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By E. Ballock. University of Colorado, Colorado Springs. 2018.

None of the sites held formal training sessions for nurses cheap 1pack slip inn amex, medics buy slip inn 1pack visa, PAs trusted 1pack slip inn, or other ancillary staff involved in the treatment of low back pain patients order 1pack slip inn otc. In most cases buy slip inn 1pack low price, these staff were simply instructed to ask patients to fill out their portion of form 695-R and, at some sites, to hand out a patient education pamphlet. Only about one-half of the ancillary staff that participated in our focus groups reported they had been introduced to the guideline. This omission contributed to reluctance by clinic staff at some sites to cooperate in using the guideline. To ensure use of conservative treat- ment for acute low back pain patients, all sites attempted to use the encounter form 695-R to support implementation of the guideline and ensure documentation of diagnosis and treatment. Compliance varied across the sites, however, depending on the support availabil- Implementation Actions by the Demonstration Sites 63 ity and frequency of rotation of ancillary staff, acceptance of the form by primary care providers, and aggressiveness of monitoring. Typically, a low back pain patient was identified at the sign-in desk or in the screening room. Clinic staff filled in the vital signs section and attached the form to the medical chart for the provider’s use. Com- pliance with this relatively simple procedure varied initially from 20 percent at some clinics to 92 percent at some TMCs, and most sites reported that compliance decreased over time. First, it was not clear to the sites whether MEDCOM mandated use of the form or gave the sites the discretion to decide whether and how to use it. MEDCOM clarified that the sites were expected to document the diagnosis and treatment of low back pain patients appropriately in the medical chart, but they could choose how to do that. The form 695-R was provided as a tool that would achieve appropriate documentation, but they were not required to use it. In response to this guidance, the sites tended to leave to the individual providers the decision about whether to use form 695-R. A second reason for low compliance in using form 695-R is that many providers were not satisfied with the contents of the form, and in particular, many complained that the form did not provide enough space to write notes. Overall, most physicians reported they used the form at the first visit (65 percent of providers in the focus groups), but only 20 percent used it at subsequent visits or for patients pre- senting with multiple problems. Providers felt that filling out the form at each return visit was duplicative and unnecessary. At one site, physicians had all but stopped using the form by the time of our last visit. Lack of standardization among providers within one clinic or TMC in use of the form made the processing of patients confusing for the ancillary staff. Third, many ancillary staff perceived that the documentation form added to an already heavy workload, and, hence, they were reluctant to use it. Ironically, about two-thirds of the ancillary staff that partic- ipated in our focus groups and had used the form reported that it shortened processing time (45 percent) or made no difference 64 Evaluation of the Low Back Pain Practice Guideline Implementation (22 percent). Some providers reported they did not insist the form be included with the patient’s chart because they knew the ancillary staff were overworked and they did not like placing new demands on them. The relatively high rotation of ancillary staff, particularly at TMCs, also contributed to low compliance with use of form 695-R. The sites did not act forcefully to maintain adequate levels of staff training regarding procedures for use of the form. Finally, some TMCs and clinics reported they ran out of forms and did not know how to replace them. MEDCOM did not set down procedures for ordering new supplies until later in the demonstration. This administrative barrier for providers and clinic staff discouraged use of the form yet further. AMEDD regulations state that only the SF-600 form can be placed in chronological order in the patient chart. Providers at some sites ex- pressed frustration at having to search for the form in the chart. Seeking to overcome some of these difficulties, one site spent con- siderable staff time to develop an automated form 695-R. The use of this automated form was being tested at one TMC at the time of our last visit, but test results were not yet available.

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Information Exchange Several information exchange mechanisms were considered to help the MTFs share their implementation experiences and learn from each other best slip inn 1pack. These included email and web-based systems as well as periodic audio and videoconferences order slip inn 1pack free shipping. We saw value in testing a vari- ety of techniques order slip inn 1pack otc, which would reinforce messages and information sharing and also would allow us to learn which techniques are most useful for the participants cheap 1pack slip inn otc. An electronic listserve can be established as a free-standing email system or as part of a web-based bulletin board purchase slip inn 1pack without prescription. With an email-based listserve, the participants are signed up as members and can exchange email with all other members by ad- dressing a single message to the listserve’s email address. The list- serve can also be linked to a web-based home site with a bulletin board and chat rooms. Participants at the low back pain kickoff conference were asked to complete a brief survey on their current use of electronic media (email and the web) and their interest in various listserve features. The results of the survey indicated that it would be important to use email for communications among the sites at the time of the demon- stration. Almost three-quarters of the demonstration team members reported they had regular access to an email system, but fewer than 44 Evaluation of the Low Back Pain Practice Guideline Implementation 10 percent had regular access to the web. Almost two-thirds of the participants reported they would prefer to use an email system for communications during the demonstration. Additional written comments on the survey form revealed a desire for a fast, easy-to-use system and raised some concerns about limitations of the current capabilities of their systems. A home site for the low back pain demonstration was set up on the AMEDD Knowledge Management Network (KMN) immediately fol- lowing the kickoff conference. It was chosen over a simpler email listserve because the AMEDD’s leadership preferred to use existing capabilities to support implementation of guidelines whenever possible. Registration involved a lengthy series of steps, and most who tried to register found the process complex and confusing. In the end, few demonstration participants chose to register, and even fewer (five to ten) actually used the system. KMN did not provide the user-friendly communication mechanism hoped for, and it ended up not being used. Later attempts to replace it with a dedicated listserve were also unsuccessful due to technical difficul- ties. Hence, the demonstration proceeded without an electronic means for quick communications across sites and between sites and MEDCOM. MEDCOM used periodic teleconferences or videoconferences to communicate with the sites during the demonstration. MEDCOM staff also participated in the two rounds of site visits for the RAND evaluation, during which they were able to address questions from the sites and more generally as- sist them in their implementation activities. However, as discussed above, the small MEDCOM staff team was being pulled in multiple directions to start up the low back pain demonstration and also to prepare for implementation of the asthma and diabetes guidelines. As a result, MEDCOM was less responsive than needed, and some sites ran out of supplies and lacked instructions for reordering them. Infrastructure for Guideline Implementation 45 STRUCTURE AND SUPPORT AT THE MTFs To prepare for implementation of the low back pain guideline, com- manders of the MTFs participating in the demonstration were re- quested to appoint a multidisciplinary implementation team of eight to ten individuals who represented the mix of clinical and support staff involved in delivering care for patients with low back pain. The responsibility of the implementation team was to develop an action plan and facilitate its implementation. In addition, the commanders were requested to designate a guideline champion and a facilitator to lead the implementation activities. Preferably, this in- dividual was a primary care physician who was an opinion leader and had a strong commitment to the successful implementation of the guideline. The facilitator was to guide the implementation team in developing an implementation action plan and then to provide support to the champion and team in coordinating and managing the implementation process. This individual needed experience fa- cilitating group decisionmaking processes as well as to be able to or- ganize work processes and to work with data for quality management and monitoring activities. Command Support and Accountability Commanders at the demonstration MTFs had agreed to participa- tion in the low back pain guideline demonstration. Over the life of the demonstration, however, the support of the MTF commanders ranged from moderately strong to absent, and some commanders appeared to be ambivalent or passive toward the guideline work.

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One method of converting health out- comes into dollars is through a contingent valuation cheap 1pack slip inn visa, or willingness-to-pay approach generic slip inn 1pack visa. Using this technique slip inn 1pack on-line, subjects are asked how much money they would be willing to spend to obtain slip inn 1pack low cost, or avoid purchase 1pack slip inn otc, a health outcome. For example, a study by Appel and colleagues (23) found that individuals would be willing to pay $50 for low osmolar contrast agents to decrease the probability of side effects from intravenous contrast. However, in general, health outcomes and benefits are difficult to transform to mone- tary units; hence, CBA has had limited acceptance and use in medicine and diagnostic imaging (15,24). Blackmore Cost-effectiveness analysis (CEA) refers to analyses that study both the effectiveness and cost of competing diagnostic or treatment strategies, where effectiveness is an objective measure (e. Radi- ology CEAs often use intermediate outcomes, such as lesion identified, length of stay, and number of avoidable surgeries (15,17). However, ideally long-term outcomes such as life-years saved (LYS) should be used (20). For example, annual mammography for women age 55 to 64 years costs $110,000 per LYS (updated to 1993 U. Cost-utility analysis is similar to CEA except that the effectiveness also accounts for quality of life issues. Quality of life is measured as utilities that are based on patient preferences (15). The most commonly used utility measurement is the quality-adjusted life year (QALY). The rationale behind this concept is that the QALY of excellent health is more desirable than the same 1 year with substantial morbidity. The QALY model uses preferences with weight for each health state on a scale from 0 to 1, where 0 is death and 1 is perfect health. The utility score for each health state is multiplied by the length of time the patient spends in that specific health state (15,28). For example, let’s assume that a patient with a moderate stroke has a utility of 0. Cost-utility analysis incorporates the patient’s subjective value of the risk, discomfort, and pain into the effectiveness measurements of the different diagnostic or therapeutic alternatives. In the end, all medical decisions should reflect the patient’s values and priorities (28). That is the explana- tion of why cost-utility analysis is becoming the preferred method for eval- uation of economic issues in health (18,20). For example, in low-risk newborns with intergluteal dimple suspected of having occult spinal dys- raphism, ultrasound was the most effective strategy with an incremented cost-effectiveness ratio of $55,100 per QALY. In intermediate-risk newborns with low anorectal malformation, however, MRI was more effective than ultrasound at an incremental cost-effectiveness of $1000 per QALY (29). Assessment of Outcomes: The major challenge to cost-utility analysis is the quantification of health or quality of life. By assessing what patients can and cannot do, how they feel, their mental state, their functional independence, their freedom from pain, and any number of other facets of health and well-being that are referred to as domains, one can summarize their overall health status. Instruments designed to measure these domains are called health status instruments. A large number of health status instruments exist, both general instruments such as the SF-36 (30), as well as instruments that are specific to particular disease states, such as the Roland scale for back pain. For example, Jarvik and colleagues (31) found no significant difference in the Roland score between patients randomized to MRI versus radiography for low back pain, suggesting that MRI was not worth the additional cost. Chapter 1 Principles of Evidence-Based Imaging 11 Assessment of Cost: All forms of economic analysis require assessment of cost. However, assessment of cost in medical care can be confusing, as the term cost is used to refer to many different things. Reimbursements, derived from Medicare and other fee schedules, are useful as an estimation of the amounts society pays for particular health care interventions. For an analysis taken from the soci- etal perspective, such reimbursements may be most appropriate.

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The appropriate use of these modalities may be helpful and should not be discouraged buy slip inn 1pack. We recognize that we cannot predict the future with anyone buy cheap slip inn 1pack, let alone those with MS 1pack slip inn free shipping, but it appears that about 20% of those with clear MS will do well with their disease no matter what we do best slip inn 1pack. This figure is often debated and much data is secured on both sides of the debate buy slip inn 1pack cheap, but 20% is a reasonable figure. The problem is determining who is going to be in that 20%, versus the 80% who will not do as well. Studies and now experience indi- cate that the medications available for altering the disease course actually make a difference. Interferon beta 1b (Betaseron®) was the first, followed rapidly by interferon beta 1a (Avonex®, Rebif®), glati- ramer acetate (Copaxone®), and mitoxanthrone (Novantrone®). If one gets a cold or sore throat, the body makes interferon, which then modulates the immune system. Gamma interferon appears to stimulate the immune system and 16 CHAPTER 2 • Managing the Disease Process makes MS worse. Beta interferon appears to settle it, and it decreas- es the attack rate, decreases the severity of attacks, increases the time between attacks, and decreases the damage to the nervous sys- tem as monitored on magnetic resonance imaging (MRI) scanning. It is a polypeptide—a combination of four amino acids whose structure in some way fools the immune system. It is used as a chemotherapy agent (similar to that used to treat cancer) and affects all aspects of the immune system. All of these medications are expensive and all have side-effects that will be discussed, thus care must be taken in making decisions regarding their use. There is some controversy as to when in the course of the disease these should be introduced. Most MS experts believe that early intervention with an interferon or with glatiramer acetate is appropriate. Some feel that treatment should be initiated when the diagnosis of MS is made or even suspected. They point out that a study done on those with the suspicion of MS resulted in a delay to the actual diagnosis. Unfortunately we do not know exactly what that means for most people with the disease, because the timing of the diagnosis may or may not have anything to do with future disability. Understanding that about 20% of people with MS may not need treatment because they will do well without it also must play a role in the decision making process. Much has been made of the fact that we can see abnormalities on the MRI and that the MRI changes in the course of MS. Clearly the MRI is an excellent tool to be used in making an early diagnosis of MS and helping to confirm the diagnosis. It is fair to assume that if there are many, many abnormalities on the initial scan, problems with func- tion will be forthcoming. Clearly 17 PART I • The Disease and Its Management the scan changes over time, sometimes actually improving. Some feel that routine checking of the MRI will give information about the future course of the disease, but that is not based on reality. Some feel that the brain of those with MS will shrink if treatment is not instituted immediately. Of course, all our brains shrink with age, but it is real- ly impossible to speculate at the front end of the diagnosis how much shrinkage will or will not occur. Thus, many unanswered questions remain that deserve an answer and undoubtedly will be answered in the next decade. In the meantime, there will be some disagreement as to when and which agent should be given and to whom. Clearly, this question must be answered by the physician who knows you and is monitoring your MS. High dose inter- feron (Betaseron®, Rebif®) appears to be stronger than low dose (Avonex®), which is a function of dose rather than the structure of the medication, because Avonex® and Rebif® are structurally identi- cal. Clearly, many people with MS can be successfully treated with a low dose, but many will need a higher dose with time.

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