By E. Fedor. Central State University. 2018.

The survey at the final site visit also included questions about education received on the guideline purchase 500mg naprosyn fast delivery arthritis pain throughout my body, ac- tions taken to implement the new practices order naprosyn 500 mg with mastercard arthritis pain in dogs medications, and how those actions affected providers and clinic staff. Documents and materials were also important sources of informa- tion for the process evaluation. These included written information about the MTF structure and management, MTF policies and proce- dures, MTF data collection and monitoring, and materials developed by the MTF implementation teams as they prepared and carried out 110 Evaluation of the Low Back Pain Practice Guideline Implementation Table A. The materials provided the primary documentation on the actions planned by the team, changes made to clinic processes, resulting events, and actions taken to monitor their progress. These measures were estimated based on episodes of treatment for acute low back pain that began with an initial clinic visit for low back pain and con- tinued through a subsequent six-week time period. According to the DoD/VA low back pain guideline, this six-week period represents acute low back pain, and pain continuing after that period is consid- ered to be chronic low back pain. For a specified quarter year (three-month period), we extracted all SADR encounter records that (a) were coded as active duty Army personnel, (b) had a code of 722 (intervertebral disc disor- ders) or 724 (other and unspecified disorders of back) in any di- agnostic code field, and (c) were treated at one of the MTFs in- cluded in the analysis. We deleted from the data set any record that was coded as no- show, canceled by facility, canceled by patient, left without being seen, or telephone consult (APPTMNT Status = 6). When two or more encounter records were found for an individ- ual during the quarter, we retained only the record with the ear- liest "start date" of service. We deleted any encounter record containing one of the following codes: • Clinic code of BCC (obstetrics), BEE (orthotics), BFD (psychiatry), or BLA (physical therapy). For records with missing specialty and provider class codes, we retained those with clinic codes of BAA, BIA, BGA, BHA, and BJA (all primary care clinics). For each candidate "initial visit" in the resulting data set, we searched for any SADR encounter records for that patient that occurred within 90 days before the date of service on the candi- date visit record and that had diagnostic codes of 722 or 724. Any candidate "initial visit" record for a patient with such an earlier encounter was deleted from the study. Building Analysis Files with Data on Low Back Pain Episodes and Patients Data on subsequent clinical encounters and pharmaceuticals for pa- tients’ low back pain episodes were extracted from the SADR, USPD, and SIDPERS source files. Data from these three sources can be merged using the patient Social Security number. The focus could be on conservative treatment during the acute care phase (first six weeks after initial low back pain visit) or the chronic care phase (up to six months after the initial visit). Although we extracted data for encounters up to six months after the initial visit, we focused on the acute care phase for this evaluation. The following records were ex- tracted for all initial patient visits: • All SADR encounter records for a six-month time period follow- ing the initial visit, regardless of the health care facility where the patient obtained care. We believe the missing data do not affect our results because all but a very small percentage of active duty personnel would obtain acute low back pain care at the MTFs where they are currently posted (this is less likely to be the case for chronic low back pain care). In addition, military rank, age, and gender were used to control for patient characteristics in modeling effects of the demonstration. An alternative variable was also defined that collapsed the offi- cer and warrant officer rank into one officer category Patient age Categories of age less than 30 years, 30 to 39 years, or 40 years or older aMedical Expense and Performance Report System for Fixed Military Medical and Dental Treatment Facilities. To be considered part of an episode of low back pain care, a follow- up outpatient MTF visit had to occur within six weeks after the initial visit and include a diagnosis code relevant to low back pain. For the physical therapy or manipulation visits and the follow-up primary care visits, all encounters with the low back pain codes of 722 or 724 were defined as relevant visits. For specialty care visits, we expanded the list of diagnosis codes to include other relevant conditions or complications associated with low back pain that might require spe- cialty care. Appendix B REPORTS FROM THE FINAL ROUND OF SITE VISITS This appendix contains the site visit reports that present findings from RAND’s second round of evaluation visits to the four Army MTFs participating in the demonstration to implement the DoD/VA practice guideline, Primary Care Management of Low Back Pain. Dur- ing each site visit, the RAND team collected information from the MTF participants about their implementation activities using indi- vidual interviews, group discussions, and focus group methods. A structured agenda was established for each site visit in collaboration with the guideline facilitator and champion. Through the site visits, we learned the successes and challenges the sites experienced during their implementation processes, and we obtained feedback from participants regarding actions to improve the systemwide implementation of the practice guideline. Since this demonstration was the first of three that were conducted by AMEDD and RAND in their partnership to field test methods for effective implementation of new evidence-based practices, the asthma and the diabetes demonstrations gained from the lessons learned from the low back pain guideline demonstration. This first demonstration allowed the incremental building of a more effective program to achieve reduction in clinical practice variation by intro- ducing consistent, evidence-based practices.

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They will discount naprosyn 250 mg with mastercard arthritis relief apple cider vinegar, it is feared order naprosyn 500 mg on-line arthritis in my back and neck, m ake judgem ents about people and their illnesses subservient to published evidence that an intervention is effective "on average". This, and other real and perceived disadvantages of guidelines, are given in Box 9. In the U K N ational H ealth Service, all doctors, nurses, pharm acists, and other health professionals now have a contractual duty to provide clinical care based on best available research evidence. W hilst the m edicolegal im plications of "official"guidelines have rarely been tested in the U K,12 U S courts have ruled that guideline developers can be held liable for faulty guidelines and that doctors cannot pass off their liability for poor clinical perform ance by claim ing that adherence to guidelines corrupted their judgem ent. An early system atic review of random ised trials and "other robust designs" by G rim shaw and Russell13 dem onstrated that, in the research setting (in which participants were probably highly selected and evaluation was an explicit part of guideline introduction), all but four of 59 published studies dem onstrated im provem ents – i. G rim shaw subsequently set up a special subgroup of the Cochrane Collaboration (see section 2. You can find details of the Effective Practice and Organisation of Care (EPOC) G roup on the Cochrane website. Both G rim shaw and Russell13 and others15, 16 found wide variation in the size of the im provem ents in perform ance achieved by clinical guidelines. The form er authors concluded that the probability of a guideline being effective depended on three factors which are sum m arised in Table 9. G rim shaw’s conclusions were initially m isinterpreted by som e people as im plying that there was no place for nationally developed guidelines since only locally developed ones had any im pact. In fact, whilst local adoption and ownership is undoubtedly crucial to the success of a guideline program m e, local team s would be foolish not to draw on the range of expensively produced resources of evidence based national and international recom m endations. For a m ore detailed discussion on the barriers to im plem enting guidelines, see Grim shaw and Russell’s com prehensive discussion of the subject,19 the review on developing17 and using20 guidelines from the BMJ’s 1999 series on guidelines, and original research by other writers. In preparing the list which follows, I have drawn on a num ber of previously published checklists and discussion docum ents. I will resist labouring the point, but a drug com pany that m akes 144 PAPERS TH AT TELL YOU W H AT TO D O horm one replacem ent therapy or a research professor whose life’s work has been spent perfecting this treatm ent m ight be tem pted to recom m end it for wider indications than the average clinician. Question 2 Are the guidelines concerned with an appropriate topic, and do they state clearly the goal of ideal treatment in terms of health and/or cost outcome? Key questions in relation to choice of topic, reproduced from an article in the BMJ,26 are given in Box 9. A guideline which says "do this" without telling the practitioner why such an action is desirable is bad psychology as well as slack science. The intended outcom e if the guideline is followed m ight be better patient survival, lower com plication rates, increased patient satisfaction or savings in direct or indirect costs (see section 10. Question 3 Was the guideline development panel headed by a leading expert in the field and was a specialist in the methods of secondary research (e. If a set of guidelines has been prepared entirely by a panel of internal "experts", you should, paradoxically, look at them particularly critically since researchers have been shown to be less objective in appraising evidence in their own field of expertise than in som eone else’s. Question 4 Have all the relevant data been scrutinised and do the guidelines’ conclusions appear to be in keeping with the data? On the m ost basic level, was the literature analysed at all or are these guidelines sim ply a statem ent of the preferred practice of a selected panel of experts (i. If the literature was looked at, was a system atic search done and if so, did it follow the m ethodology described in section 8. W ere all papers unearthed by the search included or was an explicit scoring system used to reject those of poor m ethodological quality and give those of high quality the extra weight they deserved? Of course, up to date system atic reviews should ideally be the raw m aterial for guideline developm ent. G iven that in m any clinical areas, the opinion of experts is still the best "evidence" around, guideline developers should adopt rigorous m ethods to ensure that it isn’t just the voice of the expert who talks for longest in the m eetings that drives the recom m endations. Paul Shekelle from the RAN D Corporation in the U SA has undertaken som e exciting research into m ethods for im proving the rigour of consensus recom m endations so as to ensure, for exam ple, that an appropriate m ix of experts is chosen, everyone reads the available research evidence, everyone gets an equal vote, all points of contention (raised anonym ously) are fully discussed, and the resulting recom m endations indicate the extent of agreem ent and dissent between the panel. It would be foolish to m ake dogm atic statem ents about ideal practice without reference to what actually goes on in the real world. There are m any instances where som e practitioners are 146 PAPERS TH AT TELL YOU W H AT TO D O m arching to an altogether different tune from the rest of us (see section 1.

Appropriate exercise can include regimens easily integrated into a routine day such Regular physical activity has been shown in numerous as walking naprosyn 250mg free shipping arthritis in the back and hips, climbing and descending stairs cheap 250mg naprosyn otc arthritis in feet, swimming, studies to be an extremely important preventive interven- gardening, and bicycling (mobile or stationary). Exercise promotes health and stimu- viduals unable to ambulate or transfer independently, lates a sense of well-being. Regular exer- benefits of regular exercise for older people are the fol- cise is therefore appropriate for people at any age and lowing:an increase in lean body mass and strength;a reduc- almost all stages of functional status. Of all the benefits, perhaps the most important are those gleaned from preventing age-associated functional decline and the Frailty, loss of function, and disability are common among 131–140 older individuals. Preservation of as much independence reversal of effects of adverse health episodes. Exercise, if approached properly, is safe even into as possible is a major goal in caring for older individuals, 141 especially the older old. Jogging may be one exception: in a ran- domized trial of 70- to 79-year-old men and women,injury faceted task encompassing all the preventive measures rates were 57% for those who jogged during weeks 14 to reviewed in this chapter plus very careful and thorough 26 and had walked during the first 14 weeks compared to generalized overall physical and cognitive assessment. Aerobic exercise is most helpful for for several common in-office geriatric screening instru- 143 ments. Giving permission to older patients and encouraging based recommendations for inclusion or exclusion of regular physical activity are more important than the preventive measures for the older adult population. Regular activity often to perform various preventive measures and at along with the older individual’s preference and adher- what age (chronologic or physiologic) to stop certain Table 16. Sensitivity and specificity of common screening instruments by blinded assessment (±95% CI). Likelihood Condition Description of screening test Sensitivity Specificity ratio Nutrition Ask: Have you lost 10 lb, over the past 6 months without trying to do so? Screening for common problems in ambulatory elderly: clinical confirmation of a screening instru- ment. Screening or counseling Specialist organizations High-risk elderly patients Screening for hearing impairment Y Y Y Screening for visual impairment Y Y Y American Academy of Opthamologists, African-Americans and American Optometric Association Caucasians; diabetics; family history of ocular disease Counseling on well-balanced diet/ Y Y Y Institute of Medicine, American use of BMI tables Academy of Clinical Endocrinologists Counseling on physical activity Y Y Counseling on falls/injury prevention Y I Screening for elder abuse Y* I Injured older patients Screening for IADL/ADL limitations Lachs; Moore and Siu (see references) Screening for substance abuse Y Y Substance Abuse and Mental Health Personal history of substance Administration abuse; patients with major life changes Screening for hypertension (BP) Y Y Y Y American Heart Association Screening for lipid disorders Y Y I National Cholesterol Education Program Adult Treatment Panel II, National Institutes of Health, American Heart Association Screening for oral health Y I National Cancer Institute, American Tobacco or alcohol users; Cancer Society patients with suspicious lesions Annual influenza vaccination Y Y Y Y American College of Preventive Patients with chronic Medicine, CDC Advisory Committee pulmonary, cardiovascular, on Immunization Practices or metabolic disorders; institutionalized patients Pneumococcal vaccination Y I* Y Y American College of Preventive Patients with chronic Medicine, CDC Advisory Committee pulmonary, cardiovascular, on Immunization Practices or metabolic disorders; institutionalized immunocompetent elderly patients Tetanus-diptheria vaccination Y Y Y Y CDC Advisory Committee on Immunization Practices Screening for breast cancer, ages Y Y Y Y Y American College of Preventive 50–69 (mammography) Medicine; NIH consensus conference, National Cancer Institute, American Cancer Society, American College of Radiologists, American College of Obstetricians & Gynecologists, American Geriatric Society Screening for breast cancer, ages Y Y Y Y National Cancer Institute; American 50–69 (clinical breast exam) College of Obstetricians & Gynecologists; American Cancer Society; American College of Radiology; American Society of Clinical Oncology Screening for breast cancer (breast I American College of Radiology, self-exam) American Society of Clinical Oncology Screening for cervical cancer (PAP Y* Y Y Y American College of Preventive Previous irregular tests; smear, up to age 69) Medicine; National Cancer Institute immigrants from developing nations who have never been screened Screening for colorectal cancer Y I Y Y American Cancer Society, American Familial polyposis; family (annual FOBT) Gastroenterology Association history of colorectal cancer in a first-degree relative; inflammatory bowel disease Screening for colorectal cancer Y I Y Y American Cancer Society Same as above (sigmoidoscopy) Screening for colorectal cancer I I* Y Y* American Cancer Society Same as above (colonoscopy) USPSTF, The U. Preventive Services Task Force; CTF, Canadian Task Force on the Periodic Health Examination (1997); AAFP, The American Academy of Family Physicians (2002); ACP, American College of Physicians; AMA, American Medical Association; Y, yes; N, no; I, insufficient evidence; *, screen high-risk patients. Common screening measures to consider recommending, despite lack of conclusive evidence. Specialty organizations Screening measure recommending High-risk patients Screening for cognitive I* I* Difficulties in daily activities, impairment (MMSE, SPMSQ, self-reported (or reported by or clock-drawing test) reliable informant) Screening for depression (GHQ I* N Family/personal history of or Zung self-rating scale) depression; patients with chronic illness, pain, sleep disorders, or multiple unexplained somatic complaints Screening for gait/mobility Y Over age 75; using ≥4 problems prescription medications, especially psychoactive or antihypertensive drugs Screening for diabetes mellitus I* N* N* N* American Diabetes Association Obese patients; family history of (plasma glucose measurement) disease; Native Americans, Hispanics, African Americans Screening for thyroid disease I I Y Y* American Thyroid Association, Postmenopausal women with (thyroid function tests) American Academy of Clinical vague complaints; patients Endocrinologists with possible symptoms Screening for thyroid disease N* N N* American Cancer Society Patients with history of head/ (neck palpation) neck irradiation Screening for prostate cancer N I N N American Cancer Society, American (DRE) Urologic Society, American College of Radiology Screening for prostate cancer N N N N American Cancer Society, American (PSA) Urologic Society, American College of Radiology Screening for prostate cancer N N (TRUS) Screening for skin cancer I* N* N* N N American Cancer Society, National Fair-skinned men and women (clinical skin exam) Institutes of Health, National aged >65, patients with Cancer Institute, American atypical moles, and those Academy of Dermatologists, with >50 moles American College of Preventive Medicine* Screening for ovarian cancer N N Y N* Y National Institutes of Health, Family history of ovarian cancer American Cancer Society, National Cancer Institute, American Medical Women’s Association USPSTF, The U. Preventive Services Task Force (1996); CTF, Canadian Task Force on the Periodic Health Examination (1997); AAFP, The American Academy of Family Physicians (2002); ACP, American College of Physicians; AMA, American Medical Association; CDC, Center for Disease Prevention and Control; Y, yes; N, no; I, insufficient evidence; *, screen high-risk patients. Does not recommend Screening measure Recommends Screen high-risk individuals Annual electrocardiogram I N N American College of Cardiologists/ American Heart Association, American College of Sports Medicine Screening for osteoporosis (bone I* N* National Osteoporosis Foundation, Women with history of fractures; densitometry) American Academy of Clinical loss of height with back pain; Endocrinologists* advanced age; Caucasian race; low body weight; bilateral oophorectomy before menopause; women considering estrogen prophylaxis Screening for lung cancer N N N Screening for pancreatic cancer N N N Screening for bladder cancer N* N Smokers; patients who worked in rubber or dye professions Screening for asymptomatic carotid I N N* N Patients with risk factors for cardio- disease or cerebrovascular disease Screening for peripheral artery disease N* N American Heart Association* Diabetics Screening for abdominal aortic I* I* Men over 60 who are smokers, aneurysm hypertensives, claudicants, or have family history of AAA Screening for asymptomatic bacteriuria I I Screening for iron-deficiency anemia N N N* Recent immigrants from developing nations Screening for tuberculosis N* N* N* N* Recent immigrants from developing nations; patients from underserved, low-income populations, patients with diabetes, renal failure, HIV; substance abusers; nursing home residents USPSTF, The U. Preventive Services Task Force (1996); CTF, Canadian Task Force on the Periodic Health Examination (1997); AAFP, The American Academy of Family Physicians (2002); ACP, American College of Physicians; AMA, American Medical Association; Y, yes; N, no; I, insufficient evidence; *, screen high-risk patients. In: Managing an Influenza Vaccina- As the quantity of prevention-related information in- tion Program in the Nursing Home. Atlanta: Centers for Disease Control; widespread, shared decision making between clinician 1987:3–7. Effects of ability of sites beyond the physician’s office—the Inter- influenza vaccination of health-care workers on mortality net, the workplace, senior centers, and schools, for of elderly people in long-term care: a randomised con- example—will facilitate broader access to disease pre- trolled trial. Influenza vaccination of health care workers in long-term-care hospitals reduces individuals live longer and more active lives, attention the mortality of elderly patients. Emergence demand more attention in the disease prevention/health and possible transmission of amantadine-resistant viruses promotion arena. The medical community, however, will during nursing home outbreaks of influenza A (H3N2). Efficacy of References zanamivir for chemoprophylaxis of nursing home influenza outbreaks. Drinka PJ, Gravenstein S, Schilling M, Krause P, Miller People 2000: National Health Promotion and Disease BA, Shult P.

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Pump-related complications common to nonprogrammable and pro- grammable systems include overfilling of the pump cheap naprosyn 250 mg visa arthritis in neck c6, failure of the self- sealing septum at the refill port order naprosyn 500mg visa psoriatic arthritis medication side effects, and movement of the pump in the pocket. Overfilling can result in overpressurization, with the delivery of an unpredictable amount of drug, failure of the system, or activa- tion of the reservoir valve, which in turn prevents infusion with a pro- grammable pump. Nonprogrammable pumps may show a slight de- cline in drug delivery as they approach their refill time, most likely because the pressure of gas against the bellows decreases as the Freon reaches the maximum volume it has to occupy. This behavior should be anticipated and may require a slight shortening of the refill time if the weaker dose is troublesome to the patient. Programmable pumps have an additional set of potential problems owing to the internal modules and mechanical components necessary to this type of device. Battery failure, pump rotor failure, and failure Complications 289 of the telemetry or electronic modules may occur. The battery lifetime of the pumps has been quite acceptable, generally in the 3- to 5-year range. Battery depletion requires surgical removal of the existing pump and replacement with a new pump. Pump rotor stalls may be con- firmed by taking a radiograph of the pump to show the rotor, pro- gramming a bolus dose, and repeating the radiograph 15 minutes later. Failure of the electronic or telemetry module will result in a pump that is unable to receive a change in programming. The pump will, however, continue to func- tion as a nonprogrammable pump at its last prescription infusion rate. Movement of the pump in the pocket may result in dislodgement of the catheters, extension and/or intrathecal. The pump may rotate in the pocket, resulting in a coiling of the catheter much like a fishing reel, or it may flip in the pocket, resulting in a progressive winding of the catheter. Revision of the pump and possibly the catheters may be nec- essary if catheter movement is occurring. A flipped pump is usually noticed by the patient, but it may be noted and verified in the clinic at the time of attempted refill. Revision of the pump will probably be nec- essary, often requiring anchoring the pump. In one case in the author’s clinic, an abdominoplasty was performed with good results. Infusate-Related Complications Errors involving the infusate may occur if meticulous attention is not paid to the type of system being used, the drug being used, the drug concentration being used, the dead space in the system, and the pre- scription entered with programmable systems. Some type of verification of these pa- rameters should be in place at initial filling and at each refill procedure. When more than one drug is placed into the pump, the potential errors in compound dosing require a skilled operator and careful calculation. Systems containing a side port unfortunately also have the disad- vantage of possible direct injection of an overdose volume of drug at high concentration. Medtronic has offered a solution to this problem by producing a side port with a fenestrated screen that will not admit the standard refill needle, thus preventing inadvertent overdose when standard refill technique is attempted. When the side port is used for bolus dosing or troubleshooting, care must be taken to account for whatever concentration and volume of drug exist in the catheters. Forc- ing fluid through the side port also forces whatever fluid is in the line into the intrathecal space. Proper technique would suggest aspirating the side port to clear the line before injecting. Some physicians, in- cluding the author, avoid errors of these types by not implanting pumps with side ports, believing that the advantages of troubleshoot- ing are not outweighed by the risk of overdose. Treatment of an overdose should begin by immediate removal of CSF, with replacement by preservative-free saline. An intravenous line 290 Chapter 15 Implanted Drug Delivery Systems should be placed and the patient admitted to the intensive care unit with careful monitoring for respiratory depression. Naloxone should be administered for respiratory depression, keeping in mind the pos- sibility of exacerbating the hypertension associated with massive doses of opioids. Conclusion Intraspinal drug delivery systems have made the chronic delivery of intrathecal medication a manageable and safe tool in the management of chronic pain due to cancer, as well as other causes. Careful atten- tion to patient selection, screening, drug selection, implantation tech- nique, and refill technique will assure that this modality will be an im- portant adjunct to any pain management clinic.

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