Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

Background-—Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation. Methods and Results-—Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees,using the Huber–White–sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98–0.99), having a partner (OR 1.31, 95% CI 1.17–1.48), not being employed (OR 0.86, 95% CI 0.77–0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77–0.92), greater anxiety (OR 1.02, 95% CI 1.003–1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42–0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09–2.47). Conclusions-—CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized

Exploring the implementation of cognitive behaviour therapy for psychosis using the Normalization Process Theory framework

Objective: Evidence suggests that only a minority of service users experiencing psychosis have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalisation Process Theory (NPT) is a theoretical framework which focuses on processes by which interventions are implemented and normalised in clinical practice. This study explored the views and experiences of mental health professionals regarding the implementation of CBTp. Barriers and facilitators to implementation were explored using the NPT framework. Design: A qualitative methodology was adopted involving semi-structured focus groups and individual interviews. Methods: A total of 14 members of staff working in the community and crisis mental health teams were recruited. Thematic analysis was used to generate initial themes. The Framework approach was utilised to map initial themes to the NPT framework. Results: Inductive coding generated five overarching themes consisting of 15 individual subthemes which captured the perceived barriers to engagement; contextual barriers to implementation; optimisation of implementation; positive attitudes towards implementation; and expectations of implementing CBTp. All but two subthemes mapped on to the NPT framework. The deductive analysis suggested that difficulties in making sense of CBTp among professionals were reflected as service level barriers which impeded wider implementation. Conclusion: The results of this study suggested a mixture of barriers and facilitators to CBTp implementation. Interpreting our findings within an NPT framework indicates the importance of strong clinical leadership to address difficulties in sense-making and service investment in CBTp

Uveal melanoma UK national guidelines

The United Kingdom (UK) uveal melanoma guideline development group used an evidence based systematic approach (Scottish Intercollegiate Guidelines Network (SIGN)) to make recommendations in key areas of uncertainty in the field including: the use and effectiveness of new technologies for prognostication, the appropriate pathway for the surveillance of patients following treatment for primary uveal melanoma, the use and effectiveness of new technologies in the treatment of hepatic recurrence and the use of systemic treatments. The guidelines were sent for international peer review and have been accredited by NICE. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website

Why are eligible patients not prescribed aspirin in primary care? A qualitative study indicating measures for improvement

BACKGROUND: Despite evidence-based guidelines, aspirin prescribing for the secondary prevention of stroke is sub-optimal. Little is known about why general practitioners do not prescribe aspirin to indicated patients. We sought to identify and describe factors that lead general practitioners (GPs) not to prescribe aspirin to eligible stroke patients. This was the first stage of a study exploring the need for and means of improving levels of appropriate aspirin prescribing. METHOD: Qualitative interviews with 15 GPs in the West Midlands. RESULTS: Initially, many GPs did not regard their prescribing as difficult or sub-optimal. However on reflection, they gave several reasons that lead to them not prescribing aspirin for eligible patients or being uncertain. These include: difficulties in applying generic guidelines to individuals presenting in consultations, patient resistance to taking aspirin, the prioritisation of other issues in a time constrained consultation and problems in reviewing the medication of existing stroke patients. CONCLUSION: In order to improve levels of appropriate aspirin prescribing, the nature and presentation risk information available to GPs and patients must be improved. GPs need support in assessing the risks and benefits of prescribing for patients with combinations of complicating risk factors, while means of facilitating improved GP-patient dialogue are required to help address patient uncertainty. A decision analysis based support system is one option. Decision analysis could synthesise current evidence and identify risk data for a range of patient profiles commonly presenting in primary care. These data could then be incorporated into a user-friendly computerised decision support system to help facilitate improved GP-patient communication. Measures of optimum prescribing based upon aggregated prescribing data must be interpreted with caution. It is not possible to assess whether low levels of prescribing reflect appropriate or inappropriate use of aspirin in specific patients where concordance between the GP and the patient is practised

Epidemiology of venous leg ulcers in primary health care: Incidence and prevalence in a health centre-A time series study (2010-2014)

The aims of the study were to describe and analyse the temporal trend of the prevalence and incidence of venous leg ulcers (VLU) over the years 2010 to 2014, to determine healing times and temporal trends in the study period, and to evaluate related aspects such as the use of the Ankle-Brachial Pressure Index (ABPI) in a primary care health centre. This was a retrospective study based on a time series (years 2010-2014) of the prevalence and incidence of VLUs in people aged over 40 years in a primary care centre in Barcelona City. We reviewed 3920 electronic health records selecting patients, per year (2010-2014), with VLUs based on the ICD-10 diagnoses. For prevalence, we took into account any patient with an active VLU in the year of study. For incidence, we took into account patients with a new VLU in the year of study. A descriptive analysis was carried out based on each of the collected variables. The variables were examined according to the years of study (time series) by one-factor analysis of variance (ANOVA) or Kruskal?Wallis non-parametric test, as appropriate. A survival analysis by Kaplan?Meier curves and log-rank test was also performed. A total of 139 patients met the VLU criteria. Among them, only 79.2% were classified as having a VLU and had a correct ICD diagnosis. The prevalence and incidence increased over the years, doubling in patients aged over 65 years. Incidence increased from 0.5 new cases per 1000 people/ year in 2010 to 1 new case for every 1000 people/year in 2014. Moreover, the prevalence ranged between 0.8 and 2.2 patients with VLU for every 1000 people/ year. During the study period, a total of 84.2% of the VLUs healed (117/139 VLU). Regarding average annual time to healing, the trend indicates that lesions took less time to heal (Kruskal?Wallis test, P = 0.004), ranging between 453,9 weeks in 2005 to 19 weeks in 2014. The use of ABPI also evolved and was found to be increasingly performed prior to the appearance of the lesion. The epidemiological profile of people affected by VLUs continues to be, mainly, that of women of an advanced age, over 70 years. The frequency of VLU occurrence rose continually over the years, but healing took less time, and use of ABPI improved. Assigning a reference nurse in the wounds unit and the organisational structure around this problem may have an influence on improving care and the approach to these types of lesions

A randomised controlled trial of a patient based Diabetes recall and Management system: the DREAM trial: A study protocol [ISRCTN32042030]

BACKGROUND: Whilst there is broad agreement on what constitutes high quality health care for people with diabetes, there is little consensus on the most efficient way of delivering it. Structured recall systems can improve the quality of care but the systems evaluated to date have been of limited sophistication and the evaluations have been carried out in small numbers of relatively unrepresentative settings. Hartlepool, Easington and Stockton currently operate a computerised diabetes register which has to date produced improvements in the quality of care but performance has now plateaued leaving substantial scope for further improvement. This study will evaluate the effectiveness and efficiency of an area wide 'extended' system incorporating a full structured recall and management system, actively involving patients and including clinical management prompts to primary care clinicians based on locally-adapted evidence based guidelines. METHODS: The study design is a two-armed cluster randomised controlled trial of 61 practices incorporating evaluations of the effectiveness of the system, its economic impact and its impact on patient wellbeing and functioning

Guidelines in the era of realistic medicine

No abstract available

Analysis of evidence in decision-making research between 2002 and 2012

ABSTRACT: This article presents a systematic review of 66 studies on decision making from psychology issued from 2002 through 2012, either in English or Spanish. These studies were classified according to the Scottish Intercollegiate Guidelines Network (SIGN)’s levels of evidence and degrees of recommendation. The research type, level, and design of every study were analyzed in detail, as well as the relationship between these factors and the levels of evidence in the studies involved. Stronger evidence for quality in research on physiological correlates of decision variables was found, as well as a lower quality level in comparative studies on psychological decision-making models. The latter show a high level of theoretical divergence and a lack of research focused on consolidating a coherent theoretical framework.RESUMEN: El presente artículo lleva a cabo la revisión sistemática de 66 investigaciones publicadas sobre toma de decisiones en psicología durante el periodo comprendido entre 2002 y 2012 en idiomas inglés y español. Los artículos revisados fueron clasificados de acuerdo con sus niveles de evidencia y grados de recomendación según la Scottish Intercollegiate Guidelines Network (SIGN). Se llevó a cabo un análisis pormenorizado de los tipos, niveles y diseños de investigación informados por los diferentes artículos, así como las relaciones entre estos factores y los niveles de evidencia alcanzados. Se aprecia una mayor calidad de evidencia en investigaciones sobre correlatos fisiológicos de variables de elección, a la vez que una menor calidad en estudios comparativos entre modelos psicológicos de decisión. Respecto a estos últimos, se evidencia una gran divergencia teórica y una ausencia de trabajos orientados a la consolidación de un cuerpo teórico coherente

Analysis of evidence of consciousness and language research 2000-2010 : a systematic review

ABSTRACT: Owing to the relevance of theorization about language and consciousness, this study took up 86 research articles about these processes; published between the years 2000 and 2010. For the articles’ analysis of evidence, the Scottish Intercollegiate Guidelines Network (SIGN) was used. This made possible to identify the levels of evidence and categories of recommendations of the articles. In this study it was found that most of the researches reach a correlation-descriptive level. There were few studies that reach an explicative level. For the language studies, a transversal method is consistently used; meanwhile experimental designs are more recurrent in consciousness research. Articles about consciousness have higher levels of evidence and categories of recommendations compared to language studies. This fact unveils how the interest in the study of this process.RESUMEN: Debido a la importancia de la teorización de la conciencia y el lenguaje, este estudio retomó 86 artículos académicos sobre estos procesos publicados entre 2000 y 2010. Para el análisis de los artículos se utilizó la clasificación hecha por The Scottish Intercollegiate Guidelines Network (SIGN), que permite identificar el nivel de evidencia y los grados de recomendación de los mismos. La mayoría de las investigaciones alcanzan un nivel descriptivo-correlacional, y se encontraron pocos estudios explicativos. En los estudios sobre el lenguaje, el diseño metodológico es recurrentemente transversal, mientras que los diseños experimentales aparecen con mayor frecuencia en las investigaciones sobre la conciencia. Los artículos sobre la conciencia tienen un nivel mayor de evidencia y grados de recomendación que los del lenguaje, asunto que pone de manifiesto el interés creciente por el estudio de este proceso

Standardized postnatal management of infants with congenital diaphragmatic hernia in Europe: The CDH EURO consortium consensus

Congenital diaphragmatic hernia (CDH) is associated with high mortality and morbidity. To date, there are no standardized protocols for the treatment of infants with this anomaly. However, protocols based on the literature and expert opinion might improve outcome. This paper is a consensus statement from the CDH EURO Consortium prepared with the aim of achieving standardized postnatal treatment in European countries. During a consensus meeting between high-volume centers with expertise in the treatment of CDH in Europe (CDH EURO Consortium), the most recent literature on CDH was discussed. Thereafter, 5 experts graded the studies according to the Scottish Intercollegiate Guidelines Network (SIGN) Criteria. Differences in opinion were discussed until full consensus was reached. The final consensus statement, therefore, represents the opinion of all consortium members. Multicenter randomized controlled trials on CDH are lacking. Use of a standardized protocol, however, may contribute to more valid comparisons of patient data in multicenter studies and identification of areas for further research