Use Of Evidence-based Treatments Research Articles

Continued Use of Evidence-Based Treatments After a Randomized Controlled Effectiveness Trial: A Qualitative Study

OBJECTIVE This study examined the extent to which therapists who participated in a randomized controlled trial (RCT) of evidence-based treatments continued to use them with nonstudy clients after the trial as well as the types of treatment used and the reasons for their continued use. METHODS Semistructured interviews and focus groups were conducted with 38 therapists, three clinical supervisors, and eight clinic directors three months after an RCT of evidence-based treatments for depression, anxiety, and conduct disorders among children and adolescents. The therapists had been assigned randomly to one of three conditions: modular (N=15), allowing flexible use and informed adaptations of treatment components; standard (N=13), using full treatment manuals; and usual care (N=10). Grounded-theory analytic methods were used to analyze interview transcripts. RESULTS Twenty-six therapists (93%) assigned to the modular or standard condition used the treatments with nonstudy cases. Of those, 24 (92%) therapists, including all but two assigned to the standard condition, reported making some adaptation or modification, including using only some modules with all clients or all modules with some clients; changing the order or presentation of the modules to improve the flow or to work around more immediate issues; and using the modules with others, including youths with co-occurring disorders, youths who did not meet the age criteria, and adults. CONCLUSIONS The results provide insight into the likely sustainability of evidence-based treatments, help to explain why the outcomes of the RCT favored a modular approach, and highlight the strengths and limitations of use of evidence-based treatments.

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

Increasing Age Is Associated With a Decrease in the Use of Evidence-Based Treatment at Target Doses

Increasing Age Is Associated With a Decrease in the Use of Evidence-Based Treatment at Target Doses

Implementation Outcomes of Military Provider Training in Cognitive Processing Therapy and Prolonged Exposure Therapy for Post-Traumatic Stress Disorder

Between 2006 and 2012, the Department of Defense trained thousands of military mental health providers in the use of evidence-based treatments for post-traumatic stress disorder. Most providers were trained in multiday workshops that focused on the use of Cognitive Processing Therapy and Prolonged Exposure. This study is a follow-up evaluation of the implementation practices of 103 Air Force mental health providers. A survey was administered online to workshop participants; 34.2% of participants responded. Findings on treatment implementation with the providers indicated that a majority of respondents found the trainings valuable and were interested in using the treatments, yet they reported a lack of time in their clinic appointment structure to support their use. Insufficient supervision was also cited as a barrier to treatment use. Results suggest the need to improve strategies for implementing evidence-based practices with providers to enhance clinical outcomes in military settings.

Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After Acute Myocardial Infarction

The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI). Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown. We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50% to 74% target), or goal (≥75% target). Patients with contraindications were excluded from analyses for that medication. Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each. Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.

Diagnostic Testing and Treatment of Pediatric Headache in the Emergency Department

To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample. This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine. Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non-evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning. There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED.

Missed opportunities: low use of evidence-based treatment with eplerenone after myocardial infarction - a nationwide study

Purpose: The aldosterone antagonist eplerenone reduces mortality and readmissions after acute myocardial infarction (MI) in patients with LVEF≤40% and either symptomatic heart failure or diabetes mellitus, and is recommended by ESC guidelines. We investigated evidence-based use of eplerenone in a nationwide cohort of patients after first-time MI in Denmark. Methods: From national registers we included all patients with MI, aged ≥30 years and surviving ≥30 days. Indication for eplerenone was defined as claimed prescription of loop-diuretics in addition to either ACE-inhibitor or antidiabetic drugs, within 90 days after discharge. Use of eplerenone and other aldosterone antagonists was identified, and survival compared by Kaplan-Meier analysis. Results: We included 49,479 patients (63% men, mean age 68.1±13.6 years) with a median follow-up of 1003 (IQR 420-1716) days. Treatment with eplerenone was indicated in 9,115 (18.4%) patients, of which 93 (1.02%) received eplerenone, and 2,157 (23.7%) received spironolactone. Mortality rates for groups with and without indication for eplerenone at one-year were 1,096 (16.0%) and 3,115 (8.1%), and at end of follow-up 2,871 (41.8%) and 8,680 (22.5%), respectively (Figure). Applying the evidence-based mortality reducing effect of eplerenone to our results, a potential of 164 and 431 deaths within the first year, and during long-term follow-up, respectively, could have been saved by guideline-recommended use of eplerenone. ![Figure][1] Survival by eplerenone indication Conclusions: In a nationwide cohort of post-MI patients, a low use of eplerenone was observed in patients with indication for treatment. Our findings suggest an unexploited potential in the treatment of high-risk group of patients, and therefore focus on initiation of evidence-based treatment is warranted. [1]: pending:yes

Hyaluronidase for treatment of intravenous extravasations: Implementation of an evidence‐based guideline in a pediatric population

To describe the implementation and evaluation of an evidence-based guideline, Hyaluronidase for Treatment of IV Extravasations, in a pediatric population. Evidence of hyaluronidase efficacy suggests that timely administration will decrease the severity of tissue damage caused by extravasations, and result in cost savings. Implementation of this guideline increased user knowledge, incident reporting, and initiation of treatment, and decreased the average time to treatment administration. Implementation strategies facilitate integration and sustained use of evidence-based treatments in clinical practice. Processes that promote evidence-based treatment are expected to improve outcomes and are therefore an important component of evaluation.

Impact of Cardiac Care Variation on ST-Elevation Myocardial Infarction Outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

Practitioners’ Views and Use of Evidence-based Treatment: Positive Attitudes but Missed Opportunities in Children’s Services

The extent evidence-based treatments (EBTs) are used in clinical practice within the Australian therapeutic child welfare sector is unknown. In this study, we investigated practitioners' knowledge, attitudes, and use of EBT when providing interventions to children and families and how the intended outcomes of interventions are evaluated. Practitioners (N = 112) from 41 non-government organizations were surveyed and reported few barriers to implementing EBTs and positive attitudes. While just over half the practitioners surveyed provided an accurate definition of EBT, 72 % of practitioners reported using EBTs in their clinical practice. Of those, 88 % reported modifying the EBT, however interventions were rarely evaluated systematically. Implications for the use of EBTs, how they are modified, and the role of systematic evaluation are discussed.

Maltreatment‐Associated Psychiatric Problems: An Example of Environmentally Triggered ESSENCE?

This paper presents a new concept—maltreatment associated psychiatric problems (MAPP)—a syndrome of overlapping complex neurodevelopmental problems in children who have experienced abuse or neglect in early life. Children with MAPP are a hidden population in the community and, in clinical settings, their problems can seem overwhelming. Individual disorders associated with maltreatment are discussed as well as the overlap between these disorders and their shared environmental and genetic predisposing factors. Because of the complex and overlapping nature of MAPP, with symptoms emerging in early life, I argue that it should be considered an example of ESSENCE. Children presenting with likely MAPP should receive a comprehensive assessment, probing for symptoms of all of the ESSENCE disorders and leading to the use of evidence-based treatments where these are available.

Implementation of electronic chemotherapy ordering: An opportunity to improve evidence-based oncology care.

323 Background: On April 20, 2012, Mount Sinai Medical Center was the 63rd site to go-live with the Beacon chemotherapy module of the EPIC EMR. EPIC support reports that ours was one of the most successful launches to date. Previously, all our chemotherapy orders were handwritten with variable adherence to evidence-based chemotherapy and supportive care guidelines. Our goals were 1) reduce errors and improve patient safety, 2) increase use of evidence-based treatment, 3) optimize supportive care and 4) improve practice efficiency. Methods: Fourteen months prior to the go-live we formed a Chemotherapy Council, made up of Oncology physician, nursing and pharmacy leadership and a Beacon-trained Build Team, including an oncology nurse and two chemotherapy pharmacists. Individual disease groups submitted lists of their regimens with references, which were used to create paper orders. The council met weekly to review the orders, references, nursing communications, and NCCN treatment, antiemetic and supportive care guidelines. Once approved, these paper orders served as templates for more than 400 electronic protocols. Each protocol was validated by a utilizing physician. Results: 98% of patients had electronic orders entered prior to go-live (394 chemotherapy and 116 supportive). There were no patient safety issues during the go-live period. In a survey one-month post go-live, 72% of users felt that Beacon had improved their day-to-day efficiency and 72% of users felt that the quality of patient care had improved. Conclusions: The transition to electronic chemotherapy ordering offers an institution the chance to develop evidence-based oncology practice, standardize supportive care and enhance patient safety. It is essential to develop procedures to avoid electronically immortalizing unproven regimens or chemotherapy dosing errors. The key elements that made our Beacon transition so successful were: 1) extensive involvement of oncology leadership, 2) use of a chemotherapy council to enforce evidence-based practice, 3) clinician validation of every protocol and 4) ongoing collaboration between clinical operations and IT regarding the impact of electronic ordering on downstream operations.

Integrated-Care Models Increase Psychiatrists’ Impact

Integrated-Care Models Increase Psychiatrists’ Impact

Psychotherapies provided for eating disorders by community clinicians: Infrequent use of evidence-based treatment

This study describes the psychological interventions used for eating disorders (EDs) by community practitioners. Of 573 clinicians we screened across Alberta, 130 (22.7%) had treated EDs; 118 (90.8%) were interviewed. Clinicians reported varied reasons for psychotherapy choice and diverse training experiences; the primary approaches used varied by education and field. The most common primary approach was eclectic (43.2%), followed by cognitive-behavior therapy (CBT; 22.9%). However, self-reported CBT clinicians used specific CBT techniques infrequently. Half of clinicians incorporated addictions-based techniques. These results indicate that ED treatment provided by community clinicians is varied and generally does not align with evidence-based practice guidelines.

Health‐care reform provides an opportunity for evidence‐based alcohol treatment in the USA: the National Institute for Health and Clinical Excellence (NICE) guideline as a model

Health‐care reform provides an opportunity for evidence‐based alcohol treatment in the <scp>USA</scp>: the <scp>N</scp>ational <scp>I</scp>nstitute for <scp>H</scp>ealth and <scp>C</scp>linical <scp>E</scp>xcellence (<scp>NICE</scp>) guideline as a model

Abstract 208: Physician Adherence to the Prescription of Proven Doses of Secondary Prevention Medications After Acute Myocardial Infarction. Insights from TRIUMPH and PREMIER.

Background: Performance measures after an acute myocardial infarction (AMI) are designed to improve quality by explicitly quantifying the use of evidence-based treatments. While current performance measures assess whether patients are prescribed certain medications, the doses used to establish their benefit in clinical trials are not part of the measures. It is unknown whether patients are being discharged on doses with proven effectiveness and whether these doses are increased over time in the outpatient setting. Methods: We assessed doses of beta blockers (BB), statins, and ACE/ARBs at discharge and 6-12 months post-AMI among 6699 patients eligible for these meds from 31 hospitals enrolled in 2 US registries (2003-08). Target doses were defined from clinical trials establishing benefit. Doses were categorized as none, low (&lt;50% target), moderate (50-74% target), or goal (≥75% target). Titration was defined as an increase in dose category from discharge to follow-up. Analyses excluded patients with heart rate &lt;50 (BB), SBP &lt;100 (BB, ACE/ARB), GFR &lt;30 (ACE/ARB), EF&gt;35% (ACE/ARB), or any chart-documented contraindication (all assessed at discharge). Hierarchical logistic models explored factors, including discharge dose, associated with achieving goal dose of each med at follow-up. Results: At hospital discharge, most eligible patients (&gt;87%) were prescribed some dose of each medication, although fewer than 1/5 received goal doses of BB and ∼1/3 were prescribed goal doses of statins or ACE/ARBs (Table). Of patients discharged on suboptimal doses, few were titrated up as outpatients (BB 19%, statins 25%, ACE/ARBs 27%). After adjustment for sociodemographic and clinical factors, only a goal dose of med at discharge was associated with being on goal dose at follow-up. Conclusions: Although ∼90% of eligible patients are discharged on appropriate secondary prevention medications after an AMI, most are prescribed doses far below those with proven efficacy in clinical trials. Importantly, doses are infrequently increased in the outpatient setting. Integration of dose intensity into performance measures may help improve the use of optimal medical therapy and outcomes.

Integrating Evidence-Based Tobacco Cessation Interventions in Free Medical Clinics

Free medical clinics serve a critical role in health care delivery of America's uninsured population, who are less likely to receive tobacco cessation counseling and 1½ times more likely than the general population to use tobacco. The authors evaluate the opportunities for and challenges to implementing the U.S. Public Health Service Guidelines for tobacco cessation in free clinics. Six free clinics participated in this pilot study. Five objectives were targeted: implementation of a tobacco user identification system, education of all clinic staff and volunteers, dedication of a program champion, use of evidence-based treatment, and creation of a supportive environment that reinforces provider behavior. Key informant interviews and focus group data were used to describe the opportunities and barriers of implementing the Public Health Service Guidelines. All clinics adopted a user identification system, dedicated a program champion, adopted evidence-based counseling, and created an environment conducive for cessation. Common challenges included getting volunteers to attend on-site training programs, accessing nicotine replacement therapy, and promoting Quit Line usage, all of which are part of evidence-based treatment. With more than 1,200 free clinics nationwide, it is very important to understand the opportunities and barriers of implementing tobacco cessation services and systems in free clinics.

Temporal trends of the gaps in post-myocardial infarction secondary prevention strategies of co-morbid and elderly populations vs. younger counterparts: an analysis of three successive cohorts between 2003 and 2008

Aims Epidemiological studies reported two contrasting trends: on one hand, a significant improvement in the use of evidence-based treatments of patients discharged with a myocardial infarction (MI). On the other hand, the increasing number of elderly and co-morbid patients who are usually less treated. The aim of this study is to examine whether improvements in the treatment of MI are homogeneously distributed throughout all subgroups of patients. Methods and results Based on record linkage of administrative registers, 21 423 patients discharged with MI in three different periods (2003, 2005, and 2007), were identified and followed up for major clinical events up to 1 year. Using as a reference temporal category those patients discharged in 2003 (odds ratios, 95% confidence intervals) and as a demographic category male patients aged ≤75 years (1.00), the study identified: in-hospital mortality significantly decreased in all periods and in all groups of patients; out-of-hospital mortality decreased only in younger patients and not in older patients; prescription of evidence-based treatments increased in all periods for all patients; however, the magnitude of improvement was mostly concentrated in younger patients. Conclusion Although there was a mean improvement in the treatment and outcome of patients discharged from an MI, most of these benefits were strongly concentrated in younger, healthier patients. Old and co-morbid populations-although representing a substantial proportion of the burden of disease-received significant less attention and barely improved their survival.

S.03.01 Clinical neuroproteomics and biomarkers of Alzheimer's disease

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is a long-term study designed to find out which treatments are most effective for treating bipolar disorder [1]. STEP-BD is the largest treatment study ever conducted for bipolar disorder and enrolled 4,360 participants from 22 sites over seven years (1998 to 2005). The program included several different studies, each aimed at a different aspect of treatment for the illness. STEP-BD recruited real-world patients contending with multiple mental and/or physical illnesses and offered participants long-term continuity of care. Once enrolled, participants received care for as long as they were in the program (up to five years) and were monitored systematically for the entire period. Clinicians participating in STEP-BD were extensively trained in the use of evidence-based treatments to become certified. STEP-BD’s rigorous treatment and measurement process, known as the ‘Best Practice Pathway’, allowed clinicians to reliably evaluate their patients’ full range of symptoms and monitor the course of the illness. The findings from the STEP-BD study have provided much needed long-term data on the chronic, recurrent course of the disorder, and given a precious contribute to building an evidence-base on the best treatments for the disorder. The presentation will review the benefits and pitfalls of the STEP BD study, with special reference to the lessons for future studies in general and to the ENBREC approaches to bipolar research and clinical management in particular.

An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes

There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals' behaviour and patient outcomes. To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes. We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting. We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review). Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.