Screening with mammography has the ability to detect breast cancer at an early stage but misses some cancers. Supporters of adjunct ultrasonography to the screening regimen argue that it might be a safe and inexpensive approach to reduce the false-negative rates of screening. Critics are concerned that adjunct ultrasonography will also increase the rate of false-positive findings and can lead to unnecessary biopsies and treatments in women at average risk.
The purpose of this review was to systematically assess the comparative benefits and harms of mammography with adjunct breast ultrasonography and mammography only in breast cancer screening.
We searched multiple electronic databases and the Cochrane Breast Cancer Group's Specialised Register (from 1995 to February 2012). To detect ongoing or unpublished studies, we searched trial registries and multiple sources of grey literature. Two researchers independently reviewed all abstracts and full-text articles against pre-defined eligibility criteria. We dually rated the risk of bias of studies and the strength of evidence based on established guidance.
We did not detect any controlled studies that provide evidence for (or against) the use of adjunct ultrasonography for screening in women at average risk for breast cancer. Extrapolations of results from women at elevated risk for breast cancer indicate that the false-positive rates in women at average risk who were recalled because of positive ultrasonographies will exceed 98%. In women with dense or very dense breast tissue, the evidence regarding the use of adjunct ultrasonography is not conclusive.
No methodologically sound evidence is available justifying the routine use of ultrasonography as an adjunct screening tool in women at average risk for breast cancer.
Clinicians should not use ultrasonography as a screening tool for breast cancer screening on a routine basis. The use should be limited to women with dense breasts for whom the accuracy of mammography is low, or for diagnostic purposes.
While continuity of care is an important component in the provision of mental health services, a universally accepted definition is missing. There is a need to identify areas of consensus and discrepancy in continuity theory and provide a foundation for advancing measurement capabilities. The purpose of this study was to systematically identify and examine scholarship on continuity in mental healthcare.
Using a focused literature review modelled on the Joanna Briggs Methodology for systematic reviews, MEDLINE, CINAHL, Embase, PsycINFO and Health STAR were searched from 1950 to 2011 for articles on the theoretical nature of continuity in mental healthcare. Included conceptualisations were subject to a theory analysis to critically examine similarities and differences. Next, a content analysis on the extracted data was used to identify a global understanding and set of theoretically defined concepts for the whole. Finally, the identified global concepts were compared with the original documents and to items identified on existing quantitative measurement tools to assess areas of consensus and discrepancy.
Seven documents describing the conceptualisation of continuity in mental healthcare were identified. From these, a deductive theoretical summary is proposed and theoretical consensus exists to support nine global concepts of continuity in mental healthcare. These global concepts include Longitudinality, Input & Individuality, Comprehensiveness, Flexible Consistency, Stability & Relationship, Accessibility, Information & Sharing, Realities, and Responsibility/Accountability. The original theories proposed by Dr Bachrach and colleagues and Dr Joyce and colleagues, as well as the ACSS-MH measurement tool, provide the best coverage of the proposed concepts.
Consensus exists across conceptualisations of continuity in mental healthcare, yet it is obscured by inconsistent use of language. Existing tools capture many of the associated concepts and elements, but none do so entirely. Further tool development and psychometric testing is needed. This study provides the foundational work required to advance research priorities in this area.
Self-determination and patient choice of end-of-life care are emphasised in palliative care. Advance care planning (ACP) is an approach to enabling patients' choices. The use of ACP has not been extensively studied in our current context. Little is known about oncology care nurses' views and the barriers they face in the implementation of ACP.
The aims of this study were to assess the uptake of ACP by health professionals and explore nurses' perceived barriers for implementing ACP.
This study employed a pre- and post-implementation audit design using the Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRIP) programs. An education programme on ACP was provided between pre-and post-implementation audits. Nurses and medical professionals (pre-audit, n = 32; post-audit, n = 30) working in oncology departments were invited to complete a questionnaire based on the audit criteria. A convenience sample of 25 nurses participated in the focus group interview. Interview data were analysed by content analysis.
The post-audit results were lower than the pre-audit results with a range of decreased compliance from 1% for criterion 5 to 14% for criterion 6. Lack of time to implement ACP was the most frequently raised barrier by oncology nurses.
The study findings were disappointing, but this first audit is significant to provide insights for future dissemination and implementation of ACP interventions. An ongoing mandatory professional development programme in ACP for healthcare staff is promising to promote the uptake of ACP in healthcare settings.
Appropriate management of hypertension reduces the risk of death from stroke and cardiac disease and includes routine assessment for target organ damage and estimation of cardiovascular risk. However, implementation of evidence-based hypertension management guidelines is unsatisfactory. We explore the use of audit and feedback as a quality improvement (QI) strategy for reducing the knowledge practice gap in hypertension care in a resource poor setting.
The aim of this study is to determine the level of compliance to evidence-based guidelines on assessment of cardiovascular risk and target organ damage among patients with hypertension in Thika Level 5 Hospital in central Kenya and to implement best practice with regard to evidence utilisation among clinicians in the hospital.
A retrospective clinical audit done in three phases spread over 5 months. Phase one involved identifying five audit criteria on assessment of cardiovascular risk and target organ damage in patients with hypertension and conducting a baseline audit in which compliance to audit criteria, blood pressure control and drug prescription practices were assessed. Phase two involved identifying barriers to compliance to audit criteria and strategies to overcoming these barriers. The third phase was a follow-up audit.
There was no use of a cardiovascular risk assessment tool in both audits (0% vs. 0%; P = 1.00). Testing urine for haematuria and proteinuria reduced from 13% to 8% (P = 0.230) while taking a blood sample for measuring blood glucose, electrolytes and creatinine levels improved from 11% to 17% (P = 0.401). Performance of fundoscopy and electrocardiography remained unchanged at 2% and 8%, respectively (P = 0.886 and P = 0.898). High patient load was identified as the biggest barrier to implementation of best practice. Blood pressure control improved from 33% to 70% (P ≤ 0.001), whereas the proportion of patients on two or more recommended antihypertensive drugs rose from 59% to 72% (P = 0.158).
In Thika Level 5 Hospital, audit and feedback has a poor impact on assessment of cardiovascular risk and target organ damage but positive impact on blood pressure control and prescription practices. Time and sample size may have affected observed results. Additional audits and alternative QI strategies are warranted.
Diaper dermatitis is one of the most common skin problems in children often caused by irritants that promote skin breakdown, such as moisture and faecal enzymes. It has been estimated that the incidence of diaper dermatitis is as high as 50% in children receiving chemotherapy. The scientific literature suggests a variety of preventative measures, but only a minority are systematically tested and supported by clinical evidence.
The purpose of this paper is to adapt and implement a skincare guideline to better prevent diaper dermatitis in the paediatric oncology population.
The Knowledge to Action process was used to guide the adaptation and implementation of the new guideline. As part of this process, different tools were used to identify and review selected knowledge (Appraisal of Guidelines Research Evaluation instrument), to tailor and adapt knowledge to the local context (ADAPTE process), to implement interventions (Registered Nurses' Association of Ontario toolkit) and to evaluate outcomes (qualitative analysis). The main outcomes measured included implementation of the guideline and nursing practice change.
The guideline was successfully implemented as reported by nurses in focus group sessions and as measured by changes in nursing documentation.
The implementation of the guideline was successful on the account of the interplay of three core elements: The level and nature of the evidence; the context in which the research was placed; the method in which the process was facilitated.
This project was designed to implement the best practice in nasogastric tube feeding of critically ill patients in a neurosurgical intensive care unit.
Clinical audit software programmes of the Joanna Briggs Institute (Practical Application of Clinical Evidence System and Getting Research Into Practice) were used in this project. A baseline audit, feedback, follow-up audit cycle was followed. The audit team analysed the results of the baseline audit, conducted a situational analysis and formulated and implemented a strategic plan to improve the nasogastric tube care.
Initially, the compliance with the criteria varied from 0% to 87%. The Getting Research Into Practice phase of the project identified several barriers of each criterion. After implementation of best practice, the following audit showed an improvement in all criteria, ranging from 33% to 95%. Marked improvement was achieved in the criteria that were not strictly required by local standards, such as rechecking the tube position, assessing the gastric residual volume and maintaining the airway cuff pressure.
The project had some success in improving the practice of nasogastric tube feeding. Collaboration, education, monitoring and a reward system were the key elements used to drive the project. Further actions and changes are expected to produce 100% compliance.
Familial hypercholesterolaemia (FH) is a relatively common genetic disorder associated with high risk of coronary heart disease that is preventable by early diagnosis and treatment. In a previous article, we reviewed the evidence for clinical management, models of care and health economic evaluations. The present commentary emphasises that collective action is needed to strengthen our approaches to evidence-based care, including better diagnosis and access to effective therapies. We detail how contemporary innovations in inter-operable, web-based, open-source and secure registries can provide the supporting infrastructure to: (i) address a current gap in the flow of data for measuring the quality of healthcare; (ii) support basic research through provision of high-quality, de-identified aggregate data; (iii) enable equitable access to clinical trials; and (iv) support efforts to disseminate evidence for best practice and information for care services. We describe how these aspects of enabling infrastructure will be incorporated into the development of a National FH Registry for Australasia, and proffer that a coordinated response to FH would be enhanced through a global network of inter-operable registries.