Clinician Intervention Research Articles

Adherence to guideline recommendations for antiarrhythmic drugs in atrial fibrillation

Atrial fibrillation (AF) guideline recommendations for antiarrhythmic drugs (AADs) are based on the effectiveness and safety of the AAD in patients with selected, concomitant heart disease. It is unknown to what extent these recommendations are being implemented in clinical practice. Using commercial health claims, patients with AF were identified and then categorized into mutually exclusive, guideline-established subgroups based on their most serious concurrent heart disease: heart failure, coronary artery disease (CAD), hypertension, and no heart disease. Antiarrhythmic drug use after the first AF encounter and the identified concurrent heart disease encounter was determined from prescription claims, and this was compared with guideline recommendations. From January 2006 through December 2010, a total of 331,274 patients with AF aged < 65 years were identified: 18%, heart failure; 23%, CAD; 33%, hypertension; and 25%, no heart disease. Of these, 78,877 (24%) patients filled ≥ 1 qualifying AAD prescription. The median age was 57 years (interquartile range 52-61), and 69% were male. A total of 74,191 patients had AADs after both the AF and concurrent heart disease encounters: 27% with heart failure, 25% with CAD, 21% with hypertension, and 19% with no heart disease. In the heart failure and CAD subgroups, 45% and 31% of AADs were inconsistent with first- or second-line guideline recommendations, respectively. More than one-third of the AADs used in patients with AF and CAD or heart failure did not conform to guideline recommendations. This highlights the potential need for increased clinician education and intervention to improve the safe use of AADs for AF management.

Acute Uterine Bleeding Unrelated to Pregnancy: A Southern California Permanente Medical Group Practice Guideline

Acute uterine bleeding unrelated to pregnancy has been defined as bleeding "sufficient in volume as to, in the opinion of the treating clinician, require urgent or emergent intervention." The Southern California Permanente Medical Group updated its guidelines for the management of this condition on the basis of the best available evidence, as identified in a systematic review of the available literature. Given the paucity of studies evaluating this condition, the guidelines, by necessity, include recommendations largely based on opinion or other sources such as case series that are, in general, categorized as low-quality evidence. Medical interventions with single or combined gonadal steroidal agents administered parenterally or orally show promise, but more high-quality studies are needed to better define the appropriate drugs, dose, and administrative scheduling. There is also some evidence that intrauterine tamponade may be useful in at least selected cases. Special attention must be paid to both diagnosing and treating inherited disorders of hemostasis, such as von Willebrand disease, that may otherwise be underdiagnosed in both adolescent and adult women.

Effective Strategies for Promoting Preconception Health—From Research to Practice

The development and publication of this supplement of the American Journal of Health Promotion have provided an opportunity to connect with new partners in the field of preconception health education, assess the current state of the science on this topic, and note gaps in research that we hope readers will consider filling. As guest editors, we appreciate our colleagues who submitted articles for consideration, the guest reviewers for their time and willingness to serve, and the journal staff for their flexibility and support throughout the process. This supplement serves as a platform to elevate contributions made in the context of preconception health promotion since 2006 as well as to issue a call to action to expand the work being done in this important arena. Six years ago, in partnership with over 35 national organizations and hundreds of partners, a select panel of experts on preconception health issued a series of 4 goals, 10 recommendations, and over 40 action steps focused on improving the health and well-being of women and men of childbearing age. The recommendations addressed a number of domains, including consumer education, clinical care, advocacy and policy, research, and public health and community interventions. A complete list of the recommendations and action steps is included in the online version of this article (http://www.cdc.gov/mmwR/preview/ mmwrhtml/rr5506a1.htm). Four national workgroups were created to move this agenda forward based on these different domains. To catalyze action in the context of consumer education and health promotion, the National Preconception Health Consumer Workgroup was formed. A main charge of the consumer workgroup continues to be to improve the knowledge, attitudes, and behaviors of men and women related to preconception health by using information that is relevant across various age groups, literacy levels, and cultural and ethnic groups. This journal issue on preconception health focuses mainly on women’s preconception health and is one example of the consumer workgroup’s efforts. In the context of women, preconception health refers to the health of a woman of childbearing age prior to or between pregnancies. The purpose of preconception care is to identify and modify biomedical, behavioral, and social risks to a woman’s health in order to maximize her health as well as that of any babies she may have in the future. Increasing awareness, knowledge, and engagement in preconception health practices among women and their partners are important objectives. Data suggest that pregnancy intentions can improve birth outcomes. Given the high infant mortality rates in the United States, particularly as compared to 28 other countries with better birth outcomes, this work is essential. Preconception health is unique as it is comprised of numerous components, including lifestyle (i.e., healthy weight, physical activity, smoking, drinking, substance use), screenings and vaccination (i.e., sexually transmitted infections, human immunodeficiency virus, rubella), and chronic disease management (i.e., diabetes, hypertension), along with family planning and exposure to teratogens, to name a few. Mass communication and clinician intervention about preconception health are challenging because of the volume of health topics within this issue and in light of the fact that half of all pregnancies are unplanned. Ultimately, a key task of the preconception health movement is to change social norms about the importance of the health of women and men and the impact it can have on their future reproductive goals. Formative research, education campaigns, and interventions on single health topics among women of childbearing age are well documented in the literature. However, less is known about how to effectively bundle and deliver a preconception health ‘‘package’’ to consumers in a way that resonates with them and motivates them to take action. One goal of this supplement is to inform this dialogue. In soliciting the content for this issue, we were particularly interested in preconception health audience research, advances in message development and dissemination strategies, and innovations in public and private partnerships, as well as insight into improving the preconception health of at-risk populations. A critical step in the process of developing and disseminating health promotion messages is to conduct audience Elizabeth W. Mitchell, PhD, is with the National Center on Birth Defects and Developmental Disabilities, Division of Birth Defects and Developmental Disabilities, Prevention Research Branch, National, Atlanta, Georgia. Sarah Verbiest, DrPH, MSW, MPH, is with the Center for Maternal and Infant Health, University of North Carolina at Chapel Hill.

Integration of early identification and brief intervention in frontline health services: the case of Quebec

In 2006, the Quebec provincial government committed itself to developing capacity for evidence-based alcohol and other drug screening and brief intervention (SBI) in frontline health-service delivery settings. Two studies were conducted prior to province-wide deployment to inform decision makers as to possible implementation challenges. Study 1 evaluated the efficacy of implementing a model of SBI, adapted from the World Health Organization, in three frontline public health services. Sixty-two clinicians were trained in systematic detection of substance use and brief motivational intervention. Chart review of new admissions (N = 453) prior and following training assessed clinician conformity to SBI guidelines. Forty percent of patients endorsed at least one item on the four-question CAGE-AID (Cut Down, Annoyed, Guilty, Eye Opener screen Adapted to Include Drugs). Systematic screening among new admissions peaked at 70% and decreased to pre-training levels seven months after training. However, more than half of all new patients were assessed with validated questionnaires rather than informal questioning. Implementation of motivational interviewing techniques led to modest changes in clinician interventions. A second qualitative study was conducted to document possible organizational barriers to SBI implementation. Interviews were conducted with 24 clinicians and program administrators from frontline services of the six main health regions of Quebec province. Choice of vocabulary used in public policy documents and program material and sequence of delivery of services created confusion among clinicians as to what constituted alcohol and other drug SBI. Many resources developed for other SBI health programs in these frontline services seemed to be transferable to alcohol and drug SBI. Lessons learned were as follows: complexity in the SBI program is inversely related to the subsequent integrity of program deployment; clarity as to what constitutes SBI is paramount; and integration of parallel competencies/related programs could facilitate deployment of alcohol and other drug SBI.

Effects of an assertive community program in patients with severe mental disorders and impact on their families

Assertive community treatment (ACT) is known to have a positive impact on the number and length of inpatient stays. However, recent studies have shown little or no effect of such programs in European settings. This paper aims to describe the impact of a newly implemented ACT program on patients and their families' burden. Predictive factors have also been examined. Fifty-five patients characterized by heavy use of psychiatric care, numerous hospitalizations, or failure to link with outpatient psychiatric care and their relatives were followed. Data were gathered on patients before and after follow up as well as on relatives' burden and costs. The number and domains of clinician interventions have been detailed. The ACT program had a positive effect on symptoms, psychosocial adaptation and quality of life. Age was the most significant predictor of changes. Older patients, most of them suffering from delusional disorders, showed no improvement or even some impairment. Finally, the program appeared to have a marked effect on easing families' burden in domains such as assistance in daily life activities and costs. ACT appears to be recommended for patients with poor outcome when treated in other settings. Early intervention seems to be justified as highlighted by younger age being the best predictor of positive changes. Families can be helped considerably, particularly those confronted with patients with persistent disturbing symptoms which do not, however, warrant hospitalization. Finally, the fact that patients with delusional disorder do not seem to improve warrants further research.

Adjustment Disorder Related to Bereavement

Adjustment disorder related to bereavement (ADRB) is a condition that may develop after a loss, does not resolve over time, and requires clinician intervention. This article investigates the personal factors that influence response to loss and explores the relationship between coping mechanisms and the development of ADRB. Clinical features, diagnosis, and treatment options are discussed for use in primary care.

Clinician interventions and participant characteristics that foster adaptive patient expectations for psychotherapy and psychotherapeutic change.

Patients' expectations about the efficacy and nature of psychotherapy have long been considered important common treatment factors, and the empirical literature has largely supported this perspective. In this practice-oriented review, we examine the research on the association between patients' psychotherapy expectations and both adaptive treatment processes and outcomes. We also examine the research on specific psychotherapist interventions and patient and psychotherapist characteristics that influence the development of positive expectations for psychotherapy and psychotherapeutic change. The primary function of this review is to derive applied clinical strategies from the extant empirical literature in order to help clinicians in their attempts to address and influence their patients' psychotherapy-related expectations. Although the literature is not yet conclusive in supporting such strategies, we place the results in theoretical, clinical, and empirical contexts to suggest the most likely best practices at this time, and to stimulate further research on the expectation construct.

Mind your step: developing effective mental health training for alcohol and other drug workers

Mental health problems are common among drug treatment clients with most symptoms related to anxiety and depression. In this study, we used an established manual for alcohol and drug practitioners known as PsyCheck that outlines basic mental health screening and intervention for high prevalence disorders. The aim of this study was to examine changes in clinician's mental health screening and intervention activities post-training. One hundred ninety-five staff members from 13 alcohol and drug services across Australia participated in the training, which consisted of 2 days of practical instruction in comorbidity and the use of the PsyCheck manual. The package takes a symptom-focused approach. A clinical file audit was undertaken prior to and 6 months after the training to examine changes in clinicians' screening and intervention activities. The results showed increases in screening for mental health problems 6 months after training. Although the study is methodologically limited, it suggests that manualise...

A supportive approach in psychodynamic-oriented psychotherapy. An empirically supported single case study.

This paper evaluates process and outcome in a 2 years supportive psychotherapy psychodynamic-oriented of a young adult self-referred for concerns about University choice. The diagnosis was Panic Attack Disorder (DSM-IV) with features of obsessive-compulsive and narcissistic personality disorder (PDM). Twenty-eight verbatim transcripts of the sessions were coded with the Psychodynamic Intervention Rating Scales, the Collaborative Interactions Scale and Defense Mechanism Rating Scale. A log linear analysis model showed the trends of process variables during the treatment. A hierarchical regression analysis evaluated the importance of tailoring the clinician interventions in respect to the average level of defenses. Outcome results showed how patient's diagnosis changed and symptoms decreased.

A National Study of Problematic Care Experiences among Latinos with Diabetes

Despite the large disease burden of diabetes, little is known about the care experiences of Latinos with diabetes across diverse primary care settings. This study compares problematic care experiences among Latinos with diabetes across usual care sites (community health centers [CHCs], private physician practices, or without a usual source of care), using a national sample of Latino diabetic patients (N=583). Nearly half of the respondents reported at least one problematic care experience during their last clinician visit. Compared with respondents treated primarily by private physicians, respondents receiving care in CHCs or without a usual source of care reported more problematic care experiences. However, patient health insurance coverage and acculturation accounted for the highest proportion of explainable differences in problematic care experiences between CHCs and private physician offices. Initiatives should clarify the extent to which the care experiences of Latino diabetics, particularly uninsured and less acculturated patients who tend to be cared for by CHCs, can be improved through clinician communication and patient self-management interventions.

Le repérage de l’affect dans l’entretien clinique avec le patient souffrant de schizophrénie : proposition méthodologique

The authors take up the question of expression of affect in clinical interview with schizophrenic patient from analysis of interactions; they underline that verbal interaction enable privileged investigation of affect rationality. They propose a reflection about a model of analysis and formalisation; this one may initiate the construction of a model which emphasizes the types of conversational shapes underlying therapeutic strategies of change. The emotive dimension, as it is studied in psychanalytic theories can be questionned by cognitive and conversational theories. Indeed, cognitive and conversational enlightenment are used to bring out marks of affect expression, on the one hand, about syntactic and semantic structure of utterances, on the other hand, about shapes of conversational structures. So, this article presents a method which permits to study structure of conversations as ground of accomplishment of affect expression in interaction. From an illustration, the authors explain how some clinician's interventions are a prop of exploration of affect in conversation. The studied conversational sequence invite to think that some modalities of interaction organize connection of subject with his own affects, updating it in therapeutic relation. The authors brings out the idea that conversational relation facilitate the creation of a specific psychic space permitting mutual prop between intersubjective ties and intrapsychic.

Impact of vital signs screening &amp; clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison

BackgroundThough screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates.MethodsIn five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention.ResultsAlcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients.ConclusionsVital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.

Reciprocal gut–brain evolutionary symbiosis provokes and amplifies the postinjury systemic inflammatory response syndrome

The gut and the brain serve as dual motors in the evolutionary maintenance and amplification of the postinjury inflammatory response. This gut–brain axis is dependent on, and perpetuated by, current therapeutic interventional measures. It is not intuitive that evolution dictates the postinjury response. Evolutionary processes may determine eventual patient outcome to an extent that is great, if not greater, than that influenced by clinician intervention.

Patient-Controlled Epidural Analgesia for Labor

Patient-controlled epidural analgesia (PCEA) for labor was introduced into clinical practice 20 yr ago. The PCEA technique has been shown to have significant benefits when compared with continuous epidural infusion. We conducted a systematic review using MEDLINE and EMBASE (1988-April 1, 2008) of all randomized, controlled trials in parturients who received PCEA in labor in which one of the following comparisons were made: background infusion versus none; ropivacaine versus bupivacaine; high versus low concentrations of local anesthetics; and new strategies versus standard strategies. The outcomes of interest were maternal analgesia, satisfaction, motor block, and the incidence of unscheduled clinician interventions. A continuous background infusion improved maternal analgesia and reduced unscheduled clinician interventions. Larger bolus doses (more than 5 mL) may provide better analgesia compared with small boluses. Low concentrations of bupivacaine or ropivacaine provide excellent analgesia without significant motor block. Many strategies with PCEA can provide effective labor analgesia. High volume, dilute local anesthetic solutions with a continuous background infusion appear to be the most successful strategy. Research into new delivery strategies, such as mandatory programmed intermittent boluses and computerized feedback dosing, is ongoing.

Adaptive support ventilation for gynaecological laparoscopic surgery in Trendelenburg position: bringing ICU modes of mechanical ventilation to the operating room

The aim of the present study was to test the efficacy of adaptive support ventilation (ASV) to automatically adapt the ventilatory settings to the changes in the respiratory mechanics that occur during pneumoperitoneum and Trendelenburg position in gynaecological surgeries. We prospectively studied 22 ASA I women scheduled for gynaecological laparoscopic surgery in the Trendelenburg position. After intravenous induction of general anaesthesia, patients were ventilated with ASV, a closed-loop mode of mechanical ventilation based on the Otis formula, designed to automatically adapt the ventilatory settings to changes in the patient's respiratory system mechanics, while maintaining preset minute ventilation. Respiratory mechanics variables, ventilatory setting parameters and analysis of blood gases were recorded at three time points: 5 min after induction (baseline), 15 min after pneumoperitoneum and Trendelenburg positioning (Pneumo-Trend) and 15 min after pneumoperitoneum withdrawal (final). A reduction of 44.4% in respiratory compliance and an increase of 29.1% in airway resistance were observed during the Pneumo-Trend period. Despite these changes in respiratory mechanics, minute ventilation was kept constant. ASV adapted the ventilatory settings by automatically increasing inspiratory pressure by 3.2 +/- 0.9 cmH(2)O (+19%), P < 0.01, respiratory rate by 1.3 +/- 0.5 breaths per minute (+9%) and the inspiratory to total time ratio (T(i)/T(tot)) by 43.3%. At final time, these parameters returned towards their baseline values. Adequate gas exchange was maintained throughout all periods. PaCO(2) increased moderately (+13%) from 4.4 +/- 0.6 (baseline) to 5.0 +/- 0.9 kPa (Pneumo-Trend), P < 0.01; and decreased slightly at final time (4.7 +/- 0.8 kPa), P < 0.05. Clinician's intervention was needed in only one patient who showed a moderate hypercapnia (PaCO(2) 6.9 kPa) during pneumoperitoneum. In healthy women undergoing gynaecologic laparoscopy, ASV automatically adapted the ventilatory settings to the changes in the respiratory mechanics, keeping constant the preset minute ventilation, providing an adequate exchange of respiratory gases and obviating clinician's interventions.

Pathogenesis and Management of Postoperative Ileus

Postoperative ileus (POI) is a predictable delay in gastrointestinal (GI) motility that occurs after abdominal surgery. Probable mechanisms include disruption of the sympathetic/parasympathetic pathways to the GI tract, inflammatory changes mediated over multiple pathways, and the use of opioids for the management of postoperative pain. Pharmacologic treatment of postoperative ileus continues to be problematic as most agents are unreliable and unsubstantiated with robust clinical trials. The selective opioid antagonist alvimopan has shown promise in reducing POI, but needs more rigorous investigation. Clinician interventions proven to be of benefit include laparoscopy, thoracic epidural anesthesia, avoidance of opioids, and early feeding. Early ambulation may also contribute to early resolution of POI; however, routine nasogastric decompression plays no role and may increase complications. Multimodal care plans remain the mainstay of treatment for POI.

Knee Injury Outcomes Measures

Outcomes measures have long been used in the assessment of knee injuries and management protocols. In the past decade, there has been a shift from clinician-based outcomes tools to the development and validation of patient-reported outcomes measures. General health as well as disease- and medical condition-specific outcomes measures have been so modified. The Medical Outcomes Study 36-Item Short Form is the most commonly used general health measure in orthopaedics. Joint-specific measures include the Western Ontario and McMaster Universities Osteoarthritis Index, the Knee Injury and Osteoarthritis Outcome Score, and the International Knee Documentation Committee Subjective Form. The Lysholm Knee Scale and the Cincinnati Knee Rating Scale continue to be popular, especially for the assessment of ligamentous injuries. The ACL Quality of Life score is a disease-specific, patient-reported outcomes measure of anterior cruciate ligament deficiency. The historically used Tegner activity level scale and the recently developed Marx activity level scale are used in conjunction with these outcomes measures to make possible a global assessment of recovery from knee injuries and clinician interventions.

Carers perspectives on the activity patterns of people with dementia

Participation in activity is essential for the psychological well-being of people with dementia. The potential benefits of home-based activity programmes may depend on family carers, but little is known about their experience. This study aimed to elicit carers' experiences of involving the person with dementia in activity. Thirty in-depth interviews (i.e. initial and follow-up) were carried out with 15 co-resident carers of people with dementia who were recruited through local community mental health teams. Data were analysed using a grounded theory method. Overall, findings from initial interviews were taken back to the participants at the follow-up interviews. Five activity patterns were identified, which ranged from their usual activity patterns along a continuum through recognizable, illogical, irresponsible and finally reaching a dispossessed pattern. Carers used particular strategies and experienced particular emotional responses along this continuum. This work highlights the complex, temporal and dynamic nature of family carers' involvement in activity engagement. Clinician's interventions could be enhanced by: (1) recognizing the long-term experience of carers in decision making; (2) understanding the strategies used; (3) allowing carers to talk through and share their experiences in a non-judgmental way; (4) ensuring that carers are happy with any suggested interventions.

Randomized Controlled Trial Comparing Adaptive-support Ventilation with Pressure-regulated Volume-controlled Ventilation with Automode in Weaning Patients after Cardiac Surgery

Adaptive-support ventilation (ASV) is a minute ventilation-controlled mode governed by a closed-loop algorithm. With ASV, tidal volume and respiratory rate are automatically adjusted to minimize work of breathing. Studies indicate that ventilation in ASV enables more rapid weaning. The authors conducted a randomized controlled trial to determine whether ventilation in ASV results in a shorter time to extubation than pressure-regulated volume-controlled ventilation with automode (PRVCa) after cardiac surgery. Fifty patients were randomly assigned to ASV or PRVCa after elective coronary artery bypass grafting. Respiratory weaning progressed through three phases: phase 1 (controlled ventilation), phase 2 (assisted ventilation), and phase 3 (T-piece trial), followed by extubation. The primary outcome was duration of intubation (sum of phases 1-3). Secondary outcomes were duration of mechanical ventilation (sum of phases 1 and 2), number of arterial blood gas samples, and manual ventilator setting changes made before extubation. Forty-eight patients completed the study. The median duration of intubation was significantly shorter in the ASV group than in the PRVCa group (300 [205-365] vs. 540 [462-580] min; P < 0.05). This difference was due to a reduction in the duration of mechanical ventilation (165 [120-195] vs. 480 [360-510] min; P < 0.05). There were no significant differences between the ASV and PRVCa groups in the number of arterial blood gas samples taken or manual ventilator setting changes made. ASV is associated with earlier extubation, without an increase in clinician intervention, when compared with PRVCa in patients undergoing uncomplicated cardiac surgery.

Prevention Research and Reality: Narrowing the Quality Chasm

The discovery-to-delivery gap in medical and public health services is receiving growing attention, and many observations have been made about the importance of closing the gap as well as about the challenges faced in promoting acceptance and implementation of evidence-based approaches into routine clinical practice. 1,2 Concurrently, the importance of primary care clinician intervention and patient-centered counseling has been researched and promulgated as an important factor in patient adoption of healthy lifestyle and adherence to cancer prevention and control