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1.  Evaluation of Alcohol Screening and Brief Intervention in Routine Practice of Primary Care Nurses in Vhembe District, South Africa 
Croatian medical journal  2008;49(3):392-401.
Aim
To assess the implementation of the Alcohol Screening and Brief Intervention (SBI) strategy as part of a routine practice of nurses in 18 primary health care services in Vhembe district, South Africa.
Method
We performed a cross-sectional study to assess the success of implementation of the SBI in 18 primary health care services. We examined all anonymously completed questionnaires (n = 2670) collected from all practices after a 6-month implementation period. Clinic managers were interviewed on SBI implementation after 4 months of implementation. The success of implementation was assessed on the basis of perceived benefits, beliefs, values, past history, current needs, competing priorities, complexity of innovation, trialability and observability, and feedback on SBI performance.
Results
In the 6-month period, nurses screened 2670 patients and found that 648 (23.4%) patients (39.1% men and 13.8% women) were hazardous or harmful drinkers. Nine clinics had good and 9 poor SBI implementation. Factors discriminating the clinics with good or poor SBI implementation included the percentage of nurses trained in SBI, support visits, clinical workload, competing priorities, team work, innovation adoption curve, perceived complexity of innovation, compatibility beliefs, trialability, and observability of SBI.
Conclusion
To improve SBI implementation as a routine practice, more attention should be paid to training modalities, clinic organization, and changes in the attitudes of nurses.
doi:10.3325/cmj.2008.3.392
PMCID: PMC2443624  PMID: 18581618
2.  Medicine in the 21st Century: Recommended Essential Geriatrics Competencies for Internal Medicine and Family Medicine Residents 
Background
Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation.
Methods
Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project.
Results
The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies.
Conclusions
Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.
doi:10.4300/JGME-D-10-00065.1
PMCID: PMC2951777  PMID: 21976086
3.  Core competencies in the science and practice of knowledge translation: description of a Canadian strategic training initiative 
Background
Globally, healthcare systems are attempting to optimize quality of care. This challenge has resulted in the development of implementation science or knowledge translation (KT) and the resulting need to build capacity in both the science and practice of KT.
Findings
We are attempting to meet these challenges through the creation of a national training initiative in KT. We have identified core competencies in this field and have developed a series of educational courses and materials for three training streams. We report the outline for this approach and the progress to date.
Conclusions
We have prepared a strategy to develop, implement, and evaluate a national training initiative to build capacity in the science and practice of KT. Ultimately through this initiative, we hope to meet the capacity demand for KT researchers and practitioners in Canada that will lead to improved care and a strengthened healthcare system.
doi:10.1186/1748-5908-6-127
PMCID: PMC3292943  PMID: 22152223
4.  Brief intervention strategies for harmful drinkers: new directions for medical education. 
Recent advances in the technology of behavioural interventions for harmful drinkers have created a new role for clinical practice and new challenges for medical education. Several reports from expert committees have recommended new initiatives in the secondary prevention of alcohol problems through physician-based interventions at the primary care level. The conceptual and scientific bases for these recommendations are discussed in terms of recent studies of harmful and hazardous drinkers. The behavioural principles thought to account for the effectiveness of brief interventions are explained. Despite these promising developments, difficulties are inherent in the introduction of new technologies, especially behavioural technologies, into medical practice. A major challenge to medical education will be the development of academic programs that not only teach skills and competencies in secondary prevention but also deal with the socialization of physicians as behavioural practitioners.
PMCID: PMC1452497  PMID: 2224675
5.  Perceptions and use of the national kidney foundation KDOQI guidelines: a survey of U.S. renal healthcare providers 
BMC Nephrology  2013;14:230.
Background
The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) developed guidelines to care for patients with chronic kidney disease (CKD). While these are disseminated through the NKF’s website and publications, the guidelines’ usage remains suboptimal. The KDOQI Educational Committee was formed to identify barriers to guideline implementation, determine provider and patient educational needs and develop tools to improve care of patients with CKD.
Methods
An online survey was conducted from May to September 2010 to evaluate renal providers’ familiarity, current use of and attitudes toward the guidelines and tools to implement the guidelines.
Results
Most responders reported using the guidelines often and felt that they could be easily implemented into clinical practice; however, approximately one-half identified at least one barrier. Physicians and physician extenders most commonly cited the lack of evidence supporting KDOQI guidelines while allied health professionals most commonly listed patient non-adherence, unrealistic guideline goals and provider time-constraints. Providers thought that the guidelines included too much detail and identified the lack of a quick resource as a barrier to clinical implementation. Most were unaware of the Clinical Action Plans.
Conclusions
Perceived barriers differed between renal clinicians and allied health professionals; educational and implementation tools tailored for different providers are needed.
doi:10.1186/1471-2369-14-230
PMCID: PMC4016578  PMID: 24152744
KDOQI; Chronic kidney disease; Guidelines; Survey
6.  Implementing Quality Improvement in Small, Autonomous Primary Care Practices: Implications for the Patient Centered Medical Home 
Quality in Primary Care  2011;19(5):289-300.
Background
Implementing improvement programs to enhance quality of care within primary care clinics is complex, with limited practical guidance available to help practices during the process. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient-centered medical homes (PCMH). This study examined practice members’ perceptions of the opportunities and challenges associated with implementing changes in their practice.
Methods
Semi-structured interviews were conducted with a purposive sample of 56 individuals working in 16 small, community-based primary care practices. The interview consisted of open-ended questions focused on participants’ perceptions of: (1) practice vision, (2) perceived need for practice improvement, and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analyzed.
Results
Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients’ involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking/follow-up system, standardization of processes of care, and overall clinic documentations. Changes related to the patients’ involvement in their care included improving (a) health education, and (b) self care management. Among the internal barriers were: staff readiness for change, poor communication, and relationship difficulties among team members. External barriers were: insurance regulations, finances and patient health literacy.
Practice Implications
Transforming their practices to more patient-centered models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programs. Successful strategy for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members’ perceived needs and planned improvement efforts.
PMCID: PMC3313551  PMID: 22186171
primary care practice; quality improvement; qualitative analysis
7.  Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial 
Background
The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.
Methods/design
In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.
Discussion
Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.
Trial registration
ClinicalTrials.gov. Trial identifier: NCT01501552
doi:10.1186/1748-5908-8-11
PMCID: PMC3564747  PMID: 23347874
Alcohol; Screening; Brief interventions; Primary healthcare; Training and support; Financial reimbursement; Internet; Implementation
8.  Priority setting in primary health care - dilemmas and opportunities: a focus group study 
BMC Family Practice  2010;11:71.
Background
Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria.
Methods
Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work.
Results
The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual).
Conclusions
The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.
doi:10.1186/1471-2296-11-71
PMCID: PMC2955602  PMID: 20863364
9.  Introduction of Asthma APGAR tools improve asthma management in primary care practices 
Objective:
Primary care asthma management is often not compatible with national evidence-based guidelines. The objective of this study was to assess the feasibility and impact of the Asthma APGAR tools to enhance implementation of asthma guideline-compatible management in primary care practices.
Subjects:
Twenty-four primary care practices across the US.
Methods:
This is a mixed methods study. Quantitative data were used to assess changes in guideline recommended asthma management including use of daily controller therapy, planned care visits, and education and information documentation before and after implementation of the Asthma APGAR. Qualitative data from focus group sessions were used to assess health care professional and patient perceived usability and value of the Asthma APGAR tools during office visits for asthma.
Results:
Implementing the Asthma APGAR tools in the 24 practices was associated with enhanced asthma visit-related medical record documentation including significant increases in recording of activity limitations due to asthma and asthma symptom frequency, asthma medication nonadherence, asthma triggers, and the patients’ perceived response to therapy (p < 0.01 for each item). Some care processes also increased significantly including assessment of inhaler technique and prescribing of daily controller therapy among patients with persistent asthma. Focus groups of patients and of clinical staff reported that the Asthma APGAR tools were easy to use, “made sense” and “improved care” was given and received.
Conclusions:
The Asthma APGAR tools are feasible to implement in primary care practices and their implementation is associated with increased guideline-compliant asthma management.
PMCID: PMC3121335  PMID: 21436980
asthma; guidelines; implementation; quality improvement; asthma control; mixed methods studies; qualitative research; primary care
10.  Experiences of general practitioners and practice nurses of training courses in evidence-based health care: a qualitative study. 
BACKGROUND: Clinical governance will require general practitioners (GPs) and practice nurses (PNs) to become competent in finding, appraising, and implementing research evidence--the skills of evidence-based health care (EBHC). AIM: To report the experiences of GPs and PNs in training in this area. METHOD: We held 30 in-depth, semi-structured interviews throughout North Thames region with three groups of informants: primary care practitioners recruited from the mailing lists of established EBHC courses; organizers and teachers on these courses; and educational advisers from Royal Colleges, universities, and postgraduate departments. Detailed qualitative analysis was undertaken to identify themes from each of these interview groups. RESULTS: At the time of the fieldwork for this study (late 1997), remarkably few GPs or PNs had attended any formal EBHC courses in our region. Perceived barriers to attendance on courses included inconsistency in marketing terminology, cultural issues (e.g. EBHC being perceived as one aspect of rapid and unwanted change in the workplace), lack of confidence in the subject matter (especially mathematics and statistics), lack of time, and practical and financial constraints. Our interviews suggested, however, that the principles and philosophy of EBHC are beginning to permeate traditional lecture-based continuing medical education courses, and consultant colleagues increasingly seek to make their advice 'evidence based'. CONCLUSION: We offer some preliminary recommendations for the organizers of EBHC courses for primary care. These include offering a range of flexible training, being explicit about course content, recognizing differences in professional culture between primary and secondary care and between doctors and nurses, and addressing issues of funding and accreditation at national level. Introducing EBHC through traditional topic-based postgraduate teaching programmes may be more acceptable and more effective than providing dedicated courses in its theoretical principles.
PMCID: PMC1313472  PMID: 10621987
11.  The perceived meaning of a (w)holistic view among general practitioners and district nurses in Swedish primary care: a qualitative study 
Background
The definition of primary care varies between countries. Swedish primary care has developed from a philosophic viewpoint based on quality, accessibility, continuity, co-operation and a holistic view. The meaning of holism in international literature differs between medicine and nursing. The question is, if the difference is due to different educational traditions. Due to the uncertainties in defining holism and a holistic view we wished to study, in depth, how holism is perceived by doctors and nurses in their clinical work. Thus, the aim was to explore the perceived meaning of a holistic view among general practitioners (GPs) and district nurses (DNs).
Methods
Seven focus group interviews with a purposive sample of 22 GPs and 20 nurses working in primary care in two Swedish county councils were conducted. The interviews were transcribed verbatim and analysed using qualitative content analysis.
Results
The analysis resulted in three categories, attitude, knowledge, and circumstances, with two, two and four subcategories respectively. A professional attitude involves recognising the whole person; not only fragments of a person with a disease. Factual knowledge is acquired through special training and long professional experience. Tacit knowledge is about feelings and social competence. Circumstances can either be barriers or facilitators. A holistic view is a strong motivator and as such it is a facilitator. The way primary care is organised can be either a barrier or a facilitator and could influence the use of a holistic approach. Defined geographical districts and care teams facilitate a holistic view with house calls being essential, particularly for nurses. In preventive work and palliative care, a holistic view was stated to be specifically important. Consultations and communication with the patient were seen as important tools.
Conclusion
'Holistic view' is multidimensional, well implemented and very much alive among both GPs and DNs. The word holistic should really be spelt 'wholistic' to avoid confusion with complementary and alternative medicine. It was obvious that our participants were able to verbalise the meaning of a 'wholistic' view through narratives about their clinical, every day work. The possibility to implement a 'wholistic' perspective in their work with patients offers a strong motivation for GPs and DNs.
doi:10.1186/1471-2296-8-8
PMCID: PMC1828160  PMID: 17346340
12.  Transforming Primary Care Training—Patient-Centered Medical Home Entrustable Professional Activities for Internal Medicine Residents 
ABSTRACT
INTRODUCTION
The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.
AIM
We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?
PROGRAM DESCRIPTION
The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).
RESULTS
The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.
DISCUSSION
The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.
doi:10.1007/s11606-012-2193-3
PMCID: PMC3663955  PMID: 22997002
patient-centered medical home; entrustable professional activities; graduate medical education; internal medicine; primary care
13.  Responding to GPs' information resource needs: implementation and evaluation of a complementary medicines information resource in Queensland general practice 
Background
Australian General Practitioners (GPs) are in the forefront of primary health care and in an excellent position to communicate with their patients and educate them about Complementary Medicines (CMs) use. However previous studies have demonstrated that GPs lack the knowledge required about CMs to effectively communicate with patients about their CMs use and they perceive a need for information resources on CMs to use in their clinical practice. This study aimed to develop, implement, and evaluate a CMs information resource in Queensland (Qld) general practice.
Methods
The results of the needs assessment survey of Qld general practitioners (GPs) informed the development of a CMs information resource which was then put through an implementation and evaluation cycle in Qld general practice. The CMs information resource was a set of evidence-based herbal medicine fact sheets. This resource was utilised by 100 Qld GPs in their clinical practice for four weeks and was then evaluated. The evaluation assessed GPs' (1) utilisation of the resource (2) perceived quality, usefulness and satisfaction with the resource and (3) perceived impact of the resource on their knowledge, attitudes, and practice of CMs.
Results
Ninety two out of the 100 GPs completed the four week evaluation of the fact sheets and returned the post-intervention survey. The herbal medicine fact sheets produced by this study were well accepted and utilised by Qld GPs. The majority of GPs perceived that the fact sheets were a useful resource for their clinical practice. The fact sheets improved GPs' attitudes towards CMs, increased their knowledge of those herbal medicines and improved their communication with their patients about those specific herbs. Eighty-six percent of GPs agreed that if they had adequate resources on CMs, like the herbal medicine fact sheets, then they would communicate more to their patients about their use of CMs.
Conclusion
Further educational interventions on CMs need to be provided to GPs to increase their knowledge of CMs and to improve their communication with patients about their CMs use.
doi:10.1186/1472-6882-11-77
PMCID: PMC3190343  PMID: 21933434
14.  Clinician Attitudes, Social Norms and Intentions to use a Computer-Assisted Intervention 
The National Drug Abuse Treatment Clinical Trials Network (CTN) works to bridge the gap between research and practice and tested a web-delivered psychosocial intervention (the Therapeutic Education System, TES) in ten community treatment centers. Computer-assisted therapies, such as web-delivered interventions, may improve the consistency and efficiency of treatment for alcohol and drug use disorders. Prior to the start of the study, we surveyed counselors (n = 96) in participating treatment centers and assessed counselor attitudes, perceived social norms and intentions to use a web-delivered intervention. Analysis of the intention to adopt a web-delivered intervention assessed the influence of attitudes and perceived social norms. Perceived social norms were a significant contributor to clinician intention to adopt web-based interventions while attitude was not. To promote successful implementation, it may be helpful to create social norms supportive of computer-assisted therapies.
doi:10.1016/j.jsat.2012.08.220
PMCID: PMC3541461  PMID: 23021495
15.  Program Evaluation of a Child and Youth Mental Health Training Program for Family Physicians in British Columbia 
Introduction:
This brief report presents findings from the program evaluation of a portion of an educational program developed to support family physicians in improving their mental health care competencies in children and youth in British Columbia.
Method:
The Child and Youth Mental Health (CYMH) learning module is part of a broader initiative from the Practice Support Program (PSP) of the British Columbia Medical Association and was created specifically to assist family physicians in improving their competencies in the identification, diagnosis and delivery of best evidence-based treatments for children and youth exhibiting the most common mental disorders that can be effectively treated in most primary care practices.
Results:
The initial results from the program evaluation demonstrate a substantial improvement in family physicians’ knowledge of child and youth mental disorders and their self-rated clinical confidence in identifying and treating (both pharmacologically and psychotherapeutically) the most common child and youth mental disorders. Furthermore, because the training protocol involves a team-based approach which includes specialist physicians as well as school counsellors and human services providers, collaboration between primary practice and other providers is enhanced.
Conclusion:
The initial results encourage broader roll-out and further evaluation of this program on a wider scale.
PMCID: PMC3825470  PMID: 24223049
child and adolescent mental health; primary health care; child and adolescent mental disorders; santé mentale de l’enfant et de l’adolescent; soins de santé de première ligne; troubles mentaux de l’enfant et de l’adolescent
16.  A Multi-Institutional Quality Improvement Initiative to Transform Education for Chronic Illness Care in Resident Continuity Practices 
Journal of General Internal Medicine  2010;25(Suppl 4):574-580.
BACKGROUND
There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care.
OBJECTIVE
To improve training for residents who provide chronic illness care in teaching practice settings.
DESIGN
US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives—either a national Collaborative, or a subsequent California Collaborative—to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures—HbA1c <7%, LDL <100 mg/dL, and blood pressure ≤130/80—and three process measures—retinal and foot examinations, and patient self-management goals—were tracked.
PARTICIPANTS
Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives.
INTERVENTIONS
Teaching-practice teams—faculty, residents and staff—participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly.
RESULTS
Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives.
CONCLUSIONS
These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.
doi:10.1007/s11606-010-1392-z
PMCID: PMC2940442  PMID: 20737232
residency training; chronic illness; teaching hospitals; Chronic Care Model
17.  Physician and Patient Predictors of Evidence-Based Prescribing in Heart Failure: A Multilevel Study 
PLoS ONE  2012;7(2):e31082.
Background
The management of patients with heart failure (HF) needs to account for changeable and complex individual clinical characteristics. The use of renin angiotensin system inhibitors (RAAS-I) to target doses is recommended by guidelines. But physicians seemingly do not sufficiently follow this recommendation, while little is known about the physician and patient predictors of adherence.
Methods
To examine the coherence of primary care (PC) physicians' knowledge and self-perceived competencies regarding RAAS-I with their respective prescribing behavior being related to patient-associated barriers. Cross-sectional follow-up study after a randomized medical educational intervention trial with a seven month observation period. PC physicians (n = 37) and patients with systolic HF (n = 168) from practices in Baden-Wuerttemberg. Measurements were knowledge (blueprint-based multiple choice test), self-perceived competencies (questionnaire on global confidence in the therapy and on frequency of use of RAAS-I), and patient variables (age, gender, NYHA functional status, blood pressure, potassium level, renal function). Prescribing was collected from the trials' documentation. The target variable consisted of ≥50% of recommended RAAS-I dosage being investigated by two-level logistic regression models.
Results
Patients (69% male, mean age 68.8 years) showed symptomatic and objectified left ventricular (NYHA II vs. III/IV: 51% vs. 49% and mean LVEF 33.3%) and renal (GFR<50%: 22%) impairment. Mean percentage of RAAS-I target dose was 47%, 59% of patients receiving ≥50%. Determinants of improved prescribing of RAAS-I were patient age (OR 0.95, CI 0.92–0.99, p = 0.01), physician's global self-confidence at follow-up (OR 1.09, CI 1.02–1.05, p = 0.01) and NYHA class (II vs. III/IV) (OR 0.63, CI 0.38–1.05, p = 0.08).
Conclusions
A change in physician's confidence as a predictor of RAAS-I dose increase is a new finding that might reflect an intervention effect of improved physicians' intention and that might foster novel strategies to improve safe evidence-based prescribing. These should include targeting knowledge, attitudes and skills.
doi:10.1371/journal.pone.0031082
PMCID: PMC3283612  PMID: 22363553
18.  Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination. 
BACKGROUND: Quality improvement initiatives in health services rely upon the effective introduction of clinical practice guidelines. However, even well constructed guidelines have little effect unless supported by dissemination and implementation strategies. AIM: To test the effectiveness of 'educational outreach' as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care. DESIGN OF STUDY: A pragmatic, cluster-randomised controlled trial of guideline introduction, comparing educational outreach with postal guideline dissemination alone. SETTING: One-hundred and fourteen general practices (233 general practitioners) in the Salford and Trafford Health authority catchment area in the northwest of England. METHOD: All practices received guidelines by post in July 1997. The intervention group practices began to receive educational outreach three months later. This consisted of practice-based seminars with hospital specialists at which guideline recommendations were appraised, and implementation plans formulated. Seminars were followed up with 'reinforcement' visits after a further 12 weeks. Outcome measures were: (a) the appropriateness of referral for; and (b) findings at, open access upper gastrointestinal endoscopy; (c) costs of GP prescriptions for acid-suppressing drugs, and (d) the use of laboratory-based serological tests for Helicobacter pylori. Data were collected for seven months before and/or after the intervention and analysed by intention-to-treat. RESULTS: (a) The proportion of appropriate referrals was higher in the intervention group in the six-month post-intervention period (practice medians: control = 50.0%, intervention = 63.9%, P < 0.05); (b) the proportion of major findings at endoscopy did not alter significantly; (c) there was a greater rise in overall expenditure on acid-suppressing drugs in the intervention as compared with the control group (+8% versus +2%, P = 0.005); and (d) the median testing rate per practice for H pylori in the post-intervention period was significantly greater in the intervention group (four versus O, P < 0.001). CONCLUSION: This study suggests that educational outreach may be more effective than passive guideline dissemination in changing clinical behaviour. It also demonstrates that unpredictable and unanticipated outcomes may emerge.
PMCID: PMC1314507  PMID: 12817353
19.  Educational interventions to improve the effectiveness in clinical competence of general practitioners: problem-based versus critical reading-based learning 
BMC Medical Education  2012;12:53.
Background
Evidence suggests that continuing medical education improves the clinical competence of general practitioners and the quality of health care services. Thus, we evaluated the relative impact of two educational strategies, critical reading (CR) and problem based learning (PBL), on the clinical competence of general practitioners in a healthcare system characterized by excessive workload and fragmentation into small primary healthcare centers.
Methods
Clinical competence was evaluated in general practitioners assigned to three groups based on the educational interventions used: 1) critical reading intervention; 2) problem based learning intervention; and 3) no intervention (control group, which continued clinical practice as normal). The effect on the clinical competence of general practitioners was evaluated in three dimensions: the cognitive dimension, via a self-administered questionnaire; the habitual behavioral dimension, via information from patient’s medical records; and the affective dimension, through interviews with patients. A paired Student´s t-test was used to evaluate the changes in the mean clinical competence scores before and after the intervention, and a 3 x 2 ANOVA was used to analyze groups, times and their interaction.
Results
Nine general practitioners participated in the critical reading workshop, nine in the problem-based learning workshop, and ten were assigned to the control group. The participants exhibited no significant differences in clinical competence measures at baseline, or in socio-demographic or job characteristics (p > 0.05). Significant improvements in all three dimensions (cognitive, 45.67 vs 54.89; habitual behavioral, 53.78 vs 82.33; affective, 4.16 vs 4.76) were only observed in the problem-based learning group after the intervention (p > 0.017).
Conclusions
While no differences in post-intervention scores were observed between groups, we conclude that problem-based learning can be effective, particularly in a small-group context. Indeed, problem-based learning was the only strategy to induce a significant difference between pre– and post- intervention scores for all three CC dimensions.
doi:10.1186/1472-6920-12-53
PMCID: PMC3814588  PMID: 22784406
20.  Developing Measures of Educational Change for Academic Health Care Teams Implementing the Chronic Care Model in Teaching Practices 
Journal of General Internal Medicine  2010;25(Suppl 4):586-592.
BACKGROUND
The Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents’ competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations.
SUBJECTS
Twenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives.
METHOD
Using successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs’ abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs.
ANALYSIS
Field notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance.
RESULTS
Work groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change.
CONCLUSION
Using an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1358-1) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1358-1
PMCID: PMC2940445  PMID: 20737234
Chronic Care Model; quality improvement; graduate medical education; ambulatory care; practice-based learning and improvement; systems-based practice
21.  Establishing a Southern Swedish Malignant Melanoma OMICS and biobank clinical capability 
Background
The objectives and goals of the Southern Swedish Malignant Melanoma (SSMM) are to develop, build and utilize cutting edge biobanks and OMICS platforms to better understand disease pathology and drug mechanisms. The SSMM research team is a truly cross-functional group with members from oncology, surgery, bioinformatics, proteomics, and genomics initiatives. Within the research team there are members who daily diagnose patients with suspect melanomas, do follow-ups on malignant melanoma patients and remove primary or metastatic lesions by surgery. This inter-disciplinary clinical patient care ensures a competence build as well as a best practice procedure where the patient benefits.
Methods
Clinical materials from patients before, during and after treatments with clinical end points are being collected. Tissue samples as well as bio-fluid samples such as blood fractions, plasma, serum and whole blood will be archived in 384-high density sample tube formats. Standardized approaches for patient selections, patient sampling, sample-processing and analysis platforms with dedicated protein assays and genomics platforms that will hold value for the research community are used. The patient biobank archives are fully automated with novel ultralow temperature biobank storage units and used as clinical resources.
Results
An IT-infrastructure using a laboratory information management system (LIMS) has been established, that is the key interface for the research teams in order to share and explore data generated within the project. The cross-site data repository in Lund forms the basis for sample processing, together with biological samples in southern Sweden, including blood fractions and tumor tissues. Clinical registries are associated with the biobank materials, including pathology reports on disease diagnosis on the malignant melanoma (MM) patients.
Conclusions
We provide data on the developments of protein profiling and targeted protein assays on isolated melanoma tumors, as well as reference blood standards that is used by the team members in the respective laboratories. These pilot data show biobank access and feasibility of performing quantitative proteomics in MM biobank repositories collected in southern Sweden. The scientific outcomes further strengthen the build of healthcare benefit in the complex challenges of malignant melanoma pathophysiology that is addressed by the novel personalized medicines entering the market.
doi:10.1186/2001-1326-2-7
PMCID: PMC3599425  PMID: 23445834
Malignant melanoma; Protein sequencing; Proteomics; Genes; Antibodies; mRNA; Mass spectrometry; Bioinformatics
22.  Managerial Capacity and Adoption of Culturally Competent Practices in Outpatient Substance Abuse Treatment Organizations 
The field of cultural competence is shifting its primary emphasis from enhancement of counselors' skills to management, organizational policy and processes of care. This study examined managers' characteristics associated with adoption of culturally competent practices in the nation's outpatient substance abuse treatment field. Findings indicate that in 1995 supervisors' cultural sensitivity played the most significant role in adopting practices, such as matching counselors and clients based on race and offering bilingual services. Staff's exposure to cross-cultural training increased from 1995 to 2005. In this time period, positive associations were found between managers' cultural sensitivity and connection with the community and staff receiving cross-cultural training and the number of training hours completed. However, exposure to and investment in this training were negatively correlated with managers' formal education. Health administration policy should consider the extent to which decision makers' education, community involvement and cultural sensitivity contributes to building culturally responsive systems of care.
doi:10.1016/j.jsat.2010.07.004
PMCID: PMC2967643  PMID: 20727703
23.  Comparison of Osteopathic and Allopathic Medical Schools' Support for Primary Care 
OBJECTIVE
To contrast prevailing behaviors and attitudes relative to primary care education and practice in osteopathic and allopathic medical schools.
DESIGN
Descriptive study using confidential telephone interviews conducted in 1993–94. Analyses compared responses of osteopaths and allopaths, controlling for primary care orientation.
SETTING
United States academic health centers.
PARTICIPANTS
National stratified probability samples of first-year and fourth-year medical students, postgraduate year 2 residents, and clinical faculty in osteopathic and allopathic medical schools, a sample of allopathic deans, and a census of deans of osteopathic schools (n =457 osteopaths; n =2,045 allopaths).
MEASUREMENTS
Survey items assessed personal characteristics, students' reasons for entering medicine, learners' primary care educational experiences, community support for primary care, and attitudes toward the clinical and academic competence of primary care physicians.
MAIN RESULTS
Primary care physicians composed a larger fraction of the faculty in osteopathic schools than in allopathic schools. Members of the osteopathic community were significantly more likely than their allopathic peers to describe themselves as socioemotionally oriented rather than technoscientifically oriented. Osteopathic learners were more likely than allopathic learners to have educational experiences in primary care venues and with primary care faculty, and to receive encouragement from faculty, including specialists, to enter primary care. Attitudes toward the clinical and academic competence of primary care physicians were consistently negative in both communities. Differences between communities were sustained after controlling for primary care orientation.
CONCLUSIONS
In comparison with allopathic schools, the cultural practices and educational structures in osteopathic medical schools better support the production of primary care physicians. However, there is a lack of alignment between attitudes and practices in the osteopathic community.
doi:10.1046/j.1525-1497.1999.03179.x
PMCID: PMC1496864  PMID: 10632817
osteopaths; allopaths; medical school; primary care
24.  A student-initiated and student-facilitated international health elective for preclinical medical students 
Medical Education Online  2010;15:10.3402/meo.v15i0.4896.
Introduction
Global health education is becoming more important for developing well-rounded physicians and may encourage students toward a career in primary care. Many medical schools, however, lack adequate and structured opportunities for students beginning the curriculum.
Methods
Second-year medical students initiated, designed, and facilitated a pass–fail international health elective, providing a curricular framework for preclinical medical students wishing to gain exposure to the clinical and cultural practices of a developing country.
Results
All course participants (N=30) completed a post-travel questionnaire within one week of sharing their experiences. Screening reflection essays for common themes that fulfill university core competencies yielded specific global health learning outcomes, including analysis of health care determinants.
Conclusion
Medical students successfully implemented a sustainable global health curriculum for preclinical student peers. Financial constraints, language, and organizational burdens limit student participation. In future, long-term studies should analyze career impact and benefits to the host country.
doi:10.3402/meo.v15i0.4896
PMCID: PMC2827262  PMID: 20186283
international health; preclinical students; medical education; student-initiated
25.  How students perceive medical competences: a cross-cultural study between the Medical Course in Portugal and African Portuguese Speaking Countries 
BMC Medical Education  2011;11:24.
Background
A global effort has been made in the last years to establish a set of core competences that define the essential professional competence of a physician. Regardless of the environment, culture or medical education conditions, a set of core competences is required for medical practice worldwide. Evaluation of educational program is always needed to assure the best training for medical students and ultimately best care for patients. The aim of this study was to determine in what extent medical students in Portugal and Portuguese speaking African countries, felt they have acquired the core competences to start their clinical practice. For this reason, it was created a measurement tool to evaluate self-perceived competences, in different domains, across Portuguese and Portuguese-speaking African medical schools.
Methods
The information was collected through a questionnaire that defines the knowledge, attitudes and skills that future doctors should acquire. The Cronbach's Alpha and Principal Components Analysis (PCA) were used to evaluate the reliability of the questionnaire. In order to remove possible confounding effect, individual scores were standardized by country.
Results
The order of the domain's scores was similar between countries. After standardization, Personal Attitudes and Professional Behavior showed median scores above the country global median and Knowledge alone showed median score below the country global median. In Portugal, Clinical Skills showed score below the global median. In Angola, Clinical Skills and General Skills showed a similar result. There were only significant differences between countries in Personal Attitudes (p < 0.001) and Professional Behavior (p = 0.043).
Conclusions
The reliability of the instrument in Portuguese and Portuguese-speaking African medical schools was confirmed. Students have perceived their level of competence in personal attitudes in a high level and in opposite, knowledge and clinical skills with some weaknesses.
doi:10.1186/1472-6920-11-24
PMCID: PMC3123652  PMID: 21612609

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