes three research questions and four hypotheses to identify healthcare providers and deaf/hard of hearing (DHH) patients’ preferences for VRI and in-person interpreting on critical care and non-critical care.MethodsThe study utilizes a mixed methods design incorporating both an online survey and qualitative interviews. A total of 103 participants responded to the online survey. This included 36 healthcare providers who worked with limited English proficiency (LEP) patients, 26 healthcare providers who worked with DHH patients, and 41 DHH patients. Qualitative interviews were also conducted with eight healthcare providers and eight DHH patients to explore the online survey findings.ResultsIn the Part I study, healthcare providers (n = 62) included 16 males and 45 females; most professions were dentists, nurse practitioners, and students. DHH patients (n = 41) included 17 males and 22 females; most education was graduate or professional degrees. There was no statistical difference in their preference uses for critical care (p = 1.000), but there was a statistical difference for non-critical care (p = .035). In the Part II study, both healthcare providers and DHH patients preferred in-person interpreting for critical care to obtain effective communication, translation accuracy, and better treatment.ConclusionsRecommendation to improve VRI equipment and training with healthcare providers, hospital administrators, VRI companies, VRI interpreters, and DHH patients to improve healthcare communication.