Arild Bjørndal

Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention

Background A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease. Methods and Findings We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49–2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals. Conclusions Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.

The potential for research-based information in public health: Identifying unrecognised information needs

ObjectiveTo explore whether there is a potential for greater use of research-based information in public health practice in a local setting. Secondly, if research-based information is relevant, to explore the extent to which this generates questioning behaviour.DesignQualitative study using focus group discussions, observation and interviews.SettingPublic health practices in Norway.Participants52 public health practitioners.ResultsIn general, the public health practitioners had a positive attitude towards research-based information, but believed that they had few cases requiring this type of information. They did say, however, that there might be a potential for greater use. During five focus groups and six observation days we identified 28 questions/cases where it would have been appropriate to seek out research evidence according to our definition. Three of the public health practitioners identified three of these 28 cases as questions for which research-based information could have been relevant. This gap is interpreted as representing unrecognised information needs.ConclusionsThere is an unrealised potential in public health practice for more frequent and extensive use of research-based information. The practitioners did not appear to reflect on the need for scientific information when faced with new cases and few questions of this type were generated.

A framework for mandatory impact evaluation to ensure well informed public policy decisions

Trillions of dollars are invested yearly in programmes to improve health, social welfare, education, and justice (which we will refer to generally as public programmes). Yet we know little about the eff ects of most of these attempts to improve peoples’ lives, and what we do know is often not used to inform decisions. We propose that governments and non-governmental organisations (NGOs) address this failure responsibly by mandating more systematic and transparent use of research evidence to assess the likely eff ects of public programmes before they are launched, and the better use of well designed impact evaluations after they are launched. Resources for public programmes will always be scarce. In low-income and middle-income countries, where there are often particularly severe constraints on resources and many competing priorities, available resources have to be used as effi ciently as possible to address important challenges and goals, such as the Millennium Development Goals. Use of research evidence to inform decisions is crucial. As suggested by Hassan Mshinda, the Director-General of the Commission for Science and Technology in Tanzania: “If you are poor, actually you need more evidence before you invest, rather than if you are rich.” But neither the problem nor the need for solutions is limited either to health or countries of low and middle income. Expenditures and the potential for waste are greatest in high-income countries, which also have restricted resources and unmet needs, particularly during a fi nancial crisis. Having good evidence to inform diffi cult decisions can be politically attractive, as shown, for example, by the US Government’s decision to include US

Comparison of directed and self‐directed learning in evidence‐based medicine: a randomised controlled trial

1·1 billion for comparative research (including systematic reviews and clinical trials) as part of its

Screening for toxoplasmosis in pregnancy: what is the evidence of reducing a health problem?

787 billion economic stimulus bill. To paraphrase Billy Beane, Newt Gingrich, and John Kerry, who have argued for a health-care system that is driven by robust comparative clinical evidence by substituting policy makers for doctors: “Evidence-based health care would not strip [policymakers] of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that [policymakers] can deliver the best quality care at the lowest possible cost.” Lancet 2010; 375: 427–31

Prevalence of known and previously unknown diabetes mellitus and impaired glucose tolerance in an adult Norwegian population. Indications of an increasing diabetes prevalence. the Nord-Trøndelag diabetes study

Objectives  To compare 2 educational pro‐ grammes for teaching evidence‐based medicine (EBM).

Detecting hypertension: screening versus case finding in Norway.

Objectives— Toxoplasma gondii is a parasite which may give rise to congenital infection. Screening pregnant women for antibodies against toxoplasmosis is being debated in many countries. The preventive impact of toxoplasmosis screening of pregnant women depends on the magnitude of disease caused by congenital toxoplasmosis (incidence x transmission rate to fetus x diseased proportion of infected children), on the one hand, and the preventable proportion of disease (sensitivity of the screening test x efficacy of the treatment x compliance), on the other. In this study the preventive impact of screening pregnant women for toxoplasmosis antibodies is assessed by letting the value for these variables change within reasonable limits. Methods— To obtain information on these variables, relevant publications were reviewed in the Medline database from 1983 to February 1996 and the Cochrane Pregnancy and Childbirth Database. References in review articles on congenital toxoplasmosis were also studied. Results— The literature review showed that no population based prospective studies of the natural history of toxoplasmosis infection during pregnancy, nor any randomised controlled trials of the efficacy of antiparasitic treatment, had been carried out. In the empirical studies which have been performed the values of most variables show considerable differences. According to these values, the estimates in this study of the impact of toxoplasmosis screening in pregnancy may range from 0 to 40 children in whom disease is preventable per 100 000 pregnant women susceptible to toxoplasmosis infection. Conclusion— Sufficient scientific evidence is not yet available to propose screening for toxoplasmosis in pregnant women, and efforts should be made to provide such knowledge. Also, the magnitude of the negative impact of screening, such as induced abortion of healthy fetuses, anxiety in women with false positive screening tests, and side effects of treatment, has not been sufficiently examined.

Does Personality Moderate the Effects of Mindfulness Training for Medical and Psychology Students

OBJECTIVE To establish the prevalence of known and undiagnosed diabetes mellitus and impaired glucose tolerance in a representative Norwegian adult population according to the 1980 World Health Organization Expert Committee diagnostic criteria. DESIGN Screening survey applying questionnaire and non-fasting blood glucose followed by a fasting and an oral glucose tolerance test. SETTING The county of Nord-Trøndelag, Norway, 1984-86. SUBJECTS All inhabitants aged > or = 20 years (85,100); 90.3% participated. For previously unknown diabetes: all inhabitants > or = 40 years (53,001)--participation rate 84.7%. MAIN OUTCOME MEASURE Prevalence. RESULTS The prevalence of previously known diabetes was 2.6% in men and 3.2% in women. Total diabetes prevalence > or = 40 years was 4.8% in men and 5.6% in women. The prevalence increased continuously with age until 90 years. One patient in five was previously undiagnosed. Impaired glucose tolerance in those with an abnormal non-fasting value was rare; only 0.9% in men and 0.2% in women. The prevalence of known diabetes was three times higher than 20-30 years ago and four times higher than 50 years ago. Except for known diabetes in the very old the prevalence corresponded well with recent Nordic studies. IMPLICATIONS The present diabetes prevalence was so high that interested general practitioners will get sufficient experience in follow-up of diabetic patients to facilitate a good quality of the care.

Identifying barriers to the use of research faced by public health physicians in Norway and developing an intervention to reduce them

OBJECTIVE--Evaluation of detection of hypertension in adults in the county of Nord-Trøndelag, Norway. DESIGN--Cross sectional survey with clinical follow up examinations. SETTING--Health survey by screening teams from the national health screening service, and examinations by all 106 general practitioners in the county. SUBJECTS--During 1984-6, 74,977 persons (88.1% of those aged 20 years and over) participated in the health survey. MAIN OUTCOME MEASURES--Hypertension (when assessed by standardised recording and by questionnaires on drug treatment for hypertension) according to the blood pressure thresholds used in the Norwegian treatment programme. Subjects positive on screening were grouped after clinical examination into treatment groups. RESULTS--In all, 2399 subjects were positive for hypertension. Before screening 6210 (8.3%) patients reported taking antihypertensive drugs and another 3849 (5.1%) had their blood pressure monitored regularly. All who screened positive were referred to their general practitioner and evaluated according to a standard programme. As a result, drug treatment was started in 406 (0.5%) participants screened and blood pressure monitoring in another 1007 (1.3%). Of all patients taking antihypertensive drugs after the screening, 6399 (94.0%) had been diagnosed before screening, and of those whose blood pressure was monitored after the screening, 79.3% had been diagnosed before screening. CONCLUSIONS--At the blood pressure screening thresholds used, and when hypertension is defined by an overall clinical diagnosis, the results indicate that general practitioners can find and diagnose hypertensive patients with the case finding strategy.

Many a slip between cup and lip. Process evaluation of a program to promote and support evidence-based public health practice.

The majority of mindfulness research to date has reported only on the group-level effects of interventions. Therefore, there is a need to better understand who is most likely to benefit from mindfulness interventions. This study reports on moderation analyses from a two-centre randomised controlled trial of mindfulness-based stress reduction (MBSR) among 288 medical and psychology students. The study investigated whether baseline personality factors (neuroticism, conscientiousness and extroversion) and baseline mindfulness moderated effects on mental distress, study stress and subjective well-being measured after the intervention. An increased effect of the intervention on mental distress and subjective well-being was found in students with higher scores on neuroticism. Students with higher scores on conscientiousness showed an increased effect of mindfulness training on study stress. The training protected students against an increase in mental distress and study stress and a decrease in subjective well-being that was seen in the control group. Baseline mindfulness and extroversion did not moderate the effects of the intervention on the outcomes. The majority of the 288 medical and psychology students in the study sample were female. Female participants scored significantly higher on neuroticism and conscientiousness, and they may therefore be an important target group for mindfulness interventions among students.