Studying clinical reasoning, part 2: Applying social judgement theory

Part 1 of this paper (Harries and Harries 2001) examined the reasoning studies of the 1980s and 1990s and critiqued the ethnographic and informationprocessing approaches, based on stated information use. The need for an approach that acknowledged the intuitive nature of experienced thinkers’ reasoning was identified. Part 2 describes such an approach ± social judgement theory ± and presents a pilot application in occupational therapy research. The method used is judgement analysis. The issue under study is that of prioritisation policies in community mental health work. The results present the prioritisation policies of four occupational therapists in relation to managing community mental health referrals

Studies in Ambulatory Care Quality Assessment in the Indian Health Service Volume 3: Comparison of Rural Private Practice, Health Maintenance Organizations, and the Indian Health Service

This report describes a method designed to assess the quality of ambulatory health care in the Indian Health Service. The first part of the evaluation was a description of the design phase of the quality assurance methodology. The second report describes a pilot study in six IHS Service Units, three private practices, and two large Health Maintenance Organizations. This third volume compares the three different types of health care units. The primary purpose of this report is to determine if there is any significant difference in the performance of the different health care providers of ambulatory health care.Seven tracer conditions were selected on the basis of severity of impact on the patient. The tracer conditions included: severe lacerations, iron deficiency anemia, urinary tract infection, prenatal care, infant care, streptococcal infection, and hypertension. Specific patient cohorts were identified by tracer condition and monitored by criteria indicators. These indicators describe the continuity, distribution, and appropriateness of provider care. The indicators are aggregated into three major types: population based, provider based, and health status indicators. The results were tabulated in frequency tables. Comparisons of tracer cohorts were then made for all three types of health care providers.This comparative phase of the study found that there was no substantial or consistent difference in the performance of the care providers across units. Most of the differences observed were attributable to the provider\u27s ability or inability to recognize the patient\u27s needs, and the patient\u27s ability to articulate their needs. It appeared that IHS units did a more comprehensive job of consumer education. That may be attributable to the multidisciplinary health care teams, and extensive field operations of IHS. Conversely, the recognition of patient needs tends to be higher with private practitioners and HMOs.The study suggests four major methodological areas of concern in the application of quality assurance techniques. First, the evaluation of provider performance alone does not necessarily reflect the adequacy of care provided. Second, the study indicates a continuing need to improve the continuity of care provision. Health status indicators were the weakest part of the quality assessment methodology and require further research and development. Finally, one must use tracer conditions with caution. The adequacy of care resulting from the assessment of one condition may not always be generalizable to insure adequacy of care for similar conditions. Focusing on specific conditions may serve to blind the care provider to other symptomatically similar conditions

A review of the factors involved in older people's decision making with regard to influenza vaccination: a literature review

Aims and objectives. The aim of this paper was to develop an understanding of the factors involved in older people's decision making with regard to influenza vaccination to inform strategies to improve vaccine uptake and reduce morbidity and mortality. Background. Influenza is a major cause of morbidity and mortality world-wide. In the UK, it accounts for 3000–6000 deaths annually; 85% of these deaths are people aged 65 and over. Despite this, and the widespread and costly annual government campaigns, some older people at risk of influenza and the associated complications remain reluctant to take advantage of the offer of vaccination. Methods. A review of the English language literature referring to older people published between 1996 and 2005 was the method used. Inclusion and exclusion criteria were identified and applied. Results. The majority of the literature was quantitative in nature, investigating personal characteristics thought to be predictors of uptake, such as age, sex, co-morbidity, educational level, income and area of residence. However, there was little discussion of the possible reasons for the significance of these factors and conflict between findings was often evident, particularly between studies employing different methodologies. Other factors identified were prior experience, concerns about the vaccine, perceived risk and advice and information. Relevance to clinical practice. The wealth of demographic information available will be useful at a strategic level in targeting groups identified as being unlikely to accept vaccination. However, the promotion of person-centred ways of working that value the health beliefs, attitudes, perceptions and subjective experiences of older people is likely to be more successful during individual encounters designed to promote acceptance. Without more research in investigating these concepts, our understanding is inevitably limited

Studies in Ambulatory Care Quality Assessment in the Indian Health Service

This report describes a method designed to assess the quality of ambulatory health care in the Indian Health Service. This evaluation approaches the issue of quality assurance for ambulatory care through three basic performance criteria: 1) the method must be easily and economically incorporated into the existing system; 2) the method must identify areas of deficiency in health care and suggest adaptive programs to correct deficiencies; and 3) the method must view health care from the community perspective and examine the quality of the care actually received.This study design was developed around six methodological design questions: 1) what mode of health care delivery is assessed; 2) what aspect of quality is measured; 3) what is the content of the evaluation; 4) how is quality assessed; 5) from what perspective are the measurements taken; and 6) how are the results analyzed? The results of the above design decisions are then used to develop criteria-based indicators and instruments. The project product is a set of flow charts or process maps and tables which outline in detail, the performance and process criteria, and forms to be used to connect data and index the progress and effectiveness of actual patient status and health care performance. The final stage in the process is to propose a design for field testing the established methodology. The evaluation instrument was successfully completed, and implemented at the field test study sites.For the purpose of improving the pilot study and subsequent evaluations, the designers of this methodology strongly suggest that: 1) audit specific data should include all usual patient status data, complete patient history data, including negative as well as positive progress, and educational counseling plans and outcomes; 2) validity of proposed criteria ought to be supported by controlled clinical studies; and 3) only those elements of care which can actually be changed should be subjected to compliance with performance criteria

Footing the bill: the introduction of Medicare Benefits Schedule rebates for podiatry services in Australia

The introduction of Medicare Benefits Schedule items for allied health professionals in 2004 was a pivotal event in the public funding of non-medical primary care services. This commentary seeks to provide supplementary discussion of the article by Menz (Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008 Journal of Foot and Ankle Research 2009, 2:30), by placing these findings within the context of the podiatry profession, clinical decision making and the broader health workforce and government policy

Who needs what from a national health research system: Lessons from reforms to the English Department of Health's R&D system

This article has been made available through the Brunel Open Access Publishing Fund.Health research systems consist of diverse groups who have some role in health research, but the boundaries around such a system are not clear-cut. To explore what various stakeholders need we reviewed the literature including that on the history of English health R&D reforms, and we also applied some relevant conceptual frameworks. We first describe the needs and capabilities of the main groups of stakeholders in health research systems, and explain key features of policymaking systems within which these stakeholders operate in the UK. The five groups are policymakers (and health care managers), health professionals, patients and the general public, industry, and researchers. As individuals and as organisations they have a range of needs from the health research system, but should also develop specific capabilities in order to contribute effectively to the system and benefit from it. Second, we discuss key phases of reform in the development of the English health research system over four decades - especially that of the English Department of Health's R&D system - and identify how far legitimate demands of key stakeholder interests were addressed. Third, in drawing lessons we highlight points emerging from contemporary reports, but also attempt to identify issues through application of relevant conceptual frameworks. The main lessons are: the importance of comprehensively addressing the diverse needs of various interacting institutions and stakeholders; the desirability of developing facilitating mechanisms at interfaces between the health research system and its various stakeholders; and the importance of additional money in being able to expand the scope of the health research system whilst maintaining support for basic science. We conclude that the latest health R&D strategy in England builds on recent progress and tackles acknowledged weaknesses. The strategy goes a considerable way to identifying and more effectively meeting the needs of key groups such as medical academics, patients and industry, and has been remarkably successful in increasing the funding for health research. There are still areas that might benefit from further recognition and resourcing, but the lessons identified, and progress made by the reforms are relevant for the design and coordination of national health research systems beyond England.This article is available through the Brunel Open Access Publishing Fund

Web-based interventions for weight loss and weight maintenance among rural midlife and older women: protocol for a randomized controlled trial

Background: Weight loss is challenging and maintenance of weight loss is problematic among midlife and older rural women. Finding effective interventions using innovative delivery methods that can reach underserved and vulnerable populations of overweight and obese rural women is a public health challenge. Methods/Design: This Women Weigh-In for Wellness (The WWW study) randomized-controlled trial is designed to compare the effectiveness of theory-based behavior-change interventions using (1) website only, (2) website with peer-led support, or (3) website with professional email-counseling to facilitate initial weight loss (baseline to 6 months), guided continuing weight loss and maintenance (7-18 months) and self-directed weight maintenance (19-30 months) among rural women ages 45-69 with a BMI of 28-45. Recruitment efforts using local media will target 306 rural women who live within driving distance of a community college site where assessments will be conducted at baseline, 3, 6, 12, 18, 24 and 30 months by research nurses blinded to group assignments. Primary outcomes include changes in body weight, % weight loss, and eating and activity behavioral and biomarkers from baseline to each subsequent assessment. Secondary outcomes will be percentage of women achieving at least 5% and 10% weight loss without regain from baseline to 6, 18, and 30 months and achieving healthy eating and activity targets. Data analysis will use generalized estimating equations to analyze average change across groups and group differences in proportion of participants achieving target weight loss levels. Discussion: The Women Weigh-In for Wellness study compares innovative web-based alternatives for providing lifestyle behavior-change interventions for promoting weight loss and weight maintenance among rural women. If effective, such interventions would offer potential for reducing overweight and obesity among a vulnerable, hard-to-reach, population of rural women

Understanding physical activity promotion in physiotherapy practice: A qualitative study

Objective: Physical inactivity is a major public health issue and healthcare professionals are encouraged to promote physical activity during routine patient contacts in order to reduce non-communicable diseases and enhance individuals’ quality of life. Little is known about physical activity promotion in physiotherapy practice in the UK. The aim of this study was to better understand physiotherapists’ experience of physical activity promotion in clinical practice. Design: A qualitative study was undertaken comprising 12 telephone interviews with participants using a quota sampling approach. The qualitative data was analysed using a thematic analysis approach and written up according to COREQ guidelines. Findings: Four themes were identified (1) Current physiotherapy practice (2) Barriers to, and facilitators of physical activity promotion, (3) Exercise or physical activity? and (4) Functional restoration versus general wellbeing. Conclusions: Physiotherapists use routine clinical contacts to discuss physical activity. However, brief interventions are not consistently used and no common framework to guide physical activity promotion was identified. Approaches appear to be inconsistent and informal and focus largely on short-term restoration of function rather than health promotion. There is scope to improve practice in line with current guidance to maximise potential impact on inactivity

Use of antenatal services and delivery care among women in rural western Kenya: a community based survey

BACKGROUND: Improving maternal health is one of the UN Millennium Development Goals. We assessed provision and use of antenatal services and delivery care among women in rural Kenya to determine whether women were receiving appropriate care. METHODS: Population-based cross-sectional survey among women who had recently delivered. RESULTS: Of 635 participants, 90% visited the antenatal clinic (ANC) at least once during their last pregnancy (median number of visits 4). Most women (64%) first visited the ANC in the third trimester; a perceived lack of quality in the ANC was associated with a late first ANC visit (Odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0–2.4). Women who did not visit an ANC were more likely to have < 8 years of education (adjusted OR [AOR] 3.0, 95% CI 1.5–6.0), and a low socio-economic status (SES) (AOR 2.8, 95% CI 1.5–5.3). The ANC provision of abdominal palpation, tetanus vaccination and weight measurement were high (>90%), but provision of other services was low, e.g. malaria prevention (21%), iron (53%) and folate (44%) supplementation, syphilis testing (19.4%) and health talks (14.4%). Eighty percent of women delivered outside a health facility; among these, traditional birth attendants assisted 42%, laypersons assisted 36%, while 22% received no assistance. Factors significantly associated with giving birth outside a health facility included: age ≥ 30 years, parity ≥ 5, low SES, < 8 years of education, and > 1 hour walking distance from the health facility. Women who delivered unassisted were more likely to be of parity ≥ 5 (AOR 5.7, 95% CI 2.8–11.6). CONCLUSION: In this rural area, usage of the ANC was high, but this opportunity to deliver important health services was not fully utilized. Use of professional delivery services was low, and almost 1 out of 5 women delivered unassisted. There is an urgent need to improve this dangerous situation