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Purpose: Differences in Indigenous worldviews, practices and values highlight the need for Indigenous‐specific health quality indicators, such as patient‐reported outcome measures (PROMs) and patient‐reported experience measures (PREMs). The purpose of this paper is to present our methodology, as part of a larger study that sought to develop a framework for creating Indigenous‐specific PROMs and PREMs. Methods: The research design was informed by Indigenous research methodology and a community‐based participatory approach. It had three core components: (1) a literature exploration of existing Indigenous‐specific PROMs and PREMs; (2) interviews with researchers with expertise in PROMs and PREMs developed for Indigenous populations and community leaders interested in using these Indigenous‐informed evaluation tools; and (3) conversations with Indigenous community members about their experiences with health surveys. Interviews were audio‐recorded and transcribed verbatim; transcripts were analyzed qualitatively using an inductive and deductive approach. Themes and sub‐themes were identified to build a framework that honours Indigenous knowledges and ways of knowing. Results were validated with select research participants and the Project Advisory Committee. Results: Findings demonstrate how relationship building is the necessary starting point for engagement when developing survey instruments with Indigenous peoples. Engagement requires respectful collaboration through all stages of the project from determining what questions are asked to how the information will be collected, interpreted, and managed. A relational stance requires responsibility to Indigenous communities and peoples that goes beyond research carried out using a western scientific lens. It means ensuring that the project is beneficial to the community and framing questions based on Indigenous knowledge, worldviews, and community involvement. Conclusions: This study employed a collaborative, participatory qualitative approach to develop a framework for creating PROMs and PREMs with Indigenous peoples. The methods described offer concrete examples of strategies that can be employed to support relationship‐building and collaboration when developing Indigenous‐specific survey instruments. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The objective of this study was to apply a paper-based clinical reminder to improve the adherence to lipid guidelines. Methods Patients with coronary heart disease (CHD) without lipid-lowering therapy (LLT) were recruited, and medical records were reviewed. Eligible subjects were randomized; a clinical reminder stating current standards and local insurance policy was stamped on the paper chart in the study group but not in the control. The primary outcome was new LLT subscription in the 6-month follow-up period, and the secondary end point was the composite result of LLT or lipid profile check-up. Results Ninety-two patients were assigned to the study group and 102 to the control group. The primary outcome showed no difference at the end of 6 months (OR: 1.70, P = 0.248, 95% CI: 0.69–4.19). The secondary end point was significantly higher in the reminder group (OR: 2.81, P = 0.001, 95% CI: 1.57–5.04). Conclusion A paper chart based clinical reminder providing update clinical recommendations could modify the doctor's behaviour and improve the attention to lipid levels. However, its effect cannot be transformed into an increase in LLT or a decrease in low-density lipoprotein level owing to local policy constraint. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: This paper examines a remarkable dispute between Dutch insurers, hospitals, doctors, and patients about a set of quality indicators. In 2013, private insurers planned to drastically reform Dutch emergency care using quality indicators they had formulated drawing from clinical guidelines, RCTs, and systematic reviews. Insurers' plans caused much debate in the field of emergency care. As quality indicators have come to play a more central role in health care governance, the questions what constitutes good evidence for them, how they ought to be used, and who controls them have become politically and morally charged. This paper is a case study of how a Dutch public knowledge institution, the National Health Care Institute, intervened in this dispute and how they addressed these questions. Method: We conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, in‐depth conversations, and formal interviews with 5 key‐informants. Results: The National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also—and especially—the scope, purpose, and use of the indicators. Our analysis shows the institute's struggle to reconcile the technical rationality of quality indicators with their social and political implications in practice. The institute deconstructed quality indicators as national standards and, instead, promoted the use of indicators in dialogue with stakeholders and their local and contextual knowledge. Conclusions: Even if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidence‐based Medicine always feared uncritical use of evidence by third parties. For non‐medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence‐based Medicine provides the easiest way to gain insights into "what works" in clinical practice. This case study reminds us that using standardized knowledge for the management of health care quality requires the involvement of stakeholders for the development and implementation of indicators, and for the interpretation of their results. [ABSTRACT FROM AUTHOR]

Compulsory community treatment for people with severe mental illness remains controversial due to conflicting research evidence. Recently, there have been challenges to the conventional view that trial‐based evidence should take precedence. This paper adds to these challenges in three ways. First, it emphasizes the need for critiques of trials to engage with conceptual and not just technical issues. Second, it develops a critique of trials centred on both how we can have knowledge and what it is we can have knowledge of. Third, it uses this critique to develop a research strategy that capitalizes on the information in large‐scale datasets. [ABSTRACT FROM AUTHOR]

Background Health-based journal clubs have been in place for over 100 years. Participants meet regularly to critique research articles, to improve their understanding of research design, statistics and critical appraisal. However, there is no standard process of conducting an effective journal club. We conducted a systematic literature review to identify core processes of a successful health journal club. Method We searched a range of library databases using established keywords. All research designs were initially considered to establish the body of evidence. Experimental or comparative papers were then critically appraised for methodological quality and information was extracted on effective journal club processes. Results We identified 101 articles, of which 21 comprised the body of evidence. Of these, 12 described journal club effectiveness. Methodological quality was moderate. The papers described many processes of effective journal clubs. Over 80% papers reported that journal club intervention was effective in improving knowledge and critical appraisal skills. Few papers reported on the psychometric properties of their outcome instruments. No paper reported on the translation of evidence from journal club into clinical practice. Conclusion Characteristics of successful journal clubs included regular and anticipated meetings, mandatory attendance, clear long- and short-term purpose, appropriate meeting timing and incentives, a trained journal club leader to choose papers and lead discussion, circulating papers prior to the meeting, using the internet for wider dissemination and data storage, using established critical appraisal processes and summarizing journal club findings. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: A key consideration in designing scalable solutions for improving global mental health involves balancing the need for interventions to be uncomplicated for mental health workers (MHWs) and the need for the intervention to be widely applicable to many clients. Often these needs are in competition, since interventions are routinely simplified by removing procedures or reducing their dynamic responsivity, which in turn lowers their overall utility in serving large, clinically diverse populations. The principal aim of this pilot study involved evaluating the feasibility and acceptability of a brief strategy designed to delegate problem classification and practice selection to MHWs operating within a flexible, modular, cognitive behavioural protocol. A secondary aim involved gathering data on which to base a hypothesis regarding the potential effectiveness of this strategy. Method: Within an open trial, an educationally diverse sample of local MHWs in India (N = 18) reviewed fictional case vignettes, classified mental health problems, and then selected practices before and after a two‐hour training that included a one‐page decision‐making resource. Feasibility was measured by assessing the integrity of the study protocol and training, the measurement and administration of questionnaires as well as study recruitment and completion. Acceptability of the intervention was measured by MHW‐perceived performance, ease of use, value, importance, and intention for continued use. Decision‐making accuracy was assessed by comparing MHWs' clinical decisions with criteria established through consensus among psychologists with expertise in modular protocols. Results: Results suggested high feasibility and acceptability on all metrics. Secondary analysis revealed that MHW's decision‐making accuracy and confidence also significantly improved, providing a basis for the hypothesis that this brief approach is useful for building MHW capacity in low‐resource settings. Conclusion: Overall these findings provide initial support for these methods and potential training outcomes to test within a larger, randomized controlled trial. [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims and objectives Clinical governance has been advanced as a mechanism for continuous quality improvement within the UK National Health Service (NHS). This study aimed to assess whether evidence exists to support this claim. Methods A Medline search for evidence to link the introduction of clinical governance to improvements in the quality of health care was conducted. Results Of the 335 papers retrieved initially, 114 were potentially relevant to the question, but only 10 attributed changes in quality to clinical governance directly. Of these, only three attempted to provide data to support the assertion. Conclusion No sound evidence currently exists to support the claim that clinical governance will increase service quality and moves towards its implementation must therefore be questioned. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Emergency short‐stay unit (SSU) alleviates emergency department (ED) overcrowding, but may affect in‐hospital indicators. Cardiology patients comprise a substantial part of patients admitted at SSU. This study evaluated whether SSU opening differentially modified in‐hospital indicators at a whole general hospital and at its cardiology division (CARD). Methods: We retrospectively analysed indicators based on 859 686 ED visits, and 171 547 hospital admissions, including 12 110 CARD admissions, from 2007 to 2018 at a general tertiary hospital, and compared global ED indicators and in‐hospital indicators at the hospital and CARD before (2007‐2011) and after (2011‐2018) SSU opening. Results: After SSU opening, monthly ED bed occupancy rate decreased (mean ± SD 200 ± 18% vs 187 ± 22%; P <.001) and in‐hospital admissions from ED increased at the hospital (median [interquartile range] 460 [81] vs 524 [41], P <.001) and CARD (50 [12] vs 54 [12], P =.004). In parallel, monthly in‐hospital elective admissions decreased at CARD (34 [18] vs 28 [17], P =.019), but not at the hospital (712 [73] vs 700 [104], P =.54). Average length of stay (LOS) increased at both hospital (8.5 ± 0.3 vs 8.7 ± 0.4 days, P <.001) and CARD (9.2 ± 1.5 vs 10.3 ± 2.3 days, P =.002) after SSU opening, but percent admissions at SSU showed a direct relationship with LOS solely at CARD. Furthermore, cardiology patients admitted at SSU had greater LOS, prevalence of coronary heart disease and age than those admitted at the conventional cardiology ward. Conclusions: SSU opening improved ED crowding, but was associated with changes in in‐hospital indicators, particularly at CARD, and in the characteristics of hospitalized cardiology patients. These findings suggest that in‐hospital cardiology services may need re‐evaluation following SSU opening at a general hospital. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Online modified Delphi (OMD) panel approaches can be used to engage large and diverse groups of clinical experts and stakeholders in developing health services performance measures. Such approaches are increasing in popularity among health researchers. However, information about their acceptability to participating experts and stakeholders is lacking but important to determine before recommending widespread use of online approaches. Therefore, the objective of this paper is to explore acceptability of the OMD panel approach from the participants' perspective. Method: We use data from participants in three OMD panels designed to develop performance measures for use in arthritis research and quality improvement efforts. At the end of each online panel, we surveyed clinical experts and stakeholders who shared their experiences with the OMD process by answering 13 close-ended questions using 7-point Likert-type scales. A mean of 5 or higher on a given question was treated as an indication of acceptability. Results: Ninety-eight clinical experts and stakeholders (92% participation rate) answered survey questions about the online process. They considered the OMD panel approach to be acceptable, particularly the ease of using the online system (mean = 5.3, standard deviation = 1.3) and the understanding gained from online discussions (mean = 5.2, standard deviation = 1.0). Participants also felt that participation in the Delphi study was interesting (mean = 5.6, standard deviation =1.1). Conclusion: These findings illustrate likely acceptability and a potential for a more widespread use of OMD panel approaches by stakeholders in developing health services performance measures. [ABSTRACT FROM AUTHOR]

Over the past seven decades, randomised controlled trials (RCTs) have revolutionised clinical research and achieved a gold standard status. However, extending their use to evaluate complex interventions is problematic. In this paper we will demonstrate that complex intervention RCTs violate the necessary premises that govern the RCTs logic and underpin their rigour. The lack of blinding, heterogeneity of participants, as well as poor treatment standardisation and difficulty of controlling for confounders, which characterise complex intervention RCTs, can potentially be profoundly detrimental to their integrity. Proponents of this approach argue that matching 'real world' circumstances, while maintaining the randomised design, enhances external validity. We counter this argument by pointing out that an inverted U relation exists between internal and external validity, and thus relaxing the experimental conditions beyond a certain threshold can potentially paradoxically render the RCT externally invalid, i.e. its results cannot be used anywhere. We shall illustrate the inappropriate use of RCTs to evaluate community treatment orders and propose an alternative epistemic model that is based on mechanistic reasoning and Cartwright's capacity concept. [ABSTRACT FROM AUTHOR]

Proponents of evidence-based medicine ( EBM) have argued convincingly for applying this scientific method to medicine. However, the current methodological framework of the EBM movement has recently been called into question, especially in epidemiology and the philosophy of science. The debate has focused on whether the methodology of randomized controlled trials provides the best evidence available. This paper attempts to shift the focus of the debate by arguing that clinical reasoning involves a patchwork of evidential approaches and that the emphasis on evidence hierarchies of methodology fails to lend credence to the common practice of corroboration in medicine. I argue that the strength of evidence lies in the evidence itself, and not the methodology used to obtain that evidence. Ultimately, when it comes to evaluating the effectiveness of medical interventions, it is the evidence obtained from the methodology rather than the methodology that should establish the strength of the evidence. [ABSTRACT FROM AUTHOR]

Summary Clinical governance was intended to ensure clinical quality in the National Health Service. Its first full description, in the British Medical Journal in 1998, seemed to some to be more rhetoric than substance. Now, 3 years on, its proponents believe it is starting to achieve its purpose. The British Medical Journal has again published a paper, this time subtitled ‘turning vision into reality’. Expectations might have been that this paper would present evidence of how clinical governance is changing practice to ensure quality, but analysis of the paper shows that it does little more than repeat the rhetoric of the earlier description. It describes how clinical governance might be organized and what it might do, but not what it has done. Its authors repeat the idea that everyone can be ‘the best’ and achieve ‘excellence’, which is not reality at all. Anyone introducing a new method of managing the National Health System has the same obligation as those who introduce new treatments to provide evidence that the method works, and that the financial and non-financial costs are not too high. The new paper fails to provide that evidence. [ABSTRACT FROM AUTHOR]

Objectives This paper seeks to further explore the question of how best to monitor and govern innovative clinical procedures in their earliest phase of development. We examine the potential value of proposed governance frameworks, such as the IDEAL model, and examine the functioning of a novel procedures review committee. Methods The paper draws upon 20 qualitative, semi-structured interviews. Nine interviews were conducted with members of a committee that was established as a means of governing innovative procedures within a large National Health Service Foundation Trust hospital in the UK. Eleven interviews were conducted with health providers involved with the development of a variety of novel clinical procedures. Results Prominent themes from the data include the potential willingness of clinicians to engage with regulatory frameworks for innovative procedures, existing ways in which clinicians and others attempt to ensure patient's safety and manage uncertainty in the context of novel procedures, views on the potential benefits and drawbacks of engaging with a review committee for novel procedures, and the pragmatic considerations and potential unintended consequences that are entailed in the implementation of regulatory requirements for the monitoring of innovative procedures. Conclusions The views of committee members and clinical innovators help us to understand the practical issues of implementing governance structures for novel clinical procedures. The data illustrate those factors that must be taken into account if governance is to support innovation rather than act as an inhibiting factor in the development of new clinical procedures. [ABSTRACT FROM AUTHOR]

Possibility is one of the most common modalities in reasoning and argumentation. Various kinds of modal concepts have been identified in philosophical and logical discussion of the metaphysics of modality. We focus here on the concept of clinical possibility. A critical analysis of what is intended as clinical possibility has not yet received sufficient examination, although the concept is extensively used in clinical reasoning. We present arguments to emphasize some desirable features associated with the concept of clinical possibility. We argue that almost all clinical possibilities are potentialities, that is, possibilities that may be actualized by effective, appropriate and feasible interventions. However, in some limited cases, even mere possibilities - which may or may not be actualized, since we do not have the required knowledge - may be involved in clinical reasoning, and we present some examples in this paper. We then introduce some basic views on the nature of possibility showing their validity and limitations when applied to the concept of clinical possibility. Lastly, we conjecture that clinical possibility is a normative modality that can be formalized in a multimodal system with epistemic and deontic logical operators. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims, and objectives: During the last decades, perioperative care for patients with colorectal cancer has shifted towards more standardized care, so‐called “enhanced recovery after surgery.” Those programs aim to optimize interventions in perioperative care to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. The purpose of this literature review is to identify, summarize, and operationalize the clinical content of both key interventions and clinical indicators to develop an evidence‐based model pathway for surgical patients with colorectal cancer. Methods: A systematic search in 3 databases was conducted to identify key interventions (KIs) and indicators to measure the effect of implementation of care pathways. The KIs from the enhanced recovery after surgery protocol were listed and used as framework to identify and match KIs used in the included studies. The Clinical Pathway Compass was used to categorize the indicators. Results: Fifteen studies were included. The number of KI used in the study protocols ranged from 9 to 20. In total, 33 KIs were identified. Little information was available concerning the implementation of and compliance to the protocol. Length of stay and complication rate are the most common used indicators (used in 15/15 and 14/15 of the studies), followed by 21 other measures. All but one of the included studies reported a reduction in length of stay. Conclusion: There is a considerable variation in both number of KIs and indicators as well as operationalization of key interventions, for surgical patients with colorectal cancer documented in literature. Therefore, we summarized the input from different studies and developed an evidence‐based model pathway, which can serve as a basis for a local/regional care pathway team to build their own pathway. [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]

The article discusses various papers published within the issue including one by A. Saad on the effectiveness of evidence-based medicine (EBM) and another about the over-emphasis of EBM on the use of quantitative research fundings in clinical practice.

Evidence-based medicine (EBM) and its main strategy, randomized clinical trials, have had less impact on medical practice than might be expected. Of the various reasons that make practitioners wary of applying research results, this paper explores some consequences of scientists’ and research sponsors’ adamant insistence that reliable science can only be achieved if protocols adhere exclusively to the ethics of investigation basically reduced to obtaining informed consent and avoiding risks as far as possible. This means, and has been explicitly contended, that neither patients nor doctors should fall prey to the therapeutic fallacy which leads them to expect that research will also take care of patient-subjects’ medical welfare. Doctors would betray their profession if they allowed clinical research to disregard their therapeutic obligations in favour of strict scientific methodology, as is bound to happen when using placebos in spite of existing therapy, disregarding equipoise, disallowing benefit claims, emphasizing the distinction between research ethics and clinical ethics but denying any difference between therapeutic and non-therapeutic trials. That scientists and practitioners should not agree on needs and priorities in the medical context, constitutes an additional factor in the less than optimal reception of EBM by the health care professions. [ABSTRACT FROM AUTHOR]

Rationale: While professional values are seen as a fundamental part of element of shared decision‐making, there is little research on how they are learnt within the paramedic profession. Aims and objectives: This study sought to understand how student paramedics developed their professional values within the ambulance practicum. Method: 37 paramedic students and 5 paramedic educators submitted diary entries and took part in focus groups. Results: There was a general consensus between participants that the study of professional values was viewed as a scholarly activity within the university, and the practicum subsequently viewed as unacademic. Students identified that much of their learning replicated values of the environment they were in, and educators voiced their concerns that this may not always result in the understanding behind professional values. Conclusion: This study has highlighted that professional values would be worthy of being explored within the paramedic undergraduate curriculum, in an effort to enable students to understand and develop their values during their education and appreciate the importance of values within shared decision‐making. [ABSTRACT FROM AUTHOR]

Abstract Medicine is becoming increasingly confident that scientific advances, especially in the area of genetics, will allow a major improvement in the control and eradication of disease. This development seems to go hand in hand with health-enhancement strategies, erasing the distinction between the states of health and disease, and blurring the specific goals of medical services. Medicine tends to become an increasingly technocentric practice that relies heavily on expert knowledge and on epidemiological evidence, neglecting the lived-body experience of being ill, and tending to transform costly medical services into commodities only affordable by the affluent. This paper argues that disease is not merely a functional description, but rather a definitely value-laden organismic state that is experienced by the patient, needs to be explored and treated by medical practitioners, and requires the assessment and participation of social institutions concerned with the delivery and support of medical services. Each of these perspectives introduces its own set of values, both in the clinical encounter and in public health programmes. Bioethics seems to be the appropriate discipline to discuss all these values involved, and help assign them properly in order to rescue the caring concern of medicine for the sick, as well as uphold a principle of fairness in publicly funded medical services. [ABSTRACT FROM AUTHOR]

Objectives Defining 'best practice' is one of the first and crucial steps in any Knowledge Translation (KT) research project. Without a sound understanding of what exactly should happen in practice, it is impossible to measure the extent of existing gaps between 'desired' and 'actual' care, set implementation goals, and monitor performance. The aim of this paper is to present a practical, stepped and interactive process to develop best practice recommendations that are actionable, locally applicable and in line with the best available research-based evidence, with a view to adapt these into process measures (quality indicators) for KT research purposes. Methods Our process encompasses the following steps: (1) identify current, high-quality clinical practice guidelines (CPGs) and extract recommendations; (2) select strong recommendations in key clinical management areas; (3) update evidence and create evidence overviews; (4) discuss evidence and produce agreed 'evidence statements'; (5) discuss the relevance of the evidence with local stakeholders; and (6) develop locally applicable actionable best practice recommendations, suitable for use as the basis of quality indicators. Conclusions Actionable definitions of local best practice are a prerequisite for doing KT research. As substantial resources go into rigorously synthesizing evidence and developing CPGs, it is important to make best use of such available resources. We developed a process for efficiently developing locally applicable actionable best practice recommendations from existing high-quality CPGs that are in line with current research evidence. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editor discusses various reports on evidence-based medicine (EBM) and person-centered healthcare (PCH) within the issue.

The article focuses on the interpretations of biblical texts and the dawning of the discipline of hermeneutics as a means of determining or reflecting upon the adequacies of interpretations of sacred and scholarly works. The concept of biblical hermeneutics is important because it strikes that the evidence-based medicine (EBM) has approached closely to the faith-based movements. There is a serious criticism concerning the ascendancy, triumphs, and positive benefits of EBM.

This paper argues that because it is a matter of dispute whether to assist suicide is ever morally right, the question whether assisted suicide should be legal should be decided independently of the moral issue and with reference to whether to assist suicide is genuinely to carry out the wishes of the person requesting it. It is then argued that it is possible to devise a set of criteria, based on those used in the Netherlands with regard to euthanasia, which would allow assisted suicide when the request is reasonable and genuine, but keep it illegal under other circumstances. It is further argued that there is no evidence that legalizing assisted suicide will lead us down the slippery slope to involuntary euthanasia. Finally, the question is raised to whether these assisted suicides should be legalized or, as at the moment in the UK, simply not prosecuted, but, as is about to happen, with the criteria for non-prosecution made explicit. It is suggested that, although it is in some ways both irrational and unjust, non-prosecution is politically easier to achieve and also more cautious as a first move. [ABSTRACT FROM AUTHOR]

Rational, aims, and objectives: Understanding of barriers and successes associated with the implementation of electronic patient self‐reported measures (ePSRMs) within clinical settings are limited and have not been pursued utilizing implementation science frameworks. This qualitative study is designed to assess staff perceptions of an ePSRM implementation. Methods: The study took place in an academic hospital's Consultation Liaison Psychiatry practice. Qualitative interviews were conducted with the staff and clinicians from the practice. Participants were directly involved with the implementation and use of the ePSRM system within the Psychiatry practice. Interviews were structured around the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE‐AIM) framework. Results: Participants reported increased patient engagement as well as efficiency and time savings. The intervention was perceived to be more challenging for older patients. Facilitators include communicating the ePSRM to patients prior to the care visit, having enough trained staff or super‐users who can assist with technical problems, and having a shorter questionnaire. Conclusions: Overall, assessment of the ePSRM implementation was positive. Staff and clinicians indicated benefits in time, effectiveness, and improvements in patient treatment. Results indicate that defining how the system would fit within the clinical workflow was key, as was a flexible and user‐friendly technology platform. The ePSRM implementation was dependent upon clinical involvement and interest in adoption, while barriers were associated with technical challenges as well as some patient difficulties, such as cognitive impairment. The use of the RE‐AIM framework is valuable as it allows for systematic assessment of the implementation and identifies areas in that implementation has succeeded or is lacking. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: There are well‐documented barriers that have limited widespread, sustained adoption of screening and brief intervention for risky substance use in health care settings. In order to better inform implementation efforts, this study evaluates whether patient characteristics, screening results, and implementation success indicators differed between two clinical setting types: primary care and emergency. Methods: Patients presenting to an emergency or primary care setting were screened for risky substance use (n = 41 567). Patients with a positive screen were further assessed for psychosocial, health, and substance use problems (n = 1604). Differences in patient characteristics between primary care and emergency settings were examined using chi‐square and t tests. Multilevel logistic regression was used to examine whether setting type predicted screening results. Site‐level indicators of implementation success were calculated (percentage prescreens completed, percentage full screens completed, and percentage refused services) for all patient visits (n = 78 656). Results: As compared with primary care patients, emergency patients had more severe substance use patterns and screening scores, were more likely to use a variety of illicit drugs, and reported more psychosocial issues. In logistic regression models, setting type did not predict whether patients screened positive; however, it did predict screening into a higher vs lower risk category such that emergency patients were more likely to be in a higher risk category. Emergency settings had lower indicators of implementation success (eg, 14% lower prescreen completion rate) as compared with primary care settings on some implementation measures. Conclusions: This evaluation found important differences in patient characteristics and screening and implementation results between primary care and emergency settings. Health care organizations and administrators implementing screening and brief intervention should attend to setting differences that could affect implementation and clinical care. [ABSTRACT FROM AUTHOR]

In this paper we argue that knowledge in health care is a multidimensional dynamic construct, in contrast to the prevailing idea of knowledge being an objective state. Polanyi demonstrated that knowledge is personal, that knowledge is discovered, and that knowledge has explicit and tacit dimensions. Complex adaptive systems science views knowledge simultaneously as a thing and a flow, constructed as well as in constant flux. The Cynefin framework is one model to help our understanding of knowledge as a personal construct achieved through sense making. Specific knowledge aspects temporarily reside in either one of four domains – the known, knowable, complex or chaotic, but new knowledge can only be created by challenging the known by moving it in and looping it through the other domains. Medical knowledge is simultaneously explicit and implicit with certain aspects already well known and easily transferable, and others that are not yet fully known and must still be learned. At the same time certain knowledge aspects are predominantly concerned with content, whereas others deal with context. Though in clinical care we may operate predominately in one knowledge domain, we also will operate some of the time in the others. Medical knowledge is inherently uncertain, and we require a context-driven flexible approach to knowledge discovery and application, in clinical practice as well as in health service planning. [ABSTRACT FROM AUTHOR]

Objective To establish the effectiveness of clinical guideline implementation strategies. Data sources/study setting Systematic reviews in full text, English language, 1987–2007, reporting any measure of clinical process change or cost–benefit analysis. Study design Overview of secondary evidence Data collection/extraction methods Independent critical appraisal using AMSTAR, primary author undertaking all data extraction using a purpose-built form. Principal findings We identified 144 potential papers, from which 33 systematic reviews were included. These reflected 714 primary studies involving 22 512 clinicians, in a range of health care settings. Implementation strategies were varied, rarely comparable, with variable outcomes. Effective implementation strategies included multifaceted interventions, interactive education and clinical reminder systems. Didactic education and passive dissemination strategies were ineffective. Cost-effectiveness studies were rare. Conclusions Successful guideline implementation strategies should be multifaceted, and actively engage clinicians throughout the process. [ABSTRACT FROM AUTHOR]

Background and aim Since 1998, many leg ulcer practice guidelines were developed. The aim of this paper is to describe the methodological and clinical content quality of those guidelines. Methods PubMed, CINAHL, Cochrane Library and websites known for publishing or collecting clinical practice guidelines were explored from 1998 up to June 2006. Reference lists of all identified guidelines were reviewed for other guidelines to be included. Guidelines were eligible if they were written in English, Dutch, French or German, if the scope was the treatment of venous leg ulcers, if the guideline was systematically developed and if the steps in guideline development were reported clearly. Seven guidelines were critically appraised. Results The venous leg ulcer guidelines were clearly based on evidence. The stakeholder involvement varied during the development process. Especially patients’ perspectives were often not considered. There was no uniform method used to weigh the evidence. Limited attention was given to pain and lifestyle advice recommendations. A paucity of information on compliance, quality of life, organizational aspects of care and economic evaluation data was given. Most of the guidelines failed to consider the issues of dissemination and implementation. Revisions of the guidelines for leg ulcer treatment were often not available. Conclusion and implications for future guideline developers It is recommended that leg ulcer guidelines should incorporate a multidisciplinary approach and patient involvement is necessary. Extensive background information and the formulation of the rationale are needed. The development of an implementation guide that addresses the barriers particular to the adoption of guidelines for leg ulcer treatment could support the process of implementation. Recommendations on pain, lifestyle advice, compliance and other quality-of-life issues should be incorporated in guidelines for leg ulcer treatment. [ABSTRACT FROM AUTHOR]

Rationale and aims This study focuses on the development of an instrument for the evaluation of clinical practice guidelines and is one part of a research project about the implementation and use of such guidelines among hospitals in the southern region of Sweden. The aim of the present paper was to investigate the test-retest reliability of a questionnaire. Method A questionnaire was designed to gather data about guidelines that have been implemented as well as information about factors, which, according to the Promoting Action on Research Implementation in Health Services (PARIHS)-model, influence the success of implementation. Thirty-nine health professionals at one of the hospitals included in the survey completed the questionnaire on two occasions within a mean time of 5.5 weeks. The test-retest reliability was analysed by means of Cohen's Kappa and percentage concordance. Results Eight items had good agreement in terms of strength and high percentage concordance. With regard to the Kappa values, 13 items show moderate and two fair agreement. Conclusions The test-retest reliability scores show mainly acceptable results indicating a reasonable stability, thus suggesting the possibility of further developing the instrument. The factors described in the PARIHS-model seem relevant for use in evaluating implementation and use of guidelines. The instrument could benefit from a revision of the language in order to enhance clarity and make it less abstract. [ABSTRACT FROM AUTHOR]

In order to provide effective health care to patients, clinicians must rely on their ability to accurately diagnose disease and to prognosticate the outcomes. Prognostic studies have received considerable attention in health science and medicine in relation to patient outcomes. However, little effort has been spent on evaluating prognostic accuracy. The purpose of this paper is to present a comprehensive review of the methods for assessing prognostic accuracy in patient outcome prediction. The strengths and limitations of these approaches are critically appraised. We argue that we need to consider incorporating accuracy assessment for predicting patient outcomes both in clinical practice and in research. [ABSTRACT FROM AUTHOR]

Rationale, aims and objective Evidence on the cost-effectiveness of health interventions in the development of practice guidelines has become of interest in many countries. Challenges are the quality of economic data, the use of cost-effectiveness criteria, and the consensus process. Our paper aims to assess the quality and use of economic information in the formulation of consensus guidelines in a Dutch pilot programme and to recommend improvements. Methods Retrospective qualitative review of economic evaluations and formulated recommendations, using a checklist based on international standards. Results The national programme to support the development of guidelines with economic analysis in multidisciplinary consensus groups run from 1998 to 2002. It has included 31 medical guidelines, addressing 23 conditions across seven International Classification of Diseases (ICD)-disease groups. Experts in health technology assessment have participated in the guidelines groups. Economic information in all guidelines varies by all criteria in the level of evidence used. Information on quality-adjusted life years gained is limited as is statistical analysis in most studies. Highest cost-effectiveness ratios reported are between &U20AC;20 000 and &U20AC;30 000. However, there is no uniformity in the definitions of acceptable cost-effectiveness ratios. Conclusions Economic recommendations can be included in guidelines. Interaction between clinicians and health economists promotes a balance between medical and economic arguments. Among panellists there appears to be agreement on the level of the cost-effectiveness ratios that is acceptable. It is recommended that economic analysis is used to strengthen the evidence-base of guidelines. An evidence-grading system should include the quality of economic evaluation. Roles of policymakers and providers need to be defined. [ABSTRACT FROM AUTHOR]

The article focuses on the lack of clarity on the definitions of evidence-based medicine (EBM). Authors on quality management are shy away from giving any clear account of their assumptions about the nature of proper scientific methodology. There are assertions that EBM is the right approach to follow in medicine wherever and whenever possible.

Patient decision aids (ptDAs) have been developed to assist patients with difficult health-related decisions. Despite their proven effects on decision quality in numerous efficacy trials, we lack an evidence-based approach for implementing them as part of the process of care. Pragmatic trials of ptDAs have uncovered a myriad of implementation challenges; therefore we need a better understanding of the barriers and strategies to overcome them to facilitate their widespread uptake. The following paper provides an overview of the barriers related to the uptake of ptDAs within the process of care and the strategies, opportunities and research priorities to overcome them. This report is based on our interpretation of the literature and our collective experience in implementing ptDAs within trials and other contexts. [ABSTRACT FROM AUTHOR]

This paper investigates the translation of medical information into clinical practice and the role of thoughtful dissent by exploring the influence of sociological factors on change, the impact of evidence-based medicine (EBM), and the role of industry. Changing practice related to hormone therapy for menopausal and post-menopausal women provides context for this discussion. Medical change involves diffusion of ideas to potential users and ongoing reconciliation of new information with old ideas; this process is influenced by sociological factors including values and experiences, interpersonal relationships and local context. While EBM has alerted doctors to the importance of high quality research and theoretically provides a tool for translating research into practice, there are important problems with its application: (1) it has resulted in a reductionist approach to research and illness; (2) there is a considerable gap between research findings and the complex environment of clinical practice; and (3) EBM has been appropriated by experts, thus corporately developed ‘standard-of-care’ documents have become instruments of external regulation, and EBM has ceased to be a tool in the hand of individual clinicians. In addition, industry impacts the translation of knowledge by significantly influencing academia, researchers, medical publications, consensus conferences, and practising doctors. While questioning doctrinaire practices or directives is a daunting prospect for individual clinicians, the translation of knowledge into practice and evolution of medical thought is dependent on the progressive role of thoughtful dissent. [ABSTRACT FROM AUTHOR]

Cluster randomized controlled trial (RCT), in which groups or clusters of individuals rather than individuals themselves are randomized, are increasingly common. Indeed, for the evaluation of certain types of intervention (such as those used in health promotion and educational interventions) a cluster randomized trial is virtually the only valid approach. However, cluster trials are generally more difficult to design and execute than individually randomized studies, and some design features of a cluster trial may make it particularly vulnerable to a range of threats that can introduce bias. In this paper we discuss the issues that can lead to bias in cluster randomized trials and conclude with some suggestions for avoiding these problems. [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims and objectives This paper presents selected results from a study investigating the impact of small group processes on the development of clinical practice guidelines by multidisciplinary panels. Observations of one panel developing a guideline for primary care over several months are reported here. Methods Non-participant observation with content analy-sis of transcripts aided by field notes. Results Bales’s interaction process analysis was used to categorize interactions in terms of their task-oriented or socioemotional qualities. This revealed a well-functioning, task-oriented group characterized by predominantly positive social behaviours. However, a breakdown of dialogue by speaker indicated a marked effect of professional role and status on the level of contribution to group discussions. This, and marked changes in panel composition across meetings, has implications for the multidisciplinarity of decision-making in such groups and hence for the acceptance and implementation of their outputs. Conclusions These findings are likely to generalize to other health care settings in view of the growing emphasis on multidisciplinary decision-making and the clear status hierarchies inherent within the medical and allied fields. [ABSTRACT FROM AUTHOR]

Abstract In the USA, where public reporting of data on clinical performance is most advanced, comparative performance information, in the form of ‘report cards’, ‘provider profiles’ and ‘physician profiling’, has been published for over a decade. Many other countries are now following a similar route and are seeking to develop comparative data on health care performance. Notwithstanding the idiosyncratic nature of US health care, and the implications this has for the generalizability of findings from the USA to other countries, it is pertinent to ask what other countries can learn from the US experience. Based on a series of structured interviews with leading experts on the US health system, this article draws out the key lessons for other countries as they develop similar policies in this area. This paper highlights three concerns that have dominated the development of adequate measures in the USA, and that require consideration when developing similar schemes elsewhere. Firstly, the need to develop indicators with sound metric properties – high in validity and meaningfulness, and appropriately risk-adjusted. Secondly, the need to involve all stakeholders in the design of indicators, and a requirement that those measures be adapted to different audiences. Thirdly, a need to understand the needs of end users and to engage with them in partnerships to increase the attention paid to measurement. This study concludes that the greatest challenge is posed by the desire to make comparative performance data more influential in leveraging performance improvement. Simply collecting, processing, analysing and disseminating comparative data is an enormous logistical and resource-intensive task, yet it is insufficient. Any national strategy emphasizing comparative data must grapple with how to engage the serious attention of those individuals and organizations to whom change is to be delivered. [ABSTRACT FROM AUTHOR]

The article presents the author's opinion on the relevance of epistemology to clinical medicine. Analyzing evidence-based medicine (EBM) from the view point of epistemology, biology and mysticism, he expresses his agrees with a paper on the same issue, that in clinical practice though an abstract and reductionist view is implicitly taken by all, practical application is generally avoided. He considers that its is the thinking aspect that makes EBM different from other disciplines.

Abstract: Rationale, aims and objectives: Care quality is a primary concern in health field. In France, the care practice report card (CPRC) is compulsory for practitioners. It is the first step towards the culture of excellence. In this context, practitioners have to assess and improve their practices. Competent authorities define registries as reliable sources for CPRC. The first aim of this work is to describe how we designed and built a universally transposable CPRC model based on an Utstein‐style cardiac arrest registry. The second aim is to measure the adherence of practitioners to this approach and to show how such a tool can be used in real situation. Methods: Our report card is adapted from in‐hospital CA care quality and safety indicators. We built a 2‐section grid. The first part described the quality and completeness of the analysed data. The second part distinguished medical and traumatic CA and assesses care practices. We analysed the practitioners' adherence thanks to a satisfaction survey. Finally, we presented a CPRC case study. Results: This tool was tested in 92 centres gathering 8433 patients. The satisfaction survey showed that this CPRC was well accepted by emergency professionals. We presented an implementation example of this tool in a centre in real‐life situation. Conclusions: We designed and implemented a fully automated CPRC tool routinely usable for Utstein‐style CA registries. This CPRC is easily transferable in all other Utstein CA registries. The debriefing report source codes are freely distributed upon request. This tool enables the care assessment and improvement. [ABSTRACT FROM AUTHOR]

Abstract: Rational, aims, and objectives: Registries are a powerful tool to assess specific performance measurements and quality of care in acute coronary syndromes (ACSs). In Portugal, ProACS is a nationwide registry of ACS that has been active for the past 15 years, and our objective was to assess specific quality indicators for the treatment of ACS. Methods: Descriptive analysis of data from ProACS registry in specific quality indicators previously defined by international scientific societies. Results: A total of 45,141 patients were included since 2002, 43.5% with ST‐segment elevation myocardial infarction. In ST‐segment elevation myocardial infarction, reperfusion rates, particularly by primary angioplasty, have increased dramatically with 85% being submitted to any form of reperfusion presently. In‐hospital time delays are, however, suboptimal, particularly in patients admitted first to hospitals without catheterization facilities. For non‐ST elevation ACS, invasive strategy also showed important improvements, with more than 80% of patients being submitted to catheterization. Although there was also improvement in the use of guideline recommended medication, particularly statins, it is also suboptimal, requiring additional specific interventions. Conclusion: The quality of care of ACS improved dramatically in the last 15 years in Portugal, with major improvements in hospital mortality. It is, however, suboptimal in specific points that have been identified and that require additional measures. [ABSTRACT FROM AUTHOR]

Introduces articles in the "Journal of Evaluation in Clinical Practice". Factors that influence spontaneous reporting of adverse drug reactions; Discusses of prescription-related disease; Risk factors for adverse drug effects; Effectiveness of interferon-beta treatment in relapsing multiple sclerosis.

Rationale, aims and objectives Acute myocardial infarctions (MIs) or heart attacks are the result of a complete or an incomplete occlusion of the lumen of the coronary artery with a thrombus. Prompt diagnosis and early coronary intervention results in maximum myocardial salvage, hence time to treat is of the essence. Adequate, accurate and complete information is vital during the early stages of admission of an MI patient and can impact significantly on the quality and safety of patient care. This study aimed to record how clinical information between different clinical teams during the journey of a patient in the MI care pathway is captured and to review the flow of information within this care pathway. Method A prospective, descriptive, structured observational study to assess (i) current clinical information systems (CIS) utilization and (ii) real-time information availability within an acute cardiac care setting was carried out. Completeness and availability of patient information capture across four key stages of the MI care pathway were assessed prospectively. Results Thirteen separate information systems were utilized during the four phases of the MI pathway. Observations revealed fragmented CIS utilization, with users accessing an average of six systems to gain a complete set of patient information. Data capture was found to vary between each pathway stage and in both patient cohort risk groupings. The highest level of information completeness (100%) was observed only in the discharge stage of the MI care pathway. The lowest level of information completeness (58%) was observed in the admission stage. Conclusion The study highlights fragmentation, CIS duplication, and discrepancies in the current clinical information capture and data transfer across the MI care pathway in an acute cardiac care setting. The development of an integrated and user-friendly electronic data capture and transfer system would reduce duplication and would facilitate efficient and complete information provision at the point of care. [ABSTRACT FROM AUTHOR]

Background and Rationale Evidence based medicine is the present backbone of rational and objective, modern medical problem solving and is a meeting ground for quantitative and qualitative researchers alike as it culminates into applying the fruits of clinical research to the individual patient. A systematic enquiry into the evolving paradigms in EBM is a need of the hour. Aims and methods A qualitative enquiry examining the impact of different methodologies in EBM and their role in generating meaning interpretable at individual levels. Results Present day outcome based research deals less with patients as individuals than as populations. Evidence based medicine struggles to apply the fruits of population based research to individuals who are often not as predictable as linear quantitative research would like them to be. The present EBM literature neglects a lot of events it doesn’t believe to be statistically significant and perhaps here is an area that needs to be improved on – it assumes that because associations are demonstrated between interventions and outcomes in RCTs/meta-analysis, these associations are linear and causal in the real world. While they may be demonstrated repeatedly in highly controlled environments, in the real ‘uncontrolled’ world of clinical practice with real people, their validity breaks down. Conclusions One needs to make the EBM standard model patient-individual (a projection of collective patient event data) resemble the real human individual patient so that optimal EBM individual data that matches our query can be easily and quickly spotted from the dense jungle of information that has grown over the years. This hints at rethinking our entire research methodology and modifying it to suit the needs of the individual patient. [ABSTRACT FROM AUTHOR]

Rationale When comparing patients’ pain ratings with the health care professional's conception of pain assessed by Visual Analogue Scales (VAS) ratings, statistical problems arise. Method and Result In this data simulation study we have shown that the tendency for health care professionals to underestimate severe pain compared with mild pain is probably not attributed to difficulties in judging severe pain more often than mild but the result of professionals having a different and often narrower distribution of their ratings compared with patients. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Disparities in haemodialysis outcomes among centres have been well-documented. Besides, attempts to assess haemodialysis results have been based on non-comprehensive methodologies. This study aimed to develop a comprehensive methodology for assessing haemodialysis centres, based on the value of health care. The value of health care is defined as the patient benefit from a specific medical intervention per monetary unit invested (Value = Patient Benefit/Cost). This study assessed the value of health care and ranked different haemodialysis centres. Method A nephrology quality management group identified the criteria for the assessment. An expert group composed of stakeholders (patients, clinicians and managers) agreed on the weighting of each variable, considering values and preferences. Multi-criteria methodology was used to analyse the data. Four criteria and their weights were identified: evidence-based clinical performance measures = 43 points; yearly mortality = 27 points; patient satisfaction = 13 points; and health-related quality of life = 17 points (100-point scale). Evidence-based clinical performance measures included five sub-criteria, with respective weights, including: dialysis adequacy; haemoglobin concentration; mineral and bone disorders; type of vascular access; and hospitalization rate. The patient benefit was determined from co-morbidity-adjusted results and corresponding weights. The cost of each centre was calculated as the average amount expended per patient per year. Results The study was conducted in five centres (1-5). After adjusting for co-morbidity, value of health care was calculated, and the centres were ranked. A multi-way sensitivity analysis that considered different weights (10-60% changes) and costs (changes of 10% in direct and 30% in allocated costs) showed that the methodology was robust. The rankings: 4-5-3-2-1 and 4-3-5-2-1 were observed in 62.21% and 21.55%, respectively, of simulations, when weights were varied by 60%. Conclusions Value assessments may integrate divergent stakeholder perceptions, create a context for improvement and aid in policy-making decisions. [ABSTRACT FROM AUTHOR]

AbstractResearch evidence does not necessarily translate into changed management for individual patients, but that may not mean that the evidence has been ignored. Drawing on accounts from general practitioners, we use a study of non-rheumatic atrial fibrillation (NRAF) to illuminate the processes by which practitioners became aware of and assimilated research evidence. We follow that with an account of how the evidence was incorporated into practice protocols for anticoagulation and then applied to a review of individual patients’ records. Practitioners used a range of sources of evidence. They reported difficulties arising from their own skills and circumstances and from the perceived quality of the evidence. Creating a protocol involved overcoming problems of scheduling, resources and managing judgements about the value of the review process. In applying the protocol practitioners drew on their knowledge of the patients’ preferences, circumstances and previous specialist consultations. As a result, practitioners made judgements that evidence, combined with prior experience, did not support the initiation of anticoagulation in 52% of an unselected primary care population with NRAF. Our findings have implications for evidence-based practice and for practitioner education. [ABSTRACT FROM AUTHOR]

Although much has been written on the role of randomized controlled trials and mechanistic reasoning in the evaluation of therapeutic treatments, philosophers of medicine have not yet turned their attention to the question of how diagnostic tests and procedures should be evaluated. I aim to begin to fill this gap by examining each of the following questions: What is the best way to determine the accuracy of a diagnostic test?, What is the best way to determine the clinical effectiveness of a diagnostic test?, Can an accurate diagnostic test be considered medically valuable even if it is not clinically effective?, I argue that while diagnostic accuracy is a minimum requirement for both clinical effectiveness and medical value, accuracy and effectiveness are not sufficient for determining the value of a diagnostic test, because diagnostic value extends beyond patient outcomes. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Swedish health care is regulated to involve the patient in every intervention process. In the area of post-operative pain, it is therefore important to evaluate patient experience of the quality of pain management. Previous research has focused on mapping this area but not on comparing experiences between acutely and electively admitted patients. Hence, the aim of this study was to investigate the experiences of post-operative pain management quality among acutely and electively admitted patients at a Swedish surgical department performing soft-tissue surgery. Methods A survey study design was used as a method based on a multidimensional instrument to assess post-operative pain management: Strategic and Clinical Quality Indicators in Postoperative Pain Management ( SCQIPP). Consecutive patients at all wards of a university hospital's surgical department were included. Data collection was performed at hospital discharge. Results In total, 160 patients participated, of whom 40 patients were acutely admitted. A significant difference between acutely and electively admitted patients was observed in the SCQIPP area of environment, whereas acute patients rated the post-operative pain management quality lower compared with those who were electively admitted. Conclusions There may be a need for improvement in the areas of post-operative pain management in Sweden, both specifically and generally. There may also be a difference in the experience of post-operative pain quality between acutely and electively admitted patients in this study, specifically in the area of environment. In addition, low levels of the perceived quality of post-operative pain management among the patients were consistent, but satisfaction with analgesic treatment was rated as good. [ABSTRACT FROM AUTHOR]

Clinical guidelines are essential in promoting the implementation of evidence-based practice within the NHS. But there are two broad schools of thought about their development and implementation: the first argues that guidelines should be entirely evidence-based and tolerates a degree of complexity which may make the guideline impractical; the second argues that we need simple guidelines, and sacrifices the strength of evidence in favour of ease of application and dissemination. Both arguments have merits and flaws, which are discussed, and ways to integrate the strengths of both are considered. [ABSTRACT FROM AUTHOR]