Obesity—time to wake up Haslam, David; Sattar, Naveed; Lean, Mike
BMJ,
09/2006, Letnik:
333, Številka:
7569
Journal Article
Recenzirano
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ABC of Obesity series. 1st in a series on the obesity epidemic, focusing on its epidemiology, consequences, health costs, and its management. (BNI unique abstract) 7 references
Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the ...implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED).
We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS).
There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval CI: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge.
A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.
The long-standing divide between research and practice in clinical psychology has received increased attention in view of the development of evidence-based interventions and practice and public ...interest, oversight, and management of psychological services. The gap has been reflected in concerns from those in practice about the applicability of findings from psychotherapy research as a guide to clinical work and concerns from those in research about how clinical work is conducted. Research and practice are united in their commitment to providing the best of psychological knowledge and methods to improve the quality of patient care. This article highlights issues in the research-practice debate as a backdrop for rapprochement. Suggestions are made for changes and shifts in emphases in psychotherapy research and clinical practice. The changes are designed to ensure that both research and practice contribute to our knowledge base and provide information that can be used more readily to improve patient care and, in the process, reduce the perceived and real hiatus between research and practice.
-AGREE II overall assessments are poorly reported in rehabilitation appraisals of clinical practice guidelines (CPGs).-Two third of appraisals applied cut-offs to judge guideline quality-Quality ...ratings of guidelines varied moderately applying different cut-offs
To analyze the reporting characteristics of Appraisal of Guidelines Research and Evaluation (AGREE) II appraisals in rehabilitation and explore how much quality ratings of Clinical Practice Guidelines (CPGs) vary applying different cut-offs.
We conducted a methodological study re-analyzing data of an overview of AGREE II CPG appraisals in rehabilitation. Reporting characteristics of appraisals and methods used for quality rating were abstracted. We applied the most frequent cut-offs retrieved on all CPG sample to explore changes in quality ratings (i.e., high/low).
We included 40 appraisals (n = 544 CPGs).The AGREE II overall assessment 1 (overall CPG quality) was reported in 26 appraisals (65%) and the overall assessment 2 (recommendation for use) in 17 (42.5%). Twenty-five appraisals (62.5%) reported the use of cut-offs based on domains and/or overall assessments. Application of the most reported cut-offs led to variability in quality ratings in 26% of the CPGs, of which 92% CPGs shifted their rating from low to high-quality and 8% shifted from high to low-quality.
Rehabilitation stakeholders should take care to select the highest quality CPG in view of the poor reporting of AGREE II overall assessment 1 and 2 and moderate variability of quality ratings.
This study characterizes practice characteristics and specialties of physicians and medical groups acquired by private equity firms between 2013 and 2016.
Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) emphasize the importance of mindfulness practice at home as an integral part of the program. However, the ...extent to which participants complete their assigned practice is not yet clear, nor is it clear whether this practice is associated with positive outcomes.
For this systematic review and meta-analysis, searches were performed using Scopus and PubMed for studies published through to the end of 2015, reporting on formal home practice of mindfulness by MBSR or MBCT participants.
Across 43 studies (N = 1427), the pooled estimate for participants' home practice was 64% of the assigned amount, equating to about 30 minutes per day, six days per week 95% CI 60–69%. There was substantial heterogeneity associated with this estimate. Across 28 studies (N = 898), there was a small but significant association between participants’ self-reported home practice and intervention outcomes (r = 0·26, 95% CI 0·19,–0·34).
MBSR and MBCT participants report completing substantial formal mindfulness practice at home over the eight-week intervention, albeit less than assigned amounts. There is a small but significant association between the extent of formal practice and positive intervention outcomes for a wide range of participants.
•Standard mindfulness interventions assign significant home practice.•This meta-analysis estimated participants' typical practice completion.•Average mindfulness home practice time equated to 30 min per day, 6 days per week.•The extent of practice positively correlated with intervention outcomes.
Background
The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are ...exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved.
Objectives
To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness.
Search methods
We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007.
Selection criteria
Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes.
Data collection and analysis
A minimum of two reviewers independently extracted data and assessed study quality.
Main results
Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in‐house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee‐for‐service system and from a fee‐for‐service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates.
Authors' conclusions
There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in‐house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
The American Association on Intellectual and Developmental Disabilities (AAIDD) has published terminology and classification manuals since 1921. Their goals over the last 100 years have been ...consistent: To fulfill the Association's continued responsibility to be the primary repository of intellectual disability-related research and best practices; to publish a scientific definition of intellectual disability (ID) and its assumptions based on research and one that provides a long, stable definitional history; to provide a singular focus on ID and the lives of people with ID and their families; and to communicate professional standards, ethics, and best practices regarding diagnosis, classification, and planning supports. Consistent with these historical goals, the goals of the 12th edition of the AAIDD manual (Schalock et al. 2021) are to: (a) integrate material published in the 11th edition (Schalock et al., 2010) of the AAIDD manual with post-2010 developments and historical markers; (b) develop a user-friendly manual that combines the theoretical and conceptual thoroughness of a manual with the practical aspects of a user's guide; (c) describe a systematic approach to the diagnosis, optional subgroup classification, and planning of supports for people with intellectual disability based on conceptual models, a clear rationale and purpose, and evidence-based practices; (d) combine current empirical knowledge and best practices into an integrative approach to intellectual disability; and (e) provide practice guidelines that frame best practices, increase understanding, and facilitate precise, valid, and effective decisions, recommendations, and actions. The content of the 12th edition reflects the transformation that is occurring in the field of ID. This transformation, which is occurring to various degrees internationally, is characterized by using precise terminology, incorporating a functional and holistic approach to ID, embracing the supports model and evidence-based practices, implementing outcome evaluation, empowering individuals and families, understanding better the multidimensional properties of context, and incorporating an explicit notion of professional responsibility (Schalock et al., in press). As a result of this transformation, the manual contains both modifications of previous concepts and terminology, and the addition of new terms and concepts. These modifications and additions are reflected in the definition of intellectual disability, the evidence-based approach to diagnosis and optional postdiagnosis subgroup classification, the operationalization of systems of supports, and the incorporation of an integrative approach to ID. Throughout the manual, human functioning is viewed from a systems perspective towards understanding human functioning, which includes human functioning dimensions, interactive systems of supports, and human functioning outcomes.
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