Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model.

BACKGROUND: The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation. OBJECTIVE(S): To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change. METHODS: An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed. RESULTS: Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change. CONCLUSIONS: Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

Preventive Services by Medical and Dental Providers and Treatment Outcomes.

OBJECTIVE: Nearly all state Medicaid programs reimburse nondental primary care providers (PCPs) for providing preventive oral health services to young children; yet, little is known about how treatment outcomes compare with children visiting dentists. This study compared the association between the provider of preventive services (PCP, dentist, or both) with Medicaid-enrolled children before their third birthday and subsequent dental caries-related treatment (CRT) and CRT payment. METHODS: We conducted a retrospective study of young children enrolled in North Carolina Medicaid during 2000 to 2006. The annual number of CRT and CRT payments per child between the ages of 3 and 5 yr were estimated with a zero-inflated negative binomial regression and a hurdle model, respectively. Models were adjusted for relevant child- and county-level characteristics and used propensity score weighting to address observed confounding. RESULTS: We examined 41,453 children with > 1 preventive oral health visit from a PCP, dentist, or both before their third birthday. Unadjusted annual mean CRT and payments were lowest among children who had only PCP visits (CRT = 0.87, payment = $172) and higher among children with only dentist visits (CRT = 1.48, payment = $234) and both PCP and dentist visits (CRT = 1.52, payment = $273). Adjusted results indicated that children who had dentist visits (with or without PCP visits) had significantly more CRT and higher CRT payments per year during the ages of 3 and 4 yr than children who had only PCP visits. However, these differences attenuated each year after age 3 yr. CONCLUSIONS: Because of children's increased opportunity to receive multiple visits in medical offices during well-child visits, preventive oral health services provided by PCPs may lead to a greater reduction in CRT than dentist visits alone. This study supports guidelines and reimbursement policies that allow preventive dental visits based on individual needs.

Three-Dimensional Dosimetry of a Beta-Emitting Radionuclide Using PRESAGE Dosimeters.

Three-dimensional dose distributions from liquid brachytherapy were measured using PRESAGE(®) dosimeters. The dosimeters were exposed to Y-90 for 5.75 days and read by optical tomography. The distributions are consistent with estimates from beta dose kernels.

A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care.

OBJECTIVE: To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: All 26 hospital gynaecology units in Scotland providing induced abortion care. INTERVENTION: Following the identification of barriers to guideline implementation, intervention units received a package comprising audit and feedback, unit educational meetings, dissemination of structured case records and promotion of a patient information booklet. Control units received printed guideline summaries alone. MAIN OUTCOME MEASURES: Compliance with five key guideline recommendations (primary outcomes) and compliance with other recommendations, patient satisfaction and costs of the implementation strategy (secondary outcomes). RESULTS: No effect was observed for any key recommendation: appointment with a gynaecologist within five days of referral (odds ratio 0.89; 95% confidence interval 0.50 to 1.58); ascertainment of cervical cytology history (0.93; 0.36 to 2.40); antibiotic prophylaxis or screening for lower genital tract infection (1.70; 0.71 to 5.99); use of misoprostol as an alternative to gemeprost (1.00; 0.27 to 1.77); and offer of contraceptive supplies at discharge (1.11; 0.48 to 2.53). Median pre-intervention compliance was near optimal for antibiotic prophylaxis and misoprostol use. No intervention benefit was observed for any secondary outcome. The intervention costs an average of pound 2607 per gynaecology unit. CONCLUSIONS: The tailored multifaceted strategy was ineffective. This was possibly attributable to high pre-intervention compliance and the limited impact of the strategy on factors outside the perceived control of clinical staff.

Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement.

OBJECTIVES: To undertake a systematic review of the long-term effects of obesity treatments on body weight, risk factors for disease, and disease. METHODS: The study encompassed three systematic reviews that examined different aspects of obesity treatments. (1) A systematic review of obesity treatments in adults where the methods of the Cochrane Collaboration were applied and randomised controlled trials (RCTs) with a follow-up of at least 1 year were evaluated. (2) A systematic epidemiological review, where studies were sought on long-term effects of weight loss on morbidity and/or mortality, and examined through epidemiological modelling. (3) A systematic economic review that sought reports with both costs and outcomes of treatment, including recent reports that assessed the cost-effectiveness of pharmaceutical and surgical interventions. A Markov model was also adopted to examine the cost-effectiveness of a low-fat diet and exercise intervention in adults with obesity and impaired glucose tolerance. RESULTS: The addition of the drugs orlistat or sibutramine was associated with weight loss and generally improved risk factors, apart from diastolic blood pressure for sibutramine. Metformin was associated with decreased mortality after 10 years in obese people with type 2 diabetes. Low-fat diets were associated with continuing weight loss for 3 years and improvements in risk factors, as well as prevention of type 2 diabetes and improved control of hypertension. Insufficient evidence was available to demonstrate the benefits of low calorie or very low calorie diets. The addition of an exercise or behaviour programme to diet was associated with improved weight loss and risk factors for at least 1 year. Studies combining low-fat diets, exercise and behaviour therapy suggested improved hypertension and cardiovascular disease. Family therapy was associated with improved weight loss for 2 years compared to individual therapy. There was insufficient evidence to conclude that individual therapy was more beneficial than group therapy. Weight lost more quickly (within 1 year), from the epidemiology review, may be more beneficial with respect to the risk of mortality. The effects of intentional weight loss need further investigation. Weight loss from surgical and non-surgical interventions for people suffering from obesity was associated with decreased risk of development of diabetes, and a reduction in low-density lipoprotein cholesterol, total cholesterol and blood pressure, in the long term. Targeting high-risk individuals with drugs or surgery was likely to result in a cost per additional life-year or quality-adjusted life-year (QALY) of no more than 13,000 British pounds. There was also suggestive evidence of cost saving from treatment of people with type 2 diabetes with metformin. Targeting surgery on people with severe obesity and impaired glucose tolerance was likely to be more cost-effective at 2329 British pounds per additional life-year. Economic modelling over 6 years for diet and exercise for people with impaired glucose tolerance was associated with a high initial cost per additional QALY, but by the sixth year the cost per QALY was 13,389 British pounds. Results did not include cost savings from diseases other than diabetes, and therefore may be conservative. CONCLUSIONS: The drugs orlistat and sibutramine appear beneficial for the treatment of adults with obesity, and metformin for obese patients with type 2 diabetes. Exercise and/or behaviour therapy appear to improve weight loss when added to diet. Low-fat diets with exercise, or with exercise and behaviour therapy are associated with the prevention of type 2 diabetes and hypertension. Long-term weight loss in epidemiological studies was associated with reduced risk of type 2 diabetes, and may be beneficial for cardiovascular disease. Low-fat diets and exercise interventions in individuals at risk of obesity-related illness are of comparable cost to drug treatments. Long-term pragmatic RCTs of obesity treatments in populations with obesity-related illness or at high risk of developing such illness are needed (to include an evaluation of risk factors, morbidity, quality of life and economic evaluations). Drug trials that include dietary advice, plus exercise and/or behaviour therapy are also needed. Research exploring effective types of exercise, diet or behaviour and also interventions to prevent obesity in adults is required.

Systematic review of the clinical effectiveness and cost-effectiveness of tension-free vaginal tape for treatment of urinary stress incontinence.

OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of tension-free vaginal tape (TVT) in comparison with the standard surgical interventions currently used. DATA SOURCES: Literature searches were carried out on electronic databases and websites for data covering the period 1966--2002. Other sources included references lists of relevant articles; selected experts in the field; abstracts of a limited number of conference proceedings titles; and the Internet. REVIEW METHODS: A systematic review of studies including comparisons of TVT with any of the comparators was conducted. Alternative treatments considered were abdominal retropubic colposuspension (including both open and laparoscopic colposuspension), traditional suburethral sling procedures and injectable agents (periurethral bulking agents). The identified studies were critically appraised and their results summarised. A Markov model comparing TVT with the comparators was developed using the results of the review of effectiveness and data on resource use and costs from previously conducted studies. The Markov model was used to estimate costs and quality-adjusted life-years for up to 10 years following surgery and it incorporated a probabilistic analysis and also sensitivity analysis around key assumptions of the model. RESULTS: Based on limited data from direct comparisons with TVT and from systematic reviews, laparoscopic colposuspension and traditional slings have broadly similar cure rates to TVT and open colposuspension, whereas injectable agents appear to have lower cure rates. TVT is less invasive than colposuspension and traditional sling procedures, and is also usually performed under regional or local anaesthesia. The principal operative complication is bladder perforation. There are currently no randomised controlled trial (RCT) data beyond 2 years post-surgery, and long-term effects are therefore currently not known reliably. TVT was more likely to be considered cost-effective compared with the other surgical procedures. Increasing the absolute probability of cure following TVT reduced the likelihood that TVT would be considered cost-effective. CONCLUSIONS: The long-term performance of TVT in terms of both continence and unanticipated adverse effects is not known reliably at the moment. Despite relatively few robust comparative data, it appears that in the short to medium term TVT's effectiveness approaches that of alternative procedures currently available, and is of lower cost. As TVT is a less invasive procedure, it is possible that some women who would currently be managed non-surgically will be considered eligible for TVT. Increased adoption of TVT will require additional surgeons proficient in the technique. It is likely that some of the higher rates of complications, e.g. bladder perforation, reported for TVT are associated with a 'learning curve'. Appropriate training will therefore be needed for surgeons new to the operation, in respect of both the technical aspects of the procedure and the choice of women suitable for the operation. Further research suggestions include unbiased assessments of longer term performance from follow-up of controlled trials or population-based registries; more data from methodologically sound RCTs using standard outcome measures; a surveillance system to detect longer term complications, if any, associated with the use of tape; and rigorous evaluation before extending the use of TVT to women who are currently managed non-surgically.

Metal on metal hip resurfacing arthroplasty. An economic analysis.

This paper explores the cost utility of metal-on-metal hip resurfacing arthroplasty (MOM) as an alternative intervention to total hip replacement or 'watchful waiting' for patients with advanced hip disease. Early implant failure among younger and more active elderly patients can mean that the use of total hip replacement (THR) is delayed, with patients managed through 'watchful waiting', a combination of pain control and other non-surgical interventions. Information on costs is combined with evidence on effectiveness from a systematic review in a Markov model in order to estimate the incremental cost per quality adjusted life year (QALY) of MOM relative to THR and 'watchful waiting'.

Treatment outcomes and costs of dental sealants among children enrolled in Medicaid.

OBJECTIVES: This retrospective cohort analysis of children enrolled in the North Carolina Medicaid program compared the likelihood of restorative treatments and associated cumulative Medicaid expenditures for teeth with or without dental sealants. METHODS: We assessed the dental experience of the cohort of 15 438 children from 1985 to 1992 on the basis of enrollment and claims files. We conducted regression analyses for outcomes (caries-related services involving the occlusal surface [CRSOs] of permanent first molars) and cumulative expenditures, controlling for characteristics of the child, the treating dentist, and the child's county of residence. RESULTS: Overall, 23% of children received at least 1 sealant and 33% at least 1 CRSO. Sealants were effective in preventing CRSOs, although the degree of effectiveness was highest for children with the greater levels of CRSOs before sealant placement. Estimated cumulative Medicaid expenditures indicated expenditure savings from sealants within 2 years of application for children with 2 or more prior CRSOs. CONCLUSIONS: Sealant placement was associated with expenditure savings to Medicaid for certain high-risk children, so Medicaid and, more broadly, society will benefit by providing for sealant placement in these children.

Decline in offspring viability as a manifestation of aging in Drosophila melianogaster.

The evolutionary explanation of senescence proposes that selection against alleles with deleterious effects manifested only late in life is weak because most individuals die earlier for extrinsic reasons. This argument also applies to alleles whose deleterious effects are nongenetically transmitted from mother to progeny, that is, that affect the performance of progeny produced at late ages rather than of the aging individuals themselves. We studied the effect of maternal age on offspring viability (egg hatching success and larva-to-adult survival) in two sets of Drosophila melanogaster lines (HAM/LAM and YOUNG/OLD), originating from two long-term selection experiments. In each set, some lines (HAM and YOUNG, respectively) have been selected for early reproduction, whereas later reproduction was favored in their counterparts (LAM and OLD). In the HAM and LAM lines, both egg hatching success and larval viability declined with mother's age and did so with accelerating rates. The hatching success declined significantly faster with maternal age in HAM than in LAM lines, according to one of two statistical approaches used. Egg hatching success also declined with maternal age in YOUNG and OLD lines, with no difference between the selection regimes. However, the relationship between mother's age and offspring larva-to-adult viability differed significantly between these two selection regimes: a decline of larval viability with maternal age occurred in YOUNG lines but not in OLD lines. This suggests that the rate with which offspring viability declines with mother's age responded to selection for early versus late reproduction. We suggest broadening the evolutionary concept of senescence to include intrinsically caused declines in offspring quality with maternal age.

Determination of percent composition of a mixture analyzed by gas chromatography. Comparison of a helium pulsed-discharge photoionization detector with a flame ionization detector.

We present the results of a study of percent composition for a mixture which has been separated by gas chromatography and analyzed using helium pulsed-discharge photoionization detection (He-PDPID) and flame ionization detection (FID). FID has long been the means by which the percent composition of a hydrocarbon mixture has been determined since it has been previously established as a "carbon counting device". However, in this study we present results which show that He-PDPID is more accurate in determining the percent composition of a hydrocarbon mixture and, because it is a universal detection method and can detect compounds that FID cannot, it is also more effective for determining the percent composition of mixtures containing organic compounds with a variety of other functional groups.

Characterization of formaldehyde by gas chromatography using multiple pulsed-discharge photoionization detectors and a flame ionization detector.

Formaldehyde, water, methanol, butanal, and butanone are characterized by gas chromatography using three pulsed-discharge photoionization detectors (PDPIDs) and a flame ionization detector (FID). One of the PDPIDs is operated in helium mode, and the other two are operated in argon and krypton modes. The FID is included for comparison. The PDPIDs are used to efficiently differentiate between and quantitatively identify formaldehyde and the other three compounds in a sample mixture. This is accomplished by using butanone as the internal standard and correlating the relative responses of the four organic compounds in the helium-, argon-, and krypton-mode PDPIDs with their relative retention times.

PMS and PMDD in the domain of mental health nursing.

Premenstrual syndrome (PMS) is a complex cluster of symptoms that occurs 7 to 14 days prior to menses and ends 1 to 2 days after menses. Premenstrual syndrome symptoms can create severe, debilitating psychological and physical problems. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) provides criteria for premenstrual dysphoric disorder (PMDD), which can be considered the most severe presentation on the PMS continuum. A critical part of determining the diagnosis is evaluating the timing of symptoms. True PMS only occurs during the luteal phase of the menstrual cycle, with a symptom-free period during the follicular phase. After identifying a diagnosis of PMS or PMDD, the first-line treatment of these symptom clusters continues to be lifestyle changes, including stress management, healthy diet, regular aerobic exercise, cognitive-behavioral therapy, and fortified coping strategies. Women whose symptoms are not controlled adequately with lifestyle modifications may benefit from medications. Possible medication recommendations include selective serotonin re-uptake inhibitors (SSRIs), diuretics, gonadotropin-releasing hormone (GnRH) agonists, and vitamin and mineral supplements.

Evolution in health and disease: work in progress.

This article surveys progress in Darwinian medicine since 1991. Evolutionary thinking has been providing an increasing flow of fresh ideas into medical science, ideas that would not be suggested by other perspectives. Recent contributions have shed new light on the evolution of virulence, of antibiotic resistance, of oocytic atresia, of menopause, of the timing of the expression of genetic disease, of links between mate choice and disease resistance, and of genomic conflict between mother and fetus over resource provisioning. An important consequence of changes from the environment of evolutionary adaptedness concerns reproductive cancers; the incidence of reproductive cancers may be linked to changes in the frequency of menstruation in postindustrial societies. Other intriguing developments include some unanticipated and undesirable consequences of good hygiene, hope from an unexpected quarter for progress on nerve and muscle regeneration, evolutionary interpretations of mental disease, and insights from functional genomics into the nature of tradeoffs. The application of evolutionary thinking to problems in medical research and practice has thus yielded an abundant and growing harvest of insights. Some are well founded, others remain speculative. The field is moving from an initial phase dominated by speculation and hypothesis formation into a more rigorous phase of experimental testing of explicit alternatives. Currently the most promising areas, those in which experimental rigor can be applied efficiently, include experimental evolution and functional genomics. The pioneers can be proud of what they have set in motion.

Access to palliative care and hospice in nursing homes.

Nursing homes are the site of death for many elderly patients with incurable chronic illness, yet dying nursing home residents have limited access to palliative care and hospice. The probability that a nursing home will be the site of death increased from 18.7% in 1986 to 20.0% by 1993. Dying residents experience high rates of untreated pain and other symptoms. They and their family members are isolated from social and spiritual support. Hospice improves end-of-life care for dying nursing home residents by improving pain control, reducing hospitalization, and reducing use of tube feeding, but it is rarely used. For example, in 1997 only 13% of hospice enrollees were in nursing homes while 87% were in private homes, and 70% of nursing homes had no hospice patients. Hospice use varies by region, and rates of use are associated with nursing home administrators' attitudes toward hospice and contractual obligations. Current health policy discourages use of palliative care and hospice for dying nursing home residents. Quality standards and reimbursement rules provide incentives for restorative care and technologically intensive treatments rather than labor-intensive palliative care. Reimbursement incentives, contractual requirements, and concerns about health care fraud also limit its use. Changes in health policy, quality standards, and reimbursement incentives are essential to improve access to palliative care and hospice for dying nursing home residents. JAMA. 2000;284:2489-2494.