HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities.

Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.

Use of mobile phones by medical staff at Queen Elizabeth Hospital, Barbados: evidence for both benefit and harm.

All members of medical staff, including students, were asked to participate in a self-administered questionnaire concerning patterns of mobile phone use and care. Participants' phones were cultured for micro-organisms. Healthcare professionals working in close proximity to sensitive equipment were surveyed concerning adverse events associated with mobile phones. Telephone operators were asked to monitor time elapsed as they attempted to contact medical staff by various methods. Of 266 medical staff and students at the time of the study, 116 completed questionnaires (response rate=44%). Almost all (98%) used mobile phones: 67% used their mobile phones for hospital-related matters; 47% reported using their phone while attending patients. Only 3% reported washing their hands after use and 53% reported never cleaning their phone. In total, 101 mobile phones were cultured for micro-organisms; 45% were culture-positive and 15% grew Gram-negative pathogens. The survey of staff working in close proximity to sensitive equipment revealed only one report of minor interference with life-saving equipment. Telephone operators were able to contact medical staff within 2 min most easily by mobile phone. Mobile phones were used widely by staff and were considered by most participants as a more efficient means of communication. However, microbial contamination is a risk associated with the infrequent cleaning of phones. Hospitals should develop policies to address the hygiene of mobile phones.

Risk behaviour, healthcare access and prevalence of infection with Chlamydia trachomatis and Neisseria gonorrhoeae in a population-based sample of adults in Barbados.

OBJECTIVES: To estimate the prevalence of urogenital infection with Chlamydia trachomatis and Neisseria gonorrhoeae in people 18 to 35 years of age in Barbados, and to examine factors associated with infection. METHODS: Cross-sectional survey of randomly selected people from the voters' register of one electoral district and the collection of urine samples for testing by PCR. RESULTS: The response rate was 82%; 408 people (195 males and 213 females) completed a questionnaire and had their urine collected. 397 urine samples were satisfactorily tested. Prevalence of C trachomatis urogenital infection was 11.3% (95% CI +/-2.9) and N gonorrhoeae 1.8% (95% CI +/-1.2) with 12.6% (95% CI +/-3.1) having either or both infections. The difference in prevalence by gender was not significant. Multivariate logistic regression showed that prevalence of C trachomatis and/or N gonorrhoeae decreased with increasing age (per year OR 0.89, 95% CI 0.84 to 0.96, p = 0.001), and decreasing time (6 months) since last medical consultation (OR 0.44, 95% CI 0.22 to 0.88, p = 0.02). Most (76%) infected people were asymptomatic. Condom use at last intercourse with a partner not being lived with was not protective (reported by 52%, p = 0.617). The usual source of health care was evenly distributed between the public and private sectors and was not associated with infection. Only 30% of people had ever heard of chlamydia, whereas 92% were aware of gonorrhoea. CONCLUSIONS: Asymptomatic infection with C trachomatis is an important reservoir of infection, which will remain undetected unless physicians and young people are made aware of this and screening is introduced.

Trends in the uptake of antenatal voluntary counselling and testing for HIV and HIV prevalence among childbearing women in Barbados, 1993-2004: evidence to gauge the effectiveness of HIV prevention measures.

OBJECTIVES: To describe the long term trends on the uptake of antenatal voluntary counselling and testing (VCT) for Human Immunodeficiency Virus (HIV) and on the HIV prevalence among pregnant women. These data were used to gauge the impact of the National Acquired Immunodeficiency Syndrome (AIDS) Intervention Programme on preventing mother-to-child transmission (PMTCT) in Barbados. METHODS: This was a population based study. Data for this report were drawn from the HIV Surveillance Programme for the mother-to-child transmission of HIV The study population comprised all pregnant women who attended the various antenatal care clinics throughout Barbados during the period between 1993 and 2004. RESULT: The uptake of the VCT for HIV among the pregnant women in Barbados has increased from 39.9% in 1993 to over 89.7% in 2004 (p < 0.0001). Mean annual HIV prevalence decreased from 10.53 per thousand women screened in 1993-1996 to 8.23 during 2001-2004 (p = 0.121). Mean annual incidence rate of newly diagnosed HIV infection among the pregnant women declined from 8.83 per thousand women screened during 1993-1996 to 4.53 per thousand pregnant women screened during 2001-2004 (p = 0.004). Mean annual incidence rate of newly diagnosed HIV infection among the pregnant women aged less than 25 years during the corresponding period declined from 10.17 per thousand women aged less than 25 years screened to 4.75 per thousand women screened (p = 0.003). CONCLUSION: There has been a significant decline in the prevalence and incidence of HIV since the late-1990s. Although new infections are still occurring, the numbers are small. The decline may partly be explained by the impact of PMTCT and the general preventive measures on the spread of HIV among this population.

Trends in the uptake of antenatal voluntary counselling and testing for HIV and HIV prevalence among childbearing women in Barbados, 1993-2004: evidence to gauge the effectiveness of HIV prevention measures / Tendencias en el interés por el asesoramiento y prueba voluntarios prenatales para el vih, y prevalencia del vih entre las embarazadas de barbados, 1993­2004: evidencia para evaluar la efectividad de las medidas para prevenir el vih

OBJECTIVES: To describe the long term trends on the uptake of antenatal voluntary counselling and testing (VCT) for Human Immunodeficiency Virus (HIV) and on the HIV prevalence among pregnant women. These data were used to gauge the impact of the National Acquired Immunodeficiency Syndrome (AIDS) Intervention Programme on preventing mother-to-child transmission (PMTCT) in Barbados. METHODS: This was a population based study. Data for this report were drawn from the HIV Surveillance Programme for the mother-to-child transmission of HIV The study population comprised all pregnant women who attended the various antenatal care clinics throughout Barbados during the period between 1993 and 2004. RESULT: The uptake of the VCT for HIV among the pregnant women in Barbados has increased from 39.9in 1993 to over 89.7in 2004 (p < 0.0001). Mean annual HIV prevalence decreased from 10.53 per thousand women screened in 1993-1996 to 8.23 during 2001-2004 (p = 0.121). Mean annual incidence rate of newly diagnosed HIV infection among the pregnant women declined from 8.83 per thousand women screened during 1993-1996 to 4.53 per thousand pregnant women screened during 2001-2004 (p = 0.004). Mean annual incidence rate of newly diagnosed HIV infection among the pregnant women aged less than 25 years during the corresponding period declined from 10.17 per thousand women aged less than 25 years screened to 4.75 per thousand women screened (p = 0.003). CONCLUSION: There has been a significant decline in the prevalence and incidence of HIV since the late-1990s. Although new infections are still occurring, the numbers are small. The decline may partly be explained by the impact of PMTCT and the general preventive measures on the spread of HIV among this population.

Objetivos. Describir las tendencias a largo plazo en relación con el interés en el asesoramiento y prueba voluntarios (APV) prenatales para el virus de la inmunodeficiencia humana VIH, así como en relación con la prevalencia del VIH entre las embarazadas. Estos datos fueron usados para evaluar el impacto del Programa Nacional de Intervención del Síndrome de Inmunodeficiencia Adquirida (SIDA) en la prevención de la transmisión de madre a hijo (PTMH) en Barbados. Métodos. Se trató de un estudio poblacional. Los datos para este reporte fueron tomados del Programa de Vigilancia del VIH para la transmisión madre a hijo del VIH. El estudio poblacional abarcó a todas las embarazadas que asistieron a las distintas clínicas de atención prenatal en todo Barbados durante el período comprendido entre 1993 y 2004. Resultado. El interés mostrado por el APV del VIH entre las embarazadas de Barbados, ha aumentado de 39.9% en 1993 a más de 89.7% en 2004 (p < 0.0001). La media anual de prevalencia del VIH disminuyó de 10.53 por cada mil mujeres sometidas a pesquisaje en 1993­1996 a 8.23 durante 2001­2004 (p = 0.121). La tasa de incidencia anual media de infección por VIH de diagnóstico reciente entre las embarazadas descendió de 8.83 por cada mil mujeres embarazadas sometidas a pesquisaje durante 1993­1999 a 4.53 por cada mil mujeres sometidas a pesquisaje durante 2001­2004 (p = 0.004). La tasa de incidencia anual media de infección por VIH de diagnóstico reciente entre las embarazadas menores de 25 años de edad durante el periodo correspondiente disminuyó de 10.17 por cada mil mujeres menores de 25 años de edad sometidas a pesquisaje, a 4.75 por cada mil mujeres sometidas a pesquisaje (p = 0.003). Conclusión. Ha habido un descenso significativo en la prevalencia e incidencia del VIH desde los finales de 1990. Aunque todavía se están produciendo nuevas infecciones, su número es pequeño. El descenso puede explicarse en parte por el impacto del PTMH y las medidas generales de prevención de la difusión del VIH entre esta población

Epilepsy and antiepileptic drug use in elderly people as risk factors for dementia.

OBJECTIVE: To assess the role of epilepsy and antiepileptic drugs (AEDs) as risk factors for probable Alzheimer's disease (AD) and for all dementias in the Canadian Study of Health and Aging (CSHA). A secondary objective was to isolate the effect of the AED phenytoin on the development of dementia and AD. METHODS: The cohort consists of 5376 participants aged 65 years or older with no evidence of dementia, defined as Modified Mini-Mental State (3MS) score > or =78. Primary exposure was self-report or clinical diagnosis of epilepsy at baseline (n=39), or self-report of AED therapy (n=67). Primary outcomes were development of dementia, defined as 3MS<78, or AD, determined by clinical examination using standard criteria, during a 5-year follow-up period. People whose 3MS score remained > or =78 served as the comparison group. RESULTS: People reporting AED use at baseline had an age, sex and baseline 3MS adjusted odds ratio (OR) of 2.11 (95% CI 1.11 to 4.01) for developing dementia compared to those not taking AEDs at baseline. The association remained significant using only phenytoin as the exposure. No significant association was found between AED use and development of AD, nor between epilepsy and development of either AD or dementia. CONCLUSIONS: Older adults taking AEDs are at a significantly higher relative risk of developing dementia than those not taking AEDs. Further investigation of this finding is warranted.

Waiting and interaction times for patients in a developing country accident and emergency department.

OBJECTIVE: To determine the interaction and waiting times of patients in Barbados Queen Elizabeth Hospital Accident and Emergency Department (A&E), identify their determinants, and compare them to international benchmarks. METHODS: Trained research assistants monitored all patients attending A&E during a one week period in 2003. The time in and out of each step in the process of care was recorded along with demographic data, diagnosis, and acuity. Time elapsed was calculated for various steps in care and compared to international benchmarks. Determinants of timely care were identified. RESULTS: Of 882 eligible A&E patients, 675 (77%) had accurate data and were entered into the study. Interaction times were short, with median total interaction time 13 (IQR 9-21) minutes. Waiting times were long ranging from median 6.5 (IQR 2-22) minutes for registration to 213 (IQR 154-316) minutes for lab results. Of concern was a median wait of 10 (IQR 2-46) minutes for triage and 178 (IQR 105-305) minutes to be seen by a doctor. Mean total length of stay was 377 (SD 261) minutes compared to US benchmark of 90 minutes. All other waiting times were at least twice US benchmarks. Paediatrics cases and children aged 0-11 years had the shortest waiting times and length of stay, whereas medicine patients and those over 49 years had the longest. Those with highest acuity had the shortest waiting times and length of stay. CONCLUSIONS: The A&E could improve patient care processes by shortening waiting times, especially for laboratory results, triage, and seeing a doctor, particularly for older medicine patients.

Immunological and virological responses to highly active antiretroviral therapy in a non-clinical trial setting in a developing Caribbean country.

OBJECTIVE: Few data exist on the efficacy of antiretroviral therapy in individuals infected with HIV in the Caribbean. We evaluated the virological and immunological responses of HIV-infected adults starting highly active antiretroviral therapy (HAART). DESIGN: This was a prospective observational cohort study. METHODS: A total of 158 antiretroviral-naive patients who initiated HAART between January 2002 and March 2003, and completed at least 6 months of treatment and follow up, were included in the analysis. The response to therapy was assessed by changes in CD4 cell counts and viral loads from baseline. The mean increase in CD4 cell count, the rate of virological success (a viral load of <50 HIV-1 RNA copies/mL) and the rate of immunological success (an increase in CD4 cell count of > or =50 cells/microL over the baseline value) after commencing HAART were measured. RESULTS: In total, 82% of patients (123 of 150) achieved viral loads of <50 copies/mL after 6 months of therapy. Viral success rate after 6 months of HAART was similar irrespective of gender, pre-HAART CD4 cell count and pre-HAART viral load. However, patients older than 40 years were significantly more likely to achieve virological success than those younger than 40 years. At 6 months after starting HAART, 79.5% of patients were estimated to have achieved immunological success and 17.9% had an increase in CD4 cell count of > or =200 cells/microL over the baseline value. The median increase in CD4 cell count for the 156 patients who had CD4 cell counts at baseline and at 6 months of therapy was 122 cells/microL. CONCLUSION: In this cohort of antiretroviral-naive HIV-infected adults, there was a high rate of virological and immunological success after 6 months of HAART, irrespective of the pre-HAART viral load and CD4 cell count.

Correlation of quantitative ultrasound parameters of the calcaneus with bone density of the spine and hip in women with prevalent hypovitaminosis D.

Quantitative ultrasound (QUS) of the calcaneus correlates modestly with axial dual-energy X-ray absorptiometry (DXA). Because bone mineral density (BMD) might be influenced by vitamin D status, we assessed the correlation between both techniques in 56 Arabian women, a population with high prevalence of hypovitaminosis D. The speed of sound (SOS), broadband ultrasound attenuation (BUA), and estimated BMD of the right calcaneus were determined by QUS. Spine and right hip BMD were measured by DXA scan. The serum 25-hydroxyvitamin D (25OHD) level was measured by radioimmunoassay. The correlations of QUS parameters (estimated calcaneal BMD, BUA, and SOS) with spine and hip BMD were modest (r = 0.50, r = 0.53, r = 0.41 for the spine and r = 0.54, r = 0.56, and r = 0.46 for the hip, respectively; p < 0.01 for all comparisons), but stronger in postmenopausal women. All postmenopausal women with low estimated calcaneal BMD (T-score pound -1) had a T-score pound -1 by DXA of the spine or hip. Of the 21 premenopausal women with spine or hip T-score pound -1 who had 25OHD measurements, 20 (95.2%) had levels below 50 nmol/L and 12 (57%) had levels below 30 nmol/L. The subgroup with 25OHD < 30 nmol/L had significantly lower spine (p < 0.01) and hip BMD (p < 0.05) than the subgroup with 25OHD >/= 30 nmol/L. QUS parameters were not significantly different between the two subgroups. The QUS and DXA correlated modestly well in women with prevalent hypovitaminosis D. QUS could be used in postmenopausal women with hypovitaminosis D to identify those at risk for osteoporotic fracture.

Quantitative ultrasound of the calcaneus in Arabian women: relation to anthropometric and lifestyle factors.

OBJECTIVES: To determine factors influencing quantitative ultrasound (QUS) parameters of the calcaneus in a population-based sample of United Arab Emirates (UAE) women, and to compare QUS parameters of the calcaneus for healthy young UAE women with the manufacturer's reference ranges for other populations. METHODS: All subjects completed a questionnaire on reproductive and life style factors. Height and weight were measured, and body composition was determined by bioelectric impedence. Estimated bone mineral density (BMD), Speed of sound (SOS), broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) of the right calcaneus were determined by Sahara ultrasound. RESULTS: In premenopausal women (n=330), age, weight, body mass index (BMI), lean weight, fat weight, education, age at menarche, and number of pregnancies, correlated significantly with QUS parameters. Multiple regression analysis showed that age at menarche, number of pregnancies, and BMI, were the best predictors of QUS parameters although these factors explained only small amounts of the variance (R(2)=0.05). In postmenopausal women (n=81), age, BMI and physical activity were the best predictors of BUA (R(2)=0.35), SOS (R(2)=0.39), and QUI (R(2)=0.43). Mean estimated BMD, QUI and SOS for healthy young UAE women were significantly lower than the manufacturer's reference ranges for U.S. Caucasian, European Caucasian, and Chinese Asian healthy young women of the same age range (P<0.001 for all comparisons). Mean BUA was not significantly different, however. CONCLUSIONS: Menopausal status, age, BMI and physical activity are strong predictors of QUS parameters of the calcaneus in Arabian women. Healthy young Arabian women have lower estimated calcaneal BMD compared with the manufacturer's reference ranges for other populations.

What is the quality of drug therapy clinical practice guidelines in Canada?

BACKGROUND: The Canadian Medical Association maintains a national online database of clinical practice guidelines developed, endorsed or reviewed by Canadian organizations within 5 years of the current date. This study was designed to identify and describe guidelines in the database that make recommendations related to the use of drug therapy, and to assess their quality using a standardized guideline appraisal instrument. METHODS: Drug therapy guidelines in the database were identified with the use of search terms and hand searching. Descriptive information about the developers, endorsement by other organizations, publication status, disease and drug focus was abstracted. Each guideline was independently assessed by 3 appraisers (a physician, a pharmacist and a methodologist) with the use of the Appraisal Instrument for Clinical Guidelines. Conditions were classified according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems. RESULTS: We identified 217 drug therapy guidelines produced or reviewed from 1994 to 1998. Guideline developers included national organizations (47.0%), paragovernment organizations (39.6%) and professional associations (30.9%); 31.3% of the guidelines were published, and 10.6% stated drug company sponsorship. The most common conditions addressed by the guidelines were infections and parasitic diseases (39.6%), neoplasms (11.5%) and diseases of the circulatory system (11.5%). Drugs most commonly cited were anti-infective agents (42.9%), antiviral agents (15.2%) and cardiovascular drugs (16.1%). Eleven organizations produced 176 (81.1%) of the guidelines. In all, 14.7% of the guidelines met half or more of the 20 items assessing rigour of guideline development on the appraisal instrument (mean quality score 30.0% [95% confidence interval (CI) 27.5%-32.6%]), 61.8% met half or more of the 12 items assessing guideline context and content (mean score 57.0% [95% CI 54.6%-59.3%]), and none met half or more of the 5 items assessing guideline application (mean score 5.6% [95% CI 4.7%-6.5%]). Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. The quality of the guidelines assessed varied significantly by developer, publication status and drug company sponsorship. No substantial improvement in guideline quality was observed over the 5-year study period. INTERPRETATION: Developers of Canadian drug therapy guidelines are producing guidelines that are often perceived to be clinically useful to physicians and pharmacists, although the methods (or the description of the methods) by which they are developed need to be more rigorous and thorough.

Bone density estimates and risk factors for osteoporosis in young women.

The bone mineral density (BMD) of the calcaneus was estimated in 185 young women from the United Arab Emirates, using SAHARA ultrasound. All participants completed a questionnaire on factors potentially associated with osteoporosis. In all, 29 (15.7%) of the women were classified as having osteopenia and none as having osteoporosis. Participants with osteopenia were more likely to have had a later onset of menarche, irregular periods, lower body mass index, and a positive family history of osteoporosis. Only late menarche and low body mass index, however, were independent predictors of osteopenia.

Bone density estimates and risk factors for osteoporosis in young women

The bone mineral density [BMD] of the calcaneus was estimated in 185 young women from the United Arab Emirates, using SAHARA ultrasound. All participants completed a questionnaire on factors potentially associated with osteoporosis. In all, 29 [15.7%] of the women were classified as having osteopenia and none as having osteoporosis. Participants with osteopenia were more likely to have had a later onset of menarche, irregular periods, lower body mass index, and a positive family history of osteoporosis. Only late menarche and low body mass index, however, were independent predictors of osteopenia

A comparison of clinical practice guideline appraisal instruments.

OBJECTIVE: To identify and compare clinical practice guideline appraisal instruments. METHODS: Appraisal instruments, defined as instruments intended to be used for guideline evaluation, were identified by searching MEDLINE (1966-99) using the Medical Subject Heading (MeSH) practice guidelines, reviewing bibliographies of the retrieved articles, and contacting authors of guideline appraisal instruments. Two reviewers independently examined the questions/statements from all the instruments and thematically grouped them. The 44 groupings were collapsed into 10 guideline attributes. Using the items, two reviewers independently undertook a content analysis of the instruments. RESULTS: Fifteen instruments were identified, and two were excluded because they were not focused on evaluation. All instruments were developed after 1992 and contained 8 to 142 questions/statements. Of the 44 items used for the content analysis, the number of items covered by each instrument ranged from 6 to 34. Only the instrument by Cluzeau and colleagues included at least one item for each of the 10 attributes, and it addressed 28 of the 44 items. This instrument and that of Shaneyfelt et al. are the only instruments that have so far been validated. CONCLUSIONS: A comprehensive, concise, and valid instrument could help users systematically judge the quality and utility of clinical practice guidelines. The current instruments vary widely in length and comprehensiveness. There is insufficient evidence to support the exclusive use of any one instrument, although the Cluzeau instrument has received the greatest evaluation. More research is required on the reliability and validity of existing guideline appraisal instruments before any one instrument can become widely adopted.

Use of existing data for public health planning: a study of the prevalence of hepatitis B surface antigen and core antibody in Al Ain Medical District, United Arab Emirates.

INTRODUCTION: Hepatitis B is of major public health importance. Accurate information on its occurrence, with particular reference to the prevalence of immunity and chronic infection (marked by the presence of hepatitis B core antibody and surface antigen, respectively, in serum), is essential for planning public health programmes for the control of the disease. The generation of marker prevalence data through serological surveys is costly and time-consuming. The present study in Al Ain Medical District, United Arab Emirates, investigated the possibility of obtaining sufficiently accurate marker prevalence estimates from existing data to plan public health programmes. METHODS: Two antenatal screening databases, one student serological survey database, one immunization programme database and one pre-marriage screening database containing information on marker prevalence were identified. Epidemiological data were abstracted from these databases and analysed. RESULTS: The data showed that the prevalence of hepatitis B surface antigen and the prevalence of core antibody in young citizens in 1998 were approximately 2% and 14% respectively, that any immunization campaign aimed at citizens of the United Arab Emirates should target teenagers as they had the highest risk of acquiring the disease, and that pre-immunization screening of young adults would be wasteful. However, the data did not yield information on the prevalence of hepatitis B surface antigen and core antibody in other population subgroups of public health significance. DISCUSSION: While data generated by the study are sufficient to support a hepatitis B immunization programme targeted at teenaged citizens, more accurate data, generated by a well-designed serological survey, would be essential for optimal public health planning.

Canadian physicians' attitudes about and preferences regarding clinical practice guidelines.

OBJECTIVE: To assess Canadian physicians' confidence in, attitudes about and preferences regarding clinical practice guidelines. DESIGN: Cross-sectional, self-administered mailed survey. PARTICIPANTS: Stratified random sample of 3000 Canadian physicians; 1878 (62.6%) responded. SETTING: Canada. OUTCOME MEASURES: Physicians' use of various information sources; familiarity with and confidence in guidelines; attitudes about guidelines and their effect on medical care; rating of importance of guidelines and other sources of information in clinical decision-making; rating of importance of various considerations in deciding whether to adopt a set of guidelines; and rating of usefulness of different formats for presenting guidelines. MAIN RESULTS: In all, 52% of the respondents reported using guidelines at least monthly, substantially less frequently than traditional information sources. Most of the respondents expressed confidence in guidelines issued by various physician organizations, but 51% to 77% were not confident in guidelines issued by federal or provincial health ministries or by health insurance plans. The respondents were generally positive about guidelines (e.g., over 50% strongly agreed that they are a convenient source of advice and good educational tools); however, 22% to 26% had concerns about loss of autonomy, the rigidity of guidelines and decreased satisfaction with medical practice. Endorsement by respected colleagues or major organizations was identified as very important by 78% and 62% of the respondents respectively in deciding whether to adopt a set of guidelines in their practice. User friendliness of the guidelines format was thought to be very important by 62%; short pamphlets, manuals summarizing a number of guidelines, journal articles and pocket cards summarizing guidelines were the preferred formats (identified as most useful by 50% to 62% of the respondents). CONCLUSIONS: Canadian physicians, although generally positive about guidelines and confident in those developed by clinicians, have not yet integrated the use of guidelines into their practices to a large extent. Our results suggest that respected organizations and opinion leaders should be involved in the development of guidelines and that the acceptability of any proposed format and medium for guidelines presentation should be pretested.

Physician prescribing practices: What do we know? Where do we go? How do we get there?

Although drug prescribing is one of the most important components of medical care, little is known about how prescribing practices are determined and how they can be influenced. Enhancing the quality and effectiveness of drug prescribing requires research and better dissemination of information to physicians and other decision-makers. This requires a collaborative effort and a coordinated action plan. Participants at the Physician Prescribing Practices Workshop, held in Ottawa in October 1995, addressed issues and made recommendations in three areas: current knowledge and issues for research in the field of prescribing practices, and the capacity of Canadian databases to study these issues, strategies for disseminating and implementing knowledge and research findings to enhance the quality of prescribing; and the formation of a network to foster collaboration among stakeholders.

Variability in prescription drug utilization: issues for research.

The authors report the results of a literature review to identify research issues relating to physician prescribing practices and evaluate the potential for existing Canadian databases to support initiatives to improve prescribing practices. Methodologies such as small-area variation analysis and drug utilization reviews are discussed, and Canadian data sources relating to drug prescribing are assessed. The authors conclude that small-area variation analysis can be used to identify differences in drug utilization rates. A ranking method to identify drugs with the greatest variability in utilization can then be used to establish priorities for further analysis. After statistically significant factors associated with prescribing patterns are identified, intervention and policy formation will be possible. This will involve a more sophisticated integration of existing provincial information sources and the adoption of uniform guidelines to promote rational prescribing practices.