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3.  Longitudinal Use of Complementary and Alternative Medicine among Older Adults with Radiographic Knee Osteoarthritis 
Clinical therapeutics  2013;35(11):10.1016/j.clinthera.2013.09.022.
Background
Osteoarthritis (OA) accounts for more mobility issues in older adults than any other disease. OA is a chronic and often painful disease for which there is no cure. Cross-sectional studies have shown that older adults frequently use complementary and alternative medicine (CAM) and arthritis is the most common reason for CAM use. While previous research has profiled the sociodemographic and clinical characteristics of CAM users, few have provided information on variation in CAM use over time and most only considered use of any CAM, which was often a mixture of heterogeneous therapies.
Objectives
This study sought to describe the longitudinal patterns of CAM use among older adults with knee OA, and to identify correlates/predictors of different commonly-used CAM therapies.
Methods
The Osteoarthritis Initiative included 1,121 adults aged 65 years and above with radiographic tibiofemoral OA in one or both knees at baseline. Annual surveys captured current use of conventional therapies and 25 CAM modalities (grouped into 6 categories) for joint pain or arthritis at baseline and during the 4-year follow-up. We assessed longitudinal use of CAM modalities by summing the number of visits with participants reporting use of each modality. Correlates of CAM use under consideration included sociodemographic indicators, body mass index, overall measures of mental and physical wellbeing, and clinical indices of knee OA. Generalized estimation equations provided adjusted odds ratio estimates and 95% confidence intervals.
Results
Nearly one third of older adults reported using ≥ one CAM modality for treating OA at all assessments. With the exception of glucosamine and chondroitin (18%), few were persistent users of other CAM modalities. One in five of those using NSAIDs or glucosamine/chondroitin were using them concurrently. Adjusted models showed: 1) adults aged ≥75 years were less likely to use dietary supplements than those aged between 65 and 75 years; 2) persons with more severe knee pain or stiffness reported more CAM use; 3) better knee-related physical function was correlated with more use of chiropractic/massage; 4) older adults with more comorbidities were less likely to report use of dietary supplements.
Conclusion
Patterns of CAM use are, to some extent, inconsistent with current guidelines for OA treatment. Evaluating the potential risks and benefits in older adults from commonly-used CAM modalities, with or without combination use of conventional analgesics, is warranted.
doi:10.1016/j.clinthera.2013.09.022
PMCID: PMC3880574  PMID: 24145044
complementary and alternative medicine; osteoarthritis; pain; older adults
4.  Endoscopy reporting standards 
OBJECTIVES:
The Canadian Association of Gastroenterology (CAG) recently published consensus recommendations for safety and quality indicators in digestive endoscopy. The present article focuses specifically on the identification of key elements that should be found in all electronic endoscopy reports detailing recommendations adopted by the CAG consensus group.
METHODS:
A committee of nine individuals steered the CAG Safety and Quality Indicators in Endoscopy Consensus Group, which had a total membership of 35 voting individuals with knowledge on the subject relating to endoscopic services. A comprehensive literature search was performed with regard to the key elements that should be found in an electronic endoscopy report. A task force reviewed all published, full-text, adult and human studies in French or English.
RESULTS:
Components to be entered into the standardized report include identification of procedure, timing, procedural personnel, patient demographics and history, indication(s) for procedure, comorbidities, type of bowel preparation, consent for the procedure, pre-endoscopic administration of medications, type and dose of sedation used, extent and completeness of examination, quality of bowel preparation, relevant findings and pertinent negatives, adverse events and resulting interventions, patient comfort, diagnoses, endoscopic interventions performed, details of pathology specimens, details of follow-up arrangements, appended pathology report(s) and, when available, management recommendations. Summary information should be provided to the patient or family.
CONCLUSION:
Continuous quality improvement should be the responsibility of every endoscopist and endoscopy facility to ensure improved patient care. Appropriate documentation of endoscopic procedures is a critical component of such activities.
PMCID: PMC3735732  PMID: 23712304
Colonoscopy/standards; Electronic reporting; Research report/standards; Review
5.  The endoscopy Global Rating Scale – Canada: Development and implementation of a quality improvement tool 
BACKGROUND:
Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality highlight the need for endoscopy facilities to review the quality of the service they offer.
OBJECTIVE:
To adapt the United Kingdom Global Rating Scale (UK-GRS) to develop a web-based and patient-centred tool to assess and improve the quality of endoscopy services provided.
METHODS:
Based on feedback from 22 sites across Canada that completed the UK endoscopy GRS, and integrating results of the Canadian consensus on safety and quality indicators in endoscopy and other Canadian consensus reports, a working group of endoscopists experienced with the GRS developed the GRS-Canada (GRS-C).
RESULTS:
The GRS-C mirrors the two dimensions (clinical quality and quality of the patient experience) and 12 patient-centred items of the UK-GRS, but was modified to apply to Canadian health care infrastructure, language and current practice. Each item is assessed by a yes/no response to eight to 12 statements that are divided into levels graded D (basic) through A (advanced). A core team consisting of a booking clerk, charge nurse and the physician responsible for the unit is recommended to complete the GRS-C twice yearly.
CONCLUSION:
The GRS-C is intended to improve endoscopic services in Canada by providing endoscopy units with a straightforward process to review the quality of the service they provide.
PMCID: PMC3731117  PMID: 23472242
Endoscopy; Global rating scale; GRS; Quality
6.  Patient-identified quality indicators for colonoscopy services 
BACKGROUND:
Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services.
OBJECTIVES:
To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS.
METHODS:
A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators.
RESULTS:
Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel.
CONCLUSIONS:
Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.
PMCID: PMC3545623  PMID: 23378980
Colorectal cancer screening; Indicators; Quality
8.  E-PRESCRIBING AND PATIENT SAFETY: RESULTS FROM A MIXED METHOD STUDY 
Objectives
To describe ambulatory care clinicians’ perspectives on the effect of e-prescribing systems on patient safety outcomes.
Study Design
We used a mixed-method study of clinicians and staff in 64 practices using one of six e-prescribing technologies in six U.S. states.
Methods
We used clinician surveys (web-based and paper) and focus groups to obtain clinicians’ perspectives on e-prescribing and patient safety.
Results
Providers highly valued having medications prescribed by other providers on the medication list and the ability to access patients’ medication lists remotely. Providers felt that there will always be prescription or medication errors and that the implementation of e-prescribing software changes rather than eliminates prescription or medication errors. New errors related to the dosing or scheduling of a medication, accidentally prescribing the wrong drug, or duplicate prescriptions.
Conclusions
Lessons from the ambulatory care trenches must be considered as technology moves forward so that the hypothesized patient safety gains will be realized.
PMCID: PMC3811029  PMID: 24179595
electronic prescribing; primary care; technology assessment
10.  Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy 
Several organizations worldwide have developed procedure-based guidelines and/or position statements regarding various aspects of quality and safety indicators, and credentialing for endoscopy. Although important, they do not specifically address patient needs or provide a framework for their adoption in the context of endoscopy services. The consensus guidelines reported in this article, however, aimed to identify processes and indicators relevant to the provision of high-quality endoscopy services that will support ongoing quality improvement across many jurisdictions, specifically in the areas of ethics, facility standards and policies, quality assurance, training and education, reporting standards and patient perceptions.
BACKGROUND:
Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy.
OBJECTIVE:
To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery.
METHODS:
A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants.
RESULTS:
Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), quality assurance (statements 10 to 13: 94% to 100%), training, education, competency and privileges (statements 14 to 19: 97% to 100%), endoscopy reporting standards (statements 20 and 21: 97% to 100%) and patient perceptions (statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified.
DISCUSSION:
The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services.
CONCLUSIONS:
The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.
PMCID: PMC3275402  PMID: 22308578
Digestive system; Endoscopy; Guideline; Health care; Quality assurance
11.  A literature review of quality in lower gastrointestinal endoscopy from the patient perspective 
Colorectal cancer (CRC) is the third most frequently diagnosed cancer, and the second leading cause of cancer death among men and women in Canada. Prompted by nationally accepted CRC guidelines, the use of colonoscopy – widely regarded to be the optimal method of CRC screening – has increased dramatically in recent years. However, when evaluating colonoscopy performance and the delivery of high-quality care, it is important to also consider factors relevant to the patients who require colonoscopy services. Understanding the patient perspective on what comprises quality in colonoscopy/endoscopy is essential to tailoring improvements in the standards of practice and quality of care. Accordingly, this study systematically reviewed the literature pertaining to aspects of colonoscopy and endoscopy that may be considered to be important to patients.
BACKGROUND:
Given the limited state of health care resources, increased demand for colorectal cancer (CRC) screening raises concerns about the quality of endoscopy services. Little is known about quality in colonoscopy and endoscopy from the patient perspective.
OBJECTIVE:
To systematically review the literature on quality that is relevant to patients who require colonoscopy or endoscopy services.
METHODS:
A systematic PubMed search was performed on articles that were published between January 2000 and February 2011. Keywords included “colonoscopy” or “sigmoidoscopy” or “endoscopy” AND “quality”; “colonoscopy” or “sigmoidoscopy” or “endoscopy” AND “patient satisfaction” or “willingness to return”. The included articles were qualitative and quantitative English language studies regarding aspects of colonoscopy and/or endoscopy services that were evaluated by patients in which data were collected within one year of the colonoscopy/endoscopy procedure.
RESULTS:
In total, 28 quantitative studies were identified, of which eight (28.6%) met the inclusion criteria (four cross-sectional, three prospective cohort and one single-blinded controlled study). Aspects of quality included comfort, management of pain and anxiety, endoscopy unit staff manner, skills and specialty, procedure and results discussion with the doctor, physical environment, wait times for the appointment and procedure, and discharge. Qualitative studies eliciting the patient perspective on what constituted quality in colonoscopy/endoscopy were not found.
CONCLUSIONS:
Factors related to comfort, staff, communication and the service environment were evaluated from the patient perspective using closed-ended questions that were designed by clinicians and researchers. Future research using qualitative methodology to elicit the patient perspective on quality in colonoscopy and/or endoscopy services is needed.
PMCID: PMC3266160  PMID: 22175059
Colonoscopy; Endoscopy; Patient perspective; Quality; Review
12.  Development and implementation of a comprehensive quality assurance program at a community endoscopy facility 
More that 9000 deaths in Canadian men and women were attributed to colorectal cancer (CRC) in 2010. Although screening for CRC has been shown to reduce mortality rates and, by extension, confer public health benefits, colonoscopy – one of the preferred diagnostic tests – can cause harm. Ensuring high-quality CRC screening involves the systematic evaluation of services, process improvement and ongoing appraisal. This article describes the steps taken by the authors in establishing a comprehensive quality assurance program in a nonhospital endoscopy unit located in Calgary, Alberta.
Quality assurance (QA) is a process that includes the systematic evaluation of a service, institution of improvements and ongoing evaluation to ensure that effective changes were made. QA is a fundamental component of any organized colorectal cancer screening program. However, it should play an equally important role in opportunistic screening. Establishing the processes and procedures for a comprehensive QA program can be a daunting proposition for an endoscopy unit. The present article describes the steps taken to establish a QA program at the Forzani & MacPhail Colon Cancer Screening Centre (Calgary, Alberta) – a colorectal cancer screening centre and nonhospital endoscopy unit that is dedicated to providing colorectal cancer screening-related colonoscopies. Lessons drawn from the authors’ experience may help others develop their own initiatives. The Global Rating Scale, a quality assessment and improvement tool developed for the gastrointestinal endoscopy services of the United Kingdom’s National Health Service, was used as the framework to develop the QA program. QA activities include monitoring the patient experience through surveys, creating endoscopist report cards on colonoscopy performance, tracking and evaluating adverse events and monitoring wait times.
PMCID: PMC3206550  PMID: 22059159
Benchmarking; Colonoscopy; Colorectal cancer; Patient satisfaction; Quality assurance; Quality indicators
14.  Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program – Endoscopy 
BACKGROUND
Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.
OBJECTIVE
To evaluate a colonoscopists’ practice audit tool that provides point-of-care data collection and peer-comparator feedback.
METHODS
A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smart-phones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.
RESULTS
Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference −11.3% [95% CI −2.8% to −19.9%]; P=0.01).
DISCUSSION
Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.
CONCLUSION
Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.
PMCID: PMC3027329  PMID: 21258663
Colonoscopy; Health care; Practice audit; Quality assurance; Quality indicators
15.  PERCEPTIONS OF EPRESCRIBING EFFICIENCES AND INEFFICIENCIES IN AMBULATORY CARE 
Introduction
Recent studies have demonstrated that e-prescribing takes longer than handwriting. Additional studies documenting the perceived efficiencies realized from e-prescribing from those who have implemented electronic prescribing are warranted.
Methods
We used a mixed method study design. We report on qualitative date from 64 focus groups with clinicians and office staff from six US states. Participants used one of six e-prescribing software packages. Qualitative data from the focus groups (276 participants) were coded and analyzed using NVivo software. Quantitative data regarding perceived efficiencies were extracted from a survey of 157 clinicians using e-prescribing.
Results
Perceptions of e-prescribing included 64% reporting e-prescribing as very efficient. The next closest method was computer generated fax and prescriptions in which ~25% rated the method as very efficient. Improvements in workflow and record keeping were noted. Perceived efficiencies were realized by decreased errors, availability of formularies at the point of prescribing and refill processing. Perceived inefficiencies noted included the need for dual systems owing to regulations preventing e-prescribing of scheduled medications as well as those introduced with incorrect information on formularies, pharmacy used, and warnings.
Discussion
Overwhelmingly, clinicians and their staff confirmed the perceived efficiencies realized with the adoption of e-prescribing. Perceived efficiencies were realized in knowing formularies, processing refills, and decreasing errors. Opportunities to improve efficiencies could be realized by assuring correct information in the system.
doi:10.1016/j.ijmedinf.2010.10.018
PMCID: PMC3073364  PMID: 21112243
16.  User's perspectives of barriers and facilitators to implementing quality colonoscopy services in Canada: a study protocol 
Background
Colorectal cancer (CRC) represents a serious and growing health problem in Canada. Colonoscopy is used for screening and diagnosis of symptomatic or high CRC risk individuals. Although a number of countries are now implementing quality colonoscopy services, knowledge synthesis of barriers and facilitators perceived by healthcare professionals and patients during implementation has not been carried out. In addition, the perspectives of various stakeholders towards the implementation of quality colonoscopy services and the need of an efficient organisation of such services have been reported in the literature but have not been synthesised yet. The present study aims to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators perceived by all stakeholders to the implementation of quality colonoscopy services in Canada.
Methods
First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to implementing quality colonoscopy services. Standardised literature searches and data extraction methods will be used. The quality of the studies and their relevance to informing decisions on colonoscopy services implementation will be assessed. For each group of users identified, barriers and facilitators will be categorised and compiled using narrative synthesis and meta-analytical techniques. The principle factors identified for each group of users will then be validated for its applicability to various Canadian contexts using the Delphi study method. Following this study, a set of strategies will be identified to inform decision makers involved in the implementation of quality colonoscopy services across Canadian jurisdictions.
Discussion
This study will be the first to systematically summarise the barriers and facilitators to implementation of quality colonoscopy services perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. Linkages with strategic partners and decision makers in the realisation of this project will favour the utilisation of its results to support strategies for implementing quality colonoscopy services and CRC screening programs in the Canadian health system.
doi:10.1186/1748-5908-5-85
PMCID: PMC2988067  PMID: 21044332
19.  Internal medicine residency training for unhealthy alcohol and other drug use: recommendations for curriculum design 
BMC Medical Education  2010;10:22.
Background
Unhealthy substance use is the spectrum from use that risks harm, to use associated with problems, to the diagnosable conditions of substance abuse and dependence, often referred to as substance abuse disorders. Despite the prevalence and impact of unhealthy substance use, medical education in this area remains lacking, not providing physicians with the necessary expertise to effectively address one of the most common and costly health conditions. Medical educators have begun to address the need for physician training in unhealthy substance use, and formal curricula have been developed and evaluated, though broad integration into busy residency curricula remains a challenge.
Discussion
We review the development of unhealthy substance use related competencies, and describe a curriculum in unhealthy substance use that integrates these competencies into internal medicine resident physician training. We outline strategies to facilitate adoption of such curricula by the residency programs. This paper provides an outline for the actual implementation of the curriculum within the structure of a training program, with examples using common teaching venues. We describe and link the content to the core competencies mandated by the Accreditation Council for Graduate Medical Education, the formal accrediting body for residency training programs in the United States. Specific topics are recommended, with suggestions on how to integrate such teaching into existing internal medicine residency training program curricula.
Summary
Given the burden of disease and effective interventions available that can be delivered by internal medicine physicians, teaching about unhealthy substance use must be incorporated into internal medicine residency training, and can be done within existing teaching venues.
doi:10.1186/1472-6920-10-22
PMCID: PMC2848062  PMID: 20230607
20.  A Mixed Method Study of the Merits of E-Prescribing Drug Alerts in Primary Care 
Objectives
The objective of this paper was to describe primary care prescribers’ perspectives on electronic prescribing drug alerts at the point of prescribing.
Design
We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff.
Participants
Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups.
Measurements
The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: “What do you think of the drug alerts your software generates for you?”
Results
More than 40% of prescribers indicated they override drug–drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug–drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts.
Conclusions
Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed.
doi:10.1007/s11606-008-0505-4
PMCID: PMC2359504  PMID: 18373142
e-prescribing; electronic prescribing; drug alerts; primary care; medication use
21.  Melanoma Early Detection with Thorough Skin Self-Examination: The “Check It Out” Randomized Trial 
Background:
Monthly Thorough Skin Self-Examination (TSSE) is an important practice for early detection of melanoma that is performed by a small minority of the population.
Design:
A randomized trial to determine whether a multi-component intervention can increase performance of TSSE, and to describe the effects on performance of skin surgeries, compared to a similar control intervention focused on diet.
Setting/participants:
1356 patients attending a routine primary care visit in southeastern New England
Intervention:
Participants received instructional materials, including cues and aids, a video, and a brief counseling session and (at 3 weeks) a brief follow-up phone call from a health educator, and tailored feedback letters.
Main Outcome Measures:
Performance of TSSE assessed by telephone interview and having a surgical procedure performed on the skin confirmed by examination of medical records
Results:
TSSE was performed by substantially more participants at 2, 6, and 12 months in the intervention group than in the control group (55% vs. 35%, p<0.0001 at 12 months). We also noted that a substantially higher proportion in the intervention group had skin surgery in the first 6 months (8.0% vs. 3.6%, p=0.0005), but there was no difference at 6 to 12 months (3.9% vs. 3.3%, p=0.5).
Conclusions:
The TSSE intervention was effective in increasing performance TSSE, that it resulted in increased surgery on the skin, and that increase in skin procedures only persisted for 6 months. Intervention to increase TSSE may result in long-term benefit in early detection of melanoma while causing only a short-term excess of skin surgeries.
doi:10.1016/j.amepre.2007.02.024
PMCID: PMC2440310  PMID: 17533068
22.  A web-based Alcohol Clinical Training (ACT) curriculum: Is in-person faculty development necessary to affect teaching? 
Background
Physicians receive little education about unhealthy alcohol use and as a result patients often do not receive efficacious interventions. The objective of this study is to evaluate whether a free web-based alcohol curriculum would be used by physician educators and whether in-person faculty development would increase its use, confidence in teaching and teaching itself.
Methods
Subjects were physician educators who applied to attend a workshop on the use of a web-based curriculum about alcohol screening and brief intervention and cross-cultural efficacy. All physicians were provided the curriculum web address. Intervention subjects attended a 3-hour workshop including demonstration of the website, modeling of teaching, and development of a plan for using the curriculum. All subjects completed a survey prior to and 3 months after the workshop.
Results
Of 20 intervention and 13 control subjects, 19 (95%) and 10 (77%), respectively, completed follow-up. Compared to controls, intervention subjects had greater increases in confidence in teaching alcohol screening, and in the frequency of two teaching practices – teaching about screening and eliciting patient health beliefs. Teaching confidence and teaching practices improved significantly in 9 of 10 comparisons for intervention, and in 0 comparisons for control subjects. At follow-up 79% of intervention but only 50% of control subjects reported using any part of the curriculum (p = 0.20).
Conclusion
In-person training for physician educators on the use of a web-based alcohol curriculum can increase teaching confidence and practices. Although the web is frequently used for disemination, in-person training may be preferable to effect widespread teaching of clinical skills like alcohol screening and brief intervention.
doi:10.1186/1472-6920-8-11
PMCID: PMC2329623  PMID: 18325102
23.  Training Primary Care Clinicians in Maintenance Care for Moderated Alcohol Use 
Journal of General Internal Medicine  2006;21(12):1269-1275.
OBJECTIVE
To evaluate whether training primary care clinicians in maintenance care for patients who have changed their drinking influences practice behavior.
DESIGN
We randomized 15 physician and 3 mid-level clinicians in 2 primary care offices in a 2:1 design. The 12 intervention clinicians received a total of 2 ¼ hours of training in the maintenance care of alcohol problems in remission, a booster session, study materials and chart-based prompts at eligible patients' visits. Six controls provided usual care. Screening forms in the waiting rooms identified eligible patients, defined as those who endorsed: 1 or more items on the CAGE questionnaire or that they had an alcohol problem in the past; that they have “made a change in their drinking and are trying to keep it that way”; and that they drank <15 (men) or <10 (women) drinks per week in the past month. Exit interviews with patients evaluated the clinician's actions during the visit.
RESULTS
Of the 164 patients, 62% saw intervention clinicians. Compared with patients of control clinicians, intervention patients were more likely to report that their clinician asked about their alcohol history (odds ratio, 2.8; 95% confidence interval, 1.3, 5.8). Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment, assist through offers for prescriptions and treatment referral, and receive higher satisfaction ratings for the visit.
CONCLUSIONS
Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians' inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry.
doi:10.1111/j.1525-1497.2006.00611.x
PMCID: PMC1924751  PMID: 16965560
primary health care; alcohol-related disorders; recurrence/PC
24.  BOOK REVIEW 
doi:10.1046/j.1525-1497.1999.00346.x
PMCID: PMC1496572

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