Surfing, self-medicating and safety: buying non-prescription and complementary medicines via the internet.

OBJECTIVE: To examine whether the sale of medicines via the internet supports their safe and appropriate use. DESIGN: e-Pharmacy websites were identified using key words and a metasearch engine and the quality of information published on these websites was surveyed using the DISCERN tool. A case scenario and internet pharmacy practice standards were also used to evaluate the quality of care delivered. SETTING AND PARTICIPANTS: Between July and September 2001 104 websites were surveyed and 27 sent either Sudafed (pseudoephedrine HCl), St John's wort products, or both to a residential address in Melbourne, Australia. MAIN OUTCOME MEASURES: Quality of health information (DISCERN ratings), information exchanged between e-pharmacy staff and consumers, and product and delivery costs. RESULTS: Of 104 e-pharmacies from at least 13 different countries, 63 websites provided some health information but overall the quality of the information was poor. Only three website operators provided adequate advice to consumers to avoid a potential drug interaction. The costs for a daily dose of pseudoephedrine HCl (240 mg) ranged from 0.81 Australian dollars to 3.04 Australian dollars, and delivery costs from 3.28 Australian dollars to 62.70 Australian dollars. CONCLUSION: Consumers who self-select medicines from websites have insufficient access to information and advice at the point of ordering and on delivery to make informed decisions about their safe and appropriate use.

Specialized medical search-engines are no better than general search-engines in sourcing consumer information about androgen deficiency.

BACKGROUND: The Internet provides consumers with access to online health information; however, identifying relevant and valid information can be problematic. Our objectives were firstly to investigate the efficiency of search-engines, and then to assess the quality of online information pertaining to androgen deficiency in the ageing male (ADAM). METHODS: Keyword searches were performed on nine search-engines (four general and five medical) to identify website information regarding ADAM. Search-engine efficiency was compared by percentage of relevant websites obtained via each search-engine. The quality of information published on each website was assessed using the DISCERN rating tool. RESULTS: Of 4927 websites searched, 47 (1.44%) and 10 (0.60%) relevant websites were identified by general and medical search-engines respectively. The overall quality of online information on ADAM was poor. The quality of websites retrieved using medical search-engines did not differ significantly from those retrieved by general search-engines. CONCLUSION: Despite the poor quality of online information relating to ADAM, it is evident that medical search-engines are no better than general search-engines in sourcing consumer information relevant to ADAM.

The effectiveness of local adaptation of nationally produced clinical practice guidelines.

BACKGROUND: Local adaptation is often reported in the literature to be an important strategy in achieving local ownership and relevance of guidelines in order to increase the likelihood of their uptake and implementation. However, the process is also potentially time-consuming and costly. OBJECTIVE: The aim of this study was to determine the impact of local adaptation of nationally produced clinical practice guidelines (CPGs) on the knowledge, attitude and reported practices of GPs. METHODS: Two Divisions of General Practice in Adelaide, Australia were selected and randomized to adapt a nationally produced CPG (on Stroke Prevention) by the National Health and Medical Research Council or use the original version. The order of the interventions was reversed for a second guideline (on management of Lower Urinary Tract Symptoms in Men). An identical multifaceted dissemination strategy was adopted for both sets of guidelines in the two divisions. Prior to the intervention, a random sample of 200 GPs from each Division was sent a postal survey about their knowledge, attitudes and reported practices. This was repeated 3 months after the dissemination phase. RESULTS: Sixty-one per cent (243/400) of the GPs responded to the initial survey and, of these, 76% (184/243) responded to the follow-up survey. Overall, awareness of both sets of guidelines was significantly increased. For stroke, 38% of respondents across both Divisions reported that their practice had changed as a result of the guidelines. For management of lower urinary tract symptoms in men, the corresponding proportion was 52%. Agreement with specific recommendations from both guidelines was also increased following their dissemination. However, these changes were independent of whether or not the guidelines had been locally adapted. The local adaptation process involved no substantive change in content and was estimated to cost AUD$5600 (per Division) independent of the costs of the dissemination process. CONCLUSIONS: Whilst this study found significant changes in knowledge, attitude and reported practice as a result of disseminating guidelines, it did not find any additional effect from the local adaptation process itself. This suggests that the emphasis and investment in promoting guideline implementation should be placed on multifaceted dissemination strategies rather than local adaptation per se.

Updating a systematic review--what difference did it make? Case study of nicotine replacement therapy.

AIMS: To examine the effect of updating a systematic review of nicotine replacement therapy on its contents and conclusions. METHODS: We examined the effects of regular updating of a systematic review of nicotine replacement therapy for smoking cessation. We considered two outcomes. First, we assessed the effect of adding new data to meta-analyses, comparing results in 2000 with the results in 1994. Second, we assessed qualitatively the ways in which the nature of the questions addressed by the review had changed between the two dates. For the first outcome, we compared the number of trials, the pooled estimate of effect using the odds ratio, and the results of pre-specified subgroup analyses, for nicotine gum and patch separately. Using a test for interaction, we assessed whether differences between estimates were statistically significant. RESULTS: There were ten new trials of nicotine gum between 1994 and 2000, and the meta-analytic effect changed little. For the nicotine patch the number of trials increased from 9 to 30, and the meta-analytic effect fell from 2.07 (95% CI 1.64 - 2.62) to 1.73 (95% CI 1.56 - 1.93). Apparent differences in relative effect in sub-groups found in 1994 were not found in 2000. The updated systematic review addressed a number of questions not identified in the original version. CONCLUSIONS: Updating the meta-analyses lead to a more precise estimate of the likely effect of the nicotine patch, but the clinical message was unchanged. Further placebo controlled NRT trials are not likely to add to the evidence base. It is questionable whether updating the meta-analyses to include them is worthwhile. The content of the systematic review has, however, changed, with the addition of data addressing questions not considered in the original review. There is a tension between the principle of identifying the important questions prior to conducting a review, and keeping the review up to date as primary research identifies new avenues of enquiry.

Use of systematic reviews in clinical practice guidelines: case study of smoking cessation.

OBJECTIVE: To examine the extent to which recommendations in the national guidelines for the cessation of smoking are based on evidence from systematic reviews of controlled trials. DESIGN: Retrospective analysis of recommendations for the national guidelines for the cessation of smoking. MATERIALS: National guidelines in clinical practice on smoking cessation published in English. MAIN OUTCOME MEASURES: The type of evidence (systematic review of controlled trials, individual trials, other studies, expert opinion) used to support each recommendation. We also assessed whether a Cochrane systematic review was available and could have been used in formulating the recommendation. RESULTS: Four national smoking cessation guidelines (from Canada, New Zealand, the United Kingdom, and the United States) covering 105 recommendations were identified. An explicit evidence base for 100%, 89%, 68%, and 98% of recommendations, respectively, was detected, of which 60%, 56%, 59%, and 47% were based on systematic reviews of controlled studies. Cochrane systematic reviews could have been used to develop between 39% and 73% of recommendations but were actually used in 0% to 36% of recommendations. The UK guidelines had the highest proportion of recommendations based on Cochrane systematic reviews. CONCLUSIONS: Use of systematic reviews in guidelines is a measure of the "payback" on investment in research synthesis. Systematic reviews commonly underpinned recommendations in guidelines on smoking cessation. The extent to which they were used varied by country and there was evidence of duplication of effort in some areas. Greater international collaboration in developing and maintaining an evidence base of systematic reviews can improve the efficiency of use of research resources.

Feasibility of an evidence-based literature search service for general practitioners.

OBJECTIVE: To test the feasibility of an evidence-based clinical literature search service to help answer general practitioners' (GPs') clinical questions. DESIGN: Two search services supplied GPs who submitted questions with the best available empirical evidence to answer these questions. The GPs provided feedback on the value of the service, and concordance of answers from the two search services was assessed. SETTING: Two literature search services (Queensland and Victoria), operating for nine months from February 1999. MAIN OUTCOME MEASURES: Use of the service; time taken to locate answers; availability of evidence; value of the service to GPs; and consistency of answers from the two services. RESULTS: 58 GPs asked 160 questions (29 asked one, 11 asked five or more). The questions concerned treatment (65%), aetiology (17%), prognosis (13%), and diagnosis (5%). Answering a question took a mean of 3 hours 32 minutes of personnel time (95% CI, 2.67-3.97); nine questions took longer than 10 hours each to answer, the longest taking 23 hours 30 minutes. Evidence of suitable quality to provide a sound answer was available for 126 (79%) questions. Feedback data for 84 (53%) questions, provided by 42 GPs, showed that they appreciated the service, and asking the questions changed clinical care. There were many minor differences between the answers from the two centres, and substantial differences in the evidence found for 4/14 questions. However, conclusions reached were largely similar, with no or only minor differences for all questions. CONCLUSIONS: It is feasible to provide a literature search service, but further assessment is needed to establish its cost effectiveness.

Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice.

OBJECTIVE: To determine whether provision of individualised physical activity advice by an exercise specialist in general practice is effective in modifying physical activity and cardiovascular risk factors in older adults. DESIGN: Randomised controlled trial of individualised physical activity advice, reinforced at three and six months (intervention) versus no advice (control). SETTING: Two general practices in Adelaide, South Australia, 1996. PARTICIPANTS: 299 adults aged 60 years or more who were healthy, sedentary and living in the community. MAIN OUTCOME MEASURES: Changes to physical activity (frequency and duration of walking and vigorous exercise), selected cardiovascular risk factors (blood pressure, body weight, serum lipid levels) and quality of life over 12 months. RESULTS: Self-reported physical activity increased over the 12 months in both groups (P < 0.001). The increase was greater for the intervention than the control group for all measures except time spent walking (P < 0.05). More intervention than control participants increased their intention to exercise (P < 0.001). Serum levels of total and low-density lipoprotein cholesterol and triglycerides fell significantly over the 12 months to a similar extent in the two groups. No other significant changes in cardiovascular risk factors were seen. Quality-of-life scores decreased over the 12 months. The decrease was significantly greater among intervention than control women, but not men, for emotional well-being (P = 0.02), physical well-being (P = 0.04) and social functioning (P = 0.04). DISCUSSION: Provision of general practice-based physical activity advice reinforced three-monthly produced a sustained increase in self-reported physical activity. However, there were no associated changes in clinical measures of cardiovascular risk factors and minimal changes in quality-of-life measures.

Why we should teach undergraduate medical students in rural communities.

In the eyes of many, the critical shortage of doctors in rural areas is the only reason for providing rural experiences for medical students. This article reviews the body of evidence supporting rural placements as a long-term medical workforce strategy and additional evidence regarding the apparent educational benefits of such placements. By enabling medical students to learn for significant periods of time in rural communities, it is now possible for universities to address the medical workforce imperatives of the communities they serve at the same time as providing intrinsic educational advantages to their students.

Applying the results of a systematic review in general practice.

OBJECTIVE: To assess how general practitioners might interpret and apply the results of a systematic review relevant to general practice. DESIGN: Cross-sectional postal survey of general practitioners in August 1997. PARTICIPANTS: 51 general practitioners in the Southern Division of General Practice in Adelaide and 11 professors or heads of departments of general practice. MAIN OUTCOME MEASURES: Extent to which comments on the implications for practice and implications for research coincided with the evidence presented in a systematic review of antibiotics for the treatment of acute otitis media in children; and reported probability that respondents would prescribe antibiotics in three brief case scenarios. RESULTS: There was considerable variation in the comments made by general practitioners on the implications of the review for clinical practice. After reading the review, respondents with training in critical appraisal were more likely to state that children with acute otitis media would usually recover spontaneously and reported a lower probability of prescribing antibiotics in two of the three case scenarios. CONCLUSIONS: Providing systematic reviews is not sufficient for the results of such evidence to be translated into clinical practice. There is an association between critical appraisal skills and the application of evidence-based practice.

Effectiveness and role of zanamivir in the treatment of influenza infection.

Influenza is a worldwide public health issue. The virus circulates annually in winter and can cause significant morbidity in the general population and increased mortality rates in those who are more susceptible to complications if infected by the virus, especially the elderly. Although antivirals to treat and prevent influenza have been available in several countries for up to 30 years, annual influenza vaccination strategies remain the primary focus in reducing the burden of illness caused by this viral infection. Zanamivir is the first of a new class of compounds to offer significant advantages over existing influenza treatments. It is a potent and specific competitive inhibitor of both influenza A and B virus neuraminidase. The drug is administered topically by inhalation directly to the site of virus replication in a dose of 10 mg twice daily for 5 days. In both experimental and naturally acquired treatment studies, zanamivir has been shown to have efficacy against both influenza A and B virus and to be well tolerated. Significant treatment benefits resulting in reductions in illness of up to 2.5 days have been demonstrated in both the general population and in patients considered at high risk. In addition, patients receiving zanamivir have been able to return to normal activities significantly faster.

Exercise training and blood lipids in hyperlipidemic and normolipidemic adults: a meta-analysis of randomized, controlled trials.

OBJECTIVE: To determine the effectiveness of exercise training (aerobic and resistance) in modifying blood lipids, and to determine the most effective training programme with regard to duration, intensity and frequency for optimizing the blood lipid profile. DESIGN: Trials were identified by a systematic search of Medline, Embase, Science Citation Index (SCI), published reviews and the references of relevant trials. The inclusion criteria were limited to randomized, controlled trials of aerobic and resistance exercise training which were conducted over a minimum of four weeks and involved measurement of one or more of the following: total cholesterol (TC), high density lipoprotein (HIDL-C), low density lipoprotein (LDL-C) and triglycerides (TG). SUBJECTS: A total of 31 trials ( 1833 hyperlipidemic and normolipidemic participants) were included. RESULTS: Aerobic exercise training resulted in small but statistically significant decreases of 0.10 mmol/L (95% CI: 0.02, 0.18). 0.10 (95% CI: 0.02, 0.19), 0.08 mmol/L (95% CI: 0.02, 0.14), for TC, LDL-C, and TG, respectively, with an increase in HDL-C of 0.05 mmol/L (95% CI: 0.02, 0.08). Comparisons between the intensities of the aerobic exercise programmes produced inconsistent results; but more frequent exercise did not appear to result in greater improvements to the lipid profile than exercise three times per week. The evidence for the effect of resistance exercise training was inconclusive. CONCLUSIONS: Caution is required when drawing firm conclusions from this study given the significant heterogeneity with comparisons. However, the results appear to indicate that aerobic exercise training produced small but favourable modifications to blood lipids in previously sedentary adults.

Recruitment of older adults for a randomized, controlled trial of exercise advice in a general practice setting.

OBJECTIVES: The success of any clinical trial depends strongly on recruiting enough participants in a reasonable time period. This paper aims to identify the obstacles, as well as the successful aspects, of recruiting of older participants into an exercise study. DESIGN: This describes the recruitment of 299 older adults into a randomized, controlled trial of exercise advice in a general practice setting. Letters of invitation were sent from two general practices inviting the patients to attend a 15-minute screening appointment. Patients considered eligible for enrollment were then scheduled for a baseline appointment and randomized into the trial. SETTING: Two general practices in Adelaide, South Australia. PARTICIPANTS: Healthy, sedentary, community-dwelling patients aged 60 years or older. RESULTS: A total of 2878 letters of invitation were sent, and 913 patients attended a screening appointment. Of these, 351 (38.4%) were initially eligible, with one-third excluded because they were already too physically active. Two hundred ninety-nine participants, approximately 1 of every 10 patients sent letters, were enrolled in the project at the end of a 15-week period. DISCUSSION: A general practice approach was effective in recruiting 299 older adults to an exercise project within an acceptable time frame. Factors promoting the success of recruitment through general practice included choosing large, well established practices, computerized age-sex registers, and placing minimal demands on the general practitioners and practice staff. A continuing problem with recruiting participants for a project involving exercise is that the volunteer population tends to be healthy and interested in physical activity.

A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines.

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.

Providing evidence-based answers to clinical questions. A pilot information service for general practitioners.

OBJECTIVE: To pilot a clinical information service for general practitioners. METHODS: A representative sample of 31 GPs was invited to submit clinical questions to a local academic department of general practice. Their views on the service and the usefulness of the information were obtained by telephone interview. RESULTS: Over one month, nine GPs (29% of the sample, 45% of those stating an interest), submitted 20 enquiries comprising 45 discrete clinical questions. The median time to search for evidence, appraise it and write answers to each enquiry was 2.5 hours (range, 1.0-7.4 hours). The median interval between receipt of questions and dispatch of answers was 3 days (range, 1-12 days). CONCLUSIONS: The GPs found the answers useful in clinical decision making; in four out of 20 cases patient management was altered.

Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects.

OBJECTIVES: To estimate the efficacy of dietary advice to lower blood total cholesterol concentration in free-living subjects and to investigate the efficacy of different dietary recommendations. DESIGN: Systematic overview of 19 randomised controlled trials including 28 comparisons. SUBJECTS: Free-living subjects. INTERVENTIONS: Individualised dietary advice to modify fat intake. MAIN OUTCOME MEASURE: Percentage difference in blood total cholesterol concentration between the intervention and control groups. RESULTS: The percentage reduction in blood total cholesterol attributable to dietary advice after at least six months of intervention was 5.3% (95% confidence interval 4.7% to 5.9%). Including both short and long duration studies, the effect was 8.5% at 3 months and 5.5% at 12 months. Diets equivalent to the step 2 diet of the American Heart Association were of similar efficacy to diets that aimed to lower total fat intake or to raise the polyunsaturated to saturated fatty acid ratio. These diets were moderately more effective than the step 1 diet of the American Heart Association (6.1% v 3.0% reduction in blood total cholesterol concentration; P<0.0001). On the basis of reported food intake, the targets for dietary change were seldom achieved. The observed reductions in blood total cholesterol concentrations in the individual trials were consistent with those predicted from dietary intake on the basis of the Keys equation. CONCLUSIONS: Individualised dietary advice for reducing cholesterol concentration is modestly effective in free-living subjects. More intensive diets achieve a greater reduction in serum cholesterol concentration. Failure to comply fully with dietary recommendations is the likely explanation for this limited efficacy.

The effectiveness of exercise training in lowering blood pressure: a meta-analysis of randomised controlled trials of 4 weeks or longer.

OBJECTIVE: To identify the features of an optimal exercise programme in terms of type of exercise, intensity and frequency that would maximise the training induced decrease in blood pressure (BP). DATA IDENTIFICATION: Trials were identified by a systematic search of Medline, Embase and Science Citation Index (SCI), previous review articles and the references of relevant trials, from 1980 until 1996, including only English language studies. STUDY SELECTION: The inclusion criteria were limited to randomised controlled trials of aerobic or resistance exercise training conducted over a minimum of 4 weeks where systolic and diastolic BP was measured. RESULTS: A total of 29 studies (1533 hypertensive and normotensive participants) were included, 26 used aerobic exercise training, two trials used resistance training and one study had both resistance and aerobic training groups. Aerobic exercise training reduced systolic BP by 4.7 mm Hg (95% CI: 4.4, 5.0) and diastolic BP by 3.1 mm Hg (95% CI: 3.0, 3.3) as compared to a non-exercising control group, however, significant heterogeneity was observed between trials in the analysis. The BP reduction seen with aerobic exercise training was independent of the intensity of exercise and the number of exercise sessions per week. The evidence for the effect of resistance exercise training was inconclusive. CONCLUSIONS: Aerobic exercise training had a small but clinically significant effect in reducing systolic and diastolic BP. Increasing exercise intensity above 70% VO2 max or increasing exercise frequency to more than three sessions per week did not have any additional impact on reducing BP.