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This chapter analyses the effectiveness of a range of interventions which are used to bring about changes in clinical behaviour. There is an increasing awareness that active implementation strategies are required if new evidence is to be routinely incorporated into practice. An overview of systematic review focuses on broad strategies, including continuing medical education, dissemination and implementation of guidelines, and programmes to enhance the quality and economy of primary care. A number of reviews have examined a range of interventions that are used to influence all aspects of prevention. To improve prescribing, mailed educational materials alone are generally ineffective. Educational outreach is commonly used in combination with other interventions. Clinical governance leads should ideally have access to a range of proven interventions that can support the implementation of evidence-based practice. Reviews of the effectiveness of implementation strategies confirm that the active dissemination and implementation of guidelines is required to ensure that the potential changes in practice occur.

Background Evidence supporting selective decontamination of the digestive tract (SDD) is reasonably strong. We set out to determine use in UK critical care units and to compare patient outcomes between units that do and those that do not use SDD. Methods A total of 250 UK general critical care units were surveyed. Case mix, outcomes, and lengths of stay for admissions to SDD units (with and without an i.v. component) and non-SDD units were compared using data from the Intensive Care National Audit & Research Centre Case Mix Programme database. Results A response was received from all the 250 critical care units surveyed. Of these, 13 (5.2%) reported using SDD on some or all admissions, and of these, 3 reported using an i.v. component. Data on 284 690 admissions (April 2008–March 2011) from units reporting to the ICNARC Case Mix Programme (CMP) were included in the analyses. Admissions to SDD (n=196) and non-SDD (n=9) units were a similar case mix with similar infection rates and average lengths of stay in the unit and hospital. There was no difference in risk-adjusted unit or hospital mortality. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component. Conclusions Use of SDD in UK critical care is very low. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component, but did not translate into a difference in acute hospital mortality or length of stay. There is a need to better understand the barriers to adoption of SDD into clinical practice and such work is underway.

OBJECTIVES: To compare the acceptability and feasibility of computerized and pencil-and-paper tests of cognitive function in 85-year-old people. DESIGN: Group comparison of participants randomly allocated to pencil-and-paper (Wechsler Adult Intelligence and Memory Scales) or computerized (Cognitive Drug Research) tests of verbal memory and attention. SETTING: The Newcastle 85+ Pilot Study was the precursor to the Newcastle 85+ Study a United Kingdom Medical Research Council/Biotechnology and Biological Sciences Research Council cohort study of health and aging in the oldest-old age group. PARTICIPANTS: Eighty-one community-dwelling individuals aged 85. MEASUREMENTS: Participant and researcher acceptability, completion rates, time taken, validity as cognitive measures, and psychometric utility. RESULTS: Participants randomized to computerized tests were less likely to rate the cognitive function tests as difficult (odds ratio (OR)=0.16, 95% confidence interval (CI)=0.07–0.39), stressful (OR=0.18, 95% CI=0.07–0.45), or unacceptable (OR=0.18, 95% CI=0.08–0.48) than those randomized to pencil-and-paper tests. Researchers were also less likely to rate participants as being distressed in the computer test group (OR=0.19, 95% CI=0.07–0.46). Pencil-and-paper tasks took participants less time to complete (mean±standard deviation 18±4 minutes vs 26±4 minutes) but had fewer participants who could complete all tasks (91% vs 100%). Both types of task were equally good measures of cognitive function. CONCLUSION: Computerized and pencil-and-paper tests are both feasible and useful means of assessing cognitive function in the oldest-old age group. Computerized tests are more acceptable to participants and administrators.

Objective: To determine the efficacy of a computerised decision aid in patients with atrial fibrillation making decisions on whether to take warfarin or aspirin therapy. Design: Two-armed open exploratory randomised controlled trial. Setting: Two research clinics deriving participants from general practices in Northeast England. Participants: 109 patients with atrial fibrillation aged over 60. Interventions: Computerised decision aid applied in shared decision-making clinic compared to evidence-based paper guidelines applied as direct advice. Main outcome measures: Primary outcome measure was the decision conflict scale. Secondary outcome measures included anxiety, knowledge, decision-making preference, treatment decision, use of primary and secondary care services and health outcomes. Results: Decision conflict was lower in the computerised decision aid group immediately after the clinic; mean difference −0.18 (95% CI −0.34 to −0.01). Participants in this group not already on warfarin were much less likely to start warfarin than those in the guidelines arm (4/16, 25% compared to the guidelines group 15/16, 93.8%, RR 0.27, 95% CI 0.11 to 0.63). Conclusions: Decision conflict was lower immediately following the use of a computerised decision aid in a shared decision-making consultation than immediately following direct doctor-led advice based on paper guidelines. Furthermore, participants in the computerised decision aid group were significantly much less likely to start warfarin than those in the guidelines arm. The results show that such an approach has a positive impact on decision conflict comparable to other studies of decision aids, but also reduces the uptake of a clinically effective treatment that may have important implications for health outcomes.

This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism as a health priority. A local guideline development group adapted the recommendations of an existing review and produced a local guideline. Then, a multidisciplinary implementation group developed the practical aspects of implementing guidelines into routine daily practice. They identified appropriate staff to carry out risk assessment and to administer appropriate prophylaxis, as necessary. They also produced a “guideline pack” containing a training resource manual and implementation aids. Following this a multiple strategy implementation programme was used to introduce the guidelines, and an evaluation was carried out eight to ten months after the introduction of the guidelines. The evaluation identified a number of areas for improving current practice. Guideline implementation is a complex, time‐consuming process.

Effective research transfer will ensure patients and populations benefit from evidence-based best practice. While there is an increasing rigor with which to approach research transfer in health care settings, greater demand among those responsible for research transfer for a more scientifically sound knowledge base will accelerate development of the discipline. There is greater recognition that research transfer requires sophisticated, theoretically informed and phased designs. Practitioners who seek to transfer evidence into practice must work with these epistemological deficits as best they can. Reading this chapter will help you to identify and respond to situations that require research transfer, apply a systematic approach to research transfer, learning from the work of others and planning locally in context, and contribute to a growing body of evidence about research transfer itself.

To compare the acceptability and feasibility of computerized and pencil-and-paper tests of cognitive function in 85-year-old people.Group comparison of participants randomly allocated to pencil-and-paper (Wechsler Adult Intelligence and Memory Scales) or computerized (Cognitive Drug Research) tests of verbal memory and attention.The Newcastle 85+ Pilot Study was the precursor to the Newcastle 85+ Study a United Kingdom Medical Research Council/Biotechnology and Biological Sciences Research Council cohort study of health and aging in the oldest-old age group.Eighty-one community-dwelling individuals aged 85.Participant and researcher acceptability, completion rates, time taken, validity as cognitive measures, and psychometric utility.Participants randomized to computerized tests were less likely to rate the cognitive function tests as difficult (odds ratio (OR)=0.16, 95% confidence interval (CI)=0.07-0.39), stressful (OR=0.18, 95% CI=0.07-0.45), or unacceptable (OR=0.18, 95% CI=0.08-0.48) than those randomized to pencil-and-paper tests. Researchers were also less likely to rate participants as being distressed in the computer test group (OR=0.19, 95% CI=0.07-0.46). Pencil-and-paper tasks took participants less time to complete (mean+/-standard deviation 18+/-4 minutes vs 26+/-4 minutes) but had fewer participants who could complete all tasks (91% vs 100%). Both types of task were equally good measures of cognitive function.Computerized and pencil-and-paper tests are both feasible and useful means of assessing cognitive function in the oldest-old age group. Computerized tests are more acceptable to participants and administrators.

BACKGROUND: Ensuring appropriate prescribing is an important challenge for the health service, and the need for research that takes account of the reasons behind individual general practitioners' (GPs) prescribing decisions has been highlighted. AIM: To explore differences among GPs in their decisions to prescribe new drugs. DESIGN OF STUDY: Qualitative approach, using in-depth semistructured interviews. SETTING: Northern and Yorkshire Health Authority Region. METHOD: Participants were identified from a random sample of 520 GPs in a quantitative study of patterns of uptake of eight recently introduced drugs. Purposeful sampling ensured inclusion of GPs prescribing any of the eight drugs and working in a range of practice settings. Fifty-six GPs were interviewed, using a topic guide. Interviews were recorded on audiotape. Transcribed text was methodically coded and data were analysed by constantly comparing emerging themes. RESULTS: Both low and high prescribers shared a view of themselves as conservative in their prescribing behaviour. Low prescribers appeared to conform more strongly to group norms and identified a consensus among practice partners in prescribing and cost-consciousness. Conformism to group norms was represented by a commitment to practice formularies. High prescribers more often expressed themselves to be indifferent to drug costs and a shared practice ethos. CONCLUSIONS: A shift in the attitudes of some GPs is required before cost-effectiveness is routinely incorporated in drug prescribing. The promotion of rational prescribing is likely to be more successful if efforts are focused on GPs' appreciation of cost issues and attitudes towards shared decision-making and responsibility.

There is increasing professional and policy interest in the role of clinical guidelines for promoting effective and efficient health care. The NHS Health Technology Assessment Programme identified an urgent need, when such guidelines are produced, to develop a framework and methods for incorporating the best evidence of effectiveness, taking into account information on cost-effectiveness. This paper describes the development of recent evidence-based guidelines, for use in primary care, which were the result of recent work by the North of England Guidelines Development Group. Their specific aim was to incorporate economic analysis into the guideline process and treatment recommendations. The introduction of economic data raised some methodological issues, specifically: in providing valid and generalisable cost estimates; in the grading of cost ‘evidence’; in finding a presentation helpful to clinicians. The approach used was to help clinicians aggregate the various attributes of treatment to make good treatment recommendations, rather than interpret cost-effectiveness ratios. In none of the guideline areas was there adequate information to estimate a cost per quality-adjusted-life-year. In the light of this research, future areas of work are identified and some recommendations are made for the forthcoming National Institute for Clinical Excellence.