Lifestyle intervention for prevention of diabetes: determinants of success for future implementation

Lifestyle interventions are reported to reduce the risk of type 2 diabetes in high-risk individuals after mid- and long-term follow-up. Information on determinants of intervention outcome and adherence and the mechanisms underlying diabetes progression are valuable for a more targeted implementation. Weight loss seems a major determinant of diabetes risk reduction, whereas physical activity and dietary composition may contribute independently. Body composition and genetic variation may also affect the response to intervention. Lifestyle interventions are cost-effective and should be optimized to increase adherence and compliance, especially for individuals in the high-risk group with a low socioeconomic status, so that public health policy can introduce targeted implementation programs nationwide. The aims of this review are to summarize the mid- and long-term effects of lifestyle interventions on impaired glucose tolerance and type 2 diabetes mellitus and to provide determinants of intervention outcome and adherence, which can be used for future implementation of lifestyle interventions.     

Implementation of Osteoporosis Screening Guidelines in Prostate Cancer Patients on Androgen Ablation

Androgen ablation (AA) therapy is one of the modalities used to treat prostate cancer. It is well known that AA therapy increases the risk of osteoporosis and fractures. In 2004, the British Columbia Cancer Agency published guidelines regarding bone health in these patients. A key recommendation was to arrange for bone mineral density (BMD) testing if AA was to be used for 6 mo or longer. Our objective was to evaluate how well these guidelines were implemented by reviewing the number of BMDs performed in patients who had been treated at one of the 4 cancer centers in British Columbia. We found that the overall number of BMDs documented after the implementation of the guidelines was significantly greater than the number documented before (25% vs 7.5%, p value < 0.0001). There appeared to be regional differences in implementation, with the greatest effect seen at the Vancouver center, which serves as the chief academic center for the province. The greater effect of guidelines at this center suggests a need for more effective dissemination peripherally. The care gap remaining at even the most impacted center indicates a need for greater efforts to both implement guidelines and monitor their implementation over time.     

Implementing Evidence-Based Practices for People With Schizophrenia

Over the last decade, a consensus has emerged regarding a set of evidence-based practices for schizophrenia that address symptom management and psychosocial functioning. Yet, surveys suggest that the great majority of the population of individuals with schizophrenia do not receive evidence-based care. In this article, we review the empirical literature on implementation of evidence-based practices for schizophrenia patients. We first examine lessons learned from implementation studies in general medicine. We then summarize the implementation literature specific to schizophrenia, including medication practices, psychosocial interventions, information technology, and state- and federal-level interventions. We conclude with recommendations for future directions.     

Predicting Utilization of Evidence-Based Parenting Interventions with Organizational,Service-Provider and Client Variables

Multidisciplinary service providers (N = 611) who underwent training in the Triple P-Positive Parenting Program participated in a structured interview 6 months following training to determine their level of post-training program use and to identify any facilitators and barriers to program use. Findings revealed that practitioners who had received training in Group Triple P, received positive client feedback, had experienced only minor barriers to implementation, and had consulted with other Triple P practitioners following training were more likely to become high users of the program. Practitioners were less likely to use the program when they had lower levels of confidence in delivering Triple P and in consulting with parents in general, had difficulties in incorporating Triple P into their work, and where there was low workplace support. These findings highlight the importance of considering the broader post training work environment of service providers as a determinant of subsequent program use.     

贫困山区县实施扩大免疫规划的做法与思考

目的：为贫困山区县实施扩大国家免疫规划提供参考经验。方法：总结回顾贫困山区县绩溪县实施计划免疫的做法以及取得成功的经验。结果：绩溪县自1986年实施计划免疫以来,不断调整实施策略,取得了可喜的成果,提出今后要切实贯彻实施扩大国家免疫规划,专业技术人员需要加强技术督导．政府需将免疫规划经费纳入当地财政预算,结合工作实际适时调整工作策略。结论：山区贫困县在全面落实政策和技术措施的前提下,《扩大国家免疫规划实施方案》同样能如期贯彻实施。     

A study of adherence to drug recommendations by providing feedback of outpatient prescribing patterns to hospital specialists

PURPOSE: To study the effect of feedback using prescribing profiles combined with interactive group discussions on hospital specialists' adherence to evidence-based guidelines for drug treatment of common diseases issued by a regional Drug and Therapeutics Committee. METHODS: Intervention study performed at 17 clinics at a university hospital in a Swedish metropolitan health region with comparative clinics at a second university hospital as a control. Prescribing profiles based on aggregate pharmacy dispensing data were presented for the physicians in interactive group discussions. Deviations from the guidelines were discussed at each clinic and specific goals of improvement were formulated. The effect was assessed by pre- and post-intervention comparison of the adherence to guidelines for all drugs and within 11 selected therapeutic areas. The credibility and usefulness of the prescribing profiles were evaluated by a questionnaire. RESULTS: The adherence to pharmaceutical products within the pharmacological groups stated in the guideline increased by 2.8%-units at the intervention hospital compared with 0.8%-units at the control hospital. The adherence to drug substance increased by 0.4%-units at the intervention hospital while it decreased by 1.8%-units at the control hospital. For 8 of 11 pre-defined specific goals of improvement, the change in adherence was more positive at the intervention hospital. Most doctors considered the feedback provided clear and relevant. CONCLUSIONS: Interactive group discussions with prescribing profiles were found to be useful in improving hospital specialists' adherence to guidelines. However, the effect on the overall adherence was modest, indicating the importance of clear messages for improvement and relevant guidelines for the prescribing of specialist drugs but also more precise methods for evaluating the effect of real-life-interventions.     

Sea change or quick fix? Policy on long‐term conditions in England

Long-term conditions is a policy area that has risen rapidly up the political agenda in England, culminating in the development of the National Health Service and Social Care Model in 2005, which is to be implemented over the following 2 years. The Model draws heavily upon US ideas of case management and proposes the creation of 3000 community matrons to undertake this role with the most vulnerable patients. Although welcomed in principle, the specific proposals in the Model have been subject to some criticism, and these issues are explored in the present paper. The problematic areas include patient identification, the transplanting of US models to England, the role of case management, workforce and funding issues, and the mix of medical and social models. The author concludes that there is a danger of long-term care policy developing an unduly health-focused approach at a time when the thrust of partnership working is towards an inclusive, whole-system model.     

Guidelines for clinical practice: development, dissemination and implementation

Clinical guidelines are one of the most promising and effective advances for defining and improving the quality of care (Journal of Nursing Care Quality 11(5) (1997) 48; Medical Care 39(8 Suppl. 2) (2001) II-46). However, their development, dissemination and implementation in practice are rarely straightforward. Within nursing practice, guidelines have the potential to ensure the clinical application of research findings, thus ensuring that the profession rejects ineffective practices while employing those shown to work. Nevertheless, the benefits and limitations of clinical guidelines should be carefully considered by practitioners, managers and consumers of health care alike.     

Interdisciplinary preoperative patient education in cardiac surgery

BACKGROUND: In 1998, we carried out a study of interdisciplinary preoperative education in cardiac surgery given by nurses, physicians and health educators. Overlaps were found in gathering and providing information by physicians, nurses and health educators, and gaps were found in providing psychosocial information and emotional support. Based on these findings, an information protocol was developed. AIM: This paper reports a study examining the effects of the implementation of the information protocol on the content and process of preoperative education. METHODS: Dialogues between health educators and patients were videotaped at the preoperative clinic (n = 54) and on the day of admission (n = 53), and analysed using a checklist of 123 specific topics. RESULTS: The information given by health educators at the outpatient clinic and on the day of admission accorded with the information protocol to a large extent. There was also an increase in the number of psychosocial issues raised. Nurses raised significantly more psychosocial issues in comparison with before implementation of the protocol. After implementation, patients spent approximately 3 minutes less talking with the health educator and about 7 minutes less talking with a nurse. This suggests that on the day of admission a more time-efficient co-ordination in patient education was achieved. CONCLUSIONS: Implementation of the information protocol led to a better interdisciplinary division of labour. The education is tailored more to the needs of the patient, and psychosocial items are mentioned more frequently. This straightforward intervention gave very positive results. Inconsistencies, gaps and overlaps in information provision can be avoided by the unambiguous delineation of responsibilities and tasks in information provision by different health care providers.