Rationale, aims and objectives  The Alberta Ambassador Program (AAP) adapted seven clinical practice guidelines on low back pain (LBP) into a single guideline spanning the continuum of care from prevention and diagnosis through to treatment. The Ambassador adaptation process was evaluated to

• 1
  Identify the major challenges encountered and successful strategies utilized;
• 2
  Assess strengths and weaknesses by benchmarking it with the ADAPTE framework; and
• 3
  Identify opportunities for improvement.

Method  External consultants reviewed the Ambassador and ADAPTE materials and conducted semi-structured telephone interviews with 29 participants from the AAP committees. All participants were asked about the major challenges encountered and potential areas for improvement.

Results  The response rate was 83% (29/35). There was strong consensus that the Ambassador guideline adaptation process was sound and rigorous all respondents indicated willingness to participate in further iterations of the Program. Key elements of success were identified. The main steps and sequence of the process were closely aligned with the ADAPTE framework, although the AAP incorporated additional enhancements which augmented the process. The main divergences between the two frameworks centred on the organizational structure and the methods used to overcome methodological difficulties.

Conclusion  The AAP successfully utilized existing stakeholder interest to create an overarching guideline for managing LBP across multiple primary care disciplines. The study highlighted the strengths and weaknesses of the Program, and identified practical strategies for improvement. Evaluating guideline adaptation processes is pivotal to ensuring that they continue to be an efficient, rigorous and practicable option for producing contextualized, clinically relevant guidelines.

Objective  To investigate hospital patients' reports of undesirable events in their health care.

Design  Cross-sectional mixed methods design.

Participants  A total of 80 medical and surgical patients (mean age 58, 56 male).

Intervention  Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed.

Main outcome measures  Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care.

Results  In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system.

Conclusion  Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety.

Rationale  This paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia.

Aim and objectives  The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers.

Method  In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted.

Results  Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk.

Conclusion  Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group.

Aim  To account for the means by which poor performance among career doctors is identified by National Health Service organizations, whether the tools are considered effective and how these processes may be strengthened in the light of revalidation and the requirement for doctors to demonstrate their fitness to practice.

Method  This study sought to look beyond the ‘doctor as individual’; as well as considering the typical approaches to managing the practice of an individual, the systems within which the doctor is working were reviewed, as these are also relevant to standards of performance. A qualitative review was undertaken consisting of a literature review of current practice, a policy review of current documentation from 15 trusts in one deanery locality, and 14 semi-structured interviews with respondents with an overview of processes in use. The framework for the analysis of the data considered tools at three levels: individual, team and organizational.

Results  Tools are, in the main, reactive – with an individual focus. They rely on colleagues and others to speak out, so their effectiveness is hindered by a reluctance to do so. Tools can lack an evidence base for their use, and there is limited linking of data across contexts and tools.

Conclusions  There is more work to be done in evaluating current tools and developing stronger processes. Linkage between data sources needs to be improved and proactive tools at the organizational level need further development to help with the early identification of performance issues. This would also assist in balancing a wider systems approach with a current over emphasis on individual doctors.

Rationale, aims and objectives  There are a variety of resources to obtain health information, but few studies have examined if main and allied health professionals prefer different methods. The current study was to investigate their information-searching behaviours.

Methods  A constructed questionnaire survey was conducted from January through April 2011 in nationwide regional hospitals of Taiwan. Questionnaires were mailed to main professionals (physicians and nurses) and allied professionals (pharmacists, physical therapists, technicians and others), with 6160 valid returns collected.

Results  Among all professional groups, the most commonly used resource for seeking health information was a Web portal, followed by colleague consultations and continuing education. Physicians more often accessed Internet-based professional resources (online databases, electronic journals and electronic books) than the other groups (P < 0.05). In contrast, physical therapists more often accessed printed resources (printed journals and textbooks) than the other specialists (P < 0.05). And nurses, physical therapists and technicians more often asked colleagues and used continuing education than the other groups (P < 0.01). The most commonly used online database was Micromedex for pharmacists and MEDLINE for physicians, technicians and physical therapists. Nurses more often accessed Chinese-language databases rather than English-language databases (P < 0.001).

Conclusions  This national survey depicts the information-searching pattern of various health professionals. There were significant differences between and within main and allied health professionals in their information searching. The data provide clinical implications for strategies to promote the accessing of evidence-based information.

Rationale, aims and objectives  Evidence-based medicine and clinical guidelines have been found difficult to implement in the clinical practice – mainly because lack of evidence quality and guidelines that, generally, do not account for variations in the medical cases. Variation in the medical cases enhances task uncertainty and uncertainty seems to be further enhanced through clinical guidelines. In this article, concept development is attempted, where task uncertainty is classified into a few medical problem-solving processes according to differences in medical technology and in the (initial) perception of the medical problem. Furthermore is argued the need for using different strategies in evaluating performance quality in medical health care depending on the variation in the degree of task uncertainty.

Method  Qualitative data about medical activities related to certain diseases are used to exemplify problem-solving processes representing different types of task uncertainty.

Results  It is argued that the main characteristics of medical problem-solving processes vary according to differences in medical technology and perception of perceived medical problem. Four main medical problem-solving processes are defined and demonstrated through empirical examples.

Conclusion  What may be regarded as rational behaviour is different for each type of problem-solving processes. Consequently, the processes need different organizational settings and need to be evaluated according to different criteria. Furthermore, from a practical point of view, development and education related to problem perception would seem as important as development of medical technology.

Rationale, aims and objectives  Understanding sources of knowledge used in everyday practice is very helpful in improving the quality of health care services. There is a consensus in the literature that nurses mostly relied in their practice on experiential knowledge gained through their interactions with other members of health care professionals and patients. The general aim of this study is to explore the sources of knowledge Jordanian registered nurses use during their practice.

Method  A descriptive correlational design was used to collect data from 539 Jordanian registered nurses from 10 hospitals using a self-administered questionnaire.

Results  The mean year of experience of the sample was 7.08 years. Of the 615 questionnaires distributed, 555 were returned. This yields a response rate of 87.6%. Results revealed that the top five ranked sources used by Jordanian registered nurses include: the information that nurses learned during nursing education, personal experience in nursing over time, what was learned through providing care to patients, information gained through discussion between physicians and nurses about patients, and information from policy and procedure manuals.

Conclusion  Jordanian registered nurses recognize the value of research and that research utilization (RU) is an important issue and must not be ignored. The study has many implications for practice, education and research. Health care managers and decision makers need to play a more visible and instrumental role in encouraging RU to improve patients' quality of life.

Aim  To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers.

Methods  A cross-sectional research design was used in a total sample of 35 058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel.

Results  The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure-reducing mattress (23.3–27.9%) or planned repositioning in bed (50.2–57.5%).

Conclusions  Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence-based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.

Rationale  A multidisciplinary primary care clinic in Sydney, Australia, was planning to use electronic questionnaires to measure patient-reported outcomes.

Methods  Semi-structured interviews with 20 patients were undertaken to explore, among other things, practical issues regarding different questionnaire formats. The response rates and costs of email versus postal invitations were also evaluated.

Results  Compared with postal invitations, email invitations offered a cost-effective and practical alternative, with a greater proportion of patients volunteering for an interview. Assuming the interface is well-designed and user-friendly, many patients were happy to use the Internet to answer questionnaires. Most patients thought alternate formats should also be offered. Patients discussed advantages and disadvantages of the Internet format. Although more younger patients and females had given the clinic an email address; both sexes, and young and old patients, expressed strong preferences for either wanting or not wanting to use the Internet.

Conclusion  Researchers should consider using email invitations as a cost-effective first-line strategy to recruit patients to participate in health services research. Internet questionnaires are potentially cheaper than paper questionnaires, and the format is acceptable to many patients. However, for the time being, concurrent alternate formats need to be offered to ensure wider acceptability and to maximize response rates.

Objectives  To determine IMR trends and regional variations among 47 prefectures in Japan and to identify associated population-based factors.

Methods  We conducted an ecological study of infant mortality rate (IMR) by analyzing publicly available data from the Ministry of Health, Labour and Welfare of Japan. Outcome measure for trend is the IMR for each of 47 prefectures from 1999 to 2007; for variation, IMRs for 2006 and 2007 in each prefecture were averaged. We considered as covariates prefecture-level variables related to public health, socio-economic status, clinical services and health care facilities. We conducted multivariate statistical analyses to determine covariates most strongly associated with both 1999–2007 IMR trends and 2006–2007 IMR.

Results  The mean IMR decreased from 3.42 deaths per 1000 live births (range 2.1 to 5.1) in 1999 to 2.54 (range 1.5 to 4.4) in 2007; reductions were greater in prefectures with higher concentrations of public health nurses (PHNs) and nurses. In 2006–2007, nine prefectures had IMRs ≤ 2.25; eight had IMRs ≥ 3.0. When low-, moderate- and high-IMR prefectures were compared, per capita PHNs, maternal education, centralized water supply and household income were identified as significant covariates.

Conclusions  Both national and prefecture-level IMR in Japan decreased from 1999 to 2007; however, the degree of reduction varied by prefecture. Given that more nurses and PHNs per capita were associated with greater IMR reductions from 1999 to 2007 and more PHNs with lower 2006–2007 IMRs, distribution of preventive health services may play a major role in reducing regional disparities in IMR.

Background  Various authorities recommend the participation of patients in promoting patient safety, but little is known about health care professionals' (HCPs') attitudes towards patients' involvement in safety-related behaviours.

Objective  To investigate how HCPs evaluate patients' behaviours and HCP responses to patient involvement in the behaviour, relative to different aspects of the patient, the involved HCP and the potential error.

Design  Cross-sectional fractional factorial survey with seven factors embedded in two error scenarios (missed hand hygiene, medication error). Each survey included two randomized vignettes that described the potential error, a patient's reaction to that error and the HCP response to the patient.

Setting  Twelve hospitals in Switzerland.

Participants  A total of 1141 HCPs (response rate 45%).

Measurements  Approval of patients' behaviour, HCP response to the patient, anticipated effects on the patient–HCP relationship, HCPs' support for being asked the question, affective response to the vignettes. Outcomes were measured on 7-point scales.

Results  Approval of patients' safety-related interventions was generally high and largely affected by patients' behaviour and correct identification of error. Anticipated effects on the patient–HCP relationship were much less positive, little correlated with approval of patients' behaviour and were mainly determined by the HCP response to intervening patients. HCPs expressed more favourable attitudes towards patients intervening about a medication error than about hand sanitation.

Conclusions  This study provides the first insights into predictors of HCPs' attitudes towards patient engagement in safety. Future research is however required to assess the generalizability of the findings into practice before training can be designed to address critical issues.

Rationale  Pain assessment and treatment is influenced by subjective perception of pain. Despite the international efforts to implement guidelines and protocols for pain management, pain continues to be regarded as a complication rather than a primary problem. The literature pertaining to the adequacy of pain management in the Middle East is frail. This study focuses on revealing the implemented practices of initial pain assessment, follow-up and re-evaluation of pain treatment in Lebanese hospitals.

Aim and objectives  The objective of this study is to evaluate the presence and effectiveness of acute pain management and its impact on the quality of life in hospitals throughout Lebanon, in both cancer and non-cancer populations.

Methods  A Lebanese multi-centre, prospective, chart review study was conducted over a period of 3 months. Data on demographics, pain medication, dose, route, duration and adjunct pain management were collected. Appropriateness of pain management was determined as per World Health Organization guidelines. Institutional Review Board approvals were obtained from each hospital.

Results  Results from 582 participants revealed that 50% of initial pain assessment intensity scores were based on the assumptions of health care professionals. Furthermore, as pain severity scores increased, the adequacy of pain management decreased. Only 22% of the patients had a daily follow-up, and the majority of those continued to receive inappropriate therapy.

Conclusion  This study reflects the lack of a well-structured system for pain management in Lebanese hospitals. It underlines the need for pain research in the region. It also highlights the need for implementing the recommendations discussed to minimize risk and optimize pain management.

Background  In recent years, factors that affect patients' willingness and ability to participate in safety-relevant behaviours have been investigated. However, how trained healthcare professionals or medical students would feel participating in safety-relevant behaviours as a patient in hospital remains largely unexplored.

Objectives  To investigate medical students' willingness to participate in behaviours related to the quality and safety of their health care.

Design  A cross-sectional exploratory study using a survey that addressed willingness to participate in different behaviours recommended by current patient safety initiatives. Three types of interactional behaviours (asking factual or challenging questions, notifying doctors or nurses of errors/problems) and three non-interactional behaviours (choosing a hospital based on the safety record, bringing medicines and a list of allergies into hospital, and reporting an error to a national reporting system) were assessed.

Participants  One hundred and seventy-nine medical students from an inner city London teaching hospital participated in the study.

Findings  Students' willingness to participate was affected (P < 0.05) by the action required by the patient and (for interactional behaviours) whether the patient was engaging in the specific action with a doctor or nurse. Students were least willing to ask ‘challenging’ questions to doctors and nurses and to report errors to a national reporting system. Doctors' and nurses' encouragement appeared to increase self-reported willingness to participate in behaviours where baseline willingness was low.

Conclusion  Similar to research on lay patient populations; medical students do not view involvement in safety-related behaviours equally. Interventions should be tailored at encouraging students to participate in behaviours they are less inclined to take on an active role in. Future research is required to examine students' motivations for participation in this important but heavily under-researched area.

Rationale, aims and objectives  While the science of knowledge translation (KT) has been growing steadily for the past decade in relation to understanding processes and actions which are embedded within clinical practice settings, little is known about how empirical knowledge is used within the medical education system. Despite an increase of research in this domain, we know very little about the contribution of this evidence in the development of medical students into effective physicians. This pilot study aims to: provide a synthesis of the evidence for educational strategies within medical education; explore the perceptions and experiences of faculty in undergraduate (UG) medical education in relation to their use of evidence in their educational practices; and illuminate how medical education evidence is formally integrated into a UG medical curriculum.

Method  The study will involve three phases. First, a scoping review of the medical education research literature will be undertaken to generate insight into the evidence available for curriculum development, teaching and assessment activities within this domain. Second, a content analysis of undergraduate courses at the University of Toronto will be undertaken to generate an additional insight into the extent that medical education research has been formally integrated into the UG curriculum for medical students at the University. Finally, a purposeful sample of 30–40 medical education leaders from a single large university, selected as it aims to deliver a rigorous research-oriented medical curriculum, will be interviewed to understand how they use the available evidence in their education practices.

Discussion  This study will lay the grounds to generate initial data into the determinants of knowledge use in a medical education context. In doing so, the findings will also inform the development of a larger, pan-Canadian study at medical schools that will generate a comprehensive account of the processes and challenges related to KT within an educational context. This larger study will also begin to explore the relevance of the Knowledge-to-Action model to a medical education context.

Rationale, aims and objectives  Acute myocardial infarctions (MIs) or heart attacks are the result of a complete or an incomplete occlusion of the lumen of the coronary artery with a thrombus. Prompt diagnosis and early coronary intervention results in maximum myocardial salvage, hence time to treat is of the essence. Adequate, accurate and complete information is vital during the early stages of admission of an MI patient and can impact significantly on the quality and safety of patient care. This study aimed to record how clinical information between different clinical teams during the journey of a patient in the MI care pathway is captured and to review the flow of information within this care pathway.

Method  A prospective, descriptive, structured observational study to assess (i) current clinical information systems (CIS) utilization and (ii) real-time information availability within an acute cardiac care setting was carried out. Completeness and availability of patient information capture across four key stages of the MI care pathway were assessed prospectively.

Results  Thirteen separate information systems were utilized during the four phases of the MI pathway. Observations revealed fragmented CIS utilization, with users accessing an average of six systems to gain a complete set of patient information. Data capture was found to vary between each pathway stage and in both patient cohort risk groupings. The highest level of information completeness (100%) was observed only in the discharge stage of the MI care pathway. The lowest level of information completeness (58%) was observed in the admission stage.

Conclusion  The study highlights fragmentation, CIS duplication, and discrepancies in the current clinical information capture and data transfer across the MI care pathway in an acute cardiac care setting. The development of an integrated and user-friendly electronic data capture and transfer system would reduce duplication and would facilitate efficient and complete information provision at the point of care.

Aims and objectives  Evidence-based guidelines are currently the most relevant source of information in practice. The adherence to and use of guidelines is often influenced by attitudes towards the guidelines themselves, which have not been sufficiently explored in occupational health. This study examines the attitude of Finnish occupational nurses’ and doctors’ attitudes towards evidence-based guidelines.

Methods  Ten occupational doctors and eight occupational nurses were interviewed in Southern Finland on their attitudes towards evidence-based guidelines in 2009.

Results  The nurses were not very familiar with the concept of evidence-based medicine. Rather, they used recommendations developed in their workplace or by their employer. The evidence base of these recommendations was not clear. The doctors considered the evidence-based guidelines reliable and practical, but did not always act according to them. Participants felt that they did not have time to check guidelines during their working hours. Participants wished for clearer, shorter guidelines on occupational health care topics, which would help in their practical daily work and clarify roles in teamwork.

Conclusions  Based on these positive attitudes, the use of guidelines may be more common than it seems. The viewpoints of all occupational health professional groups should be taken into account in guideline development, particularly on the availability and usability of the guidelines.

Rationale, aims and objectives  Existing literature suggests that doctors' poor adherence with guidelines is one of the major contributing factors to suboptimal control of hypertension. This study aims to evaluate doctors' adherence with Malaysian clinical practice guideline (CPG 2008) in a tertiary care hospital, and factors associated with guideline adherence and hypertension control.

Methods  This was a cross-sectional study conducted at Hospital Pulau Pinang, Penang, Malaysia. Prescriptions written by 26 enrolled doctors to 650 established hypertensive outpatients (25 prescriptions per enrolled doctor) were noted on visit 1 along with patients' demographic and clinical data. The noted prescriptions were classified either as compliant or non-compliant to CPG (2008). Five hundred twenty (80%) of the enrolled patients (20 patients per enrolled doctor) were followed for one more visit. Blood pressure (BP) noted on visit 2 was related to the prescription written on visit 1. SPSS 16 (SPSS Inc., Chicago, IL, USA) was used for data analysis.

Results  Three hundred forty-nine (67.1%) patients received guidelines compliant pharmacotherapy. In multivariate analysis, hypertension clinic had significant negative association with guidelines adherence. Two hundred sixty-five patients (51%) were at goal BP on visit 2. In multivariate analysis, angiotensin-converting enzyme inhibitors and guidelines adherence had significant positive, while renal disease, diabetes mellitus and diabetic clinic had significant negative association with hypertension control.

Conclusions  An overall fair level of adherence with guidelines and better control of hypertension was observed. Guidelines compliant practices resulted in better control of hypertension. The gaps between what guidelines recommend and clinical practice were especially seen in the pharmacotherapy of uncomplicated hypertension and hypertension with diabetes mellitus and renal disease.

Background  While studies into the implementation of clinical practice guidelines for mental health care are scarce, studies on the effectiveness of implementing practice guidelines for anxiety disorders appear to be entirely non-existent.

Objective  To examine whether adherence to anxiety disorder clinical practice guidelines in secondary mental health care yields superior treatment results than non-adherence.

Method  A closed-cohort study of 181 outpatients with an anxiety disorder or hypochondriasis who were treated in a routine mental health setting. Preceding the inclusion of these 181 patients, a start was made on the implementation of the Dutch national multidisciplinary practice guidelines for anxiety disorders. Patients were asked to complete several questionnaires before the start of treatment and again 1 year later. The medical records of these patients were reviewed to assess guideline adherence. Ultimately, adherence or non-adherence to the different treatment algorithms described in the guidelines was related to changes in the severity of psychiatric symptomatology, psychiatric functioning, general well-being and satisfaction with treatment.

Results  Compared with patients whose treatment did not adhere to the guidelines, those whose treatment adhered to the guidelines were found to have greater symptom reduction after 1 year (P < 0.01). The latter group of patients also rated their satisfaction with their treatment significantly higher (P = 0.01). No significant differences were found after 1 year with respect to changes in impairment of functioning and quality of life in the two groups of patients.

Conclusions  Adherence to anxiety disorder guidelines yields superior treatment results and increased patient satisfaction with treatment when compared with patients whose treatment did not adhere to the clinical guidelines. These results should encourage a more widespread implementation of such guidelines in mental health care facilities.

Rationale and objective  Use of evidence from systematic research is critical in evidence-based physical therapy, yet this has not been described well in developing countries where its purported benefits are most needed. This study explored research evidence uptake among physical therapists in the Philippines.

Method  A probability survey of practitioners in tertiary hospitals in the Philippines' National Capital Region was conducted.

Results  Of the 188 questionnaires distributed, 152 were returned for an 81% response rate. Positive attitudes were consistently reported (78–93%), although education and self-efficacy related to key dimensions such as searching, appraising and integrating evidence were varied (53–82%). Less than 50% reported using research evidence routinely in five of six dimensions of clinical practice, except in selecting treatments (53%). Textbooks, own observations and expert opinion were consistently relied upon (74–96%) while average-month approximations of engagement in relevant activities such as searching, reading, appraising and applying research literature were low (10–18%). Participants faced a number of barriers such as lack of time, resources, skills, access to research literature, supporting administrative policies, in-service training and authority in decision making.

Conclusions  The low research evidence uptake and heavy reliance on potentially biased evidence sources strongly indicate the need for effective professional education for practitioners to address current barriers as well as early intensive undergraduate education for students to ensure adequate preparation on being effective research evidence consumers. Given the profile of Filipino physical therapists, alternatives to ‘from scratch’ evidence searching and appraisal are required if widespread uptake is envisaged.

Given the considerable interest in the use of evidence-based medicine to guide clinical practice, it is surprising that the results of a recent randomized controlled trial have been met with such a limited response. The DECompressive CRAniectomy study investigators have recently published the results of a landmark trial in neurosurgery, comparing early decompressive craniectomy with standard medical therapy in patients who developed intracranial hypertension after diffuse closed traumatic brain injury (TBI). This is the first ever randomized controlled trial investigating the surgical management of adult patients with severe TBI. The trial clearly demonstrated that early decompression did not provide clinical benefit; however, rather than having a significant impact on clinical practice, it has been almost uniformly criticized. While there were some problems with randomization and crossover, we feel that the trial has been somewhat misinterpreted and in this article we address some of the key issues.

Background  Switzerland lacks of national guidelines for the initial treatment of an acute coronary syndrome (ACS). ACS is not as frequent in an outpatient setting as in an emergency department; nevertheless, missing an ACS is associated with high morbidity and mortality. We wanted to observe actual infrastructure and performance based on case vignettes in outpatient general practitioners (GPs) and cardiologists (CAs); as a second outcome, we wanted to compare GPs to CAs.

Methods  We conducted a postal vignette-based survey to investigate the management of outpatients presenting with acute chest pain by doctors in private practice. The use of troponin and cardiac stress testing for the evaluation of acute chest pain as well as referral practice and use of antiplatelet agents were assessed and compared between GPs and CAs.

Results  There were 507 of the 571 respondents (response rate 39.7%) who were CAs (36) or GPs (471) and were included in the analysis. Whereas all CAs were equipped with electrocardiogram (ECG), cardiac stress testing and troponin assays, the majority of GPs had an ECG (97.8%) and applied troponin testing (76.3%), and 38.7% performed cardiac stress testing. The vast majority responded to directly refer a STEMI to the next catheter lab (87.7%), or in the case of a troponin-positive NSTEMI, to an inpatient ward (94.1%) with no difference between GPs and CAs. A majority of the GPs responded to use antiplatelet agents in the case of a STEMI (89.6%) and reported further workup with cardiac stress testing in the case of a troponin-negative acute chest pain (78.7%), which was lower compared to CAs who applied antiplatelet agents and cardiac stress testing in 100% and 97.0%.

Conclusions  We could show that international guideline adherence in ACS of GPs is high and GPs perform as well as CAs. Nevertheless there is room for optimization in the antiplatelet therapy and the use of cardiac stress testing in a low-risk population. National guidelines for treatment of an ACS in an outpatient setting are indicated.

Rationale, aims and objectives  Systematic reviews, meta-analyses and clinical guidelines (reviews) are intended to inform clinical practice, and in this sense can be thought of as scientific truthmakers. High-quality controlled trials should align to this truth, and method quality markers should predict truth status. We sought to determine in what way controlled trial quality relates to scientific truth, and to determine predictive utility of trial quality and bibliographic markers.

Method  A sample of reviews in rehabilitation medicine was examined. Two scientific truth dimensions were established based on review outcomes. Quality and bibliographic markers were extracted from associated trials for use in a regression analysis of their predictive utility for trial truth status. Probability analysis was undertaken to examine judgments of future trial truth status.

Results  Of the 93 trials included in contemporaneous reviews, overall, n = 45 (48%) were true. Randomization was found more in true trials than false trials in one truth dimension (P = 0.03). Intention-to-treat analysis was close to significant in one truth dimension (P = 0.058), being more commonly used in false trials. There were no other significant differences in quality or bibliographic variables between true and false trials. Regression analysis revealed no significant predictors of trial truth status. Probability analysis reported that the reasonable chance of future trials being true was between 2 and 5%, based on a uniform prior.

Conclusions  The findings are at odds with what is considered gold-standard research methods, but in line with previous reports. Further work should focus on scientific dynamics within healthcare research and evidence-based practice constructs.

Background  In 2006, the National Inpatient Medication Chart (NIMC) was introduced as a uniform medication chart in Australian public hospitals with the aim of reducing prescription error.

Purpose  The rate of regular medication prescription error in the NIMC was assessed.

Methods  Data was collected using the NIMC Audit Tool and analyzed with respect to causes of error per medication prescription and per medication chart. The following prescription requirements were assessed: date, generic drug name, route of administration, dose, frequency, administration time, indication, signature, name and contact details.

Findings  A total of 1877 medication prescriptions were reviewed. 1653 prescriptions (88.07%) had no contact number, 1630 (86.84%) did not have an indication, 1230 and 675 (35.96%) used a drug's trade name. Within 261 medication charts, all had at least one entry, which did not include an indication, 258 (98.85%) had at least one entry, which did not have a contact number and 200 (76.63%) had at least one entry, which used a trade name.

Discussion  The introduction of a uniform national medication chart is a positive step, but more needs to be done to address the root causes of prescription error.

Objectives  Defining ‘best practice’ is one of the first and crucial steps in any Knowledge Translation (KT) research project. Without a sound understanding of what exactly should happen in practice, it is impossible to measure the extent of existing gaps between ‘desired’ and ‘actual’ care, set implementation goals, and monitor performance. The aim of this paper is to present a practical, stepped and interactive process to develop best practice recommendations that are actionable, locally applicable and in line with the best available research-based evidence, with a view to adapt these into process measures (quality indicators) for KT research purposes.

Methods  Our process encompasses the following steps: (1) identify current, high-quality clinical practice guidelines (CPGs) and extract recommendations; (2) select strong recommendations in key clinical management areas; (3) update evidence and create evidence overviews; (4) discuss evidence and produce agreed ‘evidence statements’; (5) discuss the relevance of the evidence with local stakeholders; and (6) develop locally applicable actionable best practice recommendations, suitable for use as the basis of quality indicators.

Conclusions  Actionable definitions of local best practice are a prerequisite for doing KT research. As substantial resources go into rigorously synthesizing evidence and developing CPGs, it is important to make best use of such available resources. We developed a process for efficiently developing locally applicable actionable best practice recommendations from existing high-quality CPGs that are in line with current research evidence.

Purpose  The study aims to support decision making on how best to redesign diabetes care by investigating three potential sources of heterogeneity in effectiveness across trials of diabetes care management.

Methods  Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects.

Results  Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8–12% of the heterogeneity in effects on HbA1c and systolic blood pressure.

Conclusions  The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care.

Objective  To assess the effect of the integration of evidence-based medicine (EBM) in a medical curriculum using small-group discussions with case scenario and problem-based learning on the knowledge, attitudes and skills of medical students.

Method  A quasi-experimental study was conducted in a medical school in southern Thailand during 2008–2009. EBM practice was begun before the completion of the fourth year using case scenario and continued through the fifth year using learner-centred, problem-based self-practice. Knowledge improvement was measured by summative assessment using pre- and post-tests after small-group discussions with a case scenario. Attitudes and skills were measured by self-rating assessments: before initiation of the course (T0) and after the course at week 1, 5, 13, 25 and 37 (T1, T2, T3, T4 and T5), respectively. Data were analyzed using paired t-test and linear mixed-effects model fitted by maximum likelihood.

Results  One hundred fourteen students took the course, with a mean age of 22.1 years. Before and after knowledge scores showed a significant improvement (4.93 versus 7.43). The proportion of students who achieved the highest knowledge scores was higher (4% at pre-test versus 54% at post-test). Both self-rated attitudes and skills after EBM practice increased dramatically from the initiation of the course (T0; P < 0.001). Compared with T1, significantly lower scores of attitudes and skills were observed at T2 and T3, but both were higher at T4 assessment.

Conclusions  Continuous EBM education through small-group discussion and learner-centred, problem-based self-practice can be a useful way to improve a medical student's knowledge, attitudes and skills.

Rationale, aims and objectives  The management of many inherited metabolic disorders (IMDs) is dependent on nutrition intervention, but few clinical management guidelines for these uncommon disorders exist. Clinicians are forced to make nutrition treatment decisions using limited data. This results in clinical variations in both service and cost. We describe a method for establishing management guidelines to help clinicians treat patients with IMDs.

Methods  The Southeast Newborn Screening and Genetics Collaborative (Region 3) convened a group of nine national experts in metabolic nutrition to determine the pertinent issues in the development of nutrition management guidelines for IMDs. These experts were trained in evidence analysis and examined established consensus techniques for guideline development.

Results  The workgroup developed a multi-step process for guideline development known as the Delphi-Nominal Group-Delphi-Field Testing methodology, which includes a review of scientific and grey (unpublished) literature, a Delphi survey of practice, a nominal group meeting to clarify discrepancies, a formulation of recommendations and a second Delphi round to assess the degree of consensus with the proposed recommendations. External review and field testing are also built into the process.

Conclusion  The evidence- and consensus-based method suggested for the development of nutrition management guidelines for IMDs will result in the production of consistent and accessible guidelines that can be created in a timely and cost-effective manner and offer a validated methodology to develop management guidelines for this field to optimize outcomes.

Rationale, aims and objectives  Clinical diversity and methodological heterogeneity exists between studies on chronic care management. This study aimed to examine the effectiveness of chronic care management in chronic obstructive pulmonary disease (COPD) while taking heterogeneity into account, enabling the understanding of and the decision making about such programmes. Three investigated sources of heterogeneity were study quality, length of follow-up, and number of intervention components.

Methods  We performed a review of previously published reviews and meta-analyses on COPD chronic care management. Their primary studies that were analyzed as statistical, clinical and methodological heterogeneity were present. Meta-regression analyses were performed to explain the variances among the primary studies.

Results  Generally, the included reviews showed positive results on quality of life and hospitalizations. Inconclusive effects were found on emergency department visits and no effects on mortality. Pooled effects on hospitalizations, emergency department visits and quality of life of primary studies did not reach significant improvement. No effects were found on mortality. Meta-regression showed that the number of components of chronic care management programmes explained present heterogeneity for hospitalizations and emergency department visits. Four components showed significant effects on hospitalizations, whereas two components had significant effects on emergency department visits. Methodological study quality and length of follow-up did not significantly explain heterogeneity.

Conclusions  This study demonstrated that COPD chronic care management has the potential to improve outcomes of care; heterogeneity in outcomes was explained. Further research is needed to elucidate the diversity between COPD chronic care management studies in terms of the effects measured and strengthen the support for chronic care management.

Rationale, aims and objectives  Evidence-based medicine (EBM) has gained widespread acceptance in physical therapy. However, because little is known about the attitudes, knowledge and behaviour of physical therapists towards EBM, and their participation in research to generate EBM, we explored these aspects among physical therapy students, teachers, supervisors and practising physical therapists.

Methods  This is a cross-sectional survey in which participants completed a web-based questionnaire to determine their attitudes, knowledge and behaviour regarding EBM, and their participation in research.

Results  Questionnaires were sent to 814 participants of which 165 were returned. The overall mean score for attitude was 4.3 [standard deviation (SD) 1.0; range 1–7], which indicates a weak positive attitude. Teachers scored the highest (4.9, SD 1.2) and students the lowest (4.1, SD 0.8). Although most participants had some understanding of the technical terms used in EBM, only teachers felt able to explain these terms to others. Of the students, 45% rated their perceived EBM knowledge as bad and 45% as average, whereas 78% of the teachers considered that they had good knowledge. To answer clinical questions, most students generally use textbooks (96%) and the opinion of their supervisors (87.7%).

Conclusions  There is a weak positive attitude of physical therapists, teachers, supervisors and students towards participating in research in general practice, but there is a lack of knowledge and active behaviour regarding EBM, especially among physical therapy students.

Rationale, aims and objectives  The South-East Asia Optimising Reproductive and Child Health in Developing Countries (SEA-ORCHID) project aimed to improve health outcomes for mothers and babies in nine hospitals in South-East Asia by supporting evidence-based perinatal health care. In this research, we aimed to identify and explore the factors that may have acted as barriers to or enablers of evidence-based practice change at each of the hospitals.

Methods  During the final 6 months of the intervention phase of the project, semi-structured, face-to-face interviews were undertaken with 179 nurses, midwives and doctors from the maternal and neonatal departments at each of the nine participating South-East Asian hospitals.

Results  The interviews identified several factors that participants believed had a substantial impact on the effectiveness of the SEA-ORCHID intervention. These included knowledge, skills, hierarchy, multidisciplinarity and leadership, beliefs about consequences, resources, and the nature of the behaviours. The success of the SEA-ORCHID intervention in improving practice may reflect the extent to which tailored strategies were effective in overcoming these barriers.

Conclusion  Effective interventions to align practice with evidence rely on identifying and addressing barriers to practice change. The barriers identified in this study may be useful for those designing similar clinical practice improvement projects, as well as for continued efforts to improve practice in the SEA-ORCHID hospitals.

Rationale  Despite their inherently pervasive limitations, data from observational studies are increasingly relied upon by health care decision makers to fill critical information gaps created by lack of evidence from randomized controlled trials.

Aim and objective  The aim and objective of this article was to revisit the major issues associated with observational studies from secondary data sources.

Method  The method of this article was canvass of the literature.

Results  Sources of bias are highlighted and steps intended to minimize bias are summarized.

Conclusion  Efforts should be made to improve causal inference of treatment effects from observational studies found in secondary data sources. Extra care and caution should be exercised in the interpretation and reporting of results from these studies.

Objective  To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness.

Methods  A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year.

Results  Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037).

Conclusions  Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.

Background  Child psychoanalytic psychotherapy has been criticized for its reluctance to embrace evidence-based practice. This study aims to explore the historical narrative of a sample of child psychoanalytic psychotherapists about progress in developing the evidence base.

Methods  Fourteen psychotherapists were interviewed and the transcripts analysed for common themes about evidence-based practice.

Results  Child psychoanalytic psychotherapists were generally positive about developing evidence-based practice but had reservations about the narrowness of hierarchies used by commissioners to assess evidence.

Conclusion  The child psychoanalytical psychotherapists interviewed for this study recognized the need to promote evidence-based practice, in particular, to inform commissioners of Child Mental Health Services.

Objective  The aim of this study was to compare the performance of three search methods in the retrieval of relevant clinical trials from PubMed to answer specific clinical questions.

Methods  Included studies of a sample of 100 Cochrane reviews which recorded in PubMed were considered as the reference standard. The search queries were formulated based on the systematic review titles. Precision, recall and number of retrieved records for limiting the results to clinical trial publication type, and using sensitive and specific clinical queries filters were compared. The number of keywords, presence of specific names of intervention and syndrome in the search keywords were used in a model to predict the recalls and precisions.

Results  The Clinical queries-sensitive search strategy retrieved the largest number of records (33) and had the highest recall (41.6%) and lowest precision (4.8%). The presence of specific intervention name was the only significant predictor of all recalls and precisions (P = 0.016).

Conclusion  The recall and precision of combination of simple clinical search queries and methodological search filters to find clinical trials in various subjects were considerably low. The limit field strategy yielded in higher precision and fewer retrieved records and approximately similar recall, compared with the clinical queries-sensitive strategy. Presence of specific intervention name in the search keywords increased both recall and precision.

Objectives  Asthma treatment guidelines recommend inhaled corticosteroids (ICS) as the first-line therapy. However, ICS are prescribed to lower percentages of asthmatic patients in Japan than in other developed countries. The aim of this study was to reveal factors affecting the prescription of ICS for asthmatic adults.

Methods  Using insurance claims data in Kyoto Prefecture, Japan, we performed a cross-sectional study. We assessed whether outpatients aged 15 years or older who were diagnosed with asthma had received ICS or not, and conducted logistic regression analyses to identify patients' and facilities' factors associated with ICS use.

Results  We analysed 13 428 asthmatic adults, of which 51% were prescribed ICS. Patients receiving asthma care at facilities with respiratory or allergy specialists were more likely to receive ICS than facilities without specialists (adjusted odds ratio 2.70; 95% confidence interval 2.46–2.97). Those aged 75 years or older were less likely to receive ICS than those aged 15 to 64 (adjusted odds ratio 0.71; 95% confidence interval 0.64–0.78). An examination of the interaction between the presence or absence of specialists and facility training status suggested that whether asthmatic adults received ICS depended on the former factor rather than the latter.

Conclusion  The presence of specialists in facilities and the age of patients were strong factors affecting ICS prescription. Increases in ICS therapy for the elderly and ICS prescription by non-specialists would lead to an overall increase in patients receiving ICS and consequently achieving the goal of asthma control.

Background  Performance feedback is one of a number of strategies used to improve clinical practice among students and clinicians.

Objectives  The aims of this paper were to examine conceptual underpinnings and essential components for audit and feedback strategies, to assess the extent to which recently published audit and feedback interventions include these components and to recommend future directions for feedback to improve its educational and behavioural impact.

Methods  Based on the actionable feedback model, we examined the presence of four theoretical constructs – timeliness, individualization, lack of punitiveness and customizability – in studies published during 2009–2010 which included a feedback intervention.

Results  There was wide variation in the definition, implementation and outcomes of ‘feedback’ interventions, making it difficult to compare across studies. None of the studies we reviewed included all of the components of the actionable feedback model.

Conclusions  Feedback interventions reported to date, even when results are positive, often fail to include concepts of behaviour change. This may partially explain the large variation in approaches and in results of such interventions and presents major challenges for replicating any given intervention. If feedback processes are to be successfully used and disseminated and implemented widely, some standardization and certainly more clarity is needed in the specific action steps taken to apply behavioural theory to practice.

Rationale, aims and objectives  To evaluate asthma management and control in primary care clinics so as to design improvements based on guideline-directed outcomes.

Methods  In this study, all medical records of asthma-diagnosed patients (children as well as adults, entire lifespan, asthma-related visits or not) were retrospectively reviewed as a basis for assessing the level of guideline adherence and asthma control. Six primary health care clinics were visited in the Dr Kenneth Kaunda Municipal District, Potchefstroom, South Africa during May to July 2008, 2009 and 2010.

Results  A total of 323 asthma patient records were reviewed over the three time slots, resulting in 125, 87, and 111 patients respectively. A suboptimal clinical asthma control picture, with a mere 16% (n = 20) of females and 2% (n = 3) of males with Peak Expiratory Flow (PEF) percentages above 60%, were observed in the initial assessment. Improvement in control was observed during the following time slot, but with an end result in 2010 of no PEF percentages above 60% for males and only 9% (n = 7) for females.

Conclusion  Over all three of the data collection periods adherence to effectively applied management of asthma guidelines proved to be below the minimum recommended clinical evaluation work-up as set out by the Expert Panel Report 3 (EPR3) of the National Asthma Education and Prevention Program (NAEPP). Applying a greater focus on essential outcomes through different disease management documents resulted in an improved quality of managed care, but still requires dedicated and continuous education and motivation. (NWU-0052-08-A5)

Rationale, aims and objectives  In most countries, different health care providers are involved in emergency care. In the Netherlands, out-of-hours care is provided by general practitioner cooperatives (GPCs) and emergency departments (EDs). Our aim was to describe the flow of patients attending emergency care in these settings.

Method  A retrospective record review was performed, concerning patients who had visited a GPC or ED. Recorded information included urgency, diagnostic tests, and follow-up contacts. Descriptive figures were determined for patient flows in GPC and ED for urgent contacts and non-urgent contacts.

Results  We included 319 GPC contacts and 356 ED contacts, of which 78% were non-urgent. The majority of GPC contacts were completed at the GPC without follow-up; 37% of non-urgent patients had a follow-up contact, usually with primary care. Only 5% of non-urgent GPC patients received diagnostic tests compared to 63% of non-urgent ED patients (mostly X-rays). The majority of non-urgent ED patients (88%) had a follow-up contact, usually at an outpatient clinic (67%). Most non-urgent ED patients (83%) who received a diagnostic test also had an outpatient clinic follow-up contact. Of urgent ED patients, the majority had a follow-up contact (85%), mostly with an outpatient clinic (74%).

Conclusion  Although most out-of-hours care patients present non-urgent health problems, at the ED they are more likely to receive diagnostic tests and follow-up contacts. This may reflect differences in patient populations between the ED and GPC or suggest opportunities for improving efficiency of planning follow-up contacts.

Rationale, aims and objectives  We developed a novel Internet-based blended learning programme that allows busy health care professionals to attain core competency in clinical research. This study details the educational strategies and learning outcomes of the programme.

Method  This study was conducted at Kyoto University and seven satellite campuses from September 2009 to March 2010. A total of 176 health care professionals who had never attempted to attain core competency in clinical research were enrolled. The participants were supplied with a novel programme comprising the following four strategies: online live lectures at seven satellite campuses, short examinations after each lecture, an Internet-based feedback system and an end-of-course examination. We assessed the proportion of attendance at the lectures as the main outcome. In addition, we evaluated interaction via the feedback system and scores for end-of-course examination.

Results  Of the 176 participants, 134 (76%) reported working more than 40 hours per week. The mean proportion of attendance over all 23 lectures was 82%. A total of 156 (89%) participants attended more than 60% of all lectures and were eligible for the end-of-course examination. A total of the participants accessed the feedback system 3564 times and asked 284 questions. No statistically significant differences were noted in the end-of-course scores among medical doctors, pharmacists, registered nurses and other occupations.

Conclusions  We developed an Internet-based blended learning programme providing core competency in clinical research. Most busy health care professionals completed the programme successfully. In addition, the participants could attain the core competency effectively, regardless of their occupation.

Rationale, aims and objectives  Drug-eluting coronary stents (DES) rapidly dominated the marketplace in the United States after approval in 2003, but utilization rates were initially lower among African American patients. We assess whether racial differences persisted as DES diffused into practice.

Methods  Medicare claims data were used to identify coronary stenting procedures among elderly patients with acute coronary syndromes (ACS). Regression models of the choice of DES versus bare mental stent controlled for demographics, ACS type, co-morbidities and hospital characteristics. Diffusion was assessed in the short run (2003–2004) and long run (2007), with the effect of race calculated to allow for time-varying effects.

Results  The sample included 381 887 Medicare beneficiaries treated with stent insertion; approximately 5% were African American. Initially (May 2003–February 2004), African American race was associated with lower DES use compared to other races (44.3% versus 46.5%, P < 0.01). Once DES usage was high in all patients (March–December 2004), differences were not significant (79.8% versus 80.3%, P = 0.45). Subsequent concerns regarding DES safety caused reductions in DES use, with African Americans having lower use than other racial groups in 2007 (63.1% versus 65.2%, P < 0.01).

Conclusions  Racial disparities in DES use initially disappeared during a period of rapid diffusion and high usage rates; the reappearance of disparities in use by 2007 may reflect DES use tailored to unmeasured aspects of case mix and socio-economic status. Further work is needed to understand whether underlying differences in race reflect decisions regarding treatment appropriateness.

Rationale  Herpes zoster (shingles) is a localized neurocutaneous eruption of blisters caused by reactivation of the varicella zoster virus. The cost of care for herpes zoster and its complications is estimated at $1.1 billion. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends a one-time dose of the vaccine for adults aged 60 years or older. Despite that recommendation, utilization of the vaccine is very low. One way to boost the delivery of preventive services such as vaccinations is with a computerized clinical decision support system. Our study found that the herpes zoster vaccination rate increased significantly after the implementation of such a system.

Aims  To study utilization of herpes zoster vaccine before and after the implementation of a web-based clinical decision support software solution in a primary care practice.

Methods  Billing data was utilized to determine number of herpes zoster vaccination administered to patients for a 12-month period during the implementation of the software solution.

Results  The utilization of vaccinations improved from 63 to 117 (53.8% increase) for one primary care practice and from 54 to 127 (42.5% increase) in the other primary care practice.

Conclusion  Herpes zoster vaccination rate significantly improved with implementation of a web-based clinical decision support system.

Objective  The study aims to obtain the mean relative weights (MRWs) of the cost of care through the retrospective application of the adjusted clinical groups (ACGs) in several primary health care (PHC) centres in Catalonia (Spain) in routine clinical practice.

Methods  This is a retrospective study based on computerized medical records. All patients attended by 13 PHC teams in 2008 were included. The principle measurements were: demographic variables (age and sex), dependent variables (number of diagnoses and total costs), and case-mix or co-morbidity variables (International Classification of Primary Care). The costs model for each patient was established by differentiating the fix costs from the variable costs. In the bivariate analysis, the Student's t, analysis of variance, chi-squared, Pearson's linear correlation and Mann–Whitney–Wilcoxon tests were used. In order to compare the MRW of the present study with those of the United States (US), the concordance [intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC)] and the correlation (coefficient of determination: R²) were measured.

Results  The total number of patients studied was 227 235, and the frequentation was 5.9 visits/habitant/year) and with a mean diagnoses number of 4.5 (3.2). The distribution of costs was €148.7 million, of which 29.1% were fixed costs. The mean total cost per patient/year was €654.2 (851.7), which was considered to be the reference MRW. Relationship between study-MRW and US-MRW: ICC was 0.40 [confidential interval (CI) 95%: 0.21–0.60] and the CCC was 0.42 (CI 95%: 0.35–0.49). The correlation between the US MRW and the MRW of the present study can be seen; the adjusted R² value is 0.691. The explanatory power of the ACG classification was 36.9% for the total costs. The R² of the total cost without considering outliers was 56.9%.

Conclusions  The methodology has been shown appropriate for promoting the calculation of the MRW for each category of the classification. The results provide a possible practical application in PHC clinical management.

Background  Currently, we have different scales to estimate the cardiovascular risk of one individual. The most commonly used in clinical practice are the Framingham method and the SCORE project. Both are based on mathematical models that take into account the presence and intensity of various risk factors for cardiovascular morbidity and mortality.

Aims and objectives  The aim of our study was to develop a measurement system that allows unifying criteria of both models. Thus, we will be able to estimate the cardiovascular risk globally in a cohort of patients instead of individually.

Methods  The study included a representative subgroup of 50 patients treated at in the Endocrinology Service of Virgen de las Nieves University Hospital, Granada, below 30 years or above 75 years. The equations used in the present study were in strict compliance with the original publications. The reliability and validity of results were tested, comparing them with results obtained using calculation programs developed, available on-line. The degree of similarity was determined by means of the Dice index and the distance between our values and those of the other programs were compared by using the expression: D_a–b = √Σ(a − b)²

Results  The results of the present study demonstrated our application to be reliable and valid for cardiovascular risk assessment. Our observations also demonstrated differences in the criteria applied to create cardiovascular risk calculation tools. This may have repercussions on clinical decisions for some patients, suggesting a need to compare and standardize these criteria, ensuring that programs developed for this calculation correctly manage the different risk categories considered.

Conclusion  The present study validates a computer tool developed for the simultaneous calculation of cardiovascular disease probability by applying Framingham-Anderson and Framingham-Wilson methods, the Spanish adaptations of Regicor and Dorica, and the SCORE project.

Rationale, aims and objectives  The study aims to investigate the effects of a patient safety advisory on patients' risk perceptions, perceived behavioural control, performance of safety behaviours and experience of adverse incidents.

Method  Quasi-experimental intervention study with non-equivalent group comparison was used. Patients admitted to the surgical department of a Swiss large non-university hospital were included. Patients in the intervention group received a safety advisory at their first clinical encounter. Outcomes were assessed using a questionnaire at discharge. Odds ratios for control versus intervention group were calculated. Regression analysis was used to model the effects of the intervention and safety behaviours on the experience of safety incidents.

Results  Two hundred eighteen patients in the control and 202 in the intervention group completed the survey (75 and 77% response rates, respectively). Patients in the intervention group were less likely to feel poorly informed about medical errors (OR = 0.55, P = 0.043). There were 73.1% in the intervention and 84.3% in the control group who underestimated the risk for infection (OR = 0.51, CI 0.31–0.84, P = 0.009). Perceived behavioural control was lower in the control group (mean_Con = 3.2, mean_Int = 3.5, P = 0.010). Performance of safety-related behaviours was unaffected by the intervention. Patients in the intervention group were less likely to experience any safety-related incident or unsafe situation (OR for intervention group = 0.57, CI 0.38–0.87, P = 0.009). There were no differences in concerns for errors during hospitalization. There were 96% of patients (intervention) who would recommend other patients to read the advisory.

Conclusions  The results suggest that the safety advisory decreases experiences of adverse events and unsafe situations. It renders awareness and perceived behavioural control without increasing concerns for safety and can thus serve as a useful instrument for communication about safety between health care workers and patients.

Rationale, aims and objectives  One of the main barriers against the implementation of evidence-based medicine (EBM) is the lack of search skills, an element that affects the finding of the best available evidence. Faculty staff should be capable of using the best evidence in practice and of teaching students to implement EBM elements. They should be familiar with search strategies and evidence databases. The aim of this study is to compare the application of evidence databases by faculties and by residents with no training in this field.

Methods  Two hundred fifty-seven faculties and first-year residents of the Tabriz University of Medical Sciences filled out a valid self-administered questionnaire on information-seeking behaviour from August 2008 to June 2010. A chi-square test was used to compare the variables.

Results  There were 52.1% of the respondents who were faculty members and 47.9% were residents. Only 8.7% used the Internet for their practice mostly. While Google was the most used resource, TRIP and Cochrane were less used. Significantly, the faculties used these resources more than the residents in both cases. Furthermore, two-thirds of the participants were unfamiliar with medical subject headings (MeSH), and only 14.5% consulted a clinical librarian for help.

Conclusion  Significantly, clinicians used evidence databases and online resources minimally for their practice. Additionally, as the faculties used EBM resources more than the residents, this programme should be considered for inclusion in the curricula of medical schools.

Objectives  In view of forthcoming ‘payment by results’ (PbR) for mental health, increasing number of National Health Service (NHS) Trusts are reorganizing their community services for working age adults to create care pathways. However, research base for the care pathways model in mental health is limited. Our NHS Foundation Trust was one of the first to introduce care pathways for community psychiatry in the UK. We have carried out a qualitative study to evaluate how this model works out in practice, including its impact on quality of patient care, mental health professionals and primary care.

Methods  We interviewed doctors, multidisciplinary staff and Trusts managers (19 in total). Transcripts of recorded interviews were coded and analysed thematically using a grounded theory approach.

Results  Overall, despite teething problems, working in pathways was generally seen as a positive change. It led to more focused interventions being offered, and practitioners being held to account over clear standards of care. It is more cost-effective and allows for active case management and clear clinical leadership. It is recovery focused and encourages social inclusion. The arbitrary time frame, strict criteria and thresholds for different teams can create issues. Improved communication, flexible and patient-centred approach, staff supervision, and increasing support to primary care were felt to be central to this model working efficiently and effectively.

Conclusions  Introduction of care pathways is an important step towards effective implementation of PbR for mental health. Our study would inform future research into care pathways, facilitate organizational learning and help to improve effectiveness of services.

Rational, aims and objectives  The aim of this study was to describe the characteristics of electronic medication-related information (e-MRI) via Internet offered by the hospital settings in Taiwan.

Methods  The structured Internet search and comprehensive review were performed on the most commonly used search engines in Taiwan. The assessment checklists were developed to describe the characteristics of general, e-MRI in the years 2008 and 2010, and specific digoxin information in 2011 based on the operational definitions derived from other studies. The descriptive analyses and chi-square tests for the retrieved data were performed.

Results  With approximately 15% of hospital settings providing general, e-MRI on their websites, their content varied but was not statistically significant, and different among the providers from different levels of hospitals and in different years. More medical centres provided the information with the updated dates and contact approaches than the smaller scale hospitals. Little was found about reference citation and authorships for those general, e-MRI websites. More medical centres created the accesses to search for the individual prescription in the corresponding settings and the specific information about digoxin storage. However, more district hospitals provided the precaution and dosage form information about digoxin.

Conclusions  The providers to offer the e-MRI via hospital websites in Taiwan could be more responsible for its update, authorship and evidence. Further, the provision of electronic medication-related information via the Internet should be regularly examined or audited by the neutral personnel or organizations to ensure its quality.

Background  Colorectal cancer (CRC) is one of the most common types of cancer in European countries and associated with a high mortality rate. A 16% relative risk reduction (RRR) of mortality was found in a meta-analysis based on four randomized controlled trials (RCT) on CRC screening. The aim of this paper was to scrutinize these trials for potential biases and assess their influence on the screening trials.

Methods  The four RCTs were reviewed based on the principles of ‘Critical Appraisal of the Medical Literature’. Principal investigators of the four RCTs were contacted to clarify uncertainties in their study. Data were collected from The Danish Data Archives. Authors of the Cochrane review were contacted.

Results  Six biases were identified, of which five favour screening. Three of the biases identified were specific to CRC screening: type of diagnostic method, place of surgery and diagnostic delay.

Conclusion  The 16% RRR in CRC mortality found in the updated Cochrane review's meta-analysis is overestimated.

Rationale, aims and objectives  Adverse events still occur despite ongoing efforts to reduce harm to patients. Contributory factors to adverse events are often due to limitations in clinicians’ non-technical skills (e.g. communication, situation awareness), rather than deficiencies in technical competence. We developed a behavioural rating system to provide a structured means for teaching and assessing scrub practitioners’ (i.e. nurse, technician, operating department practitioner) non-technical skills.

Method  Psychologists facilitated focus groups (n = 4) with experienced scrub practitioners (n = 16; 4 in each group) to develop a preliminary taxonomy. Focus groups reviewed lists of non-technical-skill-related behaviours that were extracted from an interview study. The focus groups labelled skill categories and elements and also provided examples of good and poor behaviours for those skills. An expert panel (n = 2 psychologists; n = 1 expert nurse) then used an iterative process to individually and collaboratively review and refine those data to produce a prototype skills taxonomy.

Results  A preliminary taxonomy containing eight non-technical skill categories with 28 underlying elements was produced. The expert panel reduced this to three categories (situation awareness, communication and teamwork, task management), each with three underlying elements. The system was called the Scrub Practitioners’ List of Intraoperative Non-Technical Skills system. A scoring system and a user handbook were also developed.

Conclusion  A prototype behavioural rating system for scrub practitioners’ non-technical skills was developed, to aid in teaching and providing formative assessment. This important aspect of performance is not currently explicitly addressed in any educational route to qualify as a scrub practitioner.

Objectives  We evaluated the performance of first trimester screening for Down syndrome in women less than 35 years of age (study group) and in women aged 35 years or more (control group) in an unselected low-risk population.

Methods  The study group comprised a total of 63 945 women who participated in the first trimester combined screening in public health care in Finland during the study period of 1 May 2002 to 31 December 2008. Women at the age of 35 or more (n = 13 004) were controls. Prevalence of Down syndrome, detection rate, false positive rate and number of invasive procedures needed to detect a single case of Down syndrome were analyzed in both groups.

Results  The overall prevalence of Down syndrome (n = 73) in the study group was 1:876. The number of detected cases was 54. The detection rate was 74.0% with a false positive rate of 2.8%. Number of invasive procedures needed to detect a single case of Down syndrome was 33. In the control group, the detection rate was 87.0% with a false positive rate of 11.9%. The number of invasive procedures needed to detect a single case of Down syndrome was 15. The differences in detection rate and false positive rate were significant, P < 0.012, P < 0.001, respectively.

Conclusion  The overall detection rate given for the entire population is an overestimate for a woman younger than the age of 35, which should be taken into consideration when counselling women of that age.

Rational, aims and objectives  Sustainability of new methods implemented in health care is one of the most central issues in addressing the gap between research and practice, but is seldom assessed in implementation studies. The aim of this study was to evaluate the implementation of a new tool for lifestyle intervention in primary health care (PHC) 2 years after the introduction, and assess if the implementation strategy used influenced sustainability.

Method  A computer-based lifestyle intervention tool (CLT) was introduced at six PHC units in Sweden in 2008, using two implementation strategies: explicit and implicit. The main difference between the strategies was a 4-week test period followed by a decision session, included in the explicit strategy. Evaluations were performed after 6, 9 and 24 months. After 24 months, the RE-AIM framework was applied to assess and compare outcome according to strategy.

Results  A more positive outcome regarding reach, effectiveness, adoption and implementation in the explicit group could be almost completely attributed to one of the units. Maintenance was low and after 24 months, differences according to strategy were negligible.

Conclusion  After 24 months, the most positive outcomes regarding all RE-AIM dimensions were found in one of the units where the explicit strategy was used. The explicit strategy per se had some effect on the dimension effectiveness, but was not associated with sustainability overall. Staff at the most successful unit earlier had positive expectations regarding the CLT and found it compatible with existing routines.

Objectives  The efficiency of a hospital's operating room (OR) management can affect its overall profitability. However, existing indicators that assess OR management efficiency do not take into account differences in hospital size, manpower and functional characteristics, thereby rendering them unsuitable for multi-institutional comparisons. The aim of this study was to develop indicators of OR management efficiency that would take into account differences in hospital size and manpower, which may then be applied to multi-institutional comparisons.

Methods  Using administrative data from 224 hospitals in Japan from 2008 to 2010, we performed four multiple linear regression analyses at the hospital level, in which the dependent variables were the number of operations per OR per month, procedural fees per OR per month, total utilization times per OR per month and total fees per OR per month for each of the models.

Results  The expected values of these four indicators were produced using multiple regression analysis results, adjusting for differences in hospital size and manpower, which are beyond the control of process owners' management. However, more than half of the variations in three of these four indicators were shown to be explained by differences in hospital size and manpower.

Conclusion  Using the ratio of observed to expected values (OE ratio), as well as the difference between the two values (OE difference) allows hospitals to identify weaknesses in efficiency with more validity when compared to unadjusted indicators. The new indicators may support the improvement and sustainment of a high-quality health care system.

Rationale, aims and objectives:  Routine outcome monitoring (ROM) was developed to establish the outcome of psychotherapeutic and pharmacological treatments through repeated assessments before, during and after treatment. Although standardization of psychiatric assessments and their reference values are essential for patient care, for various ROM instruments reference values are not available. The aim of the Leiden ROM Study is to generate reference values for 22 ROM instruments, covering generic and specific mood, anxiety and somatoform (MAS) disorders, for the general population. This article describes the extensive process of recruitment, as well as baseline characteristics of patient versus non-patient groups.

Method:  Cross-sectional study in randomly selected participants aged 18–65 years from the Dutch population, included through general practitioners.

Results:  Extensive demographic, psychosocial, mental health, and biological data from 1302 participants, recruited via general practitioners, were collected during a two-hour standardized assessment including observer-rated and self-report scales. These data will be compared with corresponding data from 7840 patients with psychopathology who were referred to secondary care. On-going quality control and calibration ensured maintenance of high quality during data collection.

Conclusions:  This reference group study for mental health assessments is the first study of this size carried out in the Netherlands. The results of this study are expected to be of value to secondary psychiatric care because they allow the indication of progress in health, treatment effect and possible termination of treatment. Additionally, the reference values can be used by primary care physicians as decision threshold for referral to specialized mental health care and vice versa.

Rational, aims and objectives  The study aims to determine the extent to which the addition of post-admission information via time-dependent covariates improved the ability of a survival model to predict the daily risk of hospital death.

Method  Using administrative and laboratory data from adult inpatient hospitalizations at our institution between 1 April 2004 and 31 March 2009, we fit both a time-dependent and a time-fixed Cox model for hospital mortality on a randomly chosen 66% of hospitalizations. We compared the predictive performance of these models on the remaining hospitalizations.

Results  All comparative measures clearly indicated that the addition of time-dependent covariates improved model discrimination and prominently improved model calibration. The time-dependent model had a significantly higher concordance probability (0.879 versus 0.811) and predicted significantly closer to the number of observed deaths within all risk deciles. Over the first 32 admission days, the integrated discrimination improvement (IDI) and net reclassification improvement (NRI) were consistently above zero (average IDI of +0.0200 and average NRI of 62.7% over the first 32 days).

Conclusions  The addition of time-dependent covariates significantly improved the ability of a survival model to predict a patient's daily risk of hospital death. Researchers should consider adding time-dependent covariates when seeking to improve the performance of survival models.

Background  Development of chronic disease risk prediction models has become a growing area of research in recent years. The internal validity of such models is sometimes lower than estimated from the development sample. Overfitting or overoptimism of the developed model and/or differences between the samples are likely causes for this. For modelling of an uncommon outcome, bootstrapping for overoptimism is the preferred method for afterwards shrinking of regression coefficients and the model's discrimination and calibration for overoptimism. However, computer programs for different types of bootstrap validation are not readily available. We developed two SAS macro programs – one for the simple bootstrap that compares the discriminatory performance of the Cox proportional hazards model from the original sample in bootstrap samples; and another (which is more efficient), known as stepwise bootstrap validation, that makes the same comparison but from models developed by variable selection from bootstrap samples in the original sample. These are illustrated through an example from cardiovascular disease (CVD) risk prediction.

Methods  Two SAS macro programs for Cox proportional hazards model using Proc PHREG were developed for estimating overoptimism in Harrell's C and Somers' D statistics. The computer programs were applied to data on CVD incidence for a Framingham cohort that combined both the original and offspring exams. The risk factors considered were current smoking, diabetes, age, sex, systolic blood pressure, diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, triglycerides and body mass index.

Results  The degree of overoptimism in both Harrell's C and Somers' D statistics were low. Both these statistics were corrected for overoptimism by subtracting overoptimism from their observed values. Between the two bootstrap validation algorithms, the degree of overoptimism was estimated to be higher for stepwise bootstrap validation.

Conclusion  The programs are very useful for evaluating the ‘overoptimism corrected’ predictive performance of Cox proportional hazards model.

Objective  The study aims to identify key enablers fostering clinical risk management (CRM) in hospitals to guide health care in this vital area of patient safety.

Method  A cross-sectional survey was conducted at the national level in 324 Swiss hospitals in 2007–2008 to assess the relationship between key elements and systematic CRM. Therefore, a comprehensive monitoring instrument for CRM was used for the first time. Organizational factors (e.g. strategy, coordination, resources) and structural conditions (e.g. hospital size) were tested as key elements. CRM was assessed by evaluating its maturity (i.e. the level of CRM development) by 12 theoretically derived indices joining together essential aspects of CRM at the hospital level and the service level. Chi-square measures were used to analyse the relationships between organizational factors or structural conditions and maturity of CRM.

Results  Participation in this voluntary survey was good, with CRM experts of 138 out of 324 hospitals responding (response rate 43%). Three key enablers for CRM were identified: implementing a function for central CRM coordination, assuring dialogue with and between the different hospital services, and developing strategic CRM objectives.

Conclusions  This study offers, for the first time, an assessment of the maturity of hospitals' CRM and identifies key enablers related to CRM. This is a feasible first step in guiding hospitals to shape their CRM and presents a basis for future studies, for example, linking CRM to outcome data.

Background  Health information exchange (HIE) allows clinicians to access patient level health care information. HIE can potentially improve patient care in emergency departments.

Methods  We present a selected piece of evaluation of an HIE implementation in three Midwestern emergency departments. Data were collected through over 210 hours of direct observations and short interviews with 13 clinicians.

Results  The results suggest that the usage rate of the HIE was low. Moreover, two ways of unreported use of the HIE system by clinicians was uncovered: (1) The HIE system was being used mostly for patients only with specific characteristics. (2) The information from the HIE system could be used to confront with the patients.

Discussion  This study provides a case of how social system may shape a HIE technology. In order to fully benefit from HIE, understanding organizational and social context during the HIE design and implementation is needed. Such an understanding will also allow us to identify and detail required additional resources and organizational interventions that will complement HIE such as a case management strategy.

Rationale, aims and objectives  There is little evidence regarding the benefit of stress ulcer prophylaxis (SUP) outside a critical care setting. Overprescription of SUP is not devoid of risks. This prospective study aimed to evaluate the use of proton pump inhibitors (PPIs) for SUP in a general surgery department.

Method  Data collection was performed prospectively during an 8-week period on patients hospitalized in a general surgery department (58 beds) by pharmacists. Patients with a PPI prescription for the treatment of ulcers, gastro-oesophageal reflux disease, oesophagitis or epigastric pain were excluded. Patients admitted twice during the study period were not reincluded. The American Society of Health-System Pharmacists guidelines on SUP were used to assess the appropriateness of de novo PPI prescriptions.

Results  Among 255 patients in the study, 138 (54%) received a prophylaxis with PPI, of which 86 (62%) were de novo PPI prescriptions. A total of 129 patients (94%) received esomeprazole (according to the hospital drug policy). The most frequent dosage was at 40 mg once daily. Use of PPI for SUP was evaluated in 67 patients. A total of 53 patients (79%) had no risk factors for SUP. Twelve and two patients had one or two risk factors, respectively. At discharge, PPI prophylaxis was continued in 33% of patients with a de novo PPI prescription.

Conclusions  This study highlights the overuse of PPIs in non-intensive care unit patients and the inappropriate continuation of PPI prescriptions at discharge. Treatment recommendations for SUP are needed to restrict PPI use for justified indications.

Rationale, aims and objectives  Poor information quality (IQ) must be understood as a business problem rather than systems problem. In health care organization, what is required is an effective quality management that continuously manages and reviews the factors influencing IQ in health information systems (HIS) so as to achieve the desired outcomes. Hence, in order to understand the issues of information quality management (IQM) practices in health care organizations, a more holistic evaluation study should be undertaken to investigate the IQM practices in health care organizations. It is the aim of this paper to identify the significant evaluation criteria that influence the production of good IQ in HIS.

Methods  Six selected frameworks and best practices both from health informatics and information systems literature have been reviewed to identify the evaluation criteria from the perspective of human, organizational and technological factors.

Results  From the review, it was found that human and organization factors are of greater significance in influencing HIS IQ. Our review depicts that there is still shortage in finding a comprehensive IQM evaluation framework. Thus, the criteria from the frameworks reviewed can be used in combination for more comprehensive evaluation criteria. Integrated IQM evaluation criteria for HIS are then proposed in this study.

Conclusions  Poor IQ is the result of complex interdependency within sociotechnical factors in health care organization and lack of formal and structured IQM practices. Thus, a feedback mechanism such as evaluation is needed to understand the issues in depth in the future.

Rationale, aims and objectives  A collegial relationship between prescribers and antimicrobial stewards, along with an appreciation of the importance of antimicrobial stewardship, is essential for optimal functioning of an antimicrobial stewardship program (ASP). Programmatic adjustments based on feedback may be beneficial to the success of ASPs. The objective of this study is to assess the experience of house officers with the ASP and the effect of programmatic improvements.

Methods  A survey of house officers at an academic medical centre was conducted assessing their experience with the ASP before (2008) and after (2010) programmatic interventions were instituted.

Results  Of 225 house officer surveys sent, we received 97 responses (88% from medical doctors). The majority indicated that ASP was either very or somewhat important in fighting antibiotic resistance (100%), improving patient care (97%), preventing medication errors (91%) and containing health care costs (89%). Ninety-one per cent indicated either a very good or good educational experience with the ASP. The ASP often reminded respondents of a patient's allergy (31%), to adjust for renal function (78%), and 38% were prevented from making a medication error. Comparing 2008 and 2010, a higher proportion of respondents in 2010 said they had a very good or good educational experience with ASP [84% versus 98%, odds ratio (OR) = 8.40, P = 0.022] and a lower proportion of respondents reported confusion about ASP procedures (59% versus 39%, OR = 0.43, P = 0.048).

Conclusions  House officer feedback resulted in ASP policy changes which improved the ASP experience.

Rationale, aims and objectives  Sufficient evidence suggests that health information technology (HIT) will soon become part of physician procedure. This paper poses that the outcome of using HIT is affected by the intentions of use. Note that ethical indoctrination is a crucial mechanism for monitoring physicians. Judicious and sufficient use of HIT is expected to be the prerequisite for deploying these technologies to help in delivering better care. This research paper, therefore, aims to define professional concerns and intent to use HIT, and identify their associations.

Methods  A survey study was conducted to collect data for developing a seven-dimensional eHealth success measure. This paper focuses on deriving a structural equation model that can explain the associations among professional concerns and intent to use HIT. Statistical analyses were, therefore, only performed on the Intent to Use and Physician Attributes constructs.

Results  The statistical results show that altruism, autonomy, physician-patient relationship and (subconscious) autonomy significantly associate with each other at least at P < 0.05. Only altruism shows to be a significant determinant of intent to use HIT (with P = 0.00005). Other professional concerns only associate with it indirectly through altruism.

Conclusions  Medicine has been a science-using and compassionate practice. Medical practice including HIT use may only be reliably assessed from a sociotechnical perspective. Professional concerns show to be associated with intent to use HIT is an expected result. This research direction may contribute to deriving policies to deploy HIT for delivering better care through implementing sufficient and judicious HIT use.

Aims  To estimate the potential gain of national screening programmes for colorectal cancer (CRC) by stool occult blood testing in the Nordic countries, with comparative reference to the burden of other causes of premature death.

Methods  Implementation of national screening programmes for CRC was modelled among people 55–74 years in accordance with the 2011 Cochrane review of biannual screening, using the faecal occult blood test (FOBT) for 10 years, resulting in 15% relative risk reduction in CRC deaths among all those invited [intention-to-treat; relative risk 0.85; confidence interval (CI) 0.78 to 0.92]. Our calculations are based on the World Health Organization and national databanks on death causes (ICD-10) and the mid-year number of inhabitants in the target group. For Finland, Denmark, Norway and Sweden, we used data for 2009. For Iceland, due to the population's small size, we calculated mean mortality for the period 2005–2009.

Results  Invitation to a CRC screening programme for 10 years could influence 0.5–0.9% (95%CI 0.4–1.2) of all deaths in the age group 65–74 years. Among the remaining 99% of premature deaths, around 50% were caused by lung cancer, other lung diseases, cardiovascular diseases and accidents, with some national variations.

Conclusions and implications  Establishment of a screening programme for CRC for people aged 55–74 can be expected to affect only a minor proportion of all premature deaths in the Nordic setting. From a public health perspective, prioritizing preventive strategies targeting more prevalent causes of premature death may be a superior approach.

Rationale  The prevention of human immunodeficiency virus/sexually transmitted diseases remains a significant global public health issue, especially among vulnerable populations.

Aims and objectives  To promote condom use skills among young urban African American men.

Methods  As a pilot study, a randomized controlled trial was conducted among 136 African American men aged 18–24 years recruited from urban communities in Chicago. Participants assigned to the intervention received 45–60 minutes of a one-on-one single-session condom promotion program delivered by trained facilitators while those assigned to the attention-matched comparison condition received a general health program. Longitudinally, 115 (85%) and 120 (88%) participants completed the 3-month and 6-month follow-up surveys, respectively.

Results  Overall, the study results indicate that positive effects were observed from baseline to 6-month follow-up for intervention participants relative to comparison condition participants for prior condom use (1.23–1.82 versus 1.34–0.97); condom use intention (2.51–3.19 versus 2.69–2.21); perceived condom availability (3.44–3.72 versus 3.42–3.38); positive reasons to use condoms (2.82–3.08 versus 2.95–1.99); favourable condom use attitude (2.41–2.69 versus 2.49–1.95); barriers to condom use (1.33–0.79 versus 1.25–1.85); and negative condom use attitude (1.45–0.66 versus 1.33–1.39), respectively.

Conclusions  We conclude that a brief single-session condom promotion program is effective in preventing high-risk sexual behaviours among urban young adult African American men.