Research on changing practitioner and patient behavior

The Institute of Medicine's report "Crossing the Quality Chasm" (2001) indicates that it takes 17 years, on average, for knowledge generated by randomized trials to be adopted in practice if there is no effective intervention in place to promote the evidence. Influencing provider behavior is a formidable task, and many strategies traditionally used, such as unsolicited distribution of consensus recommendations or guidelines, and traditional didactic lectures and seminars, have generally been proven to be ineffective in changing clinical practices. The summaries that follow provide an overview of recently published, research-based works on strategies to change clinician and/or patient behavior. Two articles focus on improving hypertension management and two focus on improving heart failure management, conditions that are seen at very high levels in home care. We hope that the following summaries will stimulate some thinking about strategies that can be tried in home care organizations to promote the adoption of evidence-based care. For additional details about the intervention and research findings, we suggest that our readers refer to the original articles.     

Doctors' views of clinical practice guidelines: a qualitative exploration using innovation theory

RATIONALE, AIMS AND OBJECTIVES: The authors undertook this qualitative study as part of a larger evaluation of the effect of eight clinical practice guidelines issued by an arm's-length government agency in a Canadian province. Using Orlandi and colleagues' version of the Rogers diffusion of innovation model as a framework, the authors mapped doctors' views on implementation of clinical practice guidelines. METHODS: In semi-structured interviews with 45 representative doctors, the authors elicited doctors' framework of meaning for behaviour change in general and for clinical practice guideline uptake in particular. These were then compared with the adapted Orlandi/Rogers diffusion of innovation model to confirm, amend or challenge that model. RESULTS: Doctors identified the following influences on changes to their clinical practice and on clinical practice guideline uptake, within a five-step innovation model: 1 innovation: evidence change is required, perceived need for change; 2 communication: awareness of innovation; 3 adoption: evidence of improved outcomes without increased patient risk, opinion leader support, consistency with current trends; 4 implementation: patient and family acceptability; and 5 maintenance: system support, patient and family support, observed improved patient outcomes without increased risk. CONCLUSIONS: Innovation for doctors is a complex decision process rather than a single decision point. Change occurs in the context of professional networks and patient and family support and demand.     

Rheumatic fever and social justice

High rates of this disease are the face of Indigenous disadvantage.     

Unnecessary admissions of head-injured patients at the University Hospital of the West Indies

The prospectively collected data in the Jamaica National Trauma Registry operated by the Section of Surgery identified 88 patients who were admitted with head injury to the University Hospital of the West Indies over a one-year period. There were 67 males (76.1%), the mean (SD) age of the entire group being 35.02 (+/- 18.45) years. Intentional injuries occurred in 47.2%. The Injury Severity Score was greater than 15 in 19.3%, severe head injuries occurred in 19% and overall mortality was 16%. Care in the Intensive Care Unit (ICU) was extended to only half of those with the severe injuries. The Scottish Intercollegiate Guidelines Network (SIGN) method was used to assess the appropriateness of admission to hospital. Sixteen (18%) of the 88 patients were inappropriately admitted according to SIGN guidelines. Increased efficiency may result from standardization of admission criteria for head-injured patients and consistent implementation of the SIGN guidelines for admission without increased risk to patients. This may be expected to minimize unnecessary admissions and result in considerable cost savings.     

Plasmacytoid dendritic cells from human lung cancer draining lymph nodes induce Tc1 responses

Dendritic cells (DC) resident in draining lymph nodes (LN) of patients with lung cancer are proposed to have a critical role in stimulating anti-tumor immunity. CpG oligodeoxynucleotides are undergoing clinical trials in patients with lung cancer and are likely to target plasmacytoid-DC. The present study, therefore, investigated the capacity of plasmacytoid-DC from human lung cancer draining LN to respond to CpG for activation of T cell responses relevant to anti-tumor immunity. The phenotype of DC was examined by flow cytometry, and cytokine production by cytometric bead array (CBA) and ELISA. Plasmacytoid-DC, purified by cell sorting, were immature but expressed the toll-like receptor, TLR9. Plasmacytoid-DC responded to the CpG oligodeoxynucleotide, CpG 2216, by production of the proinflammatory cytokines, IFN-alpha and IL-6. DC were cocultured with normal, allogeneic T cells, and cytokine production determined by CBA and immunophenotyping. CpG 2216 enhanced IFN-gamma production and induced intracellular production of IFN-gamma by CD8(+) and CD4(+), granzyme B by CD8(+), and IL-2 by CD4(+) T cells, respectively. Ligation of CD40 on plasmacytoid-DC combined with exposure to CpG 2216 also strongly enhanced IFN-gamma production. There was no significant difference between the responses of plasmacytoid-DC from patients with lung cancer and patients with benign carcinoid tumors with no pathologic LN involvement. These results indicate that plasmacytoid DC from the draining LN of patients with lung cancer effectively induce Tc1 immunity and could, therefore, represent a novel and attractive target for immunotherapeutic intervention.     

Cardiovascular manifestations of hypereosinophilic syndromes

The hypereosinophilic syndromes (HESs) are characterized by persistent marked eosinophilia (>1500 eosinophils/mm(3)), the absence of a primary cause of eosinophilia (such as parasitic or allergic disease), and evidence of eosinophil-mediated end organ damage. Cardiovascular complications of HES are a major source of morbidity and mortality in these disorders. The most characteristic cardiovascular abnormality in HES is endomyocardial fibrosis. Patients who have an HES also may develop thrombosis, particularly in the cardiac ventricles, but also occasionally in deep veins. Because of the rarity of these disorders, specific guidelines for the management of the cardiac and thrombotic complications of HES are lacking. This article reviews the diagnosis and management of the cardiovascular manifestations of HES.     

Increased 1-year continuation of DMPA among women randomized to self-administration: results from a randomized controlled trial at Planned Parenthood

Objectives

Self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-sc) is feasible, acceptable, and effective. Our objective was to compare one-year continuation of DMPA-sc between women randomized to self-administration versus clinic administration.