Road Map For Diffusion Of Innovation In Health Care

New scientific knowledge and innovation are often slow to disseminate. In other cases, providers rush into adopting what appears to be a clinically relevant innovation, based on a single clinical trial. In reality, adopting innovations without appropriate translation and repeated testing of practical application is problematic. In this article we provide examples of clinical innovations (for example, tight glucose control in critically ill patients) that were adopted inappropriately and that caused what we term a malfunction. To address the issue of malfunctions, we review various examples and suggest frameworks for the diffusion of knowledge leading to the adoption of useful innovations. The resulting model is termed an integrated road map for coordinating knowledge transformation and innovation adoption. We make recommendations for the targeted development of practice change procedures, practice change assessment, structured descriptions of tested interventions, intelligent knowledge management technologies, and policy support for knowledge transformation, including further standardization to facilitate sharing among institutions.

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services

As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system-level efforts are needed to increase the use of preventive services.

An Interactive Workshop Reviewing Basic Biostatistics and Applying Bayes' Theorem to Diagnostic Testing and Clinical Decision-Making

INTRODUCTION

Sensitivity, specificity, and predictive values-the basic statistics behind using and interpreting screening and diagnostic tests-are taught in all medical schools, yet studies have shown that a majority of physicians cannot correctly define and apply these concepts. Previous work has not rigorously examined this disconnect and attempted to address it.

METHODS

We used adult learning theory to design a case-based interactive workshop to review biostatistics and apply them to clinical decision-making using Bayes' theorem. Participants took an anonymous multiple-choice pretest, posttest, and delayed posttest on definitions and application of the concepts, and we compared the scores between the three tests. Several experiences with early iterations provided feedback to improve the workshop but were not included for analysis.

RESULTS

We conducted the finalized workshop with 54 pediatrics students, residents, and faculty. All learners completed the immediate pre- and posttests, and eight completed the delayed posttest. Average scores rose from 4.5/8 (56%) on the pretest to 6.5/8 (81%) on the posttest and 6.4/8 (80%) on the delayed posttest. Two-tailed t tests showed p < .001 for the difference between the pretest and both posttests, and post hoc power analysis showed a power of 99% to detect the observed differences. There was no significant difference (p = .8) between the posttest and delayed posttest.

DISCUSSION

Our work demonstrates that an interactive workshop reviewing basic biostatistics and teaching rational diagnostic testing using Bayes' theorem can be effective in connecting theoretical knowledge of biostatistics to evidence-based decision-making in real clinical practice.

[Choosing Wisely Portugal - Wise Health Decisions]

n/a.

How to Choose the Best Evidence?

N/A.

The Quality of EBM Sources Perceived By Belgian Family Physicians

BACKGROUND

Belgian family physicians use several local and international sources for evidence-based medicine (EBM).

AIM

This study aims to investigate the quality of these EBM sources according to the Belgian family physicians.

METHODS

A sample of Belgian family physicians completed a digital survey on the quality of EBM sources.

RESULTS

Respondents evaluated the quality of the information for the major part of the local and international EBM sources good to excellent. More than 50% of the respondents found in the major part of the sources an answer to the question. More than half of the respondents found the necessary information in less than 5 minutes in most of the sources. Younger participants self-evaluated their search skills better than older participants.

CONCLUSION

The quality of most frequently used EBM sources in Belgium is evaluated as good and client-friendly. More than half of the respondents found an answer to their questions in most of the sources and this within 5 minutes.

RELATION BETWEEN IMPACT FACTOR IN ORTHOPEDIC JOURNALS AND LEVEL OF EVIDENCE

Objective:

This study aims to assess the quality of articles published in the leading orthopedic surgery journals, by measuring the relation between the impact factor and the number studies with a high level of evidence.

Methods:

A literature review was performed of articles published in four previously selected journals. A score of journal evidence (RER - Relation between Randomized clinical trials and Systematic reviews) was calculated, considering the number of RCTs and SR published and the total number of full-text articles.

Results:

The selected journals were JBJS-Am, ASMJ, BJJ-Br and Arthroscopy, with Impact factors of 5.280, 4.362, 3.309 and 3.206 respectively in 2015. In the study, the RER Scores, in the same order, were 9.408, 6.153, 7.456 and 7.779.

Conclusion:

The journal JBJS-Am is the best available source of information on orthopedic surgery from this point of view. It has the highest Impact Factor and clearly the highest RER Score. On the other hand, we could conclude that the number of published RCT and good quality SR is very low, with less than 10% of all the articles. Level of evidence III, Analyses based on limited alternatives and costs, and poor estimates.

Explicit Bias Toward High-Income-Country Research: A Randomized, Blinded, Crossover Experiment Of English Clinicians

Unconscious bias may interfere with the interpretation of research from some settings, particularly from lower-income countries. Most studies of this phenomenon have relied on indirect outcomes such as article citation counts and publication rates; few have addressed or proven the effect of unconscious bias in evidence interpretation. In this randomized, blinded crossover experiment in a sample of 347 English clinicians, we demonstrate that changing the source of a research abstract from a low- to a high-income country significantly improves how it is viewed, all else being equal. Using fixed-effects models, we measured differences in ratings for strength of evidence, relevance, and likelihood of referral to a peer. Having a high-income-country source had a significant overall impact on respondents' ratings of relevance and recommendation to a peer. Unconscious bias can have far-reaching implications for the diffusion of knowledge and innovations from low-income countries.

Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending

An analysis of data for 2014 about forty-four low-value health services in the Virginia All Payer Claims Database revealed more than $586 million in unnecessary costs. Among these low-value services, those that were low and very low cost ($538 or less per service) were delivered far more frequently than services that were high and very high cost ($539 or more). The combined costs of the former group were nearly twice those of the latter (65 percent versus 35 percent).

Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization

The YMCA of the USA received a Health Care Innovation Award from the Centers for Medicare and Medicaid Services to provide a diabetes prevention program to Medicare beneficiaries with prediabetes in seventeen regional networks of participating YMCAs nationwide. The goal of the program is to help participants lose weight and increase physical activity. We tested whether the program reduced medical spending and utilization in the Medicare population. Using claims data to compute total medical costs for fee-for-service Medicare participants and a matched comparison group of nonparticipants, we found that the overall weighted average savings per member per quarter during the first three years of the intervention period was $278. Total decreases in inpatient admissions and emergency department (ED) visits were significant, with nine fewer inpatient stays and nine fewer ED visits per 1,000 participants per quarter. These results justify continued support of the model.

Implementation of motor learning principles in physical therapy practice: Survey of physical therapists' perceptions and reported implementation

INTRODUCTION

The field of motor learning (ML) plays a pivotal role in physical therapy (PT), and its implementation has been shown to improve intervention outcomes. The objective of this study was to assess physical therapists' ML-related self-efficacy, self-reported implementation, and environmental workplace factors. An additional aim was to report the psychometric properties of a questionnaire that was developed to assess the above-mentioned constructs.

METHODS

An observational, cross-sectional survey was completed by 289 physical therapists (average age: 38.7 (9.7), with 11.3 (9.7) years of experience and 74% female). Construct validity, internal consistency, and test-retest reliability were tested. The main outcome measures were the scores of the three scales of the questionnaire, referring to self-efficacy in ML, implementation of ML principles, and workplace environment features.

RESULTS

The questionnaire had sound psychometric qualities. Respondents perceived ML as an integral part of PT. ML-related self-efficacy and implementation of ML principles were moderate (2.95/5 (0.7) and 3.04/5(0.8), respectively). PT practice had a significant effect on ML-related self-efficacy (p = 0.035) and implementation (p = 0.0031). Respondents who had undergone ML training in their graduate program reported higher ML-related self-efficacy (p = 0.007). Respondents who had postgraduate training in ML reported significantly more extensive implementation (p = 0.024). Lack of knowledge and lack of time were perceived as the major barriers to implementation.

CONCLUSIONS

Level of self-efficacy might be insufficient to support the systematic implementation of ML principles in practice. Addressing impeding individual- and organizational-level factors might facilitate ML self-efficacy and implementation. Postgraduate education facilitates ML implementation.

Suicide Prevention: An Emerging Priority For Health Care

Suicide is a significant public health problem. It is the tenth leading cause of death in the United States, and the rate has risen in recent years. Many suicide deaths are among people recently seen or currently under care in clinical settings, but suicide prevention has not been a core priority in health care. In recent years, new treatment and management strategies have been developed, tested, and implemented in some organizations, but they are not yet widely used. This article examines the feasibility of improving suicide prevention in health care settings. In particular, we consider Zero Suicide, a model for better identification and treatment of patients at risk for suicide. The approach incorporates new tools for screening, treatment, and support; it has been deployed with promising results in behavioral health programs and primary care settings. Broader adoption of improved suicide prevention care may be an effective strategy for reducing deaths by suicide.

Critical Appraisal Worksheets for Integration Into an Existing Small-Group Problem-Based Learning Curriculum

INTRODUCTION

Since medical students matriculate with a diversity of backgrounds, there can exist a disparity in student ability to critically appraise health science literature. To address this, we developed a critical appraisal exercise and integrated it into the first-year problem-based learning (PBL) curriculum at Case Western Reserve University School of Medicine.

METHODS

For 8 weeks, first-year medical students read a weekly preselected health science literature article relating to the content of their PBL curriculum and completed a critical appraisal worksheet consisting of questions regarding study design and result interpretation. Students discussed the article and worksheet within PBL small groups. Faculty facilitators were given the critical appraisal worksheet answer key, which students later gained access to after the discussion. To measure changes in critical appraisal skills, a voluntary questionnaire based on the Berlin questionnaire, a validated tool for measuring knowledge and skills in evidence-based medicine, was administered before and after the 8-week intervention.

RESULTS

Using paired Student t tests, we found that the students who completed both questionnaires (N = 60) showed an average improvement of 4% (p = .03). Students who scored at or below the 50th percentile on the preintervention questionnaire showed an average improvement of 12% (p = .002).

DISCUSSION

These critical appraisal worksheets are easily adaptable to an existing PBL curriculum and are an effective tool for improving and teaching critical appraisal skills in those students who will benefit most.

Focused Evidence-Based Medicine Curriculum for Trainees in Neonatal-Perinatal Medicine

INTRODUCTION

While evidence-based medicine (EBM) is an Accreditation Council for Graduate Medical Education core competency, EBM teaching in pediatric subspecialties is rarely reported. Therefore, we designed, implemented, and evaluated this focused EBM curriculum for trainees in neonatal-perinatal medicine.

METHODS

This EBM curriculum consists of seven weekly 1-hour sessions. Specific EBM skills taught in the sessions include formulating a structured clinical question, conducting an efficient literature search, critically appraising published literature in both intervention and diagnostic studies, and incorporating evidence into clinical decision-making. The course was evaluated by a neonatology-adapted Fresno test (NAFT) and neonatology case vignettes, which were administered to learners before and after the curriculum. This publication includes the needs assessment survey, PowerPoint slides for the seven sessions, the NAFT, and the scoring rubric for the test.

RESULTS

The NAFT was internally reliable, with a Cronbach's alpha of .74. The intraclass correlation coefficient of the three raters' variability in assessment of learners was excellent at .98. Mean test scores increased significantly (54 points, p < .001) in 14 learners after the EBM curriculum, indicating an increase in EBM-related knowledge and skills.

DISCUSSION

This focused EBM curriculum enhances trainees' knowledge and skills and fosters evidence-based practice. The curriculum can be easily adapted for learners in pediatrics, as well as family medicine, in order to enhance trainees' EBM skills and knowledge.

Statistical competencies for medical research learners: What is fundamental?

Introduction

It is increasingly essential for medical researchers to be literate in statistics, but the requisite degree of literacy is not the same for every statistical competency in translational research. Statistical competency can range from ‘fundamental’ (necessary for all) to ‘specialized’ (necessary for only some). In this study, we determine the degree to which each competency is fundamental or specialized.

Methods

We surveyed members of 4 professional organizations, targeting doctorally trained biostatisticians and epidemiologists who taught statistics to medical research learners in the past 5 years. Respondents rated 24 educational competencies on a 5-point Likert scale anchored by ‘fundamental’ and ‘specialized.’

Results

There were 112 responses. Nineteen of 24 competencies were fundamental. The competencies considered most fundamental were assessing sources of bias and variation (95%), recognizing one’s own limits with regard to statistics (93%), identifying the strengths, and limitations of study designs (93%). The least endorsed items were meta-analysis (34%) and stopping rules (18%).

Conclusion

We have identified the statistical competencies needed by all medical researchers. These competencies should be considered when designing statistical curricula for medical researchers and should inform which topics are taught in graduate programs and evidence-based medicine courses where learners need to read and understand the medical research literature.

Understanding An Informed Public's Views On The Role Of Evidence In Making Health Care Decisions

Policy makers and practitioners increasingly believe that medical evidence plays a critical role in improving care and health outcomes and lowering costs. However, public understanding of the role of evidence-based care may be different. Public deliberation is a process that convenes diverse citizens and has them learn about and consider ethical or values-based dilemmas and weigh alternative views. The Community Forum Deliberative Methods Demonstration project, sponsored by the Agency for Healthcare Research and Quality, obtained informed public views on the role of evidence in health care decisions through seventy-six deliberative groups involving 907 people overall, in the period August-November 2012. Although participants perceived evidence as being essential to high-quality care, they also believed that personal choice or clinical judgment could trump evidence. They viewed doctors as central figures in discussing evidence with patients and key arbiters of whether to follow evidence in individual cases. They found evidence of harm to individuals or the community to be more compelling than evidence of effectiveness. These findings indicate that increased public understanding of evidence can play an important role in advancing evidence-based care by helping create policies that better reflect the needs and values of the public.

Reinventing The Wheel Of Medical Evidence: How The Boot Camp Translation Process Is Making Gains

Medical guidelines use language and concepts that are not understood by many patients, which makes it difficult for patients to choose the best treatment. The High Plains Research Network's Community Advisory Council, made up of farmers, teachers, and other community members in eastern Colorado, identified a lack of community knowledge about colon cancer and developed a process the council named Boot Camp Translation to turn complex screening guidelines into locally relevant messages. This article provides a brief history of the process and describes how it has been used to translate and disseminate evidence-based medical guidelines. The Colorado Clinical and Translational Sciences Institute tested the Boot Camp Translation process on multiple topics in communities throughout the United States from 2012 to 2015. During that period the institute used the process more than twenty-five times, addressing the topics of cancer prevention, hypertension, asthma, diabetes, and mental health. Multiple studies show that use of the process has led to improvement in cancer testing, asthma management, and hypertension control. Policies that support the translation of medical evidence into local programs will improve the health of patients.

Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information

The growth of shared decision making has been driven largely by the understanding that patients need information and choices regarding their health care. But while these are important elements for patients who make decisions in partnership with their clinicians, our experience suggests that they are not enough to address the larger issue: the need for the patient and clinician to jointly create a course of action that is best for the individual patient and his or her family. The larger need in evidence-informed shared decision making is for a patient-clinician interaction that offers conversation, not just information, and care, not just choice.

The Importance Of Integrating Narrative Into Health Care Decision Making

When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidence-based medical practice.

An Integrated, Case-Based Approach to Teaching Medical Students How to Locate the Best Available Evidence for Clinical Care

INTRODUCTION

A major step of the evidence-based medicine (EBM) process is to locate the most current evidence in support of clinical care. This requires identifying and searching appropriate evidence-based resources. Medical library faculty at the Oakland University William Beaumont School of Medicine teach these skills as part of a dedicated EBM course at the end of the second year of the medical school curriculum.

METHODS

A 3-hour "Locating the Best Available Evidence" session is divided into two major components: an optional 50-minute didactic lecture followed by a mandatory 2-hour interactive lab. Students formulate a PICO (patient, intervention, comparison, outcome) question from a case, develop search strategies, and gather evidence. Formative feedback is provided to the students to help them prepare for a final case presentation.

RESULTS

Session effectiveness is assessed using course evaluations and the case presentation grade. Course evaluations indicate that students find this session structure to be especially helpful in learning the breadth of available EBM resources, preparing for their course case presentations, and acquiring skills for clinical clerkships. Quality of the case presentations also indicates students have acquired the necessary skills to be successful in practicing EBM skills in clerkship rotations and residency.

DISCUSSION

Whether institutions have a dedicated EBM course or integrate EBM skills into the medical school curriculum, this session could easily be adapted and implemented. It could also be tailored for graduate or continuing medical education environments in any specialty.

Managing chronic illness: physician practices increased the use of care management and medical home processes

The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.

Knowledge, attitude, and practices among Iranian neurologists toward evidence-based medicine

Background: Evidence-based medicine (EBM) is a current practice in medicine to produce clinical practice guidelines from well-designed, randomized, controlled trials. We studied knowledge, attitude, and practice of EBM of neurologists who participated in the Iranian congress of neurology. Methods: A self-administered anonymous questionnaire was distributed and filled by neurologists. Results: A total of 200 neurologists were randomly sampled and with response rate of 56%. 33.9% of responder had previously participated in EBM courses. The average total knowledge score was 4.05 ± 0.80 out of a maximum possible score of 5.0. Textbooks were still the most favorite source of knowledge for our neurologists. A lack of time was the highest, and motivation the least mentioned barrier in using EBM. Conclusion: Overall, the Iranian neurologist had acceptable knowledge and attitude toward EBM and had same similar as found in other studies.