Fidelity Failures in Brief Strategic Family Therapy for Adolescent Drug Abuse: A Clinical Analysis

As evidence-based family treatments for adolescent substance use and conduct problems gain traction, cutting edge research moves beyond randomized efficacy trials to address questions such as how these treatments work and how best to disseminate them to community settings. A key factor in effective dissemination is treatment fidelity, which refers to implementing an intervention in a manner consistent with an established manual. While most fidelity research is quantitative, this study offers a qualitative clinical analysis of fidelity failures in a large, multisite effectiveness trial of Brief Strategic Family Therapy (BSFT) for adolescent drug abuse, where BSFT developers trained community therapists to administer this intervention in their own agencies. Using case notes and video recordings of therapy sessions, an independent expert panel first rated 103 cases on quantitative fidelity scales grounded in the BSFT manual and the broader structural-strategic framework that informs BSFT intervention. Because fidelity was generally low, the panel reviewed all cases qualitatively to identify emergent types or categories of fidelity failure. Ten categories of failures emerged, characterized by therapist omissions (e.g., failure to engage key family members, failure to think in threes) and commissions (e.g., off-model, nonsystemic formulations/interventions). Of these, "failure to think in threes" appeared basic and particularly problematic, reflecting the central place of this idea in structural theory and therapy. Although subject to possible bias, our observations highlight likely stumbling blocks in exporting a complex family treatment like BSFT to community settings. These findings also underscore the importance of treatment fidelity in family therapy research.

The Role of the Integrated Digital Radiology System in Assessing the Impact of Patient Load on Emergency Computed Tomography (CT) Efficiency

Time-critical management is of particular significance in the trauma and emergency setting, where intervals from patient arrival to diagnostic imaging and from imaging to radiology report are key determinants of outcome. This study, based in the Trauma and Emergency Unit of a large, tertiary-level African hospital with a fully digital radiology department, assessed the impact of increased workload on computerised tomography (CT) efficiency. Sequential, customised searches of the institutional radiology information system (RIS) were conducted to define two weekends in 2016 with the lowest and highest emergency CT workloads, respectively. The electronic RIS timestamps defining the intervals between key steps in the CT workflow were extracted and analysed for each weekend. With the exception of radiologist reporting time, workflow steps were significantly prolonged by increased workload. This study highlights the potential role of the integrated digital radiology system in enabling a detailed analysis of imaging workflow, thereby facilitating the identification and appropriate management of bottlenecks.

Healthcare practitioners' experiences of an intervention to detect and treat patients with liver disease (the LOCATE intervention): a qualitative process evaluation

OBJECTIVES

The local care and treatment of liver disease (LOCATE) intervention embedded specialist liver nurses in general practitioner (GP) practices to improve the identification of progressive liver disease, enabling earlier intervention. This current process evaluation examines GP practice staffs' perceptions of the LOCATE intervention, in order to understand any potential barriers to successful implementation in clinical practice.

STUDY DESIGN AND SETTING

A qualitative process evaluation nested within the LOCATE feasibility trial, using semistructured interviews with practice staff from five GP surgeries in the UK.

PARTICIPANTS

A purposive sample of 29 interviews with practice staff (GPs, nurses, practice managers).

DATA COLLECTION

Interview transcripts were subjected to thematic analysis.

FINDINGS

The intervention was found to be acceptable to practice staff and a number of barriers and facilitators to the success of the intervention were identified. However, interviews suggested that the intervention did not provide sufficient guidance for clinicians to be able to help patients make the behavioural changes needed to reduce risk factors associated with liver disease. The intervention did appear to improve clinician awareness and knowledge about liver disease, enabling GPs to feel more confident interpreting and managing liver function blood tests in order to identify the early signs of liver disease.

CONCLUSIONS

This study enabled identification of potential barriers to implementation of specialist nurses in primary care to identify progressive liver disease and enable earlier intervention. The next steps are to improve the intervention to make it more feasible to implement in practice and more likely to help patients to make the behavioural changes required to prevent a major liver event.

TRIAL REGISTRATION NUMBER

13/SC/0012; Post-results.

ETHICS

This study was reviewed and approved by NRES Committee South Central-Hampshire A, Bristol Research Ethics Committee Centre, level 3, block B, Whitefriars, Lewins Mead Bristol BS1 2NT.

Enhancing adolescent SBIRT with a peer-delivered intervention: An implementation study

PURPOSE

Innovations in adolescent prevention and early intervention strategies are needed to curb early substance use and bring public health models to scale, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT). Young adults in recovery may have an important role to play in delivering these innovations. However, clinics, schools, and community programs may face barriers when implementing new prevention and early intervention approaches in their settings. The purpose of this study is to examine the feasibility, barriers, and facilitators of Project Amp, an innovative, four-session prevention and early intervention model to enhance SBIRT for adolescents.

METHODS

Three school-based programs and three health clinics were selected to implement SBIRT for adolescents and refer eligible adolescents (13-17 years old, moderate risk for substance use disorder) to the study intervention. Between three and six mentors (young adults, 18-28 years old, with lived experience of substance use recovery, also known as peers), were recruited at each site and trained in core skills to deliver the intervention. Study staff communicated with each setting throughout implementation and collected quantitative and qualitative data regarding facilitators and barriers to success. The qualitative data were analyzed to identify key strategies for success when implementing Project Amp.

RESULTS

Across the six sites, 71 practitioners including physicians, nurses, social workers, and counselors, completed training in SBIRT and 30 mentors were hired and trained for the study. Twenty completed sessions with adolescent participants. A total of 1192 adolescents were screened using the CRAFFT. Of those screened, 139 (12%) were eligible, 51 eligible youth (37%) enrolled in the study, and 28 enrolled youth (55%) completed the intervention. Five of the six sites were successfully able to integrate the SBIRT-based Project Amp model into their workflow. Facilitators and barriers for implementation were identified related to three critical factors: recruitment, readiness, and sustainability.

CONCLUSIONS

The Project Amp intervention can be conducted successfully in school and healthcare settings in conjunction with SBIRT, adding capacity to expand access to screening and early intervention in a developmentally appropriate way. However, the study yielded insights into adaptations for future implementation, such as a more streamlined model and centralized staff roles such as integrated roles for young peer mentors.

What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory

BACKGROUND

Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention.

METHODS

Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices.

RESULTS

Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability.

CONCLUSIONS

NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.

Comparison of telemedicine versus in-person visits for persons with multiple sclerosis: A randomized crossover study of feasibility, cost, and satisfaction

BACKGROUND

Telemedicine, the remote delivery of health care services, increases access to care for patients with mobility or geographic limitations. Virtual house calls (VHCs) are one type of telemedicine in which clinical visits are conducted remotely using an audio-visual connection with the patient at home. Use of VHCs is more established in other neurologic disorders but is only recently being formally evaluated in multiple sclerosis (MS). This randomized crossover study systematically assessed VHCs compared with in-clinic visits in persons with MS.

METHODS

Recruitment occurred in a university based MS clinic. Each subject completed one VHC and one in-clinic follow-up visit. A 1:1 randomization determined whether the VHC or in-clinic follow-up visit occurred first. Baseline surveys included demographics and MS history; post-visit surveys elicited subject responses regarding each visit type to assess feasibility, satisfaction, and cost differences. Outcomes were compared using t-tests for continuous variables and Fisher's exact test for proportions.

RESULTS

Thirty-six participants completed both study visits and both post-visit surveys. VHC feasibility was demonstrated by a lack of statistically significant difference in the number of completed VHCs as compared with in-clinic visits. VHCs provided both cost and time savings to participants. The majority of participants reported that they would recommend telemedicine visits to others (97.1%) and rated it easy to connect via telemedicine (94.3%). In qualitative comments, participants expressed appreciation for VHCs due to convenience and similarity to in-clinic visits.

CONCLUSIONS

VHCs were found to be feasible, cost-effective, and appealing to persons with MS and physicians, supporting their utility as a care delivery method for MS.

Intramedullary nails versus distal locking plates for fracture of the distal femur: results from the Trial of Acute Femoral Fracture Fixation (TrAFFix) randomised feasibility study and process evaluation

OBJECTIVES

This feasibility study and process evaluation assessed the likely success of a definitive trial of intramedullary fixation with locked retrograde nails versus extramedullary fixation with fixed angle plates for fractures of the distal femur.

DESIGN & SETTING

A multicentre, parallel, two-arm, randomised controlled feasibility study with an embedded process evaluation was conducted at seven NHS hospitals in England. Treatment was randomly allocated in 1:1 ratio, stratified by centre and chronic cognitive impairment. Participants, but not surgeons or research staff, were blinded to the allocation.

PARTICIPANTS

Patients 18 years and older with a fracture of the distal femur, who their surgeon believed would benefit from internal fixation, were eligible to take part.Participants were allocated to receive either a retrograde intramedullary nail or an anatomical locking plate.

OUTCOMES

The primary outcomes for this feasibility study were the recruitment rate and completion rate of the EQ-5D-5L at 4 months post-randomisation. Baseline characteristics, disability rating index, quality of life scores, measurements of social support and self-efficacy, resource use and radiographic assessments were also collected. The views of patients and staff were collected during interviews.

RESULTS

Recruitment and data completion were lower than expected. 23 of 82 eligible patients were recruited (nail, 11; plate, 12). The recruitment rate was estimated as 0.42 (95% CI 0.27 to 0.62) participants per centre-month. Data completeness of the EQ-5D-5L at 4 months was 61 per cent (95% CI 43% to 83%). The process evaluation demonstrated that the main barriers to recruitment were variation in treatment pathways across centres, lack of surgeon equipoise and confidence in using both interventions and newly formed research cultures that lacked cohesion.

CONCLUSIONS

A modified trial design, with embedded recruitment support intervention, comparing functional outcome in cognitively intact adults who have sustained a fragility fracture of the distal femur is feasible.

ETHICS APPROVAL

The Wales Research Ethics Committee 5 approved the study (ref: 16/WA/0225).

TRIAL REGISTRATION NUMBER

ISRCTN92089567; Pre-results.

A method for measuring continuity of care in day-to-day general practice: a quantitative analysis of appointment data

BACKGROUND

Despite patient preference and many known benefits, continuity of care is in decline in general practice. The most common method of measuring continuity is the Usual Provider of Care (UPC) index. This requires a number of appointments per patient and a relatively long timeframe for accuracy, reducing its applicability for day-to-day performance management.

AIM

To describe the St Leonard's Index of Continuity of Care (SLICC) for measuring GP continuity regularly, and demonstrate how it has been used in service in general practice.

DESIGN AND SETTING

Analysis of appointment audit data from 2016-2017 in a general practice with 8823-9409 patients and seven part-time partners, in Exeter, UK.

METHOD

The percentage of face-to-face appointments for patients on each doctor's list, with the patient's personal doctor (the SLICC), was calculated monthly. The SLICC for different demographic groupings of patients (for example, sex and frequency of attendance) was compared. The UPC index over the 2 years was also calculated, allowing comparisons between indices.

RESULTS

In the 2-year study period, there were 35 622 GP face-to-face appointments; 1.96 per patient per year. Overall, 51.7% (95% confidence interval = 51.2 to 52.2) of GP appointments were with the patients' personal doctor. Patients aged ≥65 years had a higher level of continuity with 64.9% of appointments being with their personal doctor. The mean whole-practice UPC score was 0.61 (standard deviation 0.23), with 'usual provider' being the personal GP for 52.8% and a trainee or locum for 8.1% of patients.

CONCLUSION

This method could provide working GPs with a simple way to track continuity of care and inform practice management and decision making.

ABCDE approach to victims by lifeguards: How do they manage a critical patient? A cross sectional simulation study

Introduction

Decision-making in emergencies is a multifactorial process based on the rescuer, patient, setting and resources. The eye-tracking system is a proven method for assessing decision-making processes that have been used in different fields of science. Our aim was to evaluate the lifeguards’ capacity to perform the ABCDE (Airway-Breathing-Circulation-Disability-Exposure) approach when facing a simulated critically ill-drowned victim.

Methods

A cross-sectional simulation study was designed to assess the skills and sequence of the ABCDE approach by 20 professional lifeguards. They had to assess a victim and act according to his/her clinical status by following the ABCDE primary assessment approach. The two kinds of variables were recorder: those related to the quality of each step of the ABCDE approach and the visual behaviour using a portable eye-movement system. The eye-tracking system was the Mobile Eye system (Bedford, USA).

Results

None of the study participants were able to complete correctly the ABCDE approach. Lifeguards spent more time in the Circulation step: Airway (15.5±11.1 s), Breathing (25.1±21.1 s), Circulation (44.6±29.5 s), Disability (38.5±0.7 s). Participants spent more time in viewpoints considered as important (65.5±17.4 s) compared with secondary ones (34.6±17.4 s, p = 0.008). This was also represented in the percentage of visual fixations (fixations in important viewpoints: 63.36±15.06; fixation in secondary viewpoints: 36.64±15.06; p = 0.008).

Conclusion

Professional lifeguards failed to fully perform the ABCDE sequence. Evaluation by experts with the help of eye-tracking technology detected the lifeguards’ limitations in the assessment and treatment of an eventual critically ill victim. Such deficits should be considered in the design and implementation of lifeguards’ training programmes.

Clinical performance comparators in audit and feedback: a review of theory and evidence

BACKGROUND

Audit and feedback (A&F) is a common quality improvement strategy with highly variable effects on patient care. It is unclear how A&F effectiveness can be maximised. Since the core mechanism of action of A&F depends on drawing attention to a discrepancy between actual and desired performance, we aimed to understand current and best practices in the choice of performance comparator.

METHODS

We described current choices for performance comparators by conducting a secondary review of randomised trials of A&F interventions and identifying the associated mechanisms that might have implications for effective A&F by reviewing theories and empirical studies from a recent qualitative evidence synthesis.

RESULTS

We found across 146 trials that feedback recipients' performance was most frequently compared against the performance of others (benchmarks; 60.3%). Other comparators included recipients' own performance over time (trends; 9.6%) and target standards (explicit targets; 11.0%), and 13% of trials used a combination of these options. In studies featuring benchmarks, 42% compared against mean performance. Eight (5.5%) trials provided a rationale for using a specific comparator. We distilled mechanisms of each comparator from 12 behavioural theories, 5 randomised trials, and 42 qualitative A&F studies.

CONCLUSION

Clinical performance comparators in published literature were poorly informed by theory and did not explicitly account for mechanisms reported in qualitative studies. Based on our review, we argue that there is considerable opportunity to improve the design of performance comparators by (1) providing tailored comparisons rather than benchmarking everyone against the mean, (2) limiting the amount of comparators being displayed while providing more comparative information upon request to balance the feedback's credibility and actionability, (3) providing performance trends but not trends alone, and (4) encouraging feedback recipients to set personal, explicit targets guided by relevant information.

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room

BACKGROUND

Studies in operating rooms (OR) show that minor disruptions tend to group together to result in serious adverse events such as surgical errors. Understanding the characteristics of these minor flow disruptions (FD) that impact major events is important in order to proactively design safer systems OBJECTIVE: The purpose of this study is to use a systems approach to investigate the aetiology of minor and major FDs in ORs in terms of the people involved, tasks performed and OR traffic, as well as the location of FDs and other environmental characteristics of the OR that may contribute to these disruptions.

METHODS

Using direct observation and classification of FDs via video recordings of 28 surgical procedures, this study modelled the impact of a range of system factors-location of minor FDs, roles of staff members involved in FDs, type of staff activities as well as OR traffic-related factors-on major FDs in the OR.

RESULTS

The rate of major FDs increases as the rate of minor FDs increases, especially in the context of equipment-related FDs, and specific physical locations in the OR. Circulating nurse-related minor FDs and minor FDs that took place in the transitional zone 2, near the foot of the surgical table, were also related to an increase in the rate of major FDs. This study also found that more major and minor FDs took place in the anaesthesia zone compared with all other OR zones. Layout-related disruptions comprised more than half of all observed FDs.

CONCLUSION

Room design and layout issues may create barriers to task performance, potentially contributing to the escalation of FDs in the OR.

Effectiveness and cost-effectiveness randomised controlled trial of basic versus biofeedback-mediated intensive pelvic floor muscle training for female stress or mixed urinary incontinence: protocol for the OPAL (optimising pelvic floor exercises to achieve long-term benefits) trial mixed methods longitudinal qualitative case study and process evaluation

INTRODUCTION

Female urinary incontinence (UI) is common affecting up to 45% of women. Pelvic floor muscle training (PFMT) is the first-line treatment but there is uncertainty whether intensive PFMT is better than basic PFMT for long-term symptomatic improvement. It is also unclear which factors influence women's ability to perform PFMT long term and whether this has impacts on long-term outcomes. OPAL (optimising PFMT to achieve long-term benefits) trial examines the effectiveness and cost-effectiveness of basic PFMT versus biofeedback-mediated PFMT and this evaluation explores women's experiences of treatment and the factors which influence effectiveness. This will provide data aiding interpretation of the trial findings; make recommendations for optimising the treatment protocol; support implementation in practice; and address gaps in the literature around long-term adherence to PFMT for women with stress or mixed UI.

METHODS AND ANALYSIS

This evaluation comprises a longitudinal qualitative case study and process evaluation (PE). The case study aims to explore women's experiences of treatment and adherence and the PE will explore factors influencing intervention effectiveness. The case study has a two-tailed design and will recruit 40 women, 20 from each trial group; they will be interviewed four times over 2 years. Process data will be collected from women through questionnaires at four time-points, from health professionals through checklists and interviews and by sampling 100 audio recordings of appointments. Qualitative analysis will use case study methodology (qualitative study) and the framework technique (PE) and will interrogate for similarities and differences between the trial groups regarding barriers and facilitators to adherence. Process data analyses will examine fidelity, engagement and mediating factors using descriptive and interpretative statistics.

ETHICS AND DISSEMINATION

Approval from West of Scotland Research Ethics Committee 4 (16/LO/0990). Findings will be published in journals, disseminated at conferences and through the final report.

TRIAL REGISTRATION NUMBER

ISRCTN57746448.

Implementation and fidelity assessment of the NAVIGATE treatment program for first episode psychosis in a multi-site study

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.

Process Evaluation and Lessons Learned From Engaging Local Policymakers in the B'More Healthy Communities for Kids Trial

Partnerships linking researchers to the policymaking process can be effective in increasing communication and supporting health policy. However, these policy partnerships rarely conduct process evaluation. The Policy Working Group (Policy WG) was the policy-level intervention of the multilevel B'More Healthy Communities for Kids (BHCK) trial. The group sought to align interests of local policymakers, inform local food and nutrition policy, introduce policymakers to a new simulation modeling, and sustain intervention levels of BHCK. We conducted an evaluation on the Policy WG between July 2013 and May 2016. We evaluated process indicators for reach, dose-delivered, and fidelity and developed a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The policy intervention was implemented with high reach and dose-delivered. Fidelity measures improved from moderate to nearly high over time. The number of health-related issues on policymakers' agenda increased from 50% in the first 2 years to 150% of the high standard in Year 3. SWOT analysis integrated a stakeholder feedback survey to consider areas of strength, weakness, opportunity, and threats. Although the fidelity of the modeling was low at 37% of the high standard, stakeholders indicated that the simulation modeling should be a primary purpose for policy intervention. Results demonstrate that process evaluation and SWOT analysis is useful for tracking the progress of policy interventions in multilevel trials and can be used to monitor the progress of building partnerships with policymakers.

Feasibility and acceptability of telehealth coaching to promote healthy eating in chronic kidney disease: a mixed-methods process evaluation

OBJECTIVE

To evaluate the feasibility and acceptability of a personalised telehealth intervention to support dietary self-management in adults with stage 3-4 chronic kidney disease (CKD).

DESIGN

Mixed-methods process evaluation embedded in a randomised controlled trial.

PARTICIPANTS

People with stage 3-4 CKD (estimated glomerular filtration rate [eGFR]15-60 mL/min/1.73 m²).

SETTING

Participants were recruited from three hospitals in Australia and completed the intervention in ambulatory community settings.

INTERVENTION

The intervention group received one telephone call per fortnight and 2-8 tailored text messages for 3 months, and then 4-12 tailored text messages for 3 months without telephone calls. The control group received usual care for 3 months then non-tailored education-only text messages for 3 months.

MAIN OUTCOME MEASURES

Feasibility (recruitment, non-participation and retention rates, intervention fidelity and participant adherence) and acceptability (questionnaire and semistructured interviews).

STATISTICAL ANALYSES PERFORMED

Descriptive statistics and qualitative content analysis.

RESULTS

Overall, 80/230 (35%) eligible patients who were approached consented to participate (mean±SD age 61.5±12.6 years). Retention was 93% and 98% in the intervention and control groups, respectively, and 96% of all planned intervention calls were completed. All participants in the intervention arm identified the tailored text messages as useful in supporting dietary self-management. In the control group, 27 (69%) reported the non-tailored text messages were useful in supporting change. Intervention group participants reported that the telehealth programme delivery methods were practical and able to be integrated into their lifestyle. Participants viewed the intervention as an acceptable, personalised alternative to face-face clinic consultations, and were satisfied with the frequency of contact.

CONCLUSIONS

This telehealth-delivered dietary coaching programme is an acceptable intervention which appears feasible for supporting dietary self-management in stage 3-4 CKD. A larger-scale randomised controlled trial is needed to evaluate the efficacy of the coaching programme on clinical and patient-reported outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616001212448; Results.

Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing

BACKGROUND

Health care value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.

STUDY DESIGN

Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014 to 2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared with median use, accounting for case, patient, and attending-level variables.

RESULTS

There were 111,055 laboratory orders and 7,360 imaging orders linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% CIs > 1, p < 0.05). Compared with the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% CI >1, p < 0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.

CONCLUSIONS

Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared with imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high users and could be used to educate residents on their ordering patterns.

A qualitative study of cardiovascular disease risk communication in NHS Health Check using different risk calculators: protocol for the RIsk COmmunication in NHS Health Check (RICO) study

BACKGROUND

NHS Health Check is a national cardiovascular disease (CVD) risk assessment programme for 40-74 year olds in England, in which practitioners should assess and communicate CVD risk, supported by appropriate risk-management advice and goal-setting. This requires effective communication, to equip patients with knowledge and intention to act. Currently, the QRISK®2 10-year CVD risk score is most common way in which CVD risk is estimated. Newer tools, such as JBS3, allow manipulation of risk factors and can demonstrate the impact of positive actions. However, the use, and relative value, of these tools within CVD risk communication is unknown. We will explore practitioner and patient CVD risk perceptions when using QRISK®2 or JBS3, the associated advice or treatment offered by the practitioner, and patients' responses.

METHODS

RIsk COmmunication in NHS Health Check (RICO) is a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England will be randomised to one of two groups: usual practice, in which practitioners use QRISK®2 to assess and communicate CVD risk; intervention, in which practitioners use JBS3. Twenty Health Checks per practice will be video-recorded (n = 240, 120 per group), with patients stratified by age, gender and ethnicity. Post-Health Check, video-stimulated recall (VSR) interviews will be conducted with 48 patients (n = 24 per group) and all practitioners (n = 12-18), using video excerpts to enhance participant recall/reflection. Patient medical record reviews will detect health-protective actions in the first 12-weeks following a Health Check (e.g., lifestyle referrals, statin prescription). Risk communication, patient response and intentions for health-protective behaviours in each group will be explored through thematic analysis of video-recorded Health Checks (using Protection Motivation Theory as a framework) and VSR interviews. Process evaluation will include between-group comparisons of quantitatively coded Health Check content and post-Health Check patient outcomes. Finally, 10 patients with the most positive intentions or behaviours will be selected for case study analysis (using all data sources).

DISCUSSION

This study will produce novel insights about the utility of QRISK®2 and JBS3 to promote patient and practitioner understanding and perception of CVD risk and associated implications for patient intentions with respect to health-protective behaviours (and underlying mechanisms). Recommendations for practice will be developed.

TRIAL REGISTRATION

ISRCTN ISRCTN10443908 . Registered 7th February 2017.

Process evaluation of a cluster-randomised controlled trial of multi-component weight management programme in adults with intellectual disabilities and obesity

BACKGROUND

Providing effective weight management to adults with intellectual disabilities is necessary to challenge the high rates of obesity. The aim of this process evaluation was to explore the feasibility of conducting a full-scale clinical trial of the TAKE 5 multi-component weight management programme.

METHODS

The study was a 12-month pilot cluster-randomised controlled trial. Adults with intellectual disabilities and obesity were randomised to either TAKE 5, which included an energy deficit diet (EDD) or Waist Winners Too, based on health education principles. A mixed-methods process evaluation was conducted focussing on the reach, recruitment, fidelity, implementation, dose (delivered/received) and context.

RESULTS

The study successfully recruited adults with intellectual disabilities. Both weight management programmes were delivered with high fidelity and implemented as intended. Only one weight management programme, TAKE 5, demonstrated potential efficacy in reducing body weight and body composition. The effectiveness was largely attributed to the EDD and social support from carers.

CONCLUSIONS

The extensive process evaluation illustrated that a full-scale trial of a multi-component programme including an EDD is feasible and an acceptable approach to weight management for adults with intellectual disabilities and obesity.

Personalized Assistance for Patients with Chronic Diseases Through Multi-Level Distributed Healthcare Process Assessment

The study is aimed towards the assessment and improvement of complex informational, healthcare, and medical processes existing in the distributed environment during monitoring and providing healthcare services to patients with chronic diseases. The study is performed within a framework of a project for development a complex unified medical information system capable to work on large scale (on population-level). The presented experimental studies show that predictive modelling enables unified detection of remote patients' state using self-measuring and distributed electronic health records. In addition, an experimental mobile application is presented as a tool for data collection and user-system interaction during chronic disease monitoring and treatment.

Using Telehealth for Sexual Assault Forensic Examinations: A Process Evaluation of a National Pilot Project

INTRODUCTION

This project describes the first time live sexual assault nurse examiner (SANE) services were provided via telehealth to support site clinicians conducting sexual assault forensic medical examinations for adult and adolescent patients. It involved six sites in three states, including rural, tribal, military, and community hospitals. The purpose of this process evaluation was to determine the extent to which patients consent to telehealth technology, examine how the technology worked, and explore the types of assistance.

METHODS

We reviewed information for sexual assault patients who presented at emergency departments (N = 215) and conducted telephone and online surveys with 178 clinicians who provided or received telehealth services.

RESULTS

Between May 1, 2015, and March 31, 2018, 129 patients and site clinicians received services via telehealth and an additional 86 site clinicians received consultation advice via telehealth. Most patients consented and accepted SANE services via telehealth (86% overall and 97% in non-U.S. Navy sites). No significant technology problems were experienced for most interactions (92%). The assistance provided remotely by SANEs to site clinicians included guiding clinicians through history taking and documentation, forensic examination and evidence collection techniques, identifying and documenting injuries, and guiding clinical practice. Site clinicians reported, on average, a positive impact of the assistance on their confidence in providing an effective examination, their ability to provide their patient with the best care, and their sense of feeling supported.

IMPLICATION

Results of this pilot suggest that using live telehealth services for sexual assault forensic examinations is a promising practice.

To what degree can variations in readmission rates be explained on the level of the hospital? a multilevel study using a large Dutch database

BACKGROUND

It is not clear which part of the variation in hospital readmissions can be attributed to the standard of care hospitals provide. This is in spite of their widespread use as an indicator of a lower quality of care. The aim of this study is to assess the variation in readmissions on the hospital level after adjusting for case-mix factors.

METHODS

We performed multilevel logistic regression analyses with a random intercept for the factor 'hospital' to estimate the variance on the hospital level after adjustment for case-mix variables. We used administrative data from 53 Dutch hospitals from 2010 to 2012 (58% of all Dutch hospitals; 2,577,053 admissions). We calculated models for the top ten diagnosis groups with the highest number of readmissions after an index admission for a surgical procedure. We calculated intraclass correlation coefficients (ICC) per diagnosis group in order to explore the variation in readmissions between hospitals. Furthermore, we determined C-statistics for the models with and without a random effect on the hospital level to determine the discriminative ability.

RESULTS

The ICCs on the hospital level ranged from 0.48 to 2.70% per diagnosis group. The C-statistics of the models with a random effect on the hospital level ranged from 0.58 to 0.65 for the different diagnosis groups. The C-statistics of the models that included the hospital level were higher compared to the models without this level.

CONCLUSIONS

For some diagnosis groups, a small part of the explained variation in readmissions was found on the hospital level, after adjusting for case-mix variables. However, the C-statistics of the prediction models are moderate, so the discriminative ability is limited. Readmission indicators might be useful for identifying areas for improving quality within hospitals on the level of diagnosis or specialty.

The 2015 Amtrak Philadelphia Train Derailment: After-Action Review of the Emergency Radiology Response at Temple University Health System

PURPOSE

The aim of this article is to assess a large tertiary care medical center's emergency radiology response after the 2015 Amtrak Philadelphia train derailment.

METHODS AND MATERIALS

A total of 55 patients with 308 total CTs and radiographs ordered within 12 hours of arrival to Temple University Health System (combining Temple University Hospital and Episcopal Hospital) emergency departments on May 12 to 13, 2015, were included in this study. A retrospective PACS and electronic medical record chart review of emergency department imaging turnaround times (TAT) during this event was completed and compared with emergency department radiology operations for the same 12-hour period throughout the preceding year. Wilcoxon's rank-sum test analysis was performed.

RESULTS

A total of 308 CTs and radiographs were performed, and 91 radiologically evident injuries were observed in a total of 30 patients, with fractures (n = 51) as the most common type of injury. There were no significant differences in time from patient arrival to beginning of radiological examination (26 min; interquartile range [IQR], 11-58 min) compared with annual median (28 min; IQR, 10-131 min; P = .232). Examination completion TATs were significantly increased (35 min; IQR, 17-112 min) compared with annual median (10 min; IQR, 5-15 min; P < .001), and time required from viewing of the examination by the radiologist to the examination being marked as read was significantly decreased (17 min; IQR, 6-45 min) compared with annual median (248 min; IQR, 126-441 min; P < .001).

CONCLUSIONS

The analysis highlights areas of efficiency in our response but also indicates areas for process improvement in future potential mass casualty events.

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital

OBJECTIVE

To identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H).

DESIGN

Audits, semi-structured interviews and focus groups guided by the Theoretical Domains Framework.

SETTING

Australian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months.

PARTICIPANTS

Four children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members.

MAIN OUTCOME MEASURES

Parent awareness and involvement in escalating care and factors impacting implementation of C4H.

RESULTS

Two audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents' information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent-staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture.

CONCLUSIONS

Although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.