The information specialist in the clinical team: Building expertise in evidence-based healthcare

The Clinician Development Program (CDP) is an initiative of Queensland Health’s Quality Improvement and Enhancement Program. At the Royal Brisbane & Royal Women's Hospital Health Service Districts, evidence-base practice (EBP) is an important CDP area in which several projects were carried out in 2002. This paper describes one such project. A medical librarian was invited to accompany the clinical team on morning rounds in the Medical Assessment & Planning Unit (MAPU). The librarian conducted information skills training in the ward and helped clinicians to answer questions directly related to patient care. Questions not answered during the round were followed-up, usually within 48 hours, and responses emailed to the consultant who led the rounds. At the project’s conclusion the librarian was invited to continue as a member of the MAPU clinical team, thus acknowledging the valuable role an information specialist can play in incorporating research evidence into patient care. Clinical librarianship (CL) creates a space, albeit a contentious one, for the health librarian at the bedside. This paper describes an Australian CL project and attempts to demystify the role of an information specialist in EBP. It also highlights some of the challenges facing librarians and clinicians attempting to embed EBP in clinical settings.

Promoting better use of the PSA test in general practice: Randomized controlled trial of educational strategies based on outreach visits and mailout

Background. Prostate-specific antigen (PSA) testing for prostate cancer is controversial. Demand for PSA testing is likely to rise in the UK, Australia and other western countries. Primary care needs to develop appropriate strategies to respond to this demand. Objectives. Our aim was to compare the effectiveness of educational outreach visits (EOVs) and mailout strategies targeting PSA testing in Australian primary care. Methods. A randomized controlled trial was conducted in general practices in southern Adelaide. The main outcome measures at baseline, 6 months and 12 months post-intervention were PSA testing rates and GP knowledge in key areas relating to prostate cancer and PSA testing. Results. The interventions were able to demonstrate a change in clinical practice. In the 6 months post-intervention, median PSA testing rate in the EOV group was significantly lower than in the postal group, which in turn was significantly lower than the control group (P < 0.001). Statistically significant differences were not, however, maintained in the 6-12 month post-intervention period. The EOV group, at 6 months follow-up, had a significantly greater proportion of 'correct' responses than the control group to questions about prostate cancer treatment effectiveness (P = 0.004) and endorsement of PSA screening by professional bodies (P = 0.041). Conclusions. Primary care has a central role in PSA testing for prostate cancer. Clinical practice in this area is receptive to evidence-based interventions.

Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care, implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources. Copyright (C) 2003 John Wiley Sons, Ltd.

Academic medicine: The evidence base

The International Campaign to Revitalise Academic Medicine recognises that an evidence based approach is important in discussing the problems of academic medicine. A preliminary exploration of the evidence on academic medicine has led to a research agenda for examining and proposing realistic solutions. Copyright © 2004, BMJ Publishing Group Ltd.

Community-based interventions for the prevention of burns and scalds in children

Background Burns and scalds are a significant cause of morbidity and mortality in children. Successful counter-measures to prevent burn and scald-related injury have been identified. However, evidence indicating the successful roll-out of these counter-measures into the wider community is lacking. Community-based interventions in the form of multi-strategy, multi-focused programmes are hypothesised to result in a reduction in population-wide injury rates. This review tests this hypothesis with regards to burn and scald injury in children. Objectives To assess the effects of community-based interventions, defined as coordinated, multi-strategy initiatives, for reducing burns and scalds in children aged 14 years and under. Search strategy We searched the Cochrane Injuries Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, National Research Register and the Web of Knowledge. We also handsearched selected journals and checked the reference lists of selected publications. The searches were last updated in May 2007. Selection criteria Included studies were those that reported changes in medically attended burn and scald-related injury rates in a paediatric population (aged 14 years and under), following the implementation of a controlled community-based intervention. Data collection and analysis Two authors independently assess studies for eligibility and extracted data. Due to heterogeneity between the included studies, a pooled analysis was not appropriate. Main results Of 39 identified studies, four met the criteria for inclusion. Two of the included studies reported a significant decrease in paediatric burn and scald injury in the intervention compared with the control communities. The failure of the other two studies to show a positive result may have been due to limited time-frame for the intervention and/or failure to adequately implement the counter-measures in the communities. Authors' conclusions There are a very limited number of research studies allowing conclusions to be drawn about the effectiveness of community-based injury prevention programmes to prevent burns and scalds in children. There is a pressing need to evaluate high-quality community-based intervention programmes based on efficacious counter-measures to reduce burns and scalds in children. It is important that a framework for considering the problem of burns and scalds in children from a prevention perspective be articulated, and that an evidence-based suite of interventions be combined to create programme guidelines suitable for implementation in communities throughout the world.

Design options for sample-based mortality surveillance

Background Reliable information on causes of death is a fundamental component of health development strategies, yet globally only about one-third of countries have access to such information. For countries currently without adequate mortality reporting systems there are useful models other than resource-intensive population-wide medical certification. Sample-based mortality surveillance is one such approach. This paper provides methods for addressing appropriate sample size considerations in relation to mortality surveillance, with particular reference to situations in which prior information on mortality is lacking. Methods The feasibility of model-based approaches for predicting the expected mortality structure and cause composition is demonstrated for populations in which only limited empirical data is available. An algorithm approach is then provided to derive the minimum person-years of observation needed to generate robust estimates for the rarest cause of interest in three hypothetical populations, each representing different levels of health development. Results Modelled life expectancies at birth and cause of death structures were within expected ranges based on published estimates for countries at comparable levels of health development. Total person-years of observation required in each population could be more than halved by limiting the set of age, sex, and cause groups regarded as 'of interest'. Discussion The methods proposed are consistent with the philosophy of establishing priorities across broad clusters of causes for which the public health response implications are similar. The examples provided illustrate the options available when considering the design of mortality surveillance for population health monitoring purposes.

Appraising the quality of randomized controlled trials: inter-rater reliability for the OTseeker evidence database

Rationale and aims 'OTseeker' is an online database of randomized controlled trials (RCTs) and systematic reviews relevant to occupational therapy. RCTs are critically appraised and rated for quality using the 'PEDro' scale. We aimed to investigate the inter-rater reliability of the PEDro scale before and after revising rating guidelines. Methods In study 1, five raters scored 100 RCTs using the original PEDro scale guidelines. In study 2, two raters scored 40 different RCTs using revised guidelines. All RCTs were randomly selected from the OTseeker database. Reliability was calculated using Kappa and intraclass correlation coefficients [ICC (model 2,1)]. Results Inter-rater reliability was 'good to excellent' in the first study (Kappas >= 0.53; ICCs >= 0.71). After revising the rating guidelines, the reliability levels were equivalent or higher to those previously obtained (Kappas >= 0.53; ICCs >= 0.89), except for the item, 'groups similar at baseline', which still had moderate reliability (Kappa = 0.53). In study 2, two PEDro scale items, which had their definitions revised, 'less than 15% dropout' and 'point measures and variability', showed higher reliability. In both studies, the PEDro items with the lowest reliability were 'groups similar at baseline' (Kappas = 0.53), 'less than 15% dropout' (Kappas

Forecasting Helicoverpa populations in Australia: A comparison of regression based models and a bio-climatic based modeling approach

Long-term forecasts of pest pressure are central to the effective management of many agricultural insect pests. In the eastern cropping regions of Australia, serious infestations of Helicoverpa punctigera (Wallengren) and H. armigera (Hübner)(Lepidoptera: Noctuidae) are experienced annually. Regression analyses of a long series of light-trap catches of adult moths were used to describe the seasonal dynamics of both species. The size of the spring generation in eastern cropping zones could be related to rainfall in putative source areas in inland Australia. Subsequent generations could be related to the abundance of various crops in agricultural areas, rainfall and the magnitude of the spring population peak. As rainfall figured prominently as a predictor variable, and can itself be predicted using the Southern Oscillation Index (SOI), trap catches were also related to this variable. The geographic distribution of each species was modelled in relation to climate and CLIMEX was used to predict temporal variation in abundance at given putative source sites in inland Australia using historical meteorological data. These predictions were then correlated with subsequent pest abundance data in a major cropping region. The regression-based and bioclimatic-based approaches to predicting pest abundance are compared and their utility in predicting and interpreting pest dynamics are discussed.

Intensive case management: A critical re-appraisal of the scientific evidence for effectiveness

Intensive Case Management (ICM) is widely claimed to be an evidence-based and cost effective program for people with high levels of disability as a result of mental illness. However, the findings of recent randomized controlled trials comparing ICM with 'usual services' suggest that both clinical and cost effectiveness of ICM may be weakening. Possible reasons for this, including fidelity of implementation, researcher allegiance effects and changes in the wider service environment within which ICM is provided, are considered. The implications for service delivery and research are discussed.

Dissemination of a community-based physical activity project: The case of 10,000 steps

This paper describes the use of a web-site for the dissemination of the community-based '10,000 steps' program which was originally developed and evaluated in Rockhampton, Queensland in 2001-2003. The website provides information and interactive activities for individuals, and promotes resources and programs for health promotion professionals. The dissemination activity was assessed in terms of program adoption and implementation. In a 2-year period (May 2004-March 2006) more than 18,000 people registered as users of the web-site (togging more than 8.5 billion steps) and almost 100 workplaces and 13 communities implemented aspects of the 10,000 steps program. These data support the use of the internet as an effective means of disseminating ideas and resources beyond the geographical borders of the original project. Following this preliminary dissemination, there remains a need for the systematic study of different dissemination strategies, so that evidence-based physical activity programs can be translated into more widespread public health practice. (c) 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Seizure detection algorithm for neonates based on wave-sequence analysis

Objective: The description and evaluation of the performance of a new real-time seizure detection algorithm in the newborn infant. Methods: The algorithm includes parallel fragmentation of EEG signal into waves; wave-feature extraction and averaging; elementary, preliminary and final detection. The algorithm detects EEG waves with heightened regularity, using wave intervals, amplitudes and shapes. The performance of the algorithm was assessed with the use of event-based and liberal and conservative time-based approaches and compared with the performance of Gotman's and Liu's algorithms. Results: The algorithm was assessed on multi-channel EEG records of 55 neonates including 17 with seizures. The algorithm showed sensitivities ranging 83-95% with positive predictive values (PPV) 48-77%. There were 2.0 false positive detections per hour. In comparison, Gotman's algorithm (with 30 s gap-closing procedure) displayed sensitivities of 45-88% and PPV 29-56%; with 7.4 false positives per hour and Liu's algorithm displayed sensitivities of 96-99%, and PPV 10-25%; with 15.7 false positives per hour. Conclusions: The wave-sequence analysis based algorithm displayed higher sensitivity, higher PPV and a substantially lower level of false positives than two previously published algorithms. Significance: The proposed algorithm provides a basis for major improvements in neonatal seizure detection and monitoring. Published by Elsevier Ireland Ltd. on behalf of International Federation of Clinical Neurophysiology.

Approaches to training practitioners in the art and science of plant disease diagnosis

Allowing plant pathology students to tackle fictitious or real crop problems during the course of their formal training not only teaches them the diagnostic process, but also provides for a better understanding of disease etiology. Such a problem-solving approach can also engage, motivate, and enthuse students about plant pathologgy in general. This paper presents examples of three problem-based approaches to diagnostic training utilizing freely available software. The first provides an adventure-game simulation where Students are asked to provide a diagnosis and recommendation after exploring a hypothetical scenario or case. Guidance is given oil how to create these scenarios. The second approach involves students creating their own scenarios. The third uses a diagnostic template combined with reporting software to both guide and capture students' results and reflections during a real diagnostic assignment.