Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes.

BACKGROUND: Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. OBJECTIVES: 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. SELECTION CRITERIA: We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. DATA COLLECTION AND ANALYSIS: Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. AUTHORS' CONCLUSIONS: Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

[Teaching medical students about domestic violence and sexual abuse: teachers' perception of barriers and facilitators]. / Docencia en violencia y abuso sexual en estudiantes de pregrado de medicina: percepción de los docentes sobre barreras y facilitadores.

BACKGROUND: Considering the frequency of sexual abuse and domestic violence (SA-DV) in the population, the likelihood of a medical student meeting patients with this problem is substantial. However, most students do not consider SA-DV in their differential diagnoses. Since 2014, this team has been working in strengthening undergraduate curriculum in SA-DV. It has been a challenging and slow process. PURPOSE: To identify barriers and facilitators perceived by the undergraduate teaching team in order to suggest modifications in the curriculum in relation to the competencies required for screening and early intervention for victims of SA-DV. The conclusions obtained may be useful for other medical schools and universities facing this challenge. METHODS: Qualitative study using grounded theory method for the analysis of interviews and focus groups. RESULTS: SA-DV are perceived as a problem that is pertinent for physicians. However, there is a common belief that teaching about SA-DV should be limited to only certain specific specialties. The main barriers are the limited curricular time, the need to prioritize contents and the lack of specific training of the teachers. A key facilitator is the fact that gender violence is on the public agenda today. CONCLUSIONS: The identified barriers coincide with those reported in the literature; limited curricular time and prioritization of contents. Although this study does not show the perception of SA-DV as 'not a medical issue' nor as a subject that pertains to other health professionals, there is the perception that teaching clinical approach to SA-DV only pertains to specialists who are directly involved in this topic.

[Early child development inequalities and associated factors between public and private providers at metropolitan region in Chile]. / Desigualdades en desarrollo infantil temprano entre prestadores públicos y privados de salud y factores asociados en la Región Metropolitana de Chile.

Early child development is a population determinant of physical, mental and social health. To know the base line situation prior to the implementation of "Chile grows with you" (Chile Crece Contigo) is key to its evaluation. OBJECTIVE: To compare early child development and associated factors at baseline in pre-school children from public and private health sectors. PATIENTS AND METHOD: The sample consisted of 1045 children aged 30-58 months, 52% male, and 671 from the public and 380 from the private sector of the metropolitan region in Chile were evaluated using Battelle Developmental Inventory-1 and a household interview of primary carer. RESULTS: Abnormal child development was found in 14.4% of children in the private sector compared to 30.4% in the public sector. There were no differences in adaptive area (26.3% vs 29.2%), but there were statistically significant differents in cognitive (8.8% vs 12.1%), social-personal (13.2% vs 32.5%), motor (19.2% vs 35.3%), and communication (19% vs 36.8%) development. The logistic regression showed that, independent of socioeconomic level, the risk factors are: Apgar<7 (OR: 5.4; 95% CI: 1.24-23.84); having childhood chronic diseases (OR: 1.3; 95% CI: 1.11-1.42). Protective factor is: home with resources to learn and play (OR: 0.8; 95% CI: 0.76-0.89). CONCLUSION: These results are another input about early child development situation and its importance for paediatric social policy.

Screening for postpartum depression in a private health care network in Chile.

BACKGROUND: It has been demonstrated that postpartum depression (PPD) has an impact on infant development with repercussions in the child's cognitive, socioemotional and conduct regulation. Screening for this disorder with the Edinburgh Postnatal Depression Scale (EPDS) has been recommended because this significantly identifies more cases of PPD than usual clinical evaluation. AIM: To evaluate the use of the EPDS to screen mothers attending well child care visits with their infants during the first 6 months of age and identifying the factors associated with its use in the largest private health care network in Chile. METHODS: Cross-sectional study, conducted by random sampling of the children's medical charts from a universe of 5700 infants aged 1-6 months that attended the health care network during 2009 and 2011. Estimated sample size: 500 medical charts, assuming a recording frequency of the EPDS of 5% (confidence level of 95% and power of 80%). The descriptive data analysis of the variables was carried out using a uni and multivariate analysis. All values of P < 0.05 were considered significant (Software SPSS 17.0). RESULTS: A total of 1940 visits, belonging to 503 medical charts of infants under 6 months of age were reviewed. The use of the EPDS to screen mothers was recorded in nine medical charts (1.7% of the infant population). The only variable that was significantly associated with the recording of the EPDS was the background of previous depression in the mother (P < 0.001). CONCLUSION: The record of the use of EPDS on mothers of infants seen in the private health care network is much less than what is recommended.

[Clinical practice guidelines in the Chilean health sector reform: a critical assessment of their quality]. / Guías de Práctica Clínica en el Régimen de Garantías en Salud: una evaluación crítica de su calidad.

BACKGROUND: Clinical practice guidelines are widely used as tools for improving quality of health care. However, there is increasing concern about limitations in their development process conducting to inconsistent recommendations. During the last decade the use of guidelines has been promoted in the Chilean health system, but their quality has not yet been evaluated systematically. AIM: To assess the quality of clinical practice guidelines developed by the Chilean guidelines program. MATERIAL AND METHODS: All the guidelines developed by the Chilean program between 2005 and 2009 were retrieved from the Ministry of Health website. Each guideline was assessed independently by three appraisers using the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument. Standardized scores were obtained for each dimension in each guideline and across the whole set of guidelines. RESULTS: Sixty guidelines were assessed. The 'scope and purpose' dimension scored significantly higher (mean 82.2%, range: 25.9%-100%) and the 'applicability' dimension scored significantly lower (mean 23.3%, range: 0%-72.4%) than any other dimension. 'Publication date' was the only variable consistently associated with dimension scores. CONCLUSIONS: The quality of Chilean clinical practice guidelines is far from ideal. Although they seem to have a strong sense of purpose and vision, methodological procedures should be strengthened, especially those related to applicability.

A Group Videoconferencing Intervention (C@nnected) to Improve Maternal Sensitivity: Protocol for a Randomized Feasibility Trial.

BACKGROUND: Early childhood development is highly dependent on the sensitive care provided by caregivers, and interventions focused on supporting parents to improve their sensitivity have shown to be effective. The COVID-19 pandemic has had a significant impact on mental health, with pregnant women and mothers of infants being an especially vulnerable group and maternal sensitivity particularly affected. However, access to face-to-face interventions is restricted; thus, it is important to have remote interventions to support this group of mothers. OBJECTIVE: The objective of this study is to evaluate the feasibility and acceptability of C@nnected, a group videoconferencing intervention to improve maternal sensitivity aimed at mother-infant dyads attending primary health care centers in vulnerable areas of Santiago, Chile. METHODS: This is a randomized feasibility single-masked (outcome assessor) study with a qualitative component. It will involve a block randomization procedure to generate a 3:2 allocation ratio (with more people allocated to the intervention arm). The intervention consists of 4 group videoconferencing sessions adapted from a face-to-face intervention with proven effectiveness. The control group will receive treatment as usual, along with educational brochures. The feasibility and acceptability of this study will be quantitatively and qualitatively assessed. Changes in clinical outcomes relating to maternal sensitivity, depressive symptoms, postpartum maternal attachment, and infant socioemotional development will also be evaluated. RESULTS: We finished adapting the face-to-face intervention to the videoconferencing format in July 2021. The study began recruitment in August 2021, and enrollment is expected to end in August 2022, with final study results expected in December 2022. CONCLUSIONS: This study will contribute evidence for the use of eHealth interventions to promote maternal sensitivity. It will also inform the design and implementation of a future randomized clinical trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04904861; https://clinicaltrials.gov/ct2/show/NCT04904861. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35881.

Docencia en violencia y abuso sexual en estudiantes de pregrado de medicina: percepción de los docentes sobre barreras y facilitadores / Teaching medical students about domestic violence and sexual abuse: teachers' perception of barriers and facilitators

Background: Considering the frequency of sexual abuse and domestic violence (SA-DV) in the population, the likelihood of a medical student meeting patients with this problem is substantial. However, most students do not consider SA-DV in their differential diagnoses. Since 2014, this team has been working in strengthening undergraduate curriculum in SA-DV. It has been a challenging and slow process. Purpose: To identify barriers and facilitators perceived by the undergraduate teaching team in order to suggest modifications in the curriculum in relation to the competencies required for screening and early intervention for victims of SA-DV. The conclusions obtained may be useful for other medical schools and universities facing this challenge. Methods: Qualitative study using grounded theory method for the analysis of interviews and focus groups. Results: SA-DV are perceived as a problem that is pertinent for physicians. However, there is a common belief that teaching about SA-DV should be limited to only certain specific specialties. The main barriers are the limited curricular time, the need to prioritize contents and the lack of specific training of the teachers. A key facilitator is the fact that gender violence is on the public agenda today. Conclusions: The identified barriers coincide with those reported in the literature; limited curricular time and prioritization of contents. Although this study does not show the perception of SA-DV as 'not a medical issue' nor as a subject that pertains to other health professionals, there is the perception that teaching clinical approach to SA-DV only pertains to specialists who are directly involved in this topic.

Desigualdades en desarrollo infantil temprano entre prestadores públicos y privados de salud y factores asociados en la Región Metropolitana de Chile / Early child development inequalities and associated factors between public and private providers at metropolitan region in Chile

El desarrollo infantil temprano es un determinante de la salud física, mental y social de poblaciones. Conocer la situación de desarrollo de base, previo a la instalación de «Chile Crece Contigo¼, es clave para efectos de su evaluación. Objetivo: Comparar el desarrollo infantil temprano y factores asociados de preescolares del sector público y del sector privado de salud en la línea de base. Pacientes y método: Una muestra de 1.045 niños de la Región Metropolitana, de 30 a 58 meses, 52% hombres, 671 del sector público y 380 del privado de salud. Se evaluaron mediante el Inventario de Desarrollo Battelle-1 y una encuesta psicosocial en sus hogares aplicada al cuidador principal. Resultados: El 14,4% del sector privado y el 30,4% de la red pública tenían desarrollo alterado. No hubo diferencias en el área adaptativa entre ambos grupos (26,3% vs 29,2%). En las áreas cognitiva (8,8% vs 12,1%), personal-social (13,2% vs 32,5%), motriz (19,2% vs 35,3%) y comunicación (19,0% vs 36,8%) las diferencias fueron estadísticamente significativas. Mediante regresión logística se determinó que, independiente del nivel socioeconómico, son factores de riesgo: Apgar < 7 (OR: 5,4; IC 95%: 1,24-23,84), tener enfermedades crónicas de la infancia (OR: 1,3; IC 95%: 1,11-1,42); protector es: hogar con recursos para el aprendizaje y juego (OR: 0,8; IC 95%: 0,76-0,89). Conclusión: Estos resultados son un aporte al conocimiento de la situación del desarrollo infantil y para relevar su importancia para las políticas sociales en pediatría.

Early child development is a population determinant of physical, mental and social health. To know the base line situation prior to the implementation of "Chile grows with you" (Chile Crece Contigo) is key to its evaluation. Objective: To compare early child development and associated factors at baseline in pre-school children from public and private health sectors. Patients and method: The sample consisted of 1045 children aged 30-58 months, 52% male, and 671 from the public and 380 from the private sector of the metropolitan region in Chile were evaluated using Battelle Developmental Inventory-1 and a household interview of primary carer. Results: Abnormal child development was found in 14.4% of children in the private sector compared to 30.4% in the public sector. There were no differences in adaptive area (26.3% vs 29.2%), but there were statistically significant differents in cognitive (8.8% vs 12.1%), social-personal (13.2% vs 32.5%), motor (19.2% vs 35.3%), and communication (19% vs 36.8%) development. The logistic regression showed that, independent of socioeconomic level, the risk factors are: Apgar < 7 (OR: 5.4; 95% CI: 1.24-23.84); having childhood chronic diseases (OR: 1.3; 95% CI: 1.11-1.42). Protective factor is: home with resources to learn and play (OR: 0.8; 95% CI: 0.76-0.89).