The near ubiquitous access to information is transforming the roles and relationships among clinical professionals, patients, and their care givers in nearly all aspects of healthcare. Informed ...patients engage their physicians in conversations about their conditions, options and the tradeoffs among diagnostic and therapeutic benefits and harms. The processes of care today increasingly and explicitly integrate exploration of patient values and preferences as patients and clinicians jointly engage in reaching decisions about care. The informed patient of today who can understand and use scientific information can participate as an equal partner with her clinician. Others with beliefs or educational, cultural, or literacy backgrounds that pose challenges to comprehending and applying evidence may face disenfranchisement. These barriers are significant enough, even in the face of certainty of evidence, that clinicians and investigators have given much thought to how best to engage all patients in decision making. However, barriers remain, as most decision making must occur in settings where uncertainty, if not considerable uncertainty, accompanies any statement of what we know. In September 2011, health care and health communication experts came together in Rockville, Maryland under the auspices of the Agency for Healthcare Research and Quality (AHRQ) John M. Eisenberg Center for Clinical Decisions and Communications Science Annual Meeting to explore the challenges of differing levels of evidence in promoting shared decisions and to propose strategies for going forward in addressing these challenges. Eight scholarly papers emerged, and with this introductory article, comprise this special issue of Medical Care Research and Review.
Differing Levels of Clinical Evidence Smith, Quentin W.; Street, Richard L.; Volk, Robert J. ...
Medical care research and review,
02/2013, Volume:
70, Issue:
1_suppl
Journal Article
Peer reviewed
The near ubiquitous access to information is transforming the roles and relationships among clinical professionals, patients, and their care givers in nearly all aspects of healthcare. Informed ...patients engage their physicians in conversations about their conditions, options and the tradeoffs among diagnostic and therapeutic benefits and harms. The processes of care today increasingly and explicitly integrate exploration of patient values and preferences as patients and clinicians jointly engage in reaching decisions about care. The informed patient of today who can understand and use scientific information can participate as an equal partner with her clinician. Others with beliefs or educational, cultural, or literacy backgrounds that pose challenges to comprehending and applying evidence may face disenfranchisement. These barriers are significant enough, even in the face of certainty of evidence, that clinicians and investigators have given much thought to how best to engage all patients in decision making. However, barriers remain, as most decision making must occur in settings where uncertainty, if not considerable uncertainty, accompanies any statement of what we know. In September 2011, health care and health communication experts came together in Rockville, Maryland under the auspices of the Agency for Healthcare Research and Quality (AHRQ) John M. Eisenberg Center for Clinical Decisions and Communications Science Annual Meeting to explore the challenges of differing levels of evidence in promoting shared decisions and to propose strategies for going forward in addressing these challenges. Eight scholarly papers emerged, and with this introductory article, comprise this special issue of Medical Care Research and Review.
Abstract
P4Q can be implemented in various health care settings, targeting a range of health care providers or professionals. P4Q schemes can reward high quality measured in terms of structures, ...processes, and/or outcomes, and/or penalise low quality and are implementable in line with other quality improvement interventions. This presentation aims to clarify the concept of P4Q, highlight the use of P4Q schemes in different settings in European countries, and systematize the evidence on the effectiveness, cost-effectiveness and implementation of P4Q as a quality strategy.
We could identify fourteen primary care P4Q programmes and thirteen hospital P4Q programmes in a total of 16 European countries. P4Q schemes in primary care incentivise mostly process and structural quality with respect to prevention and chronic care. P4Q schemes in hospital care prioritize improvements in health outcomes and patient safety. Studies suggest small positive effects on process-of-care (POC) indicators in primary care but not in hospital care. Evidence on health outcomes and patient safety indicators is inconclusive. Cost-effectiveness is unlikely because of lacking effectiveness. P4Q schemes are more effective when the focus of a scheme is on areas of quality where change is needed and if the scheme embraces a more comprehensive approach, covering many different areas of care; however, such programmes are generally technically and politically difficult to implement. In this light, this presentation will conclude with a number of recommendations, both technical and policy-oriented.
Barriers to screening and early detection often result in cancers in low-income and minority women diagnosed at stages too advanced for optimal treatment. This randomized controlled trial examined ...whether a personalized form (PF) letter containing generic cancer information and a personalized tailored (PT) letter containing minimally tailored individualized risk factor information based on medical records data affected breast and cervical cancer screening among 1574 urban low-income and minority women. The personalized form-letter group was significantly more likely to schedule a screening appointment and to have undergone a Pap test and mammography within 1 year after the intervention than were the tailored letter and control groups (
P<0.001 for all comparisons). Personalized tailored letters that contain individualized cancer risk factor information may decrease the likelihood of receiving cancer screening among medically underserved low-income and minority women, but personalized form letters that contain generic cancer information may improve these rates in this disadvantaged population.
Lifestyle factors (eg, smoking, diet) and compliance with screening recommendations play a role in cancer risk, and emerging technologies (eg, new vaccines, genetic testing) hold promise for improved ...risk management.
However, optimal outcomes from cancer control efforts require better preparation of health professionals in risk assessment, risk communication, and implementing health behavioral change strategies that are vitally important to cancer control.
Although physician assistants (PAs) are substantively engaged in cancer-related service delivery in primary care settings, few models exist to facilitate integration of cancer control learning experiences into the curricula used in intense, fast-paced, 24- to 30-month PA training programs.
The aim of this study was to compare responses to two interventions (personalized-form PF letter messages versus personalized-tailored PT letter messages) using medical record data for promoting ...appointment scheduling and screening for breast and cervical cancer among urban low-income women from three ethnic groups: African-American, Mexican-American, and non-Hispanic white women. The 1,574 women participating in the randomized controlled trial were assigned to one of three groups: (1) PF letter, (2) PT letter, (3) control (no letter). Logistic regression analyses show that (1) personalized-tailored letters containing individualized references to recipients' cancer risk factors failed to increase rates of recommended cancer screening behaviors, especially among non-Hispanic white women; and that (2) in contrast, a personalized-form letter with general breast and cervical cancer screening messages increased cancer screening rates in this population, especially among non-Hispanic white and Mexican-American women.
Describes a training project for high school counselors which expanded their roles in the prevention, early detection, and appropriate referral of students at high risk for substance abuse. ...Counselors not only learned to work as facilitators of support groups for these students, they also reported greater self-efficacy, comfort, confidence, and competence. (MKA)
A Teachers as Facilitators (TAF) Program used classroom teachers as leaders of small groups that promoted social, emotional, and academic development of children at high risk of adopting potentially ...destructive substance abuse patterns. The program was intended to increase participating students' positive socialization experiences and academic achievement by successfully integrating these students into the school's social system. A longer-range goal was to increase students' sense of worth as it affects their attitudes toward relationships with other people and academic demands. Program results were: 1) school personnel were found capable of accurately identifying and referring to the TAF Program children who were at risk of substance usage and in need of assistance; 2) the TAF Program was effective in improving at-risk students' perceived academic self-concept, but was less effective in increasing students' perceived sense of social support; and 3) the program was endorsed by participating teachers, counselors, and administrators.
Disabled children in rural areas face special challenges in preparing for independence in communities where services are inadequate. Rural special education teachers must become promoters of ...independent living for disabled young people. Possibilities are outlined for teacher interventions with individuals and families and advocacy efforts. Contains 22 references. (SV)
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