Barriers and facilitators to use of a clinical evidence technology in the management of skin problems in primary care: insights from mixed methods.

OBJECTIVE: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider's perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial. METHODS: Using a convergent mixed methods design, the authors had PCPs complete a post-trial survey and participate in interviews about using the CET for managing patients' skin problems. Data from both methods were integrated. RESULTS: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact. CONCLUSION: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management.

Effect of a clinical evidence technology on patient skin disease outcomes in primary care: a cluster-randomized controlled trial.

OBJECTIVE: Providers' use of clinical evidence technologies (CETs) improves their diagnosis and treatment decisions. Despite these benefits, few studies have evaluated the impact of CETs on patient outcomes. The investigators evaluated the effect of one CET, VisualDx, on skin problem outcomes in primary care. METHODS: A cluster-randomized controlled pragmatic trial was conducted in outpatient clinics at an academic medical center in the northeastern United States. Participants were primary care providers (PCPs) and their adult patients seen for skin problems. The intervention was VisualDx, as used by PCPs. Outcomes were patient-reported time from index clinic visit to problem resolution, and the number of follow-up visits to any provider for the same problem. PCPs who were randomly assigned to the intervention agreed to use VisualDx as their primary evidence source for skin problems. Control group PCPs agreed not to use VisualDx. Investigators collected outcome data from patients by phone at thirty-day intervals. Cox proportional hazards models assessed time to resolution. Wilcoxon-rank sum tests and logistic regression compared the need for return appointments. RESULTS: Thirty-two PCPs and 433 patients participated. In proportional hazards modelling adjusted for provider clusters, the time from index visit to skin problem resolution was similar in both groups (hazard ratio=0.92; 95% confidence interval [CI]=0.70, 1.21; p=0.54). Patient follow-up appointments did not differ significantly between groups (odds ratio=1.26; CI=0.94, 1.70; p=0.29). CONCLUSION: This pragmatic trial tested the effectiveness of VisualDx on patient-reported skin disease outcomes in a generalizable clinical setting. There was no difference in skin problem resolution or number of follow-up visits when PCPs used VisualDx.

Factors contributing to suboptimal rates of childhood vaccinations in Vermont.

Childhood immunizations are invaluable in preventing contagious diseases. Nonetheless, vaccines have become increasingly controversial with growing numbers of caregivers refusing to vaccinate their children. The percentage of fully vaccinated children in Vermont is one of the lowest nationally. This study set out to determine Vermont caregivers' attitudes toward immunizations to better explain why the percentage of fully vaccinated children has fallen in Vermont. A survey regarding caregivers' health care knowledge about children, their vaccination concerns, and their children's vaccination status was sent to participants in the Vermont Women, Infants and Children's Program from two districts. In total, 83% (n = 379) of respondents reported their children received all recommended vaccinations for their age. Respondents who considered themselves highly knowledgeable regarding their children's health care and confident about the safety of vaccinations were significantly associated with reporting their children as being current on vaccinations and with their intent to continue vaccinations. Respondents indicated highest concern regarding the safety and number of vaccinations administered during one visit. Primary care providers were indicated as important resources for addressing concerns about vaccinations and health care knowledge of children. The results help to understand low vaccination rates in Vermont and can be used for targeting health campaigns to improve vaccination rates.

Soil incorporation of logging residue affects fine-root and mycorrhizal root-tip dynamics of young loblolly pine clones.

Loblolly pine (Pinus taeda L.) plantations cover a large geographic area of the southeastern USA and supply a large proportion of the nation's wood products. Research on management strategies designed to maximize wood production while also optimizing nutrient use efficiency and soil C sequestration is needed. We used minirhizotrons to quantify the effects of incorporating logging residues into soil on fine-root standing crop, production and mortality, and mycorrhizal root tips in young loblolly pine clones of contrasting ideotypes. Clone 93 is known to allocate more C to stem growth, while clone 32 allocates less C to stems and more to leaves. The relative allocation by these clones to support fine-root turnover is unknown. Clone 32 exhibited 37% more fine-root mortality than clone 93, which was mainly the result of a greater standing crop of fine roots. Fine-root standing crop in plots amended with logging residue was initially higher than control plots, but 2.5 years after planting, standing crop in control plots had exceeded that in mulched plots. Production of mycorrhizal root tips, on the other hand, was initially higher in control than mulched plots, but during the last 9 months of the study, mycorrhizal tip production was greater in mulched than control plots, especially for clone 93. As expected, turnover rate of fine roots was greater in surface soil (0-25 cm) compared with deeper (25-50 cm) soil and for small roots (< 0.4 mm diameter) compared with larger fine roots (0.4-2.0 mm diameter). Rates of fine-root turnover were similar in both clones. Organic matter additions reduced survivorship of individual roots and increased turnover rates of fine-root populations. Results indicate that management decisions should be tailored to fit the growth and allocation patterns of available clones.

Implementing the information prescription protocol in a family medicine practice: a case study.

QUESTION: Can an information prescription protocol be successfully integrated into a family medicine practice seeking to enhance patient education and self-management? SETTING: Milton Family Practice, an outpatient clinic and resident teaching site of the University of Vermont and Fletcher Allen Health Care, is located in a semirural area fifteen miles from main campus. OBJECTIVES: The objectives were to increase physicians' knowledge and use of information prescriptions, sustain integration of information prescription use, and increase physicians' ability to provide patient education information. METHODS: Methods used were promotion of the National Library of Medicine's Information Rx, physician instruction, installation of patient and provider workstations, and a collaborative approach to practice integration. MAIN RESULTS: A post-intervention survey showed increased physician knowledge and use of the Information Rx protocol. Support procedures were integrated at the practice. CONCLUSIONS: Sustainable integration of Information Rx in a primary care clinic requires not only promotion and education, but also attention to clinic organization and procedures.