How Comprehensively Is Evidence-Based Practice Represented in Australian Health Professional Accreditation Documents? A Systematic Audit.

UNLABELLED: PHENONENON: In many developed countries, accreditation documents, which reflect the practice standards of health professions, form the basis for evaluation of education programs for meeting the requirements for registration. The 2005 Sicily statement proposed a 5-step model of training in evidence-based practice (ask, access, appraise, apply, and assess). A key recommendation was that evidence-based practice should be incorporated into entry-level health professional training and registration. No previous research has assessed the extent to which this has occurred. APPROACH: We undertook a systematic audit of the accreditation documents for the registered health professions in Australia. The 11 health professional disciplines included in the audit were medicine, nursing and midwifery, pharmacy, physiotherapy, dentistry, psychology, occupational therapy, optometry, podiatry, osteopathy, and chiropractic. Two investigators independently identified the occurrence of the term evidence that related to "evidence-based practice" and the occurrences of terms related to the 5 steps in the accreditation documents. FINDINGS: Occurrence of the term evidence as it relates specifically to "evidence-based practice" ranged from 0 (pharmacy, dentistry and occupational therapy) to 8 (physiotherapy) in the accreditation documents. Overall, there were 77 occasions when terms relating to any of the 5 steps of evidence-based practice were used across all 11 accreditation documents. All 5 steps were included in the physiotherapy and psychology documents; 4 steps in medicine and optometry; 3 steps in pharmacy; 2 steps each in documents for chiropractic, osteopathy, and podiatry; and 1 step for nursing. There was no inclusion of terms relating to any of the 5 steps in the dentistry and occupational therapy documents. Insights: Terminology relating explicitly to evidence-based practice and to the 5 steps of evidence-based practice appears to be lacking in the accreditation documents for health professions registered in Australia. This is not necessarily reflective of the curricular content or quality, or dedication to evidence-based practice teaching. However, recognition and demand by accreditation bodies for skills in evidence-based practice may act as a driver for education providers to give greater priority to embedding this training in entry-level programs. Consequently, accreditation bodies are powerfully positioned to shape future directions, focus, and boundaries within and across professions. Future international audits of accreditation documents could provide insight into the global breadth of this phenomenon and contribute to closer scrutiny of the representation of evidence-based practice in future iterations of accreditation documents.

Does the current version of 'Tomorrow's Doctors' adequately support the role of evidence-based medicine in the undergraduate curriculum?

BACKGROUND: The evidence-based medicine (EBM) approach to clinical practice has been incorporated into medical training around the world. Whilst EBM is a component of the 'foundation years' (FY) programme, it appears to lack a firm foundation in the UK undergraduate curriculum. AIM: To identify whether the teaching of EBM is adequately supported by the guideline 'Tomorrow's Doctors' (TD-2003). METHODS: We mapped TD-2003 against the five steps of EBM and also reviewed the literature for reports concerning the introduction of EBM into undergraduate curricula. RESULTS: Whilst all five steps of EBM can be mapped against TD-2003, the guidance makes no explicit reference to EBM and a coherent framework is lacking. The focus of undergraduate EBM teaching should be on 'using' research evidence (rather than undertaking research). The current emphasis on 'therapy' should be expanded to include the EBM-related issues of 'diagnosis, prognosis and harm'. UK medical schools also need to exploit the NHS investment in 'national electronic libraries'.

Evidence-based medicine teaching in UK medical schools.

BACKGROUND: It is recognized that clinicians need training in evidence-based medicine (EBM), however there is considerable variation in the content and methods of the EBM curriculum in UK medical schools. AIMS: To determine current practice and variation in EBM undergraduate teaching in UK medical schools and inform the strategy of medical schools and the National Knowledge Service. METHODS: We contacted all 32 medical schools in the UK and requested that the person primarily responsible for EBM undergraduate teaching complete a short online survey and provide their EBM curriculum. RESULTS: The survey was completed by representatives from 20 (63%) medical schools and curriculum details were received from 5 (16%). There is considerable variation in the methods and content of the EBM curriculum. Although the majority of schools teach core EBM topics, relatively few allow students to practice the skills or assess such skills. EBM teaching is restricted by lack of curriculum time, trained tutors and teaching materials. CONCLUSIONS: Key elements to progress include the integration of EBM with clinical specialties, tutor training and the availability of high-quality teaching resources. The development of a national undergraduate EBM curriculum may help in promoting progress in EBM teaching and assessment in UK medical schools.

Nonequivalence of inhaled and nebulized salbutamol in the assessment of endothelial dysfunction.

A noninvasive measure of global endothelial dysfunction may be obtained by pulse wave analysis (PWA) before and after administration of inhaled salbutamol. As some subjects may have difficulty using an inhaler, we determined whether equivalent doses of inhaled and nebulized salbutamol produced similar effects on a key measure obtained from PWA-the augmentation index (AIx). Twenty volunteers (11 with vascular risk factors and 9 healthy controls) underwent PWA at the right radial artery using SphygmoCor. Subjects were randomized to receive either 400 microg inhaled salbutamol via spacer device or 2.5 mg nebulized salbutamol. PWA was performed until there was no further drop in AIx. After AIx returned to baseline, salbutamol was administered via the alternative route and measurements were repeated. The primary outcome was the intraclass correlation coefficient of agreement (ICC) between maximum change in AIx following inhaled and nebulized salbutamol. The ICC was 0.32 (95% CI -0.07 to 0.64) and 0.39 (95% CI -0.04 to 0.70) with and without correction for heart rate. The median maximum decrease in AIx after inhaler was 4.8% (IQR 1.8-7.1), and after nebulizer was 8.5% (IQR 7.5-11.4) (p = < .001). When corrected for heart rate, the median maximum fall in AIx after inhaler was 4.0% (IQR 2.0-7.9) and after nebulized salbutamol was 5.0% (IQR 3.8-9.6) (p = 0.24). Although inhaled and nebulized salbutamol produced similar median reductions in AIx, the correlation between the two methods of salbutamol delivery was weak. Further research is required to validate the fall in AIx after nebulized salbutamol as a measure of endothelial dysfunction.

Gender differences in the clinical management of patients with angina pectoris: a cross-sectional survey in primary care.

BACKGROUND: Previous research suggests that women admitted to hospital with acute myocardial infarction (MI) are managed less intensively than men. Chronic stable angina is the commonest clinical manifestation of coronary heart disease in the community, but little information is available concerning its contemporary clinical management. The aim of this study is to assess the extent of gender differences in the clinical management of angina pectoris in primary care. METHODS: A cross-sectional survey undertaken in 8 sentinel centres serving 63,724 individuals in the city of Liverpool (15% of the city population). Aspects of clinical care assessed included: risk factor recording (smoking, cholesterol, blood pressure, body mass index); secondary prevention (aspirin, beta-blocker, statin); cardiac investigation (exercise ECG, perfusion scanning, angiography); and revascularisation (percutaneous coronary intervention, coronary artery bypass grafting). Male-to-female adjusted odds ratios (AOR) were calculated (adjusted for age, angina duration, age at diagnosis and previous MI) using logistic regression. RESULTS: 1,162 patients (610 men; 552 women) with angina were identified. Women were older than men (71 vs 67 years), with a shorter duration of angina (6 vs 7 years), and a lower prevalence of previous MI (25% vs 43%). Men were significantly more likely than women to undergo detailed risk factor assessment (AOR = 1.35, 95%CI 1.06 to 1.73); receive 'triple' secondary prevention with aspirin, beta-blockers and statins (AOR = 1.47, 95%CI 1.07 to 2.02); access exercise ECG testing (AOR = 1.31, 95%CI 1.02 to 1.68); angiography (AOR = 1.61, 95%CI 1.23 to 2.12); and undergo coronary revascularisation (AOR = 1.93, 95%CI 1.39 to 2.68). CONCLUSION: Systematic gender differences exist in the comprehensive clinical management of patients with angina in primary care.

Repeatability of central aortic blood pressures measured non-invasively using radial artery applanation tonometry and peripheral pulse wave analysis.

OBJECTIVE: To estimate the repeatability of radial pulse wave analysis (PWA) in measuring central systolic and diastolic blood pressures (cSBP/cDBP), pulse pressure (cPP), augmentation pressure (cAP) and pulse pressure amplification (PPA). METHODS: After 15 min supine rest, 20 ambulant patients (aged 27-82 years; four female) underwent four SphygmoCor PWA measurements on a single occasion. Two nurses independently undertook two measurements in alternate order, blind to their colleague's measurements. Analysis was by Bland-Altman limits of agreement (LOA). RESULTS: Heart rate and brachial blood pressure (BP) were stable during assessment. Based on the average of two PWA measurements between-observer differences (LOA, mean difference +/- 2SD) were small (cSBP 1.5 +/- 10.9 mmHg; cDBP 0.4 +/- 5.2 mmHg; cAP 0.5 +/- 4.5 mmHg; cPP 1.1 +/- 10.5 mmHg; PPA -0.5% +/- 5.6%). Between-observer differences were much greater for single/initial PWA measurement (cSBP 3.6 +/- 15.9 mmHg; cDBP 2.8 +/- 8.8 mmHg; cAP 0.7 +/- 5.8 mmHg; cPP 0.8 +/- 13.6 mmHg; PPA -1.2 +/- 9.4%). Within-observer LOA were very similar for both nurse A (cSBP -4.2 +/- 14.1 mmHg; cDBP -4.6 +/- 13.1 mmHg; cAP -0.4 +/- 4.4 mmHg; cPP 0.5 +/- 11.0 mmHg; PPA 0.7% +/- 9.0%) and nurse B (cSBP 0.0 +/- 12.1 mmHg; cDBP 0.2 +/- 8.5 mmHg; cAP -0.1 +/- 4.4 mmHg; cPP -0.2 +/- 11.9 mmHg; PPA -0.7% +/- 10.6%). CONCLUSION: Non-invasive assessment of central aortic pressures using PWA on a single occasion is highly repeatable in ambulant patients even when used by relatively inexperienced staff.

Indices of cardiovascular function derived from peripheral pulse wave analysis using radial applanation tonometry: a measurement repeatability study.

Pulse wave analysis (PWA) using applanation tonometry is a non-invasive technique for assessing cardiovascular function. It produces three important indices: ejection duration index (ED%), augmentation index adjusted for heart rate (AIX@75), and subendocardial viability ratio (SEVR%). The aim of this study was to assess within- and between-observer repeatability of these measurements. After resting supine for 15 minutes, 20 ambulant patients (16 male) in sinus rhythm underwent four PWA measurements on a single occasion. Two nurses (A & B) independently and alternately undertook PWA measurements using the same equipment (Omron HEM-757; SphygmoCor with Millar hand-held tonometer) blind to the other nurse's PWA measurements. Within- and between-observer differences were analysed using the Bland-Altman ;limits of agreement' approach (mean difference +/- 2 standard deviations, 2SD). Mean age was 56 (blood pressure, BP 136/79; pulse rate 64). BP/PWA measurements remained stable during assessment. Based on the average of two PWA measurements the mean +/- 2SD between-observer difference in ED% was 0.3 +/- 2.0; AIX@75 1.0 +/- 3.9; and SEVR% 1.7 +/- 14.2. Based on a single PWA measurement the between-observer difference was ED% 0.3 +/- 3.3; AIX@75 1.7 +/- 6.9; and SEVR% 0.6 +/- 22.6. Within-observer differences for nurse-A were ED% 0.0 +/- 5.4; AIX@75 1.5 +/- 7.0; and SEVR% 1.7 +/- 39.0 (nurse-B: 0.1 +/- 3.8; 0.1 +/- 8.0; and 0.6 +/- 23.3, respectively). PWA demonstrates high levels of repeatability even when used by relatively inexperienced staff and has the potential to be included in the routine cardiovascular assessment of ambulant patients.

Randomised controlled trial of a hypothyroid educational booklet to improve thyroxine adherence.

BACKGROUND: Non-adherence with medication prescribed for chronic disease is ubiquitous and undermines the benefits of effective therapy. AIM: To evaluate the influence of an educational booklet on thyroxine adherence and health in patients with primary hypothyroidism. DESIGN OF STUDY: Unblinded randomised clinical trial of individual patients (by stratified permutated blocks) to receive an 'educational booklet' or 'usual care'. SETTING: Three general practices in the north-west of England serving 497 adults with primary hypothyroidism (prevalence 1.5%). METHOD: A total of 332 adults who had been prescribed thyroxine for hypothyroidism were allocated to either a group that was posted a hypothyroid booklet addressing lay health beliefs or to a group that received usual care. Outcomes were mean within-subject change over 3 months in thyroid stimulating hormone (TSH), the SF-36 domains of vitality and general health, and a hypothyroid symptoms index. All results were concealed until the end of the trial. RESULTS: A total of 332 randomised patients were analysed by 'intention to treat' (TSH available for 330 patients). Groups were comparable at baseline, although 'undetectable TSH' was higher in the intervention than the control group (20% versus 13%). Mean change in TSH was -0.11 mIU/L (intervention) and -0.12 mIU/L (control). An absolute difference of 0.01 mIU/L (95% confidence interval [CI] -0.93 to 0.94 mIU/L). Analysis adjusted (ANCOVA) for baseline TSH produced a difference of -0.12 mIU/L (95% CI = -1.97 to 1.95). Changes in SF-36 and hypothyroid index were minimal. Trial participants were younger than non-participants and more likely to have a previous TSH in the normal range. CONCLUSION: Brief intervention with an educational booklet has no influence on thyroxine adherence or health in patients with primary hypothyroidism. These findings do not support the routine distribution of health educational materials to improve medication adherence.