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Background: Since the early 1980s all European countries have given priority to reforming the management of health services. A distinctive feature of these reforms has also been the drive to co-opt professionals themselves into the management of services, taking on full time or part time (hybrid) management or leadership roles. However, although these trends are well documented in the literature, our understanding of the nature and impact of reforms and how they are re-shaping the relationship between medicine and management remains limited. Most studies have tended to be nationally specific, located within a single discipline and focused primarily on describing new management practices. This article serves as an Introduction to a special issue of BMC Health Services Research which seeks to address these concerns. It builds on the work of a European Union funded COST Action (ISO903) which ran between 2009 and 2013, focusing specifically on the changing relationship between medicine and management in a European context.Main Text: Prior to describing the contributions to the special issue, this Introduction sets the scene by exploring four main questions which have characterised much of the recent literature on medicine and management. First is the question of what we understand by the changing relationship between medicine and management and in particular which this means for the emergence of so called 'hybrid' clinical leader roles? A second question concerns the forces that have driven change, in particular those relating to the wider project of management reforms. Third, we raise questions of how medical professionals have responded to these changes and what factors have shaped their responses. Lastly we consider what some of the outcomes of greater medical involvement in management and leadership might be, both in terms of intended and unintended outcomes.Conclusions: The paper concludes by summarising the contributions to the special issue and highlighting the need to extend research in this area by focusing more on comparative dimensions of change. It is argued that future research would also benefit theoretically by drawing together insights from health policy and management literatures. [ABSTRACT FROM AUTHOR]

Background: Cloud computing is a recent and fast growing area of development in healthcare. Ubiquitous, on-demand access to virtually endless resources in combination with a pay-per-use model allow for new ways of developing, delivering and using services. Cloud computing is often used in an "OMICS-context", e.g. for computing in genomics, proteomics and molecular medicine, while other field of application still seem to be underrepresented. Thus, the objective of this scoping review was to identify the current state and hot topics in research on cloud computing in healthcare beyond this traditional domain. Methods: MEDLINE was searched in July 2013 and in December 2014 for publications containing the terms "cloud computing" and "cloud-based". Each journal and conference article was categorized and summarized independently by two researchers who consolidated their findings. Results: 102 publications have been analyzed and 6 main topics have been found: telemedicine/teleconsultation, medical imaging, public health and patient self-management, hospital management and information systems, therapy, and secondary use of data. Commonly used features are broad network access for sharing and accessing data and rapid elasticity to dynamically adapt to computing demands. Eight articles favor the pay-for-use characteristics of cloud-based services avoiding upfront investments. Nevertheless, while 22 articles present very general potentials of cloud computing in the medical domain and 66 articles describe conceptual or prototypic projects, only 14 articles report from successful implementations. Further, in many articles cloud computing is seen as an analogy to internet-/web-based data sharing and the characteristics of the particular cloud computing approach are unfortunately not really illustrated. Conclusions: Even though cloud computing in healthcare is of growing interest only few successful implementations yet exist and many papers just use the term "cloud" synonymously for "using virtual machines" or "web-based" with no described benefit of the cloud paradigm. The biggest threat to the adoption in the healthcare domain is caused by involving external cloud partners: many issues of data safety and security are still to be solved. Until then, cloud computing is favored more for singular, individual features such as elasticity, pay-per-use and broad network access, rather than as cloud paradigm on its own. [ABSTRACT FROM AUTHOR]

Background: The role of Artificial intelligence (AI) which is defined as the ability of computers to perform tasks that normally require human intelligence is constantly expanding. Medicine was slow to embrace AI. However, the role of AI in medicine is rapidly expanding and promises to revolutionize patient care in the coming years. In addition, it has the ability to democratize high level medical care and make it accessible to all parts of the world. Main text: Among specialties of medicine, some like radiology were relatively quick to adopt AI whereas others especially pathology (and surgical pathology in particular) are only just beginning to utilize AI. AI promises to play a major role in accurate diagnosis, prognosis and treatment of cancers. In this paper, the general principles of AI are defined first followed by a detailed discussion of its current role in medicine. In the second half of this comprehensive review, the current and future role of AI in surgical pathology is discussed in detail including an account of the practical difficulties involved and the fear of pathologists of being replaced by computer algorithms. A number of recent studies which demonstrate the usefulness of AI in the practice of surgical pathology are highlighted. Conclusion: AI has the potential to transform the practice of surgical pathology by ensuring rapid and accurate results and enabling pathologists to focus on higher level diagnostic and consultative tasks such as integrating molecular, morphologic and clinical information to make accurate diagnosis in difficult cases, determine prognosis objectively and in this way contribute to personalized care. [ABSTRACT FROM AUTHOR]

Background: Complementary and Alternative Medicine (CAM) is widely used throughout the UK and the Western world. CAM is commonly used for children and the decision-making process to use CAM is affected by numerous factors. Most research on CAM use lacks a theoretical framework and is largely based on bivariate statistics. The aim of this review was to identify a conceptual model which could be used to explain the decision-making process in parental choice of CAM. Methods: A systematic search of the literature was carried out. A two-stage selection process with predetermined inclusion/exclusion criteria identified studies using a theoretical framework depicting the interaction of psychological factors involved in the CAM decision process. Papers were critically appraised and findings summarised. Results: Twenty two studies using a theoretical model to predict CAM use were included in the final review; only one examined child use. Seven different models were identified. The most commonly used and successful model was Andersen's Sociobehavioural Model (SBM). Two papers proposed modifications to the SBM for CAM use. Six qualitative studies developed their own model. Conclusion: The SBM modified for CAM use, which incorporates both psychological and pragmatic determinants, was identified as the best conceptual model of CAM use. This model provides a valuable framework for future research, and could be used to explain child CAM use. An understanding of the decision making process is crucial in promoting shared decision making between healthcare practitioners and parents and could inform service delivery, guidance and policy. [ABSTRACT FROM AUTHOR]

Background: There is a health crisis in Turkmenistan similar to, but more severe than, in other Central Asian countries. This paper asks whether the health crisis in Turkmenistan is attributable to the consequences of the dictatorship under president Niyazov, who died in 2006. Methods: The basis for this paper was a series of semi-structured in-depth interviews with key informants complemented by an iterative search of internet sites, initially published as a report in April 2005, and subsequently updated with feedback on the report as well as a comprehensive search of secondary information sources and databases. Results: This paper describes in depth three areas in which the dictatorship in Turkmenistan had a negative impact on population health: the regime's policy of secrecy and denial, which sees the "solution" to health care problems in concealment rather than prevention; its complicity in the trafficking of drugs from Afghanistan; and the neglect of its health care system. Conclusion: The paper concludes that dictatorship has contributed to the health crisis facing Turkmenistan. One of the first tests of the new regime will be whether it can address this crisis. [ABSTRACT FROM AUTHOR]

Background: Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK Methods: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. Results: Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research. Discussion: By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts. [ABSTRACT FROM AUTHOR]

This paper comments on the role and emergence of the biopsychosocial model in modern medical literature and health care settings. The evolution of the biopsychosocial model and its close association with modern pain theory is also examined. This paper seeks to discuss the place of this model with respect to the management of hypothyroidism. This discussion represents a forerunner to a randomised control trial that will seek to investigate the effect of a biopsychosocial-based treatment regime on hypothyroidism. [ABSTRACT FROM AUTHOR]

Background: Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate.Methods: This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant "lab" to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management.Results: We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector.Conclusions: This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are "forced" or willing to take formal management roles. [ABSTRACT FROM AUTHOR]

Background: Contemporary approaches to rural generalist medicine training and models of care are developing internationally as part of an integrated response to common challenges faced by rural and remote health services and policymakers (addressing health inequities, workforce shortages, service sustainability concerns). The aim of this study was to review the literature relevant to rural generalist medicine.Methods: A scoping review was undertaken to answer the broad question 'What is documented on rural generalist medicine?' Literature from January 1988 to April 2017 was searched and, after final eligibility filtering (according to established inclusion and exclusion criteria), 102 articles in English language were included for final analysis.Results: Included papers were analysed and categorised by geographic region, study design and subject themes. The majority of articles (80%) came from Australia/New Zealand and North America, reflecting the relative maturity of programmes supporting rural generalist medicine in those countries. The most common publication type was descriptive opinion pieces (37%), highlighting both a need and an opportunity to undertake and publish more systematic research in this area. Important themes emerging from the review were: Definition Existing pathways and programmes Scope of practice and service models Enablers and barriers to recruitment and retention Reform recommendations There were some variations to, or criticisms of, the definition of rural generalist medicine as applied to this review, although this was only true of a small number of included articles. Across remaining themes, there were many similarities and consistent approaches to rural generalist medicine between countries, with some variations reflecting environmental context and programme maturity. This review identified recent literature from countries with emerging interest in rural generalist medicine in response to problematic rural health service delivery.Conclusions: Supported, coordinated rural generalist medicine programmes are being established or developed in a number of countries as part of an integrated response to rural health and workforce concerns. Findings of this review highlight an opportunity to better share the development and evaluation of best practice models in rural generalist medicine. [ABSTRACT FROM AUTHOR]

Background: Crisis resolution and home treatment (CRHT) is an emerging mode of delivering acute mental health care in the community. There is a paucity of knowledge regarding the workings of CRHT in the literature. This is the first paper in a series of three from the longitudinal survey of patients of a CRHT team in Norway, which was aimed at describing the characteristics of patients served, professional services provided, and clinical outcomes. This report focuses on describing the characteristics of the patients at admission. Methods: The study was a descriptive, quantitative study based on the patient data from a longitudinal survey of one CRHT team in Norway. The participants of the survey, a total of 363 patients, were the complete registration of patients of this team in the period from February 2008 to July 2009. Results: Although diverse in their characteristics, the patients were over represented by females, young to middle aged, and people on public support. The patients were mostly referred to the team by self/family members and primary care physicians. At admission, depression was the most prevalent symptom, the overall intensity level of mental health problems was low, and most of the patients had long-standing mental health problems. Conclusions: Self/family referral seems to be a critical route to receive services by CRTH teams as shown in our study, suggesting a need to examine policies that disallow this form of referral in some communities. The findings from our study show that the patients of the CRHT team, while mostly having long-standing mental health problems and had been receiving healthcare for them, did not have severe mental health problems at admission, although could have been in crises. There is a need for further studies to examine how people with severe mental health problems obtain services in time of crises, and to address the need to gain a greater understanding of the role of CRHT. [ABSTRACT FROM AUTHOR]

Background: Across the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policymakers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate. Methods: This three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies. Results: Despite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice. Conclusions: Interprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice. [ABSTRACT FROM AUTHOR]

Examining vulnerabilities within our current healthcare system we propose borrowing two tools from the fields of engineering and design: a) Reason's system approach 1 and b) User-centered design 23. Both approaches are human-centered in that they consider common patterns of human behavior when analyzing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in the context of healthcare. We argue that maintaining a human-centered orientation in clinical care, research, training, and governance is critical to the evolution of an effective and sustainable healthcare system. [ABSTRACT FROM AUTHOR]

Background: Although the painful shoulder is one of the most common dysfunctions of the locomotor apparatus, and is frequently treated both at primary healthcare centres and by specialists, little evidence has been reported to support or refute the effectiveness of the treatments most commonly applied. According to the bibliography reviewed, physiotherapy, which is the most common action taken to alleviate this problem, has not yet been proven to be effective, because of the small size of sample groups and the lack of methodological rigor in the papers published on the subject. No reviews have been made to assess the effectiveness of acupuncture in treating this complaint, but in recent years controlled randomised studies have been made and these demonstrate an increasing use of acupuncture to treat pathologies of the soft tissues of the shoulder. In this study, we seek to evaluate the effectiveness of physiotherapy applied jointly with acupuncture, compared with physiotherapy applied with a TENS-placebo, in the treatment painful shoulder caused by subacromial syndrome (rotator cuff tendinitis and subacromial bursitis). Methods/design: Randomised controlled multicentre study with blind evaluation by an independent observer and blind, independent analysis. A study will be made of 465 patients referred to the rehabilitation services at participating healthcare centres, belonging to the regional public health systems of Andalusia and Murcia, these patients presenting symptoms of painful shoulder and a diagnosis of subacromial syndrome (rotator cuff tendinitis and subacromial bursitis). The patients will be randomised into two groups: 1) experimental (acupuncture + physiotherapy); 2) control (TENS-placebo + physiotherapy); the administration of rescue medication will also be allowed. The treatment period will have a duration of three weeks. The main result variable will be the change produced on Constant's Shoulder Function Assessment (SFA) Scale; as secondary variables, we will record the changes in diurnal pain intensity on a visual analogue scale (VAS), nocturnal pain intensity on the VAS, doses of non-steroid anti-inflammatory drugs (NSAIDs) taken during the study period, credibility scale for the treatment, degree of improvement perceived by the patient and degree of improvement perceived by the evaluator. A follow up examination will be made at 3, 6 and 12 months after the study period has ended. Two types of population will be considered for analysis: per protocol and per intention to treat. Discussion: The discussion will take into account the limitations of the study, together with considerations such as the choice of a simple, safe method to treat this shoulder complaint, the choice of the control group, and the blinding of the patients, evaluators and those responsible for carrying out the final analysis. [ABSTRACT FROM AUTHOR]

Background: Decision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers. Discussion: Daniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based. Summary: We have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution. [ABSTRACT FROM AUTHOR]

The use of biomarkers within the procedures of the Committee of Orphan Medicinal Products (COMP) of the European Medicines Agency (EMA) is discussed herein. The applications for Orphan Medicinal Product designation in the EU are evaluated at two stages. At the time of orphan designation application, the file undergoes an assessment to establish whether the proposed condition is a distinct and serious condition affecting not more than 5 in 10,000 people in the EU, and whether the product is plausible as a therapy for that condition. In cases where therapies already exist, the significant benefit of the candidate product over existing therapies is also evaluated. The orphan criteria are reassessed at the time of marketing authorisation, so that marketing exclusivity for the product in the orphan medical condition can be granted. Within this context, biomarkers have been used in submissions in order to define an orphan condition and to justify that the criteria for orphan designation are met. The current work discusses specific examples from the experience of the COMP, where biomarkers have played a decisive role. Importantly, it identifies the proposal of sub-sets of non-rare conditions based on biomarkers as a challenging issue in the evaluation of applications. In particular two specific requirements for the candidate orphan medicines in relation to the biomarker-based subsets are highlighted: the "plausible link to the condition" and the "exclusion of effects outside the subset". [ABSTRACT FROM AUTHOR]

The article presents a study on providing British National Health Service (NHS) Heart Checks (HHCs) introduced by the British department of health. In assessing the community pharmacy component of HHCs, a selection of staff having direct involvement in the process was invited to take part in the evaluation. It was found that delivering NHS health checks through community pharmacies can be a complex process, requiring meticulous planning and may incur higher than expected costs.

A mixed hidden Markov model (HMM) was developed for predicting breeding values of a biomarker (here, somatic cell score) and the individual probabilities of health and disease (here, mastitis) based upon the measurements of the biomarker. At a first level, the unobserved disease process (Markov model) was introduced and at a second level, the measurement process was modeled, making the link between the unobserved disease states and the observed biomarker values. This hierarchical formulation allows joint estimation of the parameters of both processes. The flexibility of this approach is illustrated on the simulated data. Firstly, lactation curves for the biomarker were generated based upon published parameters (mean, variance, and probabilities of infection) for cows with known clinical conditions (health or mastitis due to Escherichia coli or Staphylococcus aureus). Next, estimation of the parameters was performed via Gibbs sampling, assuming the health status was unknown. Results from the simulations and mathematics show that the mixed HMM is appropriate to estimate the quantities of interest although the accuracy of the estimates is moderate when the prevalence of the disease is low. The paper ends with some indications for further developments of the methodology. [ABSTRACT FROM AUTHOR]

Background: Recent evidence suggests the need to reframe healthcare delivery for patients with chronic conditions, with emphasis on minimizing healthcare footprint/workload on patients, caregivers, clinicians and health systems through the proposed Minimally Disruptive Medicine (MDM) care model named. HIV care models have evolved to further focus on understanding barriers and facilitators to care delivery while improving patient-centered outcomes (e.g., disease progression, adherence, access, quality of life). It is hypothesized that these models may provide an example of MDM care model in clinic practice. Therefore, this study aimed to observe and ascertain MDM-concordant and discordant elements that may exist within a tertiary-setting HIV clinic care model for patients living with HIV or AIDS (PLWHA). We also aimed to identify lessons learned from this setting to inform improving the feasibility and usefulness of MDM care model.Methods: This qualitative case study occurred in multidisciplinary HIV comprehensive-care clinic within an urban tertiary-medical center. Participants included Adult PLWHA and informal caregivers (e.g. family/friends) attending the clinic for regular appointments were recruited. All clinic staff were eligible for recruitment. Measurements included; semi-guided interviews with patients, caregivers, or both; semi-guided interviews with varied clinicians (individually); and direct observations of clinical encounters (patient-clinicians), as well as staff daily operations in 2015-2017. The qualitative-data synthesis used iterative, mainly inductive thematic coding.Results: Researcher interviews and observations data included 28 patients, 5 caregivers, and 14 care-team members. With few exceptions, the clinic care model elements aligned closely to the MDM model of care through supporting patient capacity/abilities (with some patients receiving minimal social support and limited assistance with reframing their biography) and minimizing workload/demands (with some patients challenged by the clinic hours of operation).Conclusions: The studied HIV clinic incorporated many of the MDM tenants, contributing to its validation, and informing gaps in knowledge. While these findings may support the design and implementation of care that is both minimally disruptive and maximally supportive, the impact of MDM on patient-important outcomes and different care settings require further studying. [ABSTRACT FROM AUTHOR]

Background: Difference of perspective between patients and physicians over integrative medicine (IM) research and service provision remains unclear despite significant use worldwide. We observed an exceptionally low utilisation of IM and potential underreporting in diabetes. We aimed to explore the barriers and recommendations regarding service delivery and research of IM service among diabetes patients and physicians. Methods: A 10-group, 50-participant semi-structured focus group interview series was conducted. Twenty-one patients with diverse severity of disease, comorbidities and education levels; and 29 physicians (14 conventional medicine (ConM) and 15 Chinese medicine (CM)) with diverse clinical experience, academic background and affiliation were purposively sampled from private and public clinics. Their perspectives were qualitatively analysed by constant comparative method. Results: Seven subthemes regarding barriers towards IM service were identified including finance, service access, advice from medical professionals, uncertainty of service quality, uncertainty of CM effect, difficulty in understanding CM epistemology and access to medical records. Patients underreported the use of CM due to the concern over neutrality of medical advice among physicians. Inconvenience of service access, frequent follow-up, use of decoction and long-term financial burden were identified as key obstacles among patients. Regarding research design, ConM physicians emphasised standardisation and reproducibility while CM physicians emphasised personalisation. Some CM-related outcome measurements were suggested as non-communicable. Both physicians acknowledged the discordance in epistemology should be addressed by pragmatic approach. Conclusion: Key obstacles of CAM clinical utilisation are different between patients. Further assessment on IM should be pragmatic to balance between standardisation, reproducibility and real-world practice. Evidence-based IM programs and research should merge with existing infrastructure. [ABSTRACT FROM AUTHOR]

Background: Individuals with whiplash associated disorder (WAD) frequently experience neck pain in addition to other physical, psychological and social symptoms. Consequently, treatment is sought from a variety of health professionals. The limited data available about health services use in this population are conflicting. This study aimed to characterise health service use in individuals with WAD from a motor vehicle crash.Methods: Medical (general practitioner (GP), medical specialist, emergency services (ED), radiology - x-ray, computed tomography, magnetic resonance imaging, ultrasound) and allied health service (physiotherapy, chiropractor, psychologist, osteopath, occupational therapy) use during acute (< 12 weeks) and chronic (12 weeks to 2 years) post-injury periods were analysed in adults claiming compensation for WAD in the no-fault jurisdiction of Victoria, Australia (n = 37,315).Results: Most WAD claimants had an acute post-injury health service payment (95%, n = 35,348), and approximately one-third (29%, n = 10,871) had a chronic post-injury health service payment. During an acute post-injury period, the most frequently compensated services were for: ED (82% of acute claimants), radiology (56%), and medical specialist (38%). Whereas, physiotherapy (64.4% of chronic claimants), GP (48.1%), and radiology (34.6%) were the most frequently paid services during the chronic period. Females received significantly more payments from physiotherapists (F = 23.4%, M = 18%, z = - 11.3, p < .001, r = 0.13), chiropractors (F = 7.4%, M = 5.6%, z = - 6.3, p < .001, r = 0.13), and psychologists (F = 4.2%, M = 2.8%, z = - 6.7, p < .001, r = 0.18); whereas, males received significantly more medical services payments from medical specialists (F = 41.8%, M = 43.8%, z = - 3.7, p < .001, r = 0.03), ED (F = 74.0%, M = 76.3%, z = - 4.9, p < .001, r = 0.03) and radiology (F = 58.3%, M = 60.1%, z = - 3.4, p < .001, r = 0.02).Conclusions: Individuals with WAD claimed for a range of health services. Radiology imaging use during the acute post-injury period, and physiotherapy and chiropractor service use during the chronic post-injury period appeared concordant with current WAD management guidelines. Conversely, low physiotherapy and chiropractic use during an acute post-injury period, and high radiology and medical specialists use during the chronic post-injury period appeared discordant with current guidelines. Strategies are needed to help inform medical health professionals of the current guidelines to promote early access to health professionals likely to provide an active approach to treatment, and to address unnecessary referral to radiology and medical specialists in individuals with on-going WAD. [ABSTRACT FROM AUTHOR]

Background: Evidence-based medicine (EBM) is being embraced by an increasing number of practitioners and advocates of complementary and alternative medicine (CAM). A significant constituency within CAM, however, appears to have substantive doubts about EBM and some are expressly hostile. Discussion: Many of the arguments raised against EBM within the CAM community are based on a caricature radically at odds with established, accepted and published principles of EBM practice. Contrary to what has sometimes been argued, EBM is not cookbook medicine that ignores individual needs. Neither does EBM mandate that only proven therapies should be used. Before EBM, decisions on health care tended to be based on tradition, power and influence. Such modes usually act to the disadvantage of marginal groups. Conclusion: By placing CAM on an equal footing with conventional medicine - what matters for both is evidence of effectiveness - EBM provides an opportunity for CAM to find an appropriate and just place in health care. [ABSTRACT FROM AUTHOR]

Background: An up-to-date systematic review is important for researchers to decide whether to embark on new research or continue supporting ongoing studies. The aim of this study is to examine the time taken between the last search, submission, acceptance and publication dates of systematic reviews published in nursing journals.Methods: Nursing journals indexed in Journal Citation Reports were first identified. Thereafter, systematic reviews published in these journals in 2014 were extracted from three databases. The quality of the systematic reviews were evaluated by the AMSTAR. The last search, submission, acceptance, online publication, full publication dates and other characteristics of the systematic reviews were recorded. The time taken between the five dates was then computed. Descriptive statistics were used to summarize the time differences; non-parametric statistics were used to examine the association between the time taken from the last search and full publication alongside other potential factors, including the funding support, submission during holiday periods, number of records retrieved from database, inclusion of meta-analysis, and quality of the review.Results: A total of 107 nursing journals were included in this study, from which 1070 articles were identified through the database search. After screening for eligibility, 202 systematic reviews were included in the analysis. The quality of these reviews was low with the median score of 3 out of 11. A total of 172 (85.1%), 72 (35.6%), 153 (75.7%) and 149 (73.8%) systematic reviews provided their last search, submission, acceptance and online published dates respectively. The median numbers of days taken from the last search to acceptance and to full publication were, respectively, 393 (IQR: 212-609) and 669 (427-915) whereas that from submission to full publication was 365 (243-486). Moreover, the median number of days from the last search to submission and from submission to online publication were 167.5 (53.5-427) and 153 (92-212), respectively. No significant association were revealed between the time lag and those potential factors.Conclusion: The median time from the last search to acceptance for systematic reviews published in nursing journals was 393 days. Readers for systematic reviews are advised to check the time taken from the last search date of the reviews in order to ensure that up-to-date evidence is consulted for effective clinical decision-making. [ABSTRACT FROM AUTHOR]

Background: Supportive supervision has been found to be more effective than corrective fault-oriented inspections. Uganda's Ministry of Health in 2012 implemented a comprehensive strategy (SPARS) to build medicines management capacity in public sector health facilities. The approach includes supportive supervision. This structured observational study assesses supportive supervision competency among medicines management supervisors (MMS). Method: The study used structured observations of two groups of five purposely selected MMS-one group supervising facilities with greater medicines management improvement during one year of SPARS and one group with less improvement, based on quantitative metrics. We observed and scored behaviors and skills of supervisors in 11 categories deemed critical for effective and supportive supervision. Results: Supportive supervision was not evenly or adequately implemented, with the median supportive supervision competency score for all observed supervisors being 38%. Supervisor's main strengths were problem identification, data interpretation, education, and providing constructive feedback (45%-47%). Their weakest areas were assuring continuity and setting targets (17%) and most MMS were fair to strong in effective communication, use of tools and problem solving. MMS of facilities with little improvement in medicines management over time were weak in setting targets and promoting participation. There was a 33 percentage point difference in the median supportive supervision competency scores between MMS of facilities with more versus less improvement (57%-24%) and a 77 percentage point difference in competency between the highest and lowest scoring MMS (77%-0%). We did not find a relationship between MMS experience (number of visits implemented) and their supportive supervision competency or facility improvement in medicines management. However, there is a likely relationship between supportive supervision competency and facility improvement. Conclusion: Competency of MMS in supportive supervision among the sampled MMS was generally weak, but with much individual variation. Our results suggest that MM'S supportive supervision competency is positively related to the SPARS effectiveness scores of the facilities they supervise. We recommend strategies to strengthen supportive supervision behaviors and skills. [ABSTRACT FROM AUTHOR]

Background: International health partnerships (IHPs) are changing, with an increased emphasis on mutual accountability and joint agenda setting for both the high- and the low- or middle-income country (LMIC) partners. There is now an important focus on the bi-directionality of learning however for the UK partners, this typically focuses on learning at the individual level, through personal and professional development. We sought to evaluate whether this learning also takes the shape of 'Reverse Innovation' -when an idea conceived in a low-income country is subsequently adopted in a higher-income country.Methods: This mixed methods study used an initial scoping survey of all the UK-leads of the Tropical Health Education Trust (THET)-supported International Health Partnerships (n = 114) to ascertain the extent to which the IHPs are or have been vehicles for Reverse Innovation. The survey formed the sampling frame for further deep-dive interviews to focus on volunteers' experiences and attitudes to learning from LMICs. Interviews of IHP leads (n = 12) were audio-recorded and transcribed verbatim. Survey data was analysed descriptively. Interview transcripts were coded thematically, using an inductive approach.Results: Survey response rate was 27% (n = 34). The majority (70%) strongly agreed that supporting LMIC partners best described the mission of the partnership but only 13% of respondents strongly agreed that learning about new innovations and models was a primary mission of their partnership. Although more than half of respondents reported having observed innovative practice in the LMIC, only one IHP respondent indicated that this has led to Reverse Innovation. Interviews with a sample of survey respondents revealed themes primarily around how learning is conceptualised, but also a central power imbalance between the UK and LMIC partners. Paternalistic notions of knowledge could be traced to partnership power dynamics and latent attitudes to LMICs.Conclusions: Given the global flow of innovation, if High-income countries (HICs) are to benefit from LMIC practices, it is paramount to keep an open mind about where such learning can come from. Making the potential for learning more explicit and facilitating innovation dissemination upon return will ultimately underpin the success of adoption. [ABSTRACT FROM AUTHOR]

Background: Access to medicines and the development of a strong national pharmaceutical industry are two longstanding pillars of health policy in Brazil. This is reflected in a clear emphasis by Brazil's Federal Government on improving access to medicine in national health plans and industrial policies aimed at promoting domestic pharmaceutical development. This research proposes that such policies may act as incentives for companies to pursue a strategic Corporate Social Responsibility (CSR) agenda. CSR that supports Governmental priorities could help companies to benefit significantly from the Governmental industrial policy. We sought to determine whether CSR activities of Brazilian pharmaceutical firms are currently aligned with the Federal Government's health prioritization. To do so we examined key Brazilian health related policies since 2004, including the specific priorities of Brazil's 2012-2015 Health Plan, and compared these with CSR initiatives that are reported on the websites of select pharmaceutical firms in Brazil.Results: Brazil's national health plans and industrial policies demonstrated that the Federal Government has followed diverse approaches for improving access to medicines, including strengthening health care infrastructure, increasing transparency, and supporting product development partnerships. Case studies of six pharmaceutical firms, representing both public and private companies of varying size, support the perspective that CSR is a priority for firms. However, while many programs target issues such as health infrastructure, health care training, and drug donation, more programs focus on areas other than health and do not seem to be connected to Governmental prioritization.Conclusion: This research suggests that there are loose connections between Governmental priorities and pharmaceutical firm CSR. However, there remains a significant opportunity for greater alignment, which could improve access to medicines in the country and foster a stronger relationship between the Government and industry. [ABSTRACT FROM AUTHOR]

What does the future of medicine hold? We asked six researchers to share their most ambitious and optimistic views of the future, grounded in the present but looking out a decade or more from now to consider what's possible. They paint a picture of a connected and data-driven world in which patient value, patient feedback, and patient empowerment shape a continually learning system that ensures each patient's experience contributes to the improved outcome of every patient like them, whether it be through clinical trials, data from consumer devices, hacking their medical devices, or defining value in thoughtful new ways. [ABSTRACT FROM AUTHOR]

Background: Health-promoting interventions tailored to support older persons to remain in their homes, so-called "ageing in place" is important for supporting or improving their health. The health-promoting programme "Elderly Persons in the Risk Zone," (EPRZ) was set up for this purpose and has shown positive results for maintaining independence in activities of daily living for older persons 80 years and above at 1- and 2 year follow-ups. The aim of this study was to explore factors for maintaining independence in the EPRZ health-promoting programme. Methods: Total of 459 participants in the original trial was included in the analysis; 345 in the programme arm and 114 in the control arm. Thirteen variables, including demographic, health, and programme-specific indicators, were chosen as predictors for independence of activities of daily living. Logistic regression was performed separately for participants in the health promotion programme and in the control arm. Results: In the programme arm, being younger, living alone and self-rated lack of tiredness in performing mobility activities predicted a positive effect of independence in activities of daily living at 1-year follow-up (odds ratio [OR] 1.18, 1.73, 3.02) and 2-year, (OR 1.13, 2.01, 2.02). In the control arm, being less frail was the only predictor at 1-year follow up (OR 1.6 1.09, 2.4); no variables predicted the outcome at the 2-year follow-up. Conclusions: Older persons living alone - as a risk of ill health - should be especially recognized and offered an opportunity to participate in health-promoting programmes such as "Elderly Persons in the Risk Zone". Further, screening for subjective frailty could form an advantageous guiding principle to target the right population when deciding to whom health-promoting intervention should be offered. Trial registration: The original clinical trial was registered at ClinicalTrials.gov. Identifier: NCT00877058, April 6, 2009. [ABSTRACT FROM AUTHOR]

There is clear guidance on the responsibilities of editors to ensure that the research they publish is of the highest possible quality. Poor reporting is unethical and directly impacts patient care. Reporting guidelines are a relatively recent development to help improve the accuracy, clarity, and transparency of biomedical publications. They have caught on, with hundreds of reporting guidelines now available. Some journals endorse reporting guidelines while a smaller number have used various approaches to implement them. Yet challenges remain - biomedical research is still not optimally reported despite the abundance of reporting guidelines. Electronic algorithms are now being developed to facilitate the choice of correct reporting guideline(s), while other tools are being integrated into journal editorial management processes. Universities need to consider whether it is responsible to advance careers of faculty based on poorly reported research which is of little societal value. If journals embraced auditing of the quality of articles they publish this would give them and their readers essential feedback from which to improve their product. [ABSTRACT FROM AUTHOR]

Background: Health policy has strengthened the demand for coordination between clinicians and managers and introduced new medical manager roles in hospitals to better connect medicine and management. These developments have created a scholarly debate of concepts and an increasing 'hybridization' of tasks and roles, yet the organizational effects are not well researched. This research introduces a multi-level governance approach and aims to explore the organizational needs of doctors using Sweden as a case study.Methods: We apply an assessment framework focusing on macro-meso levels and managerial-professional modes of hospital governance (using document analysis, secondary sources, and expert information) and expand the analysis towards the micro-level. Qualitative explorative empirical material gathered in two different studies in Swedish hospitals serves to pilot research into actor-centred perceptions of clinical management from the viewpoint of the 'managed' and the 'managing' doctors in an organization.Results: Sweden has developed a model of integrated hospital governance with complex structural coordination between medicine and management on the level of the organization. In terms of formal requirements, the professional background is less relevant for many management positions but in everyday work, medical managers are perceived primarily as colleagues and not as experts advising on managerial problems. The managers themselves seem to rely more on personal strength and medical knowledge than on management tools. Bringing doctors into management may hybridize formal roles and concepts, but it does not necessarily change the perceptions of doctors and improve managerial-professional coordination at the micro-level of the organization.Conclusion: This study brings gaps in hospital governance into view that may create organizational weaknesses and unmet management needs, thereby constraining more coordinated and integrated medical management. [ABSTRACT FROM AUTHOR]

Background: While healthcare systems vary in their structure and available resources, it is widely recognized that medical doctors play a key role in their adaptation and performance. In this article, we examine recent government and organizational policies in two different health systems that aim to develop clinical leadership among the medical profession. Clinical leadership refers to the engagement and guiding role of physicians in health system improvement. Three dimensions are defined to conduct our analysis of engaging medical doctors in healthcare leadership: the position and status of medical doctors within the system; the broader institutional context of governmental and organizational policies to engage medical doctors in clinical leadership roles; and the main factors that may facilitate or limit achievements.Methods: Our aim in this study is exploratory. We selected two contrasting cases according to their level of institutional pluralism: one national health insurance system, Canada, and one etatist social insurance system, the Netherlands. We documented the institutional dynamics of medical doctors' engagement and leadership through secondary sources, such as government websites, key policy reports, and scholarly literature on health policies in both countries.Results: Initiatives across Canadian provinces signal that the medical profession and governments search for alternatives to involve doctors in health system improvement beyond the limitations imposed by their fundamental social contract and formal labour relations. These initiatives suggest an emerging trend toward more joint collaboration between governments and medical associations. In the Dutch system, organizational and legal attempts for integration over the past decades do not yet fit well with the ideas and interests of medical doctors. The engagement of medical doctors requires additional initiatives that are closer to their professional values and interests and that depart from an overly focus on top down performance indicators and competition.Conclusions: Different institutional contexts have different policy experiences regarding the engagement and leadership of medical doctors but seem to face similar policy challenges. Achieving alignment between soft (trust, collaboration) and hard (financial incentives) levers may require facilitative conditions at the level of the health system, like clarity and stability of broad policy orientations and openness to local experimentation. [ABSTRACT FROM AUTHOR]

Background: Patients who submit complaints about the healthcare they have received are often dissatisfied with the response to their complaints. This is usually attributed to the failure of physicians to respond adequately to what complainants want, e.g. an apology or an explanation. However, expectations of complaint handling among the public may colour how they evaluate the way their own complaint is handled. This descriptive study assesses expectations of complaint handling in healthcare among the public and physicians. Negative public expectations and the gap between these expectations and those of physicians may explain patients' dissatisfaction with complaints procedures. Methods: We held two surveys; one among physicians, using a panel of 3366 physicians (response rate 57 %, containing all kinds of physicians like GP's, medical specialist and physicians working in a nursing home) and one among the public, using the Dutch Healthcare Consumer Panel (n = 1422, response rate 68 %). We asked both panels identical questions about their expectations of how complaints are handled in healthcare. Differences in expectation scores between the public and the physicians were tested using non-parametric tests. Results: The public have negative expectations about how complaints are handled. Physician's expectations are far more positive, demonstrating large expectation gaps between physicians and the public. Conclusions: The large expectation gap between the public and physicians means that when they meet because of complaint, they are likely to start off with opposite expectations of the situation. This is no favourable condition for a positive outcome of a complaints procedure. The negative public preconceptions about the way their complaint will be handled will prove hard to change during the process of complaints handling. People tend to see what they thought would happen, almost inevitably leading to a negative judgement about how their complaint was handled. [ABSTRACT FROM AUTHOR]

Background: Community nurses are well placed to promote and support stroke survivors to engage in self-management. The aim of this study was to develop a stroke self-management intervention that could be tailored towards stroke survivors' self-management needs, goals and levels of activation, in the first year post-stroke. Methods: Mixed method study, designed in accordance with the British Medical Research Council's (MRC) guidance for the development and evaluation of complex interventions. The intervention was developed and evaluated in two phases. The intervention was underpinned by the theoretical concept of patient activation and was developed based on a review of published research on stroke self-management interventions and qualitative interviews and focus groups (phase 1). It was evaluated using qualitative interviews and focus groups with stroke survivors and stroke nurses (phase 2). Participants comprised 26 stroke survivors, between 3 and 12 months post stroke and 16 stroke nurses, from across three NHS Boards in Scotland. Results: The intervention consisted of a tailored self-management action plan, incorporating an individualised assessment of stroke survivor's readiness to self-manage (using the Patient Activation Measure), goal setting and motivational interviewing. Evaluation showed that many of the individual components of the intervention were perceived as feasible and acceptable to both stroke survivors and stroke nurses. Conclusions: To our knowledge, this is the first UK study to explore the use of patient activation as a theoretical underpinning in stroke self-management research and to involve stroke survivors and stroke nurses in the design and development of a tailored, person-centred stroke self-management support intervention. The study findings provide the first step in understanding how to effectively develop and deliver stroke self-management support interventions to stroke survivors living at home in the first year following stroke. Further work is needed to develop and refine the intervention and identify how to effectively embed it into nurses' routine clinical practice. [ABSTRACT FROM AUTHOR]

Background Contextual factors influence quality improvement outcomes. Understanding this influence is important when adapting and implementing interventions and translating improvements into new settings. To date, there is limited knowledge about how contextual factors influence quality improvement processes. In this study, we explore how contextual factors affected measures to reduce surgery cancellations, which are a persistent problem in healthcare. We discuss the usefulness of the theoretical framework provided by the model for understanding success in quality (MUSIQ) for this kind of research. Method We performed a qualitative case study at Førde Hospital, Norway, where we had previously demonstrated a reduction in surgery cancellations. We interviewed 20 clinicians and performed content analysis to explore how contextual factors affected measures to reduce cancellations of planned surgeries. Results We identified three common themes concerning how contextual factors influenced the change process: 1) identifying a need to change, 2) facilitating system-wide improvement, and 3) leader involvement and support. Input from patients helped identify a need to change and contributed to the consensus that change was necessary. Reducing cancellations required improving the clinical system. This improvement process was based on a strategy that emphasized the involvement of frontline clinicians in detecting and improving system problems. Clinicians shared information about their work by participating in improvement teams to develop a more complete understanding of the clinical system and its interdependencies. This new understanding allowed clinicians to detect system problems and design adequate interventions. Middle managers' participation in the improvement teams and in regular work processes was important for successfully implementing and adapting interventions. Conclusion Contextual factors interacted with one another and with the interventions to facilitate changes in the clinical system, reducing surgery cancellations. The MUSIQ framework is useful for exploring how contextual factors influence the improvement process and how they influence one another. Discussing data in relation to a theoretical framework can promote greater uniformity in reporting findings, facilitating knowledge-building across studies. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to develop an instrument to measure laypeople's beliefs about the nature of medical knowledge and knowing (the EBAM). Such beliefs should be a target of increased research interest because they influence how people handle medical information, for example in shared decision making. Methods: An online survey was completed by 284 participants. Items assessed different aspects of laypeople's epistemic beliefs about medicine and explicitly focused on the appearance of medical knowledge in everyday life and the evaluation of different sources as a way to justify knowledge. Results: Factor analysis yielded a five-factor solution for the instrument. Dimensions covered by the instrument are certainty of medical knowledge, credibility of medical textbooks, credibility of medical information on the Internet, justification of medical knowledge, and preliminarity of medical knowledge. Conclusions: Results indicate that laypeople have meaningful beliefs about the nature of medical knowledge and the trustworthiness of different sources. The instrument developed seems promising for measuring laypeople's epistemic beliefs about medicine, which may help to increase patients' compliance in medical decision making. [ABSTRACT FROM AUTHOR]

Given prior human judgments of the condition of an object it is possible to use these judgments to make a maximal likelihood estimate of what future human judgments of the condition of that object will be. However, if one has a reasonably large collection of similar objects and the prior human judgments of a number of judges regarding the condition of each object in the collection, then it is possible to make predictions of future human judgments for the whole collection that are superior to the simple maximal likelihood estimate for each object in isolation. This is possible because the multiple judgments over the collection allow an analysis to determine the relative value of a judge as compared with the other judges in the group and this value can be used to augment or diminish a particular judge's influence in predicting future judgments. Here we study and compare five different methods for making such improved predictions and show that each is superior to simple maximal likelihood estimates. [ABSTRACT FROM AUTHOR]

The article focuses on estimation of travel reduction associated with the use of telemedicine by patients and healthcare professionals. It is proposed that the research should consider all credible evidence on avoided travel through telemedicine by fitting a linear model which takes into account the relevant factors in the circumstances of the studies performed. The proposed approach is illustrated by the example of teledermatology.

The article presents a study to evaluate the impact of telemonitoring in patients with long-term conditions and social care needs. A large scale, multi-site study of the implementation, impact and acceptability of these new technologies was conducted. As mentioned, if telehealth and telecare technology proves effective, it will provide additional options for health services worldwide to deliver care for populations with high levels of need.

Background: Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community. Methods: Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers. Results: Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice. Conclusion: Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care. [ABSTRACT FROM AUTHOR]

Background: Preventable adverse drug events (pADEs) are widely known to be a health care issue for hospitalized patients. Surgical patients are especially at risk, but prevention of pADEs in this population is not demonstrated before. Ward-based pharmacy interventions seem effective in reducing pADEs in medical patients. The costeffectiveness of these preventive efforts still needs to be assessed in a comparative study of high methodological standard and also in the surgical population. For these aims the SUREPILL (Surgery & Pharmacy in Liaison) study is initiated. Methods/Design: A multi-centre controlled trial, with randomisation at ward-level and preceding baseline assessments is designed. Patients admitted to the surgical study wards for elective surgery with an expected length of stay of more than 48 hours will be included. Patients admitted to the intervention ward, will receive ward-based pharmacy care from the clinical pharmacy team, i.e. pharmacy practitioners and hospital pharmacists. This ward-based pharmacy intervention includes medication reconciliation in consultation with the patient at admission, daily medication review with face-to-face contact with the ward doctor, and patient counselling at discharge. Patients admitted in the control ward, will receive standard pharmaceutical care. The primary clinical outcome measure is the number of pADEs per 100 elective admissions. These pADEs will be measured by systematic patient record evaluation using a trigger tool. Patient records positive for a trigger will be evaluated on causality, severity and preventability by an independent expert panel. In addition, an economic evaluation will be performed from a societal perspective with the costs per preventable ADE as the primary economic outcome. Other outcomes of this study are: severity of pADEs, number of patients with pADEs per total number of admissions, direct (non-)medical costs and indirect non-medical costs, extra costs per prevented ADE, number and type of pharmacy interventions, length of hospital stay, complications registered in a national complication registration system for surgery, number of readmissions within three months after initial admission (follow-up), quality of life and number of non-institutionalized days during follow-up. Discussion: This study will assess the cost-effectiveness of ward-based pharmacy care on preventable adverse drug events in surgical patients from a societal perspective, using a comparative study design. [ABSTRACT FROM AUTHOR]

Background: Public pressure has increasingly emphasized the need to ensure the continuing quality of care provided by health professionals over their careers. Health profession's regulatory authorities, mandated to be publicly accountable for safe and effective care, are revising their quality assurance programs to focus on regular evaluations of practitioner performance. New methods for routine screening of performance are required and the use of administrative data for measuring performance on quality of care indicators has been suggested as one attractive option. Preliminary studies have shown that community pharmacy claims databases contain the information required to operationalize quality of care indicators. The purpose of this project was to determine the feasibility of routine use of information from these databases by regulatory authorities to screen the quality of care provided at community pharmacies. Methods: Information from the Canadian province of Quebec's medication insurance program provided data on prescriptions dispensed in 2002 by more than 5000 pharmacists in 1799 community pharmacies. Pharmacy-specific performance rates were calculated on four quality of care indicators: two safety indicators (dispensing of contraindicated benzodiazepines to seniors and dispensing of nonselective beta-blockers to patients with respiratory disease) and two effectiveness indicators (dispensing asthma or hypertension medications to non-compliant patients). Descriptive statistics were used to summarize performance. Results: Reliable estimates of performance could be obtained for more than 90% of pharmacies. The average rate of dispensing was 4.3% (range 0 - 42.5%) for contra-indicated benzodiazepines, 15.2% (range 0 - 100%) for nonselective beta-blockers to respiratory patients, 10.7% (range 0 - 70%) for hypertension medications to noncompliant patients, and 43.3% (0 - 91.6%) for short-acting beta-agonists in over-use situations. There were modest correlations in performance across the four indicators. Nine pharmacies (0.5%) performed in the lowest quartile in all four of the indicators, and 5.3% (n = 95) performed in the lowest quartile on three of four indicators. Conclusions: Routinely collected pharmacy claims data can be used to monitor indicators of the quality of care provided in community pharmacies, and may be useful in future to identify underperforming pharmacists, measure the impact of policy changes and determine predictors of best practices. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines have the potential to facilitate the implementation of evidence into practice, support clinical decision making, specify beneficial therapeutic approaches, and influence public policy. However, these potential benefits have not been consistently achieved. The limited impact of guidelines can be attributed to organisational constraints, the complexity of the guidelines, and the lack of usability testing or enduser involvement in their development. Implementability has been referred to as the perceived characteristics of guidelines that predict the relative ease of their implementation at the clinical level, but this concept is as yet poorly defined. The objective of our study is to identify guideline attributes that affect uptake in practice by considering evidence from four disciplines (medicine, psychology, management, human factors engineering) to determine the relationship between the perceived characteristics of recommendations and their uptake and to develop a framework of implementability. Methods: A realist-review approach to knowledge synthesis will be used to understand attributes of guidelines (e. g., its text and content) and how changing these elements might impact clinical practice and clinical decision making. It also allows for the exploration of 'what works for whom, in what circumstances, and in what respects'. The realist review will be structured according to Pawson's five practical steps in realist reviews: (1) clarifying the scope of the review, (2) determining the search strategy, (3) ensuring proper article selection and study quality assessment, (4) extracting and organising data, and (5) synthesising the evidence and drawing conclusions. Data will be synthesised according to a two-stage analysis: (1) we will extract and define all relevant guideline attributes from the different disciplines, then create a shortlist of unique attributes and investigate their relationships with uptake, and (2) we will compare and contrast the attributes and guideline uptake within each and between the four disciplines to create a robust framework of implementability. Discussion: Creating guidelines that are designed to maximise uptake may be a potentially effective and inexpensive way of increasing their impact. However, this is best achieved by a comprehensive framework to inform the design of guidelines drawing on a range of disciplines that study behaviour change. This study will use a customised realist-review approach to synthesising the literature to better understand and operationalise a complex and under-theorised concept. [ABSTRACT FROM AUTHOR]

Background: The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care. Methods: A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program. Results: Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%. Conclusions: This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making. Trial Registration: NCT00354315 [ABSTRACT FROM AUTHOR]

Background: The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. Methods/Design: We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness. The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization. The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50). The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. Statistical analysis: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05. [ABSTRACT FROM AUTHOR]

Background: As in other Western countries, the number of immigrants in the Netherlands is growing rapidly. In 1980 non-western immigrants constituted about 3% of the population, in 1990 it was 6% and currently it is more than 10%. Nearly half of the migrant population lives in the four major cities. In the municipality of Rotterdam 34% of the inhabitants are migrants. Health policy is based on the ideal that all inhabitants should have equal access to health care and this requires an efficient planning of health care resources, like staff and required time per patient. The aim of this study is to examine ethnic differences in the use of internal medicine outpatient care, specifically to examine ethnic differences in the reason for referral and diagnosis. Methods: We conducted a study with an open cohort design. We registered the ethnicity, sex, age, referral reasons, diagnosis and living area of all new patients that visited the internal medicine outpatient clinic of the Erasmus Medical Centre in Rotterdam (Erasmus MC) for one year (March 2002-2003). Additionally, we coded referrals according to the International Classification of Primary Care (ICPC) and categorised diagnosis according to the Diagnosis Treatment Combination (DTC). We analysed data by using Poisson regression and logistic regression. Results: All ethnic minority groups (Surinam, Turkish, Moroccan, Antillean/Aruban and Cape Verdean immigrants) living in Rotterdam municipality, make significantly more use of the outpatient clinic than native Dutch people (relative risk versus native Dutch people was 1.83, 1.97, 1.79, 1.65 and 1.88, respectively). Immigrant patients are more likely to be referred for analysis and treatment of 'gastro-intestinal signs & symptoms' and were less often referred for 'indefinite, general signs'. Ethnic minorities were more frequently diagnosed with 'Liver diseases', and less often with 'Analysis without diagnosis'. The increased use of the outpatient facilities seems to be restricted to first-generation immigrants, and is mainly based on a higher risk of being referred with 'gastrointestinal signs & symptoms'. Conclusion: These findings demonstrate substantial ethnic differences in the use of the outpatient care facilities. Ethnic differences may decrease in the future when the proportion of first-generation immigrants decreases. The increased use of outpatient health care seems to be related to ethnic background and the generation of the immigrants rather than to socio-economic status. Further study is needed to establish this. [ABSTRACT FROM AUTHOR]

Background: Coronary heart disease patients have to learn to manage their condition to maximise quality of life and prevent recurrence or deterioration. They may develop their own informal methods of self-management in addition to the advice they receive as part of formal cardiac rehabilitation programmes. This study aimed to explore the use of complementary and alternative medicines and therapies (CAM), self-test kits and attitudes towards health of UK patients one year after referral to cardiac rehabilitation. Method: Questionnaire given to 463 patients attending an assessment clinic for 12 month follow up in four West Midlands hospitals. Results: 91.1% completed a questionnaire. 29.1% of patients used CAM and/or self-test kits for self-management but few (8.9%) used both methods. CAM was more often used for treating other illnesses than for CHD management. Self-test kit use (77.2%,) was more common than CAM (31.7%,) with BP monitors being the most prevalent (80.0%). Patients obtained self-test kits from a wide range of sources, for the most part (89.5%) purchased entirely on their own initiative. Predictors of self-management were post revascularisation status and higher scores on 'holism', 'rejection of authority' and 'individual responsibility'. Predictors of self-test kit use were higher 'holism' and 'individual responsibility' scores. Conclusion: Patients are independently using new technologies to monitor their cardiovascular health, a role formerly carried out only by healthcare practitioners. Post-rehabilitation patients reported using CAM for self-management less frequently than they reported using self-test kits. Reports of CAM use were less frequent than in previous surveys of similar patient groups. Automatic assumptions cannot be made by clinicians about which CHD patients are most likely to self-manage. In order to increase trust and compliance it is important for doctors to encourage all CHD patients to disclose their self-management practices and to continue to address this in follow up consultations. [ABSTRACT FROM AUTHOR]

Background: The use of complementary and alternative medicine (CAM) has become more common in Western developed countries in recent years, as has media reporting on CAM and related issues. Correspondingly, media reports are a primary information source regarding decisions to use CAM. Research on CAM related media reports is becoming increasingly relevant and important; however, identifying key concepts to guide future research is problematic due to the dispersed nature of completed research in this field. A scoping review was conducted to: 1) determine the amount, focus and nature of research on CAM and the mass media; and 2) summarize and disseminate related research results. Methods: The main phases were: 1) searching for relevant studies; 2) selecting studies based on pre-defined inclusion criteria; 3) extracting data; and 4) collating, summarizing and reporting the results. Results: Of 4,454 studies identified through various search strategies, 16 were relevant to our objectives and included in a final sample. CAM and media research has focused primarily on print media coverage of a range of CAM therapies, although only a few studies articulated differences within the range of therapies surveyed. Research has been developed through a variety of disciplinary perspectives, with a focus on representation research. The research reviewed suggests that journalists draw on a range of sources to prepare media reports, although most commonly they cite conventional (versus CAM) sources and personal anecdotes. The tone of media reports appears generally positive, which may be related to a lack of reporting on issues related to risk and safety. Finally, a variety of discourses within media representations of CAM are apparent that each appeal to a specific audience through resonance with their specific concerns. Conclusion: Research on CAM and the mass media spans multiple disciplines and strategies of inquiry; however, despite the diversity in approach, it is clear that issues related to production and reception of media content are in need of research attention. To address the varied issues in a comprehensive manner, future research needs to be collaborative, involving researchers across disciplines, journalists and CAM users. [ABSTRACT FROM AUTHOR]

Background: Inter-professional learning (IPL) and inter-professional practice (IPP) are thought to be critical determinants of effective care, improved quality and safety and enhanced provider morale, yet few empirical studies have demonstrated this. Whole-of-system research is even less prevalent. We aim to provide a four year, multi-method, multi-collaborator action research program of IPL and IPP in defined, bounded health and education systems located in the Australian Capital Territory (ACT). The project is funded by the Australian Research Council under its industry Linkage Program. Methods/Design: The program of research will examine in four inter-related, prospective studies, progress with IPL and IPP across tertiary education providers, professional education, regulatory and registration bodies, the ACT health system's streams of care activities and teams, units and wards of the provider facilities of the ACT health system. One key focus will be on push-pull mechanisms, ie, how the education sector creates student-enabled IPP and the health sector demands IPL-oriented practitioners. The studies will examine four research aims and meet 20 research project objectives in a comprehensive evaluation of ongoing progress with IPL and IPP. Discussion: IPP and IPL are said to be cornerstones of health system reforms. We will measure progress across an entire health system and the clinical and professional education systems that feed into it. The value of multi-methods, partnership research and a bi-directional push-pull model of IPL and IPP will be tested. Widespread dissemination of results to practitioners, policymakers, managers and researchers will be a key project goal. [ABSTRACT FROM AUTHOR]

Background: Although the methods for conducting systematic reviews of efficacy are well established, there is much less guidance on how systematic reviews of adverse effects should be performed. Methods: In order to determine where methodological research is most needed to improve systematic reviews of adverse effects of health care interventions, we conducted a descriptive analysis of systematic reviews published between 1994 and 2005. We searched the Database of Abstracts of Reviews of Effects (DARE) and The Cochrane Database of Systematic Reviews (CDSR) to identify systematic reviews in which the primary outcome was an adverse effect or effects. We then extracted data on many of the elements of the systematic review process including: types of interventions studied, adverse effects of interest, resources searched, search strategies, data sources included in reviews, quality assessment of primary data, nature of the data analysis, and source of funding. Results: 256 reviews were included in our analysis, of which the majority evaluated drug interventions and pre-specified the adverse effect or effects of interest. A median of 3 resources were searched for each review and very few reviews (13/256) provided sufficient information to reproduce their search strategies. Although more than three quarters (185/243) of the reviews sought to include data from sources other than randomised controlled trials, fewer than half (106/ 256) assessed the quality of the studies that were included. Data were pooled quantitatively in most of the reviews (165/256) but heterogeneity was not always considered. Less than half (123/256) of the reviews reported on the source of funding. Conclusion: There is an obvious need to improve the methodology and reporting of systematic reviews of adverse effects. The methodology around identification and quality assessment of primary data is the main concern. [ABSTRACT FROM AUTHOR]

Background: The current debate about medical futility is mostly driven by theoretical and personal perspectives and there is a lack of empirical data to document experts and public attitudes towards medical futility. Methods: To examine the attitudes of the Japanese experts in the fields relevant to medical futility a questionnaire survey was conducted among the members of the Japan Association for Bioethics. A total number of 108 questionnaires returned filled in, giving a response rate of 50.9%. Among the respondents 62% were healthcare professionals (HCPs) and 37% were non-healthcare professionals (Non-HCPs). Results: The majority of respondents (67.6 %) believed that a physician's refusal to provide or continue a treatment on the ground of futility judgment could never be morally justified but 22.2% approved such refusal with conditions. In the case of physiologically futile care, three-quarters believed that a physician should inform the patient/family of his futility judgment and it would be the patient who could decide what should be done next, based on his/her value judgment. However more than 10% said that a physician should ask about a patient's value and goals, but the final decision was left to the doctor not the patient. There was no statistically significant difference between HCPs and Non-HCPs (p = 0.676). Of respondents 67.6% believed that practical guidelines set up by the health authority would be helpful in futility judgment. Conclusion: The results show that there is no support for the physicians' unilateral decisionmaking on futile care. This survey highlights medical futility as an emerging issue in Japanese healthcare and emphasizes on the need for public discussion and policy development. [ABSTRACT FROM AUTHOR]

There is a fairly closed circle between culture, language, meaning, and truth such that the world of a given culture is a world understood in terms of the meanings produced in that culture. Medicine is, in fact, a subculture of a powerful type and has its own language and understanding of the range of illnesses that affect human beings. So how does medicine get at the truth of people and their ills in such a way as to escape its own limited constructions? There is a way out of the closed circle implicit in the idea of a praxis and the engagement with reality that is central to it and the further possibility introduced by Jacques Lacan that signification is never comprehensive in relation to the subject's encounter with the real. I will explore both of these so as to develop a conception of truth that is apt for the knowledge that arises in the clinic. [ABSTRACT FROM AUTHOR]