RESEARCH LETTER: Uptake of research findings into clinical practice: a controlled study of the impact of a brief external intervention on the use of corticosteroids in preterm delivery

To the Editor: There are a large number of studies addressing the impact of continuing medical education (Davis et al. 1995) and clinical guidelines (Grimshaw & Russell 1993) on changing clinical practice, but comparatively little on the impact of purchasers of health care. There is some evidence that financial incentives and penalties can influence practice (Greco & Eisenberg 1993). It has been suggested that purchasers can play an important role in implementing research findings (Haines & Jones 1994). Indeed, the separation of purchasers and providers has been viewed as an opportunity to use knowledge about effectiveness to improve health services (Dunning et al. 1994). We report a study the aim of which was to explore the impact that a specific brief external intervention might have on a detailed aspect of clinical practice: the use of corticosteroids in preterm labour. The intervention was initiated by public health physicians on behalf of a Health Authority. It formed a part of the Getting Research Into Practice (GRIP) initiative in the old Oxford Health Region, UK.  The administration of corticosteroids to mothers expected to deliver prematurely reduces neonatal mortality and morbidity (Crowley et al. 1990). The first trial which suggested that corticosteroids were effective in this role was published in 1972, and evidence from 12 trials was assembled in a systematic review published in January 1990 (Crowley et al. 1990). Despite the accumulating evidence, in 1991 many women delivering prematurely in the UK and elsewhere were not receiving corticosteroids (Anon 1992;Donaldson 1992). The apparent failure of obstetricians to make full use of this treatment has been cited as an example of the delayed implementation of research findings that can occur in clinical practice (Haines & Jones 1994; Enkin 1996).     

Reproducibility and validity of a food frequency questionnaire in European and polynesian New Zealanders

The reproducibility and validity of a self‐administered 142‐item food‐frequency questionnaire (FFQ) was assessed in a population comprising 124 European and 52 Polynesian (17 Maori and 35 Pacific Island) New Zealanders aged 40–65 years. Reproducibility correlation coefficients, determined by administration of the same questionnaire on two occasions 3 years apart, were higher in European than Maori and Pacific Island. participants, ranging from 0.47 to 0.87 in Europeans (median 0.66) and from 0.41 to 0.79 in Maori and Pacific Island people (median 0.44). In general, there were no significant differences in mean nutrient intakes calculated from the two FFQs by Europeans or Maori and Pacific Island participants despite their cultural and language differences. When the FFQ was compared with a 3‐day food diary in a sub sample of 101 Europeans, 15 Maori and 22 Pacific Islanders, the validity was good for most nutrients, with overestimation of a few nutrients in each ethnic group. Correlation coefficients between the 3‐day food diary and FFQ ranged from 0.41 to 0.81 in Europeans (median 0.48) and from 0.36 to 0.56 in Maori and Pacific Island people (median 0.55). Ratios of energy intake to resting metabolic rate suggested that Maori and Pacific Island people were more likely to underestimate their habitual energy intake by the 3‐day diet diary method compared to Europeans, but that Europeans were more likely to underestimate total energy intake by the food frequency method and Pacific Island participants to overestimate it. Obese Europeans and Maori were more likely to under‐report dietary intakes by the 3‐day diary method. We conclude that our FFQ performed better in European than Maori and Pacific Island participants.     

Behavioral change in preventive medicine

We designed and evaluated a program to teach internal medicine residents behavioral counseling skills for multiple risk factor modification. Integrating physician-patient communication, negotiation skills, and the transtheoretical model of behavior change, we used small group discussion and standardized patients. The 18 participating residents increased their ability to modify patient behavior during videotaped interviews, mean pretest/posttest score: 33.1/40.1 (Student’s pairedt test, p<.0001). Physician self-efficacy in screening for risk factors and effecting behavioral change in patients was increased (p<.0001), as were positive attitudes toward psychosocial factors (p<.003). Our teaching effectively increased the residents’ self-efficacy and performance of behavioral counseling.     

Measurement challenges in shared decision making: putting the ‘patient’ in patient‐reported measures

Measuring clinicians' shared decision‐making (SDM) performance is a key requirement given the intensity of policy interest in many developed countries – yet it remains one of the most difficult methodological challenges, which is a concern for many stakeholders. In this Viewpoint Article, we investigate the development of existing patient‐reported measures (PRMs) of SDM identified in a recent review. We find that patients were involved in the development of only four of the 13 measures. This lack of patient involvement in PRM development is associated with two major threats to content validity, common to all 13 PRMs of SDM: (i) an assumption of patient awareness of ‘decision points’ and (ii) an assumption that there is only one decision point in each healthcare consultation. We provide detailed examples of these threats and their impact on accurate assessment of SDM processes and outcomes, which may hamper efforts to introduce incentives for SDM implementation. We propose cognitive interviewing as a recommended method of involving patients in the design of PRMs in the field of SDM and provide a practical example of this approach.