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Rationale, aims and objectives Sufficient evidence suggests that health information technology (HIT) will soon become part of physician procedure. This paper poses that the outcome of using HIT is affected by the intentions of use. Note that ethical indoctrination is a crucial mechanism for monitoring physicians. Judicious and sufficient use of HIT is expected to be the prerequisite for deploying these technologies to help in delivering better care. This research paper, therefore, aims to define professional concerns and intent to use HIT, and identify their associations. Methods A survey study was conducted to collect data for developing a seven-dimensional eHealth success measure. This paper focuses on deriving a structural equation model that can explain the associations among professional concerns and intent to use HIT. Statistical analyses were, therefore, only performed on the Intent to Use and Physician Attributes constructs. Results The statistical results show that altruism, autonomy, physician-patient relationship and (subconscious) autonomy significantly associate with each other at least at P < 0.05. Only altruism shows to be a significant determinant of intent to use HIT (with P = 0.00005). Other professional concerns only associate with it indirectly through altruism. Conclusions Medicine has been a science-using and compassionate practice. Medical practice including HIT use may only be reliably assessed from a sociotechnical perspective. Professional concerns show to be associated with intent to use HIT is an expected result. This research direction may contribute to deriving policies to deploy HIT for delivering better care through implementing sufficient and judicious HIT use. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Clinical nurse specialists ( CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials ( RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care. Methods We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation ( GRADE) tool. We pooled data for similar outcomes. Results Thirteen RCTs of CNS transitional care were identified ( n = 2463 participants). The studies had low ( n = 3), moderate ( n = 8) and high ( n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs. Conclusions There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed. [ABSTRACT FROM AUTHOR]

Rationale Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person. Method Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study. Results The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year). Conclusions This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: The development of clinical practice guidelines (CPG) suffers from the lack of an explicit and transparent framework for synthesising the key elements necessary to formulate practice recommendations. We matched deliberations of the American Society of Haematology (ASH) CPG panel for the management of pulmonary embolism (PE) with the corresponding decision‐theoretical constructs to assess agreement of the panel recommendations with explicit decision modelling. Methods: Five constructs were identified of which three were used to reformulate the panel's recommendations: (1) standard, expected utility threshold (EUT) decision model; (2) acceptable regret threshold model (ARg) to determine the frequency of tolerable false negative (FN) or false positive (FP) recommendations, and (3) fast‐and‐frugal tree (FFT) decision trees to formulate the entire strategy for management of PE. We compared four management strategies: withhold testing versus d‐dimer → computerized pulmonary angiography (CTPA) ('ASH‐Low') versus CTPA→ d‐dimer ('ASH‐High') versus treat without testing. Results: Different models generated different recommendations. For example, according to EUT, testing should be withheld for prior probability PE < 0.13%, a clinically untenable threshold which is up to 15 times (2/0.13) below the ASH guidelines threshold of ruling out PE (at post probability of PE ≤ 2%). Three models only agreed that the 'ASH low' strategy should be used for the range of pretest probabilities of PE between 0.13% and 13.27% and that the 'ASH high' management should be employed in a narrow range of the prior PE probabilities between 90.85% and 93.07%. For all other prior probabilities of PE, choosing one model did not ensure coherence with other models. Conclusions: CPG panels rely on various decision‐theoretical strategies to develop its recommendations. Decomposing CPG panels' deliberation can provide insights if the panels' deliberation retains a necessary coherence in developing guidelines. CPG recommendations often do not agree with the EUT decision analysis, widely used in medical decision‐making modelling. [ABSTRACT FROM AUTHOR]

Objectives To design and evaluate the effectiveness of a pre-notification leaflet about research to increase recruitment to a randomized controlled trial (RCT). Methods A methodological, two-arm, RCT was conducted, embedded within an existing cohort RCT (REFORM). Participants were randomized for the embedded trial, using a 1:2 ratio (intervention : control) before being randomized for REFORM. Controls received a trial recruitment pack. The intervention group received an additional pre-notification leaflet 2-3 weeks before the recruitment pack. Primary and secondary analyses were conducted using relative risk, the Cox proportional hazards model and incremental cost-effectiveness ratios. Results Of the 1436 intervention group participants, 73 (5.1%) were randomized into the REFORM trial compared with 126 (4.4%) of the 2878 control group participants. The associated relative risk (1.16) was not statistically significant [95% confidence interval (CI) 0.88-1.56]. Return rate was not significantly increased (relative risk 1.10, 95% CI 0.92-1.28) nor time to return decreased (hazard ratio: 1.11, 95% CI 0.93-1.33). Incremental cost-effectiveness ratios indicated the intervention may be cost-effective if the true estimate of effect was close to the upper bound of the associated 95% CI. Conclusion Pre-notification for potential trial participants demonstrated a small difference to randomization (0.7% difference) and return rates (1.1% difference) in favour of the intervention. Results should however be interpreted with caution as CIs for these estimates cross the point of no effect. Nevertheless, this research enhances existing evidence for pre-notification to increase recruitment rates, with further development and assessment of this potentially cost-effective intervention being recommended. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Our aim was to evaluate the effectiveness of a Post-it® note to increase response rates and shorten response times to a 4-month postal follow-up questionnaire sent to participants taking part in the Collaborative Care in Screen-Positive Elders (CASPER) trials. Method Our trial was a two-arm randomized controlled trial comparing response rates to questionnaires with a printed Post-it® note (intervention) and without (control), nested in multi centred randomized controlled trials of older people with varying levels of depressive symptoms; the CASPER+ and CASPER Self Help for those At Risk of Depression (SHARD) trials. A total of 611 participants were eligible and randomized. The primary outcome was response rates, secondary outcomes were time to response and need for a reminder. Results Of 297 participants, 266 (89.6%) returned their 4-month questionnaire in the post-it note arm, compared with 282 of 314 participants (89.8%) in the control arm (OR = 0.97, 95% CI: 0.57, 1.65, P = 0.913). There were no statistically significant differences in time to respond or the need to be sent a reminder. Patients with a major depressive episode were more likely to return questionnaires with post-it notes ( P of interaction = .019). Conclusion There was no significant difference in response rates, time to response, or the need for a reminder between the intervention and control at 4-month follow up for older people with depressive symptoms. However, there was a significant interaction between the Post-it® note group and level of depression. [ABSTRACT FROM AUTHOR]

Objectives Anesthesiology has reached a new stage which anaesthesia safety is significantly affected by human factors. The number of Chinese anaesthetists has increased to nearly twice as many as that in 2005. Attributed to traditional concepts, many problems in anesthesiology persist in Chinese hospitals. This study aims to determine the current status of anaesthesia job burnout, including problems related to burnout, as well as the conditions of anaesthesia human resources in Chinese hospitals. Methods A multi-center, cross-sectional survey of 395 anaesthetists from 60 hospitals in 6 provinces was conducted to collect data on the work conditions of anesthesiologists by using questionnaires. The Maslach Burnout Inventory (MBI) was used to measure burnout. Different statistical models were also used to evaluate the data. Results The number of Chinese anaesthetists has increased to nearly twice as many as that in 2005. According to our field survey of burnout among anaesthetists, only 17 (4.30%) respondents exhibited high levels of burnout. The average scores corresponding to the dimensions of burnout are 14.64 ± 11.40 (emotional exhaustion, EE), 4.22 ± 5.74 (depersonalization, DP), and 33.41 ± 10.05 (personal accomplishment, PA), as determined by MBI. These results indicate the differences in the spatial distribution of anaesthetists. Moreover, 15.3% of the anaesthetists showed high EE, 8.1% exhibited high DP, and 33.6% had low PA. Conclusion Anxiety and undesirable conditions experienced by professional groups in anaesthesiology need to be addressed. Educational level, an important factor in anaesthesia care, influences not only psychological health of practitioners but patient safety as well. Thus, personnel structure must be optimized to relieve tension in the practice of the profession and reduce burnout among anaesthetists in hospitals in China. Meanwhile, the management must increase its effort toward improving the mental health of practitioners and patient safety in anaesthesia care. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives We aim to determine the prevalence of reconciliation errors ( REs) at admission to surgery departments, report their potential clinical impact and analyse possible risk factors. Methods Prospective observational study was conducted for 8 months in a regional public hospital in Spain. The study included patients consecutively hospitalized in the Department of Orthopedic Surgery and Traumatology or Department of Angiology and Vascular Surgery from May through December 2010. At 24-48 hours after hospital admission, the pre-admission pharmacological treatment of patients was compared with the medication received in hospital to identify REs, which were classified by type and potential severity. Multivariate logistic regression analysis was conducted with the presence of RE as dependent variable. Results The study included 176 patients, 60.8% of whom were aged >65 years and consumed a mean of 5.55 (±4.33) drugs. 55.1% had ≥1 RE, with a mean of 3.21 REs per patient [95% confidence interval ( CI; 2.72-3.70)]. The most frequent RE was drug omission (84.1%). No clinical risk was posed by 50.5% of the REs. Multivariate analysis evidenced fourfold higher risk of an RE in patients admitted for elective versus emergency surgery and a 1.35-fold higher risk in patients receiving a larger number of drugs. Conclusions There was a high prevalence of REs among patients admitted to the surgical departments, most frequently the omission of a drug. The risk of an RE was higher in patients admitted for elective versus emergency surgery, as well as with the receipt of a larger number of drugs before admission. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Indiscriminate health screening is increasingly seen as being problematic. In particular, vitamin D testing rates are increasing rapidly despite recommendations against population screening. The purpose of this study was to determine the level of vitamin D testing among family practice/general practitioner ( GP) trainees and to establish associations of this testing. Methods Cross-sectional analysis of data from the ReCEnT ( Registrars Clinical Encounters in Training) cohort study. The setting was GP practices in four Australian states. Data from 60 consecutive consultations per trainee were recorded each 6-month training term (up to four terms). Results Vitamin D tests were ordered in 726 (1.0%) of encounters ( n = 69 412). Vitamin D test ordering was significantly associated with patients being older, female and non- English speaking. Trainees were more likely to test if they worked in a completely bulk-billing practice (i.e. a practice without any patient payment), if more problems were dealt with, more pathology tests were ordered in the consultation and if a lipid profile was ordered. They were less likely to test if they sought in-consultation advice or information. The most common reasons for testing were 'check-up' and 'health maintenance'. Conclusions In this first report of associations of vitamin D testing in the GP setting, we found that non-targeted vitamin D testing (testing inconsistent with current guidelines) is widespread in GP trainees' practice. Adoption of more rational testing approaches is needed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables. Methods 419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire. Results The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1-16). The most common treatment interventions across the three conditions were advice on posture (reported by 82-94%), advice to stay active (86-92%), and different types of exercise (65-92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29-96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience. Conclusions Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives In the United States, cardiovascular disease ( CVD) is the leading cause of death. The US Centers for Disease Control and Prevention contracted an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events ( AT GOAL) programme as part of its effort to identify strategies to address CVD risk factors. Methods This study analysed patient-level data from 7527 patients in 43 primary care practices. The researchers assessed average change in control rates for CVD-related measures across practices, and then across patients between baseline and a patient's last visit during the practice's tenure in the programme (referred to as 'end line') using repeated measures analysis of variance and random effects generalized least squares, respectively. Results Among non-diabetic patients, there were significant increases in control rates for overall blood pressure (74.3% to 78.0%, P = 0.0002), systolic blood pressure (70.3% to 80.6%, P = 0.0099), diastolic blood pressure (90.1% to 92.7%, P = 0.0001) and low-density lipoprotein (LDL; 48.6% to 53.1%, P = 0.0001) between baseline and end line. Among diabetic patients, there was a significant increase in diastolic blood pressure control (59.8% to 61.9%, P = 0.0141). While continuous CVD-related outcomes show an overall trend between baseline and end line, patients with uncontrolled measures at baseline showed a decrease between baseline and end line relative to their counterparts who were controlled at baseline. Conclusions Findings from the AT GOAL evaluation support the value of a facilitated quality improvement ( QI) initiative on managing CVD risk. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Quality indicators ( QIs) derived from the review of medical records, administrative databases, and patient questionnaires and interviews have been frequently used to assess the quality of osteoarthritis ( OA) care. The purpose of this review is to summarize studies that have assessed the quality of OA care using QIs. Method We systematically searched MEDLINE, EMBASE, CINAHL and PsycINFO for English-language studies indexed by October 2014. Articles were included if they used any QIs for assessing the quality of OA care. We summarized the results of these studies, and with meta-analysis, generated an overall conclusion about the quality of care as measured by QIs for each treatment domain for OA care. Results Fourteen studies assessed as being of high-quality were included in the review, with the number of QIs ranging from 1 to 21. Four of the 14 studies solely assessed the quality of OA care, while the other studies assessed health care quality for a range of conditions that included OA. The quality of OA care as assessed by a meta-analysis of QI pass rates across studies was suboptimal for all treatment domains (pass rates: pain and functional status assessment - 48.5%, 95% CI 32.6-64.6%; non-drug treatment - 36.1%, 95% CI 27.8-44.7%; drug treatment - 37.5%, 95% CI 30.8-44.5%; surgical referral - 78.9%, 95% CI 57.4-94.2%). Conclusion Despite efforts made at improving care for patients with OA, the wide divergence between evidence and consensus-based recommended care and practice has been reaffirmed. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives Long-term exposure to glucocorticoids can cause adverse drug reactions of long latency ( ADRLLs), including glucocorticoid-induced diabetes mellitus ( GID). Providers can monitor for GID using the glycosylated haemoglobin blood ( HbA1C) test. This study examined the utility of decisional support to improve HbA1C-based screening for GID. US veterans were identified as chronic users of oral glucocorticoids (>120 days of oral glucocorticoids in the last 2 years). The primary care providers caring for these patients were the target of the intervention. Providers were randomized to receive automatic HbA1C orders for their patients receiving chronic glucocorticoid or usual care. Methods This study was a pilot two-arm, group-randomized, controlled trial ( n = 12 providers, n = 38 patients). Data collection occurred from 5 May 2013 until 10 January 2014. A pharmacist generated the order for an HbA1C through the electronic medical record. The time between the intervention start date and the date on which an HbA1C order was signed were compared using Cox proportional and hierarchical linear regression. Results The time to sign HbA1C orders (mean 12.0 days for the intervention arm; 104.0 days for control arm) was associated with significant differences favouring the intervention [ HR (Hazard Ratio) 50.2, P < 0.001, confidence interval ( CI) 6.3 to 398.7]. For the intervention group, 95% of orders were signed, whereas only 12% of control providers signed orders (odds ratio 150, P < 0.001, CI 12.4 to 1812.9). Conclusions The results of this study strongly suggest that the clinical pharmacist-triggered order intervention is effective. This method of computerized decisional support may be useful in improving screening for GID and ADRLLs. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Routine outcome monitoring ( ROM) is used to improve quality of health care by improving the process of care. ROM was introduced nationwide in mental health care in the Netherlands with the primary goal of enhancing the quality of treatment. This study aims to establish the impact of ROM on the process quality of treatment in the daily practice of secondary mental health care in the Netherlands. Methods Two cohorts from the same treatment programme were identified, before and after implementation of ROM. Data on patient characteristics, presence of baseline ROM measurement and indicators of the quality of the treatment process were retrieved from the electronic health care information system. Patient data were collected until 6 months after enrolment in the treatment programme. The magnitude of the effect of ROM on the quality of the treatment process was established. Results The pre- ROM cohort comprised 271 patients and 231 patients constituted the post- ROM cohort. In the ROM cohort, both indicators for process quality 'presence of treatment plan' and 'presence of cancellations' were significantly higher; the odd ratios were 3,37 [confidence interval ( CI) 2.32-4.89] and 1,63 ( CI 1.14-2.33), respectively. Conclusions Indicators on process quality are important for understanding and establishing the impact of ROM in daily practice of secondary mental health care. Implementing ROM moderately increased the presence of a treatment plan. While this suggests improved treatment agreement, it did not result in better compliance of patients with individual treatment activities, as presence of cancellations was significantly higher after introduction of ROM. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Pharmacists are expected to play an important role in applying pharmacogenomics discoveries to patient care. Despite the increased attention to genetic research in Qatar, clinicians' attitudes towards the application of pharmacogenomics are not yet explored. The aim of this study was to assess the awareness and attitude of pharmacists compared with doctors towards pharmacogenomics and its implications by submitting an electronic-based survey to all pharmacists and doctors currently working in a large medical corporation in Qatar. Methods A cross-sectional survey instrument was developed based on literature review. Eligible participants were pharmacists and doctors currently practicing in Hamad Medical Corporation hospitals in Qatar. The survey comprised questions on demographic and professional characteristics. It also evaluated the awareness, attitudes and challenges towards pharmacogenomics and its application. Results We collected 202 surveys, 108 (53.2%) of which were pharmacists and the remaining 94 (46.5%) were doctors. The overall participants' mean total awareness score percentage was low (39% ± 22) and there were no difference between the mean score achieved by pharmacists and doctors. Pharmacists had significantly more positive attitudes than doctors towards: (i) taking the responsibility of applying pharmacogenomics to drug therapy selection, dosing and monitoring; (ii) perceiving a positive role of pharmacogenomics testing on the control of drug expenditure; and (iii) their willingness to participate in pharmacogenomics-related training sessions. Both pharmacists and doctors perceived lack of knowledge and guidelines as major challenges towards the application of pharmacogenomics in Qatar. Conclusion Despite doctors' and pharmacists' low level of awareness towards pharmacogenomics, they both have positive attitudes towards the clinical implications of pharmacogenomics. Pharmacists are more motivated to learn about pharmacogenomics and are more willing to take initiatives in its clinical application and patient education. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives This study aimed to evaluate the relative effectiveness of electronic and postal reminders for increasing adherence to the quality assurance programme for the international normalized ratio ( INR) point-of-care testing ( POCT) device in primary care. Methods All 213 family practices that use the Elective Laboratory of the Capital Region, Denmark, and regularly conduct INR POCT were randomly allocated into two similarly sized groups. During the 4-month intervention, these practices were sent either computer reminders ( Com Rem) or computer-generated postal reminders ( Postal) if they did not perform a split test to check the quality of their INR POCT for each calendar month. The adherence of the practices was tracked during the subsequent 8 months subdivided into two 4-month periods both without intervention. Outcomes were measures of split test procedure adherence. Results Both interventions were associated with an increase in adherence to the split test procedure - a factor 6.00 [95% confidence interval (CI) 4.46-7.72] and 8.22 [95% CI 5.87-11.52] for ComRem and Postal, respectively - but there is no evidence that one of the interventions was more effective than the other. In the Com Rem group, the expected number of split tests (out of four) was 2.54 (95% CI 2.33-2.76) versus 2.44 (95% CI 2.24-2.65) in the Postal group, P = 0.14. There was a slight decrease in adherence over the two follow-ups, but neither intervention was better than the other in achieving a lasting improvement in adherence. Conclusion Computer reminders are as efficient as postal reminders in increasing adherence to a quality assurance programme for the INR POCT device in primary care. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Continuous quality improvement programmes often target several aspects of care, some of which may be more effective meaning that resources could be focussed on these. The objective was to identify the effective and ineffective aspects of a successful continuous quality improvement programme for individuals with type 2 diabetes in primary care. Methods Data were from a series of cross-sectional studies ( GEDAPS) in primary care, Catalonia, Spain, in 55 centres (2239 participants) in 1993, and 92 centres (5819 participants) in 2002. A structural equation modelling approach was used. Results The intervention was associated with improved microvascular outcomes through microalbuminuria and funduscopy screening, which had a direct effect on microvascular outcomes, and through attending 2-4 nurse visits and having ≥1 blood pressure measurement, which acted through reducing systolic blood pressure. The intervention was associated with improved macrovascular outcomes through blood pressure measurement and attending 2-4 nurse visits (through systolic blood pressure) and having ≥3 education topics, ≥1 HbA1c measurement and adequate medication (through HbA1c). Cholesterol measurement, weight measurement and foot examination did not contribute towards the effectiveness of the intervention. Conclusions The pathways through which a continuous quality improvement programme appeared to act to reduce microvascular and macrovascular complications were driven by reductions in systolic blood pressure and HbA1c, which were attained through changes in nurse and education visits, measurement and medication. This suggests that these factors are potential areas on which future quality improvement programmes should focus. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Frequent use and serious adverse effects related to non-steroidal anti-inflammatory drugs ( NSAIDs) underscore the need to raise patient awareness about potential risks. Partial success of patient- or provider-based interventions has recently led to interest in combined approaches focusing on both patient and physician. This research tested a shared decision-making intervention for increasing patient-reported awareness of NSAID risk. Methods A group randomized trial was performed in Alabama from 2005 to 2007. Intervention group doctor practices received continuing medical education ( CME) about NSAIDs and patient activation tools promoting risk assessment and communication during visits. Comparison group doctor practices received only CME. Cross-sectional data were collected before and after the intervention. Generalized linear latent and mixed models with logistic link tested relationships among the intervention, study phase, intervention by study phase interaction and patient-reported awareness of risks with either prescription or over-the-counter ( OTC) NSAIDs. Results Three hundred and forty-seven patients at baseline and 355 patients at follow-up participated in this study. The intervention [adjusted odds ratio ( AOR) = 0.74, P = 0.248], follow-up study phase ( AOR = 1.31, P = 0.300) and intervention by study phase interaction ( AOR = 0.98, P = 0.942) were not significantly associated with patient-reported awareness of any prescription NSAID risk. Follow-up study phase was associated with increased odds of reporting any OTC NSAID risk awareness ( AOR = 2.99, P < 0.001), but the patient activation intervention and intervention by study phase interaction were not significantly associated with patient-reported awareness of any OTC NSAID risk ( AOR = 0.98, P = 0.929; AOR = 0.87, P = 0.693, respectively). Conclusions Our point-of-care intervention encouraging shared decision making did not increase NSAID risk awareness. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The management of non-technical skills is a major factor affecting teamwork quality and patient safety. This article presents a behavioural marker system for assessing neurosurgical non-technical skills ( BMS- NNTS). We tested the BMS during deep brain stimulation surgery. Method We developed the BMS in three stages. First, we drew up a provisional assessment tool based on the literature and observation tools developed for other surgical specialties. We then analysed videos made in an operating room ( OR) during deep brain stimulation operations in order to ensure there were no significant omissions from the skills list. Finally, we used five videos of operations to identify the behavioural markers of non-technical skills in verbal communications. Results Analyses of more than six hours of observations revealed 3515 behaviours from which we determined the neurosurgeon's non-technical skills behaviour pattern. The neurosurgeon frequently engaged in explicit coordination, situation awareness and leadership behaviours. In addition, the neurosurgeon's behaviours differed according to the stage of the operation and the OR staff members with whom she was communicating. Conclusions Our behavioural marker system provides a structured approach to assessing non-technical skills in the field of neurosurgery. It can also be transferred to other surgical specialties and used in surgeon training curricula. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Fibromyalgia ( FM) is challenging to diagnose, especially in primary care settings. The Fibromyalgia Diagnostic Screen was developed to facilitate the diagnosis of FM in clinical practice. The objectives of this study were to assess the performance of the Fibromyalgia Diagnostic Screen in primary care and specialty clinics, using the 1990 American College of Rheumatology ( ACR) diagnostic criteria as the gold standard, and comparing the Fibromyalgia Diagnostic Screen with the London Fibromyalgia Epidemiology Study Screening Questionnaire ( LFESSQ) and the modified 2010 ACR Fibromyalgia Diagnostic Criteria ( ACR-FDC). Methods This multicenter, cross-sectional study included 150 adult chronic pain patients who underwent a physician-administered structured history and physical exam and completed the Fibromyalgia Diagnostic Screen, the LFESSQ and the modified ACR-FDC. The analyses determined the predictive ability of the Fibromyalgia Diagnostic Screen for FM. Results Item-level analyses provided support for the response categories and predictive ability of most of the Fibromyalgia Diagnostic Screen items. Additionally, the evaluation of the Fibromyalgia Diagnostic Screen scoring models demonstrated the greatest accuracy in predicting an FM diagnosis with a combination of patient items and clinician items that included an abbreviated tender point exam (sensitivity 0.68, specificity, 0.82). Sensitivity of the modified ACR-FDC and the LFESSQ was 0.87 and 0.86, respectively, with specificity 0.62 and 0.49, respectively. Conclusions The Fibromyalgia Diagnostic Screen is a useful new clinical tool to aid in the evaluation of FM in clinical practice. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The inappropriate use and overcrowding of emergency departments ( EDs) by walk-in patients are well-known problems in many countries. The current study aimed to determine whether ambulatory walk-in patients could be treated more efficiently in a new hospital-integrated general practice ( HGP) for emergency care services compared to a traditional ED. Methods We conducted a pre-post comparison before and after the implementation of a new HGP. Participants were walk-in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used. Results The median process time from admission to discharge was 120 minutes in the ED [interquartile range ( IQR): 80-165] versus 60 minutes in the HGP ( IQR: 40-90) ( P < 0.001). The adjusted odds ratio of receiving any additional diagnostics was 1.86 (95% confidence interval 1.06-3.27; P = 0.032) for ED doctors versus general practitioners ( GPs) when controlling for patients' age, sex and injury-related medical problems. Conclusion The HGP is an efficient way to manage walk-in patients with regard to process time and utilization of additional diagnostic resources. The involvement of GPs in the HGPs should be considered as a promising model to overcome the inappropriate use of resources in EDs for walk-in patients who can be treated by ambulatory care. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to examine the performance of the Global Trigger Tool and to investigate characteristics associated with the occurrence of adverse events ( AEs). Study design Retrospective medical record review. Setting A tertiary teaching hospital, Korea. Method We employed two-stage review of a random sample of 630 charts for patients discharged between January and June 2011. Two quality improvement specialists reviewed the presence of AEs using 53 triggers developed by the Institute for Healthcare Improvement. Two physicians reviewed and validated the findings of adverse events. Positive predictive values for individual triggers were calculated. Logistic regression analysis was performed to determine factors associated with AEs. Results Of 629 patients, 45 (7%) experienced at least one AE during their hospitalization. Among the observed AEs, 61% were preventable. The frequent types of AEs were 'procedure-related' and 'medication-related'. Six triggers had positive predictive values of greater than 50.0%: 'health care-associated infection', 'any procedure complication', 'medication: other', 'return to surgery', 'occurrence of any operative complication' and 'intubation/reintubation'. Significant factors associated with the occurrence of AEs were length of stay ( OR 1.13; 95% CI 1.07 to 1.20) and the number of triggers ( OR 1.49; 95% CI 1.11 to 1.98). Conclusion The Global Trigger Tool was useful for the detection of adverse events in a Korean hospital setting. Triggers with high positive predictive values should have priority for incorporation into routine screening systems. Furthermore, patients who stay longer in the hospital need to be closely monitored using triggers to improve patient safety. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To describe primary care providers' ( PCP) attitudes about the impact of a mature, commercial electronic health records ( EHR) on clinical practice in settings with experience using the system and to evaluate whether a provider's propensity to adopt new technologies is associated with more favourable perceptions. Method We surveyed PCPs in 11 practices affiliated with three health systems in Texas. Most practices had greater than 5 years of experience with the Epic EHR. The effect of early adopter of technology status was evaluated using logistic regression. Results One hundred forty-six PCPs responded (70%). Most thought the EHR had a positive impact on routine tasks, such as prescription refills (94%), whereas fewer agreed for complex tasks, such as delivery of guideline-concordant care for chronic illnesses (51%). Two-thirds (62%) thought it interfered with eye contact with patients, and 40% reported that it interfered with in-visit communication. Early adopters of technology reported greater positive effects of the EHR, even after adjusting for age, ranging from 2% to 15% higher on satisfaction ratings. Conclusion PCPs practicing in settings with considerable experience using a common commercial EHR identified many positive effects, as well as two key areas for improvement - patient centredness and intelligent decision support. Providers with a propensity to adopt new technologies have more favourable perceptions of the EHR. [ABSTRACT FROM AUTHOR]

Background Various authorities recommend the participation of patients in promoting patient safety, but little is known about health care professionals' (HCPs') attitudes towards patients' involvement in safety-related behaviours. Objective To investigate how HCPs evaluate patients' behaviours and HCP responses to patient involvement in the behaviour, relative to different aspects of the patient, the involved HCP and the potential error. Design Cross-sectional fractional factorial survey with seven factors embedded in two error scenarios (missed hand hygiene, medication error). Each survey included two randomized vignettes that described the potential error, a patient's reaction to that error and the HCP response to the patient. Setting Twelve hospitals in Switzerland. Participants A total of 1141 HCPs (response rate 45%). Measurements Approval of patients' behaviour, HCP response to the patient, anticipated effects on the patient-HCP relationship, HCPs' support for being asked the question, affective response to the vignettes. Outcomes were measured on 7-point scales. Results Approval of patients' safety-related interventions was generally high and largely affected by patients' behaviour and correct identification of error. Anticipated effects on the patient-HCP relationship were much less positive, little correlated with approval of patients' behaviour and were mainly determined by the HCP response to intervening patients. HCPs expressed more favourable attitudes towards patients intervening about a medication error than about hand sanitation. Conclusions This study provides the first insights into predictors of HCPs' attitudes towards patient engagement in safety. Future research is however required to assess the generalizability of the findings into practice before training can be designed to address critical issues. [ABSTRACT FROM AUTHOR]

Objective The study aims to explore whether health care professionals' perceptions of patient safety in their practice were associated with the number of patient safety incidents identified in patient records. Setting Seventy primary care practices of general practice, general dental practice, midwifery practices and allied health care practices were used in the study. Methods A retrospective audit of 50 patient records was performed to identify patient safety incidents in each of the practices and a survey among health professionals to identify their perceptions of patient safety. Results All health professions felt that 'communication breakdowns inside the practice' as well as 'communication breakdowns outside the practice' and 'reporting of patient safety concerns' were a threat to patient safety in their work setting. We found little association between the perceptions of health professionals and the number of safety incidents. The only item with a significant relation to a higher number of safety incidents referred to the perception of 'communication problems outside the practice' as a threat to patient safety. Conclusions This study indicates that the assessment of professionals' perceptions may be complementary to observed safety incidents, but not linked to an objective measure of patient safety. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Understanding sources of knowledge used in everyday practice is very helpful in improving the quality of health care services. There is a consensus in the literature that nurses mostly relied in their practice on experiential knowledge gained through their interactions with other members of health care professionals and patients. The general aim of this study is to explore the sources of knowledge Jordanian registered nurses use during their practice. Method A descriptive correlational design was used to collect data from 539 Jordanian registered nurses from 10 hospitals using a self-administered questionnaire. Results The mean year of experience of the sample was 7.08 years. Of the 615 questionnaires distributed, 555 were returned. This yields a response rate of 87.6%. Results revealed that the top five ranked sources used by Jordanian registered nurses include: the information that nurses learned during nursing education, personal experience in nursing over time, what was learned through providing care to patients, information gained through discussion between physicians and nurses about patients, and information from policy and procedure manuals. Conclusion Jordanian registered nurses recognize the value of research and that research utilization (RU) is an important issue and must not be ignored. The study has many implications for practice, education and research. Health care managers and decision makers need to play a more visible and instrumental role in encouraging RU to improve patients' quality of life. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Drug-eluting coronary stents (DES) rapidly dominated the marketplace in the United States after approval in 2003, but utilization rates were initially lower among African American patients. We assess whether racial differences persisted as DES diffused into practice. Methods Medicare claims data were used to identify coronary stenting procedures among elderly patients with acute coronary syndromes (ACS). Regression models of the choice of DES versus bare mental stent controlled for demographics, ACS type, co-morbidities and hospital characteristics. Diffusion was assessed in the short run (2003-2004) and long run (2007), with the effect of race calculated to allow for time-varying effects. Results The sample included 381 887 Medicare beneficiaries treated with stent insertion; approximately 5% were African American. Initially (May 2003-February 2004), African American race was associated with lower DES use compared to other races (44.3% versus 46.5%, P < 0.01). Once DES usage was high in all patients (March-December 2004), differences were not significant (79.8% versus 80.3%, P = 0.45). Subsequent concerns regarding DES safety caused reductions in DES use, with African Americans having lower use than other racial groups in 2007 (63.1% versus 65.2%, P < 0.01). Conclusions Racial disparities in DES use initially disappeared during a period of rapid diffusion and high usage rates; the reappearance of disparities in use by 2007 may reflect DES use tailored to unmeasured aspects of case mix and socio-economic status. Further work is needed to understand whether underlying differences in race reflect decisions regarding treatment appropriateness. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Transfusion of allogeneic blood products is a key issue in cardiac surgery. Although blood conservation and standard transfusion guidelines have been published by different medical groups, actual transfusion practices after cardiac surgery vary widely among institutions. Models can be a useful support for decision making and may reduce the total cost of care. The objective of this study was to propose and evaluate a procedure to develop a simple locally customized decision-support system. Methods We analysed 3182 consecutive patients undergoing cardiac surgery at the University Hospital of Siena, Italy. Univariate statistical tests were performed to identify a set of preoperative and intraoperative variables as likely independent features for planning transfusion quantities. These features were utilized to design a naïve Bayes classifier. Model performance was evaluated using the leave-one-out cross-validation approach. All computations were done using spss and matlab code. Results The overall correct classification percentage was not particularly high if several classes of patients were to be identified. Model performance improved appreciably when the patient sample was divided into two classes (transfused and non-transfused patients). In this case the naïve Bayes model correctly classified about three quarters of patients with 71.2% sensitivity and 78.4% specificity, thus providing useful information for recognizing patients with transfusion requirements in the specific scenario considered. Conclusions Although the classifier is customized to a particular setting and cannot be generalized to other scenarios, the simplicity of its development and the results obtained make it a promising approach for designing a simple model for different heart surgery centres needing a customized decision-support system for planning transfusion requirements in intensive care unit. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Previous service development work in the area of integrated medicines management (IMM) has demonstrated clear quality improvements in a targeted group of patients within a hospital in Northern Ireland. In order to determine whether this programme could be transferable to routine practice and thereby assess its generalizability, research has been carried out to quantify the health care benefits of incorporating the concept of IMM as routine clinical practice. Method The IMM programme of care was delivered to all eligible patients (subject to inclusion criteria) across two hospital sites in Northern Ireland during normal pharmacy opening hours. All patients were followed up for a period of 12 months from their time of hospital admission. All patient data were collected using the custom-designed Electronic Pharmacist Intervention Clinical System at each stage of their hospital journey, that is, admission, inpatient stay and discharge. Results Patients who received the IMM service benefited from a reduced length of hospital stay on their reference admission (1.42 days; P = 0.020) as well as a reduced length of stay during the first rehospitalization (5.86 days; P = 0.013). There was also a trend of a reduced number of readmissions and a longer time to readmission during the 12-month follow-up period. Potential significant opportunity cost savings were demonstrated as well as a significant improvement in medication appropriateness (discharge vs. reference admission). Conclusions The IMM programme of care has proven to be transferable to routine hospital care within two hospitals in Northern Ireland. It is anticipated that this current research will further inform the development of IMM as routine clinical practice across Northern Ireland and beyond. [ABSTRACT FROM AUTHOR]

Background The Cochrane Collaboration is strongly encouraging the use of a newly developed tool, the Cochrane Collaboration Risk of Bias Tool (CCRBT), for all review groups. However, the psychometric properties of this tool to date have yet to be described. Thus, the objective of this study was to add information about psychometric properties of the CCRBT including inter-rater reliability and concurrent validity, in comparison with the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Methods Both tools were used to assess the methodological quality of 20 randomized controlled trials included in our systematic review of the effectiveness of knowledge translation interventions to improve the management of cancer pain. Each study assessment was completed independently by two reviewers using each tool. We analysed the inter-rater reliability of each tool's individual domains, as well as final grade assigned to each study. Results The EPHPP had fair inter-rater agreement for individual domains and excellent agreement for the final grade. In contrast, the CCRBT had slight inter-rater agreement for individual domains and fair inter-rater agreement for final grade. Of interest, no agreement between the two tools was evident in their final grade assigned to each study. Although both tools were developed to assess 'quality of the evidence', they appear to measure different constructs. Conclusions Both tools performed quite differently when evaluating the risk of bias or methodological quality of studies in knowledge translation interventions for cancer pain. The newly introduced CCRBT assigned these studies a higher risk of bias. Its psychometric properties need to be more thoroughly validated, in a range of research fields, to understand fully how to interpret results from its application. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Building a strong and positive safety culture in health care teams and organizations is essential for patient safety. Measuring individual perceptions of safety climate is an integral part of this process. Evidence of the successful application and potential usefulness of this approach is increasingly available for secondary care settings but little is known about the safety climate in UK primary care. We therefore aimed to measure perceptions of safety climate in primary care. Further aims were to determine whether perceptions varied significantly between practice teams and according to specific participant and practice characteristics. Method We undertook a cross-sectional, anonymous postal questionnaire survey of randomly selected west of Scotland primary care teams. Safety climate mean scores with standard deviations were calculated for respondents, practice teams and the region. Results A total of 563 (84%) team members from 49 practices (24.5%) returned questionnaires. The overall safety climate mean score was 5.48 (0.78). Significant differences in safety climate perceptions were found at the practice team level ( P < 0.001) and for specific characteristics: respondents' years of experience, whether they were community or practice based, their professional roles and practices' training status. Practice managers and general practitioners perceived the safety climate more positive than other respondents ( P < 0.001). Conclusion This was the first known attempt to measure perceptions of safety climate in UK primary care with a validated instrument specifically developed for that purpose. Reported perceptions of the prevailing safety climate were generally positive. This may reflect ongoing efforts to build a strong safety culture in primary care or alternatively point to an overestimation of the effectiveness of local safety systems. The significant variation in perception between certain staff groups has potential safety implications and may have to be aligned for a positive and strong safety culture to be built. While safety climate measurement has various benefits at the individual, practice team and regional level, further research of its association with specific safety outcomes is required. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Many clinical guidelines for cardiovascular disease (CVD) prevention contain risk estimation charts/calculators. These have shown a tendency to overestimate risk, which indicates that there might be theoretical flaws in the algorithms. Total cholesterol is a frequently used variable in the risk estimates. Some studies indicate that the predictive properties of cholesterol might not be as straightforward as widely assumed. Our aim was to document the strength and validity of total cholesterol as a risk factor for mortality in a well-defined, general Norwegian population without known CVD at baseline. Methods We assessed the association of total serum cholesterol with total mortality, as well as mortality from CVD and ischaemic heart disease (IHD), using Cox proportional hazard models. The study population comprises 52 087 Norwegians, aged 20-74, who participated in the Nord-Trøndelag Health Study (HUNT 2, 1995-1997) and were followed-up on cause-specific mortality for 10 years (510 297 person-years in total). Results Among women, cholesterol had an inverse association with all-cause mortality [hazard ratio (HR): 0.94; 95% confidence interval (CI): 0.89-0.99 per 1.0 mmol L−1 increase] as well as CVD mortality (HR: 0.97; 95% CI: 0.88-1.07). The association with IHD mortality (HR: 1.07; 95% CI: 0.92-1.24) was not linear but seemed to follow a 'U-shaped' curve, with the highest mortality <5.0 and ≥7.0 mmol L−1. Among men, the association of cholesterol with mortality from CVD (HR: 1.06; 95% CI: 0.98-1.15) and in total (HR: 0.98; 95% CI: 0.93-1.03) followed a 'U-shaped' pattern. Conclusion Our study provides an updated epidemiological indication of possible errors in the CVD risk algorithms of many clinical guidelines. If our findings are generalizable, clinical and public health recommendations regarding the 'dangers' of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but even beneficial. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The accuracy of health care professionals in reporting safety events determines their usefulness for both system improvement and research. The study objectives were to: (1) validate (assess the accuracy of) the reasons recorded by doctors and pharmacists for discontinuing medication orders at discharge in a hospital's electronic patient records (EPR); (2) investigate the causes of any detected recording inaccuracy; and (3) collect preliminary data on the frequency and types of medication discontinuation. Methods This was a validation study in one English hospital. The study comprised two steps: extraction of discontinued medication orders from the EPR followed by short structured interviews with doctors and pharmacists who made the discontinuation. A total of 104 discontinued orders were discussed during 15 face-to-face and six telephone interviews. The software package spss was used for data analysis. Results Duplication of therapy (27, 25.2%), omission of drug (23, 21.5%) and dosage regimen change (19, 17.8%) were the three most frequent reasons given for discontinuing medications. The majority of recorded discontinuation reasons were correct (100, 96.2%) and complete (101, 97.1%), and hence were judged accurate (97, 93.3%). The difference in accurate recording between doctors (15, 88.2%) and pharmacists (82, 94.3%) was not statistically significant. Potential causes of recording inaccuracy included: slip or lapse, lack of training, carelessness and electronic system rigidity. Conclusion This study showed that doctors and pharmacists recorded accurate reasons for the majority of the discontinued medication orders. It also showed that utilizing pharmacists' recorded reasons during clinical interventions using EPR was beneficial in understanding and characterizing prescribing errors. Although they require further research, the reasons identified present preliminary data about the most prevalent types of pharmacists' interventions during hospital discharge. [ABSTRACT FROM AUTHOR]

Introduction Significant event analysis (SEA) is now well established in UK primary care. Previously, considerable variation has been reported in the knowledge, skills and attitudes of general practitioners undertaking SEA. Little is known about the wider team's understanding, participation or perceptions. We therefore aimed to determine the awareness, degree of analysis and perceived risk of recurrence of a recent significant event, types of discussion forums, staff groups' participation and perceived barriers. Comparisons were made with a 2003 survey and significant changes described. Method A postal questionnaire survey was undertaken of a random selection of general practice team members in National Health Service Greater Glasgow in 2008/9. Results In total, 375/711 respondents (53%) from 111 practices participated. The vast majority was aware of a recent significant event, 29% reported not implementing a change and 23% perceived the risk of recurrence as moderate to high. Administrative and community-based staff were infrequently involved in meetings. Dedicated significant event meetings remain uncommon ( P = 0.06). Perceptions improved since 2003, but lack of time remained a concern. Discussion This survey was the first known attempt to include all members of the primary care team while studying SEA. Awareness and analysis levels were high, but only lead to sustainable improvement of care quality and clinical safety if teams implement change. Greater use should be made of dedicated SEA meetings and participation of all staff groups increased to gain full benefits. Lack of time can be managed pragmatically by prioritizing events based on their perceived severity, potential for change and potential team involvement. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The presence of multiple concomitant diseases is an increasing health problem, and prompted by the limitations of the disease count, several indices measuring multi-morbidity or co-morbidity have been described to account for the overall burden of morbidity. The Cumulative Illness Rating Scale (CIRS) is one of those indices. We developed an electronic version of the CIRS (eCIRS) to take advantage of computerized data processing. The aim of this study was to evaluate the reliability and validity of the eCIRS scored in a primary care setting. Methods Two nurses interviewed 48 adult patients recruited during consecutive consultation periods in a primary care setting and scored the eCIRS in a random order during two sessions of data collection (T1 and T2) 1 month apart. We measured intra- and inter-rater reliability [intra-class correlation coefficient (ICC)]. We also assessed concomitant validity [(Pearson's correlation ( r)] using standard CIRS scored by the attending family doctors. Results Intra-rater (ICC: 0.90 and 0.95) and inter-rater reliability (ICC: 0.86 and 0.91) were both excellent. No significant differences between the nurses' scores at T1 and T2 ( P = 0.40 for nurse 1, P = 0.73 for nurse 2) were found. The eCIRSs scored by the nurses were highly correlated with the CIRSs scored by the doctors ( r = 0.80 and 0.88). Conclusion Reliable and valid, the eCIRS completed during patient interviews with trained nurses can be used to quantify multi-morbidity in primary care, either for research or clinical use. [ABSTRACT FROM AUTHOR]

Rationale, aim and objective Effective tinnitus management starts with appropriate general practitioner (GP) triage, which in England can be guided by the Department of Health's Good Practice Guide (GPG). Despite the prevalence of the condition, there has never been a systematic survey of its management in primary care in England. We aimed to evaluate how people with tinnitus are assessed and managed in general practice, noting variation in practice across GPs and health authorities, and evaluating how closely typical practice aligns to the GPG for tinnitus. Methods A nine-item postal questionnaire was sent to 2000 GPs randomly selected to proportionally represent the number of primary care trusts and strategic health authorities in England. Results We received 368 responses. Responses indicated a mix of frequent and infrequent practices, for example, 90% of GPs assessed the impact of tinnitus on quality of life, but fewer examined cranial nerves (38%) or assessed for a carotid bruit (26%) during a tinnitus consultation. In the management of tinnitus, 83% routinely removed earwax, and 87% provided information-based advice. In contrast, only 4% of responders would offer antidepressant drugs or psychological therapies. Thematic analysis revealed a desire for concise training on tinnitus management. Conclusions GP assessment and management of tinnitus represents potential inequity of service for tinnitus patients. While the GPG aims to promote equity of care, it is only referred to by a minority of clinicians and so its utility for guiding service delivery is questionable. Although some GPs highlighted little demand for tinnitus management within their practice, many others expressed an unmet need for specific and concise GP training on tinnitus management. Further work should therefore evaluate current informational resources and propose effective modes of delivering educational updates. [ABSTRACT FROM AUTHOR]

Rationale Attrition is a threat to the validity of randomized trials. Few randomized studies have been conducted within randomized trials to test methods of reducing attrition. Aim To test whether using yellow post-it notes on follow-up questionnaires in the ATLAS treatment trial for neck pain reduces attrition. Method Nested trial within a trial. ATLAS participants were randomized to have their 6-month follow-up questionnaire have a 3′ yellow post-it note with a handwritten message encouraging return of questionnaire. Results 499 participants were independently randomized using simple allocation to receive the post-it notes or not. Two hundred fifteen of the 256 (84.0%) participants in the intervention group returned their questionnaire compared with 205 of the 243 (84.4%) in the control group. There was no difference in time to response. Conclusion Yellow post-it notes do not enhance questionnaire return rates for participants in a randomized trial of neck pain. [ABSTRACT FROM AUTHOR]